Tracy Kidder, Mountains Beyond Mountains (2004)
Mountains Beyond Mountains considers the story of Dr. Paul Farmer and, what at times appears like a solo mission to provide the best healthcare and support to the poorest communities in Haiti, Peru and Siberia to name a few. Kidder writes from experiences both following Farmer as well as through regular communication. The book starts with Farmer’s childhood before transitioning to his life in public health and life long mission to help those that need it most. Despite the tough upbringing what is clear about Farmer from the early chapters is the precocious intellect as well as a fierce stubbornness and determination.
The location most visited and essential to understanding the complex person that is Paul Farmer is Haiti and specifically Cange. His wife is from Haiti and the original location for much of his work and organizational involvement stems from work there. Interestingly Farmer’s stance is one that questions traditional development practices in ways extending beyond the health sector that his work primarily addresses. Kidder draws the book to a conclusion with statements that effectively summarize Farmer’s methods and beliefs. The statement that stuck out to me was “I don’t care if we lose, I’m gonna try to do the right thing.” In the realm of development work and public health the actions of Farmer and his organizations, partners and programs all fly in the face of traditional measured approaches. The story contains countless examples where the problems tackled would not have been addressed without his genius and concerted consistent effort. Further, many actions were taken that if judged from a utilitarian perspective or understood in economic terms would have been roundly rejected by major international organizations.
A particularly heated and informative section concerns that of appropriate technology which in the setting of Haiti would have hamstrung Farmer’s efforts if he had indeed operated in such a manner.
This person is sick, and I am a doctor. Everyone, potentially, can understand and sympathize, since everyone knows or imagines sickness personally.
The wonderfulness of Farmer’s approach is in its simplicity. Every patient is respected and worthy of dignity, no life is held in higher value and ultimately the location of birth should not be a factor that obstructs a patients access to quality healthcare. Appropriate technology underlines this situation, the infrastructure of Haitian healthcare does not lend itself to treating multi-drug resistant TB or offering open heart surgeries but as a result of Farmer’s efforts these are now reality. Under traditional models instituting these changes would be part of a slow and tedious development that would only widen the health inequity between nations. There is nuance to this state of affairs and global development literature points to efforts of Russian tractors in Ethiopia ending up unused among other initiatives as evidence that there is a need for appropriate technology. However, Farmer’s situation shows that this a fallacy if introductions are actually taken with careful reverence to local cultural environment. As the reader observes Farmer reconciling Western medicine with local witchcraft and voodoo beliefs it becomes clear how missing cultural specificity only creates frustration, distrust and ineffective programs.
This book offers a critique of traditional development wisdom, especially in the healthcare field and it is through the dogged work of Farmer that elements of global healthcare programs now operate the way they do. What is so inspiring and uplifting is his commitment to people and the dignity and worth of every individual he works with. As suggested this sometimes clashes with traditional models and processes of development but ultimately in the cases that Farmer was battling for he often came out victorious.
The reader gets to see Partners in Health (PIH) develop under the guidance of Farmer and this characterizes the narratives around challenging traditional programming. The flagship program concerning the treating of MDR TB (Multi-Drug Resistant Tuberculosis) that under WHO (World Health Organization) programming would remain untreated causing many in poorer nations to be developing far more dangerous and harder to treat strains. Farmer and PIH started to tackle and research this in Haiti before the program expanded to Peru, this also brought in work on AIDS as the virus suppresses the immune system and elevates the risk of diseases such as TB. This book has so many threads tangled together but the complexities are merely representative of how complicated it can be to adequately address public health. Furthermore it is only through an holistic program that true progress will be made. Far more goes into health crises in countries than just medicine.
This is an inspiring book and ultimately one that gives hope for addressing health inequities. It is also very graphic and there are the inevitable sadder sections were even the best efforts could not save a patient, a situation that Farmer himself sees as a point of personal failure. Ultimately many of the areas addresses in both Farmer’s life and touched upon in this book result from huge inequities in the world as well as a lack of consensus and thought out policy from developed nations on how resources can be redistributed. The anger which the reader sees from Farmer about certain situations certainly raises questions about how policy could better address the actual health crises. In addition, though it highlights how a more personal and locally based grassroots effort will inevitably generate better social health environments than bureaucratically created and overseen programming. Healthcare is a right and ultimately the state of healthcare inequity between nations means this is not necessarily true everywhere, in addition, it creates a situation in which some lives are distinctly valued less than others (read appropriate technology discussion!). I finished the book with a hope that changes will be happening as well as thoroughly inspired by the dramatic differences that Farmer and his associated efforts have created. At its root his efforts are rooted in the local communities and genuine relationships.
he’d insist, because if you say that seven hours is too long to walk for two families of patients, you’re saying that their lives matter less than some others’, and the the idea that some lives matter less is the root of all that’s wrong with the world.
A statement Kidder imagines Farmer saying
In a domestic, local and informal setting this has lessons of respecting others, understanding others despite different beliefs and looking out for the most vulnerable. Looking beyond self and doing the best possible for the greater good. During a global pandemic, the global health inequities will magnify effects and this book highlights these stark differences. It also offers a great background in subjects of epidemiology and public health that I did not previously have or understand. I would whole heartedly recommend this book simply for the great balance of biography with story-driven narrative.
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