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

by Tracy Kidder

“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.”

The health workers’ theory amounted to a description of the kind of socioeconomic arrangement that he called “structural violence.”

Of the patients who had received only free medicine, a mere 48 percent were cured. By contrast, everyone in the group that received the cash stipends and other services made a full recovery. Whether a patient believed that TB came from germs or sorcery didn’t seem to have made any difference at all.

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.”

The project was intended to improve irrigation and to generate power. It wasn’t as though the peasants of the central plateau didn’t need and want modern technology, Farmer said. But, as they themselves often remarked, they didn’t even get electricity or water for their land. Most didn’t get money either. In fact, the dam was meant to benefit agribusinesses downstream, mostly American-owned back then, and also to supply electricity to Port-au-Prince, especially to the homes of the numerically tiny, wealthy Haitian elite and to foreign-owned assembly plants.

Things got worse. 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.

I noticed, as I had around Cange, that many people we passed wore clothes from America, brand-name running shoes that had seen much better days and baseball caps and T-shirts bearing the logos of professional sports teams and country clubs. “Kennedys” was the generic name for stuff like that. Back in the 1960s, Farmer had explained, President Kennedy sponsored a program that sent machine oil, among other things, to Haiti. The Haitians tried to use the oil for other purposes, such as cooking, and concluded that the gift was of inferior quality. Ever since, the president’s name had been synonymous here with secondhand and shoddy goods.

Compared with other historical figures in medicine, such as Pasteur or Schweitzer or Florence Nightingale, Virchow isn’t very well-known. Only one full-length biography of him exists. Yet he was, as one commentator writes, “the principal architect of the foundations of scientific medicine,” the first to propose that the basic units of biological life were self-reproducing cells, and that the study of disease should focus on changes in the cell. Virchow made important contributions in oncology and parasitology, coined at least fifty medical terms still in use today, defined the pathophysiology of a host of diseases, including trichinosis, and led a successful campaign for compulsory meat inspection in Germany. He designed a sewage system for Berlin that transformed it from a fetid sty into one of Europe’s healthiest cities. He founded a nursing school and hospitals. He was a practicing archaeologist and played an instrumental role in Heinrich Schliemann’s excavations of Troy. He helped to define the field of medical anthropology. He was a physician and a teacher and a practicing politician, so nettlesome in opposition to Germany’s imperial ambitions that Bismarck once challenged him to a duel.

In his report, Virchow expressed a fundamental law of epidemiology: “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.” This meant, among other things, establishing Polish as the official language, taxing the rich instead of the poor, getting the church out of the business of government, building roads, reopening orphanages, investing in agriculture. The government fired him. Virchow would write, “My politics were those of prophylaxis, my opponents preferred those of palliation.” He had a knack for aphorism. “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.

In 1980, when Archbishop Oscar Romero was murdered by a right-wing death squad in El Salvador, faculty and students held a protest vigil at the Duke Chapel, and Farmer attended. He also did some reading about the branch of Catholicism called liberation theology, which Romero had been murdered for preaching.

Farmer told me that he found his life’s work not in books or in theories but mainly through experiencing Haiti. “I would read stuff from scholarly texts and know they were wrong. Living in Haiti, I realized that a minor error in one setting of power and privilege could have an enormous impact on the poor in another.” The eradication of the Creole pig, or the dam at Péligre, for example.

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.”

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. Its uses were obvious. A doctor who knew nothing about local beliefs might end up at war with Voodoo priests, but a doctor-anthropologist who understood those beliefs could find ways to make Voodoo houngans his allies. A doctor who didn’t understand local culture would probably mistake many patients’ complaints for bizarre superstitions, or at best be utterly baffled—by the female complaint called move san, lèt gate, for instance.

“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.

They talked about issues such as political correctness, which Jim Kim defined as follows: “It’s a very well-crafted tool to distract us. A very self-centered activity. Clean up your own vocabulary so you can show everybody you have the social capital of having been in circles where these things are talked about on a regular basis.”

In the book, a number of heroes don’t look so fine. The French revolutionaries, whose idea of fraternité didn’t include the slaves in St. Domingue, and the Haitian “mulattoes” who went to France to aid those revolutionaries in the hope that they could win the right to own slaves themselves. Woodrow Wilson, who presided over the American invasion of Haiti. Even FDR, who once boasted that, while serving as assistant secretary of the navy, he had written the Haitian Constitution of 1918. (There were others on this list whom Farmer often mentioned elsewhere: the former American slave and great abolitionist Frederick Douglass, who eagerly served as American ambassador to Haiti, in effect representing the Monroe Doctrine there. And Mother Teresa, who came to Haiti in 1981, during the time of Baby Doc, and, as one historian put it, “gushed” over the profligate dictator and his widely hated wife, Michele, who had looted millions from the Haitian treasury for her worldwide shopping sprees. Mother Teresa said Michele had taught her a lesson in humility and marveled at the closeness of the first lady to her people.)

There was a proper procedure for dealing with resistance. When a patient didn’t get better on standard therapy, a doctor should suspect that the TB was impervious to some drugs in the regimen and should find out which drugs as quickly as possible and substitute others. Giving patients the wrong drugs was both useless and dangerous. It could lead to what infectious disease specialists call “recruitment of further resistance.” The term exactly described the process that Farmer saw in the ten patients’ records. He chose to call the process “amplification,” because that term sounded worse. These ten Peruvians had gone to the doctor sick and emerged, about two years later, sicker, their TB becoming resistant to more and more drugs as it went on eating their lungs. Not because they hadn’t followed doctors’ orders, but precisely because they had. And those orders weren’t simple acts of stupidity or carelessness. They were enshrined as official policy. They came from on high, from the people in charge of Peru’s TB program, who had gotten them from Geneva, from the World Health Organization itself.

Jim’s task was like a logician’s conundrum. To lower the prices of the drugs, he had to show that a lot of TB projects would use them. For a lot of projects to use them, the prices had to be lower. For the prices to be lower, the generic manufacturers would have to get involved. They’d be more inclined to get involved if WHO would put the second-line antibiotics on its official list of essential drugs. But rarely used drugs are by definition not essential. To break through this circular chain, Jim began to lobby WHO for the drugs’ inclusion on the list.

“For me to admire Cuban medicine is a given,” Farmer said. It was a poor country, and made that way at least in part by the United States’ long embargo, yet when the Soviet Union had dissolved and Cuba had lost both its patron and most of its foreign trade, the regime had listened to the warnings of its epidemiologists and had actually increased expenditures on public health. By American standards Cuban doctors lacked equipment, and even by Cuban standards they were poorly paid, but they were generally well-trained, and Cuba had more of them per capita than any other country in the world—more than twice as many as the United States. Everyone, it appeared, had access to their services, and to procedures like open heart surgery. Indeed, according to a study by WHO, Cuba had the world’s most equitably distributed medicine. Moreover, Cuba seemed to have mostly abandoned its campaign to change the world by exporting troops. Now they were sending doctors instead, to dozens of poor countries. About five hundred Cuban doctors worked gratis in Haiti now—not very effectively, because they lacked equipment, but even as a gesture it meant a lot to Farmer.

“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. Seems like I’m the one who should hope for as much from you.”

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.

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.