Reviews

Mountains Beyond Mountains

By Tracy Kidder. Random House (www.randomhouse.com). 2003. 317 pages. $29.95.

Reviewed by Stan Baumblatt

If you have never heard of Paul Farmer and his visionary work on behalf of humanity, it is time you did. This aweinspiring biography by Pulitzer Prizewinning author Tracy Kidder captures the essence of a man who travels the world over to diagnose and cure infectious diseases and bring modern medicine to those who need it most. Farmer is a doctor, Harvard professor, renowned infectious disease specialist, anthropologist, MacArthur fellow (in 1993) and founder of Partners in Health (PIH).

Farmer seeks radical change in the way the poorest people in the far corners of the earth receive medical attention and treatment. Raised in a bus and on a boat, he understands being poor but still being happy and hopeful when facing adversity. This hope is expressed clearly in the book's title, which is based on a Haitian proverb, "Beyond mountains there are mountains." As you solve one problem, another problem presents itself, and so you try to solve that one, too.

Farmer is tireless and selfless in his efforts to save individual lives as well as control infectious diseases like tuberculosis (TB) and AIDS that plague communities in Haiti, Peru and Russia. With the help of individuals who contributed both time and money—in particular Tom White and Ophelia Dahl—and believed in his ability to change a society individual by individual and lend a voice to the voiceless, Farmer lined up the support of The Bill & Melinda Gates Foundation, the Open Society Institute and the Global Health Fund for several major projects in recent years. After some 20 years of personally writing thank you notes to donors, Farmer was asked after receiving the Soros gift why he continued to do so with his busy schedule. His reply? So that he himself could thank Soros for his multi-million dollar funding.

As amazing as Farmer's transformational projects are his views of the world and his embodiment of his beliefs. In fact, it is through the treatment of individuals, his knowledge of medicine and anthropology, and his view that poverty is the key to the world's health problems that the sum of the parts adds up to the whole. Farmer's story is exemplified in his first and continuing project in Haiti, where he lived after graduating college in spring 1983, until he entered Harvard Medical School in fall 1984. This experience working with the native poor resulted in a vision of his life's work.

Even as a medical student, "he was like a compass, with one leg swinging around the globe and the other planted in Haiti." In 1987, Farmer established Zanmi Lasante (Creole for Partners in Health) in the village of Cange. Zanmi Lasante (ZL) was the formalization of an organization Farmer and Dahl had begun a few years earlier to support the growing health system there. During a visit in 1999, the author describes Cange as "what seemed to me like the end of the earth, in what was in fact one of the poorest parts of the poorest country in the Western Hemisphere…one of the most impoverished, diseased, eroded, and famished regions of Haiti."

However, Zanmi Lasante had grown to be a leafy, walled-in medical complex of concrete buildings with running water and generator-provided electricity. The complex had an ambulatory clinic, women's clinic, general hospital, TB treatment center, church, school and a kitchen that prepared meals for 2,000 people daily. An estimated one million peasant farmers relied on ZL, with nearly 100,000 living in its catchment area. Some came great distances for treatment, but often Farmer traveled to them.

ZL built schools, houses and communal water systems throughout its catchment area. It vaccinated all children and greatly reduced local malnutrition and infant mortality. It launched programs for women's literacy and AIDS prevention and reduced the rate of HIV transmission from mothers to babies to half the U.S. rate in 1999.

In ZL's catchment area, no one has died from TB since 1988, although it remains the major killer of Haitian adults. Most patients were treated in their huts by Farmer and his staff of community health workers at a cost of $150 to $200—one percent of the cure's cost in the United States, where most TB patients are hospitalized. In 1999 alone, ZL treated about 175,000 people, roughly the same number of people as the author's local hospital in Massachusetts, but at a cost of $1.5 million—half in the form of donated drugs—as compared to $60 million.

Receiving funding from the Global Health Fund in 2002, PIH and Farmer expanded the entire ZL system, including antiretroviral treatment, throughout the central plateau. By the end of that year, staff had grown to more than 200 community health workers, a dozen nurses and a dozen doctors. Equipment and training allowed personnel to do some of their own high-tech AIDS diagnostics in caring for more than 3,000 HIV patients and providing 350 with antiretrovirals.

From the initial efforts of a few passionate individuals in 1987, ZL continues to grow and is proof of Margaret Mead's advice, "Never underestimate the ability of a small group of committed individuals to change the world."

Zanmi Lasante is perhaps the crown jewel of Farmer's many accomplishments related in Mountains, which is also an account of replicability and sustainability. Kidder's book also details Farmer's initial efforts to change the treatment of multi-drug resistant tuberculosis in a small area of Peru, which resulted not only in a globally accepted new protocol, but also in funding to control the disease throughout the country. ZL, however, is representative of Farmer's efforts at striving for equity in the world, where he notes poverty and inequality are "why life sucks."

In trying to change the equation, Farmer often finds it is easier to ask forgiveness than permission. He was an early proponent of reducing the cost of drugs for the poor and knows that poor countries can achieve good public health. He is critical of large foundations with narrowly focused campaigns against well-publicized diseases that do not see the need to pay for comprehensive care. He always carries around two photos—one of his child and the other of a sick child—to remind him how the world is. Farmer will hike seven hours to visit poor patients, because their lives matter no less than others, and because the idea that some do matter less represents all that is wrong with the world.

Kidder, who traveled with Farmer for several years, witnessed him in action day and night. Farmer always seems to be taking care of others. Yet we also learn about his childhood, education, loves, wife and daughter and delve into matters that make this wonderful, seemingly superhuman creature human.

Few, if any, can keep up with Paul Farmer, and this narrative leaves the reader breathless and inspired, perhaps inspired enough not only to share Farmer's worldview, but also to take action and make a difference.

Stan Baumblatt is senior program officer at The Picower Foundation and a member of the board of directors of Funders Concerned About AIDS.

Rhetoric of the Sincere

Global AIDS: Myths and Facts. Tools for Fighting the AIDS Pandemic

By Alexander Irwin, Joyce Millen and Dorothy Fallows. South End Press. 800/533-8478. (www.southendpress.org) 2003. 267 pages. $19.

Reviewed by Sam Avrett

HIV/AIDS, as we are told by innumerable sources, has infected some 70 million people around the world during the past three decades, already killing more than 30 million and threatening the remainder with illness and early death. Moreover, HIV continues to spread to an estimated 14,000 new people each day, and the world's combined response is still insufficient to end this plague.

Too often, dismal statistics like those are a potent recipe for fatalism, powerlessness and paralysis. Too often, the response of individuals, corporations, foundations and governments is a set of weak arguments or myths that support a shrug, saying "What can we do?" Global AIDS tackles those excuses, setting out a comprehensive inventory of arguments for AIDS activism in all sectors.

AIDS rhetoric has a long history by now. Indeed, in 1990, the publishers of this book produced a similar tome on HIV/AIDS activism, written by ACT UP New York, titled Women, AIDS, and Activism. The rhetoric then, as now, is entirely sincere, articulating humanist vision and principles and providing the basis for budding AIDS orators and essayists.

Global AIDS documents another historic time in U.S.-based progressive AIDS activism. The book is infused with the sentiment of salvation—loudly testifying that early death from disease is not inevitable, that lives must be saved and that humankind bears collective and communal responsibility to fight the injustices related to AIDS.

Importantly, Global AIDS is also an excellent review of the arguments for a global response to the pandemic. The book begins with important basics about HIV/AIDS, then methodically tackles ten common misconceptions about the global plague. The conceptual framework of chapters is easy to follow. The arguments are thorough and well-documented. Like any litany, this book should be required reading for those aspiring to ongoing AIDS activism.

Global AIDS is actually a good read, patiently itemizing the arguments for AIDS activism. Here's a summary:

1. Efforts against HIV and AIDS are needed in every region of the world, at local, regional, national and global levels.    
2. HIV is often transmitted through dangerous behavior (unsafe sex, drug use or unsafe medical procedures), but choices about behavior are often constrained by environment, and consequences of behavior are often linked to epidemiology and economics.    
3. Efforts against HIV/AIDS are, and will continue to be, slowed by corruption, inertia and a host of social and political weaknesses. Yet despite those failings, many countries (including Thailand, Uganda and Brazil) have shown successes against HIV/AIDS.    
4. HIV treatment and prevention are part of a mutually-reinforcing continuum of effort.    
5. Global treatment for HIV and AIDS is increasingly possible, not least of all because of decreased costs of medicines, improving health infrastructure and clear benefits and feasibility of HIV medications in all areas of the world.    
6. Development of HIV vaccines remains a hope and requires investment.    
7. The political and economic institutions of the world have a collective responsibility to value health over profits when designing and implementing standards for international trade.    
8. The world has sufficient resources to end the AIDS epidemic. The richest countries must lead the way.    
9. The benefits of acting against AIDS are not only moral, but practical and economic. The costs of inaction are steadily mounting and self-reinforcing.    
10. Ordinary citizens in wealthy countries such as the United States should educate, organize, advocate and fund the world's efforts against AIDS.

Global AIDS seems to be largely produced by and for America's small cadre of political intellectuals. Written primarily by individuals affiliated with Harvard and other New England universities, the book seeks greater HIV/AIDS responses through education and persuasion. It offers well-referenced arguments to rally readers, and offers its values without apology. This book is highly suited to assign to undergraduate students for lectures and class discussions.

AIDS activists and their funders will find valuable tools here for untangling obfuscations and cutting through conceptual confusions. For example, the book provides an excellent 22-page summary of the arguments for the growing feasibility of global HIV treatment access. Enduring pessimists might be swayed by the presented facts and references and spurred into dialogue.

Readers outside the United States might be struck by the optimism, collectivism and stridency of this book, which reflects a solid American progressive "city-on-a-hill" vision of what the world could be. Corruption and discrimination can be overcome, poverty can be reversed and no injustice is inevitable.

The "resources for activism" section reflects a U.S. bias, listing U.S. Federal agencies the Health Resources and Services Administration and National Institutes of Health, but not the United Kingdom's Department for International Development or Germany's Deutsche Gesellschaft für Technische Zusammenarbeit, listing the Student Global AIDS Campaign and ACT UP New York but not many international AIDS advocacy groups, such as the Canadian HIV/AIDS Legal Network, the Indian Lawyer's Collective on HIV/AIDS or the many groups in Africa, Asia and Latin America.

Readers with deeper involvement in HIV/AIDS might notice certain gaps and imbalances in this book. Research and development of microbicides, immune assays or other technological advances for prevention and treatment merit only a few mentions, compared to a 17-page review of vaccines. Social and economic factors of vulnerability to HIV infection and AIDS get greater attention than factors of HIV epidemiology and disease environment. Just one page is dedicated to global efforts to mobilize the non-pharmaceutical business sector and little is said about faith-based efforts against AIDS.

Like Women, AIDS, and Activism, this book is likely to be a useful footnote in AIDS history, describing the norms of a group of U.S. AIDS activists in 2003. Foundations that currently make HIV/AIDS grants—and foundations considering doing so—will find this book heartening.

Invest the $20 for this book, use it to find renewed optimism and arguments for an HIV/AIDS effort and then invest in the response against AIDS. Ultimately, history will leave us no choice.

Sam Avrett (savrett@earthlink.net) is a New Yorker living with HIV/AIDS and working as a consultant for a range of AIDS organizations, including Funders Concerned About AIDS, Open Society Institute and the South Africa-based Treatment Action Campaign.