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

by Tracy Kidder

And right action is freedom From past and future also. For most of us, this is the aim Never here to be realised; Who are only undefeated Because we have gone on trying … T. S. ELIOT, “THE DRY SALVAGES”

He smiled at me, and his face turned bright, not red so much as glowing, a luminescent smile. It affected me quite strongly, like a welcome gladly given, one you didn’t have to earn.

But his way would be hard to share, because it implied such an extreme definition of a term like “doing one’s best.” The world is full of miserable places. One way of living comfortably is not to think about them or, when you do, to send money.

Chest crackings, organ transplants, molecular imagings, genetic probes—gloved hands and machines routinely reaching into bodies and making diagnoses and corrections, so much of human frailty on the one hand and boldness on the other.

“That guy’s a fuckin’ saint.” It wasn’t the first time Farmer had heard himself called that. When I asked him his reaction, he said that he felt like the thief in Hawthorne’s novel The Marble Faun, who steals something from a Catholic church and, before making his escape, dips his hand in holy water. “I don’t care how often people say, ‘You’re a saint.’ It’s not that I mind it. It’s that it’s inaccurate.” This was seemly, I thought, resisting beatification. But then he told me, “People call me a saint and I think, I have to work harder. Because a saint would be a great thing to be.” I felt a small inner disturbance. It wasn’t that the words seemed immodest. I felt I was in the presence of a different person from the one I’d been chatting with a moment ago, someone whose ambitions I hadn’t yet begun to fathom.

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.

Little sleep, no investment portfolio, no family around, no hot water. On an evening a few days after arriving in Cange, I wondered aloud what compensation he got for these various hardships. He told me, “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.” He went on, and his voice changed a little. He didn’t bristle, but his tone had an edge: “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.” This was for me one of the first of many encounters with Farmer’s use of the word comma, placed at the end of a sentence. It stood for the word that would follow the comma, which was asshole. I understood he wasn’t calling me one—he would never do that; he was almost invariably courteous. Comma was always directed at third parties, at those who felt comfortable with the current distribution of money and medicine in the world. And the implication, of course, was that you weren’t one of those. Were you?

“Haitians believe in sorcery because their culture has evolved in the absence of effective medicine. So of course they believe in sorcery, in sicknesses that someone has sent to them. Why else would someone fall into a coma? And when someone is very sick and people are used to seeing them die with the same symptoms and you give them meds and they rapidly recover, people think. And then they start talking.” In his experience, most Haitians eagerly embrace effective medicine. He has dozens of Voodoo priests among his patients, some of them serving as virtual community health workers, bringing him ill parishioners. Sorcery is, at bottom, the Haitians’ way of explaining suffering, but the allegations themselves can cause suffering. Now an elderly woman enters Farmer’s office. She’s the subject of the sorcery consult. The other day in the courtyard Farmer saw her son moping around and asked him what was wrong. “My mother hates me,” he said. In fact, the mother believes her son “sent” the sickness that killed another son. As she sits down beside Farmer and he begins telling her not that sorcery doesn’t exist but that he knows sorcery wasn’t involved in this instance, she lifts her chin and averts her face. Gradually, she softens. But it will probably take months to reconcile her fully with her surviving son.

The annals of international health contain many stories of adequately financed projects that failed because “noncompliant” patients didn’t take all their medicines. Farmer said, “The only noncompliant people are physicians. If the patient doesn’t get better, it’s your own fault. Fix it.”

“There’s a WL line—the ‘They’re poor but they’re happy’ line. They do have nice smiles and good senses of humor, but that’s entirely different.” Like many of his remarks, this one gave me pause. Just when you thought you had the hang of his worldview, he’d surprise you. He had problems with groups that on the surface would have seemed like allies, that often were allies in fact, with for example what he called “WL’s”—white liberals, some of whose most influential spokespeople were black and prosperous. “I love WL’s, love ’em to death. They’re on our side,” he had told me some days ago, defining the term. “But WL’s think all the world’s problems can be fixed without any cost to themselves. We don’t believe that. There’s a lot to be said for sacrifice, remorse, even pity. It’s what separates us from roaches.”

Education wasn’t what he wanted to perform on the world, me included. He was after transformation.

This view of drowned farmland, the result of a dam that had made his patients some of the poorest of the poor, was a lens on the world. His lens. Look through it and you’d begin to see all the world’s impoverished in their billions and the many linked causes of their misery. In any case, he seemed to think I knew exactly what he meant, and I realized, with some irritation, that I didn’t dare say anything just then, for fear of disappointing him.

“If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life.”

“My politics were those of prophylaxis, my opponents preferred those of palliation.”

“Medicine is a social science, and politics is nothing but medicine on a large scale.” “It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation.” “Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community.” “The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.” This last was Farmer’s favorite.

How could a just God permit great misery? The Haitian peasants answered with a proverb: “Bondye konn bay, men li pa konn separe,” in literal translation, “God gives but doesn’t share.” This meant, as Farmer would later explain it, “God gives us humans everything we need to flourish, but he’s not the one who’s supposed to divvy up the loot. That charge was laid upon us.” Liberation theologians had a similar answer: “You want to see where Christ crucified abides today? Go to where the poor are suffering and fighting back, and that’s where He is.”

“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.”

He would say, some years later, that he had “faith,” then add, “I also have faith in penicillin, rifampin, isoniazid, and the good absorption of the fluoroquinolones, in bench science, clinical trials, scientific progress, that HIV is the cause of every case of AIDS, that the rich oppress the poor, that wealth is flowing in the wrong direction, that this will cause more epidemics and kill millions. I have faith that those things are true, too. So if I had to choose between lib theo, or any ology, I would go with science as long as service to the poor went along with it. But I don’t have to make that choice, do I?”

“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.”

WL’s were forever saying, “Things aren’t that black and white.” But some things were plenty black and white, they told each other—“areas of moral clarity,” which they called AMC’s. These were situations, rare in the world, where what ought to be done seemed perfectly clear. But the doing was always complicated, always difficult.

More than ever he seemed to her like an important person to believe in. Not as a figure to watch from a distance, thinking, Oh, look, there is good in the world. Not as a comforting example, but the opposite. As proof that it was possible to put up a fight. As a goad to make others realize that if people could be kept from dying unnecessarily, then one had to act.

Margaret Mead once said, Never underestimate the ability of a small group of committed individuals to change the world.” He paused. “Indeed, they are the only ones who ever have.”

Shortly after the Boston meeting, Jim Kim went to WHO headquarters in Geneva. No one he talked to there even knew that the patents on all but one class of the second-line antibiotics had expired years ago. And no one there seemed very interested when he declared, “We can drive down the prices by ninety to ninety-five percent.” Jim didn’t know exactly how to make that happen. Make the assertion, then figure out the means—this was his strategy. “The big-shot strategy,” Farmer called it, approvingly.

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.”

“Resources are always limited.” In international health, this saying had great force. It lay behind most cost-effectiveness analyses. It often meant, “Be realistic.” But it was usually uttered, Kim and Farmer felt, 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. Strictly speaking, all resources everywhere were limited, Farmer would say in speeches. Then he’d add, “But they’re less limited now than ever before in human history.” That is, medicine now had the tools for stopping many plagues, and no one could say there wasn’t enough money in the world to pay for them.

These days his life had one central logistical problem. Ophelia defined it succinctly: “Wherever he is, he’s missing from somewhere.” Farmer’s solution for now was sleeping less and flying more.

One time he got in an argument about Cuba with some friends of his, fellow Harvard professors, who said that the Scandinavian countries offered the best examples of how to provide both excellent public health and political freedom. Farmer said they were talking about managing wealth. He was talking about managing poverty. Haiti was a bad example of how to do that. Cuba was a good one.

How could anyone say that no war among socioeconomic classes existed, or that suffering wasn’t a “social creation,” especially now, when humanity had developed a grand array of tools to alleviate suffering.

Assume that each new promise was real and obtain as many as possible, to increase the odds that one or two might be real. And he’d follow up with calls, letters, e-mails, and if those didn’t bring results, they still might produce a little shame, which might increase the chances that the next promise would be real.

By 2000 the overall rates of HIV infection and deaths from AIDS were dropping in the United States, but infections and deaths had claimed a much larger percentage of the population than in Cuba, and HIV had become mainly a heterosexual disease concentrated among the American poor. Cuba, meanwhile, had the lowest per capita incidence of HIV in the Western Hemisphere—its HIV statistics were probably among the most accurate in the world, for the simple reason that, in Cuba, testing wasn’t optional and millions had been tested. On an island of 11 million, only 2,669 had tested positive as of 2000. The virus had progressed to AIDS in 1,003 of those people, and 653 had died. Only five children had caught HIV from their mothers, and all those children were still alive. Because Cuba had acted quickly to clean up its blood supply, only 10 people had contracted HIV from transfusions. One could argue that the U.S. embargo had protected the island, but then again, back at the start of the epidemic Cuba had engaged in a lot of commerce with Africa.

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

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,

I imagine that many people would like to construct a life like Farmer’s, to wake up knowing what they ought to do and feeling that they were doing it. But I can’t think that many would willingly take on the difficulties, giving up their comforts and time with family.

Of all the world’s errors, he seemed to feel, the most fundamental was the “erasing” of people, the “hiding away” of suffering. “My big struggle is how people can not care, erase, not remember.” I had wondered if there was room in his philosophy for anyone but the world’s poor and people who campaigned on behalf of the poor. One day on an airplane, he confided to me that he thought of all our fellow passengers as patients. An attendant’s voice had said over the intercom, “Is there a doctor onboard?” He’d gotten up at once and ministered to a middle-aged, evidently middle-class American man who, as it turned out, wasn’t having a heart attack. Back in his seat afterward, Farmer said this happened to him about once in every eighteen flights. I had the impression that he wouldn’t have minded if it happened every flight. 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.

I think it’s a fight you can’t win.” “That’s all right. I’m prepared for defeat.” “But there are the small victories,” I said. “Yes! And I love them!”

The goal was to improve the lives of others, not oneself. “It’s not about the quest for personal efficacy,” as Paul himself liked to say. Besides, frank imitations would fail. What PIH-ers should take from Paul wasn’t a manual for their own lives but the proofs he’d created that seemingly intractable problems could be solved. “Paul has created technical solutions to help the rest of us get to decency, a road map to decency that we can all follow without trying to imitate him,” Jim told me, explaining the message on the wall. “Paul is a model of what should be done. He’s not a model for how it has to be done. Let’s celebrate him. Let’s make sure people are inspired by him. But we can’t say anybody should or could be just like him.” He added, “Because if the poor have to wait for a lot of people like Paul to come along before they get good health care, they are totally fucked.”

“I didn’t say you should do what I do. I just said these things should be done!”

What’s wrong with this picture? If you say, Well, I just think how much could have been done with twenty thousand dollars, you sound thoughtful, sensible, you know, reasonable, rational, someone you really want on your side. However, if you were to point out, But a young attending physician makes one hundred thousand dollars, not twenty, and that’s five times what it cost to try to save a boy’s life—that just makes you sound like an asshole. Same world, same numbers, same figures, same currency. It’s just, you know, I never have been able to figure it out. I mean, I’ve figured it out, but I realize now it takes so much time to get to that point, to explain it, without offending someone.

I can imagine Farmer saying he doesn’t care if no one else is willing to follow their example. He’s still going to make these hikes, he’d insist, because 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 once heard Farmer say that he hoped a day would come when he could do a good job just by showing up. It seems to me that time has already arrived. A great deal of what he’s started goes on without him now, in Roxbury and Tomsk and Peru and, some of the year, in Haiti. Meanwhile, other definitions than the usual, of what can be done and what is reasonable to do in medicine and public health, have spread from him. They’re still spreading, like ripples in a pond. How does one person with great talents come to exert a force on the world? I think in Farmer’s case the answer lies somewhere in the apparent craziness, the sheer impracticality, of half of everything he does, including the hike to Casse.

in 2003, only 300,000 people were being treated for AIDS in what is euphemistically called “the developing world.” At WHO, Jim created a campaign to increase the number treated to 3 million by 2005: He called the effort “3 by 5.” An impossible goal, many thought, and they were right. But by 2005, more than one million new patients were in treatment, and the total in Africa had increased eightfold. There’s no way to predict the ultimate effects of such a “failure,” but officials who two years before had been arguing against universal treatment for AIDS began to say they had been in favor of it all along. In the high councils of international health, the 3 by 5 campaign was, as Jim put it, “like a bowling ball thrown into a chess match.”

All too often international aid organizations weaken the societies they are supposed to help. Often they rely almost entirely on professionals from the world’s wealthy countries, and they fail to make their projects indigenous. This all but guarantees that their projects will neither grow nor last. PIH is different. The organization now has on the order of 6,500 employees. The overwhelming majority come from the impoverished countries where PIH is working. Fewer than one hundred of the employees come from the United States.

PIH was still small then, in the first years of the new millennium, and yet it was already creating vivid proofs that diseases that could be treated successfully in the developed world could also be treated successfully and economically in some of the poorest, most difficult settings imaginable. That was the moving thing for me, seeing the proof. There is all the difference in the world between passively witnessing misery and witnessing people at work trying to relieve misery.

“I’m interested in public health, too!” said Paul. “But what is the public? Is it a family, a village, a city, a country? Who are these people to say what the public is?”