Mountains Beyond Mountains (2004) by Tracy Kidder
Part One, “Dokte Paul” pp. 1-45
Tracy Kidder’s Mountains Beyond Mountains tells the story of Paul Farmer and his unique approach to delivering health care in places wracked by poverty. Farmer believes, simply, that all humans deserve high-quality medical care regardless of their ability to pay. Kidder chose to tell this story in the first person so that he could trace his own struggle to accept Farmer’s radical approaches to dealing with the problem of poverty. The action of the story really concerns the health care debate which develops between Farmer and Kidder over the practicality of liberation theology in the post-Cold War era.
Liberation theology- a movement in Christian theology which interprets the teachings of Jesus Christ in terms of a liberation from unjust economic, political, or social conditions. (Wikipedia)
The title of the book, Mountains Beyond Mountains, is taken from a Haitian proverb that translates as “beyond mountains there are mountains.” Why did Kidder use this as the title? What does it mean in terms of Paul Farmer’s work? (Kidder)
Kidder opens Mountains Beyond Mountains with an account of a discussion between Paul Farmer and a U.S. army captain who was commanding a small peacekeeping force in Haiti in 1994. (3-4) Farmer and the captain initially discuss a recent murder case in the area, and the captain claims that there is little that he can do legally to put the suspected perpetrator, a local thug named Nerva Juste who belongs to a local death squad, behind bars. (Kidder)
Farmer argues that it makes little sense to observe principles of constitutional law in a country that has no functioning legal system. What are the implications of his assertion for American foreign policy?
What else do we learn about Farmer’s philosophy from the opening chapter? (He speaks Creole; he grew up in a trailer park; he teaches medicine and medical anthropology at Harvard; he works in Haiti eight months out of the year)
“The term "medical anthropology" has been used since 1963 as a label for empirical research and theoretical production by anthropologists into the social processes and cultural representations of health, illness and the nursing/care practices associated with these.” (Wikipedia) A medical anthropologist learns about a culture not from books or classes but from the people themselves.
What do we learn about Farmer’s medical philosophy from his treatment of “Joe”, the HIV positive substance abuser who is being treated for TB at Brigham and Women’s Hospital in Boston, where Farmer practices when he is in the states? Where would Joe like to go when he gets out of the hospital?
In a reference to Farmer’s latest book Infections and Inequalities, Kidder focuses upon Farmer’s poorly disguised sarcasm when he refers to a TB patient in Haiti responding to antibiotics “almost as if she had a treatable infectious disease” (17). What is Farmer’s point?
Describe the Zanmi Lasante facilities that Farmer and Partners in Health had developed during the sixteen years since he first arrived in Haiti.
What are some of the key accomplishments that the clinic had already achieved by 2000?
How is the operation financed?
How does Farmer justify spending so much money on the health of people who cannot pay?
What is the principle of ‘cost efficacy’ in health care?
Why does Farmer get annoyed when Kidder asks him about the personal sacrifices he has made in his career in order to build Zanmi Lasante?
How does Farmer treat Ti Ofa when his HIV infection progresses into full blown AIDS? (How would he be treated in an American hospital?)
How would a traditional doctor regard the Vodou beliefs of the Haitian people? What is Farmer’s attitude towards these beliefs? How has his thinking been influenced by his training in medical anthropology?
What did Farmer’s team discover was essential to their successful treatment of TB in the greater Cange community? How does this approach to care reflect Farmer’s belief that ‘structural violence’ is the fundamental cause of disease?
Farmer believes that if a patient does not get better, it is the physician’s fault. How do the health workers at Zanmi Lasante implement this philosophy? Is this approach to health care ‘sustainable’?
What makes the hydroelectric dam at Lac de Peligre on the Artibonite River a perfect example of the problems with US investment in Haitian infrastructure? How might this money have been better spent to benefit the people in this river valley?
How did the US respond to the outbreak of African swine fever in the Dominican Republic? What were the consequences of this policy?
What is the meaning of the Haitian term ‘Kennedys’?
Which characteristics of Farmer’s unusual family and upbringing would lend themselves to his later career success?
Who is Farmer’s hero from the history of medicine? Why?
By whom was Farmer first introduced to the tenets of liberation theology?
What are the basic tenets of liberation theology? How do these beliefs differ from traditional Catholicism? How do they differ from Marxism?
Farmer describes the reasons for his decision to work in Haiti as the result of his own interpretation of the causes of poverty. (73-74) Can you rebut this interpretation of Haiti’s history?
[The ] world [has been] designed by the elites of all nations to serve their own ends, the pieces of the design enshrined in ideologies, which erased the histories of how things came to be as they were. The catastrophe in Haiti is covered with the fingerprints of the Western powers, most of all those of France and the United States. (73)
How was Farmer drawn back to the religion of his youth by his experiences among the poor of Cange? What did he find inspiring about their lives?
What is the meaning of the Haitian proverb, “Bondye konn bay, men li pa konn separe.”
What problems did Farmer find with the clinics in which he first worked in Haiti? How would his own clinic be different?
How is ethnography essential to his own approach to practicing medicine? What particular information did Farmer discover about Cange in the planning his clinic? How might this approach differ from that of an international charitable agency?
How did Farmer work with the hungans to address the problem of maternal mortality in Cange?
How does Farmer reconcile his religious beliefs (Haiti) with his devotion to science (Harvard)?
How did American engineers finally solve the problem of water born diseases in Cange? Would typical American aid agencies regard this project as an ‘application of appropriate technology’?
What first line ‘preventive’ measures did Farmer implement in Cange?
Farmer says “Clean water and health care and school and tin roofs and cement floors, all of these things should constitute a set of basics that people must have as birthrights.”
Do you agree? Should government be responsible for providing these basic rights for their people? Could the Haitian government meet these challenges?
To whom did Farmer turn to find the money he would need to build Zanmi Lasante?
How do Farmer and his colleagues respond to criticism from the political left? “Good works without revolution only prolongs the status quo. The only thing projects like Cange really accomplish is creation of dependency.”
Who, in addition to Farmer, are the key members of Partners in Health and what are their functions? What do they mean when they describe the situation in Haiti as an “AMC”? (100-101)
Which group in Haitian society led the opposition to Baby Doc during the 1980’s?
Who was Jean-Bertrand Aristide, and why did Farmer support him?
What story did Farmer publish in the Boston Globe the year after the junta ousted Aristide?
How is Farmer able to wield influence with the potentially violent members of the regime?
What is the thesis of the book on Haitian history, The Uses of Haiti, that Farmer wrote at this time? Do you buy it?
Part III Medicos Adventureos (125-177)
What factors account for the convergence of TB and AIDS on the poor side of the ‘great epi divide’?
How does poverty contribute to rising antibiotic resistance to TB?
Does investment in Farmer’s studies of MDR make economic sense?
How did Partners in Health get interested in the Carabayllo District of Lima, Peru?
Why did the Shining Path guerillas blow up the Partners in Health pharmacy in Carabayllo?
How was it that the Peruvian authorities were unaware that an epidemic of MDR had broken out in Lima?
Why would people move from the countryside to the arid slums on the hilly outskirts of Lima?
How does Farmer solve the problem of poor laboratory and testing facilities wherever he practices medicine?
What had the World Health Organization’s DOTS treatment plan for TB accomplished worldwide since its inception?
What, according to Farmer’s theory, had gone wrong with the DOTS treatment plan for TB in Peru? (138-140) What had caused the ‘amplification of resistance’?
How do Farmer and his colleagues make the case that cost-effective policies limiting treatment of MDR wind up costing health systems more in the long run? Do you buy this argument?
What average expense and cure rate did experts get at the best MDR treatment facility in the United States?
Why were the Peruvian doctors who led the WHO treatment plan so reluctant to allow Farmer and his doctors to treat MDR cases?
did Farmer break down the following myths:
a. MDR is too expensive to treat in poor countries and just detracts attention and resources from treating drug-susceptible disease.
b. DOTS alone will stop outbreaks of MDR.
Where had Farmer found the drugs to treat the MDR patients in Peru?
health managers regarded what Farmer was doing as reckless:
a. They had no way of financing a regular supply of drugs for their MDR patients.
b. They had no way of financing the testing required to diagnose MDR.
c. Expert opinion in the TB field was against them.
Would you have financed them? What standard did Farmer in his colleagues use instead?
What does Kidder think of Farmer’s response to coming down with Hepatitis A? Can this criticism be applied to his philosophy of medicine as well?
What medical protocols did Farmer ignore when he prescribed second line MDR drugs for Christian when he was a baby? (How did Farmer rationalize his decision?)
What is Farmer’s strategy for overcoming the Peruvian medical establishment’s inflexible approach to TB treatment?
What additional expenses will be incurred worldwide if the DOTS program is altered?
What is the MORAL of the story? By successfully treating a small number of MDR cases at great expense, has Farmer made the case for significantly altering the DOTS program which saved the lives of millions?
Arata Kachi articulates the other side of the argument: “Don’t let perfect be the enemy of good.” What is the ‘problem’ with Farmer’s approach from the perspective of a doctor with international public health experience?
Look at the problem of the Russian doctor responsible for treating TB in the Russian prison system with a budget of six million dollars. (162) What utilitarian choices will he be forced to make? Can Farmer rebut his logic?
Do you buy Jim Kim’s rationale for devoting such a substantial portion of the PIH budget in Haiti to the treatment of MDR patients in Peru? (How many kids in Haiti went hungry because of the program?) What standard must the PIH people use when they make decisions like this one?
Note the articulation of the utilitarian argument (165): “The world has limited resources. Nations whose resources are not just limited but scarce have to make the best possible uses of what little they have. Other countries and international institutions may help out, but if you want money from big donors, if you want to be taken seriously, your proposals have to pass a cost effectiveness analysis. You must calculate costs and try to quantify your programs effectiveness.”
Is there a logical flaw to this reasoning? Must health care planning use a universal baseline to determine costs? Will a program that is successful in New York City also prove successful in an impoverished locale? Should economic decision making (with its short term perspective) drive long term health care decisions?
What variables are involved in bringing a drug to a mass market? (169) What decisions at Eli Lilly (the pharmaceutical firm) made production of 2nd line MDR drugs so expensive?
What was Jim Kim’s business strategy to get 2nd line MDR drugs approved for the WHO DOT plus program?
What business conundrum did Jim Kim have to overcome? To lower the prices of drugs, a lot of TB projects would need to use them, but for a lot of projects to use them, the prices have to be lower (ie generic production). How did he do it? How did Guido Bakker at IDA and the group Doctors Without Borders come to his rescue?
What possible NEGATIVE MEDICAL consequences could result from a successful effort to make 2nd line TB drugs widely available? What solution did Kim and his team come up with?
By 2000, how far had prices for 2nd line drugs to combat MDR dropped?
What is the moral of this story? How, in a world of limited resources and bureaucracies which naturally favor incumbent policies, had Kim and Farmer engineered a change which primarily benefitted poor people?
Once they had broken through, how did PIH plan to expand its services so that it could continue to fund its operations in both Haiti and Peru?
Part Four: A Light Month for Travel (179-237)
After his breakthrough success convincing the World Health Organization to alter its protocol on MDRs, Farmer was urged to leave his practice in Haiti behind and take an executive role in the international effort to contain MDR. Why did he turn these offers down? How instead did he put his fame to work on his vision of practicing medicine for the poor?
“Patients come first, prisoners second, and students third.” (182)
For I was an hungred, and ye gave me meat: I was thirsty, and ye gave me drink: I was a stranger, and ye took me in: Naked, and ye clothed me: I was sick, and ye visited me: I was in prison, and ye came unto me. Then shall the righteous answer him, saying, Lord, when saw we thee an hungred, and fed thee? or thirsty, and gave thee drink? When saw we thee a stranger, and took thee in? or naked, and clothed thee? Or when saw we thee sick, or in prison, and came unto thee? And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me. (Matthew 25:35-40)
Why does Farmer find it so hard to leave Haiti? (188)
Ophelia Dahl describes Farmer as ‘terribly simple’, a man who has never experienced true depression. Why is that?
How does Farmer rationalize continually working 100 hour weeks? (191) (That’s 14 hour days.)
Kidder begins this chapter with Farmer’s exclamation about the verdant Cuban countryside as their plane descends into Havana. “Look! Only ninety miles from Haiti and look! Trees! Crops! It’s all so verdant. At the height of the dry season! The same ecology as Haiti’s, and look!” (193) What is Kidder’s point? Why is Farmer fond of Cuba?
What does Farmer despise about Marxism? What does he despise about ALL ideologies?
What does he mean when he says, “All -ologies fail us at some point. At a point, I suspect, not very far from where the poor live out their dangerous lives.” (195)
What personnel problem did Farmer hope to solve in Cuba? How?
How does he hope to redefine ‘triangular trade’ for the 21st century?
What did Farmer’s study of HIV infection in women in Cange reveal about the source of infection?
How did myths about HIV and AIDS influence the two different quarantines at Guantanamo Bay and in Havana in the early nineties?
What choice did the Cuban government make which radically reduced the number of AIDS cases in that country?
At the end of this chapter, Farmer confronts Kidder with his concerns about how this visit will be represented in his book. Will he depict Farmer as a stooge of the communists? Or will he affirm the successes of this government’s health system?
Farmer suggests that the notion that a peasant revolution could ever succeed in Haiti is ridiculous. He says instead that other people, richer people, will have to perform that revolution for them? Is that ever going to happen?
How then should we regard his politics: “Patients come first, prisoners second, and students third.” (182)?
What chink in Farmer’s moral armor is revealed when he visits his family in Paris? Can we draw conclusions about his ideas from this failing?
What does ‘hermeneutic of generosity’ mean?
Musing about the parallel universe of wealth and power exhibited by Charles De Gaulle Airport, Farmer describe his philosophy of interconnectedness. What is the connection between the two worlds? What is the worst sin, in Farmer’s view, that the rich can commit?
How had the tuberculosis epidemic in Russian prisons in 1997 begun to ‘amplify’ before Farmer got involved?
How did Farmer’s commitment to this project (despite his lack of time) serve PIH’s mission and its financial needs?
What political point can be made by comparing the health systems in two socialist countries: Cuba and (formerly) the Soviet Union?
During the toasting ceremony at the dinner with Russian prison doctors, Farmer describes America less as a democracy then as a privileged nation. “The rich can always describe themselves as democratic, but the sick people are not among the rich.” What conclusion can you draw from this comment about Farmer’s political views?
Describe the complex politics involved in the competition for control of the World Bank/George Soros loan to Russia to treat its tuberculosis epidemic.
After securing the loan Farmer argues with his Russian friend Alex Goldfarb, the head of the Russian Ministry of Justice. Goldfarb accused Farmer of being a naïve sentimentalist, someone who cannot acknowledge that most people in prison are bad, not just poor. He says, “You can just disregard things which are unpleasant, and that is why you are not scientific. You disregard reality.” (236) Is this criticism fair?
Part Five: O for the P (239-301)
What new challenges did Partners in Health face as it expanded its medical scope to treat AIDS and its geographical scope to projects in Russia and Peru as well as Haiti?
Rather than waiting to administer the low cost second-line antibiotics in Russia, Farmer and Kim bought enough drugs at high prices to start treating a few dozen MDR patients right away. How did they rationalize this financial decision?
What approach to dealing with AIDS in impoverished countries had been the World Health Organization’s approach even after antiretroviral drugs had become available?
What treatment plan did Farmer propose in his plan to fight the epidemic throughout rural Haiti? (259)
Tell the story of Zanmi Lasante’s effort to save John, the ten year old boy suffering from TB and nasophayngeal carcinoma.
How much money did Farmer commit to this one patient? How much did it cost to borrow the suction device, transport John from Cange, and then treat him at Mass General in Boston?
Can such an outlay of funding be rationalized?
What was the response of the physicians at Mass General?
What was the response of Haitians when they learned of the trip?
Chapter 26 (280-298) A Housecall in Haiti
Describe the stops Farmer makes enroute to Alcante’s hut in Casse. (Note that this international expert is on a seven hour hike to treat two patients.)
From whom did Farmer learn about the importance of doing anonymous, ‘scut work’?
How does Farmer respond to Kidder’s question about triage and John’s case? What does he mean by ‘fighting the long defeat’? What is he making by comparing the expense in John’s case to the salary of a young attending physician? (288-89)
What do you make of the criticism of Farmer and Partners in Health that suggest that the organization will not survive Farmer and it cannot be replicated? (294)
Farmer’s basic philosophy is to do what is best for the individual patient. Can you argue against that model of health care?
How has Farmer changed the world in its approaches to the treatment of TB and AIDS?
Essay Question: Evaluate Farmer’s approach to public health. Is it, finally, practical? Should we rethink the health care debate in the United States with his example in mind?