Update January 24, 2010: In this post about the Tracy Kidder's book "Mountains Upon Mountains" and the MDR-TB story, we didn't talk about Haiti, where Paul Farmer began treating patients while in medical school at Harvard. There, Farmer met Ophelia Dahl, and together they started PIH with Jim Yong Kim. "Mountains Upon Mountains" tells the story of how they built the treatment facility in Haiti. The recent earthquake in Haiti is devastating and the work is not done for Haitians when the tragedy disappears from the headline news. There are many excellent agencies working in Haiti, but here's a link to the Partner's In Health page on Haiti. Remember Haiti -- even after the earthquake.
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I read Tracy Kidder's "Mountains Upon Mountains" last fall, as did many freshman college classes in the U.S. I'm not a college freshman, but I still found it a hopeful book, worth reading as antidote to ennui about the politics of healthcare or the environment, as a salve for cynicism about human nature or the media (perhaps by the end you won't need a goofy picture some fluffy, web-ubiquitous kitten), to remember where international public health was decades ago, or just because.
In Chapter 18, Kidder describes Partners in Health's (PIH) program in Peru to manage multi-drug resistance (MDR)tuberculosis (TB). By the late 1990's PIH's program, originally a trial, had decreased MDR-TB by 85%, curing the sickest patients.
The story is familiar now, perhaps legend, but still worth retelling. MDR-TB had been considered not worth treating in that patient population until PIH's persistence in Peru. Then (and now), the most successful treatment strategy was Directly Observed Treatment Short-Course (DOTS), which makes patients take first-line TB medicines under the eyes of doctor or healthcare worker, thus reducing non-compliance and risks of antibiotic resistance. While highly successful, DOTS didn't cure the MDR cases cropping up in Peru, where patients were dying regardless of medications they had or hadn't taken.
Paul Farmer and PIH's goal had always been to work towards health equity, to assure that people in poor parts of the world got comparable care to people in Boston. With MDR-TB, the PIH challenge became to convince global public health agencies, the TB community, and funders that these patients should be treated, at a time when the dominant public health paradigm dictated treating the greatest number of people with a limited pie of dollars. The PIH success in Peru helped their argument. But the expensive MDR program that PIH employed to cure patients still didn't make sense in public health circles because the cost of treating MDR-TB - to put it bluntly: didn't justify the lives saved.
PIH worked on the TB community, convincing them that the MDR protocol --"DOTS-plus"-- was technically feasible. Concurrently they worked on pharmaceutical companies and allied with NGOs to bring the drug prices down by as much as 90% on some drugs. They also worked with private funders to raise money, and by successfully coordinating these efforts, challenged the paradigm that precluded the poor from viable healthcare. As Jim Yong Kim put it, "The only time that I hear talk of shrinking resources among people like us, among academics, is when we talk about things that have to do with poor people."
It was a longer, tougher, more complicated and convoluted fight than my few sentences illustrate, or even that Kidder's skillful multi-chapter coverage details, but PIH's plan to treat MDR-TB patients more widely than in Peru worked. DOTS-plus was endorsed by public health, recognized as effective, and funded. Now people throughout the world increasingly get treated instead of being allowed to die. Their treatment decreases the spread of TB.
The challenges never end, of course, now there's the more lethal extensively drug resistant tuberculosis, XDR-TB. But, as the story shows, insistence and the persistence saves many lives.
