Doctor to the Poor

Book cover
Mountains Beyond Mountainsby By Tracy KidderRandom House. 317p $25.95

The take-home message from this review is similar to the line I wrote on my book reports in elementary school: I would recommend this book to all my friends. It is a rare experience for me to find a book that sets me on fire, stirs me up and makes me think critically about my life and commitments as a Jesuit priest, physician and medical educator. Although I do not have the same gifts as Paul Farmer, reading Mountains Beyond Mountains has made me, and likely will make all who read this, wonder about how we use the talents we have and what we can learn from Farmer about how to employ these in the service of the poor with the same ferocious joy, demanding tenacity and intelligent exuberance.

Paul Farmer is a 44-year-old physician who specializes in internal medicine, with a subspecialty in infectious disease. He is an attending physician at Boston’s Brigham and Women’s Hospital, a professor of medicine and medical anthropology at Harvard Medical School, and he directs the Cambridge-based organization Partners in Health, a group that provides funds, organization and logistical help for a variety of health-related projects throughout the world. Farmer is an extraordinarily sympathetic character, filled with energy and intelligence, who has dedicated his career to working with poor people throughout the world, but with special love and emphasis for the people of Haiti. The man who comes through in these pages is an individual I would like to meet and from whom I would love to learn. One senses a very bright man who can on occasion be a pain in the neck, not self-righteous but extraordinarily driven and usually right in his decisions, a man to whom the cliché “burning the candle at both ends” can be properly applied. The intensity of his life makes one wonder how he lives in his bones, how he deals with fatigue and where he finds rest and comfort. My suspicion is that he finds it with the poor people in Haiti, and Farmer is one of those individuals whose service feeds and energizes him. The portrait that Tracy Kidder paints is of a funny, irreverent, unconventionally spiritual individual of less than orthodox Catholic background who bursts forth with pithy statements about the “preferential option for the poor” and will speak of Matthew 25 as a code for caring for the least of the world, whether it be in Haiti, a Peruvian slum or the prisons of Russia.


Mountains Beyond Mountains is about more than Farmer; it uses his work as a way to describe places, diseases and the underlying role of poverty in making premature and miserable deaths commonplace. The diseases that are the villainous stars of Mountains Beyond Mountains are AIDS and tuberculosis, especially the ominous rise of multiply drug-resistant tuberculosis, known in medical shorthand as MDR-TB. Much of international health policy has held as dogma that AIDS in the underdeveloped world should be treated with a simplified regimen—simple, that is, when compared with the more complicated multiple-drug regimens of the developed world. And this makes sense based on assumptions of cost, infrastructure and ability to monitor compliance. Likewise, treatment for tuberculosis has rested in recent years, and has been remarkably successful, on DOT: directly observed therapy with a standard cocktail of anti-tuberculosis medications.

There is a set of problems, however, that Paul Farmer has battled because the assumptions were shaky and the consequences were death for some of those for whom he cared. In Haiti, Farmer is able to achieve excellent results with AIDS regimens similar to those used in the United States. If you can get the drugs at a price that is not insane and teach people how to take them, poor people like to stay alive as much as rich people and will follow instructions. Some data suggest that third world populations are actually more compliant than those in the developed world. With MDR-TB, the standard medications used in the DOT protocols do not work. In fact, for individuals infected with MDR-TB, the standard medications actually select for the worst bugs and create reservoirs of highly virulent organisms. Based on work at a Partners in Health clinic in Carabyllo, Peru, Farmer and his associates demonstrated the effectiveness of using DOT with a set of so-called second line agents against MDR-TB. The work of Farmer, his associates and Partners in Health has led to major changes in the treatment of disease in the third world and, after much effort, policy changes on the part of the World Health Organization.

In the midst of the descriptions of Farmer, his work and the epidemiological intricacies of the sordid relationship between disease and poverty, Mountains Beyond Mountains vividly portrays the people who face AIDS, MDR-TB, often chaotic political situations and grinding poverty and violence. The descriptions of the Haitians who come to Farmer’s clinic, Zanmi Lasante in Cange in Haiti’s central plateau, are vivid and telling. What makes this book so memorable and heart touching is that the individuals are not vaguely presented as objects of benign charity, but as fully enfleshed women, men and children.

The Pulitzer Prize-winning Tracy Kidder has written a marvelous book. His wonderfully detailed descriptions allow one to see parts of the world that can seem so foreign and distant as to be unimaginable to most Americans. Especially remarkable are his quick and accurate descriptions of complicated medical problems. He avoids the ponderously detailed and boring prose of too many scientific writers. Kidder also stays clear of modestly informative and moderately inaccurate simplifications. He has put himself in this book, not just as a writer but also as an individual who accompanied and observed Farmer in action around the world. Kidder allows himself to be a foil for the reader who is inspired by Dr. Farmer, annoyed with him from time to time, overwhelmed by Farmer’s hectic pace and sometimes uncertain of his judgments and plans. This book is a little like an icon—the artist has allowed one a glimpse of a life and a world that goes beyond the lovingly created details to see glimpses of both a holy light and a real darkness. His crafting gives the book an almost hieratic quality and makes it spiritual reading of great value.

But so what? What is the value of a nice book about a nice guy who does great things? I don’t know the long-term impact of this book on either my own life or the lives of those readers who find, as I do, my mind preoccupied with its themes even after I have handed my copy on to a friend. But this book has made me think anew about faith and justice with a depth and challenge I have not felt before. And though my faith commitment is arguably more orthodox than Farmer’s, I know that I do not have his reserves of energy or determination, and it makes me wonder about what I now need to do. As Ignatius of Loyola insists, and Farmer demonstrates, love is best shown in deeds, not words. Readers who pick this book up and do not wonder how they are doing in the light of the example Farmer provides really need a kick in the pants.

And yes, I would recommend this book to all my friends.

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