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

by Tracy Kidder

He enjoyed these transnational diagnostic excursions, for him small acts of redistribution.

The motion of his mind toward root causes had always excited him.

paying attention to individual patients was a moral imperative;

Don’t let perfect be the enemy of good.”

borrowed from the nineteenth-century utilitarian philosophers, from the notion that one should provide the greatest good for the greatest number, and it was expressed in a language of realism. The world had limited resources. Nations whose resources weren’t just limited but scarce had to make the best possible uses of the little they had.

Make the assertion, then figure out the means—this was his strategy.

He told Farmer that he felt liberated from “the self-hatred and evasion of ethnicity” he’d felt in Muscatine.

“It’s good to have to come to understandings of that, but you’ve got to put that behind you now,”

but no one could say anymore that cost alone ruled out treating the disease in poor countries.

“a preferential option for the poor”—

“Yeah, but, Jim, we trust you with power. We know you won’t betray the poor.”

“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.

diamond vs gewertz

Paul and Jim mobilized the world to accept drug-resistant TB as a soluble problem,

doesn’t matter where or what because you know he’ll do important things.

Patients came first, prisoners second, and students third.

“Wherever he is, he’s missing from somewhere.”

“Matthew twenty-five,” said Farmer. “Inasmuch as you have done it unto the least of these my brethren, you have done it unto me.”

complex personality, built of oppositions—a need for frenzied activity that verged, she thought, on desperation, and a towering self-confidence oddly combined with a hunger for affirmation.

“The problem is, if I don’t work this hard, someone will die who doesn’t have to.

had studied the world’s ideologies. The Marxist analysis, which liberation theology borrowed, seemed to him undeniably accurate. 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. And he was more interested in denouncing the faults of the capitalist world than in cataloging the failures of socialism. “We should all be criticizing the excesses of the powerful, if we can demonstrate so readily that these excesses hurt the poor and vulnerable.”

“I can sleep here. Everyone here has a doctor.”

‘You want to stop HIV in women? Give them jobs.’

was apt to be most cheerful when facing adversities, small ones anyway.

Then, it seemed, he got to the heart of the matter: what I was going to write about Cuba, especially about him in Cuba. “When others write about people who live on the edge, who challenge their comfortable lives—and it has happened to me—they usually do it in a way that allows a reader a way out. You could render generosity into pathology, commitment into obsession. That’s all in the repertory of someone who wants to put the reader at ease rather than conveying the truth in a compelling manner.

“Some people would say things will get so bad that Haitians will revolt. But you can’t revolt when you’re coughing out your lungs or starving. Someone’s going to have to revolt on the Haitians’ behalf, including people from the wealthy classes.”

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

He embodied a preferential option for the poor. Therefore, any criticism of him amounted to an assault on the already downtrodden people he served.

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.

Farmer wasn’t put on earth to make anyone feel comfortable, except for those lucky enough to be his patients, and for the moment I had become one of those.

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.

Farmer craved connections among all parts of his life

“An H of G” was short for “a hermeneutic of generosity,” which he had defined once for me in an e-mail: “I have a hermeneutic of generosity for you because I know you’re a good guy. Therefore I will interpret what you say and do in a favorable light.

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”

(Farmer once taught a course at Harvard called Varieties of Human Suffering.)

To commit “a seven-three” was to use seven words where three would do, and a “ninety-nine one hundred” was quitting on a nearly completed job.

It’s a parallel universe. There really is no relation between the massive accumulation of wealth in one part of the world and abject misery in another.’

It seemed like a place of hyperconnectivity.

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.”

Farmer believed, obviously, in the importance of intentions and the power of will, but also in revelation, in “signs.”

‘Massachusetts is a great state, it has a big TB lab, lots of TB doctors, lots of TB nurses, lots of TB lab specialists. It lacks only one thing. Tuberculosis.

that’s called privilege, not democracy.”

you’re exposing prisoners to higher risk, so it’s wrong not to treat them first.”

I have never met an efficient individual who didn’t claim to be sentimental or working for a higher cause.

“You’re a great guy,” I said, putting a hand on his shoulder. “But without your clinical practice—”

The goal was to improve the lives of others, not oneself.

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,”

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

In Jim Kim’s view, Zanmi Lasante wouldn’t survive without the support of some large foundation or international agency, and it wouldn’t get that support unless it was seen as something like a laboratory for the world, not just as a marvelous anomaly. At times this kind of talk made Farmer testy. “It’s galling,” he told me in the winter of 2002. “It should be enough to humbly serve the poor.”

To Farmer, the distinction between prevention and treatment was artificial, created, he felt, as an excuse for inaction.

“It’s embarrassing that piddly little projects like ours should serve as exemplars,” Farmer told me. “It’s only because other people haven’t been doing their jobs.”