Mountains Beyond Mountains by Tracy Kidder is a 2003 New York Times bestseller and a Pulitzer Prize winner, so it’s no big surprise that it was a book I couldn’t put down and ended up finishing in two days.
The book’s subject, Paul Farmer, is a Harvard MD and PhD, and the founder of Partners In Health, a Boston-based non-profit. Farmer’s obsession with providing first world healthcare in dirt-poor settings in Haiti will leave you in awe, and redefine passion and hard work for you.
PIH started with one small clinic in Haiti in 1984, and now provides high-quality medical care to 1.6 million Haitian peasants every year (that’s one-sixth of the country’s population), as well as low-income populations in 11 other countries.
Farmer started his work in Cange, Haiti, one of the poorest cities of the poorest, most disease-ridden nation in the western hemisphere. He split his time between Boston’s Brigham and Women’s—one of the best teaching hospitals in the world—and Cange. Six months in Boston and six in Cange. Working 100-hour weeks, racking up tens of thousands of miles flying between the two cities, rushing to Haiti every chance he got, skipping class while in medical school and only turning up for exams (yet getting impeccable grades), sometimes traveling for just the weekend to check on his Haitian patients.
Here are 4 big takeaways for me from the book:
1. The human will is capable of moving mountains beyond mountains.
Farmer wanted to provide first-world health care in a country that didn’t have roads, clean water, electricity or food, and that was ridden with violence and superstition.
And he did it.
The clinic he set up in Cange in 1984 is now cited as a barometer for international health standards by economists like Jeffrey Sachs in his work with the US Congress, WHO, the White House, and the United Nations. In 1998, when PIH’s first group of drug-resistant TB patients in Carabayllo completed their two-year course of treatment, they achieved cure rates of over 80 percent, higher than those reported by many hospitals in the U.S.
Farmer and his team’s relentless campaigning achieved some amazing outcomes, such as successfully influencing WHO and pharmaceutical companies to drive down the global prices of second-line drugs for Tuberculosis—the biggest cost of treating drug-resistant TB patients—by 95%. He certainly didn’t do this alone; his dedication inspired friends and colleagues that formed PIH’s core team and led these efforts. Among them Ophelia Dahl, who is now Executive Director of PIH, and Jim Yong Kim, who was one of PIH’s co-founders.
2. Challenge conventional wisdom.
Farmer challenges and eventually changes how world health organizations and physicians view the treatment of infectious diseases in the developing world. He views everyone around him as either a patient or a pupil. He challenges the standards of healthcare in poor nations—the widely held notion for example, that drug resistant TB cannot and should not be treated in a poor country because it is too complex and too cost-inefficient. He mobilizes the world, literally—economists, physicians, policy makers, heads of state—decision makers in every sphere of life to accept that there are solutions, and they should be tested. And his approach produces results that shock the world.
Farmer believes that the international health crisis is, at its core, an inequality issue.
While working on AIDS in Haiti, he highlighted the obvious but oft-ignored fact that countries with the steepest grades of inequality and the greatest poverty have the biggest AIDS problems, and solving this problem is about solving inequality.
Farmer’s life and work dispel myths about healthcare that have been perpetuated by health practitioners and experts. Myths, for example, about who catches HIV and why. Risk factors mentioned in expert commentaries, such as blood transfusions, intramuscular injections, drugs, sexual promiscuity, don’t contribute to the majority of cases. The primary reason is abject poverty.
Playing detective, Farmer did a study in Haiti, and found that the difference between infected and uninfected women was this—most of the infected worked as domestic servants. Obviously this had not given them HIV, but it did describe their economic desperation—working for Haiti’s elite was rarely pleasant or remunerative. Uniformly, the infected women narrated that this desperation, deep poverty and illiteracy, was what had led them to the real risk factor at work—cohabiting with truck drivers or soldiers.
Why those two groups?
Not because they are any more attractive than the rest, but because they had steady jobs. In an economy where unemployment rates ran upwards of 70%, this was a massively attractive factor when choosing a partner. And he tells his audience that when he tried to find any research on AIDS, poverty and women on MEDLINE, a database of 21 million records covering biomedicine and health since 1950, he came up with nothing. Not a single study!
Farmer once met a woman in Cange who told him:
“You want to stop HIV in women? Give them jobs!”
3. Stay connected, stay inspired.
Paul Farmer is a Harvard professor, an influential anthropologist, medical diplomat, public health administrator, epidemiologist, and a man who has helped to solve some of the world’s most terribly difficult health problems. He is invited to speak at all the premier international health conferences, lectures at dozens of American and European universities, and is the author of 4 books and countless journal articles and research papers.
And yet there are many days when he spends seven hours making house calls in rundown shacks around Cange, talking to families, crouching in the dirt to put his stethoscope on a patient, asking them about their dietary habits. He calls these house calls “journeys to the sick”. Clearly his notions of efficiency and the best use of his time are different from yours or mine, to say the least.
When the author questions Farmer about this, his reply is simple. He needs to do this in order to keep going:
“That’s when I feel most alive. When I am helping people”.
He refuses to let his schedule be usurped by his managerial and political roles—meetings with health policy makers or heads of state, speeches at conferences, emails and letters, fundraising. He knows what inspires him and he finds time to draw it into his routine.
4. O for the P!
Farmer advocates for an approach that he calls O For the P, short for the Preferential Option for the Poor, a concept that stems from Catholic social teaching and signifies ‘a special concern in distributive justice for poor and vulnerable persons’. Though PIH is a secular organization, he cites this as the moral imperative he follows in his work.
As a result, the hospitals he establishes are the opposite of what is regularly defined and accepted as a hospital in the developing world i.e. a derelict building with undertrained, underpaid and under resourced staff that has extremely low expectations and standards for healthcare. Farmer’s hospitals are like an oasis: his staff are trained to treat their patients with as much care and attention—if not more—as is afforded wealthy patients at Boston’s best hospitals. He convinces people that diseases like AIDS and TB cannot be treated with only medication. Care must be paid to things like the caloric intake of the patient (a challenge in a country like Haiti where malnutrition afflicts every third person), and the quality of water they drink. And that these are resources that should be provided to patients in addition to treatment. The effectiveness of this approach is immediately evident in the results he is able to consistently produce in patients.
In later years in Haiti, Farmer also played a role in the building of schools and community health centers for the people he served. Of this time, Farmer writes: “The establishment of a school may seem a bit out of place given the homelessness, landlessness, and hunger of many of the water refugees. But it appears that they themselves did not feel that way.”
Children flocked to the new facility. One peasant woman explained:
“A lot of us wondered what would have happened if we had known how to write. Perhaps we wouldn’t be in this situation now.”
And the school could serve as a place for teaching lessons about health and for providing free meals to malnourished children without injuring their dignity. To build a school was to unite the practical and the moral, says Kidder.
Every now and then, he steals equipment from the Harvard Medical School to put to use in Cange—calling it “redistributive justice”.
The Haitians, when asked why a just God could permit great misery upon his creation like to say: ”Bondye konn bay, men li pa konn separe” which literally translates to “God gives but does not share”.
This, as Farmer explains to Kidder, means that: “God gives us humans everything we need to flourish, but he’s not the one who’s supposed to divvy up the loot. That charge is laid upon us.”
Farmer takes on this charge with a vigor and determination that is hard to rival.
Kidder says towards the end of his book that many health practitioners argue that Farmer’s approach is not sustainable or replicable because it pays so much attention to the individual. Yet requests for PIH to work in other countries are streaming in faster than they can handle. Yet Cange is cited as a key example by WHO and the United Nations. Part of the reason is that the approach is heavy on community-based health care. PIH focuses on training locals as doctors, nurses, technicians, and health workers who could then diagnose and treat others. This means that the work goes on when Paul and his team are not on the ground.
Farmer is unfazed by claims of the lack of sustainability of his work, and the unrealistic attention and resources he showers on each of his patients.
In a 2005 TIME article, he says:
“You start down this slippery slope. But it’s a slippery slope that leads to better health care for poor people, so I say, let’s slide down it!“