Book-Blogging: Quick Thoughts on Mountains Beyond Mountains

Mountains Beyond Mountains

Paul Farmer is many things to many people: white savior, focused, self-righteous, genius, myopic, magnanimous, selfish, God, human. Parsing the man from the myth, the accolades, and the criticism isn’t easy, but Mountains Beyond Mountains, by Tracy Kidder, provides a fair – if a bit fawning – accounting of The Paul Farmer Story. Overall, this is an excellent book well worth reading; I found myself ardently debating the interrelated issue of cost-effectiveness and treatment vs. prevention as I read it, and it had an effect on the way I view the issue.

By now, most development-minded folks know the basics. Farmer, a bright child of the bayou and the house-boat, attended Duke University, where he had his first run-in with real wealth (in the students) and inequality (the Haitian immigrants doing migrant work). In Haiti, he found a country desperately in need, and went there on a quest to understand the ways in which he could help.

He split time between Harvard Medical School and Haiti – with Kidder pointing out that this was OK because he still received some of the best grades – and founded Partners in Health (PIH) with Jim Yong Kim (now the president of the World Bank) and Ophelia Dahl. They opened Zanmi Lasante in Cange – an oasis of medical care in an area of great suffering – and, bit by bit, put Farmer’s conception of faith –  “liberation theology” — into practice. Functionally, this meant homing in on the suffering of the worst off, which, in Haiti, comprised most of the population; Jean-Bertrand Aristide, a man who would become President (then an exile, then President again, then an exile again) also practiced this view.

PIH expanded into the slums outside Lima, Peru, where it found a large population infected with Multi-Drug Resistant (MDR) tuberculosis. It had an extremely difficult time convincing the Peruvian government to act – at that time, treatment of MDR with second-line drugs wasn’t indicated by the World Health Organization (WHO) – but curing the formerly-incurable brought a warming of relations.

Success in Peru and Haiti gave PIH exposure, and, with funds from the newly-formed Global Fund to Fight AIDS, Tuberculosis, and Malaria, it took on addition work in Chiapas, Mexico, and prisons in Russia. His work in these countries, in America (at Brigham and Women’s in Boston), and his increasingly global celebrity conspired to pull Farmer away from Haiti, something that clearly pained him.

Mountains Beyond Mountains also did an excellent job of illuminating the treatment vs. prevention debate, and provided a perspective that I learned a lot from. It’s well-established that prevention is cheaper that treatment when it comes to the global scourges of AIDS, tuberculosis, and malaria; given $100,000, more lives will be saved (or more QALYs or DALYs will be gained, whatever your frame of reference) by preventing the next person from getting the disease than by curing one who already has it. But Western society finds it repugnant to refuse to cure a patient with AIDS or TB simply because he/she already acquired the disease; we know how to treat/cure it, after all. And, like Kim points out in the book, it’s sometimes said that it is too expensive to cure a MDR TB patient in Peru, but that same patient in New York would be put on second-line drugs immediately.

And so there’s this ever-present tension between the “starfish savers” and “technocrat robot accountants,” as the two basic sides can facetiously think of each other during long, Tusker-filled discussions. Do we accept that some will die for the sake of the “greater good,” or do we spend precious dollars on treatment when those same dollars could alleviate more suffering via preventative measures.

Usually, I lean much more towards the technocratic, pragmatic end. And I see that side clearly – from a fixed dollars, fixed treatment/prevention ratio perspective, they’re absolutely correct that more suffering can be prevented than treated. Ironically, though, I think the technocratic side suffers from present bias in its forward-looking view, and doesn’t contend with what’s possible.

Even if treatment stayed significantly more expensive than prevention, it may still be acceptable to treat now, with the understanding that some will become sick whose illness could have been prevented; the history of science and technology has shown that prices for pharmaceuticals and medical procedures decrease over time, and technological progress is on an ever-upward trek. It’s quite possible that the means and the technology to treat/cure will be more prevalent, and cheaper, in the future. Relegating the already-infected to early graves – when we know how to cure them – reeks of forward thinking gone wrong. This is, to be sure, a strange argument to make; let them get sick now because we can (probably) treat them in the future!

But we may not need t get to that point; in PIH’s history, we can see a partial solution to the debate. When Farmer and Kim started treating four-drug MDR-TB in Peru, the cost per treatment was $15,000; later, it would fall to $1,500.This occurred because Kim lobbied the WHO to put second-line TB drugs on its essential drug list (an annex, actually), which incented generic drug manufacturers to produce the in-demand drugs, which created competition and economies of scale. Kim rejected the constraints he faced and changed the game.

This isn’t a perfect solution – treatment is still going to be more expensive than prevention – but the mechanism to make treatment and prevention acceptable is quite clear: use market forces when it is advantageous to do so. Crucially, reducing the treatment cost allows our innate moral desire – to save a life if we can – to act in concert with our pragmatic needs for equitable and wise distribution.

All in all, a great book that is well worth a read.

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