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For the majority of people heading to the village of Cange in Haiti’s high, forested interior there is little choice in making the journey. They and their family members are sick, desperate and penniless. Many have tuberculosis and HIV. They leave their mud shacks in the mountains to journey to the _Zanmi Lasante_ (Creole for Partners in Health) medical complex. They arrive at all hours of the day or night, some shouldering dying relatives on hard wood pallets like an awkward religious cortege. At dawn, dozens are camped out, waiting to be seen by the clinic’s small staff. The Zanmi Lasante clinic was started by a group of activists led by Dr Paul Farmer, a gangly American doctor and anthropologist from Harvard who views health as a fundamental issue of human rights. Farmer came to Haiti in 1983. His vision was a medical centre that could provide care to rival a rich place like Harvard, but one that was rooted in community ownership. He benefited from the commitment of Père Fritz Lafontant, a well-respected Episcopal priest who mobilized community support for the project. With several friends, Farmer founded Partners in Health (PIH) as a small non-profit organization that now sponsors the Cange clinic and similar projects in Peru, Mexico, Cambodia and Roxbury, Massachusetts, a poor Boston neighborhood. Today, PIH’s modest staff at Cange provides care for up to a million people, including 100,000 in the area. Fees for health services are nominal or free. Over the past year, Farmer and his team have put Cange at the centre of the international AIDS map and fueled a passionate debate among public-health policy makers. His team is determined to prove that it is possible not only to treat the poorest Haitians with HIV/AIDS using expensive antiretroviral (ARV) combinations but also to offer a community-based model of HIV care that could be applied in other poor countries. They advocate a strategy of Directly Observed Therapy (DOT) that his team has perfected against multidrug-resistant tuberculosis (or MDR-TB). If it can be done in Haiti, they argue, it can be done anywhere. Haiti is among the poorest countries in the world, with a per-capita income of barely $400 and an unemployment rate over 70 per cent. Most Haitians live in rural areas as sharecroppers working infertile land. PIH has been battling AIDS in Cange since 1986. Staff began administering AZT to pregnant women in 1995, with great success. In 1997, the so-called ‘triple cocktail’ was first offered to exposed health workers and victims of rape. But the chief treatment lesson has come from drug-resistant tuberculosis, a chronic illness. Although TB is clearly different from AIDS, it shares certain features that pose a tremendous challenge to daily and long-term management. Both diseases require patients to take several drugs daily and to substitute second-line drugs to overcome cases of drug failure and drug resistance, including multidrug resistance. A key difference is that resistant TB can be cured, whereas HIV therapy is viewed as a lifelong maintenance regimen. The longer patients must take drugs, the greater the chance of resistance developing, which makes MDR-HIV a real threat. That’s why some critics claim that antiretroviral therapy is inappropriate in poor countries. They argue that, aside from the cost, it’s just too hard without an adequate health infrastructure and trained professionals. They worry that mass introduction of HIV medications in poor countries will lead to new drug-resistant strains that will make it harder to treat AIDS in the future.
The people that say you can’t treat the poor with these drugs are just looking for a reason not to do it
Although he admits that drug resistance is an issue, Paul Farmer belittles these concerns. The PIH initiative is called HIV Equity, for good reason. Farmer believes the fight for access to HIV drugs is fundamentally one of justice. ‘The people who say you can’t treat the poor with these drugs are just looking for a reason not to do it,’ said Farmer, taking square aim at what he calls the heart of the problem: greed and indifference. ‘It’s amazing how many excuses people can come up with when they don’t want to do something. The bottom line is that rich countries and governments don’t want to pay for poor people. I’m not saying HIV/AIDS isn’t a complex medical disease — it is, but it can be managed with existing medicine and using DOT.’ The HIV Equity project began in 1998 when ARV drugs were offered to several patients with severe AIDS who no longer responded to treatment of their opportunistic infections. Today, 65 people with advanced AIDS are receiving what Haitians call _tritherapie_. There is a very long waiting list. Almost 4,000 people from the area have HIV and Farmer estimates that 10 per cent might be sick enough to qualify for treatment. Within a short period, most patients on triple therapy feel better and begin to gain strength. With few exceptions, the patients tolerate the regimens well and adhere to their medication. Initial drug-related side effects like vomiting are so far minimal and easily managed. Teofa, née Bernardin Gracia, nods when he hears this. A 32-year-old man who looks 18, he was frail and unable to work when Farmer found him. Like his neighbours, he had heard about AIDS and knew about condoms, but he regarded the epidemic as a distant threat. He had no idea HIV was the cause of his illness. ‘The drugs we take for HIV, they are so important we don’t even think of them as drugs, but as something God has brought us,’ Teofa says passionately. ‘There are a lot of people who say: ?In such a small, poor country you can’t get those drugs, you can’t manage them.? But for me, it’s not true. We are the evidence of the success. There is poverty and we are poor, but that’s not a reason to say we can’t manage a big thing like this. And if we succeed, it shows all of us can manage this.’
Copyright © 2001 by the American Foundation for AIDS Research (amfAR) and first displayed on amfAR’s Treatment Directory web site (
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