Summary

Peru had established its TB program only four years back in 1991, but only after years of inadequately financed and unsupervised treatment. So Farmer and Jaime know that there are probably many more cases of MDR-TB than just those first ten. They know from such men as Michael Iseman at National Jewish Hospital in Denver that the disease is hard to treat anywhere and is exorbitantly expensive. Furthermore, the side effects are just as daunting, and so each patient will need to be given not only drugs and careful monitoring, but also encouragement, food, new roofs, and water pipes. Jim reasons that what they have in their favor is that TB is airborne, and therefore, everyone is at risk just because they breathe. This means that any campaign that may be instituted will get the eyes and ears of the world, even the rich. Paul agrees, but is determined to start with the first ten patients first.

They begin treating patients in August 1996, transporting the program they used in Haiti to Peru. They already have an indigenous team of Peruvian health workers, and they also bring in a brilliant epidemiologist named Meche Bercerra and two female medical students from Harvard. They exchange e-mail daily, and Farmer sends orders in great detail and devises drug regimens for every patient, inventing tricks for the most resistant cases.

They have some problems at first, including the health workers balking at entering the homes of the patients, but they resolve that just as they take on the problem of the Peruvian government. The Peruvians fought long and hard to obtain funding from the government for the WHO program, DOTS, that has made great inroads into the epidemic of TB in their country. They fear that if Farmer and PIH pushes too hard about money for MDR, they will lose the program. They don't want to set any precedent that will give the government the excuse to cut funding. They also have to fight basic myths about MDR-TB especially that it doesn't spread as rapidly and as virulently as regular TB does. In the meantime, one of the Harvard medical students finds a probable MDR patient named David Carbajal. She and Farmer beg the authorities to treat him, but they refuse, and Sonya, the student, has to watch him die. Even the young man's parents understand that it's just the system, and they are less furious than Farmer. He sees now that he must go to higher authorities.

Farmer thinks he has found a suitable forum to begin his appeal. He has been invited to give a speech about TB in Chicago at the annual North American meeting of the International Union Against Tuberculosis and Lung Disease. Officials from WHO would be on hand along with bureaucrats, public health specialists, and medical school professors, all of whom made the controlling of TB their life's work. Unfortunately, not many of them know much about Farmer, and he knows that many of them will view him as a mere clinician, too interested in individuals to see the big picture. He rejects that idea utterly: paying attention to individual patients is a moral imperative, and it is essential to controlling TB in the communities. However, he decides he needs the support of this body of medical experts, so he decides to give what he calls a wimpy speech.

His speech begins temperately enough, but soon Farmer begins to present the Myths and Mystifications of MDR-TB and begins to present each myth, proving it is misunderstood. Myth One: it is too expensive to treat MDR in poor countries. Farmer shows that it is more costly in the long run to ignore it. Myth Two: DOTS alone can stop the outbreak of MDR. If left untreated, it would grow in the vacuum left by the cure of TB that is not resistant to the drugs in use, because it would amplify already existing drug resistance. Myth Three: MDR is less virulent and contagious than regular TB. Farmer shows that that belief is mere wishful thinking. He goes on through his list of myths, which he calls notions shared by many in the TB world. He may as well have called half of his audience fools and villains. As he begins to walk off the stage, the moderator thanks him for his provocative talk. Farmer turns back and asks why he calls it provocative? Farmer emphasizes that he is merely saying that they should treat sick people, if they have the technology.

A few days later, Jaime hears in Peru that someone had called the director of Peru's national TB program and told him that Paul Farmer was saying that this program was killing patients. To Farmer, at least, his protest has been lodged and the higher authorities have noticed.

Notes

This chapter furthers the idea of Farmer taking his radical ideas beyond Haiti. Now he is fighting for the seriously ill MDR-TB patients and in doing so, taking the risk of stepping on toes of powerful people throughout the world. It is a testament to his determination to follow through with the comment he left in Chicago: We should be treating sick patients if we have the technology.