56 pages • 1 hour read
Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World
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Part 1Chapter Summaries & Analyses
Part 1: “Dotkè Paul”
Chapter 1 Summary
Author Tracy Kidder first meets Dr. Paul Edward Farmer while covering the United States military’s mission in 1994 to reinstate Haiti’s democratically elected government after a three-year military junta. After getting a flat tire near an American compound, Farmer asks Special Forces Captain Jon Carroll about a recent political beheading. He is critical about the business-favoring economic reforms the United States wants to implement and the military’s decision to release brutal sheriff Nerva Juste in a country with no working legal system. Leadership orders hamstring Carroll’s mission, however, and he feels that holding Juste without evidence would be hypocritical.
While Farmer’s local knowledge and “downright cocky” nature impress Kidder, he doesn’t think much of the doctor until they share a flight back to the United States. Farmer clarifies facts for Kidder’s article and corrects the author when he suggests that the beheading is related to the Voodoo religion. Farmer is a graduate of Harvard Medical School with a doctorate in anthropology who treats patients in central Haiti and works four months of the year in Boston. As years pass, Kidder donates to Farmer’s charity but is reluctant to write about his extreme vision of “doing one’s best” for destitute regions (8). Finally, Kidder contacts Farmer in 1999 after learning about his global work in combating tuberculosis (TB).
Chapter 2 Summary
Kidder visits Farmer at the prestigious Brigham and Women’s Hospital in Boston. Farmer, now 40, is an infectious disease specialist who diagnoses challenging cases. One of them is an HIV-positive homeless man with drug problems, deep chest pain, colored sputum, and substantial weight loss over several months. The doctors believe it could be TB, but after studying the X-ray, Farmer diagnoses his condition as pneumonia. After talking with the man, Farmer learns that the patient’s weight loss is due to starvation and that he is not taking his antiretroviral medicine as frequently as directed. Farmer helps the man enroll into an HIV house so that he can get food and take medication without risk of developing a resistance. Farmer also sneaks a six-pack of beer to him.
Kidder notes that Farmer enjoys working with patients, though he bristles at comparisons of him to a “saint,” and is friendly with staff members. This demeanor contrasts with his writing in books like Infections and Inequalities, where he uses case studies to demonstrate the connection between poverty and disease as well as criticize the medical establishment’s apathy towards medical inequality. Farmer tells Kidder that if he wants to see his real “oeuvre,” he must go to Haiti.
Chapter 3 Summary
Kidder travels by truck on Highway 3 to Farmer’s Zanmi Lasante (Creole for “Partners in Health”) compound in Cange, Haiti, “one of the poorest parts of the poorest country in the Western Hemisphere” (20). The per capita income is about $1 USD a day, the forests and soil are disappearing, and medical facilities are unsanitary and expensive. In contrast, Zanmi Lasante is a sanctuary, with a general hospital, a women’s clinic, laboratories, a tuberculosis facility, an Anglican church, foliage and artwork, and a kitchen that feeds 2,000 people a day. Patients are to pay 80 American cents to visit, but Farmer’s fee waiver list encompasses everyone. Its 70-member team of community health workers support 100,000 people, with more traveling from the outskirts, and the facility never denies care. Zanmi Lasante builds schools, houses, and sanitation systems and offers literacy and medical information programs.
At 4%, the HIV transmission rate from mothers to babies in the catchment area is half that in the United States. The facility treats comparable patient levels to a US hospital on a drastically smaller budget. Most of its income comes from philanthropy, and Farmer has donated his $220,000 MacArthur genius grant and other award earnings to the cause.
Farmer tends to a mass of people every morning, both those with diseases and those who need money or favors, with the same comfort as in Boston. He is firm with his staff of undertrained Haitian doctors. One cultural obstacle he faces is that, regardless of their religion, Haitians believe in “maji” or sorcery that people inflict on each other. Farmer explains to them that these curses aren’t responsible for their conditions without challenging their beliefs. For a patient with worsening AIDS symptoms, he prescribes at no cost an expensive antiretroviral drug that the medical establishment does not deem viable for developing countries.
While Farmer has a home in Boston and his Haitian wife, Didi, and their daughter live in France most of the year, he spends most of his time in Haiti. After making rounds to nearby houses past nightfall, he returns to his home near the hospital to work on grants and writings, rarely sleeping.
Chapter 4 Summary
Farmer describes an early study he performed as a Harvard student to determine whether poverty or spiritual beliefs influence a patient’s willingness to complete treatment. He found that the patient group that received both medicine and a monetary stipend completed treatment more often, regardless of spiritual beliefs. Since then, Zanmi Lasante has included both medicine and a $5 USD stipend, with no lost patients in 12 years. Farmer also learns what happen to those who stop reporting results.
Farmer drives Kidder to the Péligre Dam on the Artibonite River. Developed by the US Army Core of Engineers in the mid-1950s, the dam provides electricity to foreign businesses and the wealthy in Port-au-Prince. However, the central valley does not receive any of this power, and the dam’s serene lake, the Lac de Péligre, is actually flooded farmland, leaving behind “water refugees” who must go to the capital for work. The American government also attempted to replace Creole pigs with harder-to-raise white pigs in a bid to stop swine fever, leading to a drop in school attendance due to lack of tuition money. Haitians frequently receive flimsy and poorly thought-out aid, and Farmer criticizes “WLs”—well-meaning White liberals who downplay the suffering that poor people endure.
Despite a bad back and surgically repaired leg, Farmer navigates the countryside more easily than Kidder. After finishing his rounds, Farmer tells him that the lake perfectly represents the interconnected problems of the poor. Kidder hides his reservations “for fear of disappointing him” (44).
Part 1 Analysis
Kidder divides Mountains Beyond Mountains into five parts. The first introduces the reader to Paul Farmer and the geopolitical issues that affect public health in developing countries like Haiti. He accomplishes this in part by illustrating the ignorance that Kidder and others have about the island nation. Kidder speculates that the beheading relates to Voodoo, the Haitian religion that the media often portray as primitive and demonic. Farmer quickly corrects him, saying that the death only “has some basis in the history of brutality” (6). Meanwhile, a soldier scoffs at the mission and feels that nothing can change the brutal inequality in the country, an argument that Farmer challenges through his own work and philosophy. While Kidder explains more in later parts, he notes Haiti’s unstable political history and miserable health system with unsanitary facilities and prohibitively high costs.
Kidder introduces Farmer though his confrontation with the military commander, demonstrating the doctor’s knowledge of Haiti’s politics and direct nature as he criticizes the US presence in the region. Kidder’s initial visits with Farmer in Boston and Cange also reveal more of Farmer’s personality. Highly credentialed doctors often leave patient encounters to assistants, but these visits are his favorite part of the job, and he walks for hours to make house calls in the countryside. He is casual with staff members, using the word “comma” in place of expletives, but fierce when writing about inequality. He does not treat patients as untouchables, whether it is the homeless man in Boston or the people of Cange. Further, he defies medical norms as he sneaks a six-pack of beer to the homeless man and orders an expensive antiretroviral for a Haitian man despite international guidance.
The Brigham and Women’s Hospital and Zanmi Lasante represent both the pinnacle of healthcare in their respective countries and the contrast between medicine in developing and developed nations. The Brigham is a fully equipped teaching hospital and partner with Harvard University with a roster of leading scientists. While its capabilities are not as robust, Zanmi Lasante represents a medical ideal that goes beyond treatment to address the squalid living conditions and malnutrition that contribute to disease. The hospital’s mostly Haitian staff has limited training, but they understand their patients and are less likely to leave than overseas physicians. However, Zanmi Lasante is the exception when it comes to international intervention in Haiti. Farmer is suspicious of the United States’ intentions in Haiti as its idea of aid is business-expansion efforts that do not involve an understanding of the island’s needs and often harm the poor. The biggest example is the Péligre Dam, which provides electricity to cities and businesses while exasperating terrible conditions in the countryside. This occurs regardless of which political party is in office as Farmer mentions that the Haitian nickname for these efforts is “Kennedys.”
Kidder also sets up the tension between himself and Farmer that underlies their interactions. The writer donates to Farmer’s cause over the years and commends his work, but he doesn’t write about him until years later. This decision has less to do with journalistic ethics than with his feeling that Farmer’s worldview is “hard to share” (8). It’s simple: There are only the oppressed and the oppressors, and one should do everything in their power to help the oppressed without any reward. While Farmer may be morally right, Kidder struggles to accept his views and doesn’t comment on Farmer’s quip that the Lac de Péligre represents everything wrong with global inequality.
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