The Good Doctor.

Mountains beyond Mountains 

The Quest of Dr. Paul Farmer, a Man Who Would Cure the World

Tracy Kidder 

Random House, $25.95, 317 pp.

Pathologies of Power

Health, Human Rights, and the New War on the Poor

Paul Farmer

University of California Press, $27.50, 402 pp.

The Uses of Haiti

Health, Human Rights, and the New War on the Poor

Paul Farmer

Common Courage Press, $19.95, 432 pp.

In Haiti, there seems to be no exit from poverty and political futility. One hellish pit follows another. Last March, for a second time, democratically elected president Jean-Bertrand Aristide was ousted by an armed opposition, supported, at least indirectly, by the United States. Yet again, Haitians were plunged into a maelstrom of terror and deeper deprivation.

The books reviewed here immerse the reader in what physician and reformer Paul Farmer calls Haiti's "long defeat." They recount the troubling history of Western, and especially U.S., involvement in Haiti, and the connection between poor health care and social, economic, and political violence. The books also provide an unexpected window of hope.

Tracy Kidder tells the story of Paul Farmer and his Partners in Health (PIH), the not-for-profit organization Farmer cofounded in 1987. Kidder recounts the happy adventures of young Farmer, a cradle-Catholic whiz-kid who, with his five siblings and parents, spent his childhood living in a series of less than conventional places, including a bus. Farmer is a professor of both medicine and medical anthropology at Harvard Medical School, where in 1990 he concurrently earned an MD and a PhD while commuting back and forth to Haiti. He is an attending specialist in infectious disease at Boston's Brigham and Women's Hospital, and codirects Harvard's Program in Infectious Disease and Social Change. At least, that is what he does four months of the year.

The rest of the time he works in Haiti, his home for the past twenty years. In the town of Cange, Farmer has created--nearly from scratch--a highly effective public-health system. Called Zanmi Lasante (Creole for "Partners in Health"), this oasis in one of the poorest parts of the poorest country in the Western Hemisphere serves almost two hundred thousand people annually (out of a regional population of roughly one million). It includes an ambulatory clinic, a women's clinic, a general hospital, a large Anglican church, a school, a kitchen that prepares meals for about two thousand people a day, and a center for the treatment of tuberculosis.

Zanmi Lasante is no ordinary third-world clinic: its medical outcomes are stunning. It has reduced the rate of HIV transmission from mothers to babies to 4 percent--about half the current U.S. rate. It has developed a successful, remarkably efficient approach to the treatment of tuberculosis, which kills more adult Haitians than any other disease. Whereas curing an uncomplicated case of tuberculosis costs approximately $15,000 to $20,000 per patient in the United States, Zanmi Lasante spends about $150-$200--and has not lost a patient since 1988.

But Zanmi Lasante's success extends beyond Haiti. As Kidder explains, the programs developed there by PIH have transformed even the World Health Organization's (WHO) approach to treating multi-drug-resistant tuberculosis (MDR-TB), a disease Farmer says "makes its own preferential option for the poor." In Peru, for example, Farmer and fellow PIH founder Jim Yong Kim discovered that the WHO approach to treating TB actually led to a greater resistance to first-line drugs. Second-line drugs needed to treat resistant strains were prohibitively expensive. With a characteristic "we'll figure out how to pay for it later" attitude, Kim and Farmer challenged conventional wisdom and developed a method for treating MDR-TB that led to an un-heard-of 85-percent cure rate, while simultaneously dropping the cost of second-line drugs 90 percent over two years. Like a Gospel narrative, Mountains beyond Mountains inspires hope.

Pathologies of Power is much more sobering. Writing more as a medical anthropologist than as a clinician, Farmer offers a structural analysis of the poverty and suffering he has encountered across the globe (including that of Russian prisoners with MDR-TB). He has a dual aim: to challenge human-rights advocates to recognize that social and economic rights are central to guaranteeing the rights of the poor, and to argue that public-health access is essential for insuring such rights. In so doing, Farmer provides a compelling critique of neoliberal economic policies and what he calls "the political economy of suffering."

Farmer's title encapsulates many of the book's key themes: how political and economic power are linked to the devastating scale of human suffering across the globe; and, more specifically, how this pathology relates directly to the massive health crises in the third world. These pathologies create what Farmer calls "structured risk": highly predictable patterns of violence, human-rights abuses, social and economic deprivation, and illness. This systemic violence constitutes an undeclared war on the poor.

The first part of the book, "Bearing Witness," recounts individual narratives from diverse locales--Haiti, Guantanamo Bay, Chiapas, Russian prisons. Farmer's examples provide a basis for examining issues more theoretically later in the book. He mounts scathing critiques of anthropology, public health, human rights, and medical ethics. For example, anthropologists are taken to task for ignoring the violent social structures that hamper the lives of their study subjects, focusing instead on the "primitive" aspects of their lives. Medical ethicists are faulted for failing to raise issues about the disparity in medical delivery across the global economic divide. Rigorous and extraordinarily well-documented (don't skip the footnotes), this book is worth reading simply for the epigraphs and frequent, fabulous one-liners.

Equally rigorous and well documented is Farmer's 1994 book, The Uses of Haiti. If Pathologies is sobering, The Uses of Haiti--updated and reissued in 2003 with an introduction by Noam Chomsky and a foreword by Jonathan Kozol--is grim. Farmer methodically recounts the history of Haiti, from the "discovery" of Hispaniola through the recent U.S. embargo of humanitarian aid that helped bring down the Aristide government. His objective is "to move readers to reject dominant readings of Haiti." The Western press has consistently distorted Haitian history and current events, and perpetuates potent stereotypes about Haitians which, in turn, have been used to justify U.S. policies. It is a powerful indictment of U.S. actions, and a scathing account of the effect of "market economies" on Haiti. In light of the events of March 2004, The Uses of Haiti is required reading.

These three books differ in focus but share two fundamental commitments. First, Farmer always begins from the perspective of the poor. In The Uses of Haiti, he "renarrates Haiti" from the point of view of Haitians--telling the story in a way it is seldom told. In Pathologies of Power, his analysis begins with the actual people with and for whom he has worked. Kidder's book recounts how Farmer's success in Haiti stems from his consistent manner of first asking the Haitians what they need, developing a network of local Haitian community health workers, and then listening to and responding to their analyses and recommendations. Farmer notes that Zanmi Lasante's 100-percent success rate in treating TB resulted from heeding the advice of Haitian community health workers rather than health-care professionals.

This approach or "methodology" draws its inspiration from liberation theology, which has shaped Farmer's life and work. In Mountains beyond Mountains, Kidder asks how Farmer's work in Haiti led to his work with Russian prisoners. The answer is quite simple: "Prisoners were part of PIH's special constituency--the Gospels said so; you could look it up in Matthew 25," Farmer responds.

Farmer was raised Catholic but did not find his American Catholic experience terribly compelling. As an undergraduate at Duke, he discovered liberation theology and what he considered a viable form of Christianity. This led him to migrant labor camps, where he met nuns and others who were championing Haitian migrant farm workers, and finally to Haiti, where, Kidder writes, the essence of liberation theology came alive for him. "Almost all the peasants he was meeting shared a belief that seemed like a distillation of liberation theology .... He felt drawn back to Catholicism now, not by his own belief but in sympathy with theirs, as an act of what he'd call 'solidarity.'" Church connections have helped provide an infrastructure for much of Farmer's work.

Although Farmer identifies his work as that of a clinician-anthropologist, it is difficult not to read Pathologies of Power without a sense of its theology. Not only does Farmer devote an entire chapter to liberation theology and its implications for medicine and health policies, his language is deeply scriptural.

Farmer's story, then, is not simply that of an individual but of a community (in Pathologies, he thanks no less than 185 people in the acknowledgements). His larger work challenges us to begin living the story of the gospel, even if it means starting small--but necessarily by joining others in fighting the long defeat.

M. Therese Lysaught teaches in the religious studies department at the University of Dayton