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Thursday, May 26, 2011

The Cold That Won't Quit



     We all get colds once in a while. Usually we suffer a couple of days of runny nose, sneezing, the feeling of congestion, and the feeling of being a little run down. Most (but not all) colds are done in 72 hours, and we're used to dealing with them. Colds are caused by viruses and do not require antibiotics. The problem is that many colds lead to secondary complications, what we call a bacterial superinfection. Examples of such superinfection include ear infections (otitis media), strep throat, sinus infection (sinusitis), goopy eyes (conjunctivitis), chest cough (bronchitis), or even pneumonia. These infections happen because the preceding viral infection reduced our immunity and gave these germs a better chance to set up shop in one of our cranial cavities or airway passages. These infections are the reason most patients come to see a doctor after a cold. Most of these will respond to an antibiotic. The usual practice is for a doctor to prescribe an antibiotic for 7 days--usually something like amoxicillin, sulfa, or azithromycin. We are now increasingly realizing that most of these infections do not even require a full 7-days of antibiotics. For most symptoms will resolve in 2-3 days. 

     The problem I want to talk about today are the exceptional cases--the ones where symptoms have not resolved even after a full 7-days. What do you do then? 

     There are 3 main patterns to these exceptional cases:

  1. An ear infection that does not resolve. Most often this is caused by retained fluid in the ear. Occasionally, it is a problem because the initial antibiotic used does not cover whatever particular germ was in the ear fluid. The standard approach to this problem is to undertake another round of antibiotics with a different, stronger antibiotic. Occasionally, if the problem is clearly due to fluid in the ear, we will prescribe some form of cortisone, either as a nasal spray like Flonase, or as cortisone pills (prednisone) for 7 to 14 days. Ultimately, failure of symptoms to resolve with this treatment will lead to a referral to an Ear-Nose-Throat (ENT) specialist. Usually, they will repeat this same kind of therapy for another round, and, if that doesn't work, they will offer a surgical option like placing tubes in the ears. It is quite rare that an adult would need this kind of surgery, but occasionally, especially among persons with severe allergies, it is appropriate.
  2. Sinus infections that do not resolve. Sinuses can be notoriously difficult to clear up. In fact, many patients, especially those with allergies, will have repeated bouts of sinus infections during a year. Each episode of infection tends to make it more difficult to clear up the next one. In recent years, the experts have generally recommended delaying antibiotic therapy for at least a week to give it a chance to resolve on its own. If symptoms of face pressure or pain or severe congestion persist for over a week, then amoxicillin is the most often prescribed antibiotic. The exception is when you have previously been treated with amoxicillin for some other infection within the last 2-3 months. In this case, the high-strength form of amoxicillin is used--i.e., Augmentin, which is significantly more potent, but also more likely to cause intestinal upset and diarrhea. For persons with chronic, frequently recurring sinusitis, treatment needs to be for longer periods of time--for 14-21 days. Failure of symptoms of sinusitis to resolve is the most common good reason for using one course of antibiotics right after another and perhaps even for a third time. Failure to resolve with a third course of antibiotics will result in a referral to an Ear Nose Throat specialist and x-rays of the sinuses or a CT scan.
  3. Chest infections that do not resolve. Here the primary symptom is cough, often associated with a sensation of chest tightness, and occasionally even by frank wheezing.  One practical tip to remember is that there are basically two kinds of cough: (1) the cough due to a tickle in the throat or drainage in the back of your throat from your nose or sinuses. This usually feels like a scratchy throat and is accompanied by a constant upper airway cough to clear the throat; (2) the second type of cough is the deep in the chest cough. It will be very obvious that the cough is coming from deep in the chest, often with production of yellow-greenish phlegm. This combination of symptoms (cough and yellow-green sputum) is indicative of the common diagnosis of acute bronchitis     The experts are still arguing about what is the best treatment for acute bronchitis, and the majority trend is to believe that antibiotics are usually not necessary for simple, acute sinusitis where symptoms have only been present for 1-7 days. Experts differ on whether you should wait for 7 or 14 days to start antibiotic treatment. I have reviewed all the major bronchitis studies myself and I reach a slightly different conclusion. Basically there are about a dozen major studies (and several studies studying these studies), and the truth is that they split right down the middle on whether antibiotics help the resolution of acute bronchitis symptoms or not. So it's a toss up. It is perfectly reasonable to treat these symptoms with antibiotics, and it is also perfectly reasonable not to treat them. I usually let patients make this decision. My personal rule of thumb is to consider antibiotics if symptoms have persisted for more than 3 days, and definitely to recommend them if they last for 5 days or more. I usually prescribe either amoxicillin or azithromycin for these infections. Usually 5 days of antibiotics is enough.
               When cough is associated with more symptoms than just purulent sputum and chest tightness, the other diagnosis that must be consider is pneumonia. Pneumonia is basically just an extension of bronchitis as the germs move all the way down the airways and actually begin to enter into the lung tissue (alveoli) itself. Pneumonia is accompanied by much more severe symptoms--usually including high fever, shaking chills, and shortness of breath, often severe fatigue of just a feeling of being really sick. In fact, just the combination of acute cough, high fever, and shortness of breath (rapid breathing) is enough to make a diagnosis of pneumonia; you don't even need a chest x-ray. There is a variation of pneumonia, however, that is more subtle; in these cases it can present with just a cough, but no fever, and usually with a sense of malaise. This kind of pneumonia is often referred to as "walking pneumonia" or an atypical pneumonia. Pneumonia, of all types, is treated with amoxicillin, azithromycin, or Levaquin (or their equivalents) for at least 7 days. Symptoms usually improve dramatically after 48 hours.

    So the real issue for today's article is what do you do if your cold is still causing severe chest cough, tightness, and/or wheezing one to two weeks after onset? I am assuming that you have already made one visit to the doctor and that appropriate treatment with antibiotics was undertaken if there were any signs of bacterial infection. There are basically two courses to follow here:
  1. If the doctor told you that initially all you had was a viral infection and did not prescribe antibiotics, then you may in the mean time have acquired a secondary bacterial infection (otitis media, sinusitis, or bronchitis). The appropriate plan for this is antibiotic treatment for 5 to 7 days with a common antibiotic like amoxicillin and treatment for the most severe symptoms--like a decongestant for severe runny nose or nasal obstruction, a cough syrup for severe cough, and/or asthma medications (an inhaler usually) for wheezing or tightness. In this scenario, symptoms usually resolve quickly and you're done.
  2. The other scenario is the classic prototype of the cold that just won't quit. After your previous treatments, your cough is improving some, you're no longer coughing up as much yellow or green phlegm, you don't have any fever or chills, but you still feel tight in your chest, may have occasionally whistling or wheezing sounds in your chest, and tend to have bad spasms of coughing that make you really breathless and leave you feeling weak with aching ribs. The first thing to do in this scenario is to take a chest x-ray to make sure than no atypical lung infection (pneumonia) has been overlooked, and to make sure there is nothing else there that could cause such symptoms (like a lung mass in smokers). If the chest x-ray is negative, then the most common cause of this scenario is asthma. In many cases there may be a past history of asthma in childhood. For many, there is no history of asthma, but severe viral infections (and bacterial infections) can trigger new asthma (usually short-lived) even in a patient who has never had it before. In others there is a history of smoking. Smokers are the one group of patients who should expect to have recurrent episodes of the "cold that won't quit" since smoking so damages the airways. The treatments for asthma are an inhaler (albuterol, 2 puffs every 4 to 6 hours for coughing spells, chest tightness, and/or wheezing). If this is tried and does not bring enough relief, the next step is cortisone, usually by pills, usually in a dose of 40 mg of prednisone (or equivalent) for 7 to 14 days. This should take care of the asthmatic part of any infection that won't quit. For the rare patient, who is not better even after this, I will prescribe Advair; this is a dry-powder inhaler that combines a long-acting form of albuterol with a long-acting cortisone. It is probably the most effective medication on the market right now for persistent symptoms due to bronchospasm and asthma. Note that once you have had one course of antibiotics for a chest cough and the x-ray is negative, there is no real point in taking any more antibiotics.
     Sometimes there is still a nagging cough and a general feeling of fatigue and just not feeling well. This is very distressing to patients, and they generally want the doctor to do something and to do it quickly. If we have already run through the steps described above, there is not much else to do. For some infections, and certainly at this stage of the cold that won't quit, you just have to wait it out. It will go away. About once in every 5 years most adults will get a severe infection like this that seemed to start as an ordinary cold, but it keeps them feeling sick and miserable for as long as one to two months. If you have run through the protocol above, there is nothing else to do. You just wait. After a while, simple time will cure most everything. While you're waiting to feel better, just ask yourself if you've had any other cold this bad in recent years. If you haven't had one like this in the last 5 years, then you can tell yourself that everything is normal, and you've paid your dues for another 5 years.

Thursday, May 19, 2011

Hanging on to Your Feet!

The View from the Office

Hanging on to Your Feet!

    Now this article will only apply directly to relatively few readers. I would nonetheless urge you all to read it (it is brief and with pictures) because undoubtedly you know people--friends and relatives--who have problems like this with their feet. You can be very helpful in their care. The biggest problem for these persons and their feet is the natural and understandable urge to put off seeking intensive medical care. But that is exactly what is needed. And in so many cases it is the prodding of friends and relatives (especially spouses, if they have them) that finally brings them to the office.
     The problem with the foot disorders that I am talking about is that, if you do not take early and aggressive care of ulcers in your feet, you are at risk for losing them--that is an amputation, which is, of course, a disaster.
     The people who tend to get the kinds of foot problems I illustrate below are those primarily with one of two conditions (or perhaps both at the same time)--diabetes and/or peripheral vascular disease. Take a look at 3 different variations on the same theme.

Figure 1: Early severe heel blister which often turns into an ulcer. Get in to see your physician as soon as possible when you see this in order to prevent the problem seen in Figure 2.

Figure 2: Evolving heel ulcer: This will be difficult to heal at this point.

Figure 3: Severe foot ulcer over the ball of the foot. These are extremely hard to heal because they are subjected to dirty conditions and constant pressure.

Figure 4: Early gangrene of the 2nd toe. The tip of this toe clearly has to be amputated. The real problem, however, is that it is poor circulation that led to all of these ulcers. If the underlying problem with circulation is not diagnosed and treated, the patient will just continue to lose more and more of his foot until finally s/he has a below knee amputation. Below knee amputations are generally entirely preventable if patients receive the proper evaluation in these early stages of diabetic foot complications and peripheral vascular disease.

     So what happens when patients with this kind of foot problem presents to the doctor or the emergency room. The treatment that is usually focused on is antibiotics to control any related infection; these can be given either orally or intravenously in the hospital. What you have to remember is that the primary problem here is not infection; infection is only a secondary side-effect. The primary problem is inadequate circulation.
     To get these wounds to heal there are two basic steps are required
  1.  You have to surgically clean the wound and remove all excess dead tissue. The nature of the circulatory insufficiency process is that tissue gradually dies and leaves behind yellow, soupy dead tissue. This dead tissue is just a natural breeding ground for bacteria, which is how the infections get started. But remember--infection is NOT the primary problem. All the antibiotics in the world won't do any good unless you remove the dead tissue, which creates the seeds for continuing infection. The problem here is that 99% of all primary care physicians (including most Emergency Physicians) have no specific training in the cleaning (surgical debridement) of these wounds, which is so crucial to care. You really want to take these wounds to someone with a lot of experience and expertise. In most major hospitals, the doctor who takes care of these wounds is a VASCULAR SPECIALIST. Thus, effective care of these kinds of wounds requires evaluation by a vascular specialist. In our area I have already had good experience with two vascular specialists in Reno, Dr. Ahktar and Dr. Desai; in Truckee, we have Dr. Kitz.
  2. You have to perform an evaluation of the circulation to the feet. This process starts with a measurement of your blood pressure in the ankle comparing it to your blood pressure in the arm--a measurement that is called the "Ankle-Brachial Index". If the blood pressure in the ankle is less than 90% of the blood pressure in the arm, it is likely that there is a circulation problem. This is usually considered an indication for a vascular specialist to perform an "angiogram" (injecting dye into the arteries in the leg to see where the flow is good and where it is not). There are a number of highly effective procedures to restore circulation to areas of the leg with impaired blood flow. These include balloon angioplasty--stretching the artery out with an inflated balloon to improve flow; a kind of "roto-rooter" procedure where a special instrument is passed through a catheter in your artery that chops up the plaque that is blocking circulation. These are the two quick and simple procedures. There are a number of full surgical bypass approaches to the problem where the arteries are reconnected in a special way to bypass the area of worst obstruction.  

Bottom LIne: Foot ulcers tend to occur in patients with diabetes and/or peripheral vascular disease. If not adequately treated initially, they tend to progress to a need for amputation over many years. These ulcers can NOT be treated just with antibiotics and dressings. They require surgical wound cleaning (debridement) and vascular evaluation. Good healing does not take place without an adequate circulation.  Don't ever ignore this kind of problem or resort to just hoping it will go away. Get the full evaluation early in order to prevent having similar ulcerations and infections occurring again and again over many years.

Thursday, May 12, 2011

Taking Care of Your Health in Hard Economic Times

The View from the Office

Taking Care of Your Health in Hard Economic Times

Sad to say, in America it is commonplace not to have any health insurance. Yet as we all age we gradually accrue more health conditions needing chronic attention and more acute health problems. For citizens without health insurance taking care of yourself is very challenging since health care has become so expensive. But there are things you can do to stay healthy and minimize the impact on your budget. Remember—taking care of things now saves you a lot of money over the long-term.

Step 1: Work on developing a healthy lifestyle.

            If you smoke, start cutting down immediately. This is the fastest and healthiest way to save money. If you need help, call 1-800-NO-BUTTS.  Help there is free, and, if you complete the telephone program for smoking cessation, they will pay for your medication, if you need it to quit smoking. The first and most important step for any health program is to stop smoking—and then to help those you love stop smoking and help your kids never to start.
            Eat right. The simplest way to do this is to focus on eating 5 servings of fruits or vegetables a day. This is a healthy source of vitamins, fiber, and just good general eating habits. The more fruits and vegetables you eat, the less junk you eat. If you reduce your red meat intake to no more than 4 ounces (a portion size about the size of a deck of cards), you save money, which will help pay for the fruits and vegetables. Studies have shown that when you make these kinds of changes in your diet at the same time, the net effect on your pocketbook is a wash.
            Focus on ways to relax and be religious about attending to whatever relaxes you. Many people feel guilty if they focus on doing things to relax when economic times are tough or they are out of work, but, in fact, it is during these times that it makes the most sense. Being out of work or otherwise on a tight budget or having health problems without health insurance are sources of extreme stress. These are usually the worst of times. It is exactly during times like these that you benefit the most by taking some time out of the day to just relax, unwind, let it all go. Your body needs this. And it has a very helpful effect on chronic diseases like hypertension, diabetes, and depression.
            When things are tight is also an ideal time to work on your weight. Step one is to know your BMI (body mass index). To calculate this you just need to know your height and weight. If you have a computer, there are lots of free BMI calculators on the Internet. If you don’t have a computer, stop by the library, and they can help you do this calculation. For your weight and BMI there is a magic number30. If you’re below that, you are at a perfectly healthy weight for your height. If you are above that, you have some work to do. Tough economic times are a good time to work on weight—both because you have more time and because the money you save from eating less will really make a difference.  For most of us, BMIs over 30 are due to snacking or junk food on a long-term basis. This is a great time to stop this. You will appreciate the health benefits (more energy, less fatigue, more exercise tolerance) right away if you make a change. All chronic diseases will be improved by losing weight—particularly hypertension, diabetes, and depression.
            Finally, such times are a great time to get back to exercise. Usually these periods are periods where you have more time to spare. Your exercise program does not need to be more vigorous than brisk walks once or twice a day. Your goal is to get 150 minutes of exercise in each week. The more the better. Exercise has been shown to have an equivalent effect to treatment with standard anti-depressant medications for people with depression. You can’t afford not to be exercising.
            A healthy lifestyle is your first line of defense against having health problems at all times of life.

Step 2: But what if you have some chronic conditions already, how do you take care of those during tight times?

Let’s take a look at some of the most common chronic medical problems—hypertension, high cholesterol (hyperlipidemia), and diabetes. For these conditions you need to be able to track certain basic numbers (lab tests) and to take certain medications.

Hypertension: You can have your blood pressure checked for free at the drugstore or many supermarkets. There are no regular blood tests that you absolutely need to have done, but, if you can, it is good to check your cholesterol and your kidney function once a year. You can get all of the most common blood pressure medications (generics) for just $10 for a 3-month supply at Wal-Mart or Target or other stores with this special drug pricing program.

Hyperlipidemia: For this you want to check your cholesterol tests at least once a year. The cheapest way to adequately measure cholesterol levels is to have a total cholesterol level done and an HDL (good) cholesterol level done. You don’t even have to be fasting for these tests. You can make all important treatment decisions, just based on these numbers. The most cost-effective way to have your cholesterol checked is to wait for the nearest health fair in your community. They often offer bargain basement prices in order to provide you with access to this important testing. We have our health fair for Portola coming upon September 10th. In addition the hospital offers specials on testing for cholesterol at various times during the year.
            During really tight economic times, you don’t necessarily need to have your cholesterol checked. If you know, for example, that several members of your family have had heart problems at an early age, then you would be better off on a cholesterol medication regardless of the test results. The same is true if you know you have multiple risk factors for heart disease, like smoking, overweight, high blood pressure, diabetes, lack of regular exercise, chronic high stress. In cases like these it is easier, cheaper, and more effective just to go to Wal-Mart (or Target, or similar programs) where they have $4 a month, $10 for 3 months prescription discounts for the most common medications. For cholesterol what you want is a statin medication like lovastatin, which these programs cover.

Diabetes: This is the most serious common disease that you might have to manage during tough economic times. It’s a challenge because there is a lot to do to take care of diabetes, and a lot of it is expensive. It is very important to take care of it well during such times in order to prevent much worse problems later. There are simpler approaches, however.
            One is to follow my ABCDEF approach:

A-Get yourself an A1c test at your local health fair or through a special with your hospital. Eastern Plumas District Hospital offers a special program to allow patients to get their A1c tests done regularly at a discounted price.

B-Check your blood pressure at your local pharmacy for free and keep it under 140/90 mm Hg.

C-Check your cholesterol through your local health fair or hospital program and keep taking your cholesterol medication through a Wal-Mart discount program for $10 for each 3 month period.

D-Check your kidney function once a year. The basic panel you can get at a health fair will do this for you.

E-Have an eye check once a year or every other year. Often, after the first check, your doctor will tell you they don’t need to see you again for 2-3 years.

F-Check your feet. You can do this yourself. Check for any areas of numbness or tingling. Check for any breaks in the skin or severe fungus infection of the skin or nails. If you have bad fungus, use the over-the-counter Lamisil 1% cream twice a day for the skin (it won’t help with the nails).

This simple approach will keep your diabetes in very good control until you get your health insurance back and can have the full check-up.

To keep up with your medications, the Wal-Mart program has most of the common diabetes medicines (except insulin) on their $10 for a 3-month supply list. If you are currently on a fancy, brand name diabetes medicine, change to a $10 per 3-month generic. Your results will be about the same with really substantial cost savings.

Here is a link to the full list of drugs that Wal-Mart and Target cover at these reduced prices:  [link]    Other plans:

Some other conditions:

Depression:  This is a very important condition to take care of during tough economic times, which are likely to make depression worse. Of course, the place to start is with the 5-steps for a healthy lifestyle as described above. Exercise is particularly important for people with depression; it is as effective as most depression medications. If you need medications, Wal-Mart covers the full range of generics for the treatment of depression for just $10 for 90 days. Some of the Wal-Mart antidepressant medications can also be used to treat insomnia, if that is a problem.

Arthritis:  A healthy lifestyle is going to help this a lot. Wal-Mart has most of the common generic anti-inflammatories for discount prices, but since these are available over-the-counter, places like Costco often offer the cheapest source of medication over the long-term.

Common Infections: If you get an acute cold or skin infection or other common infection (sinuses, ear infections, bronchitis, etc.) while you are without adequate health insurance, your doctor can work with you to find low cost ways to manage them. If you have had a general check-in with your doctor recently and have explained your situation [See below.], it should be no problem just to call your doctor, explain your symptoms, and get reasonable treatment for the most common and probable conditions. If any special evaluation is required, your doctor will let you know, but usually ear infections, sinus infections, bronchitis, simple skin infections, and bladder infections can all be managed over the phone with a prescription for common antibiotics. If the initial round of antibiotics doesn’t work, however, then it will be necessary to come in for a visit. Most doctors will work with you in this way, but you have to have had a check in visit to explain the situation, review your overall health status, and make a general plan. Often this “check-in” visit as described below, will be the best investment you can make.

Other conditions unique to you and your situation: Don’t forget your doctor. Your doctor will often not be aware of your financial situation or lack of insurance unless you tell him/her. If you do tell, most of us are very willing to work with you to see that you get the care you need when you can’t afford regular visits or testing. What I would suggest, if you are just entering a period of economic uncertainty, is to make an appointment with your doctor to discuss the situation and share your concerns. Together you can make a cost-effective plan for how to manage your conditions with less frequent check-ups or testing. I know that, if I have such an initial meeting with a patient, I am very willing to manage most chronic conditions with just telephone consultations for extended follow-up with no charge and refills of medication by phone. If you stay in touch with your doctor, then s/he can tell you when it is important that you actually come in for a visit or for testing.
            You should also be aware that if you need any special medications that are not on the Wal-Mart or Target discount list, there are ways of getting help with the cost of these prescriptions for most drugs. Sarah in the Eastern Plumas District Hospital business office can provide you with more information about these programs.

            The bottom line is that it is very possible to take care of yourself when you don’t have the benefit of a full health insurance program. Let’s talk about it and see what we can do for you.

Friday, May 6, 2011

Great Reading: Mountains Beyond Mountains


Tracy Kidder Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World.  2003

    Tracy Kidder met Paul Farmer when Paul was 35. Farmer had graduated Harvard Medical School, also with a PhD in anthropology from Harvard. Worked in Boston 4 months of the year, living in a church rectory in a poor neighborhood, worked the rest of the year without pay in Haiti. Saw himself as a poor people’s doctor and an action kind of guy. About medicine, “I don=t know why everybody isn’t excited by it.”
    He claimed as his mentor, Rudolf Virchow, the principle architect of the foundations of scientific medicine--the first to propose that the basic units of biological life were self-reproducing cells, and that the study of disease should focus on changes in the cell. Virchow made important contributions in oncology and parasitology, coined at least fifty medical terms still in use today, defined the pathophysiology of trichinosis, led a successful campaign for compulsory meat inspection in Germany, designed a sewage system for Berlin that transformed it from a fetid sty into one of Europe’s healthiest cities, found a nursing school and hospitals, was a practicing archaeologist who played a role with Schliemann in discovering Troy, helped to define the field of medical anthropology, was a teacher, physician, and politician (so effective that Bismarck once challenged him to a duel). Most important to Farmer was Virchow’s emphasis on a fundamental law of epidemiology: “If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life.” For this his prescription was “full and unlimited democracy.” Among other apt conclusions, Virchow had stated: “Medicine is a social science, and politics is nothing but medicine on a large scale…It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation…Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community...Physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.”
    Tracy Kidder started out with the attitude, “The world is full of miserable places. One way of living comfortably is not to think about them or, when you do, to send money.”
    Haiti has the distinction of being Latin America’s first independent nation and the world’s first black republic. Haiti is the poorest country in the Western Hemisphere. Per capita incomes are about one America dollar a day. It has the worst health statistics in the Western world. 25% of Haitians die before they reach 40.
    Paul did his main work in Cange in central Haiti, which he first encountered in 1983, in a hospital that he built known as Zanmi Lasante (“Partners in Health”). Patients were supposed to pay user fees, about 80 cents per visit. As the policy was enforced, every patient had to pay the eighty cents, except for women and children, the destitute, and anyone who was seriously ill. And no one, Farmer ruled, could be turned away. A million peasant farmers relied on Zanmi Lasante. A hundred thousand lived in its catchment area, which was served by 70 community health workers. Seven doctors worked there. Zanmi Lasante had built schools and houses and communal sanitation and water systems throughout its catchment area. It had vaccinated all the children, and had greatly reduced both local malnutrition and infant mortality. It had launched programs for women’s literacy and for the prevention of AIDS; in its catchment area it had reduced the rate of HIV transmission from mothers to babies to 4%, about half the current rate in the US. In Haiti, tuberculosis still killed more adults than any other disease, but no one in Zanmi Lasante’s catchment area had died from it since 1988. The money came from a small public charity set up by Farmer called “Partners in Health” with headquarters in Boston. It cost about $150 to $200 to cure an uncomplicated case of TB (vs. about $15,000 to $20,000 in the US).
    Mr. Kidder noted that his local hospital in Massachusetts was treating about 175,000 patients a year and had an annual operating budget of $60 million. In 1999 Zanmi Lasante treated roughly the same number of people for about $1.5 million.
Farmer’s lifestyle involved about 4 hours of sleep a night, no investment portfolio (his paycheck went straight to PIH), no family around, no electricity, no hot water, and lots of unsavory food, what he called “the fifth food group.” Of his work he says, “I feel ambivalent abut selling my services in a world where some can’t buy them. You can feel ambivalent about that, because you should feel ambivalent. Comma.” [“Comma” is a Farmerism that is short for “asshole.”]

    Dr. Farmer speaks of “WLs”—White liberals. “I love WLs, love ‘em to death. They’re on our side. But WLs think all the world’s problems can be fixed without any cost to themselves. We don’t believe that. There’s a lot to be said for sacrifice, remorse, even pity. It’s what separates us from roaches.”
    When he first came to Cange he started his work with a simple needs assessment. He enlisted five Haitians and went from hut to hut through Cange and two neighboring villages tallying up the numbers of families, recent births and deaths, and the apparent causes of morbidity and mortality. He then planned the first line of defense--vaccination programs, protected water supplies and sanitation--and at the heart of the defenses, a cadre of people from the villages trained to administer medicines and give classes on health, to treat minor ailments and recognize the symptoms of grave ones like TB, malaria, typhoid. Then he planned a project for women’s gynecological services, health education, and family planning to reduce local maternal mortality, which led to so many subsequent health and economic disasters in families. The second line of defense was the hospital.
As he undertook the treatment of TB and noted his initially poor results, he designed a study. During the study, each group of TB patients got free treatment, but one group got other services as well, including regular visits from community health workers and small monthly cash stipends for food and child care and transportation to Cange. Of the patients who received only free medicine, a mere 48% were cured. By contrast, everyone in the group that received the cash stipends ($5 per month) and other services made a full recovery. Whether a patient believed that TB came from germs or voodoo made no difference. This study became for him a command to worry more about his patients’ material circumstances than about their beliefs. No patient has died of TB at Zanmi Lasante in 12 years.
    As a footnote, Kidder notes that one of the major causes of the poverty in Cange and Zanmi Lasante was the Peligre Dam in the Lac de Peligre. This project was planned by the US Army Corps of Engineers and built by corporations in the mid-1950s during the reign of one of Haiti’s American-supported dictators with money from the US Export-Import Bank. It was advertised as “a development project.” Under the rubric of improved irrigation and power generation land was taken from peasants (now under water) without compensation while agribusinesses downstream, mostly American-owned back then, benefited. The wealthy in Port-au-Prince received electricity. The peasants received neither irrigation nor electricity.
When asked, “How can you expect others to replicate what you’re doing here?”, he responds, “Fuck you.” Then adds, “The objective is to inculcate in the doctors and nurses the spirit to dedicate themselves to the patients, and especially to having an outcome-oriented view of TB...In other words, ‘Fuck you.’...Do you know what ‘appropriate technology’ means? It means good things for rich people and shit for the poor.”
Farmer got a break o make his vision come into being. He found a like-minded, retired Bostonian, who had run a construction company and done well, and who now wanted to see his money used for work like this.
AIDS came to Cange about two years after Farmer arrived in 1985. One of the things that Farmer is incensed about was the action of the CDC in formally classifying Haitian origin as a risk factor for AIDS. When Farmer did his own research, which he later published, he found that, in fact, AIDS came to Haiti from the US via tourists who mingled with prostitutes in Port Au Prince.

    At the end of the 20th century TB was still killing about 2 million people a yea--more adults than any other infectious disease except for AIDS; TB shared a ‘noxious synergy’ with AIDS. In poor countries, TB was the most common proximate cause of death among people who died with AIDS. About 2 billion people on earth, one-third of all humanity, have TB bacilli in their bodies. It turns into clinical illness in about 10% of those infected. Each year about 2 million people die from TB. The new standard of treatment for TB in the developing world was with standard first-line drugs in a program of directly observed treatment (DOTS). The new problem in TB control and in Haiti was multi-drug resistant TB (MDR). About 750,000 people around the world now have this disease.
    Unfortunately, the official WHO DOTS manual contained the following statement: “In settings of resource constraint, it is necessary for rational resource allocation to prioritize TB treatment categories according to the cost-effectiveness of treatment of each category...In developing countries, people with multi-drug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries.” This was unacceptable to Farmer. He noted with some annoyance that when there was an outbreak of multi-drug resistant TB in New York City in the late 1980s, centered in prisons, homeless shelters, and public hospitals, no one took this attitude. About a billion dollars were spent and effectively ended the outbreak. In 1993, at the best US center for this disease, National Jewish in Denver, only about 60% of cases could be cured and at a cost of up to $250,000 per case. There seemed no solution to the cost problem. Farmer recruited some allies and went on the international lecture circuit giving speeches citing and rebutting WHO policy. WHO stated that “MDR-TB is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease.” To which he responded, “But is treating MDR-TB really too expensive? Even if TB control is to be governed by considerations of cost-effectiveness, it s should be easy to show that failure to diagnose and treat MDR-TB is what is really costly. Consider the case of the family in Texas in which one member had exposed nine others to MDR. Care for these ten persons alone exceeded one million dollars.”
    “Myth number two: Some people think DOTS alone will stop outbreaks of MDR. This is nonsense. What will happen if programs treat drug-susceptible TB successfully and let MDR flourish? Transmission of MDR will continue, and even where MDR cases are now a tiny percentage of all TB cases, their relative importance will grow. Moreover, DOTS will amplify already existing drug resistance. In short, failure looms for programs now deemed success stories.” His audience often responded to his talk as “provocative,” to which he responds: “What’s provocative. I just said we should treat sick people, if we have the technology...I remember signing an oath to assist the patient and do him no harm. I don’t really remember signing that I would do it in a cost-effective way. 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...Strictly speaking, all resources everywhere are limited, but they’re less limited now than ever before in human history. Making a distinction between prevention and treatment is artificial--merely an excuse for inaction.”
As Margaret Mead has stated, “Never underestimate the ability of a small group of committed individuals to change the world. Indeed, they are the only ones who ever have.” Farmer and friends found a way out of the cost dilemma. They analyzed the structural pieces of the problem. The price of a drug has little to do with either its usefulness or the costs of manufacturing it. Often, the price is high simply because only one company makes it. In the case of second-line drugs used in the treatment of MDR-TB, huge amounts of drugs are required because treatment lasts so long. Most candidates for treatment, however, have no money. Thus there is no incentive for drug companies to manufacture quantities of the drugs at “reasonable” prices. Capreomycin is one of these second-line drugs; it is manufactured exclusively by Eli Lilly. Eli Lilly was selling it for $21 a vial in Peru; the same vial in Boston, where Farmer got his supply, cost $29.90. Farmer found out that the drug cost only $8.80 in Paris, and he tried to buy some there. He was told he couldn’t. “There’s a global shortage of capreo due to an emergency in Peru.” Then Farmer encountered someone named Guido Bakker, a Dutchman in his twenties, who worked for a nonprofit company, the International Dispensary Association, IDA. It specialized in driving down the prices of essential drugs, the kinds of drugs that poor countries need most urgently. IDA tended to deal only with generic drug manufacturers. IDA got the MDR-TB drug scarcity problem some relief by teaming with Doctors Without Borders to sponsor generic production. The solution to the problem got a further boost when, after intense political lobbying, they got the WHO to add second-line TB drugs to its list of ‘essential medicines’. This acted as a major inducement to generic manufacturers to get involved. Oddly, various eminent TB experts wrote to the WHO saying that they ‘couldn’t countenance’ the elevation of second-line antibiotics to the essential drugs list. Increased generic supply gradually reduced the cost of these drugs. By the year 2000, projects working with MDR TB paid 95% less for four of the second-line drugs than they would have in 1996, and 84% less for two others. The drugs to treat a 4-drug resistant case of MDR now cost Partners in Health/ Zanmi Lasante about $1500 instead of $15,000.

    Then there is the Cuban example. Cuba has life expectancies about the same as in the US. It has achieved control over diseases still raging in Haiti only 90 miles away. By American standards Cuban doctors lack equipment, and even by Cuban standards they are poorly paid. They are, however, well-trained, and Cuba has more of them per capita than any other country in the world--more than twice as many as the US. Everyone has access to service and even to procedures like open heart surgery. According to a study by WHO, Cuba has the world’s most equitably distributed medicine. Cuba was now in the position of exporting doctors to other needy countries. Cuba also has the lowest per capita incidence of HIV in the Western Hemisphere, and it has the most accurate HIV statistics in the world. (Testing is mandatory.) On an island of 11 million, only 2,669 tested positive as of 2000; the virus progressed to AIDS in 1,003 of these, and 653 died. Only 5 children caught HIV from their mothers, and all of those children were still alive. Because Cuba had acted quickly to clean up its blood supply, only 10 people had contracted HIV from transfusions. Yet Cuba is not a particularly rich country.
    The book concludes with a dramatic story of a boy named John. John’s official age was unrecorded, but he appeared to be about eleven or twelve. He had swellings in his neck, but they were harder than the usually fluctuant swellings of scrofula. Dr. Farmer was concerned about cancer. A PIH physician found an oncologist in Mass General who was willing to make the diagnosis for free, if they could get the tissue there. This required a biopsy that Farmer did not feel comfortable doing. A competent Haitian surgeon was willing to do the biopsy for a thousand dollars. Time for the specimen to travel to MGH resulted in a diagnosis of cancer four days later. It was nasopharyngeal carcinoma, which, if caught early, could be cured in 60-70%. It was decided that it was only practical to stage the disease and administer chemotherapy in Boston. It took a month to negotiate with MGH to do the treatment for free. John was much worse by this time. Now his legs and arms were emaciated; you could see all the bones. He had been given a tracheotomy, required regular suctioning, and was in constant pain from the masses in his neck. It was very difficult to look right at him. In fact, he was too sick to be transported by commercial airline. It was determined that a private flight would cost about $20,000. The question was, Could/should PIH/ Zanmi Lasante use their resources in this way for this patient? When this decision had to be made Farmer was on an international trip and could only be reached by e-mail. Two of his young PIH doctors had to decide what to do and whether to act without his direct involvement. The first e-mail that was sent was:
    “John’s condition is growing more tenuous. He is curious, sweet as can be, interactive with us and they would not have let him on the plane. And yet weak, weak, weak, and I fear would not survive the trip to the airport and they would not have let him on the plane. Polo [Farmer], I know this sounds crazy but he still has his fighting chance. This could still be a localized tumor with abscess tipping him over and increased mass size. I will take responsibility to pay for this flight. We are proceeding with plan while we wait to hear from you.”
    The initial response was, “Serena, honey, please consider other possibilities.”
    This was interpreted as a ‘no.’ Usually Dr. Farmer would say something like, “I trust you. Go ahead.”
Other staffers were injecting comments like, “What are we going to do if another kid like this comes to us?”
    “I'm looking at only one child, The fact that he has free care at the other end makes it excruciating,” Serena said.
    A staffer got on the computer and wrote Dr. Farmer, “You have to say yes or no.”
    The reply came, “Well, it could be worse. I’ll be there within twenty-four hours, but would not try to second-guess all of you there. Getting him on a plane is the only way to save his life, so I’m for it. In any case, his hope is in leaving Haiti, by one way or another, like many other Haitians, alas.”
John made it to MGH, but only to have the initial scans show invasion of bone and metastases through out his body. He is made comfortable, spends some hospice time with his mother in the home of a PIH staffer in Boston, and died in a few weeks.
    In reaction to observing all this, Mr. Kidder feels a need to ask Farmer, only after a decent interval, what were his thoughts on this whole case. Finally, on another 11 hour hike for a house-call, he does. “What about the case of John? What about the twenty thousand dollars that PIH spent on the medevac flight to get him out of Haiti? Not long after John died, a PIH staffer, a relatively new one, said to me that she couldn’t help thinking of all the things they could have done with that twenty thousand dollars. What is your response to that?”
Dr. Farmer responds:
    “Let me say a couple of things about this particular case, if you like. One is, remember of course that John was referred to Boston as dying of a treatable tumor, a very rare tumor. He wasn’t referred to Mass General before we knew what he had. So when he was referred, it was for free care because ha had such a rare thing and it was treatable, and the predicted cure rate was sixty to seventy percent. All right. Good enough. That was what the decision was made on. And there as no way for us to find out that John didn’t have locally invasive disease without metastases, because it required a diagnostic test that we can=t do here. So the other thing is, the bottom line is, why do we intervene as aggressively as we can with that kid and not with another? Because his mother brought him to us and that’s where he was, in out clinic...

    “I have to tell you, though, I’m a little troubled by these comments from the new PIH-er. Because I have to work with these people. The last thing I want to do is expend my energy trying to convince my own co-workers. Now I have to, of course. But I don=t like it.”
Kidder tries to apologize for the staffer, “Your PIH-er wasn’t saying you shouldn’t have brought John to Boston. Only that it was a shame you had to spend so much, given what else you could do with twenty grand.”
    “Yeah, but there are so many ways of saying that,” Farmer replies. “For example, why didn’t the airplane company that makes money, the mercenaries, why didn’t they pay for his flight? That’s a way of saying it. Or how about this way? How about if I say, I have fought for my whole life a long defeat. How about that? How about if I said, That’s all it adds up to is defeat? A long defeat.
“I have fought the long defeat and brought other people on to fight the long defeat, and I’m not going to stop because we keep losing. Now I actually think sometimes we may win. I don’t dislike victory.
    “You know, people form our background--like you, like most PIH-ers, like me. We’re used to being on a victory team, and actually what we’re really trying to do in PIH is to make common cause with the losers. Those are two very different things. We want to be on the winning team, but at the risk of turning our backs on the losers, no, it’s not worth it. So you fight the long defeat.
    “And most of the time when people ask about triage, most of the time they’re asking not with open hostility but deep distrust of our answer. They already have the answer. And that of course is the energy-draining process, because you understand that a substantial proportion of the questions are asked in a, you know, in a very, what’s the word?”
    “With an animus?” Kidder suggests.
    “Yeah.” Farmer is silent for a moment.
    “The salary of a first-world doctor. How about that? Talk about all the money that could have been spent on other things, what about a doctor’s salary?
    “Well, of course. See, the truly humble think of that before they say the other. I’m not truly humble. I’m trying to be humble. So let me ask you another question. What is it that makes people not think that? Why doesn’t a young American doctor say, ‘Gee, my salary is five times what John’s airplane ride cost. And I’m twenty-nine or thirty-some years old.’ If you say that stuff out loud, you sound like an asshole. Whereas if you say the other stuff, you just sound thoughtful. Now what’s wrong with that? What’s wrong with this picture? If you say, ‘Well, I just think how much could have been done with twenty thousand dollars, you sound thoughtful, sensible, you know, reasonable, rational, someone you really want on your side. However, if you were to point out, But a young attending physician makes one hundred thousand dollars, not twenty, and that’s five times what it cost to try to save a boy’s life.’ “That just makes you sound like an asshole. Same world, same numbers, same figures, same currency. It’s just, you know, I never have been able to figure it out. I mean, I’ve figured it out, but I realize now it takes so much time to get to that point, to explain it, without offending someone. I have to limit the amount of time I put into explaining all that or it just sucks your soul dry. “
    This conversation then leads to the last rumination of the book as they complete the seven hour house-call trek. Kidder ponders that some would say that this is what is wrong with the Farmer approach. “Here’s an influential anthropologist, medical diplomat, public health administration, epidemiologist, who has helped to bring new resolve and hope to some of the world’s most dreadful problems, and he’s just spent seven hours making house calls. How many desperate families live in Haiti? He’s made this trip to visit two. All the serious, sympathetic critiques of Farmer’s work comes down to these two arguments: Hiking into the hills to see just one patient or two is a dumb way for Farmer to spend his time, and even if it weren’t, not many other people will follow his example, not enough to make much difference in the world.” To this he imagines Farmer’s response as something like this: “If you say that seven hours is too long to walk for two families of patients, you’re saying that their lives matter less than some others, and the idea that some lives matter less is the root of all that=s wrong with the world.”
    Farmer’s creed has been expressed as, “Patients come first, prisoners second, and students third; that doesn’t leave out much of humanity. He doctors first of all because he believes it is the right thing to do. If you do the right thing well, you avoid futility. Doctoring is the ultimate source of his power. Every sick person is a potential patient, and every healthy person is a potential student. He is fighting poverty all the time, in a long defeat. For him the reward is inward clarity, and the price perpetual anger or, at best, discomfort with the world. Paul Farmer was not put on earth to make anyone feel comfortable, except for those lucky enough to be his patients. He does not want his hospital to be some laboratory for the world. It should be enough just to serve the poor.”
As Kidder leaves Haiti on the long, muddy, unpaved road from Cange to the airport, they get, at one point, stuck behind a slow-moving cart with a sticker on it that in Creole says, “Lord, a word on all this.”
    In an afterword, Kidder notes that Cange / Zanmi Lasante saw its first open-heart surgeries, performed by teams from the Brigham and South Carolina. He feels tempted then to ask Farmer if this was ‘appropriate technology’? He wants, not to hear the answer, but just to hear Farmer say it.

 COMMENT:  This is an absorbing story of a fiercely independent man who elevated common sense to the genius level and has changed the world.