Mountains Beyond Mountains Book Review

Ruffa Aquino

Mountains Beyond Mountains

Book Review Questions, Part 1

1.    Paul Farmer finds ways of connecting with people whose backgrounds are vastly different from his own.  How does he do this?  Are his methods something to which we can all aspire?

Paul Farmer is able to connect with people whose backgrounds are vastly different from his own because he puts aside his own personal and cultural biases when treating a patient and instead endeavors to see problems through the patient’s own eyes, a skill that enables Farmer to tailor solutions to the individual patient’s specific needs.  As a Harvard-trained doctor, Farmer easily could have cashed in on his credentials to develop and serve a wealthy clientele in the United States who looked and thought and talked just like him.  Instead, he chose to employ his gifts in the treatment of Haiti’s poor and needy, people with debilitating illnesses whose life experiences are galaxies removed from Farmer’s own hard-won status in life.

For example, Farmer is able to connect with Joe, who has HIV and uses cocaine, by getting to know Joe on a personal level and earning his trust before going to work on Joe’s medical problems.  The two men couldn’t be any different, but Farmer approaches Joe as a unique and worthy human being rather than as just another patient on an assembly line.  Farmer shares personal tidbits about himself with Joe, who reciprocates by opening up about his cocaine problem with a candor that he probably would not have exhibited with a less approachable doctor.  When Joe starts telling Farmer about his cocaine use, Farmer does not judge him, but instead offers the disarming advice that he should try marijuana instead.  Drawing on his experience with other drug users, Farmer refrains from imposing unrealistic expectations on Joe (e.g., “Quit using drugs!”) and settles for incremental steps that may take more time, but will stand a better chance of success in the long run.  Whatever perceived demographic differences may exist between the two men are neutralized by Farmer’s caring and empathy, making it much likelier that Joe will become a willing participant in his own healing.

Farmer’s dealings with other patients illustrate his practice of caring for the soul as much as for the body.  A tuberculosis patient, a blind man named Ray Charles, told Farmer he wanted glasses.  Rather than laugh off Ray’s request as an exercise in futility, Farmer gave him a pair of glasses.  Ray might not have been able to see any better, but the boost to his confidence and joie de vivrelikely served as ample justification for Farmer’s small gesture.  Another of Farmer’s patients, Ti Ofa, felt isolated and depressed because he was in the latter stages of AIDs and the townspeople were avoiding him, quite literally, like the plague.  In addition to treating Ti Ofa with an expensive new antiretroviral drug that was not generally available to the poor, Farmer also soothed his inner pain by assuring him that he wasn’t alone in his struggle.  “I don’t want you to be discouraged,” Farmer told him.  The impact of Farmer’s words was arguably as important to Ti Ofa as the impact of the medication.  When Ti Ofa realized that Farmer was willing to give him not just a pill bottle, but also a sympathetic ear, he bared his soul in a torrent of fear, anxiety, and gratitude.  “Just talking to you makes me feel better,” Ti Ofa told Farmer.  “Now I know I’ll sleep tonight.”

Farmer’s methods are ones that we should all should aspire to replicate in our dealings with other people, particularly those whose needs we are in a position to fulfill.  We should set our minds to transcending whatever racial, ethnic, gender-based, or other immutable characteristics seem to separate us from others so that we may reach them in ways that can maximize our contributions to their lives—and make them more accepting of those contributions.  Farmer knew that marijuana probably wasn’t good for Joe, but by establishing a personal connection with him and moderating his expectations, Farmer was able to enlist his cooperation in taking a first step towards a meaningful, long-term solution to his cocaine problem.  Like “mountains beyond mountains,” there will always be new challenges to replace those already conquered.  But men like Farmer teach us that the journey is worth making.   

2.    Paul Farmer believes that “if you’re making sacrifices … you’re trying to lessen some                 psychic discomfort” (p. 24).  Do you agree with the way that Farmer makes personal sacrifices?  What are your expectations about sacrifices for both you and others?  What things are worth your sacrifice?  Under what circumstances do you think others should make sacrifices?

I have no quarrel with Farmer’s sacrifices – which are undoubtedly numerous and profound – because that is how he has chosen to address his moral and ethical obligations in life as he sees them.  All of us – or at least those of us endowed with the ability to help others – must strike our own balance between what we see as our own needs versus the needs of others.  Usually, the two are readily distinguishable.  For example, I have a need to satisfy my love of sports by going to a ball game every week, but I sacrifice that need in order to spend more time walking my dogs out.  I also have a need to satisfy my wanderlust by going on vacation more often, but I sublimate that need in favor of using my vacation time to organize fundraising activities for causes I believe in.  And so on.

What’s special about a man like Farmer is that his needs don’t fall neatly into one side of the ledger or the other – i.e., his needs versus someone else’s needs.  In his case, the sacrifices themselves are his needs.  He survives on four hours of sleep per night because he can’t sleep soundly knowing that he could be using that time to relieve other people’s suffering.  So he cuts out other important parts of his life, including his time with his own family, to serve his burning psychic need to make every possible sacrifice in service of the sick and needy.  That’s what he means when he says that making sacrifices is an effort to “lessen some psychic discomfort.”  To Farmer, his choices are not so much a tradeoff as an imperative bursting from his insides.  If he weren’t making these sacrifices, he would be, well, sacrificing his own identity and peace of mind.  In that sense, Farmer’s efforts in Haiti are not so much a sacrifice as they are a surrender to a higher need that overpowers all others.  Thus, Farmer states: “If I took steps to be a doctor for those who don’t have medical care, it could be regarded as a sacrifice, but it could also be regarded as a way to deal with ambivalence” (Kidder, 2009).

I personally admire Farmer’s selflessness, although he would insist his efforts in Haiti are not selfless but merely part of his DNA.  Each of us “sacrifices” for others to one extent or another, with some of us willing, if not driven, to give up more of our own self-gratification so that we can help others attain more gratification for themselves.  I tend to fall on the “Farmer” end of the spectrum, feeling uneasy whenever I find myself with “me” time that I could (or, in my mind, should) be using to the benefit of those less fortunate than myself.  While I am by no means on the level of a Paul Farmer, the discomfort of others does tend to make me uncomfortable, so the way I ease my own discomfort is to seek to ease theirs.  I do not judge those who feel less of a need to sacrifice for others because not everyone is wired the way I am.  As long as a person is reaching outside themselves to share their gifts with others, it is for their own conscience to judge whether or not it’s enough.

3. The title of the book comes from the Haitian proverb, “Beyond mountains there are mountains.”  What does that saying mean in the context of the culture if comes from, and what does it mean in relation to Farmer’s work?  Can you think of other situations – personal or societal – for which this proverb might be appropriate?

In Haitian culture, the proverb “beyond mountains there are mountains” has several possible meanings.  The glass-half-empty interpretation is that Haiti, as one of the most impoverished nations in the world, faces such deep-seated and, some would say, intractable problems that overcoming one obstacle simply leads to more obstacles, which lead to more obstacles, ad infinitum.  If read this way, the proverb conveys a sense of hopelessness and defeat, which, taken to its logical extreme, could make Farmer’s efforts seem like a waste of time and resources.  

But Farmer, is no dummy, and he certainly is no fatalist.  If anything, he is a hopeless optimist whose every waking moment is imbued with an abiding faith that he is working towards a better future for Haitians.  Seen in this light, the proverb “beyond mountains there are mountains” could mean that for each problem that is resolved, opportunities are presented to resolve still other problems.  In other words, the mountains are not so much obstacles as challenges for people like Farmer to conquer through their knowledge and tireless dedication.  If Farmer’s work shows anything, it’s that Haiti’s problems are endless, but so are its opportunities.  That interpretation breathes meaning and purpose into Farmer’s mission rather than rendering it pointless.

One societal problem to which the proverb might be applied is California’s never-ending battle against wildfires. These fires destroy homes and kill people, and they are only getting worse over time as global temperatures rise and the state’s forests dry up.  The costs of containing the fires is putting an enormous strain on California’s budget, and no solution is in sight.  For every fire that is put out, a wave of new ones is not far behind, due in no small part to the unchecked advance of climate change.  Does this mean we give up the fight, send our firefighters home, and let the houses burn?  Of course not.  We reach into taxpayers’ pockets and devote our common resources to help those of our fellow citizens who are in harm’s way, and we hope that with each small victory, we can learn something that will make us more effective in fighting the inevitable next wave of wildfires.

On an individual level, one analogy that comes to mind may be the struggle of a recovering alcoholic to remain sober. Alcoholics Anonymous counsels its members to take their sobriety “one day at a time,” treating each day without a drink as a victory but knowing full well that they will always be just one drink away from a relapse.  Abstention is supposed to get easier with time, but the bogeyman of alcoholism will always lurk in one’s life to one extent or another.  The symbolic medallions that are awarded to AA members to commemorate their first month of sobriety and then every milestone reached after that serve a similar purpose to the Haitian proverb “beyond mountains there are mountains,” reminding us that the struggle, while never-ending, is well worth the effort.

3.     Kidder explains that Farmer and his colleagues at PIH were asked by some academics, “Why do you call your patients poor people? They don’t call themselves poor people” (p. 100).  How do Farmer and Jim Kim confront the issue of how to speak honestly about the people they work to help?  How do they learn to speak honestly with each other, and what is the importance of the code words and acronyms they share?

    Plain talk – blunt, honest exchanges unadorned by political correctness – was how Farmer and Kim chose to confront the harsh realities they faced on a daily basis.  When asked by academics why he called his patients “poor people” even though they didn’t use that term to describe themselves, Kim’s succinct retort was, “Okay, how about soon-dead people?”  The message could not have been lost on the academics: Doctors like Farmer and Kim who were in the trenches, fighting daily to save the lives of the poor and desperate, could not allow themselves the luxury (although to them it wouldn’t have been a luxury, but a self-indulgent waste of time) to dwell on the nomenclature attached to their work, especially by doctors who rarely left the comfort of a faculty lounge or an elite teaching hospital.  Farmer and Kim saw their work as too urgent and too important to stop to ponder how their words might offend some lofty academic’s political sensibilities. And most importantly, they knew that their patients felt the same way.  Did dying patients have a problem with their doctors calling them “poor?” Did they have a problem with their doctors showing up in suits or lab coats instead of “poor” people’s attire? On the contrary, says Kim: “They want you to dress in a suit and go get them food and water” (Kidder, 2009, p. 100). Farmer and Kim knew that nothing mattered more to their patients than survival, and if a doctor could deliver that to them, then whatever was deemed to be politically incorrect in the rarefied halls of academia was entirely beside the point.  These were what Farmer and Kim referred to as “areas of moral clarity,” or AMC’s, where the calls to action are not even a close call.

        Code words and acronyms seemed to serve multiple purposes in PIH.  In addition to their most obvious advantage – making communication more efficient in such a fast-paced environment – they helped foster a sense of camaraderie and belonging among the doctors and staff members who shared a common, and private, vocabulary.  Farmer was what a friend once described as “a word gymnast,” regularly coming up with code words and acronyms by which PIH members could communicate and understand each other.  “H of G” was short for “a hermeneutic of generosity,” Farmer’s term for what might be described as giving someone the benefit of the doubt.  “TBMI” stood for transnational bureaucrats managing inequality, obviously a pejorative term.  “DQ” stood for drama queen.  “Geek flowers” was the completed research that PIH-ers presented to Farmer or Kim, and “scholbutt” was short for “scholarly buttressing,” which meant attributing every statement of fact made in a paper to an authoritative source.  A “seven-three” was the use of seven words where three would suffice, and a “ninety-nine one hundred” meant abandoning a task when it was nearly completed.  These terms reflected Farmer’s world view as to the subjects they addressed, and helped to reinforce the values and priorities that Farmer set for PIH.

 

5.  Paul Farmer had an eccentric childhood, and his accomplishments have been unique.  Do you see a relationship between the way Farmer was raised and how he has chosen to live his life?  How has your own background influenced your life and your decisions?  

Farmer was one of six children born to Ginny and Paul Farmer Sr. His parents were a study in contrasts: Ginny was kind, nurturing, and forgiving; Paul Sr. was a hard worker, a risk taker, and somewhat of a martinet whose strict rules for his daughters – they couldn’t use makeup, have boyfriends, or stay out late – earned him the nickname “The Warden.” A restless sort, Paul Sr. moved the family from western Massachusetts to Alabama when Farmer was just 7 years old, then moved them again – this time to Florida – to take a teaching job in the public schools. 

While in Florida, the family of eight lived in a campground inside an old bus that Paul’s father had bought at auction back in Alabama. At one point during their five years in Florida, the family had to live in a tent while the bus underwent repairs following a crash. The Farmers eventually left Florida and spent years living in the Gulf of Mexico on a boat purchased by Paul Sr. at auction. The cabin’s roof leaked, cockroaches roamed at night, and the family washed the dishes in the “brackish water of the bayou.” (Kidder, 76.) They washed their clothes in a laundromat and traveled for miles to fill jugs with water from a spigot outside a convenience store. 

On those facts alone, the parallels between Farmer’s upbringing and his later choices in life are readily apparent. He was uprooted several times as a child, lived in cramped surroundings, and spent years at sea. These early experiences must have instilled in Farmer a sense of curiosity and adventure, a fearlessness of the unknown, a high comfort level with chaos, and an innate confidence that wherever he went and whatever conditions he faced, he could survive and even prosper. Farmer’s often penurious and itinerant childhood no doubt steeled him for the often unsanitary and disease-infested conditions he would labor under while tending to the sick in such far-flung countries as Haiti, Rwanda, and Peru. And as one of six children who spent a large part of their formative years living in cramped quarters inside a bus, a boat cabin, and even a tent, it is also not surprising that Farmer was able to function at such a high level while tending to the desperately sick in the cacophony and hurly-burly of PIH’s clinics.

Farmer modeled some of the best qualities of each of his parents. His empathy and respect for the poor and sick may have been forged through his loving and caring relationship with his mother, who put her own education on hold so she could marry and raise a family, and who took low-paying jobs to help support the family without complaint. Farmer’s rigorous standards, and his propensity to become demanding and exacting of his colleagues at times, could be echoes of his strict father. At the same time, Farmer’s ability to remain calm and focused on the task at hand in a crisis is reminiscent of his father’s can-do attitude. In one particularly revealing vignette, Kidder tells of the time the family’s boat got caught a major storm and they managed to ride it out by throwing the generator overboard as an additional anchor. The idea was Ginny’s; Paul Sr. wasn’t fazed one bit by the peril they faced. Farmer later explained his father’s reaction: “But the thing was – it was a strange feeling – you knew he didn’t know what he was doing, but you also felt the security. That he would get us out of the situation. That nothing was really going to beat him.” (Kidder, 74.)

Farmer’s sister Jennifer felt Farmer had a lot in common with their father, particularly in that both were tireless and goal-driven. “Above all, she thought, once they’d focused on a goal, neither one would quit.” (Kidder, 82.)  Paul Sr.’s generosity towards those less fortunate than him also set an example for his son. Kidder describes how Farmer grew to admire his father’s “fondness for underdogs,” which included donating money and working with mentally disabled adults to improve their knowledge and everyday functioning (Kidder, 80). Moreover, Paul Sr. wasn’t beneath picking fruit – a job usually performed by poor immigrants – to help make ends meet when money was tight. When Farmer pointed out to his father that white people don’t pick fruit, Paul Sr. retorted: “Yeah? I’ll give you white people.” (Kidder, 73.)

My own values as an adult were forged in the crucible of struggle, deprivation, and the uncertainty of what each day would bring, even to a greater extent than the young Farmer. I grew up in a rural outpost of Luzon province in the Philippines, an area covered by vast green fields of corn and rice in the spring, and brown fields of dried plants during the summer harvest. As a farmer, my father eked out a living from the soil, but there were many times we did not know where our next meal would come from. In the town of Tumauini, there was only one hospital to serve almost 75,000 people. The cold and rainy season was the most dangerous time because no matter how sick you got, the hospital wouldn’t have room for you. Several of my relatives and family friends were claimed by disease before they could get treatment. My uncle Merly never knew that a dog bite had given him rabies until it killed him. Two of my classmates in elementary school died from dengue and malaria. Without access to healthcare, people in my hometown resorted to medicinal plants and prayers recited by the town elders. Many believed that five cloves of garlic, calamansi, and ginger extracts mixed with warm water could cure high fevers and the flu. We sure could have used a Paul Farmer in my community.

As young as I was at the time, I had seen too many people die to place too much faith in these so-called home remedies. Deep inside, I sensed that society did not believe our lives were worth saving, at least not to the same extent as the lives of those people we read about who lived in big houses and drove their own cars. At some point – I’m not sure when, but it was sometime in junior high school – I decided that I was going to do everything in my power to break free of this vicious cycle, obtain the best education available to me, and devote my life to helping the people who could not do for themselves, particularly when it came to their healthcare. I have come way farther than I ever thought possible, and although I may not have any panaceas to propose, I am determined to change the paradigm that devalues the lives of poor people and largely ignores their healthcare needs.

6. Kidder points out that Farmer is dissatisfied with the current distribution of money and medicine in the world. What is your opinion of the distribution of these forms of wealth? What would you change, if you could? 

Farmer is deeply troubled by – and equally motivated to struggle against – the inequalities in wealth and medical care that have been all too readily accepted by the world’s elites, i.e.,the public and private interests that control the healthcare policymaking apparatus. He recognizes that wealth and medical care are closely correlated in our world and believes that the two must be separated – decoupled, if you will – in the public mindset if real progress is to be made in leveling the playing field.  

In Farmer’s view, poor societies bear the brunt of the world’s pain, suffering, disease, and death because we have all been socialized to accept this state of affairs, to believe that the poor should be grateful for what little they have and should not expect more because they don’t have the wherewithal to do it themselves. From the perspective of privileged societies, what’s realistic and what’s a pipe dream is too often defined by bureaucrats buried in charts, regulations, and grant applications who are rarely confronted head-on with the steep human cost of continuing with the status quo. To Farmer, there are many complex reasons, but no good excuses, for why the world’s health resources are so unequally distributed. It’s no accident that one of his many titles is chief of the Division of Global Health Equity at Brigham and Women’s Hospital in Boston.

I agree with Farmer that the reason these inequalities persist in the world is our own lack of imagination, resolve, and willingness to invest in the long-term, structural changes that are necessary to correct some of the worst imbalances in healthcare. Taking the example of Haiti, the general attitude seems to be that the wealthy countries can turn on the money spigot whenever a crisis erupts, whether it be an earthquake, a gang war, or a cholera outbreak. But then what happens when the crisis is contained and begins to fade from the headlines?  

Entire health-care systems can be wiped out by disasters both natural and man-made, but as wealthy countries, we tend to treat the symptoms of inequality rather than its causes. Why wait for the next Ebola outbreak in West Africa, only to hurriedly put up tents and cots where the sick can go to die? To really make a difference – to conquer today’s mountain and start climbing the next one – we have to think long-term by building teaching hospitals, producing homegrown physicians, educating local doctors in all the key specialties, integrating prevention with high-quality care, dispensing free medicine to all those who can’t afford it, and making all these things possible by changing attitudes in the wealthy countries so that people see the impoverished black and brown people of the world as no less deserving of life and good health than we are. It will take many Paul Farmers to inspire universities, corporations, policymakers, and the media to rise to the challenge and heed his rallying cry: “The idea that some lives matter less is the root of all that is wrong with the world.”

7. Compare and contrast Zanmi Lasante to the Socios en Salud project in Carabayllo. Consider how the projects got started, the relationships between doctors and patients, and the involvement of the international community. 

Zanmi Lasante (the Creole translation of “Partners in Health”), the flagship project of Partners in Health, was founded in the village of Cange in the central plateau of Haiti in the mid-1980s while Farmer was entering medical school. About a decade later, Farmer’s trusted second-in-command, Jim Kim, established Socios en Salud (the Spanish translation of “Partners in Health”) in Carabayllo, Peru, in an effort to replicate the success of Zanmi Lasante in a country that posed its own set of challenges. After laboring in Farmer’s shadow for years, Kim felt ready to take the lead in Peru, although he continued to rely heavily on Farmer’s counsel throughout the journey.

Both Zanmi Lasante and Socios experienced growing pains in their early years, but through a combination of Farmer’s vision and creativity and Jim Kim’s hard work, the sister projects have made a significant impact on the health of their communities. At the outset, both projects had to cope with turbulent political environments that distracted them from their respective missions. A military coup in Haiti generated a wave of violent political protest that caused many civilian casualties. As a result, Zanmi Lasante had to shift resources away from the treatment of tuberculosis and refocus itself on treating the wounded, which set back the project’s mission. Similarly, in Peru, revolutionaries fighting a civil war against the government obstructed Socios’ work because the guerrillas believed that improvements in medical care would dampen the people’s revolutionary fervor and ease popular pressure on the regime. In one case, a Socios-run pharmacy next door to Father Jack’s church dispensed free medicine to the poor until it was blown up by guerrillas. Jim Kim rebuilt the pharmacy in a safer location.

What eventually enabled Zanmi Lasante and Socios to outlast the initial setbacks and become mainstays of their communities was, more than any other factor, Farmer’s dogged creation of an international patchwork of financial and logistical support from individuals such as Howard Hiatt, the former Harvard dean and PIH board member who provided entrée to TB experts, funding agencies, and pharmaceutical companies, and George Soros, the deep-pocketed head of the Open Society Institute whose connections ran from Hillary Clinton and other world leaders to the WHO and the World Bank. These individuals and entities provided PIH and its sister organizations with the platform, credibility, and funding to keep Farmer’s dream alive in the face of the obstacles.   

The key PIH asset that should not be underestimated is the passion, drive, humility, and sheer force of personality that Farmer exuded not only with policymakers, but with his own patients. In one of Kidder’s anecdotes, an older woman arrives at the Zanmi Lasante clinic and “Farmer stands when she enters, addressing her endearingly as “my mother” in Creole. “He bends down, practically kneeling, and she kisses him on one cheek, then the other” (Kidder, 26). The woman is so sick with Pott’s disease that she cannot be cured, but she seeks out Farmer’s companionship anyway. In Peru, the doctors at a Socios children’s hospital did not have the luxury of developing the level of intimacy with their patients because onerous government taxes and regulations left them little time with each patient. By no coincidence, the mortality rate from tuberculosis was higher in Peru than in Haiti. But those treated at the clinics in both countries were grateful for the improvements in care, and Farmer always reciprocated their thanks by reminding them that “for me, it is a privilege” (Kidder, 158). 

Socios went on to become one of Peru’s largest healthcare NGOs, providing a wide spectrum of medical services to a population of about 700,000 inhabitants, many of whom were refugees from poverty and political violence in the Peruvian countryside. After some initial resistance, Peru's Ministry of Health agreed to partner with Socios in formulating national policies for the prevention and treatment of drug-resistant tuberculosis and HIV, and has provided training and support to help implement those policies nationwide. For its part, Zanmi Lasante today has a network of 15 clinics and hospitals in two of Haiti’s most underprivileged and  remote regions. It is the country’s largest healthcare provider outside of the government and works closely with the Haitian Ministry of Health to provide primary care, maternal and child health care, HIV and tuberculosis services, and more advanced secondary and tertiary care to a population of more than 1.3 million people.

8. There are many “moral” lessons to be learned from the work of Dr. Farmer. What are some of the lessons that have caused you to think differently about yourself, your life, or your future?

Two of the most important lessons I have learned from studying Farmer's life and career are (i) the need to maintain a sense of moral clarity in whatever I choose to do with my life by serving the less fortunate and valuing their lives as much as anyone else’s, and (ii) not allowing the enormity of the world’s public-health challenges to immobilize or deter me from doing everything within my power to make a difference, no matter how small my contribution may seem in the big picture. As I said in my response to Question No. 6, the world needs many Paul Farmers, and while I don’t harbor any illusions of matching his accomplishments, I do hope to emulate his drive, compassion, humility, and selflessness in pursuing a career that nourishes my soul more than my bank account and makes a meaningful difference in other people’s lives.