Mountains Beyond Mountains
It’s embarrassing that piddly little projects like ours should serve as exemplars. It’s only because other people haven’t been doing their jobs. – Paul Farmer
It’s about starting. It’s about proceeding without a roadmap and scribbling it down as you go. I doubt Paul Farmer has even uttered the phrase “best practice” or sought to maximize his internal rate of return through a strategic leveraging of his core competencies. The fundamental equation he faces is simple: Poverty + Corruption = Poor Healthcare.
A typical policy prescription would be to start with the variables on the left of the equation— decrease poverty and corruption through the introduction free markets and elective democracy. By attacking the root causes of poor health care, the thinking goes, the seeds are planted for a sustainable rise in the quality of living. Although eloquent in theory, influencing this change is easier said than done as the coefficient of political and economic friction proves too high to make marked progress.
Farmer instead attacks the other side of the equation by honing in on the problem of poor healthcare. Addressing the issue from the top down strikes most as counterproductive. Those who spend time in a garden know that without unearthing the roots, a weed will just grow back. To treat disease on a case by case basis seems akin to taking on the mythical Hydra; take off one head and two appear in its place.
The danger of getting nowhere intimidates most people, but not Farmer. Farmer gains traction with his approach and surprises everyone, even Tracey Kidder, the author of Mountains Beyond Mountains.
A phrase Farmer uses often is “managerial success, clinical failure” to explain how international care policies can fuel pandemics rather than cure them. In Russia and in other regions, the World Health Organization’s approved DOTS program exacerbated TB pandemics because it not only failed to treat, but emboldened drug resistant strains. In addressing these oversights, Farmer demonstrates that treating a patient for their illness, rather than their social, economic, or political status is how measurable progress is made in disease treatment and prevention. As Farmer’s colleague Jim Kim notes, “if you focus on the individual patients you can’t get sloppy.”
And focus on the patients Farmer does. His base of operations is in Haiti where he lives and treats individual patients. He spends time in Cuba. He treats TB in Peru. He goes to Russia and treats prisoners. And far from failing, he succeeds.
The defining feature of Kidder’s narrative is how Kidder handles his audience, the readers who feel a mixture of awe and doubt as they try to understand why it is that Farmer succeeds in an arena where a world has failed. Kidder narrates tense moments between himself and Farmer in the first person while deftly maintaining a third person objectivity when it comes to his judgments about him. In one instance, Kidder considers but ultimately backs away from the notion that Farmer deploys his work with the poor as a shield because “any criticism of him amounted to an assault on the already downtrodden people he served.”
Later Kidder reflects on a heroic rescue attempt by the members of Paul’s foundation. Kidder admits, “I had at moments, in my darkest thoughts, worried that the event might have more to do with them [the organization] than with John [the patient], more to do with proving the organization’s capacity for heroics than with saving a child.”
But Kidder never strays very far down the route of the cynic as he snaps himself— and the reader— back to reality and an understanding that “you do all you can for a patient. If I were seriously ill myself, I wouldn’t find that policy unreasonable.”