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

by Tracy Kidder

“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.”

“You can’t sympathize with the staff too much, or you risk not sympathizing with the patients.”

I’ll take great pleasure in violating the principle of cost-efficacy.”

“Haitians believe in sorcery because their culture has evolved in the absence of effective medicine.

“Giving people medicine for TB and not giving them food is like washing your hands and drying them in the dirt.”

Farmer had taken his greatest pains to assert the interconnectedness of the rich and poor parts of the world, and the dam was his favorite case study.

“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,

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

All true, but not the truth. We’re asked to have tidy biographies that are coherent. Everyone does that.

He wrote them that he couldn’t belong to an all-white organization. (“I received quite a frosty reply,” he would say, in a tone of voice that implied this still surprised him.) He’d come to admire his father’s distaste for putting on airs, and the man’s fondness for underdogs—

Above all, she thought, once they’d focused on a goal, neither one would quit.

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

His prescription for curing Upper Silesia was “full and unlimited democracy.”

“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.”

But it was staffed mainly by white, expatriate doctors. He’d imagined something different—a hospital at least partly devoted to training Haitians to treat Haitians.

anthropology concerned itself less with measurement than with meaning. As in mastering a language, one had to learn not just the literal meanings of words but also their connotations, and to grasp those one had to know the politics and economic systems and histories of a place. Only then could you really understand an event like the mango lady’s death.

“highly reticulated relations among disease, nutritional status, socioeconomic factors, and health and illness beliefs and practices.”

comprehensive theory of poverty, of a world designed by the elites of all nations to serve their own ends, the pieces of the design enshrined in ideologies, which erased the histories of how things came to be as they were.

During one of their long talks in his room, she found herself thinking, “Oh dear, oh good, my life has changed.” Years later she would tell me, “I think there’s a point where you realize the world has just been revealed to you. It’s like realizing your parents are both good and bad. It’s sort of, Oh no, things will never be quite the same again.”

“the shared conviction that the rest of the world was wrong for screwing them over, and that someone, someone just and perhaps even omniscient, was keeping score.”

Looking back at this first year of living in Haiti, Farmer would speak of the feeling that many things in his mind coalesced into a vision of his life’s proper work. But, he’d insist, this happened in stages, not all at once. “For me, it was a process, not an event. A slow awakening as opposed to an epiphany.”

“What does that mean, ‘I’m an American’? How do people classify themselves?”

‘We’re all human beings.’

he’d wondered obsessively about the role anthropology should assume in his life.

He’d been taught that an ethnographer should observe, not try to change what was being observed. But practiced in that way, anthropology seemed “impotent” in the face of “everyday problems of adequate nutrition, clean water, and illness prevention.”

He had settled not for a synthesis between observing and acting, but for doctoring and public health work that would be partly guided by anthropology.

“I was fully formed at twenty-three.” He meant, I think, that by then he had his philosophy and worldview in order, and knew that he wanted to marry them to action, first of all in Cange.

“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?”

it was hard to avoid comparing herself with him.

concrete latrines, scattered through the village. “But,” Farmer asked, “are they appropriate technology?” He’d picked up the term in a class at the Harvard School of Public Health. As a rule, it meant that one should use only the simplest technologies required to do a job.

And a school could serve as a place for teaching lessons about health and for providing free meals to malnourished children without injuring their dignity.

they had an argument about guilt. White said he thought it was a useless emotion. On the contrary, Farmer said, it could be quite helpful.

He seemed to be saying that if he and the peasantry could get along without things like Diet Coke, so could she. “He was so sure about some things,” she remembered. “The frustrating thing was, he usually was right.” In the car, she started in on him, accusing him of self-righteousness. She didn’t let up. Finally, he slammed on the brakes, reached across her, and pushed open her door. “Get out!” he yelled, and called her a foul name. She didn’t obey. She sat rigidly in her seat, feeling both offended and also exultant, smiling inwardly, thinking, “Yes! I got to you. You have this human quality. You’re flawed.”

“It was very important to Paul to witness things,”

They were no longer merely asking if infant diarrhea was caused by germs but asking whether the germs were caused by dirty water. And didn’t dirty water come from the neglect of feckless, greedy governments?

They talked about the insignificance of “cultural barriers” when it came to the Haitian peasant’s acceptance of modern Western medicine: “There’s nothing like a cure for a disease to change people’s cultural values.” They talked about appearance: “The goofiness of radicals thinking they have to dress in Guatemalan peasant clothes. 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.”

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.

“I knew that he loved me. And I loved him,” she would say. But for her, relations were strained: “the strain of living with a fellow who was in love with something else, something that I could never compete with, even if I’d wanted to.”

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.

“Being his wife would have been no bargain. But to be his friend is simply wonderful.”

There was violence on all sides, but as usual the side with guns and money was responsible for most of it.

Lives of service depend on lives of support.

Farmer got formal permission, that is, to spend half his time at the Brigham and the other half in Cange.

It is, I think, the best of Farmer’s books, certainly the most passionate, essentially a history of American policy toward Haiti.

Perhaps it is a universal tendency to view the deaths of strangers philosophically.

In PIH’s 1993 annual report, he’d written that they should never change their mission or soften their message in order to broaden their appeal. Accordingly, he wrote, they should resign themselves

the line dividing the two color-coded parts of humanity—what Farmer called the “great epi divide” (epi being short for epidemiological)—

Soon he’d taught himself to read patients’ records upside down. Again and again he read stories of patients who hadn’t been cured by standard chemotherapy, or by repeated retreatment with first-line drugs. He’d saunter out of the health centers, then drive as fast as he could to the Socios office in Carabayllo, a concrete building that belonged to Father Jack’s church, now named the Father Jack Roussin Center. He’d hurry inside, sit down at his computer, and type up what he’d read, in e-mails addressed exclusively to Farmer and Kim.

do the ridiculous whatever it is, in the moment. the sense doesnt come until later