Intro
Tracy Kidder’s Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World shook me like few books do. Kidder, a Pulitzer Prize-winning journalist, follows Farmer through his daily routine, from Haiti to Peru to Paris to Russia to Boston, while telling the story of Farmer’s childhood, his first love, his medical school years, his years a maverick at the World Health Organization, and later as a leader. As a person, doctor, advocate, and reformer, Dr. Paul Farmer is utterly captivating – in short, he’s a mensch, but not the kind of mensch you'd want to marry.
We meet Paul at a young age and watch him grow through his various nicknames, P.J., Pel, Dokte, and so on. The central concepts in Farmer’s life also have nicknames, and I spent the week after I read Mountains Beyond Mountains talking in PIH-speak (the lingo of the organization he co-founded, Partners in Health). Having an “H of G” (a hermeneutic of generosity) means interpreting people’s intentions in a favorable light (215); “Love, ID” (infectious disease) is a shorthand response to the rather complacent TBMIs, the transnational bureaucrats managing inequality (216);“the poor” and if not that, “the soon dead” is Farmer’s preferred term for the world’s destitute populations (100); WLs (white liberals) are people who moralize that “things aren’t that black and white” as a way of obscuring AMCs (areas of moral clarity) which, if fully recognized, would compel these WLs to radically alter their lavish lifestyles (101).
I've been that “white liberal.” It's the person content to have the right ideas without necessarily the right actions; the person more enamored by the idea of justice than the work of justice. I am, I admit, more enthused by philosophical discussions of “human rights” than by the logistics of providing the “[c]lean water and health care and school and food and tin roofs and cement floors” that Farmer takes as a “set of basics that people must have as birthrights” (91). In the spirit of academia, I have learned to “problematize” the world but not to fix it – as if the life expectancy in Haiti (53 for men, 56 for women) were merely a moral conundrum and not, firstly, a moral outrage.
Between sitting in the dirt with his patients, lobbying at the WHO, working to lower prices for TB drugs, and shuttling from Boston to Haiti to Moscow to Peru to Paris, Farmer somehow manages to write academic works that are regularly reviewed in major medical journals. Between site visits, he gives presentations like the 2005 Tanner Lectures (PDF) at the University of Utah. I heard a version of that lecture when he spoke at Brown in 2006. Even though he arrived two hours late, six hundred students sat in a six hundred seat auditorium and waited. I did too.
I appreciate Farmer’s stance toward academia. He not only educates, but agitates as well. As a result, he succeeds as an academic where many others have fallen short. He sees academia not as a vain pursuit to enhance knowledge for its own sake, but as a forum for activism, for developing a plan to improve people’s lives. Indeed, one should always approach academia with caution, lest one succumb to its potential faults: “the arrogance, the petty infighting, the dishonesty, the desire for self-promotion, the orthodoxy” (195). As an aspiring academic (sometimes), I take that message to heart.
Mountains Beyond Mountains has its imperfections, minor as they are. The eccentricities of Farmer’s childhood are a bit overblown. It’s true that most people don’t grow up on a boat – too poor to afford a real house – but most have equally good stories to tell. Also, in some of Kidder’s exchanges with Farmer, I got the sense that Farmer was performing, i.e., that he was working too hard to shape a persona. Now there’s nothing terribly wrong with that. Malcolm X dictated his whole autobiography that way. But it sometimes compromised the aura of unrehearsed spontaneity that made this book so much fun to read. Take, for example, when Farmer tells Kidder: “I’m not truly humble. I’m trying to be humble” (289). But these are faults with the book, not with Farmer.
Can I find faults with Farmer? Before answering that question, I should ask why I even asked it. In reading this book, I felt as Ophelia Dahl – Farmer’s early love and now the long-time executive director of Partners in Health – did when this young man she just met seemed to do everything to perfection. Once in Haiti with young Paul, she set her alarm clock for five to beat out her companion. But she woke to the sound of his voice anyway. “I just want to do something better than him,” she thought. “For a moment.” I felt similarly sometimes. As a result, I am perhaps exceedingly eager to find faults with this giant, critiquing his work with moral scrutiny he doesn’t deserve. The question, I realized, was not: “Does Farmer have faults?” but rather, “Can I find any?”
I recognize that’s unfair. And I recognize that I’m just some joe with a blog and a dubious claim to moral authority. So you will have to take my comments accordingly.
Inequality
I was uncomfortable with his Robin Hood mentality; that is, the ease with which he can take from the rich to give to poor. When Farmer began to equip the laboratory of Cange’s clinic, he consulted a booklet from the World Health Organization that offered tips for planners working from modest resources. It recommended, for instance, that planners use a homemade solar-powered microscope to cut costs. Farmer tossed out the booklet. Kidder writes: “The first microscope in Cange was a real one, which he stole from Harvard Medical School. ‘Redistributive justice,’ he’d later say. ‘We were just helping them not go to hell’” (90).
I feel uncomfortable with it, but “uncomfortable” in the sense of choosing between evils. I suspect, though without terrific evidence right now, that first-world affluence is in large part responsible for the continued impoverishment of the third world, in ways often unacknowledged because the causality is indirect and mitigated by geography. There is a third world because there’s a first world. So when Farmer steals, it’s possible to construe this theft as some sort of “just redistribution,” even though the people of Haiti never owned that microscope in the first place. I also recognize that part of Farmer’s appeal – part of his heroism, even – is his willingness to f*ck the system. It’s a system both complicit and complacent in acting like poor people dying at middle age were a normal occurrence. To the extent that Farmer’s Robin Hood mentality makes us reconsider the legitimacy of the current world order, it becomes less blameworthy.
To put it another way, it’s still wrong for the food bank to steal your car.
To a Robin Hood, one reason why it’s acceptable to steal from the rich to give to the poor is because the poor gain more from the theft than the rich lose by the loss. So the theft increases overall well-being, even if some people are less happy as a result. I can’t help but think that Paul Farmer is in part motivated by this rationale: the observation that so much good can be done at little cost to the rich. Kidder writes upon their arrival in Paris: “As we entered the city proper, the great dove-colored epicurean city, he murmured something about how much could be done in Haiti if only he could get his hands on the money that the first world spent on pet grooming” (210).
Now, in brief sketch (with apologies), there are two major positions in ethics. Deontologists value principles above all, while utilitarians seek to maximize over well-being, even at the expense of individual freedoms and luxuries. Deontologists tend to fault utilitarians for failing to respect differences between people; utilitarians tend to fault deontologists for obscuring issues of fairness. In truth, we’re all both deontologists and utilitarians. I believe, for example, that what’s mine is mine, what’s yours is yours, and that people are entitled to spend their money however they choose. At the same time, though, I believe there’s something wrong with being very well-off when others are dirt-poor. Or put another way: There is something wrong (though it’s not clear what) with spending five dollars on a beer while another person dies for lack of a five-dollar bed-net.
Paul Farmer doesn’t deeply differentiate between persons. Anyone’s suffering is his suffering, and in fact, the suffering of us all. That’s a virtue, I think, especially in inspiring his donors to fund start-up medical clinics in the poorest areas of the world. His care for others is contagious. Nor does Farmer differentiate between persons with respect to himself. He returned to work shortly after coming down with a near-fatal case of Hepatitis A. He told Tracy Kidder, “The problem is, if I don’t work this hard, someone will die who doesn’t have to. That sounds megalomaniacal. I wouldn’t have said that to you before I’d taken you to Haiti and you had seen that it was manifestly true” (191). If Farmer had some superpower ability to restructure the world, he would divert the wealth of the affluent to those who need it to survive. He’d do it, I think, even if it made people in the first world worse off. I wonder how far he’d go, and I wonder how far I’d go.
At the beginning of this post, I called Farmer a mensch but not the kind of mensch you’d want you to marry. His devotion to improving the health prospects of the world’s poor means that he rarely sleeps and that he sees his wife and daughter every few months for a day (or at least that’s the sense I get from the book). Patients before family. Most people would carve out a larger space for family. It’s obvious that personal relationships pose special obligations that sometimes conflict with principles of impartiality and fairness. So I visit my friends when they are sick, but don’t visit people I don’t know. Though I donate to humanitarian relief, I probably spend more money visiting friends. It may be selfish, but I think I’d want to see my spouse more than once every few months.
I don’t mean to imply that Farmer is somehow acting wrongly in his personal life. I only want to note that Farmer has a different conception of his personal commitments than many other people have of their own. There is room for pluralism here, I think. In any case, the question of “love versus justice” has been hotly debated in the feminist literature under the code word, “the ethics of care.” Any person who starts a family will face these questions someday.
Incision
An incision is a surgical cut to reach the underlying cause of injury or disease. I use it here to signify a theoretical cut through surface level explanations for why the poor bear the bulk of the global burden of disease. A person who dies of cholera, typhoid fever, or dysentery hasn’t really died of the illness itself, but of shoddy municipal water systems that transmit waterborne bacterial diseases. Though a doctor, Farmer echoes my sense that economic well-being is the best medicine. He pays homage to the social determinants of health, maintaining that “the great burdens of disease in Cange were just a symptom of a general deprivation” (Kidder’s words, 91).
At a meeting of the World Health Organization where Partners in Health (PIH) was lobbying for resources to treat multidrug resistrant tuberculosis, many skeptics said that the funds simply didn’t exist. One PIH-er responded, “I remember signing the oath to assist the patient and do him no harm. I don’t really remember signing that I would do it in a cost-effective way” (162). PIH-ers see the public health mantra – that “resources are limited” – as a clever way of absolving oneself of responsibility for the poor. In Farmer’s view, it was uttered “without any recognition of how, in a given place, resources had come to be limited, as if God had imposed poverty on places like Haiti” (Kidder’s words, 175). Farmer’s broader view of poverty investigates why resources were limited – not just to work within the constraints, but to work to remove the constraints themselves.
Improving the social context is pivotal to public health, so I'm glad Farmer draws attention to dollars and cents and other less sexy aspects of health care like nutrition and access. If health care workers are really going to be the “natural attorneys of the poor,” as Farmer believes, they will have to learn not only to cure disease but also to prevent it. Prevention has never been the glory of medicine, but preventative efforts will have to expand in developing countries. Doctors will play an important part, I think, but development workers and public health officials – people without M.D.’s stamped after their names – will make equally great and perhaps greater contributions. For those of us with no health care skills and no plan to acquire them (i.e., me), pay attention.
Inadequacy
It is a feature of hero-ness that we expect things from heroes that we don’t expect from ourselves. That is, after all, why they are heroes: because they go “above and beyond.” We expect even more when they adjure us to reform our lifestyles. Responding to Peter Singer’s admonition to live cheaply and give the rest to the needy, many of my classmates found reason to attack Singer himself, ad hominem. “I bet he doesn’t live in a shack,” one of my classmates snarled. The same thing happens with Farmer. Kidder writes that “at some point … I realized that I’d become inclined to hold Farmer to a higher standard than I did most people, including myself” (153). Yet Farmer seems quite capable of meeting our expectations: he does live in a shack, if he lives anywhere at all.
Farmer tells Kidder: “‘When others write about people who live on the edge, who challenge their comfortable lives – and it has happened to me – they usually do it in a way that allows a reader a way out. You could render generosity into pathology, commitment into obsession. That’s all in the repertory of someone who wants to put the reader at ease rather than conveying the truth in a compelling manner’” (207).
I did want Farmer to leave me “a way out,” some assertion like, “Yeah, I’m really insane; no reasonable person would do this kind of work.” Of course that never comes. I doubt I was the only person to finish this book feeling terribly inadequate. Kidder quotes Farmer’s friend and PIH-cofounder Jim Yong Kim as saying, “Paul has a gift for making people feel guilty” (212). Farmer’s activities, from tending at the bedsides of patients to seeing them in prison to lobbying at the WHO, produced a jealousy in me that I hadn’t felt since my interactions with the rare peacemakers in Israel/Palestine who could converse fluently in both Arabic and Hebrew. It angered me because it requires skills I will never acquire and made me a coward by comparison.
On reflection though, my jealousy fizzled. Jealousy focuses on the self, as if improving my own well-being were the purpose of my volunteer work. Jealousy’s not one of the seven deadly sins for nothing. Yet jealousy, with its many vices, also has a certain usefulness: to the extent it overlaps with self-interest, it can inspire social action. I started volunteering in the prison system mostly to fight the injustice of “criminal justice,” but also out of curiosity. Curiosity is obviously different from jealousy, but self-interest is evident in both. Social activists, after all, are people, too.
I can imagine telling my grandchildren years from now that it was at this point in my life, after reading books on injustice, including Kidder’s book, that I decided I would lead a life whose luxuries wouldn’t drive me insane. Farmer, too, seems to have felt a similar motivation. Kidder notes that Farmer’s fanaticism (that’s my word) “freed him from the efforts that many people make to find refuge and distinction from their pasts, and from the mass of their fellow human beings” (219). We say, genuinely I think, that our primary purpose is to improve the lives of others. But another purpose, ancillary and usually hidden, is to avoid the “uneasiness that some of the fortunate feel about their place in the world.” Farmer isn’t so superhuman as to transcend it. Kidder says it’s “the thing he once told me he designed his life to avoid” (Kidder’s words, 295).
Inspiration
Certain images from the book stay with me: A young Farmer diving through bullets to take wounded Haitians to the hospital, popping up from Haiti just in time for his med school exams in Boston, crying when a patient miscarries, sitting on a patient’s bed at Brigham’s, carrying bundles of gifts through the Miami airport, writing AIDS and Accusation from a rocky Haitian hilltop. I imagine it sometimes like the hilltop in Be’er Sheva that I used to climb at twilight: a place to reflect on the city, away from the city. These are images of work, yet they return at night. They are images of a man, yet they exemplify an idea.
I wasn’t as inspired as the book cover said I’d be, but Mountains Beyond Mountains affected me in a different way. I’d say that I am more agitated than inspired. I am agitated by questions about our obligations to far-away others - people dying of diseases I’ve never heard of. I am frustrated because I want to help but I’m not sure how. I am anxious about conveniently blurring their interests – whatever those may be – with my own. So for now, I'm going to do the one thing I know best: read more. I purchased Farmer’s most recent book, Pathologies of Power: Health, Human Rights, and the New War on the Poor. Perhaps I should have bought Infections and Inequalities, a book Farmer published in 1999, when he wasn’t receiving hundreds of emails a day. He may have had more time to invest in book-writing then – though something tells me: no, probably not.
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