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

As they fly out of Paris, Farmer warns Kidder not to think of France and Haiti as separate worlds. This lesson comes from the doctor’s wife, who reminds him that Paris’s beauty is partially due to its exploitation of enslaved Haitians. Rich nations often play a role in the problems of developing countries.

Haiti is a prime example. Christopher Columbus eliminated the indigenous peoples on the island, and France turned it into a focal point for the slave trade. Haiti liberated itself and developed a unique culture but remained vulnerable to French and American interference. Lacking the on-the-ground perspective of someone like Farmer, American aid projects like the dam and the replacement of pig populations indirectly harm poor neighborhoods and mostly benefit business interests. Farmer’s writings show that many oppressive Haitian military leaders received training from the United States. Meanwhile, Zanmi Lasante’s patient levels jumped after the United States soured on the democratically elected Jean-Bertrand Aristide and placed sanctions that closed many hospitals.

Rich countries also control medical access and set priorities. Because tuberculosis is under control in developed nations, treatment development stalled for two decades, enabling the development of drug-resistant strains in Peru. Drug companies keep the prices of second-line treatments artificially high due to lack of competition, leading Farmer to engineer a price war. Farmer and Kim also must deliver foolproof scientific papers and schmooze with dignitaries to change the scientific community’s opinions. This dynamic is tough for Farmer to stomach, as citizens of rich countries have ill-informed biases against poor nations. They view Haiti as an unsalvageable mess with a primitive religion. Farmer learns early on that his facts and first-hand experiences can lose a debate against someone who treads the status quo. Even receptive audiences have issues: PIH staff scoff at “white liberals” who fixate on word choice and academic leftists who claim solidarity with the poor but look down at their religion and claim that anything other than an unlikely revolution is meaningless. Ultimately, Partners in Health must walk this tightrope between helping the poor and convincing the wealthy to help or else it won’t be able to change anything.

Partners in Health’s early success is partially thanks to construction company owner Tom White, whose willingness to fund any project gets it through its early years. When Farmer tells George Soros that it would cost roughly $5 billion to control tuberculosis worldwide, the progressive investor jokes that it’s a low price. However, these free-range donations are uncommon in the charity field. Instead, Farmer must pit his radical idealism against a faulty form of pragmatism.

To Farmer and PIH, a doctor must do anything possible to save a patient regardless of the expense. Zanmi Lasante’s wavier list is so broad that virtually no one pays for treatment, and Farmer liberally provides expensive AIDS antiretrovirals to Haitian patients. PIH expands into Peru and Russia because there are medical challenges in those countries whose solutions would help Haitian operations. The organization even sells its headquarters building to buy HIV treatments for 250 patients. Farmer’s sense of “redistributive justice” promotes the breaking of medical guidelines: He steals a Harvard microscope, gets White to pay for medication he takes from the Brigham without permission, spends money on non-medical equipment, and prescribes aggressive treatments for patients with no medical precedent.

Most philanthropies operate with a pragmatic perspective like the Soros Foundation’s Alex Goldfarb. Even though he has Soros’s financial backing, Goldfarb must navigate political relationships and consider alternative aid, such as using the potential loss of a World Bank grant to get more money from private donors. Once a philanthropy wins a major grant, such as from the Bill and Melinda Gates Foundation, they must follow the foundation’s guidelines. In addition, several question whether Farmer should stop treating individual patients and focus on the greater good.

Regulations are necessary to protect patients and prevent exploitation, and anyone without Farmer’s clout could lose their career if they attempt what he does. However, Farmer sees much of what the establishment considers practical as an excuse to do nothing. For example, a cost-effectiveness analysis discourages organizations from using effective regimens in developing countries and leads them to prioritize containment over treatment. Furthermore, forcing the charity to justify the costs ignores the role of medical companies in making treatments expensive. PIH’s Peru operation reflects this issue, as Kim finds that the WHO doesn’t know that many second-line treatments have expired patents that allow for cheaper manufacturing. Several MDR-TB patients also die because Peruvian authorities insist on following the DOTS regimen to save face even though Farmer proves that the program is exasperating the issue.

John, the Haitian boy with cancer, epitomizes this dilemma. It is easy to second guess Zanmi Lasante’s spending so many resources on an ultimately untreatable patient who is on ventilation when Kidder first sees him. However, few question the medevac company for charging for the flight or other logistical issues that delay diagnosis. Both Serena Koenig and Farmer see the boy as still treatable until the end, and that Farmer argues John does not deserve to die in pain if he could get palliative care. Farmer maintains this mentality because he remains a doctor at heart and genuinely likes the grunt work necessary to enact real change.