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

“On maps of Haiti, the road we traveled, National Highway 3, looks like a major thoroughfare, and indeed it is the gwo wout la, the only big road across the central plateau, a narrow dirt track, now strewn with boulders, now eroded down to rough bedrock, now, on stretches that must have been muddy back in the rainy season, baked into ruts that seemed designed to torture wheels, hooves, and feet. It wound through arid mountains and villages of wooden huts. It forded several streams. Trucks of various sizes, top-heavy with passengers, swayed in and out of giant potholes, raising clouds of dust, their engines whining in low gear.” 

As the only major roadway from Port-au-Prince to Cange, National Highway 3 exemplifies the country’s inequality as the road becomes increasingly unstable the further into the countryside Kidder travels. The road becomes a metaphor for Haiti’s poverty as Kidder describes how various people react to the dreadful conditions, from Tom White insisting on bringing construction teams over to Serena Koenig worrying about floods and bandits interfering with a medical transport. 

“He was staring out at the impounded waters of the Artibonite. […] From here the amount of land the dam had drowned seemed vast. Still gazing, Farmer said, ‘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.’

The list was clearly jocular. So was the tone of his voice. But I had the feeling he had said something important. […] In any case, he seemed to think I knew exactly what he meant, and I realized, with some irritation, that I didn’t dare say anything just then, for fear of disappointing him.”

Farmer takes Kidder to the Lac de Péligre, a lake created by the damming of the Artibonite River, which flooded farmland and caused a refugee crisis. To the doctor, it is a symbol of how foreign aid projects place business interests over the poor and how miserable conditions often have “many linked causes” (44). The list Farmer brings up also serves as foreshadowing for countries the two visit and the concepts they discuss later in the book. While Kidder understands Farmer’s point, the author still harbors doubts, but it is difficult to challenge someone who is so confident in his own views.

“Around the time P.J. entered high school, the Warden bought at public auction an old Liberty launch, a fifty-foot-long empty hull with a hole in it, which he repaired. […] He built a cabin for the boat, cussing and fuming, learning his ship’s carpentry, such as it was, as he went along. In the middle of his labors—the whole family had to pitch in—he started running short of cash, and he announced to P.J. and the two younger boys, ‘We’re going to pick citrus.’

P.J. said, ‘But, Dad, white people don’t pick citrus.’

‘Yeah? I’ll give you white people.’” 

Kidder discusses Farmer’s youth, when his family called him PJ, in relation to his father, nicknamed the Warden for his sternness. The two have much in common as the Warden would pursue his passions regardless of cost, prior experience, or practicality. The rugged life his family lived makes his transition to Haitian life easier. While his mother reads the apartheid-era novel Cry, the Beloved Country to them growing up, Farmer’s assumptions about who works in farms show that he is still susceptible to the racial prejudice surrounding him. It is in the fields that he learns about the challenges that Haitians face, and this correction of his ignorance influences Farmer’s worldview and willingness to do difficult jobs.

“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 was Farmer’s favorite. […] ‘Virchow had a comprehensive vision,’ he said. ‘Pathology, social medicine, politics, anthropology. My model.’” 

The German polymath Rudolf Virchow is less known than other medical innovators, but his holistic views influence Farmer as an undergraduate student. Not only did Virchow make scientific advances in pathology and oncology, but he also married them to social projects, like improving Germany’s meat inspection and sewage systems, and noted that epidemics often occur after political upheaval. Like Farmer, Virchow prioritizes social justice over political correctness and promotes anthropology as a means of guiding medical policy. Farmer becomes a modern Virchow over his life as he makes contributions in many fields, confronts the status quo, and emphasizes the correlation between healthcare and living conditions.

“We start, eyes drawn reluctantly back

over baskets, to the dead mango lady

stretched stiff on her bier of tropical fruit.

She is almost covered by a cardboard strip,

like the flag of her corrugated country,

a flimsy strip too thin to hide the wounds.” 

Farmer writes this poem, “The Mango Lady,” and dedicates it to Ophelia Dahl after witnessing a roadside accident in which a woman died when she fell from an overcrowded pickup truck and a basket of mangos crushed her. A piece of cardboard covers her face. Farmer falls silent at the sight and later uses the scene to teach Ophelia what anthropology is. Anthropology is about understanding the meaning of events just as learning connotations is part of language. The flawed US foreign policy enables the tyrannical Duvalier dynasty, which spends aid packages on the elites instead of road improvement or support for the poor. Once one factors in those dynamics, random deaths like this have a logical cause.

“How could a just God permit great misery? The Haitian peasants answered with a proverb: ‘Bondye konn bay, me 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.’” 

A key difference between liberation theology and Marxism is the role of religion. Marxism often views religion as a means for the elites to placate the underclasses by promising a better afterlife in exchange for fealty. Liberation theology views God as a scorekeeper who will judge abusive leaders and help those who resist inequality. The Catholicism of Farmer’s youth didn’t appeal to him, but this form speaks to his pragmatism and desire for “solidarity” with his patients. Farmer now wears a wooden cross while working, as many of the world’s poor are religious, and understanding their beliefs is more productive than treating them with disdain.

“‘You eatin’ enough?’

‘Oh, I’m fine,’ said Farmer.

‘Need any money?’

‘No,’ said Farmer. ‘Well, maybe forty dollars?’

[…] Farmer looked down at the loot. ‘Now I can tell you what happened last night.’ He’d gone to the home of an AIDS patient whom he had treated at the Brigham and found out the man was about to be evicted. ‘I signed my check over to him.’

‘Jeez, Paul, don’t you think that’s kind of impractical?’

Farmer smiled. ‘Well,’ he said, ‘God sent you today.’” 

Farmer often discusses morality, guilt, and purpose with Tom White, a key benefactor to Partners in Health during its early years. Despite his having wealth and enough political prestige to be part of John F. Kennedy’s inauguration, White is uncomfortable with other elites and refuses credit for his contributions. Farmer’s intelligence, dedication, and frankness lead White to run errands for the doctor and unconditionally fund any project. Farmer’s willingness to pay his patient’s rent foreshadows his justification for paying the $18,000 medevac flight at the end of Mountains Beyond Mountains: When expensive bills are the difference between life and death, doctors can afford to spend a fraction of their high salaries to help their patients.

“Paul was restive in his clumsy cast, and angry because he yearned to get back to his clinic in Cange. She’d remind him he was supposed to keep weight off his broken leg, but he wouldn’t listen. She’d cook for him but he wouldn’t eat. She did her best, but she didn’t suffer silently. They had some rows. Finally, he said to her, ‘I’m going to Haiti. They don’t mind looking after me there.’ […] When he proposed to her a couple of years later, she found it hard to say no but impossible to say yes. Hurt and angry, he told her, ‘If I can’t be your husband, I can’t be your friend. It would be too painful.’” 

Kidder reveals that Ophelia and Farmer broke up in Chapter 7 before even describing how they meet. Ophelia’s letter reads like an apology for her lack of dedication to his mission and how “the qualities I love in you […] also cause me to resent you” (66). Chapter 10 exposes more about how Farmer’s righteous but inflexible morality makes him difficult as a partner. While the two eventually patch things up and Farmer marries another woman, the incident demonstrates how Farmer isn’t perfect and why he bristles at others' calling him a saint.

“From where he sat, Cange looked like a collection of small dwellings scattered in no particular pattern on the side of an almost treeless mountain. There, near the top, was the house of Dieudonné, empty now because he’d died of AIDS last October. Over there near the road was the house where Anita Joseph had died of AIDS, slowly. A lot of painful memories were incorporated in the landscape. He remembered many other patients who had died, along with their lab data, and remembered vividly three young Haitians who had worked with him on the first health census of Cange: Acéphie, picked off by malaria, Michelet by typhoid, Ti-tap Joseph by puerperal sepsis. Good medicine could have prevented all those deaths.” 

Farmer partly wrote his anthropology thesis, “AIDS and Accusation,” on the hills that encircle Cange. The AIDS epidemic hit the village in 1985, and Farmer’s paper used epidemiological data to disprove the academic and medical community’s theories that perverse Voodoo rituals in Haiti spread the disease into the United States. In fact, American sex tourists likely brought the disease to the island, and the CDC’s labeling of Haitians as a risk group caused massive financial and social harm. For Farmer, the cost of persecution and ignorance is personal as his patients and friends are among the dead. However, Kidder notes that he can also see Zanmi Lasante and the new and upgraded houses that it’s responsible for from this vantage point.

“The perspective is interesting. One learns, for instance, that the United States tried to help the French put down the Haitian revolution in the 1790s and, during the time of American slavery, refused to recognize Haiti and practiced gunboat diplomacy there. Also that, during the American occupation, the U.S. Congress had reconstituted the modern Haitian army and helped to finance it right up until the time when it deposed Aristide; […] while formally deploring the coup, Washington, with the help of a generally compliant mainstream American press, was busily denouncing Aristide, even manufacturing lies about him, and maintaining a leaky embargo that seemed calculated to preserve appearances but not drive the junta out of power.” 

Kidder calls Farmer’s The Uses of Haiti, a history of American intervention in the country, his most passionate work. Despite its egalitarian ideals, the United States acted in terms of the elites’ self-interest, whether in preventing the rise of a self-sufficient Black nation during the slavery era or facilitating its brutal military governments. This and other works also single out hypocritical French revolutionaries, mixed-race Haitians who wanted to own slaves themselves, and American heroes like Fredrick Douglass and Franklin Delano Roosevelt who were willing participants. Despite Farmer’s efforts to get the United States to intervene for the right reasons, the United States tied its 1994 overthrow to “structural economic adjustment” (117), and Aristide accused the US military of engineering his second deposing in the 2000s.

“On this map, the line dividing the two color-coded parts of humanity—what Farmer called the ‘great epi divide’ (epi being short for epidemiological)—would partition many countries, many cities. Most of Haiti would wear the color of ill health, but parts of the hills above Port-au-Prince would be a patch of well-being. The map of the United States, by contrast, would depict a healthy nation speckled with disease. In Boston’s Mission Hill neighborhood, right next to the Brigham, for instance, infant mortality is higher than in Cuba. In New York City’s Harlem, a famous study from 1990 showed, death rates for males between the ages of five and sixty-five were higher than in Bangladesh.”

Kidder begins Part 3, where Partners in Health’s work shifts to a global stage, with an explanation of an epidemiological map that depicts which populations live to an old age and which die young, often because of disease and poor healthcare access. This mapping goes beyond whether the United States has better doctors or technology than Haiti as the wealthy in both nations can access treatment and others cannot—often in ways that reflect income, racial, and gender inequality. The fact that poor neighborhoods can lie next to state-of-the-art facilities is also important as multi-drug resistant strains of tuberculosis arise more often where “wealth and poverty are mingled” and treatments get interrupted (127).

“She told him her story. A government clinic had treated her for TB, but she had relapsed. Her second course of therapy had been interrupted by a strike of medical workers—the government of Alberto Fujimori had cut social service spending drastically, and the health workers had gone out in protest. Eventually her TB had been cultured and found to be resistant to four first-line drugs. She’d been re-treated again—with those very same drugs, strangely enough—and now she was sick again and coughing blood. Along the way doctors had accused her of ‘noncompliance,’ and her son had died of TB, more than likely from a strain of the disease that he’d caught from her.” 

The death of Father Jack Farmer turns into a mystery to find out how he contracted an MDR-TB strain with resistance to four first-line drugs. Peru project director Jaime Bayona struggles to find answers until he learns about Señora Brigida’s story after asking if there are any tuberculosis patients that the DOTS system didn’t cure. Because DOTS is a WHO-approved program, doctors blamed patients for failing to maintain their treatments. However, the problem is the DOTS program itself. The flawed treatment procedures and the disruption of Brigida’s treatment by the strike also demonstrate the far-reaching repercussions of major political decisions.

“In effect, WHO had prescribed this for them, too. The official DOTS manual contained the following statement: ‘In settings of resource constraint, it is necessary for rational resource allocation to prioritise TB treatment categories according to the cost-effectiveness of treatment of each category.’ Farmer and Kim began collecting a number of official WHO statements. Some put the case more plainly: ‘In developing countries, people with multidrug-resistant tuberculosis usually die, because effective treatment is often impossible for poor countries.’”

If an MDR-TB patient’s condition does not improve, the DOTS program recommends a second cycle. This only strengthens the tuberculosis’s resistance to frontline drugs. After that, they must consult private pulmonologists for expensive second-line drugs that many cannot afford, leading to more resistant strains. The WHO’s claim that MDR-TB is too expensive to cure in poor countries is based on cost-effectiveness analysis, which Farmer and Jim Yong Kim see as rationalizing the status quo. Farmer and his colleagues compare the billion dollars that the United States spent to stop an MDR-TB outbreak in New York City to the smaller amount necessary to amend the DOTS system before the strains become widespread. They also compare it to the billion dollars in foreign loans that Peru pays each year, making the response even more unjust.

“‘Thank you, Paul, for that provocative talk,’ said the moderator, a TB specialist from the U.S. Centers for Disease Control, a friend of Farmer’s named Ken Castro.

Farmer was on his way offstage. He turned back. ‘Excuse me, Ken, but why do you qualify my talk as provocative? I just said we should treat sick people, if we have the technology.’”

Farmer’s disdain of political correctness comes from his efforts to influence public opinion. Facing roadblocks from Peruvian authorities, Farmer speaks at a TB conference in Chicago to warn the audience that expecting MDR-TB to remain a small, less-transmissible concern will turn the DOTS program into a disaster. However, Farmer was not well-known in TB circles at the time, and the speech frames “half his audience as fools and villains” (147). The moderator’s qualifier gives the audience an excuse not to treat his cause seriously.

“Doctors are notorious for taking peculiar views of their bodies. They tend to develop hypochondria in medical school and, once they get over it, if they do, tend to think they’re invulnerable. Many people refuse to set their work aside for matters of personal convenience. But Farmer seemed to be unwilling to set it aside for any reason. It was as if he couldn’t allow himself to be the one to set it aside. A force stronger than his own will had to intervene, like the car that had hit him back in 1988.” 

Hepatitis A is rarely fatal in developed countries, but Farmer puts off vaccination and ignores the symptoms until he nearly requires a kidney transplant. Kidder criticizes Farmer’s attitude about his own body as violating his belief in “pragmatic solidarity.” Taking a break from his global schedule does create the risk that he won’t be there when someone with a serious condition needs help, but dying from a preventable disease would keep him from his mission forever.

“I want to share with you a simple reality. I have six million dollars. With three million dollars I can implement DOTS for five thousand Russian prison inmates. And assuming that ten percent have MDR-TB, forty-five hundred will be cured and five hundred will go down with MDR-TB and die. And there’s nothing much you can do. So. I have a choice. And my choice is to use another three million dollars to treat the five hundred with MDR-TB, or go to another region and treat another five thousand. I’m working with limited resources. So my choice is not involved in the human rights of five hundred people, but five hundred people verses five thousand people.” 

At a TB conference in Boston, Alex Goldfarb of the Soros Foundation explains the MDR-TB crisis in Russian prisons and shuts down a PIH ally’s comment that costs shouldn’t matter when treating patients as well as Howard Hiatt’s suggestion of a hypothetical pilot program. Goldfarb presents the situation as a sort of trolley problem in which he can either treat the prisoners and address the source of the MDR-TB epidemic or focus on the countryside, an approach that would cure more people and be more politically popular. Kidder presents Goldfarb as Farmer’s opposite: a representative of a giant charity who is well-meaning but cynical and political. However, Goldfarb’s dilemma isn’t as rigid as he presents it. Russia secures funding for both prisons and the countryside once PIH joins the endeavor, and Farmer implements a pilot project once a political scandal forces Goldfarb out.

“The price reductions came in stages. By the year 2000, projects buying through the Green Light Committee paid about 95 percent less for four of the second-line drugs than they would have in 1996, and 84 percent less for two others. Howard Hiatt and Jim had persuaded Eli Lilly to donate large amounts of two antibiotics to PIH, and Lilly had promised to grant other MDR treatment projects vastly lowered prices […] The drugs to treat a four-drug-resistant case of MDR now cost PIH about $1,500, instead of $15,000, and prices were still falling, substantially and rapidly.” 

PIH refuses to deny treatment due to costs or even wait for a price drop before purchasing medicine, but the high cost of MDR-TB treatment required Farmer and Kim to get drug companies to lower their artificially high prices. Farmer encourages competition to mixed results and convinces Eli Lilly that a large donation would benefit public relations. Kim plays a pivotal role in convincing the WHO to include second-line drugs in its essential drugs list. To prevent resistant strains of second-line treatments from appearing, the WHO introduces a Green Light Committee to regulate who can purchase these treatments. The result is drastically reduced drug prices in comparison to the seemingly unfixable situation beforehand.

“good morning, david. the damage from bacterial meningitis is ultimately due to the host inflammatory response. white cells. so that purulent meningitides that go for the base of the brain cause an almost mass-like inflammation there. now what courses under the base of the brain? the cranial nerves. and what do they do? permit little girls to hear. and what happens to them when they are surrounded with mass-like gelatinous inflammation (pus?) they get pinched. and they get anoxic. there goes hearing, and often ability to open both eyes, etc. even hydrocephalus is often due to inflammatory debris blocking the foramina.…it’s anatomy, my friend. anatomy and pus. it’s always anatomy and pus.” 

Farmer answers a steady stream of emails throughout the day from his various projects, including this one from a medical student asking about how meningitis causes hearing loss. The email reveals much about the doctor’s personable nature. The scientific cause would probably take only a sentence to explain, but Farmer provides a human element by explaining how the cranial nerves allow people to hear and how step-by-step meningitis disrupts it. This passage reflects the joy that Farmer gets from diagnosing patients and his occasional dreams of abandoning his global duties. However, while Ophelia notes that he’s always “missing from somewhere” (184), the doctor finds it particularly hard to leave his work in Haiti.

“When others write about people who live on the edge, who challenge their comfortable lives—and it has happened to me—they usually do it in a way that allows a reader a way out. You could render generosity into pathology, commitment into obsession. That’s all in the repertory of someone who wants to put the reader at ease rather than conveying the truth in a compelling manner. I want people to feel unhappy about Lazarus and all the others who are shafted. Otherwise why would I have you with me? I don’t have a lot at stake in how you depict me. I’ve been yelled at by generals and denounced by people who don’t have any data when I have a shitload. It does no harm to me, but plenty to my patients.”

When Kidder suggests that the Cubans praise Farmer because he’s critical of the United States, the doctor warns him of the consequences of this framing. This disagreement threatens the rest of the trip not only because of the personal tension, but also because Kidder cannot avoid controversial topics just because they may hurt Farmer’s mission. However, the doctor does make several good points. Framing Farmer as a maniac or radical allows the reader to ignore the plight of the people he’s trying to help. The same goes for ignoring how Cuba’s system for expanding medical expertise in Latin America is more effective than the United States’ capitalist approach or even Farmer’s own work in Haiti.

“It really wasn’t hard to imagine—making the kind of mistake that would end in a cell inside this place. In Russia just now, a young man could get thrown in jail for stealing a loaf of bread or a bottle of vodka and, because the criminal justice system was clogged, languish in a detention center for a year or even four years before his case came to trial. While waiting or while serving his sentence, he’d probably get infected with TB—it was estimated that about 80 percent of all Russian prisoners had bacilli in their bodies. […] a young prisoner could contract susceptible TB and, through inadequate treatment, end up with MDR. Or, increasingly likely, he could catch a strain of MDR directly from another inmate and die from it before he even got sentenced for stealing his loaf of bread.” 

Prisoners are a politically unpopular target for aid because most people assume that they did something wrong to deserve their sentence. However, 100,000 inmates in Russia’s cavernous prisons have TB, with 30,000 contracting MDR strains at the time PIH began its Russia operations. This means that thousands who only committed minor crimes or political disobedience are at risk of contracting a disease that could become a death sentence. In addition, prison guards are at risk of contracting the disease and spreading it in their communities.

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

Zanmi Lasante’s AIDS program, the first to select patients only on medical need and not ability to pay, becomes a global model for treating the disease and receives a $14 million grant from the newly formed Global Fund. However, the organization’s focus area of several hundred patients pales in comparison to the 40 million people who have the disease, and the United States' financial pressure on Haiti results in the closing of medical facilities and overloading of Zanmi Lasante’s facilities. Farmer’s criticism of this praise also extends how others view him, as trying to emulate the doctor would quickly lead to burnout. The goal should be to do what should be done and not what Farmer would do.

“But I didn’t see what good it would do to transfer the suction device. It was electrical. It would take better mechanics than these guys to hook it up to Zanmi Lasante’s truck, in the middle of the night, during a rainstorm on the slopes of Morne Kabrit. Hours—it seemed like hours—went by. […] More time went by, and then I saw Serena’s hand appear out of the back of the ambulance with the thumb turned upward, and moments later Ralph was carrying the suction device to the truck. He had mounted it on a board and wired I to a plug that would fit the socket of the truck’s cigarette lighter. He leaned into the cab, inserted the plug, and the machine began whirring. Serena clapped her hands.” 

Chapter 25 covers the storm of logistical issues in treating patients in Haiti. A young cancer patient, John, has to wait days for a diagnosis that would take hours in Boston, and PIH debates the financial feasibility of flying the patient. Then there is the challenge of physically moving the patient as he deals with severe conditions. The need for a private ambulance places financial strain on Zanmi Lasante, and the combination of flooded roads and inadequate equipment means that the patient could die before reaching the plane. However, Serena Koenig sees the life-saving pro bono treatment in Boston as too good to give up, and this struggle makes the insensitive comments about Haiti that she hears in the United States more insulting.

“How about if I say, I have fought for my whole life a long defeat. How about that? How about if I said, That’s all it adds up to is defeat. […] You know, people from our background—like you, like most PIH-ers, like me—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.” 

As Farmer defends Zanmi Lasante’s efforts to save John, he relates this story to previous discussions with Kidder. To Farmer, the reasoning is simple: “Because his mother brought him to us and that’s where he was, in our clinic” (287). However, there is also a greater philosophical meaning. He and other PIH members abandoned comfortable lives to cure the sick in an impoverished region that continues to endure oppression and inequality. Each death is personally crushing. Helping these victims means that they have to make do with the resources they have and cannot only serve patients with the best chances of recovery. This also means a constant struggle to convince critics, including allies like Kidder, that failure is expected and necessary.