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Curing the world: Healthcare and justice in ‘Mountains Beyond Mountains’

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One day in the 1980s, a young white doctor named Paul Farmer was standing in the central plains of Haiti, looking around at a set of concrete latrines that had just been installed in the village of Cange. Farmer was eager to discuss public health with a local priest, and he nodded approvingly at the new latrines. “But,” Farmer asked the priest, “are they appropriate technology?” A vogue term in international aid, “appropriate technology” meant the most cost-effective technology necessary to do the job. The priest, though, felt stung. “Do you know what appropriate technology means?” the priest retorted. “It means good things for rich people and shit for the poor.”

From that priest’s comment came Farmer’s singular take on an age-old crusade: equalizing healthcare between the global poor and the global wealthy. “Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World” is Tracy Kidder’s sweeping biography of Farmer’s life and work. Farmer lived through an often-turbulent childhood in Florida, then studied medicine and anthropology in Boston, motivated by his work in Haiti. We witness his founding of a healthcare provider in Cange and his rise to become an advocate for more equitable public health, garnering accolades from the Haitian government and the World Health Organization.

Unlike many doctors, Farmer pushed back on the entire structure that undergirds global inequality: His work questions capitalism, engages with Haitian politics and witheringly criticizes the West’s neo-colonialist projects. Kidder is swept up in this work and advocacy. First meeting Farmer while reporting on the American military’s intervention in Haiti, Kidder goes on to travel with him to Boston, Havana and Lima, interrogating his own assumptions about global health along the way.

Much of “Mountains Beyond Mountains” centers on the Zanmi Lasante center in Cange, Haiti — an oasis of medical care where Farmer developed a model to bring tuberculosis treatments to one of Haiti’s poorest regions. After graduating from college in 1982, Farmer spent a year working in hospitals in Port-au-Prince, Haiti, before founding Zanmi Lasante as a medical student. Zanmi Lasante has since grown, treating all sorts of ailments free of charge and embedding doctors in the local community.

What is so surprising about the center is how much it is willing to commit to individual patients. Farmer and other doctors might spend five or six hours hiking through Haiti’s rugged central highlands to conduct a house call. Occasionally, they spend thousands of dollars to fly patients from Haiti to Boston for treatment.

To outside observers, this investment seems like misprioritization: a triage error on a public health stage filled with needy patients. But to Farmer, this perception misses the point. “We can spend sixty-eight thousand dollars per TB patient in New York City,” Farmer remarks in one of the book’s conversations, “but if you start giving watches or radios to patients here, suddenly the international community jumps on you for creating non-sustainable projects.” This retort is incredibly refreshing: Instead of focusing solely on cost-effective treatments, Farmer questions the entire system, asking why we must pinch pennies on healthcare for the poor — and simply accept the resulting disease and death.

Fueled by this belief, Farmer’s tactics are renegade, often rule-breaking. He steals medicine from Massachusetts General Hospital to bring to Haiti, at one point racking up $92,000 in debt, and counts on a donor to pay it off later.

All of this raises questions about how actionable Farmer’s model of public health even is in a capitalist world. After all, much of the work of Partners in Health relies on his connection to grant money and wealthy American donors. Without these connections, can others hope to implement anything on the scale of Zanmi Lasante? Without a donor to pay off those $92,000 in debts, would Farmer be receiving awards — or criminal indictments instead? In the United States’s capitalist framework, it’s hard to imagine that many others could pull off the same feat as Farmer.

It is no surprise, then, that Kidder and Farmer invite us to consider more socialized models of healthcare. One particularly strong section of “Mountains Beyond Mountains” features Farmer taking Kidder on a tour of AIDS sanatoriums in Cuba. Kidder, a veteran of the Vietnam War, is extremely skeptical of the Cuban government. Yet his tour of Cuba, its undeniable success in containing AIDS and the equity of Cuban public health, start to bring him around. Farmer terms it “social justice medicine,” and suggests that he would gladly trade Haiti’s healthcare system for Cuba. By the end of the tour, Kidder almost seems to agree.

Despite these tours, and despite Farmer’s rebellious and anti-colonial message, Kidder and Farmer can be somewhat oblivious to critiques of white saviorism. Yes, Farmer is livid at U.S. interventionism in Haiti and elsewhere, as one can find in his recent book on the Ebola outbreak in West Africa. But readers might take away a problematic conviction that only well-meaning white doctors can fix Haiti’s healthcare system, even though many Haitians could do the same should they have the same resources as Farmer.

Similarly, the book can sometimes feel like a glittery, individualistic profile, skimming over the contributions of those who are not Farmer. In the San Diego Union-Tribune, John Wilkens writes that “Mountains Beyond Mountains” will “restore your faith in the ability of one person to make a difference.” Even the book’s subtitle — “A Man Who Would Cure the World” — evokes a saintly hero-worship. Yet Zanmi Lasante is the product of many hands — not least of whom are many Haitians who had the first stake in these healthcare systems, and who I feel get short shrift throughout much of the book.

Despite these critiques, the reviewers are right. Paul Farmer’s story is stubbornly and defiantly inspiring. At our age, around this time of year, Farmer was buying his first plane tickets from North Carolina to the hospital he would staff in Port-au-Prince. And as many of us prepare to graduate this June, his story in “Mountains Beyond Mountains” invites us to consider what we can do with the years that lie ahead.

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