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The Story of the 'Miraculous' Inhaler and Why Inequality Is Everyone's Problem

I was diagnosed with asthma in 1984. It was easy for me, then a student at Harvard Medical School, to get the medication I needed, even as I shuttled between Haiti and Harvard.
My Haitian colleagues, who had built a clinic in rural Haiti, and I attended to the sick and injured as best we could. We could see that much more preventive care was needed, and to this end we trained and salaried community health workers in dozens of villages. Part of my job was to visit them and their neighbors. One day I walked eight miles to attend a town meeting in a thatch-roofed, dirt-floored church. Afterward, anxious to get back, I looked up at the gathering storm clouds. It was afternoon already, and getting back across the reservoir meant a lot more walking, even if we took a dug-out canoe halfway.
“Dr. Paul, he can’t breathe!”
A community health worker wanted me to see a patient. I had an image, in my mind, of an older person, short of breath. I responded firmly, “The patient’s home is not even in the right direction and it will soon be dark. He should get to the hospital for a chest X-ray and lab tests.” I added, perhaps guiltily, “I didn’t even bring my stethoscope.”
The sick man’s young wife came to my side. “Please come see him. He’s been sick since yesterday.” Frustrated, I acceded, complaining en route that whatever he had would be better treated in the hospital.
It took 45 minutes to reach the house. There, leaning against a dirty pillow on a mat on the floor, was Jean. His muscles looked corded and tensed; his lips were the color of bruises; and he couldn’t speak. Even without a stethoscope, I could see that he was dying of nothing other than an asthma attack.

I thought I’d been telling the truth when I protested that I had no medications with me. But I did have one: an inhaler of albuterol, one of the few things that might save Jean’s life. One of the community health workers pinched Jean’s nose shut while I pushed the canister into the blue plastic tube, trying to force some of the albuterol mist into his open mouth and down into his seized-up airways.
Within minutes—suspenseful, painful minutes—his shallow gasps turned into quiet wheezing. Within half an hour he could speak haltingly. “Thank. You, doctor,” he said, squeezing my hand. A little crowd had gathered outside. Huge mounds of praise were heaped upon me. “I can’t believe it! You saved him!”
Technically, it was true. That is, the inhaler had saved his life. There was no other illness I might have palliated on that afternoon. Since I had the inhaler in my pocket and managed to get half a dose into his lungs, I had, technically, saved him.
It seemed unnecessary to explain, then and there, that it was pure dumb luck, or that I’d originally been unwilling to come to his house. I left the inhaler with him and explained that we had other medicines at the clinic that would reduce the risk of another attack. There was no point in explaining the gravity of the illness—no one understood that better than Jean.
Less than a week later Jean was back in clinic, this time with clear lungs, a gift of a small goat, and another heaping of thanks and praise. My discomfort mounted.
“It was only dumb luck!” I said, coming clean.
“Nonsense!” he replied. “So what if you have asthma, Dr. Paul, and were walking with the inhaler for yourself? It was meant to be!”

To this day, Jean and the community health workers probably feel the same way. But I want to underline what the inhaler story really means in a world rife with inequality.
First, and most obviously: we inhabit a bizarrely unequal planet. This was true in 1492, when Columbus crossed the ocean only to shipwreck off Haiti’s northern coast. It was true when Haiti became a French slave colony. And it was true more than 25 years ago when I was led unwillingly to Jean as he lay dying on his mat.
It’s even more true today. In 2011, 93 percent of all new wealth generated in the U.S. economy went to the “one percent.” Worldwide, 0.5 percent of the global population holds more than 35 percent of the world’s wealth. Meanwhile, two billion people live on less than $2 a day.
Plutarch, in ancient Greece, noted that, “an imbalance between rich and poor is the oldest and most fatal ailment of all republics.” Such imbalances are even less tolerable in modern times. What does it mean to die unattended of a severe asthma attack in the age of Facebook or LinkedIn? I hope all of you will seek new ways, and old ones, of narrowing our world’s growing inequalities.
Second, I’ve come to understand that there is something miraculous in the Story of the Inhaler. I don’t mean miraculous in some fatalistic sense, but rather the miracle of human solidarity. We are all intrinsically connected across one world, not three, and occasionally we need other people to spin us around and yank us out of our stubborn ways.
Third point, and hardest one to make: inequality and injustice can make fools of us all. Only a fool would take full credit for saving Jean’s life, or mistake happenstance for destiny. Inequality is everybody’s problem, whether we contemplate pandemic disease or global warming. How we choose to build systems to deliver the fruits of science and technology is critical to our planet’s flourishing in the coming decades. It will take all of us, together. It will take a collective rethinking of age-old problems to counter the failures of imagination that have plagued our efforts to make this beautiful but wounded planet a little more equal.
Paul Farmer, MD, PhD, is Kolokotrones University Professor and Chair of the Department of Global Health and Social Medicine at Harvard Medical School, Chief of the Division of Global Health Equity at Brigham and Women’s Hospital in Boston, and co-founder of Partners In Health. He also serves as UN Special Adviser to the Secretary-General on Community Based Medicine and Lessons from Haiti. Dr. Farmer and his colleagues have pioneered novel, community-based treatment strategies that demonstrate the delivery of high-quality health care in resource-poor settings. He has written extensively on health, human rights, and the consequences of social inequality.
The Story of the Inhaler is adapted from Dr. Farmer’s May 2012 commencement address at the College of the Holy Cross. The address appears in full in Dr. Farmer’s most recent book, To Repair the World: Paul Farmer Speaks to the Next Generation.

Dr. Farmer examining a patient photo credit: Mark Rosenberg. Photos showing Cange— where Dr. Farmer worked in Haiti and where PIH continues to work today—in the early 1980s and again 20 years later. The reservoir from the story can be seen in the background.


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