The title Mountains Beyond Mountains comes from a Haitian proverb and is a metaphor for life’s challenges. Once you have scaled one mountain, you reach a place where you can see that there are always more mountains farther away: you will never stop climbing, never be finished. In the case of Paul Farmer, whose visionary spirit is the subject of this book, his mountain is the struggle to provide medical help to all desperately poor people. In fact, the man Tracy Kidder writes about in this nonfiction account is something of a secular saint, for Paul Farmer really only comes alive when he is tending to the illnesses of people the rest of the world has forgotten.
During the years chronicled in the book, Farmer crosses the globe many times, from his origins in the American South to his medical training at Harvard University, but he focuses his attention on some of the world’s most struggling people: the prison population in Russia, the slum dwellers of Lima, Peru, and, most especially, the rural poor of Haiti, who have a particularly intense grasp on his heart.
Mountains Beyond Mountains tells Farmer’s story but less for its own sake than as a way to understand what led this man to dedicate his entire life to solving health crises that everyone else seems willing to let stand. The book is informative, but Kidder also writes it as a kind of challenge, a challenge that can be summed up in three lines: Helping the suffering poor is possible. Paul Farmer is doing it. Why aren’t you?
As readers follow Farmer’s treatment of developing ideas and practices of public health, his gentle interactions with rural Haitians, his development of a private charity, and his attempts to change international medical policies, that challenge will always be echoing through their minds.
Part I: Dokte Paul
Part I: Dokte Paul
This section introduces Paul Farmer and explains how Tracy Kidder came to write his story. It opens with a dramatic line: “We met because of a beheading, of all things.” Kidder then dramatically recounts a clash between Farmer and Jon Carroll, a captain in the American Special Forces. Both men were in Haiti to save the country, but each in different ways. Carroll was one of 20,000 American soldiers who had come to Haiti to oversee the reinstitution of democracy (Kidder was there to report on this mission). Farmer was in Haiti to implement an ambitious public health program. The two men argued over how to pursue the beheading of a local assistant mayor. Everyone knew who had killed the...
(The entire section is 592 words.)
Part II: The Tin Roofs of Cange
Part II: The Tin Roofs of Cange
Kidder begins the next section with another revealing sentence: “It was impossible to spend any time with Farmer and not wonder how he happened to choose this life.” He follows this claim with an extended review of Farmer’s life. His father, Paul Sr., was an athletic and strong-minded but idiosyncratic man who led his family on a life of self-chosen adventure. Paul Sr. left a good job in Massachusetts to move his family to Alabama. Once there, he bought a bus and the family lived on it, moving from campground to campground without running water. Later, they lived for a time on a boat. Farmer’s parents encouraged them all to pursue their own interests, but Paul Sr. was...
(The entire section is 1018 words.)
Part III: Medicos Aventureros
Part III: Medicos Aventureros
While in medical school, Farmer had lived at St. Mary of the Angels. The priest there, Father Jack Roussin, had left Boston in the early 1990s to go work in Lima, Peru. He urged Farmer to establish a branch of Partners in Health there, which they did. However, while the pharmacy they built was helping the poor, Father Jack died of multidrug resistant (MDR) TB. In the industrialized world, TB was relatively easy to treat for a serious disease, but if treatment was interrupted, there was a strong chance that the surviving TB bacillus would become resistant to the drugs first used to treat them. This made the disease harder and more expensive to cure and more likely to kill the...
(The entire section is 448 words.)
Part IV: A Light Month for Travel
Part IV: A Light Month for Travel
The next section of the book uses descriptions of Paul Farmer in the act of travel and on site as a way to show how his work was developing, how the developments were putting Farmer under ever-greater tensions, and how his actions showcase the complex ideological context in which medicine occurs. Chapter 20 focuses on Farmer’s travels between the United States and Haiti, describing how he takes responsibility for all Haitian challenges (including, for example, flying or using an escalator for the first time), adapts his personal dress to Haitian demands (somewhat), and maintains an almost continuous stream of email correspondence with friends and colleagues around the...
(The entire section is 296 words.)
Part V: O for the P
Part V: O for the P
The fifth section of Mountains Beyond Mountains brings the narrative up to the present. It shows what happens when Farmer and Partners in Health move from being struggling rebels to becoming models for others’ actions; it also shows how much has changed since Farmer began his quest—and how much has not. Chapter 24 begins with a measure of Partners in Health’s success: the Gates Foundation donated $45 million to eradicate MDR TB in Peru. It is an enormous project, with plans to last five years and treat thousands of patients, and it would be a tremendous victory, fundamentally changing conditions for the poor there, perhaps for decades. This very success, however, pushed...
(The entire section is 683 words.)
Summary and Analysis
Part I, Chapter 1 Summary and Analysis
Chapter 1 introduces Paul Farmer and describes author Tracy Kidder's first encounter with Farmer. Kidder had come to Haiti as a reporter to cover the actions of American soldiers there. It was just before Christmas in 1994 when Kidder observed Farmer arguing with Captain Carroll, one of the American soldiers. The assistant mayor of the Haitian town of Mirebalais had been killed—beheaded, in fact—and Carroll had taken the main suspect (Nerva Juste, a sheriff) into custody. They had not been able to find proof or testimony that Juste had done the killing, so they released him.
Dr. Farmer and Captain Carroll argue over the best way to seek justice in the situation, with the soldier arguing...
(The entire section is 322 words.)
Part I, Chapter 2 Summary and Analysis
Chapter 2 is set five years later, in the middle of December 1999. It follows Paul Farmer through a day of rounds at Brigham and Women's Hospital in Boston. It describes the hospital's placement in Boston and its neighborhood, then moves on to describe Farmer, who dresses much more formally in Boston than in Haiti. Brigham and Women is a teaching hospital, and Farmer leads younger doctors on rounds to teach them. He quizzes them on preferred modes of treatment, and they spend a lot of time on a patient Kidder calls "Joe." Joe is 35, an alcoholic and a drug user who has HIV. The virus has not yet really begun destroying him, but Joe had lost 26 pounds over the previous few months. Farmer tries to...
(The entire section is 341 words.)
Part I, Chapter 3 Summary and Analysis
Chapter 3 begins with Kidder's arrival in Haiti. Farmer sent a truck to pick him up, and Kidder rides with a group of Haitians along National Highway 3. The thirty-five-mile trip from the capital Port-au-Prince to the village Cange takes three hours. Once there, Kidder visits Farmer's clinic Zammi Lasante (which means "Partners in Health" in Creole). Kidder follows Farmer on his rounds, watching Farmer interact with countless sick and desperately poor Haitians. The clinic has seventy community health workers, but it is the main source of health care for roughly one million peasants, many of whom travel long distances by foot or on donkey to see "Doktè Paul."
Officially everyone treated at...
(The entire section is 612 words.)
Part I, Chapter 4 Summary and Analysis
Kidder continues to follow Farmer as he treats the Haitian sick. Farmer tells stories about how one woman's death led him to revise his treatment program, including running an experiment with TB patients. One group received the standard medical treatment. The other group received standard treatments, plus visits from Zammi Lasante workers and stipends to buy better food. Only half of the control group recovered, whereas everyone in the experimental group did. From this, and from discussions with Haitians about their beliefs in sorcery, Farmer concluded he had "to worry more about his patients' material conditions" than what they believed.
Kidder accompanies Farmer as he goes out into the...
(The entire section is 485 words.)
Part II, Chapter 5 Summary and Analysis
Chapter 5 steps back emotionally from Haiti and moves back through time to give Paul Farmer's biography. In 1959, Farmer was born in North Adams, Massachusetts. He had three sisters and two brothers. His father, Paul Sr., was a large and energetic man who loved sports and physical activities, but did not always have complete focus. His mother, Ginny, left college to marry Paul Sr., and she and the family accompanied him through a range of adventures. In 1966, Paul Sr. moved the family to Birmingham, Alabama, and then, in 1971, to Florida in a school bus Paul Sr. had purchased. The family lived in the bus for some time, with erratic power and no running water, and sometimes slept in a tent. About the...
(The entire section is 495 words.)
Part II, Chapter 6 Summary and Analysis
Chapter 6 continues to focus on Paul Farmer's background; this chapter shifts focus to Paul himself and especially to his experience in higher education. As a child, Farmer had been very gifted intellectually. In college, he really blossomed, both intellectually and socially. He had many friends at Duke and took the opportunity to study in Paris, where he took a course with the famous anthropologist Claude-Levi Strauss. After studying broadly in the sciences, Farmer focused on medical anthropology. He also found a mentor through his reading: the German Rudolf Virchow. Virchow worked in many fields—medicine, archaeology, education, politics—but Virchow's...
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Part II, Chapter 7 Summary and Analysis
This chapter opens with an excerpt from a letter to Paul Farmer from Ophelia Dahl. Dahl, daughter of author Roald Dahl and actress Patricia Neal, came to Haiti to volunteer with Eye Care and see the world. When she came to Eye Care's building in Mirebalais, she met Farmer. He was then twenty-three, and she was eighteen. They talked endlessly about their lives during the week Dahl was at Mirebalais, then road back to Port-au-Prince (the capital of Haiti) with the Eye Care team. As they navigated the twisting roads, they ran across a wrecked "tap-tap" (a truck that carried both passengers and cargo). One woman had been killed in the wreck.
They saw each other...
(The entire section is 415 words.)
Part II, Chapter 8 Summary and Analysis
In 1983, with Ophelia out of Haiti, Farmer traveled from Mirebalais to Cange with Fritz Lafontant, a Haitian Anglican priest. Lafontant had set up a basic health clinic in Mirebalais and was trying to serve smaller communities like Cange through building it a chapel and school. Farmer did not stay in Cange, but traveled throughout Haiti. He lived with the peasants and he ate with them, resulting in a case of dysentery so intense that an American public health authority wanted to send him home. He recovered, and he studied all aspects of Haitian life at close range. He talked with the peasants about their lives and went to voodoo ceremonies. Through these direct experiences, Farmer grew clearer on what...
(The entire section is 508 words.)
Part II, Chapter 9 Summary and Analysis
Chapter 9 covers three interwoven topics: Farmer going back and forth between Haiti and Harvard, his developing relationship with Ophelia, and his new relationship with Tom White. Farmer studied medicine intensely whether in the United States or in Haiti, but it was in Haiti that his studies were applied and took on meaning. It is also where Paul and Ophelia became lovers: in Lafontant's rectory in Mirebalais, in a rain storm. The couple made love, studied together, had food fights, and traveled around Haiti. During these travels, they gathered more data about Haitian health conditions, data that deepened these young people's understanding that many of the health problems came from poverty and the...
(The entire section is 504 words.)
Part II, Chapter 10 Summary and Analysis
Chapter 10 focuses on two interwoven relationships: Farmer's increasingly troubled romantic relationship with Ophelia, and his emerging relationship with those who would work to help Haiti with him. Tension grew between Paul and Ophelia because of his commitment to the Haitian poor: Farmer often acted like he wanted to do nothing else but help the poor, while Ophelia wanted to help the poor incredibly generously...and sometimes do some other things for herself, and with Paul. This led to disagreements, and in one case to a fight in which Farmer screamed at Ophelia to get out of the car and insulted her. During another trip to Port-au-Prince, in 1986, political violence erupted. There had been a...
(The entire section is 627 words.)
Part II, Chapter 11 Summary and Analysis
Chapter 11 begins with Farmer's return to Haiti in a wheelchair (due to his broken leg) in December of 1988. He finds Haiti politically agitated. The peasants protest and try to oust any remnants of the former Duvalier power structure; the military government who took over after Duvalier and rule with U.S. aid and support strike back even more violently. The result is considerable social upheaval, and a society where patients might be killed in their hospital beds and voters at the polls. The small Catholic churches of the Haitian countryside are the seedbeds of political resistance. In 1986, Farmer was excited to hear one of these priests, Jean-Bertrand Aristide, articulate the political theology he...
(The entire section is 632 words.)
Part II, Chapter 12 Summary and Analysis
In Chapter 12, Paul continues to focus on politics, and Kidder shows how this involvement affects Farmer's friends and coworkers. When Ophelia visits him in Haiti, she seems him uncooperative with the soldiers at roadblocks and leaving politically dangerous literature in view. When he visits Boston, Farmer asks Tom White for $10,000 cash to smuggle back to the resistance movement; this leads to a shooting match with his friends over the risks he is taking. In 1993, Farmer won a MacArthur grant, and wrote The Uses of History. The Uses of History tells the history of America's ongoing involvement in Haitian politics over the last two hundred years. However, back in Haiti, many of...
(The entire section is 395 words.)
Part III, Chapter 13 Summary and Analysis
Chapter 13 opens by describing an "epidemiological map" in two colors: one for groups who die of old age, and the other who die from other causes, such as accidents, starvation, and illness. The two colors (populations) would be found on maps of every part of the world. While there is often a racial association for the groups, with people of color dying of illness more often, that is not universal. The only universally shared characteristic is poverty. Paul Farmer and his colleagues experienced this vividly when trying to treat diseases such as AIDS and tuberculosis (TB). TB has been largely eradicated from richer countries, but kills two million people a year in poorer countries. Moreover, TB is...
(The entire section is 325 words.)
Part III, Chapter 14 Summary and Analysis
While he was attending medical school, Farmer lived at St. Mary of the Angels. This church, in the largely Black Roxbury neighborhood of Boston, was run by Father Jack Roussin. Roussin was a was politically active priest, but also had a great sense of humor and accepted people: he knew Ophelia and Paul were sleeping together in Paul's room in the rectory but teased them about it rather than forbidding it. Father Jack served on Partners in Health's board of advisers until he moved to Carabayllo, a slum in Lima, Peru. Once there, he suggested PIH start a public health project there. Jim Kim agreed to do so. Kim had served as Paul's assistant for eight years and wanted to repeat Farmer's successes...
(The entire section is 599 words.)
Part III, Chapter 15 Summary and Analysis
In Chapter 15, Farmer shows author Tracy Kidder around Lima, Peru. The city sprawls in immense waves of building after building. Kidder's description of Carabayllo focuses on the poor, many of whom came to Lima from mountain villages of Incan heritage seeking the trappings of modern civilization and to escape the ongoing war between Peruvian military forces and the guerrilla fighters of the Shining Path (the Marxist rebellion movement). What they found was urban poverty, filth, and, increasingly, tuberculosis.
Jaime Bayona located ten Carabayallaons (residents of the slum Carabayllo) who appeared to suffer from MDR. They needed to test cultures taken from these patients, but the Peruvian...
(The entire section is 492 words.)
Part III, Chapter 16 Summary and Analysis
The scale and expense of the MDR issue in Peru made PIH hesitate, forcing them to ask themselves if this was a challenge they should even try to solve. They eventually decided it was, because no one else was doing it and people were dying—and because it would allow them to tackle other public health issues along the way. In August 1996, they started treating TB sufferers in Carabayllo. They combined a team of Peruvian health workers with doctors and medical students from Boston. They ran into problems almost immediately. The Peruvians did not want to visit the homes of MDR patients, they needed money, and Peruvian officials did not want to admit they had such a serious problem. Jim and Paul were not...
(The entire section is 531 words.)
Part III, Chapter 17 Summary and Analysis
Chapter 17 begins with a brief mention of Didi Bertrand, the new love of Paul's life. He courted her for two years before they married in 1996 in Cange, where 4,000 people attended.
The bulk of the chapter focuses on PIH's work in Peru. It cost $15,000 to $20,000 per patient to treat those sick with MDR, and the more PIH investigated, the more infected people they found. Farmer dealt with some of this expense creatively—talking individuals at Harvard Medical School into giving him the drugs he needed without paying the $92,000 at the time. They spent Tom White's money freely, and in general tried to do what they needed to do first and then figure out how to pay for it (or get permission to...
(The entire section is 559 words.)
Part III, Chapter 18 Summary and Analysis
Chapter 18 focuses on a pivotal meeting of the International Union Against Tuberculosis and Lung Disease in April 1998. Tuberculosis expert Arata Kochi, who had been one of the champions of DOTS ("directly observed treatment short-course chemotherapy") as a way to treat TB, recognized the success Farmer was having treating MDR patients. He coined the phrase "DOTS-plus" as a name for it, which gave the TB specialists a way to discuss it. However, this success was met with a serious challenge: Alex Goldfarb raised the question of cost of treatment. Goldfarb was responsible for treating TB in Russia, which was quite widespread in the prison system. Goldfarb argued that his choice was between treating 500...
(The entire section is 363 words.)
Part III, Chapter 19 Summary and Analysis
International health organizations used a process called "cost-effectiveness analysis" to evaluate proposed public health projects. They judged how much something would cost and then how effective it would be. These estimates were compared to other proposed projects to decide what to fund. The project to treat MDR in Peru challenged this model. It suggested that the World Health Organization's facts were incorrect but also that how it was thinking about projects was wrong. Jim Kim led PIH's efforts here.
Kim had been born in Korea, but was raised in Iowa. His family was one of only a few Asian families in Muscatine, and Jim was isolated as a result. He went to the University of Iowa, then to...
(The entire section is 593 words.)
Part IV, Chapter 20 Summary and Analysis
Chapter 20 begins several years later, in 2000, with Kidder talking to Howard Hiatt, who was arguing for Farmer to spend his time in ways that were more useful for more people. This is followed by a summary of Farmer at 40 years old, a summary that includes his successes, his failures, and his idiosyncrasies. Kidder describes Farmer dealing with his daily email—up to 75 messages a day, many of which were requests for help.
Kidder accompanies Farmer to the Cange for two weeks. Farmer used to dress casually when he traveled but now wore a black suit, black because he was often a formal representative of a group now and because it took ink stains without showing. As they travel, they talk...
(The entire section is 416 words.)
Part IV, Chapter 21 Summary and Analysis
Chapter 21 describes Farmer's trip to Cuba (and Kidder's trip with him). Farmer admires Cuba's public health system, and Kidder indicates that Cuba does a better job of tracking illnesses such as AIDS than most countries. However, despite Farmer's admiration for Cuban practice and equality, and his support of Marxist theories of social and economic analysis, Farmer distrusts the more theoretical and ideological elements of Marxism.
Farmer went to Cuba to attend a conference, and while in Cuba, he visited his friend Dr. Jorge Perez and with Dr. José Miyar Barruecos, a representative of Cuba's Council of State. Luc Montagnier, who discovered the HIV virus, was there, as was the French...
(The entire section is 415 words.)
Part IV, Chapter 22 Summary and Analysis
Chapter 21 ended with Kidder and Farmer on the plane flying out of Miami. Chapter 22 starts in Paris, where Kidder accompanies Farmer for his daughter Catherine's second birthday before going on to Moscow. Kidder summarizes how Farmer's friends criticize him for spending so little time with his family, then recounts Farmer's story about trying to save a pregnant woman and child—and how Farmer judged himself for loving his own child more than others' children.
After the visit, they leave for the airport, where Farmer goes back to work checking things off his list. While Farmer works, they talk, and the discussion leads into a list of some of the specialized vocabulary and abbreviations...
(The entire section is 384 words.)
Part IV, Chapter 23 Summary and Analysis
In Chapter 23, Kidder accompanies Farmer to Russia for an international meeting to fund TB treatment there. TB was exploding in the Russian prison system; people were getting TB at a rate of "forty to fifty times higher" than civilians were. Many prisoners—some of whom were in for minor crimes like stealing a loaf of bread—died from TB, while others lived through their sentences only to get out and spread MDR through the general population.
When Farmer visited Russia, a number of international attempts to deal with the Russian TB situation had been made, but they were too small, under-funded, and committed to a DOTS treatment plan. The result was that most of the prisoners were not...
(The entire section is 486 words.)
Part V, Chapter 24 Summary and Analysis
Chapter 24 opens with the Gates Foundation giving PIH $45 million to fight MDR-TB in Peru. This influx of wealth produced new challenges, taxing Jim Kim's capacity and causing Paul to remind previous donors that their funds were still needed. Kidder follows this with a quick description of the PIH offices, where Farmer is held up as the (impossible) model, and with how the organization's growth was forcing changes, some of which, like paying overtime wages, directly contradicted Farmer's wishes.
In addition to Haiti and Peru (and the United States), PIH had expanded into Siberia. This produced a serious rift between Kim and Farmer over Kim's choices (where to focus his time) and actions...
(The entire section is 453 words.)
Part V, Chapter 25 Summary and Analysis
All of Chapter 25 focuses on the attempt to save a young Haitian named Paul. Paul's mother brought Paul to the clinic in Cange with swellings in his neck. A surgeon was hired to come from Mirebalais to biopsy them. John was diagnosed with nasopharyngeal carcinoma, a rare form of cancer, but one that had a good survival rate if diagnosed and treated early. Farmer and Serena Koenig, a Brigham doctor serving in Haiti, were going to try chemotherapy in Haiti, but were convinced it would kill him. They decided to bring him to the United States. This meant creating a birth certificate for John and then getting a passport. They hired a battered truck to haul John and his doctors along crumbling, flooded roads,...
(The entire section is 415 words.)
Part V, Chapter 26 Summary and Analysis
Kidder accompanies Farmer on an extended hike through the Haitian countryside to visit patients. They walk for miles—11 hours in a single day—so that Farmer can treat two families of patients. Ti Jean, the clinic's handyman in Cange, accompanies the two men and often offers specifically Haitian interpretations on the things they see. Farmer and Kidder talk about the patients Farmer is treating, but primarily about the larger context of Farmer's work and criticisms of it. Kidder summarizes the two primary criticisms of Farmer's practice as (1) how can he justify dedicating so much time to individual patients when his time would be better spent working on a large scale, and (2) since no one else will...
(The entire section is 467 words.)