Summary
Chapter 18 focuses on a pivotal meeting of the International Union Against Tuberculosis and Lung Disease in April 1998. Tuberculosis expert Arata Kochi, who had been one of the champions of DOTS ("directly observed treatment short-course chemotherapy") as a way to treat TB, recognized the success Farmer was having treating MDR patients. He coined the phrase "DOTS-plus" as a name for it, which gave the TB specialists a way to discuss it. However, this success was met with a serious challenge: Alex Goldfarb raised the question of cost of treatment. Goldfarb was responsible for treating TB in Russia, which was quite widespread in the prison system. Goldfarb argued that his choice was between treating 500 patients with Farmer's more expensive program or 5,000 patients with standard treatments (and saving most of those). Though Jim Kim opened the discussion about expanding resources (raising more money to fight TB), at this time PIH had no answer to Goldfarb's challenge.

Analysis
In Chapter 17, Farmer had had to deal with complexity on the scientific and personal levels to save two specific children. In Chapter 18, several members of PIH had to deal with complexity in the social, political, and economic realms in hopes of saving entire populations with TB. It is darkly humorous that renaming Farmer's treatment "DOTS-plus" created such an advantage among a group of scientists. The ideal would be, of course, that scientists can deal with the facts of the physical world, without bias or prejudice. Instead, a simple renaming can alter their response. At the same time, Goldfarb's challenge, while political, is not so ironic. While they are suffering, the patients that he mentions with TB are in fact prisoners. Ideally, that means they are criminals. Why should a population like Russia's, with an unsettled economy and limited resources, spend so much more on those who have broken their nation's laws?

Kidder demonstrates both dramatic control and moral honesty when he lets the challenge stand unanswered. What will Farmer's team at Partners in Health do? How will they address the fact that economic resources are limited and poorly distributed? As if part of a serial cliffhanger, readers must tune in to the next chapter to learn the answer.