Mountains Beyond Mountains: The Quest Of Dr. Paul Farmer, a Man Who Would Cure the World

This book, by the extraordinary journalist Tracy Kidder, is a sobering portrait of Dr. Paul Farmer, who has spent his life caring for the sick in Haiti and other poverty-stricken parts of the world. He is no Mother Theresa: Acerbic, angry and impatient, he has the incisive just-get-it-done attitude of a Fortune 100 CEO combined with a revolutionary’s fury at injustice. While one back-cover review calls it “a true-to-life fairy tale, one that inspires you to believe in happy endings,” that’s evidence that the reviewer didn’t read or understand the book, not an accurate description of the book, which will leave you disturbed and uncomfortable.

Kidder first meets Farmer while he’s arguing with a U.S. Special Forces captain, who’s part of a peacekeeping force. A local politician has just been beheaded, and Farmer is insisting that the captain do more to relieve suffering, rather than just trying to make things safe for American business again. The captain, Kidder feels, is making the best of a bad lot and Farmer is being unfair and rude. Weeks later, Kidder runs into Farmer on a flight back to the U.S. and, asking him about Haiti, wonders, “Does beheading have any basis in the history of Voodoo?” Touching his arm, as if to tell him it’s OK, everyone asks stupid questions sometimes, Farmer responds, “It has some basis in the history of brutality.”

That’s Farmer in a nutshell: Absolutely uncompromising, and impatient with anyone who tries to layer complexities over the simple reality of brutal murder. His language is filled with shortcuts and abbreviations, usually angry and/or insulting: “TBMI” (transnational bureaucrats managing inequality) who produce “well-formed stool” (clever arguments) against treating the poor.

Again and again he breaks traditional health-care protocols, doing things that are considered not “sustainable” or “appropriate,” like giving retrovirals to AIDS patients in Haiti who can’t possibly afford them. Or he’ll spend the whole day on a hike to check on one TB patient in a remote village, giving him a watch to reward him for compliance. “How do you expect anyone to replicate what you do?” Kidder asks him. “Fuck you,” he responds. And then he takes pity on Kidder and explains. “We can spend sixty-eight thousand dollars per TB patient in New York City, but if you start giving watches or radios to patients here, suddenly the international health community jumps on you for creating nonsustainable projects!” [42]

“Do you know what ‘appropriate technology’ means?” he asks at another point. “It means good things for rich people and shit for the poor.” [90] At a TB conference, he lectures the audience that “too expensive” is not a good excuse for not treating multiple-drug resistant TB, and the host thanks him for his “provocative remarks.” He responds, “I just said we should treat sick people if we have the technology.” [147]

Others ask how much he spent in one trial that cured 53 patients. The Japanese head of the WHO panel on TB says Farmer’s approach is “similar to HIV activists. All good clinicians without significant public health experience. Patient in front me is the most important thing.” [160] Another doctor says, “My choice is not involved in the human rights of 500 people, but five hundred versus five thousand people.” [162]

Another PIH executive responds, “There are more billionaires today than ever before. We are talking about wealth that we’ve never seen before. And the only time that I hear talk of shrinking resources among people like us, among academics, is when we talk about things that have to do with poor people.” The limited-resources line was usually used “without any recognition of how, in a given place, resources had come to be limited, as if God had imposed poverty on places like Haiti.” [175] The UN would reject funding for his AIDS treatment programs, saying they “failed to meet sustainability criteria” (the drugs were too expensive for Haitians to buy on their own), and the drug companies he approached for discounted drugs told him to seek funding from the UN. [243] But through his work, the undeniable effectiveness of his approach, and the sheer insanity of answers like these, he was able to get funding from people like Bill Gates and George Soros to expand the programs. “People think we’re unrealistic,” a PIH executive says. “They don’t know we’re crazy.” [169]

The idiocy and hypocrisy of the officials he deals with are staggering, and you have to sympathize with him as he loses his temper with them. After one banker suggests AIDS would be more controllable in Africa if Africans controlled their sexual appetites, he says ” My suspicion is that [bankers] are not getting a lot of sex, because they spend a lot of time screwing the poor.” [253] After the US cuts funding to the Aristide government, including loans for water projects and road improvements, he says, “I think, sometimes, that I’m going nuts, and that perhaps there is something good about blocking clean water for those who have none, making sure that illiterate children remain so, and preventing the resuscitation of the public health sector in the country most in need of it. Lunacy is what it is.” [258]

The message that disease is not caused by dirty water, or mosquitoes, or misbehavior by patients, but by the deliberate exploitation and mistreatment of the poor by the rich and powerful, is not one people want to hear. One of Farmer’s role models is a European doctor named Rudolf Virchow, who was sent by German government to Upper Silesia to report on the causes of an epidemic. His answer was that it was caused by abysmal social conditions and that the cure would be “full and unlimited democracy”: establishing Polish as the official language, taxing the rich, getting the church out of the business of government, building roads, opening orphanages, and investing in agriculture. Needless to say he was recalled and fired. “My politics were those of prophylaxis,” he said. “My opponents preferred those of palliation.” [61] Farmer’s favorite of his quotes is almost his motto: “The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.”

“I think of myself more as a physician than as an American,” he says. “Americans are lazy democrats…the rich can always call themselves democratic, but the sick people are not among the rich.” [229] He quotes a woman in Haiti, who points out that women often get HIV because they are forced by poverty to have sex with men to survive, either as prostitutes or just as companions for the soldiers who have guns and money. “You want to stop HIV in women?” she tells Farmer. “Give them jobs.” [199]

Farmer is by no means selfless. At one point Kidder mentions that people call him a saint, and he replies, “It’s inaccurate.” But he’s not being modest. “People call me a saint and I think, I have to work harder. Because a saint would be a great thing to be.” It’s hard to imagine how he could work any harder. In addition to his affiliation with a Boston hospital and heading up a clinic in a remote area of Haiti, he’s involved with TB treatment in Russian prisons and in Peru, with obtaining AIDS medication for Africans who can’t afford it, and with any number of other efforts that take him around the world constantly, usually in the same battered black suit. The woman who takes care of his finances at one point tells him, “Honey, you are the hardest-workin’ broke man that I know.” [23] He grew up poor, in a bayou, living in a trailer, eating food that gave him “a very compliant GI system” and working hard for his whole life. Kidder comments to his mother that there were no couch potatoes in the family. “No couch,” she replies. [55] He’s often brutal to the people he works with, expecting as much from them as he gives. “You can’t sympathize with the staff too much,” he tells Kidder at one point, “or you risk not sympathizing with the patients.” [25] “He demanded a great deal from proteges and colleagues,” Kidder says, “and he always forgave them when they didn’t measure up.

Later he expands on why he does what he does.

If you’re making sacrifices, unless you’re automatically following some rule, it stands to reason that you’re trying to lessen some psychic discomfort. So, for example, if I took steps to be a doctor for those who don’t have medical care, it could be regarded as a sacrifice but it could also be regarded as a way to deal with ambivalence.

I feel ambivalent about selling my services in a world where some can’t buy them. You can feel ambivalent about that because you should feel ambivalent. Comma.[24]

The latter is Farmer’s shorthand for the implied word that follows the comma: “asshole.” He is not very sympathetic even to those who might be considered allies, especially the white liberals, or “WLs” as he calls them, who “think all the world’s problems can be fixed without any cost to themselves.” [40] He ridicules the hippie liberals who dress in peasant clothing. “The poor don’t want you to look like them. They want you to dress in a suit and go get them food and water. Comma.” [100]

But he doesn’t have much use for conservatives either. After a visit to Cuba, where public health is better and more equitable than most other countries including the U.S., he talks to Kidder about how he’ll write about it. “When others write about people who live on the edge, who challenge their comfortable lives … they usually do it in a way that allows a reader a way out,” he says. Will his warm reception in Cuba be portrayed as a typical response of the Marxist state to one of its sycophants? Of the chief of Cuba’s Infectious Disease Institute, he says, “He’s at the pinnacle of power in Cuban medicine and he lives like a lower-middle-class American, and he doesn’t care. I have no generic liking for modest living. What I like is that Jorge believes this is right. He doesn’t like social inequality. He believes in social justice medicine. That moves me. I hate to see that ridiculed, I hate it.” [207]

Farmer abhors the Catholic hierarchy but found tremendous respect for the liberation-theology priests and nuns who actually worked with the poor. “They were just so much more militant, if that’s the word, than the WLs and the academics. They were the ones standing up to the [American-financed] growers in their sensible nun shoes.” [62] He calls their brand of religion “a powerful rebuke to the hiding away of poverty” and describes its philosophy as “the shared conviction that the rest of the world was wrong for screwing [the peasants] over and that someone, someone just and perhaps even omniscient, was keeping score.” [78]

He spends enough time with the locals that he understands the Haitian religion, Voodoo, and how it really relates to illness–the vast majority of rituals are intended to heal someone, and Voodoo is a religion that plays a very real part in people’s health just as religion does for anyone. He uses Voodoo priests as community health workers, respecting their beliefs as he uses scientific medication to cure people. At one point he does a study proving that TB cure rates are much higher when the treatment includes not only medication but also money for food and other community health services. (One of the many “duh” moments.) As he does the study he asks whether the patient believes TB is caused by sorcery, and almost everyone does. But one woman, who told him in the survey, “Don’t be stupid. I know TB is caused by germs,” tells him after she gets better that she knows who sent her sickness and that she’s going to a Voodoo priest to get revenge. “But if you believe that,” Farmer asks, “Why did you take your medicine?”

Smiling like a parent explaining something to a slow child, she says, “Honey, are you incapable of complexity?” [35] He took this as a command to worry about his patient’s material circumstances, which could make a proven difference in their health, and not worry about their beliefs.

His feelings about religion also figure into his scorn for the WLs: “The fact that any sort of religious faith was so disdained at Harvard and so important to the poor … made me even more convinced that faith must be something good.” [85] And he justifies his work by paraphrasing Matthew 25: “Inasmuch as you have done it unto the least of these my brethren, you have done it unto me …. Then it says, inasmuch as you did it not, you’re screwed.” [185] He wonders how much he could do for people in Haiti if he could get his hands on the money Americans spend on pet grooming.

At one point on a flight leaving Haiti, he asks another doctor if it won’t be hard to leave. “Are you kidding? I can’t wait,” the other doctor says, citing the miserable conditions. Farmer asks if he’ll be able to forget the poverty and the disease, and the doctor says, “I’m an American, and I’m going home.”

“Right. Me too,” responds Farmer. [80]

I saw Farmer speak a few weeks ago at the Keep A Child Alive benefit. Most of us were there to see David Bowie perform, and Farmer’s pointed remarks were probably viewed by most as the sermon to sit through in order to see what we were really there for. Exactly the kind of screwed-up priorities that would send him off on an impassioned rant.

Intentionally or not, most of us have set our priorities so that saving the lives of poor people with curable diseases is less important than significant changes in our standard of living. This book raises uncomfortable questions for us, poking at what Kidder calls “the often unacknowledged uneasiness that some of the fortunate feel about their place in the world.” As you read it, you ask the obvious questions about the reality of what Farmer does. At one point his organization spends upwards of $20,000 to fly one Haitian boy with cancer to Boston for treatment. The cancer turns out to be untreatable, the boy dies, and even people in Farmer’s organization ask whether something better couldn’t have been done with the money. After a day-and-a-half hike up a mountain to visit a couple of patients, Kidder poses the question to him. Farmer first points out the other questions that could be asked — why didn’t the airplane company donate its services? If $20,000 is so precious, why are first-year doctors making $150,000 a year not asking those questions about their own salaries? But he also acknowledges that it may not be a winning battle.

How about if I say, I have fought for my whole life a long defeat. How about that? How about if I said, That’s all it adds up to is defeat? … I have fought the long defeat and brought other people on to fight the long defeat, and I’m not going to stop because we keep losing …

People from our background … we’re used to being on a victory team, and actually what we’re really trying to do in PIH is to make common cause with the losers. Those are two very different things. We want to be on the winning team, but at the risk of turning our backs on the losers, no, it’s not worth it. So you fight the long defeat. … I don’t care if we lose, I’m gonna try to do the right thing. [288-89]

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