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 man, but the two disagreed on how to seek justice. Captain Carroll insisted on following due process; Farmer argued that the rules of constitutional law did not apply in a country like Haiti, which lacked a rule of law. This incident provides a snapshot of Farmer’s character: he is willing to challenge anyone to help the poor he loved.
The second chapter shifts back to Boston, where Kidder follows Farmer through treating patients at Brigham and Women’s Hospital. When Farmer spoke with other doctors, he was casual, even jocular; when communicating with the impoverished poor, Farmer was sympathetic and accepting, willing to bend any rule he had to if it would help them get better (for example, helping an HIV patient choose less-damaging illegal drugs).
The third chapter returns to Haiti, introducing the realities of Zanmi Lasante (“Partners in Health” in Creole). Kidder followed Farmer on rounds in Haiti as he did in Boston. The two chapters highlight the economic and social distance between Farmer’s realities. In Boston, his HIV patient had been impressed by Farmer’s Harvard training and the high-powered medical help he received. In Haiti, Farmer was called “Dokte Paul,” whom the locals saw as a saint. His Zanmi Lasante provided the primary health care for a million poor Haitians. While Farmer treats their AIDS and tuberculosis (TB), he also does whatever else it takes to heal them. This includes listening to them about the sorcery that they believe causes illness, walking many hours to treat them, and providing whatever financial help is needed to establish a situation in which the actual medicine will help them—and the rules be damned through all of this. Farmer is shown...
(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 an extreme perfectionist. In this combination, and in the similarities Kidder sketches between their characters, one can see Farmer freed by his father to do whatever he wants—but almost doomed to be impossibly hard on himself.
Farmer went to college at Duke, where he experienced the gap between rich and poor firsthand. He spent two semesters in Paris, mastering French and strengthening the wanderlust he inherited. While in Paris, he studied with the world famous anthropologist Claude Levi-Strauss and learned to fuse politics with his studies from the French college students. At Duke, Farmer found an academic interest—anthropology—and models for the social activism and medicine he wanted to do. His first role model was Rudolf Virchow, a nineteenth-century German intellectual. Virchow, considered the founder of scientific medicine, thought it essential to address the social and economic conditions causing a disease in order to really cure it. Farmer’s living model was Sister Juliana, a nun serving the migrant workers who worked on North Carolina’s farms. Through Juliana, Farmer encountered liberation theology, which applied religious principles for political change, and met Haitians whose stories of their impoverished country struck Farmer as an epic struggle like those he had loved reading about in his favorite books: Lord of the Rings and War and Peace. In Haiti, though, Farmer would get to play a real-life role in the battle between the forces of light and dark.
Farmer went to Haiti after college. While there, he met his first serious girlfriend, Ophelia Dahl. Dahl was the daughter of actress Patricia Neal and author Roald Dahl (Charlie and the Chocolate...
(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 patients. Farmer found that the normas (treatment norms) in Peru had led to many patients becoming infected with MDR TB. What’s worse, the standard policy for the World Health Organization (WHO) was to ration treatment—to treat only the cheaper patients, and to let the rest die.
This combination of infected poor and dysfunctional official policies led Farmer into a new arena: shaping international public health policy. He started by having to challenge national health policies in Peru, where Farmer’s anthropological training and stubbornness led him to expose problems with existing treatments. Some of these were both personal and poignant; Farmer, for example, treated one Peruvian doctor’s daughter who had TB, but the doctor could not challenge the normas because he would lose his job if he spoke up. In February 1997, Farmer spoke at a meeting of the International Union Against Tuberculosis and Lung Disease, publicly challenging current TB treatments. While he waited for policies to change, Farmer kept doing what he needed to do to treat MDR patients in Peru, even essentially stealing drugs from Boston to do so. The result was that he had results from an MDR treatment program to share with an international audience, which he did in Boston in 1998, at a session of the American Academy of Arts and Sciences. There Farmer entered into direct discussion with people like Arata Kochi, head of the WHO’s TB division, who had helped develop current TB treatment norms, and Alex Goldfarb, who was looking for help addressing Russia’s massive TB program with his limited funds. The Partners in Health Peru project started to be held up as a model and to have influence. Among other accomplishments, Jim Kim...
(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 world. In chapter 21, Farmer visits Cuba, which he admires for its superior public health program. While Farmer is shown as distrusting all political theories, he does support Marxist social analyses, seeing them as fundamental in understanding the contemporary political situation—specifically, that human suffering does not just happen but is created by society. In chapter 22, Farmer goes to Paris for his daughter’s second birthday party. Farmer clearly loves his family and carries a picture of his daughter, Catherine, with him everywhere. However, he also carries a picture of a little Haitian girl about the same age, who has kwashiorkor (an illness caused by malnutrition), a pairing which for Kidder symbolizes Farmer’s dedication to his patients. Chapter 23 describes Farmer’s trip to Russia, where he toured Siberian prisons with Alex Goldfarb, working with him to improve the country’s treatment of TB. No matter where Farmer was, though, or how hard others pushed him toward stepping back into a more administrative role, he insisted on seeing patients and treating them firsthand. Without seeing patients, he said, “I wouldn’t be anything.”
(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 Farmer to reassure older supporters that they were still needed, especially for the less glamorous day-to-day help the poor so often needed.
As for Partners in Health itself, it was expanding so fast that it often outgrew its locations and had to move. In the earlier days, the small staff had clearly functioned not just as a community but almost a private society, complete with in-jokes and an extensive private vocabulary that functioned as a kind of shorthand. As the organization grew, Ophelia Dahl tried to maintain continuity, but some of this original flavor was lost. And while Farmer was seen as a great inspiration for many inside and outside of the organization, he was perhaps not the best role model. When others measured their contributions and/or lifestyles against Farmer’s, the result was inevitably disappointing. As for Farmer himself, his focus on his mission and disregard for many standard rules of behavior led to him creating what Dahl had named “little hurricanes”: Farmer would “blow in” to the offices, dumping off materials from his just-completed trip, grabbing supplies for the next—and leaving some office workers in tears when he left, from his sheer, overwhelming brusque energy.
Throughout his medical career, Paul Farmer has been dedicated to obtaining equal-access medical treatment for the poor. (It is one reason he admires Cuba so much.) All of chapter 26 is devoted to describing an attempt by some of Farmer’s colleagues in Partners in Health to get medical care for a poor Haitian named John, a young man suffering from nasopharyngeal carcinoma. This cancer is very rare but would likely be treatable … in the United States. In Haiti, the attempt to save John became an...
(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 for due process and the doctor for preventive custody. Despite their disagreement, they part in a friendly fashion.
Kidder then encounters Farmer again by chance: they share a flight back to Miami. Although Farmer is flying first class and Kidder is not, Kidder is allowed to join Farmer for a while. They talk about Haiti, and Farmer shares some of his background.
The entire first section is dedicated to painting a multifaceted portrait of Paul Farmer in his various contexts. Chapter 1 introduces both Farmer and Kidder, and emphasizes the situation and position of both men. Kidder finds it ironic and meaningful that Captain Carroll, who calls himself a "redneck," argues for the side of due process, while Farmer, who is more aligned with the liberals, argues that the mechanisms of justice must be adapted to the specific circumstances of Haiti. This first chapter also begins two processes. It begins the process of showing just how desperate the situation in Haiti is (and how overtaxed Western attempts to help are). By closing with Kidder's account of how he had given a small donation to help, and then forgotten about it, Chapter 1 also begins the process of showing how Paul Farmer creates change in the world.
(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 figure out why and eventually suspects tuberculosis (TB).
Farmer spends a lot of time with Joe, talking with him about his life, his health, and his drinking and drug use. Farmer's rapport with Joe leads the patient to share more with him than he had with previous doctors, and they close the encounter with Joe asking for help finding a place off the street where he could fight his illnesses. The chapter ends with Farmer giving Christmas gifts to a number of patients, and then heading to Haiti on New Year's Day. Farmer and Kidder having grown closer, Farmer invites Kidder to Haiti to see his real work.
Chapter 2 shows the other side of Paul Farmer, and how it is like and unlike the Haitian side. Farmer is different in America because of the resources he has at his command, the formal support, and his position in a medical and social hierarchy. He is alike in that his concern is always for the poor and suffering. When someone calls Farmer a saint in Kidder's presence, Farmer denies that he is one—but says it would be a great thing to be a saint. Kidder here emphasizes Farmer's tremendous spiritual ambition, but also how grounded it is in the physical world and, always, in Haiti's suffering.
(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 Zammi Lasante has to pay, but Farmer allows everyone to be treated whether they can afford it or not. The clinic's annual budget is around 1.5 million dollars. Some of this comes from Farmer directly, though more comes through donations. (Tom White, from Boston, was the largest donor.)
Kidder follows Farmer through many rounds at Zammi Lasante. The patients all seem to know Farmer well; he knows and clearly likes them. In addition to practicing traditional Western medicine, Farmer gives food and dietary supplements when he can, just as Zammi Lasante promotes health through building schools and water systems.
Farmer often narrates his treatments to Kidder. In doing so, he tries to educate Kidder, but also to speak through him to the larger world, to correct misconceptions about Haiti and poverty. As part of one of these narrations, Farmer explains the Haitian belief in sorcery as a way of explaining bad or tragic events. The most extreme example of this concludes the chapter: while Farmer is doing a spinal tap on a girl, she cries because she is hungry. He also explains the world to the Haitians he treats, educating them on the fact that HIV is simply a virus, not a source of shame.
In addition to getting to know Farmer as a doctor, Kidder learns a bit about his personal life. Farmer had married a Haitian woman named Didi Bertrand four years earlier, and they had a daughter. Farmer divides his time between Haiti, where he lives in a modernized "ti kay" (Haitian peasant house), an apartment in Boston, and Paris, where Didi is earning a degree in anthropology. Though he called them regularly, Farmer did not spend much time with his family. Instead, he dedicated his time to caring for the poor,...
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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 countryside to visit patients. They start in a truck, drive as far as they can, and then walk on. As they travel, the men walk across a dam that is an example of American foreign aid. By blocking the water, it displaced many Haitian farmers who were just getting by. Their homes flooded, so they had to move to poorer ground.
Though he has a slipped disk and a leg injured by an old car wreck, Farmer repeatedly leaves Kidder behind as they walk on, then stops at the top of the next hill to wait for him. They walk, visit patients, and then continue walking, talking about Haitian society, medicine, and international politics as they do so. At their final stop, there is a cockfight. The spectators bring out chairs for Farmer and his "blan" (his white visitor). They visit with the villagers and then walk back.
In Chapter 4, Kidder and the reader follow Farmer deeper into Haiti and deeper into Farmer's view of the world. It also reminds the reader of Farmer's education and of the literary construction of the world readers are exploring. This begins with the trope in the chapter's first paragraph of Farmer as Kidder's Virgil in Haiti. By implication, this casts Haiti as hell, and Kidder as Dante—and suggests that while Farmer will remain in Haiti as Virgil remained in the afterlife in Dante's Divine Comedy, Kidder will return to the world of the living/Western civilization, and will carry the story of those suffering in Haiti/hell to that world.
That the book's narrative will be complex, rather than simple, is underscored through the inclusion of the story Farmer tells Kidder about his discussions of sorcery with an...
(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 time Paul Jr. (who was called PJ) was entering high school, his father bought an old boat and started restoring it for the family to live on, even though he knew nothing about boats. When they eventually tried to take the boat to sea, Paul could not navigate, and ran the boat onto a sandbar. Paul Sr. died at age forty-nine, after a game of basketball.
Throughout this strange childhood of adventure, Paul faced a mix of complete acceptance and extremely high standards. The family mixed with people of all classes, and Paul Sr. had an affection for social "underdogs." At the same time, Paul Sr. was extremely hard on his children, always pushing them to do better academically.
This chapter shows how many of Paul Farmer's actions and attitudes are deeply rooted in his childhood, and even grew out of his family. An average middle-class American who lived in a house and the same town his whole life would have found Haiti impossibly challenging. Paul Farmer had lived with blacks and whites, with the poor, and as an outsider. Paul Farmer's standards for himself are extremely high, so high that it seems impossible that he would ever feel like he had done enough to help the Haitian poor—and that seems very close to Paul Farmer Sr.'s rigorous standards turned to the realm of medicine. Just as earning an "A" produced a question from Paul Sr. about why it wasn't an "A+," so working twelve-hour days healing the poor produces a question from Paul Jr. about why he did not work fourteen hours. It also established Paul as someone who must carry his home with him because he is already completely out of place wherever he goes. Paul's interest in science, and his gifts for it, can be...
(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 primary appeal for Farmer was the way he analyzed the social and economic roots of illnesses. Even when his superiors fired him because they found his analysis distasteful, Virchow did not back down: long before it was universally accepted, Virchow pointed out how the social conditions in which individuals live shape their health, a foundational tenet of modern public health.
While at Duke, Farmer also met many of the socially active Catholics trying to solve poverty among workers in America and in Central America. Through one of them—Sister Julianna DeWolf—Farmer met a number of Haitian farm workers. They sparked his interest, and he began to study Haiti obsessively, including its language of Creole. Paul Farmer had found his purpose. He applied to two colleges (Harvard and Case Western Reserve) where he could get graduate training as a "doctor-anthropologist." Farmer took the $1,000 he had won at Duke for an essay and his experience volunteering in emergency rooms there and went to Haiti in 1983. He went to explore the politically volatile nation, where he planned to work in a hospital run by people he had met during his time in Paris. However, once there he found it too separate from the people of Haiti, and sought out another position, this one with Eye Care Haiti, a charity which ran clinics in the country.
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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 almost every day as they worked with Eye Care and became romantically involved. Farmer wrote Ophelia poetry and educated her on the social and economic realities of Haiti. As they talked, Farmer's plans for his future became clearer, and Ophelia realized that she too wanted to become a doctor. Eventually Ophelia left and went home to England. When she did, she called Farmer's family at his request to let them know he was okay—but Paul's dad thought it was one of Paul's sisters putting on a fake English accent and treated it as a joke.
This chapter gives a different perspective on Paul Farmer, or rather, several of them. The primary shift is, of course, from Kidder's point of view to Ophelia Dahl's perspective, filtered through time and memory. However, since their time together was a time of transformation, the account also becomes one of change. Farmer is shown as very young emotionally at twenty-three, but very deep spiritually and very powerful intellectually. Farmer came from a complex but fairly impoverished background, with nowhere near the privileges Dahl had had with parents who were both famous artistic successes. However, despite that general background, it was Farmer who learned Creole much faster, soaking up the language along with the culture. Chapters 5 and 6 had given a sense of where Farmer came from, and how he appeared in context; Chapter 7 starts to show how Farmer changes the world and people he comes in contact with. As a piece of writing, this chapter aligns internal and external events almost poetically: in the midst of Haitian poverty and punctuated by tragedies like the woman's death in the wreck, there is...
(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 he wanted to do. He did not want to help for a little while, like the doctors who helped and then went back to America. He did not want to think of himself as American. Instead, Farmer's mission emerged through his encounters with the people and land of Haiti. He drew some inspiration from the liberation theology the Catholics helping these people practiced, but his real creed was articulated by a poor Haitian woman who had just watched her sister die because she did not have enough money for a blood transfusion: "We are all human beings."
Farmer worked for a time in the clinic Lafontant ran in Mirebalais, and he also began to do his own study of Haiti. He studied both the economic contexts of their illnesses and suffering and the conceptual studies. Though he was a doctor trained in Western medicine, Farmer was willing to use whatever belief was necessary to help these people. In the fall of 1984, Farmer entered Harvard Medical School.
If Mountains Beyond Mountains were a work of fiction, this would be a bridge chapter taking Farmer from his first love affair to his entrance into medical school. It is largely exposition, and covers an entire intense year in less than ten pages. There is only an occasional snapshot of intense suffering to suggest the nature of Farmer's experience in Haiti: Paul Farmer running around trying to collect the few dollars needed for a truck rental and a blood transfusion to save a woman's life. However, it is in this chapter that Kidder sketches in the essence of Farmer's approach. He bumps up against Catholicism again and again (in his background, in those serving the workers in North Carolina, and again here). He shares the...
(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 Haitians' terrible living conditions (especially lack of clean, disease-free water). They continued to work with Lafontant, helping him build and equip a clinic in Cange.
By 1985, Farmer's health survey had led him to develop a sequence of actions that could be taken to improve conditions, but they would cost far more than he had money for. This meant raising money. In 1983, Farmer had helped Lafontant fund a bread oven for the Cange by approaching Project Bread in Boston. One of their donors had committed money for helping Haiti and, once he read some of Farmer's writing, wanted to meet him. This was millionaire Tom White, who was involved in construction in the Boston area. White came to Haiti to meet Farmer and see what he was doing there. The two clashed a bit on the first meeting, but met again in Cambridge. They talked on an ongoing basis when Farmer was in the country, and White began to help Paul, including giving him money after he had given all of his salary away to an AIDS patient and running errands all over Boston for projects in Haiti.
Chapter 9 reveals the many contrasts in Farmer's life. He was at once a young man in love, having food fights and romantic sex—and he was an emerging international activist, committed to helping people in a country not his own. He was confident and at home in his research and his studies; the descriptions of him studying with Ophelia leave the impression of a man with an intensely powerful mind. However, the descriptions of his first encounter with Tom White, in which he alternately pre-judged, challenged, and educated White give the impression of quite a young man, a man who is still somewhat naïve. This is seen as well...
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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 protest, then the couple heard shots from their stopped car and a mob of peasants was suddenly running from them. Ophelia wanted to leave, for safety's sake; Paul wanted to stay, to witness the crimes and help people.
Eventually, in 1988, the couple's stresses came to a head while they were in Cambridge. A car hit Farmer and broke his leg. He would not obey medical orders about taking care of himself, and they fought over this and their life together until, on December 10, Farmer went back to Haiti.
However, while this relationship was deteriorating, Farmer was recruiting people to help him in his mission. With Tom White's support, Farmer started Partners in Health (PIH), with the parallel organization Zammi Lasante in Haiti. He enlisted a classmate from Duke (Todd McCormack) to serve on the board of directors and another anthropology/medical student from Harvard (Jim Yong Kim). The three young men and Ophelia (and sometimes Tom White) talked endlessly about what they should do and how to understand the world. They named their approach "pragmatic solidarity," identified "areas of moral clarity" (AMCs) where right action was clear, and started to act, including building another school near Cange. After their breakup, Ophelia kept away from this group for a time, but she then returned as Paul's friend and colleague, and as an employee of PIH.
In Chapter 2, Kidder had recounted an occasion in which Farmer was called a saint. Chapter 10 shows two things. First, it shows just how hard it is for a normal good person, even a deeply committed person, to live with a saint. Years later, Ophelia Dahl's descriptions of her time with Paul are filled with a mix of...
(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 had been looking for. They became friends, though obligations on both sides kept the men from spending much time together. In 1990, by the people's request, Aristide ran for president and was elected with 67 percent of the vote. This promised a great deal of change for Haiti, but most immediately, it led to even more violence in response.
Some of this spilled over onto Farmer, and Farmer's own work also led him into political involvement. Farmer completed his studies, earning an MD and a PhD in 1990. He won a prize with his anthropology thesis, which was titled "AIDS and Accusation." Studying the spread of the AIDS epidemic led him to commenting on American policies and attitudes toward AIDS, which included grouping Haitians as a risk group for the disease. Farmer's thesis analyzed the effects of AIDS on Cange and led him to realize once again how much medical suffering was tied to economics: he could prevent and/or cure more diseases if he had the means. When at the clinic in Cange, Farmer got threatening phone calls, and the clinic's phone was bugged. In September 1991, when Farmer tried to return to Haiti from the United States, he found his flight canceled. When he did make it back to Haiti, he treated a man who had been beaten by the authorities, but he had been so savaged that Farmer could not save him. He did, however, report the case to Amnesty International and wrote a piece on the incident for the Boston Globe.
As a narrative, Chapter 11 is a bit crowded; so much is going on that it is almost hard to keep track of what is happening. Difficult though this is for the reader, this is a useful reflection of the tumult of Haiti—and Farmer's life....
(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 Paul's friends were being killed by the military. Throughout 1994, Farmer lectured throughout the U.S. on Haiti, even addressing Congress and debating a general on the topic, to mixed responses. Once Aristide's presidency was restored, Farmer returned to Haiti. He found a country whose health had been destroyed by violence and by the results of military rule. AIDS infections were up, as were tuberculosis cases, and many of the staff had resigned. (Chapter 12 also touches on how PIH has grown; like Paul, it is moving up in the world. It has started programs in Boston, Haiti, and Mexico, and published the book Women, Poverty, and AIDS.)
Chapter 12 documents how Farmer's life pulls him in radically different directions. As the MacArthur Foundation says about itself: "The MacArthur Foundation supports creative people and effective institutions committed to building a more just, verdant, and peaceful world." Popularly, MacArthur grants are also known as "genius grants," and winning one is a sign that one is doing something special and doing it especially well. This would be a great achievement, as would writing over 200 pages of a book in 10 days (as Farmer did with The Uses of History). On the other hand, Paul is progressively isolated: literally, politically, and emotionally. He is literally isolated by taking himself away from things and people, and through the intensity of his passion, which burns casual interests from his life. He is politically isolated both by his insights into health and politics and by his unwillingness to bend any longer to the military. He is emotionally isolated by the death of his Haitian friends, through his experiences, and through his...
(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 cured through administering drugs over a number of months, and the poor often find their treatments disrupted through circumstances. The result was that new strains of TB known as MDR (for "multidrug-resistant" TB) were bred through partial treatments. These resistant strains often spread through the poor populations, killing people who could have been saved. Farmer found himself trying to treat MDR in Haiti: he often failed while the military junta was in charge, but saved most of his patients after that time.
Chapter 13 begins a new section of Mountains Beyond Mountains and marks a new period in Farmer's life when he became move involved with public health concerns on a global scale. The image of the epidemiological map symbolizes this larger concern. It also serves as a useful symbol of Farmer's medical mission and of Kidder's approach to it. Farmer is trying to solve issues that cross national boundaries, matters that make common divisions like nationality, religion, or ethnicity irrelevant...and Kidder is willing to accept that approach as valid. (He does not apply any further political analysis on his own, to see, for example, if the rich/poor division holds, or if specific political systems do better or worse jobs of keeping their citizens healthy.)
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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 somewhere else.
Farmer convinced Jack White to donate $30,000 (about half the cost of the project), and advised Kim as he worked on his plan to create "Socios en Salud" (Partners in Health in Spanish) and tried to train a team of public health workers. Kim, however, ran into trouble, first with Father Jack's choice of workers, and then with the political upheaval in Peru. One New Year's Eve, guerrillas from the Shining Path movement blew up the pharmacy they had built in Carabayllo. A rumor said they had done so because the pharmacy was a "palliative" that would diminish the poor's drive for revolution. Farmer counseled Kim to patience, and to focus on the work, rather than his own frustration. He came to Lima to complete a public health survey like the one he had done in Haiti. He learned that the Peruvian government had recognized the danger of TB and had instituted a national program to deal with it that the World Health Organization (WHO) had said was superior.
Then Father Jack became sick and died in 1995. Tests done in the United States showed he died of a strain of TB that was resistant to even the best drugs American doctors were using to treat TB. Father Jack's death shattered Farmer emotionally and drove him to find out what was really happening in Peru's TB treatment program. Farmer discovered that they were not tracking patients who were treated but not cured properly, and, as a result, releasing patients back into the community carrying strains of MDR TB. Farmer tried to get the Peruvian authorities to listen to him, and Jamie Bayona, a Peruvian Catholic who had worked with Farther Jack, tried to help him.
Chapter 14 shows Farmer and his disciples...
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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 national lab would not do it for Socios en Salud. Instead, Farmer flew them back to the United States to be tested. Most of those selected were infected with TB that was in fact resistant to the main drugs and most of the back up drugs. Farmer then faced three challenges: heal these ten sick people, figure how what had gone wrong in their treatment, and get them (and him) the help they all needed from governmental sources. Farmer eventually deduced that the patients were as sick as they were—and their TB as drug-resistant and dangerous to others as it was—because their doctors had followed a treatment regime slavishly and without reflection. Through continuing to treat these patients with drugs that were not working, the medical establishment had in fact bred mutated forms of TB, setting up their own later and more vicious health crisis. These policies came from the World Health Organization, and, when combined with the patients' economic conditions, were a death sentence. The doctors had done what they thought should have worked. After that, desperately poor people had to pay for their own treatments.
Chapter 15 accomplishes several functions in the narrative. First, it quietly reintroduces Kidder as a direct observer: he has witnessed Farmer's mission in Haiti, and now does so in Peru. This lends his descriptions vivid detail, and his account marked credibility, establishing his ethos. Following Farmer gives Kidder the right and ability to talk about Farmer's thoughts and feelings, and about the suffering of the poor. He has been there to see, hear, and sympathize with them all.
Second, the descriptions of Farmer's diagnosis of the MDR TB and the problems with...
(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 licensed to practice medicine in Peru, and the TB director threatened to force them out of the country.
When they were allowed to keep working on the problem, Socios could only do so after "las normas" (the official clinical procedures or norms) had been tried. This meant Socios entered the treatment process late in the infection, and sometimes it meant watching people die. The Peruvian medical authorities were stuck. Allowing this treatment meant admitting there was a problem and they did not have the funds to implement new treatment regimes nationally. Jaime eventually told Farmer he would have to go over the national government's head. Farmer agreed and went to talk to the International Union Against Tuberculosis and Lung Disease annual meeting in Chicago in February 1997. After planning to give a "wimpy" speech, Farmer gave a fiery one, debunking many "myths" about TB treatment and directly challenging established wisdom.
Chapter 15 had in many ways set Farmer and PIH up against the Peruvian authorities, almost in a good-guys-versus-bad-guys situation (or at least, good guys versus bureaucrats). This tone had lasted until the end of Chapter 15, when Kidder had touched on the Peruvian debt crisis, which complicated the matter. Chapter 16 continues that process. It shows many more faces of the situation. The Peruvian workers who do not want to face MDR patients in their homes are afraid for their lives. The Peruvian doctor who labeled Farmer and Kim as "Medicos aventureros" (adventuring doctors) had good reason to suspect the motives of these "gringo" doctors. Were they not part of the same social and economic structure that was oppressing Peru? And they 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 do it) later. Jim Kim and Farmer both traveled to Carabayllo often, usually without Farmer cutting anything out of his already crowded schedule. Sometimes he would drive (and run!) from Cange to the airport in Port-au-Prince, fly to Miami, then to Lima, then to Carabayllo where he treated patients all day, then back to the Lima airport, Miami, Port-au-Prince, and Cange, traveling 22 of 48 hours.
In early 1997, Farmer planned to spend a month in Boston, but when he got there, he felt sick. At first he thought he had come down with MDR, but test results revealed he had hepatitis A. Farmer's liver functions were impaired, and for a time Jim Kim and other doctors thought he might need a liver transplant. He recovered, and then took a two week vacation with Didi.
The remainder of Chapter 17 describes Farmer's actual treatment of two young patients. One, a little boy named Christian, had been suffering from TB so badly it had started to destroy his spine. Farmer improvised a new treatment using "second-line" TB drugs and cured him. In the other treatment, this one of a small girl, Farmer had to play through an elaborate "charade" of consultation: the child's father and doctors knew she had MDR, but the Peruvian doctors risked too much by diagnosing it, and so had to have Farmer do so.
The limited space given to Farmer's courtship and marriage (half a page) and then to his illness (just over two pages) communicate volumes about the focus of Farmer's life and Kidder's narrative. Although Farmer was sick enough that he almost needed an organ transplant, this was no more than a stumbling block in his mission. Moreover, Farmer himself noted that his condition—and...
(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 patients with Farmer's more expensive program or 5,000 patients with standard treatments (and saving most of those). Though Jim Kim opened the discussion about expanding resources (raising more money to fight TB), at this time PIH had no answer to Goldfarb's challenge.
In Chapter 17, Farmer had had to deal with complexity on the scientific and personal levels to save two specific children. In Chapter 18, several members of PIH had to deal with complexity in the social, political, and economic realms in hopes of saving entire populations with TB. It is darkly humorous that renaming Farmer's treatment "DOTS-plus" created such an advantage among a group of scientists. The ideal would be, of course, that scientists can deal with the facts of the physical world, without bias or prejudice. Instead, a simple renaming can alter their response. At the same time, Goldfarb's challenge, while political, is not so ironic. While they are suffering, the patients that he mentions with TB are in fact prisoners. Ideally, that means they are criminals. Why should a population like Russia's, with an unsettled economy and limited resources, spend so much more on those who have broken their nation's laws?
Kidder demonstrates both dramatic control and moral honesty when he lets the challenge stand unanswered. What will Farmer's team at Partners in Health do? How will they address the fact that economic resources are limited and poorly distributed? As if part of a serial cliffhanger, readers must tune in to the next chapter to learn the answer.
(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 Brown, where he found consolation in identity politics, educating himself on America's history of dealing with ethnic minorities and his Korean heritage, even traveling to Seoul as part of his PhD thesis for anthropology. However, by the time he met Farmer, Kim was coming to the end of this exploration and was looking for a new direction. Over the years they spent together, their philosophies fused, even though the specific methods they used eventually split: Jim Kim enjoyed the political side of things more than Farmer did.
Kim had studied the pharmaceutical industry for his dissertation and knew what factors determined the cost of a drug. Kim tried to get the World Health Organization to encourage the production of second-line drugs, but when they backed out of the meeting, he held it himself. This led to help from the International Dispensary Association (IDA), a non-profit which helped the poor by working to lower drug prices. They approached smaller companies, working around WHO's bureaucracy and legitimate fears about misuse of drugs and following the model of the Green Light Committee, who had done something similar earlier for another vaccine. In the end, they drove down the drug prices tremendously: 97% for some drugs, and 90% for the complex drugs PIH used to treat MDR in Peru. PIH hoped to build on this success and to plan for funding after Tom White's passing by approaching major donors for money.
This chapter accomplishes several tasks. First, in the biographical sketch of Jim Kim, Kidder introduces another character to the narrative. In doing so, he documents the expansion of PIH's core, as well as the variety of approaches it could accommodate....
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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 about the suffering they see. Farmer talks about his love for Haiti and Haitians, and demonstrates it through his observations on the plane, through guiding new travelers in the airport, and through working continually as he travels.
Kidder incorporates a brief description from Ophelia about the complexity of Farmer's personality: a need for praise and for continual activity, frequent sadness and frequent cheer. Kidder follows this with a description of Farmer's travel routine at the Miami airport and with a sketch of Farmer's managerial /organizational style that illustrates his character. No one could be fired from any of their enterprises unless that person stole from the organization or for "slapping a patient twice." Farmer also complains about not having any time off, but then fills in any scheduled breaks with activity.
This chapter with its mosaic of highly varied glimpses of Farmer fulfills numerous functions. By starting so long after the time period presented in Chapter 19, Kidder reminds the reader of his long exposure to Farmer; traveling with him underscores Kidder's firsthand perspective. Together, they reinforce Kidder's credibility as a witness. This makes the moments in which Farmer seems odd, idiosyncratic, or simply human all the more useful, moving, and poignant. The complexity of Farmer's personality is most visible in the rule that an employee had to slap a patient twice to get fired. Hitting a patient once seems unforgivable...but a worker in Cange had slapped a patient, and Farmer changed the rule to fit his desire to keep the worker. This aligns with Farmer's general rule of letting reality trump theory or ideology. The description of Farmer's...
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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 ambassador to Cuba. Farmer tried to get both Barruecos and the ambassador to help Haiti. Farmer's conference presentation explained that in Haiti, HIV infection is rooted in the country's extreme poverty, especially for women. Kidder accompanies Farmer to an AIDS quarantined treatment facility. While describing their travels, and Farmer's visits with patients, Kidder recounts Cuba's success against HIV. When they discuss Cuba, Farmer insists that Kidder tell things his own way, fearing that his admiration for Cuba will make him seem less credible. This leads to a squabble between the two men, which is resolved after Kidder gets sick with diarrhea and Farmer treats him.
As part of a narrative, this chapter is odd and crowded. On one hand, it is quite straightforward: it describes Farmer in another context, where he continually, even tirelessly, works for the health of the poor. Paul Farmer remains who he is, no matter what context. In that it further demonstrates Farmer's consistency. On the other hand, Kidder foregrounds his own role in the narrative more explicitly than in any other. He quotes entire stretches of dialogue, touches on his own feelings, and even discusses the state of his bowels. This seems a direct response to Farmer's request that Kidder tell his own side of the story about Cuba. In doing so this way, Kidder is careful not to embrace Farmer's enthusiasm for Cuba too fervently. He also includes his own speculations about Cuba's loss of political freedoms as the cost for its superior public health. The result is a portrait of Cuba that is beautiful but relatively stiff and distant when compared to the descriptions of Haiti. Haiti, and Haitians, are portrayed as...
(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 Farmer and his circle use. This leads to a discussion of the PIH crowd as a group of insiders—a private culture that could seem superior to outsiders. However, this group of insiders included people from all backgrounds and clashing ideologies, and Farmer was continually inventing private jokes or references for specific individuals (Kidder and Farmer even swap lines from the movie Caddyshack). The chapter ends with a reflection on Farmer's worldview, which sees everything as interconnected.
Chapter 22 ends on an evocative note in which Kidder seems at ease with Farmer's character and respectful of the dense web of interconnections Farmer experiences throughout the world. The chapter itself documents that web: Catherine's birthday gift was purchased in the Miami airport, Farmer's wife lived in Paris (as he had when younger) and was from Haiti, Farmer started tasks in one country and finished them in a second as preparation for travel to a third, and so on. However, in the middle of the chapter, Kidder describes a paradoxical and exclusionary side of Farmer and PIH: they are so focused on their goals that they can judge others who do not support them; they are also essentially a private community, one with its own language. Kidder, who at this point had associated with the PIH group off and on for years, says they feel like "a club, or even like a family." The paradox seems almost unavoidable: this is an organization dedicated to solving problems most of the world accepts as impossible and perhaps necessary, and thus they give up most of the world's rewards in their quest to do so.
(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 cured, and in fact, through their partial treatment, had their TB made resistant to at least one of the main drugs used to treat TB. Farmer met with George Soros to ask for the $5 billion needed to treat the Russian epidemic, and Soros arranged a meeting with the White House. Hilary Clinton asked the World Bank to loan the needed money, and the World Bank put together a team to visit Russia and work out the details.
During the trip to Russia, Farmer (along with Kidder) toured the prison in Moscow to get firsthand observations of prisoner conditions with TB. Later, at the meetings with the World Bank, Farmer continually argued for the prisoners, trying to get them the help they needed. He also had the task of managing Alex Goldfarb, the representative of the Russian Ministry of Justice (who ran the prisons). Farmer did not enjoy the international politics, but he charmed, joked, and argued tirelessly on behalf of the poor. Sometimes he argued politics with Goldfarb; sometimes Goldfarb was on his side as they worked together on methodology.
In Chapter 23, Farmer is shown at his most transformed and in some ways his most ideological. Distanced from his actual patients, with whom he can demonstrate his compassion through his actions, Farmer has only words and charisma to make his case. The result is sometimes a kind of good-hearted rant, as when he explains how America is and is not a democracy. At other times, as when Farmer and Goldfarb argue the politics of crime and imprisonment in the chapter's final pages, Farmer sounds profoundly and at times naively radical. The radical nature of his politics is ultimately that of the saint, or even Jesus; when Kidder asks Farmer if he...
(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 (including tourism when working for the poor). It blew over, and the two made up.
Kidder accompanied Jim Kim to Siberia. There in the city of Tomsk, at the banquet starting the discussions of how to treat TB there, attendees were separated into two distinct groups—the Russian military on one side, Russian doctors and foreigners on the other—until Kim broke the ice by singing karaoke. Everyone started singing and drinking. Farmer, who had run into visa trouble, arrived the next day.
Kidder sketches Farmer's travels: to Haiti, Paris, Siberia, New York, South Africa, and so on. In each place, Farmer argues for medical help for the poor. The remainder of the chapter sketches a few of Farmer's cases, then focuses on how the PIH programs are starting to serve as a model for other programs, and on Farmer's attempts to raise money and educate people. It ends with Farmer's account of the two voices he heard: one arguing for the meetings he attended, the other calling him to heal Haiti's sick children directly.
The final page of this chapter is, frankly, the only place where the chapter's narrative comes together and makes sense. Before that, while it may be what was actually happening at the time, the organization is a narrative jumble. Too much is included, and too many people are heard from. The very activity makes it hard to track what specifically is accomplished...and that is no doubt Kidder's point. In this chapter, Kidder creates for the reader a textual equivalent of one of Farmer's "little hurricanes," one in which Farmer blows into the PIH offices, then sprints away, leaving everyone dazed and blinking. Just as Farmer is having trouble holding on to his...
(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, then, eventually, decided on hiring a medevac flight to carry John from Port-au-Prince to Boston. Once there, John received first-rate treatment in Massachusetts General Hospital, but it was too late. John died.
Chapter 25 is as focused as Chapter 24 had been scrambled and confused. Kidder artfully recounts this humanitarian mission until it is as tense and emotionally charged as the best suspense thriller. Rather than fighting spies or evil geniuses, however, Zanmi Lasante, Serena, and Farmer are fighting economic conditions, treacherous roads, and subtle forms of politics. Here again one can see how his extended mission has changed Farmer. His instinct is to heal the sick, regardless of cost or implication...but he now worries that buying one medevac flight for a sick patient will set a precedent and others will expect similar treatment. In his early days, Farmer was the man on the spot, fighting illness alone. Now he has to settle for being the voice on the phone, the distant advisor, somewhat like the figure of Q in a James Bond film (and somewhat like a guardian angel).
Without Kidder saying so in so many words, efforts like this one, in which people fight to save one sick boy, are clearly what makes all of Farmer's struggles worthwhile. This is the child about whom the voice of Haiti whispered at the end of Chapter 24. And this is what happens if Farmer and PIH do not act—and sometimes, even if they do.
Running in harmony to the mission and the tension is a continual tone of condemnation. John died because he was Haitian (not American). John died because of the bureaucratic delays in his treatment. John died for a host of reasons when he did not...
(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 be able to do what he did, his organizations offer flawed models for future programs. Farmer answers that working with theoretical models often ignores individual patients, and that not treating these suffering individuals sends the message that they matter less. A third thread of conversation is woven in with Ti Jean's commentary, and Farmer and Kidder's discussion of Farmer's mission: an ongoing highly personal account of the whole trip—including Kidder's chest pains, exhaustion, and dehydration—as a kind of adventure.
By focusing the book's final chapter on another trip with Farmer through the Haitian countryside to visit patients, much like the one he had shared in Chapter 4, Kidder brings Mountains Beyond Mountains full circle. In the process of doing so, he returns to many earlier themes, much as a composer of a great symphony might. In an earlier expedition to Haiti, visitors had brought fish for Farmer's pond; in this chapter, Kidder visits the pond. Early chapters had touched on local medical beliefs versus Western medicine, and on how magical worldviews and scientific worldviews intersect; Ti Jean's commentary in this chapter provides an opportunity to return to these discussions, and so on. Even Farmer's references to Lord of the Rings show the narrative coming full circle, and all elements of his life carrying forward as he continues his mission.
However, the overwhelming point of this final chapter is to drive home the meaning of the title of this section of the book: "O for the P," which in PIH shorthand means a preferential "option for the poor." In the end, a viable O for the P forbids Farmer, or anyone, from resolving the...
(The entire section is 467 words.)