Wednesday, July 6, 2022

Mountains Beyond Mountains

 


Book: Mountains Beyond Mountains
Basic Information : Synopsis : Characters : Expectations : Thoughts : Evaluation : Book Group : New Words : Book References : Good Quotes : Table of Contents : References

Basic Information:

Author: Tracy Kidder

Edition: epub on Libby from the Sacramento Public Library

Publisher: Random House Trade

ISBN: 0812973011 (ISBN13: 9780812973013)

Start Date: June 11, 2022

Read Date: July 6, 2022

333 pages

Genre:  History, Biography

Language Warning: Medium

Rated Overall: 4  out of 5


History: 3 out of 5


Religion: nominal Christianity

Religious Quality: example more than teaching

Christianity-Teaching Quality: none



Synopsis :

Tracy Kidder biography of Paul Farmer. He talks about meeting Farmer in Haiti and on his flight back and being impressed and disturbed. And then finding our more about his work. He talks about Farmer’s childhood, which formed a lot of Farmer’s values.


Then in college he excelled without really trying. But he was moving towards helping take care of needs in Haiti. Because of his excellence in school, he had choices about where to do his residency. He arranged to spend part of his time in Boston with the rest of it in a remote part of Haiti.


This was the beginning of his work which developed into Partner’s in Health. As he became more known and respected, other places with TB problems requested his help-places like Lima Peru, Cuba, Russia, Siberia all came under his influence.


Rather than becoming an executive of Partners in Health, he dedicated himself to seeing patients, developing protocols which would work for them, rather than the health care system. Parts of the book talk about choices he made-to remain with patients rather than bureaucracy. The argument he faced was he could be more effective and reach a wider range of people. But he felt that was not his calling.


Part of this book is Kidder doing a typical biographer’s work: checking sources, reading about him, interviewing associates. But what makes this book special is that Kidder spent at least two years with Farmer, traveling with him, hiking with him, and most importantly, meeting his patients. So Kidder was able to get a good perspective on the man and his work.




Cast of Characters:
  • Paul Farmer-Main person. Doctor, humanitarian, …
  • Tracy Kidder-author, accompanied many trips with Farmer
  • Jim Yong Kim-protese of Farmer. More of an organizational man than a in contact with patients. He rises up to being a senior medical advisor in WHO.

  • Ti Jean-Maintenace man for Farmer and Farmer’s confident
  • Ti Fifi-Medical person who is important at Cange
  • Jon Carroll-Special Forces captain who was there to help gain order after the overthrow of the Jaitian military junta
  • Ophelia Dahl-Farmer and her were deeply in love. SHe realized it would not work out. But she continued to be one of the leading figures in Partner in Health. She was the daughter of Roald Dahl and Patricia Neal. Farmer and her met at Eye Care Haiti.
  • Tom White-Major donor and initial instigator in Partners in Health. Made his money in construction. Also a good sounding board for Farmer.
  • Todd McCormack-classmate of Farmer. Became a founding board member of PIH.
  • Didi Bertrand-Farmer’s wife
  • Fritz Pete Lafontant-Anglican priest who operated a small clinic and had built a chapel in Cange.
  • Father Jack Roussin-Farmer met him in Boston, roomed in his rectory. On the board of PIH. In the early 1990’s, went to a church in Lima, Peru, in a section of town called Carabayllo. Died of TB while in Lima.
  • Jamie Bayona-local point person in Lima
  • Howard Hiatt-former dean of medicine. Advisor to PIH.
  • Arata Kochi-WHO lead doctor on TB. Created DOTS and DOTS-Plus
  • Alex Goldfarb-biologist, Russian American. Took the lead on the Russian TB project
  • Guido Bakker-Leader of the International Dispensary Association (IDA) which specializes in driving down the prices of essential drugs.
  • Bill Foege-lead the drive to eradicate smallpox. Head of the CDC for awhile. Senior Fellow of the Gates Foundation
  • Jorge Perez-Cuban doctor, leader in the Cuban health sector



Expectations:
  • Recommendation: Unknown-saw the book long time ago and bought it. I have read other Kidder books and I have enjoyed and learned from them
  • How come do I want to read this book: I have read a couple of Tracy Kidder’s books and liked them. Our book group decided to read it.
  • What do I think I will get out of it? Biography of Paul Farmer

Thoughts:

In so many ways, read the Epilogue first. Then you get the idea of where Kidder wants to take this story.


As I read this story, it occurs to me that to be a biographer of Farmer, one must be in very good shape to follow him around on a normal day, let alone for a prolonged time.



Farmer Short Hands

  • ID-Infectious disease(s)
  • PIH-Partners in Health
  • WHO-World Health Organization
  • Comma-a placeholder for another word at the end of a sentence. Usually the word asshole
  • Bwat-box, such as checkbox
  • Blan-white, but not just the color of skin, but of how one acts. Even Farmer could not get away from being a blan
  • WL-White liberals
  • O for P-preferential option for the poor
  • JPS-Journal of Popular Studies, i.e., People magazine
  • Dismount-end the conversation
  • H of G-hermeneutic of generosity. Being able to interpret something in a favorable light.
  • DQ-Drama Queen (Not Dairy Queen)
  • Geek Flowers-papers done for Farmer
  • Scholbutt-scholarly buttressing. Making sure all of your facts and conclusions are correct.
  • Lugar-luggage
  • Koutoms-customs
  • Seven-three-to use seven words when three would do
  • Ninety-nine one hundred-quitting on a nearly completed job



Part 1 - Doktè Paul

Chapter 1

Kidder talks about how he first met Paul Farmer. Kidder came to Haiti in December 1994 as a reporter when the American Special Forces took down the military junta. He was attached to Capt Jon Carroll. There was a murder in Mirebalais which Carroll needed to investigate. The main suspect was Nerva Juste, a local sheriff. Farmer came to Port du Prince and met with Carroll about the murder. Farmer made it plain he didn’t like the American government’s plan for fixing Haiti’s economy, a plan that would aid business interests but do nothing, in his view, to relieve the suffering of the average Haitian. In Farmer’s mind, Two clear sides existed in Haiti, Farmer said—the forces of repression and the Haitian poor, the vast majority.


That was the last Kidder saw of Farmer while in Haiti. But he was on the same plane as Farmer going back to the United States. He had the opportunity to talk more with him then and understand him a bit better. He was not happy that Carroll had not arrested Juste. It sent the message to the common Haitians that the Americans had no intention of changing things.


As Kidder knew Farmer better, What struck me that evening was how happy he seemed with his life. To Farmer commuting back and forth from Haiti and Boston was great. He enjoyed living in Haiti and doing good there. … after our dinner I drifted out of touch with him, mainly, I now think, because he also disturbed me. It sounds to me that Farmer did not preach anything to Kidder, but just how Farmer lived and his values was making Kidder uncomfortable.


Chapter 2

Farmer’s arrangement was to spend about three months a year in Boston at the Brigham Hospital and teaching courses at Harvard. He taught future doctors, particularly in infectious diseases. Takes place in December 1999.


Talked about a patient in Boston who had fluid on the brain. Possible TB or pneumonia. Even for a bum, Farmer gives undivided attention and concern. He becomes the patient’s friend and the patient respects Farmer because of it. The patient feels Farmer is a saint. Kidder: 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. But to know Farmer, you needed to go to Haiti, his oeuvre.


Chapter 3

To get from Port au Prince to Farmer’s medical center in the central highlands, you take Highway 3. Even calling it a highway is a misnomer as it is not paved, there is room for a single vehicle, and the road has boulders and ravines in it which has to be navigated around. But what Kidder remembered from this first trip was, One noticed absences. An oxcart and no ox, only a man pulling it. Most of the area has been deforested and there are no power lines.


Zanmi Lasante-in Cange. The translation from Creole is Partners In Health. It is a large walled compound with foliage in it. Sort of an oasis in the middle of an ocean of despair. Has an ambulatory clinic, a women's clinic, a hospital, an Anglican church, school, kitchen, capable of serving 2,000 meals.


Kidder follows Farmer on his daily routines and gets an education on the needs of the common person in Haiti. The rule was that everybody had to pay 80 cents for medical care. But Farmer subverted it with his own exceptions. On the other hand, Farmer gave almost his entire earnings to PIH.


Sounded like Farmer was driven. Not by greed or to get ahead. Maybe guilt? I do not know this is true and Kidder does not explore further-at least in this chapter. Kidder talks about the guilt Farmer feels later on in the book. I [Farmer] can’t sleep. There’s always somebody not getting treatment. I can’t stand that. Kidder does ask a bit further and gets this answer: 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. Kidder’s take was that his anger was not directed towards Kidder, but towards a system which prioritizes the accumulation of wealth over the lives of people.


One of Farmer’s characteristics is personal courtesy. It’s so awful you might as well be cheerful. Kidder notes: One local peasant told me, speaking of Farmer, “God gives everyone a gift and his gift is healing.


Kidder and Farmer talk a lot in the book about voodoo and sorcery-they are not the same. Sorcery is a type of perceived magic. It is the explanation of the unknown. Sorcery is, at bottom, the Haitians’ way of explaining suffering, but the allegations themselves can cause suffering. While Farmer does not believe sorcery exists, the Haitian belief is very real. What can happen is the belief that someone has caused another person’s suffering. The accused may be ostracized or worse. A great many beliefs and practices in Haitian magic originate from Normandy, Berry, Picardy or ancient Limousin,” writes the anthropologist Alfred Métraux. Farmer’s tendency to explain things like this is what Kidder calls narrating Haiti..


Farmer liked to tell his Harvard students that to be a good clinician you must never let a patient know that you have problems too, or that you’re in a hurry.


Chapter 4

You could title this chapter the education of Kidder. At least that seems to be what Farmer set out to do.


When a person died while he was in Boston, his staff noted, she would not have died if he was in Cange. Rather than a compliment, he internalized it as a self-reproach. This goes along with my comments about guilt in the previous chapter. Is this a good way to handle when bad things happen in your absence?


Farmer was not only a medical doctor, but also an anthropologist. So when he saw a cultural problem, such as patients getting better, but not finishing their regiment of medicine-the locals thought more in terms of sorcery rather than microbes. He conducted an experiment with half of the patients also receiving home visits to follow up. There was close to 100% complete cure vs 48% of the non-home visit. He concluded that medicine is not only about providing medical treatment, but also being concerned with home life. Farmer’s take on it was The only noncompliant people are physicians. If the patient doesn’t get better, it’s your own fault. Fix it.”


Haitian proverb: Beyond mountains there are mountains. Which is where the title comes from. It basically means the farthest reaches of the area. They were going to a part of the area which was remote. A little bit of riding in a jeep. Lots of walking. As the crow flows, it looks like 2½ miles, but up and down many ridges.


Talks about the impact of the Peligre Dam. Removed peasant farmers from their land with the promise of electricity and water. They received neither.


Farmer:. “I love WL’s [white liberals] , 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. This gives one pause. Usually liberals think of themselves as the good guys. But here, Farmer is calling them out that they want solutions which do not cost them [me] anything.


Kennedys:. 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.


Throughout the book, Farmer is fighting the “cost-effectiveness” argument. He looks after each patient. His thought is that … you can never invest too much in making sure this stuff works. This was walking four-five hours to visit a single patient to make sure that the patient was taking his medicine. He is not concerned with replicating himself, more of making sure his patient gets well. The objective is to inculcate in the doctors and nurses the spirit to dedicate themselves to the patients, and especially to having an outcome-oriented view of TB.


Zo- Haitian board game


Wherever Farmer went in this area, people knew him and gathered around him. Respect and wanting help.


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


To understand Russia, to understand Cuba, the Dominican Republic, Boston, identity politics, Sri Lanka, and Life Savers, you have to be on top of this hill. Concluding sentence to this part. This is on the return back to the jeep from their hike.



Part 2 - The Tin Roofs of Cange

Chapter 5

Talks about Farmer’s upbringing. Family background was Roman Catholic. Raised in a bus. Early on he read the Lord of the Rings and War and Peace. Moved from Alabama to Florida. They lived a vagabond life. The father bought a boat and fixed it up, sort of. They got caught in a storm, far from land. Farmer’s brother said: it was a strange feeling—you knew he[the father] didn’t know what he was doing, but you also felt the security.


Farmer tells a shortened, neat biography about why he got interested in Haitians. All true, but not the truth. We’re asked to have tidy biographies that are coherent. Sort of. I think we all have a story we have in our minds of who we are. We try not to make it messy.


Farmer would say, it was hard to feel embarrassed or shy in front of anyone. He allowed that growing up as he did also probably relieved him of a homing instinct=that is as a vagabond, he did not have the image of a house which he felt he had to have.


He went to Duke. He quit his fraternity-it was all white. He’d come to admire his father’s distaste for putting on airs, and the man’s fondness for underdogs. He got accepted to Harvard.


Chapter 6

Farmer was very popular in college, fun to be around, and smart. He also studied in Paris.


Rudolf Virchow-the person who Farmer considered his mentor. This man pretty much set up the definitions modern medicine is based upon. If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life. Another one of his sayings: Medicine is a social science, and politics is nothing but medicine on a large scale. Also The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them. Farmer felt he had a comprehensive view of the world.


Farmer was taken by liberation theology. He [Farmer] was impressed, not by their [[church ladies, such as Julianna DeWolf] piety but by what they were willing to do on behalf of the migrant workers.


To Farmer, the world seemed to be caught up in a Lord of the Rings type struggle. He started to be more involved with Haitian immigrants, particularly the farmworkers. In 1983 he spent a year in Haiti having already learned Creole. He ended up being at Eye Care Haiti.


Chapter 7

Talks about Farmer’s relationship with Ophelia Dahl. She decided it would not work out. You pointed out to me once, during an emotional argument, that the qualities I love in you—that drew me to you—also cause me to resent you… I would place my own emotional needs in the way of your important vision; a vision whose impact upon the poor.


Paul said, “Tell me about your family.” Many years later a friend of hers would offer this recipe for seduction: “Go out to dinner and say, ‘Tell me about your life.’ ”



Dahl’s take on Farmer was that He’s innocent about meanness. He was deep and would not tell you all his thoughts until he knew he could trust you. Ophelia’s and Farmer’s relationship deepened. She had money, he had knowledge of Haiti.


Farmer: anthropology concerned itself less with measurement than with meaning.


Dahl translated one of Farmer’s mystery sentences to something like this: Accidents happen. Sure. But not every bad thing that happens is an accident. It was left up to the hearer to understand and give meaning to it.


[Farmer] laid out a 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.


Chapter 8

In May 1983, Farmer was searching for a suitable place to do his work. He first came to Cange then. His first impression was of a community depressed. it was hard to imagine an entire community poorer and sicker than this. A huge freshwater reservoir was a half mile away and all was dusty with little fresh water source. He kept touring Haiti. Got sick, did work as a volunteer. Farmer told me that he found his life’s work not in books or in theories but mainly through experiencing Haiti.


He felt drawn back toward Catholicism now, not by his own belief but in sympathy with theirs, as an act of what he’d call “solidarity. Also toward liberation theology. The peasants understood its basic concept; everybody hates us, but at least God loves us.


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. The meaning according to Farmer is that there is an abundance which God has given to us humans. But it is up to humans to share that abundance and we do not do it.


There was no aha moment for Farmer, seeing his life work. He felt it came on him as a process. He worked with a doctor who was leaving after a year-the doctor had worked well with the Haitians and loved them. But Haiti was something he [the doctor] was seeing that he could leave and erase from his mind, and I was thinking, Could I do that? He was leaving Haiti, really leaving in body and mind, and I realized I was going to have trouble with that.


In cooperation with Lafontant, Farmer set up shop in Cange. He had a vision of a wider and comprehensive system for the area, to provide not only a free clinic, but also other medical services, including a hospital. With his anthropology training, he did a medical survey to find out what the needs are. (I would have thought he would have seen with his own eyes, since he was drawn there. But I think he had a better way.) 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.


With this kind of background, where he understood local customs, even the Voodoo practices, he went back to Harvard and enrolled in Harvard Medical School in 1984. He hardly attended lectures, but was there for the labs. His time away he spent in Haiti.


Chapter 9

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. Interesting way to start the chapter. Whatever Harvard hates, and the rest of the world loves, must be good.


Chapter starts off talking about a sort of belief Farmer has, I hesitate in calling it a faith. He now wore a cross, but in some ways this seemed more in unity with the peasants of Haiti than a sign of personal affirmation. He had sympathies to the religious.


It is interesting that he felt that he needed to say he also had a faith in science as well as in liberation theology. How Kidder writes, it sounds like having fun, playing around is an exception to religion rather than part of it. On the other hand, Farmer does not sound like he has a terribly large amount of morals which might come with a religious faith.


There was something about learning and saying latin names which turned Farmer on.


A lesson which Dahl learned was one time when she slipped, an old man offered her his walking stick. She refused. Farmer said she was refusing a gift and one should never do that.


Dahl’s thought one time (or probably more) was I just want to do something better than him. For a moment.


Farmer had Dahl do a second, more refined survey. One thing which happened is that a group of engineers from a church realized the issue and constructed a pipeline which gave Cange fresh waters. The infant death rate dropped almost immediately. Farmer was learning about the great importance of water to public health.


Lafontant and his church group established a clinic which Farmer helped stock, including a lab. While the physical construction was his vision, Farmer was the one who envisioned a whole health system. We have to think about health in the broadest possible sense. Lafontant also established a school. This brought education with the promise of the future for advancement. Farmer: To build a school was to unite the practical and the moral. … 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.


Farmer had asked an organization for a small donation. They lined up a donor, which eventually became Tom White. During World War II, Tom White learned to dislike the tendency of the powerful to view human beings as pins on a map. White found himself imagining himself in Haiti and what could be done.


Chapter 10

Being in a relationship with Farmer could be exhilarating and uplifting. But Farmer was also very driven so there was never a feeling of having personal time with him. Not that he ever made Dahl feel second place, just not looking at her needs.


In the summer of 1987 Partners in Health came into being.


Kim and Farmer and Dahl would talk about various issues. Some of the discussion would become a bit self-interest, such as a statement like There’s nothing like a cure for a disease to change people’s cultural values. Their thinking was that medicine really addressed the symptoms of a culture. They felt they should make common cause with anybody who was working to make the lives of common people better. PIH felt that they needed to provide services to the desperately poor—directly, now. They called this “pragmatic solidarity,” a goofy term perhaps, but the great thing about it was that, if you really practiced it, you didn’t have to define it, you could simply point at what had been accomplished.


In 1988, he got hit by a car in Boston, shattering a knee. This laid him up for a while. Farmer was not a good patient. Dahl realized that things would not work out with them. But she still wanted to remain in his sphere. Being his wife would have been no bargain. But to be his friend is simply wonderful.”


Chapter 11

Farmer returns to Haiti in December 1988,, in a wheelchair, then crutches. He witnesses changes of government, but realizes that it is the United States who is behind the military who actually runs the country.


Haiti is a predominantly Catholic country which also believes in VooDoo. Then Jean-Bertrand Aristide became known. A priest who had substantial influence and eventually became president. When Farmer went to his church, he saw that People read the Gospel as if it pertained to another place and time, but the struggles described there are in the here and now. Isn’t this how we should be reading the Gospel? It is Good News after all. Aristide and Farmer became friends.


AIDS had now come to Cange, not only TB. That became the topic of Farmer’s Phd dissertation in anthropology. The official US position was that AIDS had come from Haiti to America. Farmer’s data showed it probably came to Haiti from the US and Canada.


Farmer got his Phd and MD at the same time. One of the perks of being a top flight student is to be given the choice of what you want to do. He and Kim shared a residency at Brigham. Half the time he spent in Boston, the other half in Haiti. But apparently he now had become noticed and started getting threatening phone calls from an unknown source.


Aristide won the election. Farmer had hopes for Haiti. But then he was deposed while Farmer was in Boston.


Chapter 12

By the books Farmer was reading, he was a socialist-Che Guevaro and Castro. He was someone who was a supporter of the resistance to the military, but not overtly. Probably the one reason Farmer had not been taken in was that everybody knew he was the best doctor in central Haiti and he would doctor anybody-resistance or soldier. Friends of Farmer were being killed. He was not able to return until October 1994 when Aristide was returned to power.


1993-Farmer wins a MacArthur award. He write what Kidder thinks is his best book: The Uses of Haiti



Part 3 - Médicos Aventureros

Chapter 13

Usually lack of income goes with poor health, for a community. This part now talks about how TB gets resistant to drugs and how Farmer and PIH had to fight to get appropriate treatments in the third-world. The action goes to Lima Peru.


Chapter 14

Father Jack, a priest who Farmer had stayed with in Boston, moved to Lima. Father Jack saw a need for a medical outreach like Farmer had down in Cange. After a lot of convincing, Kim was sent to set this up. The organization in Lima was called Socios en Salud-roughly Partners in Health. Farmer spent time in Lima. A pharmacy was set up. Farmer did a health survey.


Father Jack got sick with TB. Was treated in Boston and still died. What they found out was that Father Jack’s TB was resistant to all of the standard TB drugs. His death caused Farmer to re-evaluate the work in Lima. Was Father Jack an isolated case or was it endemic? As Bayona started asking around, it became apparent this was a larger issue.


Chapter 15

In the Acts account of St Paul’s travels, there is a place where Paul’s adventures become Luke’s eyewitness account. This chapter is similar. Kidder takes more of I was there than in the previous chapters.


Lima is a study in contrasts. First impression is of a gleaming modern environment. And then there are the slums.


To test for TB which was resistant to first line drugs (MDR-TB), you had to get a culture and test it against the drugs. Farmer did not have access to testing in Peru-only the government and its clinics could. So he sent them to Boston under his own title. All ten samples came back resistant-to Farmer this was both alarming and rare. It had vast significance.


Usually when patients have MDR-TB, it is because their standard WHO DOTS treatment was interrupted. But here, all ten had completed treatment. The standard approach is to add another drug and then another until you can get a drug where the patient is not resistant. As Farmer thought about the possibility, he realized that they were now four to five drug resistant and that they needed to get on second tier drugs, which were expensive. He loved the challenge of diagnosis and all its accoutrements—the stains on the microscopic slides, the beautiful morphologies of the creatures under the lens.


Chapter 16

Second tier or second line defense drugs against TB were expensive, weak and had strong side effects. So it was not to be used lightly. Peru had a model WHO TB treatment. But prior to four years back, it was chaotic.


PIH debated about taking this project on. But in the end, it needed to be done. As Kim said, if done right, they could have global impact.


They put together a team of native Peruvians who were the contact people and Harvard medical people who would help with the medical part. Meche Becerra was one of the people.


There was hostility when the news was presented to the Peruvian medical establishment. They had a model program. Besides what did Americans know? They do not have TB. He [Farmer] looks like a gringo,” Jaime answered mildly. “But he’s a fake gringo.” There was a practical concern for the Peruvians. If this was true, their big problem of TB was going to grow exponentially. Then there was the money issue-how do you pay for all the drugs.


Farmer now meets the treating the patient vs how do you administer this to the whole health system issue. Especially in an impoverished nation like Peru. Farmer gave a speech to an International TB group in Chicago where he brought out the issues being faced in Peru.


Michael Iseman


Chapter 17

By 1994 the romantic relationship with Dahl was finished, but still friends. He had found a woman in Cange who would be his wife-Didi. She really does not play too much into the book’s story. That in itself is interesting. What part in Farmer’s life did she play? They had a child together, but it seems like Farmer is more of an absent father than someone who is close to his daughter.


The Lima patients had grown from 10 to 50. More were coming. How to manage the care and expenses for all of these, with more, a lot more in the pipeline. Hiatt was approached by the president of Brigham and noted that Farmer and Kim were playing Robin Hood with the hospital’s pharmacy. White made good on the cost. To many seasoned managers of public health projects, what Farmer and Kim were doing would have looked quite reckless—like a stunt, as some would later insinuate. That seems to me the case as well. Was Farmer taking on all of the sick of Lima, of Peru? Or did he have limits? How was he going to limit those he would doctor to? I do not think Farmer’s mentality thought through the ramifications-he is focused on the here and now. He was thinking more of what was in front of him and letting someone else have the headaches. Essentially, They lacked proper institutional support.


It is easy to think, I can do things without a big government or a big organization. All is wonderful, until what they are doing catches on and blows up.


Farmer just added Peru to his list of activities of Haiti, PIH, Brigham, Harvard teaching and speaking engagements. Between all of that, he came down with hepatitis A. 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. Kidder realized that I’d become inclined to hold Farmer to a higher standard than I did most people, including myself. And, as a rule, to see him in action was to excuse him.


As the Lima patients were improving, the Peruvian doctors noticed. Kidder saw the gratefulness of a family. But then he also saw that a child was sick with MDR-TB. The drug’s dosage was for adults. Farmer pretty much guessed at what the right dosage would be and administered it. I think in this way, Farmer could be very reckless. On the other hand, would the child have died or suffered irrecoverable destruction without? I think Farmer, he would also try rather than wait to find out. Different from me who wants to know before trying. Farmer had the intelligence to pull this off.


Kidder has Farmer making a statement about that people, in this case doctors, want to do what is right. They just do not want to disobey orders.


Chapter 18

A meeting of the TB community was called to hear what was happening in Lima. The meeting was called by Hiatt with Arata Kochi of WHO present. He was the one who created DOTS. He was on the public health side of the equation.


Alex Goldfarb was at this meeting. He and Farmer would later be involved in a TB project in Russia. Goldfarb hit the nail on the head. How to come up with the money for expensive drugs for a large population. In Goldfarb’s case, TB was very prevalent in Russian prisons. They only had enough money to use one drug. $3,000,000 will treat 5,000 TB patients or 500 MDR-TB patients. If he has $6 million, how should he spread out the money? The young PIH-ers glared at Goldfarb. But he’d made an argument that they’d have to answer, sooner or later. A thought-Farmer never felt constraint by money.


Kim talked about why PIH took on the project in Lima. He concluded with 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.”


Chapter 19

The philosophy of the established TB community was 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. I would say this should be a good starting point. if you wanted to be taken seriously, your proposals had to pass a test, called cost-effectiveness analysis. Sounds very business-like. Sounds like you would be able to spread the good across a wide variety of people. But as Farmer and Kim were about to point out there are some fallacies to this:

  • You concentrate on the known and make due with that.
  • You do not concentrate on part of the equation which allows for better cost-effectiveness. You look more at the part which gives you the greatest bang for the buck.
  • This equation tends to favor the status quo and/or those who work the equations, rather than those who can be helped the most
  • Innovation is stifled
  • You reduce people to numbers rather than looking at them as God would look at them.


Lima had shown the MDR-TB treatment could be effective. How did that affect this cost-effectiveness equation?


Gives background on Jim Kim. One of the things which Kim saw as he grew up and went to college was various inequities, such as the racial ones. But he was also very naive, such as not being aware of what the Japanese did to Koreans prior to and during World War II. As these became known to him, he would become disillusioned with a cause. They[Farmer and Kim] hadn’t talked long before Jim declared that he wanted to make Farmer’s preferential option for the poor his own life’s work


Kim looked at the cost of the second-line TB drugs. He found that most of the patents had expired. The problem was that there were 750,000 users and most of them could not pay for the drugs. He found that the price also varied from country to country.


The International Dispensary Association (IDA) got interested in driving down the prices. They worked with smaller companies to manufacture these drugs at a lower price. Kim worked on WHO to get these drugs listed as essential, which would help be a selling point. There was a precedent through the work of a committee called the Green Light Committee. Kim set up his own. Prices began to fall.


Kim had been training to be a doctor. Now he was more interested in the public health aspects of it. Farmer thought that was a good idea. Kim said: There have been fundamental frame shifts in what human beings feel is morally defensible, what not.


And now the finances were catching up with PIH. Now Kim wanted to go and get funding from the Gates Foundation. Bill Foege now comes into the picture.



Part 4 - A Light Month for Travel

Chapter 20

TB was part of a trio of health concerns: AIDS and malaria being the other two. the world faced public health catastrophes on a scale not seen for centuries, since the eras of plague in Europe or the near extinctions of indigenous peoples in the Americas. Remember this was written in the early 2000’s, before the COVID pandemic hit.


Farmer was being encouraged to operate at a higher level so he could be more effective in reaching a broader audience. After all, look what he had done in Haiti or Lima part time. But Farmer felt that was not his calling. He still wanted to be close to people.he didn’t seem disposed to abandon any side of his work, including seeing patients one-on-one in Haiti. He continued to answer letters and emails, about 75 a day. The problem was defined by Dahl: Wherever he is, he’s missing from somewhere.


Kidder and Farmer discuss Matthew twenty-five, the part about if you have done to the least of these, you have done to me. On the way out of town, Farmer has brought along a truck full of Haitians to do various tasks. They stop at a jail to see one of the farmer’s sons.


Kidder talks a bit about Farmer’s mind. he made himself immune to the self-consuming varieties of psychic pain. You do wonder how Farmer coped with the misery around him, not that he put himself higher. Rather he got immersed in it. Some of the trade offs Farmer made was in limiting his clothing on travel. This was so he could carry more medical supplies. complaint didn’t seem to be his usual mode. Traveler tip: keep clean so you can use less clothing. Farmer worked about 100 hours a week. Why? He felt if he worked less, people died needlessly. Sounds like trying to outrun some guilt.


Havana the next stop.


Chapter 21

As Kidder and Farmer are landing in Havana, Farmer notes that while Haiti has been deforested, Cuba is verdant. As an American, I think of Cuba as a backward country which has been run down by Castro. But Kidder shows several things. One of them is that even with limited resources, Cuba has been able to take care of its TB patients in a way definitely much superior to Haiti and close to being on par with the United States. There were twice as many trained doctors in Cuba per capita than in the United States. 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.


Farmer had studied the world’s ideologies. The Marxist analysis, which liberation theology borrowed. To Farmer this analysis seemed to be accurate. I wonder if he thought the Marxist solution was correct. Farmer was more interested in denouncing the faults of the capitalist world than in cataloging the failures of socialism. Shows both Farmer’s thinking and maybe a blind spot. Kidder notes that to Farmer’s view, the Marxist solution is too academic and not focused on the people. the arrogance, the petty infighting, the dishonesty, the desire for self-promotion, the orthodoxy. I can’t stand the orthodoxy, and I’ll bet that’s one reason that science did not flourish in the former Soviet Union.[Farmer]


It’s an ology, after all,” he[Farmer] had written to me about liberation theology. “And all ologies fail us at some point.


Kidder does not explain this statement about rereading the gospels so that the poor can stand up and reclaim what is theirs.


Farmer feels he is not needed in Cuba-there is enough medical support for people. He sleeps well.


Farmer was here to see if he could get aid for his AIDS patients from Jorge Perez. He also wanted to send a couple of his students to Cuba to educate them as doctors. He also attended a conference on AIDS.


Everywhere Farmer goes, he sees people whom he has doctored. Even driving into Santiago de la Vegas, he sees one of his former patients riding a bicycle and stops to greet him. Kidder notes that even when he does not have patients, he borrows them from his host. Farmer also lent his Boston patients to visiting doctors.


Farmer and Kidder get into a discussion on how his relationship with various people in Cuba be portrayed. Farmer said he was not concerned about himself, but about how Cuba’s outreach to Haiti would look. He sees people like Perez has being generally moved by the plight of the poor in Haiti, not by a means of furthering the Cuban system. He[Dr Perez] believes in social justice medicine. What is this?


In Miami, after coming back from Cuba, Kidder and Farmer had an argument about why the Cuban’s treated him well. One thing Kidder could not dispute is that Cuba had done what Haiti did not do: give their citizens a health care system which worked. I just wondered what price in political freedom its people paid for that achievement. But I understood that Farmer would frame the question differently, and ask what price most people would be willing to pay for freedom from illness and premature death


Kidder got in a gut punch on Farmer which seemed to deflate him. Among a coward’s weapons, cynicism is the nastiest of all.


Next stop: Russia.


Chapter 22

On the way to Russia, Kidder and Farmer stop in Paris where his wife and child are. Farmer did not seem to spend much time with either.


Jim Kim said, “Paul has a gift for making people feel guilty.”


When Farmer told his wife he was leaving the next day, right after getting in. He felt an emotional loss. I don’t think anyone who knew how much Farmer craved connections among all parts of his life could have looked at him at that moment on the couch in Paris, all folded up as if trying to hide, and not felt some sympathy for his predicament.


Farmer had built a network of people who knew him and loved him, throughout the world. For Farmer, the worst kind of exile wouldn’t be geographical. It would be something like excommunication.


Impolite terms, used intramurally, were meant as philosophical rebukes to the misplaced preoccupations of those who believed in “identity politics. I wonder if he could get away with that today with all of our puritanical need to be correct and not offend anybody when we say anything.


suffering isn’t equal” was an article of the PIH faith


When people get around Paul, they start talking like Paul,”


you’re doing these things for the poor, amidst arguments that it’s not cost-effective to treat them, you have to be perfect or you’ll be picked apart.”)


You could hang around the inner circle of PIH for a long time without understanding what the rules were and feeling excluded, and the more left out you felt, the more you suspected you were being told you weren’t as good as they were, even as you suspected that your irritation proved.


Of all the world’s errors, he [Paul Farmer] seemed to feel, the most fundamental was the “erasing” of people, the “hiding away” of suffering.


Chapter 23

Soros’ foundation was supporting treatment of TB patients in Russia, but only the DOTS patients. Farmer had been tapped to work out the conditions of a World Bank loan for Russia’s fight against TB. This got Farmer in contact with Goldfarb. PIH felt that its involvement with Russia fit their criteria about serving the underserved. In this case, prisoners.


When Farmer and Goldfarb toured the prisons, they found TB 40-50 times the amount of the general population. They also found that a large proportion had MDR-TB. When a prisoner got released, they spread both TB and the MDR-TB to the general population. The Russian response was haphazard. What it showed was that DOTS alone not only wouldn’t serve but would amplify the epidemic. But their announcement was ill-timed as it was on the same day which the Monica Lewinsky scandal special prosecutor report was released.


Erasing history, he liked to say, always served the interests of power-Farmer


They visit a Moscow jail where AIDS patients are housed. There is the sound of a crowded cell door clanging close. It makes Kidder wonder about Cuban jails and the treatment he saw there.


It was estimated that 80% of the prisoners had TB. With about 30% having MDR-TB (this is my calculation based upon the numbers Kidder gives.) Not only that, to compound the issue, AIDS was rising as well.


I think that the rich can always call themselves democratic, but the sick people are not among the rich. Farmer He talks about how he feels a closer bound to other doctors who try to heal the sick. That being an America gives him privilege, not democracy. This was 20 years before Jan 6th. How does he define democracy? I think he is being rather cynical.


Goldfarb’s view of Farmer was: Paul is so fragile,” he told me privately. “He is so thin. He is like Chekhov. Sentimentality fuels him rather than otherwise



Part 5 - O for the P

Chapter 24

Gates foundation gave $56 million to Harvard for PIH to get MDR-TB under control. Kim felt they would need to get 80% of the cases cured. It also meant ramping up a community program to a nation-wide scale. This leads to the effort to keep existing financial support-a tendency is to say they got this pile of money, let's find another needy cause.


PIH was getting bigger and there were more specialized jobs,such as IT. This also lead to friction between the old timer who would sacrifice themselves for the good vs those who wanted a home-work balance. Many people viewed Farmer as the model for their lives. But Kim was discouraging that. They were bound to be disappointed. 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. Also 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. There was a tendency that when Farmer was around, he left a wake of nervous exhaustion-from trying to keep up.


Farmer felt that if you are working for the poor, you should not get overtime. Ophelia, who managed such matters, was following those rules. She simply didn’t tell Paul


Boris Berezovsky. Goldfarb had helped Berezovsky escape Russia when he was going to be arrested. So a new TB director was appointed and PIH got more involved in Russia and Siberia.


Farmer never lost his temper in front of people. But Dahl and Kim were safe people and things could get tense then.


Kim had to do a PR event without Farmer in Tomsk, Russia. Farmer was to be the main person. Because Goldfarb had been sidelined for his involvement, this event was to lend credibility to DOTS-plus. Kim purposely embarrassed himself by singing, but this opened things up and relationships were formed and the project was able to go on. All the people in the world have the same emotions. We just want to do something good for this earth. When Farmer was able to join them the next day, he noted to Kidder that it comes in handy in my line of work. To like people. A lot of truth there.


Farmer noted that project managers can wait for lower prices, but patients cannot always wait. But this attitude could also jeopardize PIH. It was constitutionally impossible for Farmer and Kim to sit on resources.


About this time, Kidder discontinued being by Farmer’s side, recording his activities. But he kept in contact, almost daily. It was not easy following where Farmer was-he would often not say where he was. So Kidder lost context. But one of the things which came out was that Cange needed a stable source of funding, not as a demonstration project, but as an ongoing establishment. Farmer felt that It should be enough to humbly serve the poor.


Cange was unique in the world of impoverished people with AIDS. It was not based upon if you could pay, but if you were sick.


A Farmer article got published in the August 2001 issue of Lancet. This created a large demand for information, including praise from Jeffery Sachs. The Global Fund was created, but not fully funded.


The United States was blocking aid to Haiti, even with Aristide’s re-election. This drove Farmer nuts as how cloud depriving peasants of clean water be good?


Farmer talked about retiring. Kidder did not believe him. For as long as he could manage the travel, I thought, he’d be leaving Haiti for places like Tomsk and Lima, to doctor individual patients and to do his part fighting plagues and inequities in health, practicing his own combination of wholesale and retail medicine.


Chapter 25

In the beginning, going from Boston to Cange and back was jarring to Farmer. It built into anger at the disparity. Now he was transmuting anger into something that felt better, a dream of ending the disparities. Cange was a good basic hospital, but lacked what in the United States would have considered essential: blood bank, CT scanner, sophisticated lab ,...


Then there was the story of John, who had a rare form of cancer. He could not get adequate treatment in Cagne. A lot of money and free gratis was spent to get him to Boston and get him care which could have saved him. In the end, there was too much going wrong with his body. He died. Several concerns came out of this. First, would this be seen as a precedent? Second, a lot of money was spent on this one person who died. Couldn’t the money have been better spent on those who had a better chance of living? One the first one, the reaction from the Haitians was “see how much they cared about us”, rather than me too. On the second, Farmer noted they did not know how bad he was until they got to Boston. They were doing this for a living boy with a future.


A doctor at Mass General Hospital noted that it is hard to personalize a situation until it is in front of you.


It is so easy, at least for me [Kidder], to mistake a person’s material resources for his interior ones. This was said in the context of adapting a suction device to how an ambulance operates-it was successful.


Chapter 26

Kidder is back with Farmer in Haiti. Talks about Ti Jean. He knows something about medicine and shares Farmer’s scorn for notions that there’s special virtue in a culture’s old technologies, in the idea for instance that herbal remedies are generally to be preferred over manufactured drugs. Ti Jean thinks that with all of Farmer’s travels, he is a nestless bird. But he says ``Your nest is Haiti,” … “You go everywhere, but this is your base.”


Kidder recounts how things changed and what has happened to people.


Farmer is going to Casse, about a 12 mile as the crow flies, round trip. Ti Jean asks if he brought a flashlight-no. I’ve never found it easy to trust another person to lead me anywhere, but I trust Farmer. They make house calls along the way. Talking about triage: I say there must always be situations here where the choice to do one necessary thing also means the choice not to do another—not just to defer the other but not to do it. Kidder gets dehydrated before getting to Casse.


They talk about the boy who had cancer and died in Boston. Farmer’s take was that they did not know how bad he was until he could get a good diagnosis in Boston. Until then, he was like many other severely sick, but possibly treatable Haitians.


Farmer talks about spending his whole life fighting a long defeat. We’re used to being on a victory team, and actually what we’re really trying to do in PIH is to make common cause with the losers. Those are two very different things. We want to be on the winning team, but at the risk of turning our backs on the losers, no, it’s not worth it. So you fight the long defeat. … “I don’t care if we lose, I’m gonna try to do the right thing


Farmer points out that a first year doctor makes about five times a year what that plane ride cost to bring the boy to Boston. Farmer points out that nobody says I’m twenty-nine or thirty-some years old.’ If you say that stuff out loud, you sound like an asshole. Whereas if you say the other stuff, you just sound thoughtful. The other stuff is you could have used the money better on more people.


Are you incapable of complexity


The Farmer Method:

  • First, you perform what he calls “the distal intervention” and cure the family of TB.
  • Then you start changing the conditions that made them especially vulnerable to TB in the first


Kidder ponders the people who would praise Farmer as having good intentions but then damn him for being impractical. Here’s an influential anthropologist, medical diplomat, public health administrator, epidemiologist, who has helped to bring new resolve and hope to some of the world’s most dreadful problems, and he’s just spent seven hours making house calls. How many desperate families live in Haiti? He’s made this trip to visit two. Farmer observed that big people doing big projects is not fool proof either. He learned early on from watching the [North Carolina] nuns doing menial chores on behalf of migrant laborers, and in the years since he’s come to think that a willingness to do what he calls “unglamorous scut work” is the secret to successful projects in places like Cange and Carabayllo. Kim also thinks that there are benefits to thinking small: If you focus on individual patients,” … “you can’t get sloppy.”


Farmer’s thought is 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. Dahl thinks that these hikes are what strengthens Farmer. He gets close to his patients, to those who are sick and he is able to better understand their problems. Consequently, he is able to work on the person’s entire situation.


In a conversation, it is noted that about ¾ of the reason why Haitians consult VooDoo is because of illness.


Kidder as he is wrapping up notes that If you do the right thing well, you avoid futility.



Afterword

In this chapter Kidder has finished his time with Farmer, at least as far as the book goes. In the meantime, the book comes out and it is about a decade later. Farmer has been exposed as someone who cares and someone who can treat diseases. The tension is to extend this out to the wider poverty stricken populace of the world. A protese of Farmer, Jim Kim, is now high up in WHO and helping put Farmer’s ideas into practice.



Epilogue

In some ways, this chapter should be read first so that the reader knows what they are in for. Kidder says that I had one overarching aim when I wrote this book. I had stumbled across what I believed to be an interesting story, and I wanted to tell it as well as I could. But I think there is more to it than just an interesting story of a man. Kidder talks about how Farmer was not out to change the world, but to help people whom he say were under-served. People in Haiti who could not get proper medical help. As he came more in touch with them, his influence spread throughout an area of central Haiti.


As an individual, he could easily be ignored. But as he served more, he needed additional medicines to combat TB and then AIDS. For that he needed people with money. There are people who are interested in helping effective people, such as Tom White. They incorporated under an organization called Partners in Health (PIH). Even at the time of this writing, the organization was about 600 people, with at least 80% non-North Americans. Farmer found that All too often international aid organizations weaken the societies they are supposed to help

Farmer introduced me to more reasons for despair than I’d ever seen before, or indeed imagined.


Farmer was criticized about not thinking larger about what could be done, about the wider mission of public health. His response? “I’m interested in public health, too!... 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?” And that is the crux of Farmer. His take on being a doctor was to serve an individual. In order to do that, he needed to serve a wider group. Making sure they had livable conditions.


It seems a bit quaint and undercutting that one person can change the world. That is until you come across a story of that one person and recognize the drive of what it takes for that one person. Kidder portrays Farmer as being a normal man, with a latent intellect-nothing really special until he gets exposed to the poverty and depression of Haiti. That awakens him and his desire to help.



Evaluation:

 As I was reading Mountains Beyond Mountains, I got the impression of looking at what Jesus might be doing in our current era. This book is about Paul Farmer who went to the poorest part of Haiti to give himself to people and provide medical service. Farmer himself I do not consider terribly religious, but more goal oriented. His goal was to provide medical assistance to the neediest people in a very personable way.


Kidder takes the time to be with Farmer, to understand him and where he worked. He takes us through how Farmer started serving in Haiti all the way through when he was being recognized for someone who had an understanding of how to treat illnesses in underserved areas of the world.


Part of this book is Kidder doing a typical biographer’s work: checking sources, reading about him, interviewing associates. But what makes this book special is that Kidder spent at least two years with Farmer, traveling with him, hiking with him, and most importantly, meeting his patients. So Kidder was able to get a good perspective on the man and his work.


This is a book which will challenge you, not by either Farmer or Kidder issuing a challenge. Farmer himself does not want to make disciples just like him. Rather he wants us to be transformed into new ways of thinking and consequently responding to the world around us. Be aware if you pick up this book. It will cause you to think about our world.


 
Notes from my book group:

In the first chapter, Kidder says after our dinner I drifted out of touch with him, mainly, I now think, because he also disturbed me. Why was Farmer disturbing to Kidder? Were there parts of this book which were disturbing to you? Why?


Kidder says that when he first went to Haiti, it was the absences which he noted. What kind of absences were there? What would you notice if there were things missing from your experience?


Voodoo and magic/sorcery are talked about. Explain the difference. How does Farmer co-exist in this setting? Do you think a Christian could do that?


Talk about Farmer’s view of God and religion. How do you think it fits in with traditional Christianity? He espoused liberation theology. What is it? How would it differ from what you might hear in a typical church today? I note that I think medically, Farmer emulated how Jesus would have been in our world. What similarities do you see in how Jesus interacted with people during his time on earth with how Farmer does. How is Farmer different from Jesus?


When Farmer went to Aristide’s church, he saw that People read the Gospel as if it pertained to another place and time, but the struggles described there are in the here and now. How should the Gospel’s be read in context to living today?


Atone point Farmer quotes Matthew 25 where Jesus talks about the sheep and goats coming to judgment. How does Farmer interpret this passage?


Farmer concluded that medicine is not only about providing medical treatment, but also being concerned with home life. How did Farmer come to this conclusion? How would you apply that to the city you are in? Later there is the thought that medicine only addresses symptoms of societal issues rather than its causes? Is there truth there? What implications does this have?


“I love WL’s [white liberals] , 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. Is how Farmer views white liberals a valid view?


Farmer was very patient intensive in his approach to doctoring. What concerns did other medical personnel have to this approach?


As the solutions which Farmer provided were shown to be successful, he was encouraged to turn over some of the face-to-face to other people, so that he could concentrate on expanding his solutions. Farmer refused. What were Farmer’s reasons for not giving up this part of his work? Do you think he would have been successful at expanding the use of his solutions without his hands-on approach? How do you know when you should pursue a greater vision vs the more doing it yourself?


Alex Goldfarb laid out the chief problem with PIH’s approach. TB was very prevalent in Russian prisons. They only had enough money to use one drug. $3,000,000 will treat 5,000 TB patients or 500 MDR-TB patients. If he has $6 million, how should he spread out the money?


The term cost-effectiveness is used in juxtaposition to how Farmer looked at medicine. Explain this term. Why does Farmer think this is an inadequate term? What are its failings? Its strengths? When should a cost-effective approach be used?


Kidder notes that Education wasn’t what he wanted to perform on the world, me included. He was after transformation. What is the transformation which Farmer wants to take place?


Accidents happen. Sure. But not every bad thing that happens is an accident is a statement which Farmer makes. Explain what Farmer means by it. Do you find it to be true?


Haitians have a saying concerning how could God allow such suffering. The Haitian peasants answered with a proverb: “Bondye konn bay, men li pa konn separe,” in literal translation, “God gives but doesn’t share.


Before reading this book, what impression did you have of life in Cuba? How did seeing Cuba through Farmer’s eyes change your view? Do you think Farmer/Kidder was being manipulated? Are there medical practices the United States can learn from Cuba? Do you think the United States should modify its policy towards Cuba? If so how?


Tom White learned to dislike the tendency of the powerful to view human beings as pins on a map. Is this true? If true, how do the powerful get to a place where people are resources rather than humans? What consequences does that have?

Two clear sides existed in Haiti, Farmer said—the forces of repression and the Haitian poor, the vast majority. In Farmer’s view, why does the United States intervene in Haitian affairs? Do you think he has a reasonable perspective?


As you read through this book, it becomes evident that what a citizen of the United States or Europe or Canada might take for granted, such as testing or medicines, was not available in countries like Haiti or Peru. Describe the effects of this lack of medical availability. How did this disparity of availability come into being? How do you think the playing field can be/should be leveled?


Farmer bent rules and cut corners. Give some examples. Did he ever do so to benefit himself? Did this make breaking the rules justifiable?


The MDR-TB drugs were dosaged for adults. Farmer was confronted with a child who had MDR-TB and he adjusted the dosage of the medicines. Do you think Farmer knew how much to give the child or was he guessing? Was he being kind or reckless? What allowance should be made for genius to bend the rules?


As Partners in Health became known as an organization who would help the helpless, the requests for service started coming in. It seemed like that the more pressing the need the less likely Partners in Health would refuse. In an organization such as theirs, what are the ways to screen requests for help? What should be the considerations? Should money be the determining factor on the medical care you receive?


When money is spent to aid someone, particularly a large amount, what is the important outcome? Is it the outcome or is it the attempt to relieve suffering? (This is in relation to the child John who had cancer. When he reached Boston, it was determined that nothing could be done for him, except to relieve his suffering.)


Farmer talks about fighting the “long defeat.” Describe what Farmer is talking about. Do you find this a pessimistic or optimistic term? Is this a good way to look at a “good work” you are doing? How did it help Farmer?


For a time, the United States would not allow blood to be donated from people who visited Haiti due to the potential for AIDS. Why? How does Farmer view this equation as being backwards? How does Farmer view this as being symptomatic of the United States relationship with Haiti? Who do you think has a more accurate picture?


Describe Farmer’s relationship with the United States. With capitalism. Do you think he had quarrels with democracy? In what form do you think democracy would be acceptable to him? What type of economic system would be acceptable?


How do you want your life to change because you read this book?


Many of these questions are either from or adapted from LitLovers.

Why the title of Mountains Beyond Mountains?

Does this story work as a biography?

Did the ending seem fitting? Satisfying?

Every story has a world view. Were you able to identify this story’s world view? What was it? How did it affect the story?

In what context was religion talked about in this book?

Was there anybody you would consider religious?

How did they show it?

Was the book overtly religious?

How did it affect the book's story?

Why do you think the author wrote this book?

What would you ask the author if you had a chance?

What “takeaways” did you have from this book?

What central ideas does the author present?

Are they personal, sociological, global, political, economic, spiritual, medical, or scientific

What evidence does the author use to support the book's ideas?

Is the evidence convincing...definitive or...speculative?

Does the author depend on personal opinion, observation, and assessment? Or is the evidence factual—based on science, statistics, historical documents, or quotations from (credible) experts?

What implications for you, our nation or the world do these ideas have?

Are these idea’s controversial?

To whom and why?

Are there solutions which the author presents?

Do they seem workable? Practicable?

How would you implement them?

Describe the culture talked about in the book.

How is the culture described in this book different than where we live?

What economic or political situations are described?

Does the author examine economics and politics, family traditions, the arts, religious beliefs, language or food?

How did this book affect your view of the world?

Of how God is viewed?

What questions did you ask yourself after reading this book?

Talk about specific passages that struck you as significant—or interesting, profound, amusing, illuminating, disturbing, sad...?

What was memorable?

-------------

From Penguin’s READERS GUIDE

Questions and Topics for Discussion

1. Paul Farmer finds ways of connecting with people whose backgrounds are vastly different from his own. How does he do this? Are his methods something to which we can all aspire?

2. Paul Farmer believes that “if you’re making sacrifices . . . you’re trying to lessen some psychic discomfort” (p. 24). Do you agree with the way that Farmer makes personal sacrifices? For what kinds of things do you make sacrifices, and when do you expect others to make them?

3. Kidder points out that Farmer is dissatisfied with the current distribution of money and medicine in the world.What is your opinion of the distribution of these forms of wealth? What would you change, if you could?

4. Farmer designed a study to find out whether there was a correlation between his Haitian patients’ belief in sorcery as the cause of tb and their recovery from that disease through medical treatment.What did he discover about the relative importance of cultural beliefs among his impoverished patients and their material circumstances? Do you think that this discovery might have broad application–for instance, to situations in the United States?

5. The title of the book comes from the Haitian proverb,“Beyond mountains there are mountains.” What does the saying mean in the context of the culture it comes from, and what does it mean in relation to Farmer’s work? Can you think of other situations–personal or societal–for which this proverb might be apt?

6. Paul Farmer had an eccentric childhood, and his accomplishments have been unique. Do you see a correlation between the way Farmer was raised and how he has chosen to live his life? How has your own background influenced your life and your decisions?

7. Compare Zanmi Lasante to the Socios en Salud project in Carabayllo. Consider how the projects got started, the relationships between doctors and patients, and the involvement of the international community.

8. Kidder explains that Farmer and his colleagues at PIH were asked by some academics, “Why do you call your patients poor people? They don’t call themselves poor people” (p. 100). How do Farmer and Jim Kim confront the issue of how to speak honestly about the people they work to help? How do they learn to speak honestly with each other, and what is the importance of the code words and acronyms that they share (for example, amc’s, or Areas of Moral Clarity)?

9. Ophelia Dahl and Tom White both play critical roles in this book and in the story of Partners In Health. How are their acts of compassion different from Farmer’s?

10. Tracy Kidder has written elsewhere that the choice of point of view is the most important an author makes in constructing a work of narrative nonfiction. He has also written that finding a point of view that works is a matter of making a choice among tools, and that the choice should be determined not by theory, but by an author’s immersion in the materials of the story itself. Kidder has never before written a book in which he made himself a character. Can you think of some of the reasons he might have had for doing this in Mountains Beyond Mountains?

--------

A Teacher’s guide pdf can be found at Penguin’s web site.

 

New Words:

  • hydrocephalic-an abnormal buildup of fluid in the ventricles (cavities) deep within the brain. This excess fluid causes the ventricles to widen, putting pressure on the brain's tissues.
  • oeuvre-the works of a painter, composer, or author regarded collectively.
  • Lurkaceous-seems to be either Kidder’s or Farmer’s own word
  • stentorian-(of a person's voice) loud and powerful.
  • Scrims-a durable plain-woven usually cotton fabric for use in clothing, curtains, building, and industry.
  • prophylaxis-action taken to prevent disease, especially by specified means or against a specified disease.
  • palliation-Relief of symptoms and suffering caused by cancer and other life-threatening diseases. Palliation helps a patient feel more comfortable and improves the quality of life, but does not cure the disease.
  • tontons macoutes-a special operations unit within the Haitian paramilitary force created in 1959 by dictator François "Papa Doc" Duvalier. Named after the Haitian mythological bogeyman
  • leonine-of or resembling a lion or lions
  • Kouri-dry watercourse
  • bibulous-excessively fond of drinking alcohol.
  • dosh-money
  • rifabutin- rifamycin antibiotic. It works by stopping the growth of bacteria.This antibiotic treats and prevents only bacterial infections
  • pathophysiology-the disordered physiological processes associated with disease or injury.
  • hortitorture-The cruel and unusual manipulation of plants to meet human desires or expectations. Usually in the form of pruning, staking, bending, or abandonment.
  • eclampsia-a severe complication of preeclampsia. It's a rare but serious condition where high blood pressure results in seizures during pregnancy. Seizures are periods of disturbed brain activity that can cause episodes of staring, decreased alertness, and convulsions (violent shaking).
  • ethnography-the scientific description of the customs of individual peoples and cultures.
  • kwashiorkor- a severe form of malnutrition
  • crenellated-(of a wall or building) having battlements
  • scrofula- disease with glandular swellings, probably a form of tuberculosis
  • Canadian crutches-A forearm crutch

Book References:

Good Quotes:
  • First Line:Six years after the fact, Dr. Paul Edward Farmer reminded me, “We met because of a beheading, of all things.
  • Last Line: I don’t idolize him, but I am grateful that he is living on this planet.
  • you can never invest too much in making sure this stuff works. Chp 4
  • If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life. Rudolf Virchow
  • Medicine is a social science, and politics is nothing but medicine on a large scale. Rudolf Virchow
  • The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them. Rudolf Virchow
  • Never doubt that a small group of thoughtful committed citizens can change the world. Indeed, it is the only thing that ever has. Margaret Mead, Kabir, Hajara Muhammad (2010).
  • Among a coward’s weapons, cynicism is the nastiest of all. Chp 21
  • Of all the world’s errors, he [Paul Farmer] seemed to feel, the most fundamental was the “erasing” of people, the “hiding away” of suffering. Chp 22
  • Erasing history, he liked to say, always served the interests of power-Farmer. Chp 23
  • I think that the rich can always call themselves democratic, but the sick people are not among the rich. Farmer. Chp 23
  • If you do the right thing well, you avoid futility. Chp 26
 
Table of Contents:
  • Cover
  • Title Page
  • Copyright
  • Contents
  • Part 1 - Doktè Paul
    • Chapter 1
    • Chapter 2
    • Chapter 3
    • Chapter 4
  • Part 2 - The Tin Roofs of Cange
    • Chapter 5
    • Chapter 6
    • Chapter 7
    • Chapter 8
    • Chapter 9
    • Chapter 10
    • Chapter 11
    • Chapter 12
  • Part 3 - Médicos Aventureros
    • Chapter 13
    • Chapter 14
    • Chapter 15
    • Chapter 16
    • Chapter 17
    • Chapter 18
    • Chapter 19
  • Part 4 - A Light Month for Travel
    • Chapter 20
    • Chapter 21
    • Chapter 22
    • Chapter 23
  • Part 5 - O for the P
    • Chapter 24
    • Chapter 25
    • Chapter 26
  • Afterword
  • Epilogue
  • Dedication
  • Acknowledgments
  • Selected Bibliography
  • Other Books By This Author
  • About the Author


References:
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Location: Cange, Haiti

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