|
Mountains Beyond Mountains:
The Quest of Dr. Paul Farmer, A Man Who Would Cure the World
by Tracy Kidder (Random House, 2004)
Epigraphs:
Dèyè mòn gen mòn. (Beyond mountains there are mountains)
– Haitian Proverb
…And right action is freedom
From past and future also.
For most of us, this is the aim
Never here to be realised;
Who are only undefeated
Because we have gone on trying…
– T. S. Eliot
The Partners in Health (PIH) Vision: Whatever it takes
At its root, our mission is both medical and moral. It is based on solidarity, rather than charity alone. When a person in Peru, or Siberia, or rural Haiti falls ill, PIH uses all of the means at our disposal to make them well—from pressuring drug manufacturers, to lobbying policy makers, to providing medical care and social services. Whatever it takes. Just as we would do if a member of our own family—or we ourselves—were ill.
(From: http://www.pih.org/who/vision.html)
Overview:
Part I: Doktè Paul (1) [Chapters 1-4]
Part II: The Tin Roofs of Cange (45) [Chapters 5-12]
Part III: Médicos Adventureros (123) [Chapters 13-19]
Part IV: A Light Month for Travel (179) [Chapters 20-23]
Part V: O for the P (239) [Chapters 24-26]
Afterword (299)
Themes/Questions for Discussion/Consideration:
1. Farmer’s abilities and genius (social, medical, and academic); heretical…
Able to relate to people with backgrounds vastly different from his own
(Patients, administrators, prisoners, nationalities, students, races, etc.)
Priorities and major dilemma – choosing between levels of suffering
Patients, prisoners, and students (sermon on the Mount)
Farmer’s idea of being an American and nationalism
Fake gringo and way he responded to the Russians (joke/speech)
How does Farmer’s curious indignation help him from
burning out or becoming overcome by despair?
2. Guilt, sacrifices, and “psychic discomfort”: Building a movement (life after Paul?)
What does he expect from himself; what does he expect from others?
Made himself immune to self-consuming varieties of psychic pain (189)
*Extreme service to the poor and sick; not just education, but transformation
3. Poverty, inequality, and moral stance (new religion – Lib Theo – O for the P)
Comprehensive theory of poverty; power, exploitation, wealth, U.S. & the rest
Erase the connections and hide the poor and how they got that way
Egalitarian interaction with staff and patients – no conceit or false pride
Public Health philosophy: not-for-profit (to sell services in world that can’t pay)
Link between social conditions and epidemiology (justice and health connected)
Impatient with standard definition of public health:
Add homelessness, landlessness, hunger, lack of education…
Interconnectedness of all parts of the world; health, economy, structure…
“I am an American” vs. “tout moun se moun”
4. Anthropology, culture, sorcery, medicine, science, and material circumstances
Listen to and understand another culture, language, class (tools?); complexity
5. Mountains beyond mountains and the Long Defeat
Achievement, goals, futility, hope vs. despair, effectiveness, efficiency
“Myths and Mystifications about MDR-TB”:
How/why is Farmer often seen as taking on a quixotic, even heretical undertaking (146)?
Constantly questions conventional wisdom, “experts”
*Different concepts of the word “triage” (286)
*“I have fought for my whole life a long defeat, but I’m not going to stop just because we keep losing. We’re used to being on the winning team, but our duty is to make common cause with the losers” (Camus / O for the P) (288)
6. Farmer’s origins and his choices; your origins and your choices
What key early lessons did Farmer learn from his parents, experiences, origins?
What is Farmer’s secret? Is it intelligence, commitment, attitude, compassion?
Constant dilemma of where best to use his talents and energy (Haiti vs. world)
7. Political correctness, identity politics, and special vocabulary of PIH
White Liberals – what is Farmer’s issue with them? (sacrifice to themselves)
8. Politics and action: What are the political consequences of Farmer’s philosophy?
U.S. policy toward Haiti, Latin America, and the Third World
Wealthy countries (global north) vs. poor countries (global south)
The “great epi divide” – Global north vs. the Global south
Relative poverty vs. Absolute poverty (123-124)
“The Anthropologist Within” (83): applied research – research and action (84)
*“The Uses of Haiti” (1993-1994) – History of U.S. Policy Toward Haiti (116)
CUBA vs. HAITI: What do we learn from this comparison? Is this a legitimate
comparison – why or why not? What are some other instructive comparisons?
9. Different people in PIH, different roles, come to terms (Farmer, Ophelia, White, Jim)
How do the different personalities in PIH interact and work together?
PIH as a Laboratory for the World: Spread the word on Zanmi Lasante
One of a kind, but is it replicable and sustainable? (256-257)
10. Point of View of the narrator – too close vs. too far, effectiveness, and why?
Describe the development of the relationship between Farmer and Kidder
Disagreements and emotional peak between Kidder & Farmer (202-203)
*Farmer’s relationship with Cuba (challenge the reader’s prejudices) (206-7)
Part I: Doktè Paul (1)
- Introduction: How Kidder met Farmer (Christmas 1994) (3)
Another way of thinking of a place like Haiti; but hard to share because it implied such an extreme definition of a term like “doing one’s best.” (8)
- Farmer in Boston; Joe (December 1999) (9)
No conceit or hierarchy; everyone’s a friend or potential patient (12)
Message Board: window into Farmer’s mind and philosophy – OUT vs. IN (15)
Books: shouting on every page – different manner from clinician
Not my oeuvre – “To see my oeuvre you have to come to Haiti” (17)
- *Zanmi Lasante* (Partners in Health) – Farmer in Action (18)
A miracle in poorest part of the poorest country in the Western Hemisphere (20)
Rule: Everyone had to pay, that is, except for almost everyone
Farmer’s Rule: And no one could be turned away (21)
MacArthur ($220,000): All to PIH – Institute for Health and Social Justice (23)
*“I feel ambivalent about selling my services
in a world where some can’t buy them”; Comma… (24)
“You can’t sympathize with the staff too much,
or you risk not sympathizing with the patients.” (25)
Checking off one of his bwats – inordinate pleasure (26)
Narrating Haiti… (28)
“To be a good clinician you must never let a patient know that you have problems too or that you’re in a hurry.” (29)
*Ti Ofa: “When I was sick and no one would touch me,
you used to sit on my bed with your hand on my head.” (30)
“Only in Haiti would a child cry out that she’s hungry during a spinal tap” (32)
- Farmer’s Philosophy (Structural Violence) (33)
Germs vs. Sorcery; Free Medicine vs. FM plus Cash Stipends and Visits (34)
*“Honey are you incapable of complexity?” – Material circumstances vs. beliefs
DOT (directly observed therapy) PLUS cash stipend (35)
Blan – “all you blan look alike!” (36)
Interconnectedness of rich & poor parts of world – Army Corps of Engineers Dam (37)
WL’s (White Liberals) – “world’s problems can be fixed without any cost to themselves”
Sacrifice, remorse, and pity (40)
Inculcate in doctors and nurses the spirit to dedicate themselves to the patients, and especially to having an outcome-oriented view of TB (i.e., Fuck You) (42)
Farmer’s aim was not just education, but transformation
*“To understand (Russia, Cuba, DR, Boston, identity politics, Sri Lanka, Life Savers)… the world – you have to be on top of this hill” (44)
Part II: The Tin Roofs of Cange (45)
- Farmer Family History (Massachusetts, Alabama, Florida) (47)
From the Blue Bird Inn to the Lady Gin (from living in a bus to living in a boat)
From Lord of the Rings to War and Peace (48-49)
Run-in with Haitian migrant workers; “white people don’t pick citrus” (51)
Senior class president and full scholarship to Duke (55)
Various rites of passage at Duke (discover wealth, join frat, quit frat, etc.)
Always seeking his father’s approval – discovers letters of pride after death (58)
- College / Liberation Theology / Haiti (spring, 1983) (59)
Studies with Claude Levi-Strauss, learns French, & chooses Medical Anthropology (59)
Mentor: German polymath named Rudolph Virchow
Links social conditions and epidemiology: Fundamental Law (Mass Life) (60-61)
*My politics those of prophylaxis, my opponents those of palliation (61)
Physicians are the natural attorneys of the poor (solve social problems) (61)
Moral Understanding of Public Health (61) – Oscar Romero
“When I was a kid the only sin was impurity and the only virtue was obedience;
No one ever talked about things like social justice, LT, O for the P, or IS”
*Liberation Theology, Preferential Option for the Poor, Institutionalized Sin (62)
“Wow! This ain’t the Catholicism I remember!”
More curious about the world than outraged (62)
Belgian nun and church ladies – Friends of the UFW –
More militant, radical, and activist than all WL’s and academics
Seeing conditions of life of Haitian migrant workers – read about Haiti
“Haitians without a Home”; U.S. immigration policy toward Haitians
Moved from curiosity to indignation (but curiosity remained)
Interested in all things Haitian (esp. history and society and US)
Spring, 1983: plans to spend a year in Haiti (64-65)
- Meeting Ophelia and Farmer’s Comprehensive Theory of Poverty (66)
Dear John: “Your unswerving commitment to the poor
, your limitless schedule, and your massive compassion for others”
*Comprehensive Theory of Poverty and Ethnography (73)
Translate/narrate Haiti: “A world 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” (73)
Ethnography: Learning about a culture, not through books and artifacts but from the people who had inherited and were making culture (themselves)”
Medical anthropology: Voice to the voiceless; Doctor to poor people
- Farmer’s Epiphany / I am (not) an American (76)
Minor error can lead to enormous impact…; Prefer LT and “solidarity” (78)
*Slow Awakening vs. Epiphany à I am an American vs. tout moun se moun (79-80)
LT: O for the P – But choice between degrees of poverty
Not just Haiti, but the poorest and remotest area of Haiti (central plateau) (81)
“The Anthropologist Within” (83): applied research – research and action (84)
Fall, 1984: Entered Harvard Medical School – 24 years old (fully formed at 23)
Paul Farmer – Paul Foreigner: spent most of med school in Haiti
- Tom White and “appropriate technology” (85)
Godless world that worshiped money and power; or efficacy and advancement
Crucifixion is found every day in Haiti
The Luddite trap and Appropriate Technology: use only the simplest technologies
required to do a job (89) vs. good things for the rich and shit for the poor (90)
Redistributive justice: We are just helping them not to go to hell (90)
Impatient with standard def of public health: add homelessness, landlessness, hunger
Tom White: Bread Oven – sounds like a winner
So intelligent so dedicated to his work – place to hang my hat (94)
- Partners in Health (1987-1988) (96)
Duvalierism without Duvalier
December 10, 1988 – date of final breakup between Farmer and Ophelia
WL’s (White Liberals) and AMC’s (Areas of Moral Clarity)
- Aristide’s rise / “4H Club” / Aristide’s fall (104)
Dechoukaj
*Haiti is 90 percent Catholic and 100 percent voodoo (105)
Aristide: Rise and link to Farmer and his philosophy
Thesis: “Aids and Accusation”
4H Club: homosexuals, hemophiliacs, heroin users, and Haitians
Coup: September 29, 1991
Story of Chouchou Louis: political repression and public health
- Goin’ Back to Haiti (Aristide and Farmer) and Goin’ Big Time (1993-1994) (114)
MacArthur Grant
*“The Uses of Haiti” (1993-1994) – A History of American Policy Toward Haiti (116)
Banned from Haiti: Op-Ed in the Miami Herald
From marginal status to the Big Time
Mid-October, 1994: Aristide (and Farmer) back in Haiti
Part III: Médicos Adventureros (123)
- MDR TB (multiple drug resistant tuberculosis) à Lima (125)
The “great epi divide” – Global north vs. the Global south
Relative poverty vs. Absolute poverty (123-124)
- Father Jack (death and discovery); MDR TB epidemic (129)
Carabayllo, Lima, Peru: Father Jack Roussin and Jim Kim
- WHO – DOTS vs. DOTS+ (135)
Official Policy (WHO/Peru) vs. Médicos Adventureros
Massive urbanization and rural to urban migration in Lima’s outskirts (136)
“Amplification” – following the WHO DOT treatment actually made it worse (140)
- Myths and Mystifications (142)
“Superbugs” – strains resistant to every known antibiotic, spread rapidly
Médicos Adventureros: Only looks like a gringo – really a fake gringo (144)
IUATLD meeting in Chicago – makes his statements to provoke a response
Could be taken for starting a quixotic, even heretical undertaking (146)
“Myths and Mystifications about MDR-TB”
“We should treat sick people if we have the technology” (147)
- Didi Bertrand and two Peruvian kids (148)
Marriage in 1996 in Cange
Robin Hood attitude in taking medicines from Boston to Peru –
“Better to ask forgiveness than permission” (149)
White’s conviction to “spend all my money before I died” (150)
Farmer comes down with hepatitis A – Peruvian seafood?
Rest and relaxation in South of France w/ Didi – child is conceived and born
Farmer’s refusal to set aside his work for any reason – severe sickness only
Farmer’s visit to Lima’s Children’s Hospital – two children (one the child of a doctor)
Farmer’s charade and professional composure (157)
- Boston meeting (American Academy of Arts and Sciences, April, 1998) (159)
Announce results (85% cure rate) of Peruvian study – look for new financing
Arata Kochi vs. Jim Kim (Margaret Mead)
Alex Goldfarb and Russian TB nightmare (Soros Foundation and Gates Fdn $45M)
- Drug companies and Jim Kim’s history (165)
Question of cost-effectiveness: Greatest good for the greatest number
But in some places certain treatments would never be cost-effective?
Move to drive drug prices down by going to second tier generic drugs
*Jim Kim: Ethnicity: central problem of his life & (selfish) politics of racial identity
Asian racial solidarity (short-lived) (168)
International Dispensary Association (G. Bakker): Drive down price of essential drugs
Jim moves into political work & Journal of Popular Studies (JPS – People Magazine)
Part IV: A Light Month for Travel (179)
- Haiti à Miami (181)
Priorities: Patients, Prisoners, and Students (182)
Should I stay (in Haiti) or should I go (Global)?
Demands for his time and attention: Priests, nuns, anthropologists, fellow doctors
Haiti: “We miss you as the dry, cracked earth misses the rain” (183)
Trip to Cuba for an AIDS conference: Who is paying your way? (184)
Counting on Capitalists (Soros), Communists (GOC), and Christians (Church)
Haitian friends wanted him to wear a suit when traveling and representing them abroad
Sermon on the Mount (Matthew 25):
The least of these, for me; Inasmuch as you did not – you’re screwed (185)
*Kidnapped from West Africa – see Haiti from above in a plane (188)
Haitians arriving at Miami International Airport (horrible)
Never experienced true depression, nor despair and never will
Made himself immune to self-consuming varieties of psychic pain (189)
Rules: No one could be fired except for stealing or slapping a patient (twice)
If you don’t work this hard, someone will die who doesn’t have to (191)
One can guess a lot about the economic condition of a country by inspecting the baggage
people carry there from the United States (or return with) (191)
Cuba advantage: “No dead babies for a while” (192)
- CUBA (vs. Haiti) à Miami (193)
Farmer fond of Cuba: Not for ideological reasons…
Cuba’s health statistics (vetted by WHO) regarded as most accurate in the world
The direct opposite of Haiti – epi profile reversed
*Admiration of public health program in Cuba – Why (prevention & equity, 194)
Scandinavian countries vs. Cuba: Managing wealth vs. managing poverty
Marxist analysis (Lib Theo) undeniably accurate
*More interested in denouncing the faults of the capitalist world
than in cataloging the failures of socialism (194-195)
Criticize the excesses of the powerful, but Marxism not the answer, like academic
pursuits: Full of arrogance, in-fighting, dishonesty, self-promotion, and orthodoxy
Distrusted all ideologies, including his own, at least a little
Cuba had food rationing and allotments of coffee adulterated with ground peas,
but no starvation, no enforced malnutrition (195)
“I can sleep here, everyone has a doctor” (196)
Dr. Perez, Cuban connections, Cuba’s Medical School, “Triangular Trade” (196-197)
*AIDS, women, and poverty; Give them jobs; 3rd World myths vs. 1st World myths (199)
200-210:
Cuban AIDS policy: quarantine controversy (difference between Cuba & Gtmo, 200)
Disagreements and emotional peak in relationship between Kidder & Farmer (202-203)
*Portrayal of Farmer’s relationship with Cuba (challenge the reader’s prejudices) (206-7)
Cuban medicine and social justice, hate to see that ridiculed…
Image of commitment of Cuban doctors and priorities of patients first
What is the price of freedom from illness and premature death?
“If I could turn Haiti into Cuba, I’d do it in a minute”; but… (208)
- Paris, France (family time) (211)
Family time in Paris
Going to Russia “tomorrow morning” – chink on moral armor…
Care about “my child” vs. “all children”
H of G: Hermeneutic of generosity (benefit of the doubt)
Lexicon/special vocabulary of PIH (215-219)
Anti-identity politics (216)
Interconnectedness: massive accumulation of wealth vs. abject misery (218-219)
Erase time and place, intimate inescapable connections; reject “erasing” of people
- Moscow meeting (220)
No fee – Refuses to be paid on principle (problems with policies of World Bank)
TB Joke: Boston lacks only one thing to deal with TB – TB itself
Lazy Democrats and privilege vs. democracy (229)
Alex Goldfarb vs. Paul Farmer (232)
Resurgent TB in Russia (234)
Part V: O for the P (239)
- Laboratory for the World (241)
July 2000: $45M from the Gates foundation
Expand operations to Siberia
The Night of the Singing Gulagmiesters: Dancing Generals and Jailers
Routinization / Institutionalization of PIH?
Haiti home – Heart in Haiti (despite world traveling)
*Hiatt and Sachs: Spread the word on Zanmi Lasante – one of a kind, but replicable and sustainable (256-257)
U.S. policy toward Haiti – post-2000 after re-election of Aristide (258)
- John’s Journey (consequences and questions) (261)
“Dying of Haiti” – Jean Paul and Yolande…
God helps those who help themselves… (271)
“You are the best Haitian I know” (275)
*Challenge and consequences of John’s Journey: Patient advocate
*Futility vs. What if it has been my son (or an insured tourist)
*A Harsh and Dreadful Love (278-279)
- The Long Defeat (hike and triage) (280)
*Different concepts of the word “triage” (286)
*“I have fought for my whole life a long defeat, but I’m not going to stop just because we keep losing. We’re used to being on the winning team, but our duty is to make common cause with the losers” (CAMUS / O for the P) (288)
Asking the right questions and making the right comparisons (289)
Farmer method and sympathetic critiques: inefficient and too hard to replicate (294)
Unglamorous scut work – apparent craziness
The idea that some lives matter less root of all that is wrong with the world
Afterword (299)
*AIDS and TB
A global challenge that will define the moral standing of a generation
Africa, Asia, Eastern Europe, and Latin America
*Beefing up PIH in Cange and Haitian Central Valley
Resources:
Books by Paul Farmer
Pathologies of Power [Some chapters on line (University of California)]
http://www.ucpress.edu/books/pages/9875.html
This book contains Farmer’s comparison of two AIDS quarantines
Infections and Inequalities
Women, Poverty, and AIDS
The Uses of Haiti
AIDS and Accusation
Articles by Farmer
“From ‘Marvelous Momentum’ to Health Care for All,” Foreign Affairs, January 23, 2007
http://www.foreignaffairs.org/special/global_health/farmer)
“Who removed Aristide?” Paul Farmer reports from Haiti, April 14, 2004
http://www.lrb.co.uk/v26/n08/farm01_.html
Pestilence and restraint – logic of quarantine (Gtmo) (1995)
NACLA (1995) – The Significance of Haiti
The Anthropologist Within (1985)
Graham Green (1993)
Pathologies of Power (1999)
AIDS heretic (2001)
Interviews with Farmer (on-line)
Fresh Air: Interview with Dr. Paul Farmer, September 25, 2003
http://www.npr.org/templates/story/story.php?storyId=1446061
Pathologies of Power – University of California Website – Author interview
“Championing Health Care as a Human Right: An Interview with Paul Farmer”
http://www.ucpress.edu/books/pages/9875/9875.auint.html
Other items of interest
NPR Story available online: October 20, 2003 – Interview with Kidder
“The Quest of Dr. Paul Farmer: New Book Tells of an American Doctor's Life, Mission in Haiti”
http://www.npr.org/templates/story/story.php?storyId=1472188
Tracy Kidder. “The Good Doctor.” The New Yorker, July 10, 2000 (vol. 76, issue 18, p. 40.)
M. Danner. “Beyond the mountains.” The New Yorker, November 27, 1989, pp. 55-100.
Gary Marx. “I've seen more death than anyone should.” Chicago Tribune, June 3, 2007.
http://www.chicagotribune.com/news/local/chi-haiti_doctor_bdjun03,1,891406.story?coll=chi-news-hed&ctrack=1&cset=true
AIDS and Cuba:
Rosenthal, A.M. “Individual ethics and the plague.” NYT, May 26, 1987, p. A23.
Scheper-Hughes, Nancy. “AIDS, Public Health, and human Rights in Cuba.” Lancet, 1993; 342:965-967.
|
