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

by Tracy Kidder

Trucks of various sizes, top-heavy with passengers, swayed in and out of giant potholes, raising clouds of dust, their engines whining in low gear. A more numerous traffic plodded along on starved-looking donkeys and on foot. Here and there beggars stood on the banks of the road, rubbing concave bellies with one hand while holding out inverted straw hats. Here and there boys with hoes smoothed out little patches of roadway, making shows of their diligence, then lifting their hands in the hope of reward.

In Haiti, tuberculosis still killed more adults than any other disease, but no one in Zanmi Lasante’s catchment area had died from it since 1988. The money for Zanmi Lasante was funneled through a small public charity that Farmer had founded—Partners In Health, with headquarters in Boston. The bills were small by American standards. Farmer and his staff of community health workers treated most tuberculosis patients in their huts and spent between $150 and $200 to cure an uncomplicated case. The same cure in the United States, where most TB patients were hospitalized, usually cost between $15,000 and $20,000.

A man with gastritis in late middle age. In Haiti, Farmer told me, that could mean thirty years old, since 25 percent of Haitians die before they reach forty.

Even after the dam, most peasants still had their black, low-slung Creole pigs, which they kept like bank accounts, to pay for things such as school tuition. But in the early 1980s, they lost those as well. Alarmed about an outbreak of African swine fever in the Dominican Republic, afraid that it might threaten the American pork industry, the United States led an effort to destroy all the Creole pigs in Haiti. The plan was to replace them with pigs purchased from Iowa farmers. But these were much more delicate, much more expensive to house and feed, and they didn’t thrive. Many peasants ended up with no pigs at all. When school started the year after the slaughter, enrollments had declined dramatically, throughout the country and around Cange.

We’re asked to have tidy biographies that are coherent. Everyone does that. But the fact is, a perfectly discrepant version has the same ending.”

“The fact that any sort of religious faith was so disdained at Harvard and so important to the poor—not just in Haiti but elsewhere, too—made me even more convinced that faith must be something good.”

To build a school was to unite the practical and the moral. Farmer would say, “Clean water and health care and school and food and tin roofs and cement floors, all of these things should constitute a set of basics that people must have as birthrights.”

When Farmer was back in Boston, doing his internship at the Brigham, White would drive over at lunchtime and buy sandwiches at the restaurant inside the hospital. He and Farmer would eat them in White’s car. One day White asked Farmer, who looked pale as usual, “You eatin’ enough?” “Oh, I’m fine,” said Farmer. “Need any money?” “No,” said Farmer. “Well, maybe forty dollars?” White happened to have a wad of hundred-dollar bills in his pocket. He tossed one into Farmer’s lap. “You look hungry to me.” Saying this, he felt impelled to reach in his pocket again. He tossed another hundred to Farmer. “Please, for God’s sakes, eat,” he said, and to emphasize the point, he gave Farmer yet another hundred. Farmer looked down at the loot. “Now I can tell you what happened last night.” He’d gone to the home of an AIDS patient whom he had treated at the Brigham and found out the man was about to be evicted. “I signed my check over to him.” “Jeez, Paul, don’t you think that’s kind of impractical?” Farmer smiled. “Well,” he said. “God sent you today.”

One time when they were together in Boston, White said, “You know, Paul, sometimes I’d like to chuck it all and work as a missionary with you in Haiti.” Farmer thought for a while, then said, “In your particular case, that would be a sin.”

Lives of service depend on lives of support. He’d gotten help from many people.

Meager incomes don’t guarantee abysmal health statistics, but the two usually go together.

Doctors are notorious for taking peculiar views of their own bodies. They tend to develop hypochondria in medical school and, once they get over it, if they do, tend to think they’re invulnerable.

The World Health Organization serves as the coordinating body for virtually all the world’s ministries of health. It sets guidelines and standards, publishes recommended approaches, acts as an advisory group. It’s where all the information about health and a lot of the complaints go, and it performs some crucial functions well, such as the collection and dissemination of worldwide epidemiological data. But it is perennially short of money, and like most parts of the United Nations it is infamously, inevitably, tangled in bureaucracy. It has a tendency to freeze in the face of controversy. The organization’s critics said it had two mottoes: “Slow down” and “It’s not our fault.”

One can guess a lot about the economic condition of a country by inspecting the baggage people carry there from the United States, the shopping mall for the poor countries of the world.

Among a coward’s weapons, cynicism is the nastiest of all.

It still seemed to me that he took a stance all too conveniently impregnable. He embodied a preferential option for the poor. Therefore, any criticism of him amounted to an assault on the already downtrodden people he served. But I knew by now he wasn’t simply posing. I felt something about him that I’d later frame to myself this way: He said patients came first, prisoners second, and students third, but this didn’t leave out much of humanity. Every sick person seemed to be a potential patient of Farmer’s and every healthy person a potential student. In his mind, he was fighting all poverty all the time, an endeavor full of difficulties and inevitable failures. For him, the reward was inward clarity, and the price perpetual anger or, at best, discomfort with the world, not always on the surface but always there. Sensing this, I’d begun to be relieved of the shallower discomforts I sometimes felt in his company, that I’d felt keenly back in the airport in Cuba. Farmer wasn’t put on earth to make anyone feel comfortable, except for those lucky enough to be his patients,

Impolite terms, used intramurally, were meant as philosophical rebukes to the misplaced preoccupations of those who believed in “identity politics,” in the idea that all members of an oppressed minority were equally oppressed, which all too conveniently obscured the fact that there were real differences in the “shaftedness,” also sometimes called the “degrees of hose-edness,” that people of the same race or gender suffered. “All suffering isn’t equal” was an article of the PIH faith, generated in reaction to the many times when they had tried to raise money and instead had been offered lectures about the universality of suffering, or simply lines like “The rich have problems, too.”

Embracing a continuity and interconnectedness that excluded no one seemed like another of Farmer’s peculiar liberties. It came with a lot of burdens, of course, but it also freed him from the efforts that many people make to find refuge and distinction from their pasts, and from the mass of their fellow human beings.

large foundations tended to finance narrowly focused campaigns against well-publicized diseases.

It occurred to me that PIH would probably always be in some kind of financial jeopardy, because it was constitutionally impossible for Farmer and Kim to sit on resources—to wait for lower drug prices while MDR killed Russian prisoners, to save for an endowment for Zanmi Lasante while Haitian peasants died of AIDS. Their approach, especially toward money, was completely impractical, it seemed to me, and yet it appeared to be working.

travel, Farmer told Ophelia that he heard two sets of voices. At one ear he heard friends and allies saying he should concentrate on the big issues of world health and, at the other ear, the groans of his Haitian patients: the voice of the world saying, “This meeting’s important,” and the voice of Haiti saying, “My child is dying.”

Poverty in a place like Haiti is difficult to personalize. If it’s in front of you, it has a reality.”

if you say that seven hours is too long to walk for two families of patients, you’re saying that their lives matter less than some others’, and the idea that some lives matter less is the root of all that’s wrong with the world. I think he undertakes what, earlier today, he called “journeys to the sick” in part because he has to, in order to keep going. “That’s when I feel most alive,” he told me once on an airplane, “when I’m helping people.” He makes these house calls regularly and usually without blan witnesses, at times when no one from Harvard or WHO can see him kneeling on mud floors with his stethoscope plugged in. This matters to him, I think—to feel, at least occasionally, that he doctors in obscurity, so that he knows he doctors first of all because he believes it’s the right thing to do. If you do the right thing well, you avoid futility. His patients tend to get better. They all get comforted.