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In many ways, life in Great Missenden was idyllic, bucolic, sweet. The author Roald Dahl and the movie star Patricia Neal called their cottage there, in the rolling English countryside of Buckinghamshire, Gipsy House, because they’d parked a bright-blue caravan in the garden for their four children to play in, and because there was a freewheeling spirit to the place. A dozen people might show up for dinner on any given night; Neal would frequently be on her way to the United States to shoot a film; Dahl wrote his famous children’s books in a little hut—his “nest”—at the edge of the garden, surrounded by the roses and rhododendrons he liked to tend. “It was a very unmanufactured garden—very cobbled together, not unlike the house,” Ophelia Dahl, the second-youngest of the siblings, recalled recently. “I remember Dad in the garden all the time. In the summer, he’d be standing there in the evening with a whiskey-and-soda. I remember sipping it, and saying, ‘Oh, God, this is a horrible taste!’ He told me, ‘I don’t drink it for the taste. I drink it for the nice whizzly feeling it gives you.’ ”
There was a small orchard on the property, and Dahl taught Ophelia to drive there when she was only eleven years old. Like Dahl’s child hero in “Danny, the Champion of the World”—who lived with his widowed father in a Gypsy caravan, and started driving when he was nine—Ophelia was a brave and competent child, who soon took to driving around the village. “I often chose my friends for their moms, these warm, interesting moms, and I would drive over to these people’s houses, and, even if my friend wasn’t there, I’d stop in for a cup of tea and a chat.” The next day, she’d drive to another house, making her rounds.
There was the palpable world of country roads and cocktails in the garden, and the fantastic world of stories that sprang from her father’s “delicious imagination.” But there was also a silent world of grief, a world that could not be seen or spoken of. The first great sadness had come in 1960, when the family was visiting Manhattan and a taxicab hit the carriage in which Neal and Dahl’s four-month-old son, Theo, was being wheeled by his nanny along Madison Avenue. The carriage flew forty feet, and the baby’s skull shattered when he landed. He underwent multiple surgeries, and a tube was implanted to drain fluid from his brain into his heart, but it kept getting blocked. At the height of Theo’s suffering, his father contacted Stanley Wade, a toymaker he knew who specialized in crafting engines for model airplanes with tiny hydraulic pumps. Together with Kenneth Till, a pediatric neurosurgeon who cared for Theo, they created the Dahl-Wade-Till shunt, which was used on almost three thousand children around the world, and cost a third as much as its predecessor, because the inventors declined to profit from it. Theo required nine craniotomies, but he lived.
Two years after Theo’s accident, when Dahl was in the midst of writing a story he later called “Charlie and the Chocolate Factory,” his seven-year-old daughter, Olivia, contracted measles. Within four days, she was dead. “There was just this sense that my father’s heart had been fully broken,” Ophelia, who was born a year and a half after Olivia’s death, said. Neal grieved openly and outwardly. Dahl, on the other hand, “went to bed for something like a month, and then got up, but he couldn’t talk about it. My mother said he just never talked about it again.”
More misfortune followed. When Ophelia was nine months old, Neal suffered a burst cerebral aneurysm and fell into a coma. She came out of it, but it took months for her to learn how to walk and talk again. “I have very strong memories growing up, of knowing immediately—as soon as I became conscious—that she had been ill, that she wasn’t like other mothers,” Ophelia said. “She would trip and fall regularly. I was on high alert most of my childhood.”
But, if her mother fell, Ophelia could help her up. The other, deeper sorrows persisted, and there was nothing she could do about them. “I feel, in some ways, I was born into the echo of something that had happened at another time,” Ophelia, who is fifty-three, and has icy pale skin and green eyes and her mother’s delicate features, said. “There were clearly ramifications, but I hadn’t been there.” There were relics around Gipsy House of the losses: a trunk in Dahl and Neal’s room that contained Olivia’s clothes and toys; a prototype of the Dahl-Wade-Till shunt in a frame, hanging on the wall. “Funny old thing—looked like the inside of a watch,” Ophelia recalled. “He never talked about it with us. But my father never talked about his accomplishments. He did none of that boring stuff that people who look back on an accomplished life do.”
Recently, Ophelia Dahl was in Rwanda, speaking to a group of graduate students at the University of Global Health Equity, which was opened in 2015 by Partners in Health, an aid organization that Dahl co-founded when she was very young. “For the first time in a lecture like that, I included my father as an example of the suggestion that you can transcend your training. Don’t do this thing where you say, ‘Well, I don’t know that that can be done.’ You have to keep pushing. You don’t say, ‘I’m sorry, I’m not an inventor, I’m a writer.’ I think it’s connected to feeling entitled in the right way: ‘Fuck it. I’m not going to stand for that.’ You push. You push, push, push.”
In the final version of “Charlie and the Chocolate Factory,” Willy Wonka exhorts Grandpa Joe, “You mustn’t despair! Nothing is impossible!” On the Partners in Health Web site, the organization’s stated purpose is to bring the benefits of modern medical science to some of the poorest people in the world. (The group operates in Haiti, Peru, Mexico, Siberia, the Navajo Nation, Sierra Leone, Malawi, Lesotho, and Liberia, in addition to Rwanda.) But Partners in Health also aspires to do something more amorphous, more imaginative, and more improbable: “to serve as an antidote to despair.”
There are, as people often say in Sierra Leone, “many challenges” at the government clinic in Kangama, near the country’s eastern border. It is situated many hours’ drive from the nearest town, on a rocky and frequently flooded dirt road through the bush, and few patients can afford a car or a motorcycle or even the fuel to power one. It is also difficult to reach by phone: there are no landlines in the area, so in order to make or receive calls a member of the clinic’s staff has to walk a mile to “the point”—a spot where there is intermittent cell-phone service. “It is often very frustrating,” Fodei Daboh, a tall young man who is the community health program manager, explained to Ophelia Dahl on an afternoon in October when she visited. Calls always seem to drop just when a plan—to get an ambulance, say—is on the verge of completion. There are shortages of medication in the clinic dispensary, and basic supplies often run out. On that day, there was a large jug of water by the front door, next to two posters touting the benefits of handwashing. There was not, however, any soap.
What the Kangama clinic has plenty of is bathrooms: nine of them, built with aid money donated during the Ebola crisis of 2014. “The intent was good, but the lack of coördination was horrifying,” Regan Marsh, a former medical director of Partners in Health Sierra Leone, who had joined Dahl for the visit, said. They had seen this kind of thing all over the world. Development organizations will donate something finite, even if it’s redundant, rather than something essential but ongoing; thus, a community might receive a bathroom, a handwashing sign, or a thousand packets of oral-rehydration salts, instead of salaries for trained nurses, or, say, electricity. “There are endless examples of bigger interventions—like a hospital—in the middle of nowhere, and it falls apart because it hasn’t been built within a community of trained people, or with the normal pipeline for overhead and upkeep,” Dahl said. If a hospital is erected, but there is no running water or sewage system—to say nothing of diagnostic equipment or personnel who can operate it—it is as useless as a bucket of water without soap. Consequently, Partners in Health often helps supply things that fall outside a medical-aid organization’s typical purview, such as bridges and satellite dishes and gasoline. “These things need to be done in order for people to have a reasonable chance of being healthy,” Dahl said, “and not being . . . dead.”
When P.I.H. became involved with the Kangama clinic, a year and a half ago, there was no power at the facility. One of the basic functions of this sort of clinic is to care for women as they give birth, but if a woman went into labor at night she would have to deliver by flashlight. During the rainy season, someone had to hold an umbrella over the proceedings, because the ceiling leaked. There is electricity now, and the ceiling has been patched, but there is still no doctor on staff. In fact, there are only about a hundred and fifty Sierra Leonean doctors in the entire country—which helps explain why it is the most dangerous place in the world to be pregnant. One out of every seventeen women in Sierra Leone will die during a pregnancy, a delivery, or its aftermath. In the United States, the rate is one in thirty-eight hundred; in Finland and Italy, it’s one in twenty thousand.
P.I.H. first came to West Africa in 2014, at the invitation of the governments of Liberia and Sierra Leone, during the height of the Ebola epidemic. Emergency intervention is distinctly not P.I.H.’s project; in contrast with organizations like Médecins Sans Frontières, which specialize in addressing intense crises, P.I.H. works to remake entire health-care systems, by collaborating with local governments. Its commitments are long-term and large in scale. (One board member told me, “M.S.F. is sex. P.I.H. is love.”) P.I.H. has been in Rwanda for twelve years, and in Haiti for more than thirty.
In Sierra Leone, Dahl and her colleagues were convinced that many people were dying of Ebola for the same reason that they were dying in childbirth: the lack of a functional health-care system. “Ebola was the canary in the coal mine,” Joia Mukherjee, the chief medical officer of P.I.H., told me. “What you’ve got to look at are the dangerous conditions in the mine.” Sierra Leone is still reeling from a decade-long civil war, and evidence of it is everywhere: the charred skeletons of homes, schools, and hospitals throughout the countryside; the omnipresence of people whose limbs were systematically amputated by the rebels of the Revolutionary United Front; the lack of basic infrastructure. There are twenty public hospitals in Sierra Leone, and less than half have running water. One Sierra Leonean doctor, T. B. Kamara, co-authored a study in 2010 comparing surgical care in his country with what was available in the United States during the Civil War. It concluded that the nineteenth-century U.S. facilities had been “equivalent and in many ways superior.” Dahl told me, “Ebola was ‘acute on chronic.’ That’s what they call it when someone has smoker’s lung, and then suddenly something precipitous happens, like pneumonia. It happens with systems themselves.”
Dahl, who was the executive director of P.I.H. during the Ebola crisis and is now the chair of the board, had secured financial commitments from the Office of U.S. Foreign Disaster Assistance and from the British Department for International Development. P.I.H. workers began by establishing emergency-treatment centers, and moved to shore up major public hospitals. Then they began training and paying community health workers, which is usually P.I.H.’s first priority when it goes into a country. Local people are employed to visit sick neighbors and administer medications, take note of symptoms, and accompany patients to seek treatment at a nearby clinic. Ninety-six per cent of P.I.H. employees are residents of the communities where they work.
That afternoon in Kangama, Dahl made the rounds with Sahr Christian Allieu, a community health worker who visits seven patients three times a week. The first, a pregnant woman who had recently been given a diagnosis of H.I.V., lived in a small settlement in the bush, and on the way there they walked past children outside their homes, pounding grain in wooden mortars as tall as they were, and past women balancing stacks of cassava leaves on their heads. When they arrived, the patient was wearing a white tank top stretched taut over her big belly and a vibrant red cloth knotted just below it. “How de body?” Dahl asked, using the local greeting. The woman put her hand on her stomach and said that she was feeling healthy, but that, with a fifteen-year-old, a five-year-old, and aging parents, she had “a lot of people to take care of.” She invited Dahl into her house, a three-room structure of mud bricks under a corrugated-tin roof, where she lived with twelve family members. “Imagine how wet it is sleeping on the floor during the rainy season,” Dahl said, outside. “In Haiti, they have a saying about these sorts of houses: they fool the sun but not the rain.”
A few minutes’ walk through the bush, the next patient, who also had H.I.V., was gaunt and exhausted, with sunken eyes. She worried about how she would survive, she said. Her husband had abandoned her and their three children—including a baby she was still breastfeeding—when he found out that she had the disease. They were staying with her brother and eleven other people in a small house with no electricity or running water. She had been taking antiretroviral medication that her community health worker brought her, and her appetite was returning, but that only meant she was hungry; her brother had had difficulty feeding his extended family even before he took her in. “I don’t know how to thank God enough for the medications,” she said. “I wouldn’t be alive without them. That gives me some hope.” But even as she said this she stared at the floor, looking despondent. Dahl, visibly shaken, talked to Allieu afterward about getting her some food assistance. The medicine would do no good if the woman starved to death.
When Dahl was eighteen, she decided to volunteer in Haiti with a nonprofit that provided eye care to the poor. “My father told me, ‘Go do something worthwhile, and have an adventure—see a different part of the world.’ ” It was a good time to leave Great Missenden, as her parents were on the verge of a painful and public divorce. For a cosseted teen-ager, arriving in Port-au-Prince proved to be transformational. “It was a fundamental sort of messing about with your own internal system,” Dahl said. “Everything was different—that’s what garbage smells like, that’s what illness smells like, that’s what children begging look like.” Most people encounter poverty and then relegate the knowledge of others’ misery to the periphery of their mind. Dahl had a different experience. “To have seen this and to not do anything, I knew wasn’t an option. I would never sleep well again. The rest of my life I’d then be feeling like, ‘Look at the house we’re living in.’ ”
But she had no idea what effective action might entail. “I went to these outreach clinics in Haiti, and I was writing home, like, ‘Dear Dad, today I saw . . .’ And you would see things! I didn’t lie; I didn’t say, ‘Oh, I scrubbed in on some surgery.’ The implication, though, was that I was doing important things—because you want to believe that.”
In a town called Mirebalais, in Haiti’s Central Plateau, she met another volunteer, an American named Paul Farmer, who had recently graduated from Duke with a degree in medical anthropology. Their upbringings were starkly different: Farmer was raised, with five siblings, in a bus in a Florida campground. (They joked that Farmer had grown up looking for diners where kids eat free, while Dahl went to places where kids eat Brie.) But they had the same yearning to improve the lives of the poor. “I knew I wanted to be a doctor,” Farmer said. “And I convinced her that she should be a doctor, too—which is something I wouldn’t do as a more mature person, but I was a twenty-three-year-old idiot.” Dahl didn’t see it that way. “It’s weird to use the word ‘mentor,’ because he also became my boyfriend,” she said. “But he was really pretty visionary. Paul said, ‘I know how to get there.’ And I said, ‘Well, I’m coming with you, babe.’ ”
Dahl returned to England to take her A-levels, and Farmer enrolled at Harvard Medical School, but they would reconvene in Haiti, where Farmer continued to volunteer: he often flew there on Thursday nights after he finished classes for the week, and then returned to Cambridge on Monday mornings. The people he worked with had been flooded out of their farmland when a hydroelectric dam was built—water refugees, they called themselves—and were living in a squatter settlement called Cange, where they covered their shacks with banana leaves because they could not afford tin. Most families were afflicted with some kind of illness, in addition to malnutrition. Farmer was outraged that health policymakers did not see these people as worthy of the same standard of treatment as the wealthy. The prevailing idea was that prevention is better than cure—that aid should be focussed on vaccination and education, and that poor people should make do with what they had. “Already the field was polluted by health economists,” Farmer said. “When you hear things like ‘cost effective’ or ‘appropriate technology,’ they don’t come from the patients. Nobody says, ‘Hey, I’d really like you to build a cost-effective health-care facility in my squatter settlement.’ ” It seemed to him that his patients were being penalized by the global-health intelligentsia for being impoverished because of circumstances beyond their control.
Dahl studied science, thinking that she, too, would go to medical school, which delighted her father, who thought of himself as a “frustrated doctor.” She joined Farmer in Haiti during summer breaks, and they stayed with Fritz Lafontant, a radical priest who had built the first school in the area. Together, they took a census in Cange, to find out how people lived and what was killing them. “We’d go off every morning at eight and walk for four or five hours on these little paths,” Dahl said. “Usually, there’d be a kid, and they’d run off and find an adult in the field, and we would explain what we were doing. They would open their door and make sure you were in the shade and often offer you some corn or a coconut. No one had fewer than six kids. Everyone had a dirt floor.”
Stupid deaths, as the residents of Cange called them, were the norm; children died from diarrheal diseases, because there was no clean drinking water. “We started taking a little felt-tip pen to write a number on the doors so we could start a medical record and come back,” Dahl said. With Lafontant, they began to build a health-care system from the ground up. “Years later,” Farmer recalled, “I was at Roald’s seventieth-birthday party, and he said to me, ‘You guys like working in Haiti because you like being big fish in a small pond.’ I took umbrage, but he was probably right. And there’s a good reason—you can make a big difference in a place where there isn’t much.”
Dahl raised some money from her parents’ friends in London, and bought scales for weighing malnourished infants. Farmer began training locals to recognize the symptoms of TB, malaria, and typhoid. These recruits were the first of many community health workers Farmer and Dahl relied on in remote areas; the Haitians called them accompagnateurs. Farmer also taught them to administer medication, a fair amount of which he finagled from Harvard and smuggled over in his suitcase. Crucially, Lafontant worked with an American church group to hire engineers to pipe water from the dammed river into a communal spigot. Almost immediately, the incidence of typhoid decreased. It reminded Dahl of the famous story of John Snow, the doctor in nineteenth-century London who traced a cholera outbreak to a particular pump on Broad Street by conducting a door-to-door census. After Snow persuaded the city council to remove the pump’s handle, people stopped dying, thus dispelling the idea that they’d got sick because they were poor and wretched and breathing “bad air.”
In Boston, Farmer had befriended a retired construction magnate and Second World War veteran named Tom White, and he brought him to Haiti to see how people were living. White began donating money for such necessities as concrete floors and tin roofs, and ended up financing the construction of a clinic. “I was twenty at that point—I didn’t even have an undergraduate degree,” Dahl said. “Paul was a medical student. But we all sort of rolled up our sleeves and did whatever there was to do. We were planting trees on the hillside to try and stop the erosion. We were writing to people, long letters asking for money; driving to Port-au-Prince to pick up tons of things, like cough medicine and bar soap.” When the clinic opened, with three examining rooms staffed by Farmer and several Haitian doctors, patients poured in from all over the country—travelling on foot for days to reach them, sometimes carrying sick loved ones on their backs, sleeping outside while they waited their turn for care. “That’s how few the options were,” Dahl said. “It was tiny, but we left all this rebar sticking out the top because we knew that we would need to build more. The rebar sticking out felt like a beautiful thing, because it said, ‘We know this isn’t enough, not nearly—but it’s what we can do right now.’ ”
In Cange, Dahl realized that there were ways besides being a doctor to improve the health of the poor. This was reassuring, because she had found that she was interested in science only up to a point. “I loved thinking about life cycles, or mosquitoes and how they’re connected to these tropical diseases and how a parasite goes through the liver of a sheep before it’s recirculated,” she said. “I mean, that stuff—that’s literature. That’s the poetry of systems.” Literature, ultimately, is what Dahl decided to study, at Wellesley College. In Boston, she and Farmer got an apartment together. “We would talk and talk and talk about what it was we were doing,” Dahl said. They believed passionately that their aid work was about “redistributive justice,” as Farmer put it to Tracy Kidder, who wrote a biography of him. Many development professionals advocated a doctrine of self-reliance, typified by the slogan “African solutions to African problems”—which Dahl and Farmer felt ignored the West’s role in creating those problems. “In the affluent world, history gets erased,” he told me. “Erasing history is unfair to some people, and it’s fine for others. At med school, nobody even talked about these things.” He sighed. “I hope I wasn’t uppity and sanctimonious to my classmates, but I probably was.”
At Harvard, Farmer met Jim Yong Kim, a young man from a family of South Korean immigrants, who, like him, was pursuing a Ph.D. in anthropology along with a medical degree. With Dahl they formed a trio. “We all read liberation theology together, and Ophelia was sort of a keeper of the faith,” Kim, who is now the president of the World Bank, recalled. They were particularly taken with the Peruvian philosopher and priest Gustavo Gutiérrez’s conception of a “preferential option for the poor.” Because God favors the poor and the powerless, Gutiérrez argued, Christianity should focus on the injustices visited upon the destitute. To Dahl, Farmer, and Kim, it seemed clear that this doctrine applied to health care, too. “The thing about looking for some grand theory, like Marxism or whatever ‘ism,’ is that a lot of those sort of peter out or are eventually discredited,” Farmer said. “It was hard for me to see how you could discredit an injunction to serve poor people preferentially. You don’t have to be an epidemiologist to realize that infectious diseases make their own preferential option for the poor—they afflict them more, and worse.”
Dahl, Kim, and Farmer drew up a mission statement for what they called “the Project.” They would work toward providing health care that prioritized poor people’s needs, rather than the cheapest or the easiest intervention. “You don’t say, ‘When I’m in Boston, I have this one set of standards, and when I’m in Haiti or Rwanda I’m just going to lower the shit out of them,’ ” Dahl said. Tom White, who had by then decided to systematically divest himself of his wealth, donated a million dollars of seed money. “We were not going to be a regular self-congratulatory do-gooder organization,” Kim said. “We were going to grapple with deep questions of responsibility. Ophelia was the one who could explain to all the people coming around why our approach was different.” Dahl had a knack for disarming defensive people and for convincing donors that the world’s most fortunate people had a moral obligation to investigate—and compensate for—the suffering that underlies their comfort. “If we can’t connect our own good fortune with the misfortune of others, then we’ve missed the boat completely,” she often said.
But, soon after the organization came into being, Dahl and Farmer’s romance fell apart. In 1989, she sent a letter explaining why she would not marry him. “You pointed out to me once, during an emotional argument, that the qualities I love in you—that drew me to you—also cause me to resent you,” she wrote. “Namely your unswerving commitment to the poor, your limitless schedule and your massive compassion for others.” Farmer didn’t speak to Dahl for nine months. Then they ran into each other at a restaurant in Cambridge. “I looked up and I saw him,” Dahl recalled, “and there was this recognition—just knowing that you’ve always known each other, and that we understood why we had to be apart, but hoped not to be apart again.”
“I’m still working with all the people I met then who are alive—because they’re willing to be involved!” Farmer told me. “The qualities you most need to do this are solidarity and empathy. Those are rare. Ophelia was, and is, exquisitely sensitive to other people’s suffering—she gets physically anguished about it. And that’s a wonderful thing to have.”
In 2013, Partners in Health opened a two-hundred-thousand-square-foot, three-hundred-bed teaching hospital in Haiti—the largest solar-powered hospital in the world. It is in Mirebalais, where Farmer and Dahl first met.
The economist William Easterly divides development agencies into two philosophically distinct groups: planners and searchers. In his 2006 book “The White Man’s Burden: Why the West’s Efforts to Aid the Rest Have Done So Much Ill and So Little Good,” he writes that the planner “thinks of poverty as a technical engineering problem” that can be solved with enough money, intelligence, ingenuity, and data. Searchers, by contrast, “are just on the lookout for favorable opportunities to solve problems—any problem, no matter how big or small.” The searcher sees that Cange needs a water spigot, or that Kangama needs an ambulance, and starts working to help obtain it. She may hope that eventually the strategy—and the money—will emerge to provide the entire region or nation or continent with water and ambulances. But she doesn’t wait for it.
Especially in the early years, Dahl said, “we adopted this stance that we’re not the experts—you tell us how we can accompany you.” But, as the clinic in Cange was overwhelmed by demand, it became clear that it was not enough to conduct a neighborhood census: they needed to partner with governments, so that the work they did could be coördinated and sustainable. “If you believe health care is a right, then you have to work with governments, because they are the only group that can confer rights,” Dahl said. “Ninety-nine per cent of people, the first thing they ask is, ‘What about corruption?’ It’s an easy nugget to grab on to. ‘There’s nothing to be done. Let’s sleep now, free from worry.’ ” Though P.I.H. won’t collaborate with a government that is dictatorial or hopelessly dysfunctional, it expects to have to work around patronage systems. “It’s not that we’re crazy bleeding hearts that just choose not to see any of this stuff,” Dahl continued. “It’s just that we don’t let it be a showstopper. Imagine if we shut things down whenever there was corruption in the United States: ‘Sorry, now you can’t have any health care.’ ” This reasoning reminded her of another common accusation: that white, Western people doing aid work in poor countries are practicing a kind of latter-day colonialism. “It’s often used as a not very eloquent excuse to do nothing,” she said. “It brings out the worst in one. You feel like saying, ‘So what are you doing?’ ”
In 2014, a Sierra Leonean doctor name Bailor Barrie persuaded the country’s President to write a letter to P.I.H., asking the group to come to West Africa. Ebola was spreading rapidly, and Barrie knew firsthand how ill-equipped the health-care system was, even before the burgeoning crisis. In 2006, he’d started a clinic in Kono District, to serve the thousands of amputees in the region. Kono, the most diamond-rich area in Sierra Leone, was the base of the rebel army, and thus the region hardest hit by the war. “When I moved to Kono, we went to the government hospital and there was nothing—no beds, patients were lying on the floor, no doctors, only volunteer nurses,” Barrie, a round man of thirty-eight, told me. He started volunteering at the hospital, seeing patients every morning; he’d work the rest of the day at his clinic, Well Body, and sleep there at night.
He had read about the success that Partners in Health had with community health workers achieving early diagnosis and treatment of H.I.V. in remote places, and so he obtained training materials from Joia Mukherjee. “I thought the P.I.H. model in Rwanda and Haiti was great, so we wanted to replicate it.” In 2013, he moved to Boston, on a Fulbright Fellowship, to pursue a master’s degree in global health at Harvard. “I went back to Sierra Leone to do my research,” Barrie said. “And then Ebola struck.”
P.I.H. agreed to come to Sierra Leone partly because it was an opportunity to partner with a functional government on a dysfunctional health-care system, and partly because it had an invaluable accomplice in Bailor Barrie. Barrie had wanted to be a doctor since he was six years old, but there was no medical school in Sierra Leone then, and going abroad to get an education was out of the question: his father was a village tailor who earned less than a cent a day. In 1988, the country’s first medical school opened, in Freetown, and, when Barrie took the entrance exam, he got the highest marks in the country. He moved to Freetown, and, in 1996, he started school.
But his plan was derailed by the war. When classes began, his mother had recently been captured by the rebels. “We thought she was dead—we had a ceremony and everything,” he said. The rebels forced her to work as a cook and a porter, but when she got an infection they left her behind to die. She was found during Barrie’s first year of medical school and reunited with her family, but the following year the rebels shot his father, who died soon after. The year after that, they staged a coup in Freetown, and Barrie soon fled to a refugee camp in Guinea, where he remained for eight months. When he heard that the medical school had reopened, he returned, but then had to flee again when the rebels invaded, in a strike they called Operation No Living Thing. It took eight years of stopping and starting before Barrie graduated.
One humid morning in October, Barrie accompanied Dahl and Regan Marsh, the former medical director, on a visit to Well Body. A man named Mani Kanda opened the gate to greet them. His right arm had been amputated at the elbow, and hadn’t healed properly. Asked if he had pain in his arm, he said, “Yes—in my good arm, because it does all the work.”
Since the Ebola treatment centers closed and P.I.H. has been focussed on the slower task of over-all system building, the organization has been partnering with Barrie at Well Body to create a model clinic for maternal health. Dozens of mothers with babies strapped to their backs waited to have the children weighed and checked. Dressed in the bright oranges, purples, and blues of traditional fabrics, the women were a blaze of color, except for a few wearing black Islamic robes. (The population of Sierra Leone is divided between Christians and Muslims, who are markedly unconcerned by their differences. They intermarry and attend one another’s religious services; Christian families send children to Islamic schools.)
In an open-air pavilion, a group of about fifty pregnant women stood listening to a clinical assistant in green scrubs and Crocs. “If you are sick, don’t do country medicine, don’t take herbs,” she told them in Krio, the country’s most common language. “If you don’t feel well, come here, where we measure our medicine. Don’t go to the mommy who is your neighbor. If you come here, nothing bad will happen to you.” Many of the women had had negative experiences, Barrie explained. “There is a lack of trust. In the past, at the government hospital, the clinical staff was yelling at patients. They were always angry, because they never got paid.”
The government of Sierra Leone, hoping to reduce the grim levels of maternal mortality, passed a law fining traditional birth attendants who were caught delivering babies in homes. But many women are reluctant to deliver at a clinic or a hospital. “When you go to the clinic for the first time and you don’t receive good care, you think, Next time, you know what? I’ll go to the traditional healer,” Barrie said. “If I pay the small money I have to get to the hospital and they don’t have the drugs and I’ve used my money to pay transport, next time I’ll go to the traditional birth attendant who delivered a lot of the babies in the village.”
“And if there are no tools and no nurses at the hospital,” Dahl added, “the birth attendants may have as much experience as the staff.” Well Body employs traditional birth attendants from neighboring communities as support staff. “Women trust the T.B.A.s,” Barrie continued. “If they see them here, they feel they can tell them their problems.” In the maternity ward, two T.B.A.s in scrubs stood next to an effervescent young nurse from Freetown named N’damba Mansaray. Dahl asked the attendants what they’d learned to do differently from their training. One attendant explained that she used to take women who were having prolonged labor out into the bush, to give them privacy from the men in their family while they delivered, and that she had cut umbilical cords with razors that weren’t sterilized. Asked if there was anything they’d taught the staff at the clinic, the two women grew shy. “They help with the language barrier, and they know how to talk to the patients,” Mansaray said. “And I have learned Kono music from them, to sing for my patients when they are in pain!” She started singing, and the other women joined in. Together, they made a sound so enveloping that it was easy to imagine how it might comfort you and transport you during the most frightening moments of a birth. “It means, ‘With God, all things are possible,’ ” Mansaray said.
Once women decide to seek treatment, two major obstacles contribute to maternal mortality. The first is the time it takes to reach a medical facility. Adjacent to the clinic, P.I.H. built an airy room with mosquito nets over the beds, where women in high-risk groups can stay as their due date approaches. On that day, a teen-age girl and a woman with a spinal abnormality that could make delivery dangerous sat chatting on the stoop, while a cook, an old man in a rain slicker, made groundnut stew over a charcoal fire for their lunch.
The second obstacle is the delay while the staff of a facility makes a decision about treatment—usually whether to perform a Cesarean section—and implements it. “In the United States, decision to incision is about fifteen minutes,” Marsh said. “In Sierra Leone, it is not uncommon for a woman to arrive at ten at night and have to wait for a nurse until ten in the morning.” One of the first things that P.I.H. did at the hospital to which Well Body refers difficult cases—after fixing the electricity to keep the lights on overnight—was to set up a twenty-four-hour rotation for staff.
In the clinic, Jonathan Lascher, the executive director of P.I.H. Sierra Leone, joined the group. A thirty-four-year-old Peace Corps veteran from upstate New York, he is a wiry, energetic man, who has gone prematurely “P.I.H. gray” in his hair and beard. “These things are solvable,” he said. “We don’t need Elon Musk to design some cool new innovation for us.” The leading cause of maternal death in Sierra Leone is hemorrhage, which in Western hospitals can be addressed by routine procedures. In America, depictions of the Ebola epidemic often featured startling images of bleeding victims. In fact, most patients did not display hemorrhagic symptoms. The majority of Sierra Leonean women who die in childbirth, however, simply bleed to death.
As a young woman, Dahl imagined that she’d have four children. She ended up having one, at the age of forty-three. “Things don’t go absolutely as planned—and I am in a relationship with a woman, so there’s no accidental pregnancy,” Dahl told a interviewer for PBS several years ago. “Then you feel enormously lucky to be able to go to that kind of trouble to have a child.” Dahl’s partner of nineteen years, Lisa Frantzis, is a senior vice-president at Advanced Energy Economy, an organization that promotes policies to expand clean-power technologies. They live in a stately town house in Cambridge, and one warm afternoon this fall their ten-year-old son, Luke, was climbing a tree in the back yard while Dahl filled a bowl with organic raspberries in the kitchen. She was a little tired, because she’d been out late the previous evening, having dinner with two hedge-fund donors at a nearby restaurant, where she’d helped them select several good bottles of wine. “I’m a sybarite at heart,” she said, popping a berry in her mouth. She took the fruit onto the porch. “Ophelia, can we go to the hardware store later?” her son yelled from the tree. “I need to get a crank.”
“You live with a crank,” she said. He went back to climbing.
When Dahl was helping to found P.I.H., she sometimes explained its mission by saying that its members would treat patients like their own family—that each case deserved the dogged inventiveness a mother would marshal to save her child’s life. “Being visionary isn’t just something you’re born with,” Dahl told me. “We can all do it for our own children.”
In the early nineties, P.I.H. began hearing about a vexing group of tuberculosis sufferers in Lima, Peru. At the time, the Peruvians were thought to have the best tuberculosis program in the world. “They were the darling of the global TB community,” Jim Kim told me. They had dramatically improved cure rates using a protocol called “directly observed therapy” to administer antibiotics. But the patients that P.I.H. was hearing about never got better, no matter how many times they were treated. Their illness was known as multidrug-resistant TB, or MDR-TB.
P.I.H. wanted to start treating the disease, using “second-line” antibiotics, which were more expensive and difficult to procure. Peruvian authorities said that P.I.H. would be expelled from the country if it attempted to do so. Peru was adhering to the recommendations of the World Health Organization, the arm of the United Nations that sets global policy, which had concluded that MDR-TB ought to be left to “run its course,” because it was too difficult to treat. “But ‘Let it burn itself out’ and ‘It’s not as virulent as regular TB’ are just dishonest arguments,” Farmer said. “Honest would be ‘These people are not as important as we are, so let them die.’ ”
The daughter of an official at the Ministry of Health in Lima became sick, and the man asked if Farmer would treat her with second-line antibiotics. He agreed, and the child got well. “The only reason that we weren’t kicked out of the country is because that Ministry of Health official whispered to Paul, ‘Will you treat her?’ ” Dahl recalled. “He had helped to make that policy: ‘It wasn’t worth it to try and treat.’ But then your own child gets it? And then gets well?”
Tom White, who died in 2011, was again willing to finance a P.I.H. experiment. He paid as much as thirty-five thousand dollars a patient for the drugs, which were administered to people in their homes by community health workers. Eighty-three per cent of the patients who took part in the experiment were cured. “So we won that argument,” Kim continued. “But then it was: Even if you can do it, the meds cost too much.” It occurred to Kim that nobody had bothered to check whether the drugs were off patent. They were. P.I.H. coördinated with several other organizations to get generic versions manufactured in China and India: suddenly, MDR-TB could be treated for ten per cent of the cost.
While P.I.H. was working on tuberculosis in Lima, it was also securing a partnership with Harvard Medical School, where Kim and Farmer had become professors. “We were changing from a grassroots group,” Dahl said. “Our evidence had been anecdotal, but if you have academics who are part of the Harvard system woven into P.I.H., then you have the research to substantiate it and say ‘It’s possible to treat MDR-TB—therefore it must be done.’ ” Harvard and P.I.H. received a forty-four-million-dollar grant from the Gates Foundation to treat MDR-TB in Peru. “It was one of our first major inflection points as an organization,” Dahl said.
In 2002, the World Health Organization amended its policy to acknowledge that MDR-TB should be treated. “I was actually sitting in the room at the W.H.O.,” Kim said. “I sent a note around to our colleagues that said, ‘Today the world changed.’ ” (Farmer sees it differently. “Jim is always thinking the world changes because a policy shifts, but I’m around these people who are saying, ‘My mother coughed up blood,’ ” he said. “There are a hundred thousand new cases a year just in China!”)
Dahl took over as executive director of P.I.H. in 2001, working out of a room at Harvard Medical School with eight employees and an annual budget of twelve million dollars. As the group’s initiatives grew more ambitious, she had to decide whether to make use of public-sector funding. “It was a wrenching decision,” she recalled. For years, P.I.H. had argued that the United States had helped keep impoverished postcolonial nations from advancing, by making loans from the World Bank and the International Monetary Fund contingent on such “structural adjustments” as diverting funds from public health and education to infrastructure. “To then turn around and take the money from the U.S. government felt tricky for us,” Dahl said. “But this is just as aids was ravaging Haiti. The physicians there said, ‘When you hear the knocking on your door of patients with this disease, which is all we hear, all day . . .’ I felt sort of ashamed. Like, oh, my God—what was I thinking?” P.I.H. accepted initial funding of $2.8 million from the Global Fund and $3.9 million from the President’s Emergency Plan for aids Relief (pepfar) under George W. Bush. “But we negotiated to get the money from the C.D.C., rather than through the State Department,” Dahl said, and laughed.
Dahl and her co-workers came up with a broad interpretation of what it meant to treat aids. “We made a strategic decision—we’re going to use that money to revitalize the public sector, because that’s where people get care,” Joia Mukherjee, the chief medical officer, recalled. “We didn’t say, ‘To hell with the rules,’ ” Dahl was quick to interject. “You can go to jail if you spend government money improperly. But we knew if we were going to do this successfully we were going to have to expand the definition of what they meant.” Dahl was questioned at one point about using pepfar money to drill a well in Haiti. “We said, ‘How will they swallow their pills if they don’t have any clean water?’ ” The line item was approved. “Our Haitian colleagues had a term for what we were doing,” Dahl went on. “Chwal batay. It means Trojan horse.” Contained within their plan for treating H.I.V. was a plan to treat everything.
“Over thirty years, we may have changed, or gone to new countries, decided that we were going to work with governments—but if you really adhere to our mission, it means that more and more things have to fit on our platform,” Dahl said. “This is why we’re involved in training, and starting universities, and capacity-building in all kinds of ways.” During the fifteen years that Dahl was executive director, P.I.H.’s revenue increased tenfold. “We have often had to fight this idea that P.I.H. is gold-plated,” she continued. “ ‘You’re the Cadillac,’ people would say. We’re really not. What we’re fighting for is spending something like a hundred dollars per person on health. In Boston, it’s probably ten thousand dollars!”
In Dahl’s kitchen, with its gleaming granite countertops, was a wrought-iron sign that she had salvaged from Gipsy House—a relic of Great Missenden. “I know what it is to have a lovely life,” she said. “I know what it is to be able to take Luke to a really good hospital. But, more than that, I know what it is to luxuriate: to plant a tree and assume we’ll be able to see it every year. I don’t want to not be able to do that, but I don’t think it’s possible to do without knowing about all the inequity.” She shook her head. “The idea that we live in somehow different worlds calms us all: First World, Second World, Third World. It’s all one world.”
Rising from the low skyline of Koidu, the capital of Kono District, is what appears to be a mountain with its top sheared off but is actually the pile of rubble that has accumulated around Sierra Leone’s largest diamond mine. The wealth that has been extracted from it fuelled the civil war, and also paid for the mercenary group Executive Outcomes to help reclaim the land from rebels; the mine now enriches an Israeli businessman named Beny Steinmetz, who was reported by Forbes in 2017 to have a net worth of $1.1 billion. Locals in Koidu have managed to find a way to make money from the mine, though: at all hours of the day, the tower of rubble is crawling with human beings who are mostly too poor to afford shoes, hauling rocks down in empty gas cans or one by one, then cracking them by hand to make gravel that they can sell for pennies. The rubble is its own economy, its own tiny, merciless system.
One evening at dusk, Dahl walked around the mine, past families sorting the gravel they’d made into piles of different-sized stones. She was struck—again—by how it is always the poorest people, with the least access to care, who are the most exposed to injury and illness. “If we got in line together, there’s no question about who is always first in that line,” she said. She remembered the time she spent at a treatment center during the Ebola epidemic, and what it felt like to know that if she got infected she would be airlifted to one of the best hospitals in the world, while the Africans around her would likely die.
William Easterly, the economist, pointed to a fundamental difficulty with P.I.H.’s approach. “If you’ve said, ‘There’s a right to health care,’ you haven’t said whose obligation it is to provide it,” he told me. “From an economist’s point of view, that’s kind of fatal. That is the major flaw of positive rights: Who is to blame if they’re not met?” A moral imperative is not the same as a financial solution. Regan Marsh, who spent four weeks wearing spacesuit-like protective gear to treat Ebola patients, said that, as P.I.H. was getting involved in Sierra Leone, Dahl handled government agencies with trepidation: “Ophelia was sitting with people saying, ‘O.K., we will do this, but we are not a disaster-relief program. We will come only if you say that you are going to stay.’ Everyone said, ‘Yes, yes, we will be your partner to put a health system in here.’ And then, as soon as Ebola appeared to be stabilized, the money evaporated.” Dahl told me that you could “hear the sucking sound” as aid was pulled out of West Africa in the wake of the disease. “But, without an effective health-care system, it’s a matter of time before it resurfaces.”
It was crucial, Dahl said, that during crises people could count on organizations like Médecins Sans Frontières—“I mean, thank God for M.S.F.”—to set up self-contained triage units. But it was frustratingly difficult to persuade donors that long-term solutions are as necessary as emergency intervention. M.S.F. receives more than a billion dollars a year from donors, whereas P.I.H. takes in about seventy million. (Both organizations have four-star ratings, the highest, from Charity Navigator.) P.I.H. Sierra Leone started with an annual budget of seventeen million dollars, which has declined to five million, as donations have trailed off. “I wish we had more money,” Dahl said. “The idea that we’re constrained because we can’t find enough money, and not because we’ve failed to adapt. . . . But that’s what money forces you to do: make a series of terrible tradeoffs.”
P.I.H. has had to pull out of one of the two hospitals it supported during Ebola. Koidu Government Hospital, where it has remained, is now the best in Sierra Leone. But, as Dahl put it, “the bar is so incredibly fucking low”—the hospital still doesn’t have an intensive-care unit. In Kangama, they’re seeing modest gains, which they’d like to extend to four other clinics in the district, but there are thirteen other districts where they can’t afford to start reifying systems. Like the first clinic in Cange, built with rebar sticking out, it is not nearly enough; it is what they can do right now.
The next morning, at the Shine On Guesthouse, Dahl was still thinking over the problem, as she had breakfast with Regan Marsh and Jonathan Lascher. “That systems piece gets the hell in the way for people,” she said. “People go to sleep when we talk about systems. They switch off! ‘Oh, that’s too complicated.’ When it involves money and companies, it can always be done. Think about the airline industry—which really got going after the Second World War! Can you imagine how complicated it is to run a passenger air system across this world? None of this stuff, if it’s related to profits of companies, is too complicated.”
I pointed out that the lack of a profit motive is precisely why many people doubt that social justice is even possible. Dahl looked crestfallen. She was silent for a moment and then said, “So that’s it?”
“We are never going to convince everyone you should care,” Lascher said. “But this is why I think it’s important that we have people like Paul and Ophelia, who’ve been doing this for thirty-plus years, who have not shifted their belief that we should continue to push back against that narrative: ‘Appropriate technology.’ ‘African solutions for African problems.’ All of the things that have failed poor people over and over again. We have people who believe they can change the system by just doing it, by saying, ‘It doesn’t matter if you believe that a cholera vaccine is a waste of money. We’re going to do it because it’s the right thing to do.’ And then the World Health Organization—and everybody else—will change their minds.”
Thirty years of experience has not made persevering any easier for Dahl. “This work feels more crushing and sadder to me than it’s ever felt—you see all the ways in which you’ve failed to do certain things, even though there’s incremental progress,” she said. “I am unfailingly optimistic, though. I think to not be optimistic is just about the most privileged thing you can be. If you can be pessimistic, you are basically deciding that there’s no hope for a whole group of people who can’t afford to think that way.” ♦
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