Global Policy Forum

By Celia W. Dugger

In the cool mist of daybreak, hundreds of villagers fanned out across the forsaken reaches of this nation's remote interior, fording rivers swollen by torrential rains, slogging through muddy cornfields and clambering up slippery mountainsides to reach people sickened by AIDS. At each home, they handed out the little white pills that have brought their neighbors, wasted by the disease, back to robust life. "If the medicines weren't here, I'd be dead," said Manesse Gracia, 39, a mother of six who was plump in a workday dress the color of orange sherbet. "My children would live in destitution. My husband is a farmer, but the earth gives back nothing."

Mrs. Gracia is part of a pioneering program run here by a Boston-based nonprofit group, Partners in Health, that has become an influential model in the frenetic global race to expand drug treatment in dozens of poor countries. More than two decades into the pandemic, 22 million people have died of AIDS, and 40 million people are infected with H.I.V., the virus that causes AIDS. Millions will perish next year unless they get the medicines.

"Bringing antiretroviral therapy to all who need it is the most medically challenging task that the world has ever taken on," said Dr. Richard Feachem, executive director of the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria. The fund has approved $800 million for AIDS treatment, but that is only enough to supply antiretroviral drugs to just 700,000 people in five years. The World Bank is increasing support, and the United States Congress is close to appropriating about $2 billion, more than half of it for treatment.

No program to treat people in the poorest countries has more intrigued experts than the one started in Haiti by Partners in Health — which has succeeded by enlisting help from hundreds among Haiti's vast pool of unemployed and underemployed workers.

It is the rainy season now. So each morning and evening, 700 villagers strike out across dirt roads turned into a morass of mud and dung to deliver medicines to people with AIDS and tuberculosis. They tramp through muck and wade through streams on foot; a lucky few sit atop mules or donkeys. Margareth Guerrier, wearing a jaunty, broad-brimmed hat, set out on a recent morning from her small concrete house, threading her way past squatters' shacks up a steep, treacherously slick mountain.

At the top, she stopped at a small house and took the AIDS medicines from a black case slung over her shoulder. A 9-year-old girl named Fanise, ready for school in a navy dress, swallowed her pills dutifully as her grandmother looked on. Then Mrs. Guerrier walked on to deliver pills to another grandmother, two mothers and a father. "There were some among them who seemed more dead than alive," she said. "When they start taking their medicines, they get better."

The AIDS treatment program here, one of the first of its kind in the world, was started by Dr. Paul Farmer, an American, and the group he founded, Partners in Health. It began giving antiretroviral drugs to patients here in 1999, when such efforts were virtually unknown. "We didn't do it to be a model program," said Dr. Farmer, 44, a Harvard medical professor and anthropologist, who is also the subject of a recent book, "Mountains Beyond Mountains," by Tracy Kidder. "We did it because people were croaking."

Adeline Merí§on, who tested positive for H.I.V. in 1991, took a terrible turn for the worse in 1999. When Dr. Farmer hiked through jagged hills to her home, he found her bedridden and withered to about half her usual weight. Her father drew him outside to the rickety stoop and showed him the planks he had gathered to build her coffin. Dr. Farmer promised to return with medicines to save her. Back in Boston, he scavenged drugs from AIDS patients, doctors and clinics. Partners in Health bought more with money donated by Thomas J. White, a retired Boston businessman, and raised yet more cash by selling its headquarters in Cambridge.

"We couldn't get anyone to support us," Dr. Farmer said. "In 1998, 1999 and 2000, we went to Unaids, the World Health Organization and the World Bank and they said treatment is not cost effective or sustainable. We went to some of the drug companies and asked, `Can we have medicines?' Every single one turned us down." In the early days, Dr. Farmer carried the pills back to Haiti in suitcases.

On Oct. 28, 1999, a shrunken Mrs. Merí§on, weighing only 69 pounds, was brought to the hospital here on a stretcher. She was put on the drugs. "I haven't been sick since," said Mrs. Merí§on, 37, who now weighs 120 pounds.

The Spartan model of care used by Partners in Health was born of necessity, but its very spareness is now seen as a virtue by many experts who want the scarce dollars for treatment to stretch as far as possible. Doctors here grafted AIDS treatment efforts onto the existing program for tuberculosis control. AIDS patients, who will have to take the drugs daily for the rest of their lives, are visited in their homes every morning and evening by a health worker who hands out pills and watches as they are gulped down. Ensuring that the medicines are taken properly reduces the risk that drug-resistant strains of H.I.V. will emerge.

One of the biggest obstacles to rapid expansion of treatment in poor countries is the extreme scarcity of doctors, nurses and high-tech equipment. And the program here has minimized reliance on them. Generally, there are no lab tests done once treatment begins. The only monitor is a scale to weigh patients monthly. Peasants have been trained to dispense the medicines, draw blood, take X-rays, clean bedpans, measure vital signs and spread the word about condoms preventing H.I.V. infection. Most of the workers who visit patients' homes are paid a small stipend of $38 a month.

Last year, Partners in Health won a $13 million grant from the Global Fund — money now being used to build clinics, laboratories and drug warehouses, and to install generators and satellite dishes in a region largely bereft of electricity and phones. While other countries can copy the Partners in Health model, they cannot clone Dr. Farmer, a charismatic and chatty healer, and the small, idealistic band of American doctors he has brought to Haiti.

As Dr. Farmer, tall and whippet thin, drove through a village one recent day, jouncing over boulders and crevasses, a low murmur wafted in the window along with the dust. "Paul, Paul, Paul," chanted the women peddling wares at the roadside. Dr. Farmer has been here since he was in his 20's. He lives most of the year in Cange, a squatter settlement, and regularly commutes about 35 miles — three hours over some of the worst roads in the world — to reach the airport in Port au Prince before flying on to Boston and his teaching job at Harvard.

The example set by Dr. Farmer has helped inspire a similar dedication in Haitian colleagues. "When I was in my family planning residency, I heard about this white doctor who visits sick people in their homes," said Dr. Roland Desiré. "I'm from a peasant family myself. I came to see what he was doing." Dr. Farmer listened to the young doctor, choking back tears. He had made this recent visit to the group's clinic in Lascahobas hobbling on crutches. In August, Dr. Farmer broke his leg in a bad fall while hiking uphill in a drenching rain to reach a patient. Surgeons sawed his thigh bone in half and put in a titanium plate to repair it.

With his slight build and boyish face, Dr. Desiré, 31, looks more like a laid-back high school student in his jeans and T-shirt than a briskly efficient doctor. Among those who had come from great distances to see him in Lascahobas were two women — symbols of how far Haiti still has to go and of how far it has come.

Imitane Pierre had brought her baby daughter Francesca from Port au Prince. Both are H.I.V.-positive, and Francesca had developed painful lesions on her face. Hospitals in the capital had turned them away because the mother was too poor to pay. After two weeks in the clinic in Lascahobas, the bright-eyed girl had gotten better. But now she and her mother had to return to Ms. Pierre's other children in Port au Prince, where treatment programs are not yet established. "We send them home, but who will take care of them?" Dr. Desiré asked. "There's no one."

Later that day, the doctor turned to Ipoline Occeus, 26. He had to break the news that she was H.I.V.-positive but he coupled it with hope, because she lives in the area served by the clinic. "You can die from it," she whispered. In most developing countries, Dr. Desiré's diagnosis would indeed have been a death sentence. But he replied with the words that promised her life: We have the medicines. We can treat you.

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