Summary

The author is back as narrator in this chapter describing the first time he saw Carabayllo in Farmer's company. He arrives at night, and he sees the beauty of Lima with the hillsides smothered in darkness, but dotted with twinkling lights like Japanese lanterns. The next day, the truth emerges. Lima is a vast coastal city with a ramshackle-looking development. On the hills are the huts and shacks where the poor live, and the lights that twinkled the night before are mounted on highway-style pylons over the shacks. Many of the poor come from the Andes Mountains and have come here for the electricity, clean water, schools, medical care, and jobs, as well as distance from the war between the government and the Shining Path. The roads here turn into paths with convenience stores with dirt floors, metal-roofed cook shacks, barbershops, and even graveyards. But it is all surrounded by sewage and disease.

Jaime Bayona has found ten patients with MDR. They take a sputum sample from each one, and because the national labs will not allow PIH to use their facilities, Paul takes them back to Boston. The results are alarming, because most of the patients are, at the least, resistant to the two most powerful drugs, but many are resistant to all five. This is an unusual pattern to Farmer, but here it seems like it might be the norm. Farmer immediately returns to Peru, and Jaime has the ten patients waiting for him. He sits on a wooden stool and interviews each patient. He is a definite TB expert, and he had written a treatment manual for the house staff at Brigham. He has also seen cases of severe resistance from too little treatment interrupted by strike or flood. However, here, the ten patients have received treatment daily, and they have been observed taking their medicine. So it can't be a case of noncompliance. They have followed the WHO regimen called DOTS, the most significant advance in TB control since the advent of antibiotics. Even the quality of the drugs cannot be blamed. So, for these ten patients at least, something has gone terribly wrong.

Farmer begins to review all the possibilities, and suddenly, his suspicions come together. The dynamics of tuberculosis make it nearly impossible for a person to require resistance to more than one drug at a time, but repeated improper therapy can select for increasingly resistance mutants and create strains resistant to any number of drugs. These ten people had gone to the clinics with one-or more likely, two-drug resistance and through treatment and repeated treatment under the DOTS protocol had emerged four-and five-drug resistant. The treatment should have been for the health care workers to determine which drugs they were already resistant to and then start them on drugs that would work. This had not happened, because they had been treated as if they were not yet drug resistant at all. These were not acts of stupidity or carelessness, but rather just following the treatment enshrined as official policy. The policy did not allow for MDR. Also, the money didn't either. When the same effect had happened in the USA in the late 1980's in New York City, the government spent about a billion dollars to staunch the outbreak. However, MDR was just too expensive to treat in Peru.

Notes

This chapter continues to emphasize the basic premise of Farmer's work: poverty leads to disease that often is not treated or is untreatable and that, of course, leads to unnecessary deaths.