Mountains Beyond
Mountains
The Quest of Paul Farmer, The Quest of Dr. Paul Farmer, A Man Who Would Cure the
World by
Tracy Kidder 2003
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Property of www.mountainsbeyondmountains.info
Copyright 2010
KEY-LITERARY
ELEMENTS SETTING
Boston and Cambridge, Massachusetts; Cange, Mirebalais, and Port-au-Prince, Haiti; Lima, Peru; Tomsk, Siberia,
Russia; Paris, France from 1982 through 2003.
Character List
Major Characters
Paul Farmer - Obviously the heart of the book, Farmer is an amazing individual whose shoes can be filled, but
who can never be imitated. He has devoted his life to what he calls the long defeat. The odds of Haiti ever
completely changing from a poor country are astronomical, but Farmer believes he must try to win.
Tracy Kidder - He is the author of the book, but ever-present in it. He documents all the experiences he has with
Paul Farmer from 1994 through 2003 while researching the other years of his work in Haiti and around the world.
Ophelia Dahl - The daughter of the actress Patricia Neal and the writer Roald Dahl, Ophelia is a great success in
her own right. She begins to work with Paul in Haiti, falls in love with him, and then continues her work with him
as his great and abiding friend. She is the one who makes the managerial side of Partners In Health work.
Jim Yong Kim - A Korean-American doctor, he becomes entranced by the work Paul is doing in Haiti. He works
alongside him for several years and then begins his own clinics to try to control the TB epidemic in Peru. He
comes to like the political side of world health care and eventually becomes the senior advisor to the director of
the World Health Organization in 2003.
MINOR CHARACTERS
Didi Bertrand - She is Farmer’s wife and mother of his daughter Catherine. She lives in Paris and studies for own
degree and bears up under the disadvantage of having a husband whom she seldom sees.
Jean-Bertrand Aristide - He is the former priest who became the president of Haiti. He is admired by Farmer and
is his friend. His intentions are to pull Haiti out of poverty.
Jorge Pérez - He is the Cuban doctor who is head of the health services there. Farmer sees him and his program as
a great model for how health care can be made available even for the poor.
Soros - His foundation helps obtain money for the Russian anti-TB program.
John - He is the little boy who dies even though the doctors and care givers at Zanmi Lasante do everything they
can to get him to Boston in time for treatment that may save his life. He is a symbol of all the poor in Haiti who
usually never have a chance, because of the poverty which hold them in its grip.
Ti Fifi - She is one Farmer’s oldest and dearest friends and an administrative assistant in Haiti. She works very
hard with Serena to get John to the United States.
Ti Jean - He is Paul’s “chief of staff,” his closest male confidant in Haiti. He seems to understand just exactly
what makes Farmer tick.
Alcante - He is the little boy whom Farmer cures of scrofula and whose home situation prompts Farmer to make
one of his long treks to care for patients on an individual basis, a characteristic that sets Farmer above all other
doctors.
Tom White - He is the multi-millionaire who nearly gives away all of his money helping Paul in Haiti.
Father Jack Roussin - He is the priest who convinces Farmer to expand PIH into Peru and later dies of the very
TB he was trying to wipe out.
Jaime Bayona - He is the Peruvian doctor who acts as a go-between for Farmer and Jim Kim in Peru.
Howard Hiatt - He is one of the men who wants to expand better health care globally and tries to convince Farmer
to become a bureaucrat to do that until he see him in action in Haiti.
Alex Goldfarb - He is the Russian who convinces Farmer to help set up his model in Cange in Siberia to begin to
control the epidemic of TB in Russia. His politics and his mouth often get him in trouble, but his heart’s in the
right place.
Serena Keonig - She is the doctor who almost single-handedly brings young John to Boston for help even though
he eventually dies. She is the perfect example of O for the P – finding options for the poor.
CONFLICT
Protagonist -The protagonist is Paul Farmer, the most amazing doctor who works the long defeat his entire life,
meaning he works incessantly to eradicate poverty and give decent health care to the poor even though the attempt
is almost impossible to achieve.
Antagonists -The greatest antagonist in this book is poverty and the inherent epidemics that come with it. Of
course, the people who turn their backs on poverty are also the antagonists as are the government policies that
allow it to flourish.
Climax -The climax occurs when Tracy Kidder finally realizes the true definition of Paul Farmer’s character: he is
a man who is more interested in trying to win over the long defeat, even though he wants to win. The man tries to
eradicate the evil of poverty and illness among the poor and it’s his trying that makes him great.
Outcome -Many of the goals Paul has set for himself come about, including the adoption of new prescriptions for
MDR-TB by the World Health Organization (WHO). However, again, the outcome is still uncertain, because there
is still so much for people like Paul Farmer to do. If the world continues to turn its back on the health needs of the
poor, then the outcome will once again be uncertain rather than hopeful.
SHORT PLOT / CHAPTER SUMMARY (Synopsis)
Tracy Kidder travels with, and chronicles the life and work of Dr. Paul Farmer. Farmer's mission is to serve the
poor in countries like Haiti, Peru, and Russia. It runs from approximately 1982 to 2003. Farmer's crusade is to
end infectious disease and bring lifesaving medicines to those that have no access to it and most need it.
THEMES
The first and most important theme is: the poor deserve decent health care and living conditions. This is the
message that Farmer promotes his whole life from the individual patient to the greatest politicians of all the
countries of the world.
Another theme involves the idea of the long defeat. This refers to Farmer’s realization that changing the fortunes
of such poor countries as Haiti may be an impossible goal, but that he refuses to give in and not try to win. A third
theme involves the idea of the fortunate of the world turning their backs on the poor and needy. In spite of
their great wealth, they fail to see the less fortunate around them and usually do nothing to alleviate the problem.
A final theme is more subtle, but nonetheless important: the importance of trying to imitate Paul Farmer even
though no one can ever be like him. This means taking on the same work with the same devotion as he does and
hoping that you’ll win over the long defeat.
MOOD
The mood is often troubling and dark, but there are so many lights of hope along the way that reader can’t help but
feel uplifted by the end.
BIOGRAPHY OF TRACY KIDDER
Tracy Kidder was born in New York City on November 12, 1945. He graduated from Harvard in 1967. He
st
served as a 1 Lieutenant in the Army in Vietnam from 1967 - 1969 for which he received a Bronze Star. After
the war, he earned a Masters of Fine Arts degree from The University of Iowa. He began writing for the Atlantic
Monthly magazine in 1973 and has served as a contributing editor since 1981. In his relationship with the
magazine, his articles have includes subjects such as: energy, architecture, the environment, and more. He also
contributes to The New Yorker and the New York Times Book Review.
The Road to Yuba City: A Journey into the Juan Corona Murders (1974) The Soul of a New Machine (1981)
Pulitzer Prize and American National Book Award House (1985) Among Schoolchildren (1989) Old Friends
(1993) Home Town (1999) Mountains Beyond Mountains (2003) My Detachment: a Memoir (2005) He has also
written several short works of fiction.
He has also received the Robert F. Kennedy Book Award (1990), the Ambassador Book Award (1990) and the
Sarah Hale Award (1998).
Kidder lives with his wife and two children in western Massachusetts and Maine.
ACRONYMS / ABBREVIATIONS USED IN THE BOOK
WHO - World Health Organization -The United Nations public health agency. It monitors disease outbreaks and
assesses the performance of health systems around the world. Established in 1948 and based in Geneva,
Switzerland. AMC - Area of Moral Clarity - What ought to be done, morally, is clear, however the logistics and
details are often more muddled and difficult O for the P - preferential option for the poor. Coming from Catholic
social teaching, this concept expresses a special concern in distributive justice for poor and vulnerable persons.
The "poor" includes but is not limited to those who are economically deprived. The principle is rooted in the
biblical notion of justice, where God calls us to be advocates for the voiceless and the powerless among us H of
G - hermeneutic of generosity; interpreting what people say and do in a good light because we believe them to be
moral, even though they may say and do things that seem otherwise or ignorant DQ - Drama Queen - pleading
for things emotionally TBMI - transnational bureaucrats managing inequality; many people handling inequality
in an inefficient, inhumane manner, intellectual, callous TB - Tuberculosis; the predominant TB organism is
Mycobacterium tuberculosis. It is spread person-to-person in airborne droplets caused by sneezing or coughing,
the bacterium usually infects the lungs. Factors which affect TB are nutrition, housing, sanitation, medical care,
and the availability of antibiotics. HIV - Human Immunodeficiency Virus; the precursor to AIDS MDR - Multi
Drug Resistant DOTS - Directly Observed Treatment or Directly Observed Therapy PIH - Partners in Health - A
Boston, Massachusetts based non-profit health care organization dedicated to providing care to the poor. They
focus predominantly on international problems.
CHAPTER SUMMARIES WITH NOTES AND
ANALYSIS PART I – Doktè Paul
CHAPTER
1
Summary
This chapter explains how the author came to meet Dr. Paul Edward Farmer. Two weeks before Christmas 1994,
in a market town in the central plateau of Haiti called Mirebalais, the author is sitting with an American Special
Forces captain named Jon Carroll at a Haitian army outpost. He is in Haiti to report on American soldiers, 20,000
of which had been sent to reinstate the country’s democratically elected government and to strip away power from
the military junta that had deposed it and ruled cruelly for three years. With only eight men, Captain Carroll is
temporarily in charge of approximately 150,000 Haitians spread across one thousand square miles. Political
violence has all but disappeared except for one particularly grisly murder: a few weeks back, American soldiers
had fished the headless corpse of the assistant mayor of the town from the river. A rural sheriff named Nerva
Juste, a frightening figure to most of the people of the area, had been arrested by Captain Carroll, but was released
for lack of evidence or witnesses. The release of Juste was a source of great frustration to Captain Carroll, but
because the US government had determined that they would not be in the business of “nation building,” he was
given no tools to properly govern the area he now controlled.
As the chapter begins, Captain Carroll is advised that he has five visitors: four Haitians with one American friend.
The American steps forward to explain that his name is Paul Farmer, and he is a doctor working in a local
hospital. Captain Carroll asks Farmer if he has any medical needs and that he himself has even bought medicines
when needed. However, Farmer’s concern is who cut off the head of the assistant mayor. Carroll answers that he
doesn’t know for sure, but Farmer says that in that small area it is very hard not to know the answer. The two men
then have a somewhat circuitous conversation with Farmer expressing his concern that the American
government’s plans for fixing Haiti would aid business interests but do nothing to relieve the suffering of the poor.
He says he is on the side of the poor but it is still unclear which side the American soldiers are on, especially in
light of Nerva Juste’s release. The author realizes that Farmer knows Haiti better than Carroll does, and he’s trying
to impart the fact that the Haitians are losing confidence in the Captain. However, Carroll becomes riled at
Farmer’s criticisms and raises his voice to say that when he has enough evidence he’ll slam the man, but until he
does, he’s not going to stoop to the level of those who make summary arrests. Farmer argues that it makes no
sense to apply principles of constitutional law to a country that has no functioning legal system. So they come to a
stalemate – one is a “redneck” arguing for due process while the other is a champion of human rights arguing for
preventative detention.
The author stays with the soldiers for several weeks and then meets up with Farmer again on the flight home.
Kidder proceeds to have an in-depth conversation with Farmer about the murder of the assistant mayor in which
the doctor explains that he had come to Captain Carroll to warn him. The Haitians in the area were upset with
Carroll’s decision about Nerva Juste and had challenged the doctor to stop and talk to the soldier. Ironically, as
they were passing the army compound, the got a flat tire and Farmer had commented that “you have to listen to
messages from angels.”
Kidder also gets Farmer to tell him about his life. The doctor is 35 and graduated from Harvard Medical School
and also has a Ph.D in anthropology. He works in Boston for four months of the year, living in a church rectory in
a poor neighborhood. The rest of the year he works without pay in Haiti, doctoring peasants who had lost their
land to a hydroelectric dam. He had sneaked back into Haiti when the junta was in power by paying a small bribe.
After the plane lands, Kidder speaks to Farmer again in a small coffee shop and a few weeks later, he takes him to
dinner in Boston, hoping the doctor could help him make sense of what he is writing about Haiti. Kidder is very
impressed with Farmer’s enthusiasm about the island nation and how he clearly enjoys living among the poor.
However, after their dinner, Kidder loses touch with the doctor. In the interim, he comes to take on the same the
belief as the soldier that there’s not much they can do to alleviate the extreme poverty in Haiti, which appears in
what he writes about the country. It’s only when he thinks about Farmer that he comes to have a different view of
the island. He knows that this view will be hard to share, because it implies a definition of a term like “doing one’s
best.” In the meantime, Kidder sends monetary donations to which Farmer sends a handwritten thank-you note
each time. Then, the author hears that Farmer is working in international health, notably with tuberculosis, but
they don’t meet again until 1999 when Kidder calls the doctor and Farmer names the place.
Notes
This entire opening chapter is foreshadowing of the kind of man Kidder is going to tell the reader about – Dr. Paul
Farmer, a true humanitarian. His willing to do his best among the poor and downtrodden everywhere is about to
unfold to the reader.
CHAPTER
2
Summary
The setting of this chapter is Boston’s Brigham and Women’s Hospital whose great works and fame make people
feel stilled in its presence. Kidder is gathered with Dr. Farmer and his team in radiology where they are discussing
the cases for the day. Dr. Farmer is now 40 years old and dresses, like the “big-shot” he is, in formal attire. He still
spends most of his time in Haiti, but he is also a very important professor of both medicine and medical
anthropology at Harvard Medical School as well as being an attending physician on Brigham’s senior staff. They
are discussing a patient who has recently been treated for a parasite in the brain. Farmer elicits opinions of his staff
about whether to continue treatment for infection. He listens carefully, but it is evident that he is in charge. He
calls a female parasitologist, an old, close colleague, whom he calls “pumpkin.” He tells her they are going to treat
the patient. This is part of a typical ordinary day for Farmer and his staff. They have dealt with six cases all of
which are somewhat of a puzzle, until the last patient who they are concerned may have TB as a result of being
HIV positive. They head upstairs to see the patient, and along the way, Kidder is impressed by Farmer’s
demeanor: he speaks to everyone in a personal manner and stops at various places to do small office duties and
help other physicians.
Kidder is further impressed by how Farmer deals with the patient, named Joe. Joe is a drug addict and often
doesn’t take his medication or eat properly. Farmer curls right on the bed to the point that Kidder thinks he’s going
to climb in with the man. He is very close and personal with the guy to show how much he cares. The patient tells
him he want to have a home to go to where he can have a six-pack of beer a day and someone to make sure he eats
and takes his medicine. On the outside, he is too distracted by finding drugs and a warm place to sleep to take care
of himself. Farmer stares at Joe’s face intently as if he and his patient are the only ones in the world, and he
promises Joe he will do everything he can to fulfill his wish. A few days later, on a message board outside the
door of Brigham’s social work department is the message: “Joe OUT: cold, their drugs, ½ gal. vodka; IN: warm,
our drugs, 6 pack Bud.” Beneath this message are the words, “Why do I know Paul Farmer wrote this?” A
homeless shelter is found, but they forbid alcohol, understandably, which doesn’t deter Farmer from pleading his
patient’s case.
On Christmas, when he is on duty, Farmer wraps a six pack of Bud as a present for Joe, and when they leave the
patient, Kidder overhears him say, “That guy’s a fuckin’ saint.” When Kidder asks him how he reacts to these
kinds of comments, the doctor says that he doesn’t mind that they say that, it’s just that he feels it’s inaccurate, and
it makes him think he has to work harder to live up to the label. Kidder feels his own inner disturbance to this
comment. It isn’t that the words seem immodest to him; it’s that he feels he’s in the presence of a very different
person, whose ambitions he hasn’t yet begun to fathom.
Farmer finishes his service at Brigham and returns to Haiti on New Year’s Day. He sends Kidder a copy of his
latest book, Infections and Inequalities, in which he makes connections between poverty and disease. In it, Farmer
can hardly contain his anger at how the necessary drugs don’t make it to the patients. He isn’t at all like the
teaching doctor at Brigham. He shouts on every page. Kidder e-mails him that he loves the book and is going to
read his previous ones as well – his oeuvre (body of work). Farmer tells him that those books are not his oeuvre.
To see his oeuvre, Kidder has to go to Haiti.
Notes
This chapter reinforces the type of doctor Farmer is. To Kidder, he is like a split personality: he is a calm, caring
laid-back doctor who goes the extra mile for his patients. In his book, he is an angry physician, shouting out the
needs of his patients and how the poor suffer more, because they’re poor and don’t have access to necessary care.
Kidder seems intrigued and even somewhat disturbed about what he will see in Paul Farmer in the future.
CHAPTER
3
Summary
Kidder, the author, has arrived in Haiti to see Farmer’s oeuvre. He is met at the Port-au-Prince airport by a
four-wheel-drive pickup and rides on a two-lane paved road until he comes to the other side of the Plaine du
Cul-de-Sac. There, the truck moves steadily upward, while pitching and rolling, along a road that seems little more
than a dry riverbed. Along the way, he sees many arid mountains and villages of wooden huts, trucks of various
sizes and a lot of foot traffic, beggars, ox carts being pulled by men, few trees, and no electricity after the town of
Péligre. The trip is only 35 miles long, but lasts three hours. Finally, kidder’s truck pulls up to a tall concrete wall
where a sign reads, “Zanmi Lasante,” or Partners In Health. It is a very dramatic sight in the all but treeless, baked
brown landscape. There are tall trees beside courtyards, walkways, and walls, an ambulatory clinic and a women’s
clinic, a general hospital, a large Anglican church, a school, a kitchen which prepares meals for 2000 people a day,
and a brand new building to treat tuberculosis. Inside, the building has tiled floors, clean white walls, and
paintings by Haitian artists.
The morning after Kidder arrives, he goes on the first of many times with Farmer on his rounds. It begins at dawn
and there are many, many people waiting to see him. A large number are there just to ask Farmer to help them in
ways that are not really medical or urgent, so he searches the crowd for people in real need. One is a young
woman with her hand in a towel. She has waited fifteen days before seeking medical care for a severe wound and
now she is has gangrene. He is frustrated that even minor injuries go untended and then more severe consequences
are the result. The woman will probably lose her hand.
Kidder explains to the reader that when he arrived at Zanmi Lasante, he came to what seemed to him the end of
the earth. It is the poorest part of the one of the poorest nations in the world, but he feels he has encountered a
miracle. The people make the equivalent of one dollar a day or less, the country has lost most of its trees and a
great deal of its soil, it has one of the worst health statistics in the Western world, and yet in one of the most
impoverished regions of the world is this lovely, walled citadel called Zanmi Lasante. Other clinics treat patients
there, but none are as well-equipped, and the patients do not have to pay at Farmer’s clinic like in the others. His
Haitian colleagues had told Farmer that the patients must pay user fees of about eighty cents a day. However,
Farmer has his own rule: every patient must pay the eighty cents, except for women, children, the destitute, and
anyone who us seriously ill. So everyone has to pay except for almost everyone!. And no one is allowed to be
turned away.
In addition to the excellent medical care the clinic provides, it also had built schools, houses, sanitation systems
and water systems in the catchment area. What’s more, in a country where the greatest killer is TB, there has not
been one death from it in Farmer’s catchment area since 1988. The money for Zanmi Lasante is funneled through
the public health charity called Partners In Health with headquarters in Boston. The bills are small by American
standards, so that Kidder’s local hospital in Massachusetts treats about 175,000 patients with an annual operating
budget of $60 million, while Zanmi Lasante treats the same number of patients for about $1.5 million. Much of
what they receive is from donated drugs and charitable contributions.
Farmer himself contributes a great deal to Zanmi Lasante, also. He had received from the MacArthur Foundation a
so-called genius grant of $220,000. He had donated the entire sum to Partners In Heath for a research branch for
the organization. He personally makes about $125,000 a year from Harvard and the Brigham, but all his paychecks
for honorariums or royalties also go to Partners In Health. Now he is married to a Haitian woman named Didi
Bertrand and has a daughter born in 1998. They moved from the basement of Partners In Heath’s headquarters and
live in a small apartment in Eliot House at Harvard when they are in America. While they are in Haiti, they stay at
the clinic. However, these days Farmer doesn’t see much of his family, because Didi is finishing her studies in
anthropology in Paris. When told he should spend more time in Paris, Farmer says, “But I don’t have any patients
there.” So he spends four months in Boston and the rest of the time in Haiti and has traveled to so many places
where doctors are needed that he has traveled more than three million miles by airplane. He has a small house
similar to a ti kay that peasants live in only with an indoor bathroom (without hot water). Whenever Kidder looks
into Farmer’s little house, he is amazed to see that his bed remains unused. Farmer claims that he sleeps about four
hours a day, but later he confesses that he just can’t sleep, because there’s always someone who’s not receiving
treatment when he does.
Once, Kidder wonders aloud what compensation Farmer receives for all his sacrifices. Farmer, with an edge to his
voice, responds, “I feel ambivalent about selling my services in a world where some can’t buy them. You can feel
ambivalent about that, because you should feel ambivalent. Comma.” This is Kidder’s first experience with
Farmer’s use of the word comma at the end of a sentence. It stands for the word that would follow the comma –
asshole. Kidder understands that Farmer isn’t calling him an asshole, but instead is referring to third parties who
feel comfortable with the current distribution of money and medicine in the world. And implication is that you
aren’t one of those. Are you?
Kidder follows Farmer into his office where Farmer says that now the objective is to stay put. The patients then
come to him: an elderly man being treated for pulmonary TB who is blind, but wears glasses. He had said he
wanted them, so Farmer saw to it that he received them; a younger man called Lazarus by Farmer who had been
wasting away from AIDS and TB and had gone from 90 pounds to 150 in Farmer’s care; a woman who looked
healthy and well, but only a few months before, her father had been saving to buy her a coffin; a lovely-looking
young woman being treated for drug-resistant TB and now is in the midst of a sickle-cell crisis; a man with
gastritis in late middle age which Farmer explains could mean thirty years old since 25% of Haitians die before
they reach the age of forty; a sixteen-year-old boy too weak to walk because of an ulcer; and a very small
elderly-looking woman who had developed TB of the spine before Farmer could treat her. Farmer is especially
solicitous of her needs and calls her “mother.” Then a very pregnant woman enters cheerily calling all the men in
the clinic her husbands. She is infected with HIV and has been exposed to TB.
While Farmer deals with this last patient, Kidder examines the yellow legal pad lists taped on the wall. There is a
task to be completed written on every line of each of three pages. When he gets a task done, he checks a box he
has drawn beside it. This seems to give the doctor inordinate pleasure when he sees he’s getting a lot done. There
are sixty imperatives on the list such as sending sputum samples to Boston. One tantalizing item reads, “Sorcery
consult.” This refers to the deep belief in the Haitian culture that someone can be made ill through sorcery. It is
called “maji” and all Haitian doctors know how to deal with it. Because Farmer has such a gift for healing, the
people think he is a god and that he works with both hands – science and magic. Farmer is embarrassed and
amused by these kinds of consults, but on a serious note, he explains that the beliefs of the All these interpretive
discourses he has with Kidder Farmer calls “narrating Haiti.” Normally, the doctor can be silent during his rounds
or at the least, reticent about benign conversation, so Kidder eggs him on in order to get him to “narrate Haiti,”
which brings forth his drawing of a moral about the suffering of the Haitian poor as well as the world’s poor. He
often pauses for a reaction, “You feelin’ me?” As for Kidder himself, he finds he can’t muster a sufficient
response internally. He feels sorry for so many Haitian children, who often die of something as common as
measles, but he knows he can never feel sorry enough to satisfy Farmer. It sometimes makes him feel annoyed
with Farmer.
Farmer teaches his students that to be a good clinician, you must never let a patient know that you have problems,
too, or that you’re in a hurry. He says that the rewards are so great for simple things. Of course, this means that he
seldom leaves his office before dark. A young man named Ti Ofa comes in as a chronic infectious patient.
Because the clinic doesn’t have the equipment to measure viral loads and CD4 counts, Farmer knows only from
long experience that Ti Ofa is in the endgame of his AIDS infection. Even though it is exorbitantly expensive and
no doubt a waste of resources, Farmer has started patients like Ti Ofa on new antiviral drugs. The man is
embarrassed by his situation, but accepts the drugs and promises to take them faithfully. He tells Farmer that just
talking to him makes him feel better.
The end of the day brings more rounds, this time of the Children’s Pavilion where there are babies with
kwashiorkor, a form of starvation. Farmer has recently lost a baby to meningitis and another to tetanus. He croons
softly to a baby girl named Michela who he refuses to give up on even though she is bloated with pleural effusion.
The last stop is the TB hospital where the patients are sitting on the beds in one room watching a soccer game on
TV. He jokes and teases them, which cheers him up. He points out to Kidder that they’re failing on 71 levels, but
not on one or two. The day ends on Farmer’s little patio lit by battery power. He puts a pile of medical studies on
his lap to read, but decides he’s not into that and instead takes Kidder along, while he surveys the plant life he has
nurtured over the years. The, he goes back to his studies for awhile. Even that is interrupted when he is called back
to the clinic for a moaning thirteen-year-old who has arrived by donkey ambulance. He must give her a spinal tap
and when he inserts the needle she cries out in Creole that it hurts and she is hungry. Farmer is amazed and
“narrates Haiti” again, “Only in Haiti would a child cry out that she’s hungry during a spinal tap.
Notes
This chapter shows the reader how Farmer spends his days and how dedicated he is to each and every patient.
They love him and call him a god, bring him gifts like pigs or chickens. However, none of these accolades are
what motivates this man. It is the thought that there is some patient in need that keeps him going.
CHAPTER
4
Summary
Farmer tells Kidder soon after he arrives in Haiti that he, Farmer, will be Kidder’s Virgil. That’s because he views
everyone as a potential subject for education. He tells him about his own education concerning the relation
between medicine and beliefs in sorcery. He had been in Boston recovering from a broken leg when one of his
patients died of TB. When he returned, he was told by the staff that she wouldn’t have died if he had been there.
Their intended meaning was complimentary, but Farmer converted it to self-reproach. He wanted a medical
system that continued to work in his absence.
So Farmer calls a staff meeting to figure out what is wrong. Some of the staff points out that the poorest patients
fare worst, but many of the staff point out that failure with a patient can often be placed on his mindset: once he
feels better, he stops taking his medicine which then inevitably leads to setbacks. Farmer is intellectually torn over
the possible reasons and so designs a study. He selects two groups of TB patients. Both groups receive the same
treatment for free, but one of the groups also receives other services, such as visits from health care workers and
monthly cash stipends. Farmer visits all the patients personally to monitor their care. When the study ends, only
48% of the group who only received free medicine is cured, while in the group that received extra services,
everyone fully recovers. So whether a patient believes that his illness comes from germs or sorcery makes no
difference at all in his recovery. Farmer is at a loss to why the study comes out the way it does, until he interviews
a sweet, rather elderly woman who asks him, “Are you not capable of complexity?” That’s when Farmer realizes
that this is no different than the dynamic he sees in America where people rely both on medicine and prayer. Thus,
the study becomes a command to him to worry more about his patients’ material circumstances than about their
beliefs. So the money he receives for his clinic also is used for extra health care workers and cash stipends. As a
result, he hasn’t lost a single patient in twelve years.
A patient from a village called Morne Michel has not shown up for his monthly appointment, so Farmer, believing
that one of his rules is to find a patient when he doesn’t appear, decides to go into the countryside. To him, the
noncompliant one is the doctor who doesn’t fix a patient who doesn’t get better. As a result, Farmer decides to go
to Morne Michel and take Kidder with him. On the day he sets out, he tells the women in the kitchen where he and
kidder are going. They admonish him that such a trip will kill his “blan,” a term referring to Kidder. Actually the
term has a complicated meaning such as “white person,” but also anyone from outside Haiti, even black
Americans. The Haitians think they all look alike!
The trip is long and difficult. Their first stop is an abandoned cement factory which sits beside a concrete buttress
dam. This dam is a subject that Farmer has discussed in all of his books and many of his journal articles. To him, it
is the perfect example of what’s wrong in Haiti. In the 1950’s, under one of Haiti’s many dictators who was
supported by the USA, the dam was built by the US Army Corps of Engineers under the pretext of improving
irrigation and generating power. In reality, the peasants who were supposed to benefit from the project received
nothing but the loss of their homes and property. In fact, the dam had always been intended to help agribusinesses
downstream, mostly American-owned, and also to supply electricity to Port-au-Prince and to the homes of the
Haitian wealthy.
As a result, the young soon left the countryside and moved into the cities. The old reminisce about what the
countryside looked like before the dam. They describe the experiences of running from the rising water and then
fighting over who owned the scabby land that was left. After that, they even lost their pigs in the 1980’s when
American fears of swine flu invading their own pigs led to Haiti destroying the Creole pigs. Even supplying the
peasants with American pigs didn’t work, because they couldn’t survive the rigors of the Haitian countryside.
Farmer and Kidder walk across the top of the dam, being greeted all along the way by the locals. Then, they find a
footpath that moves straight up. Even with Farmer’s bad back, he makes it to the top of the first hill before Kidder.
It is the first of many hills. They pass smiling children, carrying water in buckets that had once held paint, oil, and
antifreeze. They pass patches of millet, the national staple, and small stands of banana trees. On a fair number of
the trees that are still standing are political graffiti, which is one way, Kidder believes, that the poor here avoid
hopelessness. They pass women washing clothes in a rivulet of a gully. Farmer explains that they are a fastidious
people in spite of their poverty. He also comments on their smiling faces that are evident even though they’re very
aware of their own misery. He says there’s a WL (white liberals) line that says, “They’re poor but happy.” He
even has problems with groups who appear to be his allies, because even though he loves them, he is angry that
they believe all the problems of poverty can be fixed without any personal costs.
Kidder notices that many of the people he passes are wearing second-hand American clothes. The people call
these “Kennedys,” because President Kennedy had sponsored a program for Haiti that sent machine oil among
other things to the country. The people thought the machine oil was cooking oil, and so came to apply the name
Kennedy to goods of inferior quality.
The two men continue their trek with Kidder sweating buckets and Farmer as dry as a bone. About three hours
after they began, they arrive at the hut of the patient who hadn’t shown up for his appointment. When Farmer asks
him if he dislikes his TB medication, the man replies with an emphatic yes, because he wouldn’t be here without
it. However, he hadn’t received his standard cash stipend and so hadn’t come in to the clinic. Farmer is satisfied
that he has resolved the problem, and they begin the long journey back, slipping and sliding this time down the
hills. When Kidder asks him what his reply would be if other health care workers were unwilling to make the
same effort he is, Farmer says he would reply, “F*** you,” his way of saying that they are responsible for assuring
an “outcome-oriented view of TB.”
They soon come to a cock-fighting pit where two chairs are found for both men and where Farmer is soon
surrounded by all the women of the men participating in the match. They admire him and want to talk to him,
because he is the first physician who has ever provided them with gynecological or obstetric help. Once they set
out again, it is mostly downhill, but there are still a few hills to climb. At the top of one, Farmer stops as if to
admire the view. It is beautiful, but Kidder now sees it as more than just picturesque – perhaps he now knows the
truth that lies within these hills. Farmer says that to understand Russia, Cuba, the Dominican Republic, Boston, or
Sri Lanka, you just have to be on the top of that hill. He seems to be joking, but Kidder understands now that
viewing this drowned land of the poorest people is a lens on the world. However, he fears to voice his ideas,
because he doesn’t want to disappoint Farmer.
Notes
In this chapter, Kidder begins to learn the great lessons that Farmer teaches: there is a definite link between
poverty and poor health; behind the beauty of the hills is the truth about the poorest of the poor; WL stands for
more than white liberals, but also for anyone who champions Farmer’s cause without any personal sacrifice.
PART II – The Tin Roofs of Cange
CHAPTER
5
Summary
This chapter is Kidder’s research into how Farmer’s background caused him to make the choices he made. His
parents came from western Massachusetts, and Paul was born in the mill town of North Adams in 1959, the
second of six children, three boys and three girls. He looks mostly like his mother who had quit college early to
marry and be a mother. His father was a big man and a ferociously competitive athlete known as Elbows to people
with whom he played basketball. His daughters called him the Warden, because he wouldn’t allow them to use
make-up, have boyfriends, or stay out late.
Because his father was a restless sort of man, he left his steady job as a salesman in Massachusetts and moved his
family to Birmingham, Alabama in 1966. It would be some of the happiest years for the family, especially Ginny,
Paul’s mother, because they lived in a house and even had an automatic washing machine. They even bought, at
public auction, a large bus for family vacations. They named it the Blue Bird Inn. Paul flourished here as well,
being placed in gifted classes in school and even subjecting his siblings to his “herpetology class.” He went to
Catholic Church, but didn’t feel engaged, pointing out that his books caught his attention more. He even likened
War and Peace to The Lord of the Rings.
When sales work disappointed the Warden, he turned to teaching, but the atmosphere in Alabama in the 1960’s
worried him and Ginny, so he found a job in the public schools of Florida, and the family moved there in 1971.
Unfortunately, the beloved washing machine wouldn’t fit in the bus, and it would be many years before Ginny saw
another one. They parked the bus at a campground, and it became their home. Ginny was forced to take a job at a
local Winn-Dixie, and she also was expected in their “traditional home” to do all the wifely duties as well.
However, she insisted on reading aloud to her children and pushing the concept of education on them all. Years
later, she herself would graduate from Smith College. The family remained in the campground for five years
where Paul learned to concentrate in the midst of all kinds of noise and where he used a tent after an accident in
the bus forced the family out until repairs were made.
Because the pay picking the fruit was so meager, the Warden decided to quit that project after a few days. Instead,
he bought an old boat and fixed it up and renamed it The Lady Gin after his wife. He declared that it would be a
source of revenue in the area of commercial fishing and so the family set out on their first voyage. They got caught
in a major storm, and Ginny rose up against her husband for once and demanded they throw the generator
overboard as an extra anchor. The experience turned out alright, but the danger they were in didn’t faze the
Warden at all. Paul said later, “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.” Nonetheless, future voyages were limited to staying moored on an uninhabited bayou on the Gulf
Coast called Jenkins Creek. Paul continued to flourish here, because he loved the nature that surrounded him. He
even saved money from his part-time jobs to landscape the area around the boat. This life, of course, was the
hardest on Paul’s mother: working all day and caring for the family all night, having to deal with a refrigerator that
was much too small, washing clothes at a laundromat and washing themselves and their dishes in the brackish
water of the bayou, stealing their drinking water from an outdoor spigot at a convenience store, and living with
vehicles that often broke down and were embarrassing to look at.
Farmer’s comment on his childhood was, “The way I tell myself the story is a little too neat. I’d like to be able to
say that when I was young I lived in a trailer park, picked fruit with Haitians, got interested in migrant farm
workers, and went to Latin America. All true, but not the truth. We’re asked to have tidy biographies that are
coherent. Everyone does that. But the fact is, a perfectly discrepant version has the same ending.” In spite of this
truth, his upbringing was good for both Paul and his siblings. They grew up well, albeit choosing to live in houses,
and became successful people. His childhood especially helped Farmer prepare for a traveling life, sleeping
anywhere, including a dentist’s chair, and never having needed a sense of a hometown. Cange in Haiti became his
hometown. His childhood also helped him score a full scholarship to Duke University.
At Duke, Paul failed to score all A’s his first semester, because he plunged into every organization and cultural
event he could. For the first two years there, his family feared he was turning into a preppy, which the Warden
quickly dispelled when he told his son that a preppy can still clean the bilge. Eventually, however, he saw that this
wasn’t the life for him, even quitting his fraternity, because they wouldn’t admit anyone who wasn’t white. He
also returned home less and less in his final two years, because he needed to get out from under his father. All the
Farmer children craved their father’s approval, but the man made it hard to get. He never allowed Paul to see any
pride in his achievements out of fear he’d make his head swell. Also, the Warden had been forced to move the
family once again, this time to a trailer that the two youngest sisters called the Star Road State Prison. None of the
children wanted to live near there, so they all began to drift away.
Paul did share certain qualities with his father, above all their intense focus on a goal. The Warden died a few
years later in July, 1984, while playing a pick-up game of basketball. He evidently had a heart attack at the young
age of 49. Paul brought home a girlfriend soon after his father’s death, and they explored the Blue Bird Inn while
he was there. He discovered an old letter that his father had written him saying, “I just want you to know how
proud I am.” Paul sat there holding the letter and sobbing his heart out. He had finally received his father’s
approval.
Notes
This chapter is not only revealing of what molded Paul’s character but it is also very touching. It helps the reader
understand what made Paul the man he is. His childhood was not easy, but he adapted and flourished within it.
And it’s easy to see that it provided him with the tools to accomplish his oeuvre.
CHAPTER
6
Summary
Paul was described by his college friends as a guy who made friends easily and had a photographic memory for
facts about each one. He talked to everyone he met and was open to late night food fights and singing Broadway
songs while walking across the campus.
After his first semester, Paul started getting all A’s. He also spent one summer and fall in Paris where he lived
with a family that needed an au pair. He went frequently to political demonstrations and took four courses, among
which was the last anthropology class taught by the great Claude Lévi-Strauss. By the time he returned to Duke,
he read, wrote, and spoke French fluentlym and he had claimed as his personal mentor Rudolf Virchow, a German
polymath who had been dead for the better part of the century.
Virchow isn’t very well-known in the medical world, but he is considered the “principal architect of the
foundations of scientific medicine.” He made important contributions in oncology and parasitology, coined at least
50 medical terms in use today, and helped define the field of medical anthropology. He published more than two
thousand papers and dozens of books. He was sent by the German government to Upper Silesia to report on an
epidemic called relapsing fever. His report included a prescription for “full and unlimited democracy” as a means
to help cure the epidemic. The government fired him. His aphorisms after such experiences included, “Physicians
are the natural attorneys of the poor, and the social problems should be largely resolved by them,” a favorite of
Farmer’s. Farmer made no secret of his admiration for Virchow. He said, “Virchow had a comprehensive vision.
Pathology, social medicine, politics, anthropology. My model.”
After his study of Virchow, Farmer came to have a moral understanding of public health. He also became
interested in current events after the murder of Archbishop Oscar Romero by a right-wing death squad in El
Salvador. After this, his understanding of Catholicism changed radically when he saw Catholic prelates preaching
against the oppression of the poor rather than the perils of premarital sex. He came to believe that there was so
much more to countries like El Salvador that people in the United States knew. He later met a Belgian nun named
Julianna DeWolf who was working with United Farm Workers. She was fearless, radical, and committed to the
farmers of Haiti. Paul called women like her “the church ladies” and was very impressed by what they were
willing to do on behalf of migrant workers. His discovery through her of the misery of the Haitians led to an
article of over 6,000 words about those farmers laboring in the fields near Duke University, called “Haitians
Without a Home.”
After graduating summa cum laude from Duke, Farmer joined protests at Krome Detention Center where
American Immigation officials were allowing Cuban immigrants entrance and sending Haitians back. He became
interested in all things Haitian including its violent history and its ongoing struggle between great and terrible,
between good and evil. He had won a one thousand dollar prize at Duke and figured it would be plenty to last him
when he went to Haiti. In the meantime, he applied to both Harvard and Case Western Reserve where he could get
a joint degree as a doctor-anthropologist. He figured his time in Haiti would help him know if that’s what he really
wanted.
In 1983, when Farmer landed, Haiti was still controlled by the Duvalier family. It had been controlled by the
dictator Papa Doc Duvalier from 1957 until his death in 1971. Now it was controlled by his son, Baby Doc, who
had declared himself President for Life. The tourist areas were patrolled by the tontons macoutes , the Duvaliers’
Praetorian Guard so Haiti seemed an exotic destination. But Farmer knew the interior would be different. Using
his friendship with a member of the Mellon family on Pittsburgh, he hoped to get on the staff of the Hôpital Albert
Schweitzer. Unfortunately, there was no opening, so Farmer looked into other situations, including Eyecare Haiti
which had mobile outreach clinics and a base for their operations out in the central plateau in the town of
Mirebalais. Farmer headed there.
Notes
This chapter explains the circumstances that led Paul Farmer to realize there is a moral understanding to public
health and that his talents would be better employed on behalf of the poor of Haiti.
CHAPTER
7
Summary
This chapter is written from the viewpoint of Ophelia Dahl, the young lady with whom Paul fell in love and
wanted to marry. It begins with a letter from her to him, explaining why she couldn’t marry him. She loved him
very deeply and was as committed as possible to him, but she felt she couldn’t be the kind of wife he deserved,
because the very qualities that drew her to him also caused her to resent him. He was just too committed to the
poor, his schedule is limitless and his massive compassion for others would leave little room for her. She tells him,
however, “In the end, I hope you know that as part of my histology you can never be replaced.”
Ophelia was the daughter of the actress Patricia Neal and her writer husband, Roald Dahl. She came from England
to Haiti in 1983 to please her father and with the rather vague intention of doing good works. She was only
eighteen and was working as a volunteer at the Eye Care house in Mirebalais when Paul Farmer arrived.
Mirebalais was the country home of Madame Max Adolphe, the warden of Fort Dimanche, the prison where the
Duvaliers sent their enemies, likened by one historian to Buchenwald. She was now the national chief of the
tontons macoutes. Mirebalais, because it was a place of some significance, had a teleco, and Ophelia had gone
there to call home after a letter from her father indicated troubles at home. Unfortunately, the teleco was unable to
connect her call, and she headed back to the Eye Care house feeling glum and homesick. On her way back, she
saw Paul standing on the balcony of the Eye Care house, calling him a “pale and rangy fellow.” They sat down
together after introductions in the common room, and she found herself telling this perfect stranger some of her
deepest feelings. He seemed close to ideal as a listener, not only listening intently, but offering ways to help her
cope. She asked herself how he could know at only age 23 what would comfort her. He also described his own
family, making her laugh, and she described the team at the Eye Care house. He was so sincerely grateful for her
telling him all she did that she was amazed at his compassion.
Later, they went out together with the team in the Land Rover. He brought his tape recorder, camera, and a
notebook to practice his anthropology which prompted her to ask him many questions. He did nerdy things, but
was also extremely enthusiastic. He asked the peasants he met just as many questions as Ophelia asked him. After
that trip, he began mastering Creole with enviable speed, soon passing Ophelia’s skills in the language. On the
way back from the trip to the countryside of a few days time, the Rover came around a corner beside a cliff and
came across a truck accident on the side of the road. The truck was carrying people and mangoes to market and
because it was overloaded, it couldn’t master the turn. The people stand beside the road in shock while one of the
women lies dead on a bed of the fruit, a piece of corrugated cardboard laying over her. This memory would
become fixed in Ophelia’s brain, including the sight of Paul staring out the window, very, very silent.
Over the next month or so Ophelia and Paul saw each other almost every day. He lived in a huge old ruin of a
mansion in Port-au-Prince and they often went there to be together. It was there he composed a poem called “The
Mango Lady” and dedicated it to her:
We start, eyes drawn reluctantly back
Over baskets, to the dead mango lady
Stretched stiff on her bier of tropical fruit.
She is almost covered by a cardboard strip,
Like the flag of her corrugated country,
A flimsy strip too thin to hide the wounds.
In the process of their relationship, Ophelia realized that he was subtly educating her. She knew if he made a
cryptic or broad statement that it was best not to challenge him, but instead ask him to tell her more. One of the
questions she asked was, “What is anthropology exactly?” He defined it as being less concerned with
measurement than meaning. To grasp it, one had to know the politics, economic systems, and the histories of a
place. Only then could you understand an event like the mango lady’s death. What he meant was: “Accidents
happen. Sure. But not every bad thing that happens is an accident. There was nothing accident about the
wretchedness of the road . . . or the over-loaded truck . . . of the desperation of a peasant woman who had to get to
market to make a sale, because otherwise her family would go hungry.” He blamed this anthropology on the
Duvaliers and the American government that supported them. Now she had someone to translate Haiti for her. He
could lay out a comprehensive theory of poverty where the world is designed by the elite of all nations to serve
their own ends and which erased the histories of how things came to be as they were. His aims were clear: he had
come here to do ethnology – learning about a culture, not though books and artifacts, but from the people who had
inherited and were making culture. He was going to specialize in medical ethnology to learn everything he could
about morbidity and mortality in the most disease-ridden country in the hemisphere. She said after hearing him
talk about what he wanted to accomplish that she reached a point where she realized that world had just been
revealed to her and that things would never quite be the same again. She told him that when she went home in the
spring that she was entering premed herself. They promised to write.
Paul was ardent in his requests for letters, but Ophelia, for a time, didn’t write back. She wasn’t sure why, because
she hated the thought that she might never see him again. One day, she went to lunch with her father and Graham
Greene, Paul’s favorite writer. He inscribed his book to her, “To Ophelia, who knows the real Haiti.” She
wondered, if he really thought that of her, what would he have made of Paul Farmer?
Notes
Seeing Paul Farmer through the eyes of someone other than the author, Tracy Kidder, brings more emphasis to the
great compassion and empathy Paul had for the poor and down-trodden. It also brings into greater clarity why a
woman like Ophelia would be unable to make a life with a man like him. As wonderful as he is, he is first
committed to his patients and has little of any commitment left for someone who loves him.
The story of the Mango Lady is a metaphor for Haiti itself as seen in Paul’s poem. She is the country dying in the
midst of circumstances created by the wealthy and the elite.
CHAPTER
8
Summary
Soon after Ophelia left Haiti, Paul first saw Cange. He was still searching for a place to do his work when he met
up with a Haitian Anglican priest named Fritz Lafontant. He was running a rudimentary one-doctor health clinic in
Mirebalais. He also had built schools, organized community councils, and programs for adult literacy in several
small towns, including Cange. He went with the priest one day by truck and was struck by the beautiful greenness
of Haiti in the spring; that is, until he passed the dam and saw the barren, dry area around it. Most of the dwellings
were crude hovels with banana-bark thatched roofs patched with rags to stop the leaking. Farmer was struck by his
memories of the tin roofs he’d seen in Mirebalais which were emblems of poverty. The roofs in Cange screamed
misery.
Farmer kept traveling through Haiti, hitching rides with whoever would take him. He came down with dysentery,
probably from eating foods sold on the street. An American public health expert told him, as he lay in a grubby
hospital in Port-au-Prince, that if he got any sicker, she would have to take him back to America. At the same time
he was telling her no, his heart was saying yes. After he recovered, his determination to understand what Haiti
needed returned, and he continued to travel around the country asking questions of the peasants. He knew that the
scholarly texts were wrong. He came to realize by living there that a minor error in one setting of power and
privilege could have an enormous impact on the poor in another setting. That could be seen in the Creole pig
eradication and the dam at Péligre.
Farmer also became interested in liberation theology. It was a powerful rebuke to the hiding away of poverty. The
peasants didn’t follow doctrines that encouraged them to accept their plight in life and anticipate the afterlife.
Instead, they believed that the rest of the world was wrong for “screwing them over, and that someone, someone
just and perhaps omniscient, was keeping score.” Religion was the one thing they still had. The peasants also
believed that God gives humans everything they need, but he leaves it up to them to divvy up the goods. This is
also the tenet of liberation theology which demands that we redress the horrors of poverty in the here and now
with service and remediation. This fit Farmer perfectly, because as he said of himself, “I’m an action kind of guy.”
This was further emphasized to him through two events: in one, an American doctor, who loved the Haitians and
loved caring for them, was returning to the States, ecstatic to be going home. He said he was an American and
that’s where he belonged. Farmer wondered about the idea of saying, “I am an American;” in the second, a woman
and her baby died of malaria because there was no blood or money to buy it. Her sister sobbed that it was terrible
that you couldn’t get a blood transfusion when you were poor. She says, “We are all human beings.” As a result,
he wrote his relatives asking for donations for blood-banking equipment. He happily received a thousand dollars
and turned it over to the hospital for the equipment they needed, but he wrote to Ophelia that things hadn’t turned
out as he had thought: the hospital was not for the poor, because when a blood transfusion was needed, they were
still demanding payment in advance. Farmer decided he would build his own hospital.
It was a relief to Paul to discover that there was no clinic at all in Cange. Not because he didn’t feel they needed
one, but because he knew he couldn’t work on one like that of Mirebalais. It was all about the patients and their
awful outcomes, and he wanted a clinic that reflected that. He began with a modest health census. Hiring four
th
young Haitians who had at least finished the 7 grade, he sent them to two neighboring villages, going hut-tohut,
tallying up the numbers of families, recent births and deaths, and the apparent causes of morbidity and mortality. It
confirmed what Farmer already suspected – the mortality rates were horrific and the deaths of mothers, common
events in this squalid area, led to “skeins of catastrophes in families, to hunger and prostitution, to disease and
other deaths.”
Farmer also learned from another experience how cooperation with the beliefs of the people was important to
meeting their needs. A woman with malaria was treated by a local hougan, a Voodoo priest, because her father
insisted, but after Farmer explained his role in healing, her mother agreed for her to be treated with chloroquine,
and she recovered. Farmer reiterated what he learned in an essay entitled “The Anthropologist Within.” He stated
that when he had learned that an ethnographer should observe and not try to change anything within a culture, he
knew that this made anthropology impotent. To him, it was a tool rather than a discipline unto itself, a tool for
intervention. A doctor-anthropologist who understood the religion would find a way to make the hougan his ally
rather than fighting his methods. Furthermore, he knew the people of Cange weren’t interested in having their
suffering merely scrutinized; they wanted both research and action.
Farmer entered Harvard Medical School in 1984 at the age of twenty-four. However, he didn’t linger there just
studying and learning. He would take off for Haiti, then showing up at Harvard just in time for lab practicum and
exams and avoiding basic lecture courses. Being a commuter like this didn’t cause any disapproval from his
professors who understood that he was trying to bring medicine to people. Besides, his grades were the best of his
class.
Notes
When Farmer spends time in Haiti, he formulates his own philosophy about how his love of both medicine and
anthropology can become tools to help the people who most sorely need it.
CHAPTER
9
Summary
The combination of Harvard and Haiti brought Farmer back to his religious belief. He had come to accept the
peasant view that there was Someone keeping score. He said that in such a godless world that worshiped money
and power, the only place to find God was in the suffering of the poor. When Ophelia returned to Haiti, Paul had
taken to wearing a large crucifix outside his shirt which enhanced his “priestliness,” a characteristic she had
sensed in him before. He proclaimed that he had faith in God, but also in science, and he would have to choose
science if it were the only service to the poor. He was just glad he didn’t have to choose.
He and Ophelia became lovers, and she spent the whole summer with him. She helped him with his formal
education by quizzing him with his self-designed flashcards, which she found as amazing as he was. They also
walked through the villages where they would continue to take down information at every hut, and where she tried
very hard to do something better than he did. She was frustrated by it, but far from angry, that she just couldn’t
outdo him! During her wanderings with him, she suffered greatly from the heat, but her Creole began to improve
immensely. She was also amazed at the strange smell in every hut – not a smelly socks stinky – a smell of people
living too closely in poverty.
One of the greatest problems in Cange was the drinking water the people gathered in calabash gourds or recycled
plastic jugs. It was retrieved from the stagnant reservoir, and people often left it uncovered for days as well. So a
team of Haitian and American engineers from a South Carolina church group devised a plan to use the force of an
underground river to carry its own water in a pipe up to communal spigots. After it was built, infant deaths began
dropping. Father Lafontant had also constructed thirty fine, clean latrines as well as supervising the building of a
clinic. Farmer stole a microscope from Harvard for this clinic. He said, “Redistributive justice – we were just
helping them not to go to hell.”
Paul himself began to plan for what he called “first line defenses” out in the community. What the first line didn’t
prevent the Clinique Bon Sauveur would. He was impatient for it to happen, but understood that all of his plans
would require money far beyond the means of the South Carolinians. In 1983, he had gone to Boston for his
pre-admission testing at Harvard and had asked an organization called Project Bread for money to build a bread
oven in Cange. They had willingly given him the money, explaining that an anonymous donor had earmarked
some of their money for Haiti. The following year his article “The Anthropologist Within” was published at
Harvard and Paul learned that the anonymous donor had read it and wanted to meet him. Paul said to tell the man
to come to Haiti.
Paul found out the donor was the owner of a heavy-construction company and that made Farmer war that he was
an anti-union Republican working out unfair deals in back alleys. To his delight, however, the man, named Tom
White, came to Haiti and Farmer soon discovered that he was far from the typical construction businessman. He
had been giving away money for years and had always had a deep feeling about the needs of the poor. He also had
a great deal of influence politically in Boston and knew and associated with famous people. He didn’t like the
attitudes of the rich, however, and was more than upset by what he saw in Haiti. That’s when he began giving
money to help with Paul’s plans.
When Farmer came home to Boston, White would bring sandwiches to him at lunch and they’d eat in his car. One
day, White became perturbed at how pale Farmer looked and asked him if he was eating properly. He pulled out a
wad of hundred dollar bills and began pulling one after another out and throwing them at Paul. Paul finally
admitted that he had given his entire check to an AIDS patient who was being evicted. When White asked him if
he didn’t think it was kind of impractical, Paul said, “Well, God sent you today.” White also told Paul that
sometimes he’d like to chuck it all and work as a missionary in Haiti. To that, Paul replied, “In your particular
case that would be a sin.”
Notes
This chapter especially exemplifies that there are no coincidences. Just when Paul seems to need help or money to
further his plan, something or someone comes along to make sure they are fulfilled. Father Lafontant, Tom White,
the Bread project, and the engineers from South Carolina are part of the motif which reflects the peasants’ idea
that there really is Someone keeping score.
CHAPTER
10
Summary
Ophelia came back to Haiti every summer from 1985 through 1989. They were months of nearly constant work.
From time-to-time, she longed to get away from the desolate region where they worked and convinced Paul to
take a trip into Port-au-Prince on the pretext that they needed medical supplies. She’d take along a pile of his
flashcards in case they’d end up broken down, as was often the case. However, it wasn’t enough to satisfy Paul
who wanted to get back to Cange. Once, she wanted to stop along the way at a supermarket, which was used only
by the elite, for a case of Diet Coke. Paul refused, saying they didn’t have time to do it. It would mean only a
twenty minute delay, but it would also mean walking by the beggars at the market. She knew he was right, that she
could get along without the Coke, but she lashed out at him, calling him self-righteous. He became so angry that
he slammed on the brakes and ordered her out of the car, calling her a foul name at the same time. She refused to
get out, feeling offended, but she also smiled inwardly and exalted that she had finally found a human flaw in him.
On another trip to Port-au-Prince, they arrived after Baby Doc had left Haiti, and the peasantry was rebelling,
because the military was acting like it was life as usual, just a different dictatorship. The smell of burning tires
filled the air, and at one point, their car was trapped when some kids stole the car keys. Then, a military truck
came screaming down the street after a huge crowd of protestors, firing indiscriminately into the crowd. Paul got
her to the house where they were staying, but he went back into the crowd again and again, helping the wounded
and viewing the action. Once they returned to Cange, they saw changes there as well. They people were now
openly talking about politics and how the government could be blamed for dirty water and the resulting illnesses
and death. These events and the smell of burning tires would be an abiding part of Ophelia and Paul’s lives for
years to come.
In 1988, Ophelia came to Boston to live with Paul, who had now entered the phase of medical school called
clinical rotations. Paul rarely missed a day of these clinical labs, but Haiti was never far from his thoughts. He
asked Ophelia to help him bring resources to the country, and he also turned to Tom White again. Together, the
three of them, plus another friend named Todd McCormack, created an organization called Partners In Health
(Zanmi Lasante). This organization would solicit contributions, make them tax-free and funnel them to Haiti.
White himself put up one million dollars as “seed money.” This became Paul’s Catholic Church. He expanded the
group a few months later with a fellow Harvard anthropology and medical student, a Korean-American named Jim
Yong Kim. They would spend many hours together, even into the wee hours of the morning, discussing such ideas
as political correctness, the significance of cultural barriers, appearance, and medicine addressing the symptoms of
poverty. They believed anything was possible. Among other things, PIH decided to build a school in Cange called
Kay Epin (House of Pines). Because there wasn’t much in the way of trees, Ophelia’s father gave a large sum of
money to plant some.
On one evening in 1988, Farmer was rushing around with last-minute errands in Cambridge, before leaving the
next morning for Haiti, when he stepped off a curb into the path of a car. His knee was shattered, and so instead of
going to Haiti, he went to Mass General for surgery. He spent three weeks in the hospital and then was discharged
to the apartment he shared with Ophelia. Setting up housekeeping with Paul was a difficulty that Ophelia hadn’t
anticipated. She knew he loved her, but for her, relations were strained: “the strain of living with a fellow who was
in love with something else, something that I could never compete with, even if I wanted to.” Even before the
accident, it was difficult when he left for Haiti, but afterwards, when he couldn’t go, he became very restive, and
they argued frequently over his recovery. Finally, he said, “I’m going to Haiti. They don’t mind looking after me
there.” That was December 10, 1988, and Ophelia knew something had irrevocably changed. A couple of years
later, he proposed to her, but she found it hard to say no and impossible to say yes. He was hurt and angry and
said, “If I can’t be your husband, I can’t be your friend. It would be too painful.”
For a time after that, Ophelia received word about Paul only through Jim Kim. However, she hated being
separated from him. More than ever, he seemed like a person to believe in. he was proof that it was possible to put
up a fight. Because she knew he had a weakness for forgiving people, she decided to remain a part of PIH and his
life. She gradually filtered back in, taking on the organization’s finances. As for her relationship with Paul, within
a few years, they seemed perfect to her: no one could make him laugh like her and he could tell her anything. So
she said to herself, “Being his wife would have been no bargain. But to be his friend is simply wonderful.”
Notes
This chapter reinforces how the relationship between Ophelia and Farmer gradually evolved from one of a couple
on the verge of marrying to a deep and abiding friendship. Ophelia knew he was really in love with Haiti and
helping the poor and so has to find a way to be with him that doesn’t mean a marriage. This also reinforces the
motif of Farmer as a kind of priest to what he so firmly believes and that he is married to Haiti.
CHAPTER
11
Summary
In December 1988, Farmer returned to Cange in a wheelchair, and while his leg mended, he launched his study to
improve TB treatment in the central plateau. Meanwhile, big events were happening in the country. Several
un-elected governments attempted to take power, but invariably the country was under the control of the military.
As a result, a great popular movement seemed to be gaining momentum. The peasants and the people in the slums
had embraced what they called dechoukaj, which meant the uprooting of every visible symbol of the Duvalier
family and the tontons macoutes. There was violence on all sides, but the Haitian military was particularly brutal.
Catholic churches became the center of the popular revolt, and the most important priest among them was
Jean-Bertrand Aristide.
Farmer decided to go to mass at St. Jean Bosco, the church where Aristide presided, to hear the priest speak. The
crowd was rapt at his words when he applied the poverty and suffering of the Gospel to what they were suffering
in their “dear Haiti.” Farmer remembered thinking that he had been looking all over for the progressive liberation
theology church, and now he had finally found it. He joined the crowd moving forward to meet the priest, and
after that, the two became friends. They didn’t see much of each other in 1988, because of their commitments and
because Aristide was busy surviving a series of assassination attempts, including the fire-bombing of his church
arranged by the mayor of Port-au-Prince.
Farmer was working on his Ph.D. thesis in anthropology which he entitled “AIDS and Accusation.” AIDS had
arrived in Haiti in 1985, and he would catalogue what he called the “geography of blame.” Haiti had been
assigned the role of scapegoat in the eyes of American health officials. They insisted that the virus had originated
in Africa, come to Haiti, and then to the United States. Farmer had marshaled a host of epidemiological data which
proved that the virus had come to Haiti from the US, most assuredly through American, Canadian, and
Haitian-American sex tourists who could buy assignations for a pittance in the slums called Carrefour. The
accusations that Haiti had visited AIDS on America had done incalculable harm to the fragile economy of the
country and to the poor Haitians themselves. The thesis he wrote was to be “an interpretative anthropology of
affliction,” combining evidence from ethnography, history, epidemiology, and economics. He would use Cange as
his example, renaming it Do Kay to protect it. Standing up above the town, he was reminded of all the failures and
deaths he had experienced there, but he could also see the successes: communal water fountains, communal
latrines, the public health project, the greenhouse, the artisans’ workshops, and the Clinique Bon Sauveur. It had
grown from 107 families to 178 households, and now nearly all the roofs were made up tin. It was no longer a
miserable encampment of refugees , but just a typical extremely poor Haitian village.
Farmer received his Ph.D and his M. D. simultaneously in the spring of 1990. His thesis won a prize and was
accepted for publication. He had been protected by numerous physicians at the medical school in his unorthodox
attendance habits, and they hadn’t hurt his educational standing. What’s more, his experiences in Haiti as a virtual
doctor made his acceptance by Brigham and Women’s Hospital into their residency program By 1990, it seemed
possible that Haiti would have a real national election. It wouldn’t happen without a fight. Because the military
had the country tightly controlled. Farmer himself was threatened by unknown voices over the phone. When there
was an audible clicking sound with each call, he climbed the roof and discovered a crude bugging device and
happily kicked it to pieces. He hadn’t played a visible role in the politics of Haiti so he could only assume he was
being targeted because he had been seen with Aristide. Once, Aristide had shown up at Zanmi Lasante with a
truckload of flour for his orphanage. His truck wouldn’t start, so they had loaded the flour into one of the clinic
trucks which then broke down in a large puddle in the road. With the thought of the horror of the roads in Haiti on
his mind, he said to Aristide, “In the newspapers, it says you’re going to be a candidate for president. I guess they
don’t know you very well, because you would never run for president.” Aristide was noncommittal, but a week
later, he declared his candidacy. It angered Paul at first, but then he realized that Aristide was the man the people
wanted and he thought, “Perhaps this is a singular chance to change Haiti.”
Soon Farmer was ardently rooting for Aristide. On Election Day, many foreign observers oversaw the counting of
the ballots, and Aristide won 67 percent of the vote, while 12 other candidates took 33 percent. Now, as Aristide
said in one of his speeches in a revision of an old Haitian proverb, “The rocks in the water are going to find out
how the rocks in the sun feel.” To Farmer, it wasn’t Aristide who was the real victor, but instead the people of
Haiti who had braved massacre and death to vote and reclaim their country. He had never felt so moved.
In the summer of 1991, Farmer returned to Brigham full of hope for his adopted country. Rumors of coups
abounded, but there were no longer military checkpoints on the roads and a revitalized Haitian Ministry of Health
had begun collaborating with Zanmi Lasante on AIDS-prevention work in the central plateau. Also, the money
was now available to build a real hospital in Cange.
On September 29, 1991, Farmer got Jim Kim to cover for him and decided to take a short trip back to Haiti for a
meeting about the new hospital. A Haitian refugee in America drove the cab that took him to the airport and told
him there was trouble again “down there.” Farmer refused to believe it, but when he arrived at Miami, the sign
above the check-in desk for Port-au-Prince said cancelled. He stayed in Miami to see if flights resumed and
watched CNN stupefied to see that the Haitian army had deposed Aristide. Even when the flights resumed, he
couldn’t return, because the junta had placed his name on a persona non grata list. Finally, Father Lafontant bribed
a Haitian army colonel to expunge his name from the list, and Farmer got a flight out. He made it through
immigration without incident and drove to Cange through two military checkpoints.
Two days later, he was called away by a woman who said the local authorities had beaten her husband and he was
dying. Farmer had seen a lot in Haiti, but this case impacted him more deeply than anything he had ever seen
there. The man, whom Farmer called Chouchou Louis to protect his family, had made a disparaging remark about
the road of the country. Unbeknownst to him, inside the truck he was riding was a soldier dressed in plain clothes.
At the next checkpoint, he was taken inside an official building and beaten severely. They let him go, but his name
was added to their blacklist. Eventually, he came out of hiding and sneaked back home. He was met by a local
section chief and an attaché. They beat him again and what was left of him absolutely appalled Farmer. Paul
recorded all his wounds and eventually wrote a report called “A Death in Haiti” for Amnesty International. After
the man died, Farmer took a different way back to the clinic out of fear for his own life. Later, Paul told some of
his students that he took pains not to remember Chouchou even though he described his death several times in
print. He told Tracy Kidder that to him, “He died in the dirt.”
Notes
This chapter is bittersweet, because it expresses the hope Farmer has that change will finally come to Haiti
through the efforts of Jean-Bertrand Aristide. For awhile, Haiti is changed and the Health Ministry takes steps to
help the poor, but the dream is crushed when the military deposes the man and the violence begins again. In this
sense, Chouchou Louis is a metaphor for Haiti. In a moment of freedom, he speaks disparagingly about his
country and is then beaten to death. In the same way, Haiti rises up to grab freedom momentarily and then is
beaten back into submission.
CHAPTER
12
Summary
Ophelia visited Cange during the rule of the junta in the early 1990’s. She had felt nervous there in the early years,
but now she felt living there was worse. Paul also took many chances, acting rude to the soldiers at checkpoints
and refusing to take down the iron sculpture in the clinic supporting Aristide. The soldiers began poking around at
Zanmi Lasante, and Ophelia worried that they would come in and massacre them. Iron Pants (a generic name for a
strong woman in Haiti) comforted Ophelia by telling her, “We’ll defend this place with our lives.” However,
Ophelia wondered what they would use as weapons: pots and pans?
Farmer continued his frequent commute between Boston and Cange. One time, Farmer got $10,000 from Tom
White and smuggled it in to the underground, pacifist movement. When Jim Kim cautioned him to be careful,
Farmer actually screamed in frustration and anger. He fretted about everything, especially what he would do if the
soldiers came in and arrested a patient. He even tried to defy soldiers who told him to say, “Long live the Haitian
army,” at one of the checkpoints. He eventually said it, but only when a rifle was pointed at him. A soldier
actually came into the compound one day, and Farmer told him he couldn’t bring a gun in there. The man
demanded from Farmer, “Who are you to tell me what to do?” Farmer’s answer saved him, “I’m the person who’s
going to take care of you when you get sick.” The soldier knew that only at Zanmi Lasante could he get good
medical care, too.
Farmer received a MacArthur grant in the summer of 1993. He was depressed by it, because it was meaningless in
the face of the junta’s control. The body count continued to grow there. Three of Farmer’s closest friends were
murdered, and Farmer retreated to Quebec City, one of his favorite places, and began the draft of a book he would
call The Uses of Haiti. He wrote as if in collaboration with a Haitian peasant and revealed the history of American
policy all the way back to the 1790’s and up to the present day where the American position was openly against
the junta while privately unwilling to drive it out of power. People considered heroes were not so heroic in his
book, including Woodrow Wilson, FDR, the CIA, and even Mother Theresa, who openly embraced the so-called
good works of Michele, the wife of Baby Doc Duvalier.
When it seemed like the Clinton administration might support the restoration of Aristide, Farmer wrote an
editorial in the Miami Herald in which he said, “Should the US military intervene in Haiti? We already have. Now
we should do so in a way to restore democracy.” The editorial was mentioned in Haiti on government radio, and
the soldiers came looking for Farmer. Fortunately, he was back in Boston, but now he was formally expelled from
the country. At the same time, he heard that another friend had been murdered, and he became almost
inconsolable.
That summer, 1994, he spent as much time as could lecturing people about Haiti in small towns in Maine, Texas,
Kansas, and Iowa. He also went on radio talk shows and challenged anyone who said they couldn’t allow the
Haitians to come into our country. Finally, in mid-October, 1994, Aristide was reinstated, and Paul returned to
Haiti the day after.
The three years of military rule had nearly decimated the country, especially its health system. All the programs
they had set in place were suspended, once the clinic had been briefly shut down, patients were afraid to come
there for help, the ones who did come were victims of assaults by soldiers, cases of typhus and measles were up,
the number of patients with AIDS had increased by 60% and much of the staff had resigned or were afflicted with
a lassitude. However, to Farmer, the situation was far from hopeless, and he was glad to be back.
Farmer was now 35 years old and on the rise in both medicine and anthropology. PIH now had permanent
headquarters in a building in Cambridge. It was involved in many programs not only in Haiti, but also other areas
of poverty around the world. However, Farmer felt that they were still just a small public charity and that they
should reign themselves to a somewhat marginal status. Little did he know that a big change in PIH was about to
begin. They were about to become players in international health.
Notes
This chapter describes how Farmer dealt with the military junta both before and after he was expelled from the
country. He lost many friends, but ultimately never lost hope that he could return and help the people who meant
so much to him.
PART III - MEDICOS AVENTUREROS
CHAPTER
13
Summary
This chapter discusses the concept of an epidemiological map and the rise of TB in Haiti as a result of the military
junta. An epidemiological map is based on what makes people sick and what kills them and in what numbers and
at what ages. It could be color-coded into two colors: one would stand for populations that tend to die in their
seventies of age-related illnesses; the other would stand for groups who on the average die ten and even forty
years earlier from violence, hunger, and infectious diseases that medical science knows how to prevent and treat, if
not always to cure. Farmer says there is a line dividing the two color-coded parts which he calls the “epi line.”
Most of Haiti would bear the color of ill health, but parts of the hills above Port-au-Prince would be a patch of
well-being. The map of the United States would contrast with large areas of well-being speckled with disease.
Meager incomes don’t guarantee abysmal health statistics, but the two usually go hand-in-hand. Also, many of the
groups who live on the wrong side of the epi divide have brown or black skin. What they all have in common is
poverty – absolute poverty – meaning the lack of almost any necessity like clean water and shoes, medicine, and
food.
Tuberculosis vividly illustrates the great epi divide. This is a dreadful and lethal disease if untreated. Fortunately,
there are good and inexpensive “first-line” TB drugs existing. These drugs must be administered for several
months, but they almost always cure the patient. By the end of the twentieth century, however, this disease is still
killing about two million people a year, more adults than any other infectious disease than AIDS, and the two
diseases share a “noxious synergy,” since an active case of one often makes for a latent case of the other.
Unfortunately, because the disease mainly afflicts the poor side of the epi divide, the industrial nations and the
pharmaceutical companies have all but abandoned any research on new technologies to cure the disease.
The disease usually options for the poor, because it is a latent bacillus that takes advantage of malnutrition, AIDS,
and its ability to be passed on among people who live closely together. What’s more, even with treatment, if the
antibiotic is one-dose only or inadequate doses of several antibiotics, or the medicine is taken erratically, the
drug-resistant form of the disease will actually grow into what doctors call MDR or multi drug-resistant TB. It’s a
scary disease and a serious problem in places with the fewest resources to deal with it.
MDR tends to arise where wealth and poverty are mingled, but not usually in places of near universal poverty like
Haiti. However, by the mid-1990’s, Farmer begins to deal with several cases of MDR in Cange. The first appears
sometime during the junta, and Paul is filled with dread. He blames himself when a young man dies, but the fact is
that treating MDR is tricky at best, and during the junta, he can’t find the necessary medicines. However, it is a
learning situation, and now he has assembled the resources to fight the disease at Zanmi Lasante, both with tools
and procedures. He is curing most of the cases that appear sporadically in Cange, when in 1995, it claims a close
friend who has been living in a shanty town on the outskirts of Peru.
Notes
This short chapter explains how poverty gives rise to disease, especially to TB and most horribly to MDR. It is a
segue way to the following chapters which show how Partners In Health would become players in international
health.
CHAPTER
14
Summary
During his years at medical school, Farmer had boarded at St. Mary of the Angels run by a parish priest known as
Father Jack. The church was in Roxbury, one of Boston’s run-down neighborhoods, and largely African
American. His sermons had the feeling of a revival meeting, and he would declaim on poverty and injustice, with
voices in the congregation calling out amen’s. He was also on the board of PIH. In the early 1990’s, he left St.
Mary’s for a place called Carabayllo, a slum on the outskirts of Lima, Peru. Now on visits back to Boston, he is
telling Paul that PIH should start a project in his new parish. Jim Kim agrees eagerly.
Jim has happily served Paul for eight years as his second in command, but now he wants to do more, by learning
how to do what Paul had done in Haiti. At first, Farmer is not enthusiastic, but eventually, he gives in and gets
Tom White to contribute $30,000, half the initial cost of the project. And he gives Jim advice and encouragement
almost daily. Jim plans to imitate a part of Zanmi Lasante: he’d create a system of community health workers in
Carabayllo which they’d called “Socios en Salud, but he wasn’t thinking small. He envisions a project so
well-designed and managed that it would inspire inspiration in other peri-urban slums all over the world. One of
the first systems he implements is a pharmacy which various leaders in Carabayllo had requested. They build it
right next to Father Jack’s church. Unfortunately, there is a civil war going on between the government forces and
the Shining Path guerrilla movement. The guerrillas have their own idea of what is best for the slums, so on New
Year’s Eve, while Jack is saying mass, there is a large explosion destroying the pharmacy. The Shining Path takes
credit, saying that it represents “crumbs for the poor,” which to them is a way to curb the growth of revolutionary
fervor. Paul and Jim are philosophical and just rebuild the pharmacy in another spot.
Farmer also travels to Peru to help Jim conduct a health census in the slum. He finds many of the same kinds of
problems there as in Haiti, but none as acute. Naturally, he wonders if TB is a problem there and is encouraged to
learn that the country has created a nationwide program with the help of the World Health Organization, which
declares that the new program is the best in the “developing” world. Once he reads the official data, Farmer agrees
and decides the one thing they don’t need there are TB programs. Then, Father Jack gets sick and flies to Boston
for treatment in May, 1995. He is diagnosed with TB, and they put him on the standard regimen. Unfortunately,
Jack dies a month later. He had developed drug resistant TB, impervious to all five TB drugs.
Paul is inconsolable once again at the loss of a friend. However, he knows that the clinical facts of Jack’s death are
what matters now. They have happened upon something much more complicated and also more significant and
maybe even more frightening than they thought. In order for Jack to have caught MDR, he would have had to have
caught it from someone else, most likely in Carabayllo. Unfortunately the official records show nothing, and so
Jaime Bayona, the project director, sets to work to dig deeper. He is introduced to a woman named Senora
Brigida, who in telling her story, exposes a system reluctant to admit that MDR exists in Lima. Jaime tells the Paul
the story just as he is catching a plane for Miami. Paul realizes, as he ponders information on the flight, that Peru
must now step up and pay attention to the problem. Unfortunately, to Jaime Bayona, it seems the government is
doing exactly the opposite. When he tries to gain access to patient records, he has to rely on sympathetic health
workers who say that they have something that might interest him, but they aren’t allowed to show him. So they
open the file to the records and walk away and Jaime teaches himself to read them upside down. Then, he hurries
and types up the information to send in e-mails to Jim and Paul.
Notes
The program in Carabayllo becomes PIH’s first foray outside of Haiti. Theyu face many of the same problems
CHAPTER
15
Summary
The author is back as narrator in this chapter describing the first time he saw Carabayllo in Farmer’s company. He
arrives at night, and he sees the beauty of Lima with the hillsides smothered in darkness, but dotted with twinkling
lights like Japanese lanterns. The next day, the truth emerges. Lima is a vast coastal city with a
ramshackle-looking development. On the hills are the huts and shacks where the poor live, and the lights that
twinkled the night before are mounted on highway-style pylons over the shacks. Many of the poor come from the
Andes Mountains and have come here for the electricity, clean water, schools, medical care, and jobs, as well as
distance from the war between the government and the Shining Path. The roads here turn into paths with
convenience stores with dirt floors, metal-roofed cook shacks, barbershops, and even graveyards. But it is all
surrounded by sewage and disease.
Jaime Bayona has found ten patients with MDR. They take a sputum sample from each one, and because the
national labs will not allow PIH to use their facilities, Paul takes them back to Boston. The results are alarming,
because most of the patients are, at the least, resistant to the two most powerful drugs, but many are resistant to all
five. This is an unusual pattern to Farmer, but here it seems like it might be the norm. Farmer immediately returns
to Peru, and Jaime has the ten patients waiting for him. He sits on a wooden stool and interviews each patient. He
is a definite TB expert, and he had written a treatment manual for the house staff at Brigham. He has also seen
cases of severe resistance from too little treatment interrupted by strike or flood. However, here, the ten patients
have received treatment daily, and they have been observed taking their medicine. So it can’t be a case of
noncompliance. They have followed the WHO regimen called DOTS, the most significant advance in TB control
since the advent of antibiotics. Even the quality of the drugs cannot be blamed. So, for these ten patients at least,
something has gone terribly wrong.
Farmer begins to review all the possibilities, and suddenly, his suspicions come together. The dynamics of
tuberculosis make it nearly impossible for a person to require resistance to more than one drug at a time, but
repeated improper therapy can select for increasingly resistance mutants and create strains resistant to any number
of drugs. These ten people had gone to the clinics with one- or more likely, two-drug resistance and through
treatment and repeated treatment under the DOTS protocol had emerged four-and five-drug resistant. The
treatment should have been for the health care workers to determine which drugs they were already resistant to
and then start them on drugs that would work. This had not happened, because they had been treated as if they
were not yet drug resistant at all. These were not acts of stupidity or carelessness, but rather just following the
treatment enshrined as official policy. The policy did not allow for MDR. Also, the money didn’t either. When the
same effect had happened in the USA in the late 1980’s in New York City, the government spent about a billion
dollars to staunch the outbreak. However, MDR was just too expensive to treat in Peru.
Notes
This chapter continues to emphasize the basic premise of Farmer’s work: poverty leads to disease that often is not
treated or is untreatable and that, of course, leads to unnecessary deaths.
CHAPTER
16
Summary
Peru had established its TB program only four years back in 1991, but only after years of inadequately financed
and unsupervised treatment. So Farmer and Jaime know that there are probably many more cases of MDR-TB
than just those first ten. They know from such men as Michael Iseman at National Jewish Hospital in Denver that
the disease is hard to treat anywhere and is exorbitantly expensive. Furthermore, the side effects are just as
daunting, and so each patient will need to be given not only drugs and careful monitoring, but also encouragement,
food, new roofs, and water pipes. Jim reasons that what they have in their favor is that TB is They begin treating
patients in August 1996, transporting the program they used in Haiti to Peru. They already have an indigenous
team of Peruvian health workers, and they also bring in a brilliant epidemiologist named Meche Bercerra and two
female medical students from Harvard. They exchange e-mail daily, and Farmer sends orders in great detail and
devises drug regimens for every patient, inventing tricks for the most resistant cases.
They have some problems at first, including the health workers balking at entering the homes of the patients, but
they resolve that just as they take on the problem of the Peruvian government. The Peruvians fought long and hard
to obtain funding from the government for the WHO program, DOTS, that has made great inroads into the
epidemic of TB in their country. They fear that if Farmer and PIH pushes too hard about money for MDR, they
will lose the program. They don’t want to set any precedent that will give the government the excuse to cut
funding. They also have to fight basic myths about MDR-TB especially that it doesn’t spread as rapidly and as
virulently as regular TB does. In the meantime, one of the Harvard medical students finds a probable MDR patient
named David Carbajal. She and Farmer beg the authorities to treat him, but they refuse, and Sonya, the student,
has to watch him die. Even the young man’s parents understand that it’s just the system, and they are less furious
than Farmer. He sees now that he must go to higher authorities.
Farmer thinks he has found a suitable forum to begin his appeal. He has been invited to give a speech about TB in
Chicago at the annual North American meeting of the International Union Against Tuberculosis and Lung
Disease. Officials from WHO would be on hand along with bureaucrats, public health specialists, and medical
school professors, all of whom made the controlling of TB their life’s work. Unfortunately, not many of them
know much about Farmer, and he knows that many of them will view him as a mere clinician, too interested in
individuals to see the big picture. He rejects that idea utterly: paying attention to individual patients is a moral
imperative, and it is essential to controlling TB in the communities. However, he decides he needs the support of
this body of medical experts, so he decides to give what he calls a “wimpy” speech.
His speech begins temperately enough, but soon Farmer begins to present the “Myths and Mystifications of
MDR-TB” and begins to present each myth, proving it is misunderstood. Myth One: it is too expensive to treat
MDR in poor countries. Farmer shows that it is more costly in the long run to ignore it. Myth Two: DOTS alone
can stop the outbreak of MDR. If left untreated, it would grow in the vacuum left by the cure of TB that is not
resistant to the drugs in use, because it would amplify already existing drug resistance. Myth Three: MDR is less
virulent and contagious than regular TB. Farmer shows that that belief is mere wishful thinking. He goes on
through his list of myths, which he calls “notions” shared by many in the TB world. He may as well have called
half of his audience fools and villains. As he begins to walk off the stage, the moderator thanks him for his
“provocative” talk. Farmer turns back and asks why he calls it provocative? Farmer emphasizes that he is merely
saying that they should treat sick people, if they have the technology.
A few days later, Jaime hears in Peru that someone had called the director of Peru’s national TB program and told
him that Paul Farmer was saying that this program was killing patients. To Farmer, at least, his protest has been
lodged and the higher authorities have noticed.
Notes
This chapter furthers the idea of Farmer taking his radical ideas beyond Haiti. Now he is fighting for the seriously
ill MDR-TB patients and in doing so, taking the risk of stepping on toes of powerful people throughout the world.
It is a testament to his determination to follow through with the comment he left in Chicago: “We should be
treating sick patients if we have the technology.
CHAPTER
17
Summary
Paul is given Ophelia’s blessing to court and marry someone else. He falls in love with Didi Bertrand, the
daughter of the schoolmaster in Cange, and they are married there in 1996 with over 4000 guests – all of the town
of Cange included!
In Peru, the patients are beginning to tax PIH’s resources. The cases of MDR are growing, and whole families are
affected. Paul and Jim’s friend in Boston, Howard Hiatt, a very influential physician at Brigham and Harvard, is
told that Farmer and Kim owe Brigham $92,000. They have been sweet-talking their way into medications from
the hospital pharmacy, in what Hiatt calls their Robin Hood attitude. Fortunately, Tom White comes through with
the money. However, even he is worried about their refusal to realize that the money could be finite. He wants to
die penniless, but is afraid the two doctors will take all his money before he dies! Nonetheless, he is there with
money whenever they need it. The sad part of all this is that they lack institutional support, and the weight of
opinion is against them. Furthermore, Peru is putting a strain on all their other projects. Add to all these problems
the costs of travel that both men, but especially Farmer, incur not only the cost to the treasury of PIH, but also the
cost to Farmer’s health.
Farmer hadn’t been feeling well when he gave his speech in Chicago, but he feels even worse when he begins a
month of service in Boston. At first, he just tells himself he is exhausted because of the schedule he has been
keeping. However, when he reviews his symptoms, he fears that he has contracted MDR. He gets a friend in
radiology to do an x-ray in secret, and fortunately, it’s normal. Didi, his wife, begs him to see a doctor, but he
insists he is a doctor and can care for himself. He has the colleagues he’s working with give him fluids
intravenously, but he just feels worse. One of the infectious disease specialists comes back with the news that he
has hepatitis A, against which he had never taken the time to vaccinate himself. He gives up to their pleas to be
treated and hospitalizes himself. For a time, his doctors worry that he might need a liver transplant, but eventually,
he improves, and then Ophelia sends him and Didi to the South of France for his first vacation in nine years. All’s
well that ends well, because nine months later, his daughter Catherine is born.
Kidder, the author, wonders at Farmer’s recklessness in not protecting himself against disease. However, at some
point, he has come to hold Farmer to a higher standard than most people he knows. After he has seen him in
action, he is much more able to excuse him.
Finally, the MDR program has begun to make progress, and the Peruvian doctors are beginning to notice.
Accordingly, Farmer and Jim are making progress with them. One day, Kidder follows Farmer to an appointment
at Children’s Hospital in downtown Peru. Because of traffic, they are an hour late, but all is forgiven when Farmer
sees little Christian. At the age of three, the little boy had been diagnosed with MDR-TB and was dying in agony
when Farmer finally saw him. The boy was on his second regimen according to DOTS and Farmer knew he would
die if they didn’t break from those protocols. He devised a regimen with second-line drugs which no one knew
how to apply to children. Farmer followed an “empiric” regimen, which was based on his best guesses. He was
enormously successful and little Christian is now chubby and healthy.
Farmer is impressed to see Christian healthy, but the case he has come to see is the daughter of one of the
Peruvian doctors. Farmer has now learned how to play the game that will allow these doctors to see the truth about
how to treat MDR patients. They cannot pronounce a new protocol themselves, but Farmer can. So when he says
how the child should be treated, the others are willing to implement his ideas. Christian being there is his most
eloquent argument for adding flexibility to the norms. He tells Jim that a few more success stories like Christian’s
and they will have turned the corner with the Peruvian doctors. As he leaves the hospital, Christian’s mother
approaches him and says in Spanish, “I want to say many thanks.” Then, Farmer, with great humility, replies in
Spanish as well, “For me, it is a privilege.”
Notes
This chapter shows the steady, sure changes that Farmer and Jim are making in Peru, but it also reinforces the
possibility that Farmer could destroy his own health in trying to improve the health of others. Nonetheless, even
Kidder, our author, is so impressed with the kind of man Farmer is that he is willing to excuse how he cares for
himself.
CHAPTER
18
Summary
In April 1998, a special meeting of physicians working on TB is convened at the American Academy of Arts and
Sciences, a meeting to present the early results from the MDR treatment project in Peru. They want to show that
they have had a more than 85% cure rate for MDR-TB patients. Howard Hiatt moderates the meeting and declares
it an astonishing result that the world must hear about.
One of the world’s ranking TB experts who attends is Arata Kochi, the head of WHO’s TB program. He actually
comes to quell the bad publicity Farmer had been stirring up, because he had been laboring for years to sell DOTS
to the world. However, he has also come to the conclusion that WHO needs to come up with a solution for
drug-resistant TB: one of his staff has coined the phrase DOTS-plus for this new initiative. He knows that they
have to respond to clinicians like Paul Farmer who are screaming at them for help. It’s time to start a dialogue. As
for Farmer and Jim, they love the phrase and are encouraged by Kochi’s attitude: if you can’t beat them, join
them, and then control them!
Kochi has made a dramatic concession, but the discussion is just beginning for other doctors there. One of the first
to express his concern is Alex Goldfarb, a microbiologist from Russia who states first off that “Russia is a TB
nightmare.” He is most concerned about the prison inmates who are being treated with a single drug. His
nightmare is money. There is not much Farmer can say to alleviate Goldfarb’s money worries, but he does indicate
they have overcome these problems for a small number of patients and that it’s possible to do it on a bigger scale.
Goldfarb also has a bigger conundrum: He has only six million dollars from the Russian government, and he can
spend a large portion of it on the 10% of patients who have MDR-TB or go to another region and make it available
for 5000 who have regular TB. How do you use limited resources? It is a very serious question. He is also angry
that men like Kochi are trying to control TB globally, and so have a different set of priorities. He doesn’t have
time to do a pilot project like Kochi would recommend. Hiatt responds that Kochi is thinking about controlling TB
not in a few months, but in decades to come. That is an admirable goal. Of course, Goldfarb has made an
argument that they will all have to respond to sooner or later.
Jim speaks to the group the next day, explaining that they had taken resources from PIH in Haiti, feeding 4000
children, in order to try to assure that they would attract the very men and women from the around the world who
are sitting in the room at that very moment. They want to expand resources to a problem that afflicts the
populations they serve. When one of the members comments that they must find the political will, Jim responds
that politics is outside of their focus, because places like Zaire, where the country’s president had stolen more than
30% of the loans from the World Bank, need outside help. He opines that shrinking resources are only ever a
reality when it has to do with poor people. They need endorsements from academics with clout and the total
support of the TB community. He concludes by quoting Margaret Mead who said, “Never underestimate the
ability of a small group of committed individuals to change the world.” Jim then responds to that quote by saying,
“Indeed, they are only ones who ever have.”
Notes
The meeting with physicians from around the world is an important step in drawing attention the TB problem
everywhere, but especially to patients who have MRD-TB. The argument of course is an old one: where do you
use the resources?
PART IV - A LIGHT MONTH FOR TRAVEL
CHAPTER
19
Summary
This chapter explores the optimism of Jim Kim. His meeting had produced a committee to study the feasibility of
st
DOTS-Plus programs, but the arguments about MDR are far from over. Jim is fighting with his 21 century
th
optimism the basically 19 century utilitarian philosophy of the greatest good for the greatest number. He knows
that any proposals he makes must pass the cost-effectiveness analysis. This philosophy, however, is flawed when
Jim and Farmer think about how international health care councils often use it to rationalize an irrational status
quo: MDR treatment is cost-effective in a place like New York, but not in a place like Peru.
What the two men, especially Jim, come to realize is that what makes MDR treatment inordinately expensive is
the high-priced drugs used to treat it. They need to drive down prices and that’s where Jim finds his calling. He
doesn’t exactly know how to do it, but he’s willing to make the assertion and then figure out the means.
Jim is a South-Korean who grew up in Muscatine, Iowa where his father was a periodontist. His father was very
proud of his practice, and his mother was a small elegant woman who spent her years as a wife and mother
teaching her children about exploring their world.
Jim was the quarterback on the Muscatine High School football team, a starting guard in basketball, and the
valedictorian of his class. They were the only Asian family in town and Jim spent much of his youth embarrassed
by his parents’ Koreanness. He went to the University of Iowa and then transferred to Brown where he discovered
an organization called the Third World Center. He became its director and would only associate with
African-Americans, Hispanics, and Asians. He eventually went to Korea to live and learn his native language.
However, he became bored with the politics of racial identity and was ready to change direction when he met
Farmer. It wasn’t long before he wanted to make Farmer’s preferential option of the poor part of his own life’s
work. Like many students who had joined PIH after hearing Farmer speak, he believed he could change the world.
He said of PIH, “People think we’re unrealistic. They don’t know we’re crazy.”
Through his research in Korea, Jim learned that the price of a drug is often based on how many companies make
it. Usually, only one company makes it, and they don’t want to deal with second line drugs, because even if the
market is large, it is usually poor, so the demand is small. When he and Farmer try to buy capreomycin from Eli
Lilly, they are quoted $21.00 a vial. They find out they can buy it in Paris for $8.80, but the French won’t sell it,
because there is a global shortage created by the need in Peru! When Howard Hiatt hears this news, he comments
that it sounds like price gouging. This is standard practice among drug companies and is the reason why
Americans pay so much more for their drugs than other countries. Hiatt then proposes that he will put pressure on
a friend, who is on Lilly’s Board of Directors, to donate the drugs as a means of good publicity.
Jim then calls a meeting to encourage drug companies to produce more second line drugs but WHO backs out. Jim
holds it anyway, using slides to show the drug company representatives the numbers indicating the demand for
these medicines. The drug company reps just argue that second line drugs ought to stay high. That’s when a
Dutchman named Guido Bakker, who works for the International Dispensary Association (a company that
specializes in driving down prices of essential drugs needed in poor countries), rises to announce that his company
is going to doe everything it can to lower prices by exploring generic manufacturers. This strategy is intended to
ignore the giant multinational drug companies and rely on the smaller companies that make and sell at greatly
reduced prices already invented drugs under different names. Jim loves the idea and like many other inspirations
he has, he borrows from someone else and adapts it to what he is working on.
Now the biggest problem is going to be to get WHO to add the second line drugs to its list of essential medicines.
WHO becomes reluctant to do so when physicians from all over world begin to write and insist that these drugs
should not be included, because if prices fall, they will become too widely available. This means that black market
salesmen and unscrupulous pharmacists will flood the market with them and breed resistant strains that no drugs
can cure. That’s when Jim knows he has to find a mechanism to ensure control of the cheaper drugs. He gets
another idea, this time from the Green Light Committee, an international entity established to control the
distribution of the meningococcal vaccine. He believes PIH can do the same thing and suggests they use the same
name – Green Light Committee – to show they are following precedent. Simply put, the committee will serve as
the ultimate distributor for second line TB drugs. Once prices fall, they will have real power. Then, if a TB
program proves that they have a good plan and a good underlying DOTS program, they will receive the drugs.
WHO capitulates and places all the TB antibiotics in an annex to the essential drugs list. The prices fall in stages,
but eventually, capremycin costs 98 cents per vial. Now no one can say anymore that cost alone rules out treating
MDR in poor countries. Guido Bakker claims that 85% of the work that made this happen can be attributed to Jim
Kim who pushed and pushed and pushed until it all came true.
Soon, Jim tells Farmer that the political side of public health interests him much more than patient care and
Farmer encourages him this endeavor, saying, “We trust you with power. We know you won’t betray the poor.”
Jim has finally come of age with Paul’s blessing. He is no longer second fiddle, but a doer and a shaker of his
own.
One of the biggest problems for PIH, unfortunately, comes to a head. They desperately need cash, and Tom White
is now in his 80’s with much of his fortune already given to them. Farmer believes, as a result, that within a year
or two, they’ll have to go back to supporting their one little corner of Haiti, but Jim believes otherwise. He thinks
they should propose a project to wipe out TB all over Peru and then go international and show the world it is
possible to beat back the dread disease. If they can win out over it, why not AIDS? For over a year, he has been
courting “big shot” donors, including the Gates Foundation. It has an endowment of 22 million dollars and wants
to work on projects to improve world health. Jim and Paul meet the foundation’s senior science advisor, Bill
Foege, who likes programs that favor unconventional methods to solve supposedly impossible problems. He
encourages them to write a grant for money to help PIH. Jim and Paul discuss how much to ask for and Paul
suggests two or maybe four million dollars. However, Jim reaches for the sky and insists they ask for 45 million
dollars. Paul says they’ll never get that much. To which, Jim replies, “On exactly what data do you base that
statement?”
Notes
This chapter is a wonderful showcase for the talents of Jim Kim. He is an enthusiastic member of PIH and always
seeks to go high and higher. With his know-how and determination, Partners In Health are poised to go
international.
CHAPTER
20
Summary
Howard Hiatt tells Kidder that Paul and Jim have mobilized the world to accept drug-resistant TB as a soluble
problem. He feels this is no small matter, because two million people a year die of TB, and when they include
MDR patients, the number can increase dramatically. Add malaria to this problem, and it’s obvious the world
faces catastrophe on a scale not seen in centuries. He wonders what would happen if the time Paul gives to
patients one-on-one in Haiti were converted to a major program elsewhere in the world. Think what he
accomplishes now, and what he could do if he spent most of his time on worldwide projects.
Farmer is widely respected throughout the world for his work, but only he seems to know what his overall plan is.
Kidder likes to watch him answer his e-mail in Cange, on airplanes, and in airport waiting rooms. He receives
many, asking him for a variety of help and from all over the world. Farmer always answers promptly even though
he may have upwards of 75 messages a day. These days, as Ophelia says, “Wherever he is, he’s missing from
somewhere.” In a two week period, Kidder accompanies him from Cange to a church group in South Carolina to
Cuba for an AIDS conference to Moscow for TB business and a stop in Paris en route. On these trips, he maybe
wears one of his two suits and drives the truck to the airport in Cange, because he gets motion sick. The road along
the way makes Kidder narrate Haiti for the reader: the road had been built by
Mountains Beyond Mountains by Tracy Kidder - MonkeyNotes by PinkMonkey.com American
Marines
early in the 20 century using slave labor; he had seen one picture of a slave who had refused to work and the
Marines had cut off his hands; sights along the road are less dramatic than they were , but nonetheless still
poignant, like the old man riding an emaciated pony as he tries to go to work on a rocky, infertile piece of ground;
the sights remind Kidder of Matthew 25 which says, “Inasmuch as you have done it unto the least of my brethren,
you have done it unto me.” They encounter a kwazman along the way. That is something you encounter on the
road that isn’t good. Farmer is pleased it’s just an overturned truck with no dead bodies.
th
Their first stop on the road is a prison where one of the men in the truck will visit with his son who has been
accused of murder. Farmer has already found the kid a lawyer and talks softly to him about his prospects. Then,
the truck won’t start when they leave, so they have to push it until it catches, and they go on their way. Farmer
tells Kidder that it occurs to him that with all this “cost-efficacy crap,” if he saved just one patient, it wouldn’t be
so bad. However, what he really loves is his chance “to save a zillion of them.” The next stop is a downtown
errand and then the airport. The traffic is snarled, as it always is on the road to the airport, but they arrive with
Farmer still in a great mood. On the airplane, however, Kidder realizes his mood has saddened. Farmer actually
hates leaving Haiti, mostly because as he looks back from the plane window, he knows that the Haitians are never
going anywhere. Writing thank you notes and putting a checkmark on his bwan improves his mood. Nonetheless,
his thoughts of a baby girl who had died the night before keep him sad until he and Kidder go over the patients
back at Zanmi Lasante. Then, he remembers how well the little premie was doing, and he brightens up again.
Ophelia describes Farmer’s personality as fairly complex, built of oppositions – a need for frenzied activity that
verges on desperation and a towering self-confidence oddly combined with a hunger for affirmation. However, she
believes he has never experienced true depression, no matter how bad the conditions he experiences. He always
seems to find a way to bounce back.
Farmer loves Miami Airport, because it’s here he can get a haircut with his favorite Cuban barber with whom he
speak Spanish, buy his favorite People magazine, sit in the Admiral’s Club, and sip some wine. He calls this a
“Miami Day” and when he has to stay over at a hotel there, it’s a “Miami Day-Plus.” However, he often spends a
long time finding his gate, because the people in Cange are not able to keep his schedule in order, and he doesn’t
often know where he’s supposed to be. When it comes to managing his staff, he has only one major rule: no one
can be fired except for stealing or slapping a patient twice.
That night in the Miami hotel, Farmer breaks his toe when he gets up in the night and won’t turn on the light in
fear of waking Kidder. It doesn’t stop him, however; he just limps along with a minimum amount of luggage and a
smattering of clothes. He prefers to fill his suitcases with medicines and gifts so he only has three shirts to last him
two weeks. Kidder remarks on Paul’s sleepless nights, his hundred-hour weeks, and his incessant travel. His
answer to that is, “If I don’t work this hard, someone will die who doesn’t have to.”
Finally, they come to the check-in point where, like everyone else, they are carrying the gifts and the extras to
people who have no access to them. Kidder figures Farmer is looking forward to Cuba, because he says, “No dead
babies for awhile.”
Notes
This chapter reveals a great deal about the kind of man Paul is as Kidder follows him on a typical trip from Cange
to Miami to Cuba. His personality and mood bounces all over the place at times, but he always manages to find
something optimistic to think about.
CHAPTER
21
Summary
This chapter details Farmer’s and Kidder’s time in Cuba. Farmer’s first commentary about the island of Cuba The
Cuban doctor who is running the AIDS conference is a friend of Farmer’s named Jorge Pérez. He has sent a car
for them, and as they travel to Havana, Kidder sees the large billboard with Ché Geuvera. It reminds him that
Farmer is fond of Cuba, not for ideological reasons, but for its health statistics, vetted by WHO and generally
regarded as among the most accurate in the world. Since its revolution, Cuba had achieved real control over
infectious diseases. Farmer says it is a given for him to admire Cuban medicine. It’s a poor country, largely in part
because of the American embargo, but the regime had listened to its epidemiologists and had increased health
expenditures. In fact, their doctors are so well trained that the country has largely abandoned any idea of exporting
its armies, but sends out its doctors instead. Farmer even becomes incensed at comparing Cuba to Scandinavian
countries which have learned how to manage their wealth. Cuba has learned how to manage its poverty. He also
wasn’t a Marxist in any way. It seems to him an undeniably inaccurate philosophy. However, he is more interested
in denouncing the faults of capitalism than in cataloguing the failures of socialism. He distrusts all “-ologies” even
his own liberation theology. What happens when the poor stand up behind an ideology to reclaim what is theirs?
He says we know already, because we are digging up their bodies in Guatemala. As for Kidder, he finds the sights
of Cuba lovely after the deep and destitute vision of Haiti while Farmer can finally sleep, because everyone here
has a doctor.
Farmer is looking to Cuba first of all for money to stockpile antiretroviral drugs, enough to treat twenty-five
patients with full-blown AIDS in Cange. So he begins his lobbying tactics with Peggy McAvoy, a woman at the
conference who is in charge of the United Nations’ project on HIV/AIDS. He also hopes to begin creating more
doctors willing to stay in Cange and has picked out two local youths to go to medical school in Cuba. Pérez
introduces him to the Secretary of Cuba’s Council of State, Dr. José Miyar Barreuecos who immediately says of
course. Then, he approaches the French ambassador and the keynote speaker, Dr. Luc Montagnier, the man
credited with discovering the human immunodeficiency virus. He speaks to them about his dream of a new kind of
“triangle” between France, Cuba, and Haiti, which includes doctors from Cuba and money from France. His
ability to speak French so well impresses them, and they agree to help. These may be polite promises, but Farmer
believes the more he lobbies people, the more the help will appear, even if later down the road.
Farmer is giving two speeches at the conference. The first has to do with HIV and TB coinfection, and as he says,
the second is entitled, “Why Life Sucks.” The second asks the audience to remember the days when expert opinion
had retailed all sorts of nonsense about who caught HIV and why. Those were the days when to be Haitian meant
you were part of a “risk group.” He had designed a study, as a result, about why two particular groups of Haitian
women didn’t fit the definition of a risk group. They had not been exposed to intramuscular injections, blood
transfusions, or intravenous drug use. They practiced what he called “serial monogamy,” that is they had had sex
with no more than two men and only one man at a time. They worked as servants in Port-au-Prince for Haiti’s elite
and were either cohabiting with truck drivers or soldiers. Farmer had to wonder why these two groups of men? He
came to the conclusion that these two groups had steady jobs which attracted the women, but they also traveled or
had access to other women rather steadily. This is why these men contracted HIV and passed it on to the two
groups of women. After coming to this conclusion, Farmer logged onto Medline on the internet and
cross-referenced the terms “Aids, women, and poverty” and found absolutely no studies meeting those
specifications. These ideas he asserts make people uncomfortable, but he warns that they need to deal with these
details. He agrees that co-infections of AIDS and TB are important topics to know, but it’s also important to
understand that poverty is the basis for them both. Farmer says, “A woman in Cange said to me, ‘You want to stop
HIV in women? Give them jobs.’ “ He receives a long, loud round of applause.
Even though he would like to hang out at the conference, Paul spends most of his down-time in the hotel room
working on his laptop. If he begins to doze, he jumps up and shouts at himself to get it together. He is typing grant
proposals and writing a counter-editorial questioning the wisdom of treating TB in Russia. He’s also working on
his next book entitled Pathologies of Power. He tells Kidder that he doesn’t approve of quarantine as a means of
controlling AIDS. He cites two examples: the one in which Americans quarantined Haitians at Guantanamo Bay
and treated them so badly that an American judge ordered them released; and the one in Havana which is
conducted at an old hacienda called Santiago de las Vegas. When they visit there, Kidder notices that there are
some small problems with the building, but it’s far from shabby. Pérez tells them that it came about at the orders
of Fidel Castro who told them it was their responsibility to keep AIDS from spreading in Cuba. Each patient has
his own set of rooms, like mini-apartments, which Kidder says he finds kind of depressing. He thinks that Paul is
just looking for things to praise in Cuba, and he decides to take the opposite view, maybe looking for an argument.
However, the statistics speak for themselves: on an island of 11 million people, only 2,669 had tested positive as
of the year 2000; the virus had progressed to AIDS in 1,003 of the people infected, and of those, 653 had died;
only 5 children caught HIV from their mothers, and they were all doing well; finally, because Cuba had acted
quickly to clean up its blood supply, only 10 people had contracted HIV from transfusions. Perhaps the US
embargo had protected the island to a great degree, but at the same time, Castro was engaging in a lot of
commerce with Africa, which tends to negate that argument. The island nation had just taken the right steps to
control the onset of the disease.
Jorge takes Farmer and Kidder to meet the chief forensic pathologist of Cuba who tells them how he and his team
had found the body of Ché Guevara in Bolivia and brought it back to Cuba. Of course, some would say that was
just a claim, not a reality. He also takes them to dinner at his home, and Kidder sees that, even though he is a
doctor, he lives like a lower-middle class citizen in America. To Paul, it is all like a holiday. He can’t e-mail out
because of internet restrictions in Cuba, and even though he will pay for that later, he is happy to be free of it now.
He enjoys the tarnished heirloom atmosphere of Havana, but it does make him feel guilty about Haiti, which he
thinks in the 18 years he has worked there, the country has only gotten worse. He thinks Zanmi Lasante is an oasis
in the midst of despair in Haiti, but he feels the Cubans would have done a better job.
Farmer marvels at the attentions lavished on him in Cuba. He asks Kidder what he thinks is the reason for all this.
Kidder knows he should find an answer that Farmer already thinks he knows, just to keep the peace, but instead he
says that he thinks the Cubans like Farmer’s published attacks on American policy in Latin America, his frank
admiration of Cuban public health and medicine, and his efforts to create connections between Harvard and Cuba.
Farmer just stares at him and says he receives the same sort of reception even in Russia, whose wacky health
system he hates. So he definitively tells Kidder that it’s because of Haiti that he’s admired: he serves the poor.
Kidder feels like Farmer is now angry, disappointed, and a little hurt, but he doesn’t stay angry for long. It’s a
relief to Kidder to believe he’s forgiven. However, at the airport, he takes the opportunity to tell Kidder that if he’s
going to write about Ché, he should write it from his own opinion, not Farmer’s. This is actually his way of
warning Kidder about how he should write about Cuba. He insists that he doesn’t care how Kidder portrays him,
but if he shows him as a sycophantic ally of Cuba, then the Cuban doctors concern for the poor of Haiti will be
lost. He also doesn’t want Pérez’s efforts within the Cuban health system to be ridiculed. Kidder wonders if he’s
being told that Farmer doesn’t want to travel with him anymore. He asks that very question when Farmer begins to
talk about their next destination, Russia. Farmer simply scolds him, “No, no. It’s important.” He calls the end of
the scolding a “dismount,” a term used in his family when they became interested in gymnastics during the
Olympics. To them and to Farmer, a dismount is the term meaning the end of the conversation.
It’s difficult for Kidder to stay angry at Farmer. He does so much for so many and in a usually cheerful attitude.
Kidder also knows that there is no question that Cuba has pulled off a great achievement with its health system.
He just wonders what the price is in political freedom for its people. However, he also knows that Farmer would
frame that question a little differently: what price would most people pay for freedom from illness and death?
Farmer would turn Haiti into Cuba in a minute if he could. His hope for Haiti is that someone will revolt for the
people who are too ill to do so themselves. They see a large sign on an airplane hanger which reads: “Patria es
humanidad,” the only real nation is humanity. To Farmer it is a lovely saying, but to Kidder, it’s just a slogan.
They finally catch their plane in Miami to Paris, although Farmer’s busyness with shopping and e-mails almost He
finally comes to this conclusion about Farmer: in Farmer’s mind, he is fighting all poverty, all illness, all the time.
The reward is inward clarity and the price, perpetual anger. Farmer wasn’t put on this earth to make anyone feel
comfortable, except for those lucky enough to be his patients, and for the moment, Kidder has become one of
those and that’s what gives a feeling of reassurance.
Notes
Their time in Cuba is interesting for Kidder, but he has a hard time disassociating himself from what he has
learned all his life about Cuba by living in America. To Farmer, it’s not about the politics, but about the health
system. He doesn’t care where the compassion for and willingness to help the ill and poor comes from, just as long
as it comes.
CHAPTER
22
Summary
Farmer and Kidder arrive in Paris to see his wife and daughter on their way to Russia. Farmer once had asked Didi
if Paris wasn’t the loveliest city in the world. She had been moved by it differently: “Knowing that this splendor
came from the suffering of my ancestors.” That also became the subject she is studying now – the archives of
French slave masters and the detailed records they had kept of their commerce in West Africans. Didi and
Catherine live in the Marais district, and Farmer and Kidder are staying long enough to celebrate Catherine’s
second birthday. The lack of time Farmer is devoting to his family becomes a bone of contention between him and
Didi. For those who have always seen him as a monument to perfection, it is relief to see that he has this chink in
his armor. He has a hard time himself justifying the idea that he loves his own daughter more than Haitian
children. He came to realize this when he tried to save a baby whose mother had developed eclampsia. He hurried
to save the child, but it was still-born. He began to cry and realized that it wasn’t for the dead child, but because he
imagined Catherine lying there dead at birth. He knows that this is the way he’s supposed to feel, but it still
induces guilt in him. He says if people ask him where he gets off thinking he can love all children as much as his
own, he will answer, “I can’t, but I’m going to keep on trying. Comma.”
It occurs to Kidder that many people would love to be like Farmer, waking up knowing what they ought to do and
feeling that they are doing it. But there wouldn’t be many who would willingly take on the difficulties, giving up
their comforts and time with their families. Farmer spends the summers with his family, but in the meantime, there
are the hard and lonely days and nights. He carries two pictures of children with him: one is of Catherine and the
other is of a Haitian child with kwashiorkor. The second picture is a symbol of all the people suffering from TB
and perhaps his willingness to try to love them all equally.
At Catherine’s party, there a number of people with whom Farmer has made PIH connections. They are people
who are more than mere acquaintances, because he doesn’t allow many of them to slip away. They become a part
of his PIH family.
At the airport, early the next morning, Farmer sits at a café working on his bwats (French boîtes or boxes). He says
it’s shameful that only 2/3 of the list has been checked off. They were all supposed to be finished by the time they
left Cuba. Among them is a dual bwat which consists of two chores: he can buy new underwear or finish a letter.
Since he hasn’t bought the underwear, he sits down to finish the letter he had begun in the Haitian countryside.
When Kidder asks if he’s cheating on his bwat, Farmer answers that it depend on if it’s a “H of G or hermeneutic
of generosity,” which means whether he looks upon it in a generous light, just the way he feels about Kidder. This
is just one of the many terms he has in his strange lexicon, a language that the PIHers have picked and follow
perfectly. For example, when his brother Jeff misspelled Haitians as Hatians, Farmer began to shorten it “Hateans
or Hats” and their country became “Hatland.” The French were “Fran-chayze” and their tongue “Franch-chayze
language.” The Russians were “Rooskies.” Farmer calls himself “white trash” and even though he has the utmost
respect for women, he still calls them “chicks.” People of the same race and gender who suffer because of it have
“different degrees of shaftedness or hose-edness.” To commit a “seven-three” was to use seven words when three
would do, and “ninety-nine one hundred” was quitting on a nearly complete job, something he hated more than
anything else. He admitted anyone and everyone to his club of PIHers who was willing to learn their language and
do their work and at times, he had a way of creating a club that consisted of just him and you.
Once Farmer had given a speech at the Harvard School of Public Health and used the Haitian phrase ”looking for
life, destroying life.” He explained it as an expression they used if a poor woman selling mangoes falls off a truck
and dies. In other words, trying to keep her family alive, she sells mangoes, only to die when she falls off the
mango truck. At that moment, Kidder feels as if he can see a little into Farmer’s mind. What Paul wants is to erase
time and geography connecting all parts of his life and tying them instrumentally to a world in which he sees
inescapable connections, for example, between the gleaming, corporate offices of Paris and New York and a
legless man lying in a mud hut in the remotest part of Haiti. He sees the greatest error of the world as the “erasing”
of people, the “hiding away” of suffering. Kidder wonders if there is any room in Farmer’s world for anyone but
the poor. His question is answered one day on a plane when Paul says that he thinks of every passenger as a
patient, and in fact, is called away by the pilot to help a man who thinks he is having a heart attack. This happens
to him about once in every eighteen flights, but Kidder thinks that Farmer wouldn’t mind if it happened every
flight. “Embracing a continuity and interconnectedness that excluded no one seemed like another of Farmer’s
peculiar liberties. It came with a lot of burdens, of course, but it also freed him from the efforts that many people
make to find refuge and distinction from their pasts, and from the mass of their fellow human beings.”
Notes
This chapter is particularly important in understanding Paul Farmer’s character. He has peculiarities in his
language and feels guilt at loving his daughter more than Haitian children. He tries hard to change that
nonetheless. He works hard also at embracing a world where he excludes no one which frees him from other kinds
of guilt that make people ignore others and try to find refuge from their pasts.
CHAPTER
23
Summary
This chapter examines Farmer’s and Kidder’s trip to Moscow. This is Farmer’s fifth trip trying to obtain a loan
from the World Bank for the Russian TB program. On the airplane, he explains the history of the mission. Two
years before, Howard Hiatt had sent him to George Soros’ foundation to search for new money for Peru. This
foundation declined to become involved, but described to him the similar work they were doing in Russia. The
letter they sent explains the details of the $13 million Soros had committed to it. They had insisted on a DOTS
only program with hospice care for those who didn’t respond to it. Then, the collapse of the Soviet Union had
been an ideal situation for the increase of TB and rising crime had led to over-crowded prisons where the TB
flourished. Farmer told Soros his program was doomed to fail. Soros then yelled at Alex Goldfarb over the phone
and asked Farmer for his help. At first, Farmer didn’t want to give up his time in Haiti, but because prisoners were
special constituents of PIH, he decided to get involved, especially because it was a way to show the consequences
of neglecting health everywhere.
So Farmer went on a tour of the Siberian prisons with Goldfarb and realized, just as he had believed, that prisoners
contract TB at higher rates than civilians, and in Russian prisons, it was 40 to 50 per times higher. It had become
the leading cause of death there. What’s worse, many of the TB patients left prison before they were cured and
took it back to the civilian population. The situation was dire and the Russian response puny. It was worse than
anything he had seen in Peru or Haiti. Unfortunately, when he and Goldfarb held a press conference to announce
their findings, it was the same day that the Special Prosecutor released his report on the Monica Lewinsky scandal,
so few reporters showed up. As a result, Farmer and Goldfarb flew to New York to speak with Soros. Farmer told
the man that it would take $5 billion to control TB throughout the world, but he only wanted Soros to put up more
money for Russia. Soros felt that would delay the international response, so using his friendship with Hilary
Clinton, he went about getting a loan from the World Bank. Even though, Farmer was against the idea of a loan,
he became more and more involved. Now he is on his fifth trip, hoping this time the money will become available.
Farmer, Kidder, and Alex Goldfarb visit Moscow’s Central Prison, Mastrosskaya Tishina, an immense building
where you don’t want to get lost. Farmer, as prisoners come into view, points out how much worse it is even than
Haiti. They enter a cell filled with fifty AIDS patients, and Farmer talks through an interpreter and is thanked for
his visit. After this visit, Kidder explains, one can understand the problem more clearly. Too many people are
being thrown into prison for minor crimes, really adding to the spread of TB throughout the country. Furthermore,
the TB department in the prison has overworked doctors, almost no protection, exhausted X-ray equipment, not
enough drugs for the number of patients, and no support from Moscow. Of 100,000 inmates, probably 30,000 had
TB. Farmer even took the problem to the American TV program, Sixty Minutes where he’s asked how soon the
problem will get out of hand. Farmer soberly replies that it already is.
Then, they are taken to a cell filled with TB patients and amazingly Farmer meets people who have met him
before. He also really likes the medical personnel, because they are really trying. Farmer tells Kidder as they walk
along that they have 700 beds in this prison and 500 of them are filled with TB patients. Add to that a rise in
syphilis, which indicates there will be a rise in AIDS. “It’s gonna be a disaster,” Farmer says. When they sit down
to eat, Farmer tells an interesting story: he had been named the TB commissioner for the state of Massachusetts
and so every time he needed lab resources, he went back there, because Massachusetts has a lot of TB labs, lots of
TB doctors, lots of TB nurses, lots of TB lab specialists. What Massachusetts doesn’t have is TB. That’s just the
opposite in Russia.
The next day, they go to speak to representatives of the World Bank, who believe the loan should be used to treat
all strains of TB, that is, both DOTS and DOTS-plus. The division comes in how the money should be allocated.
Farmer knows he has to keep Alex in check, because he can be offensive in how he views all the bureaucrats, so
he brings him first to their hotel room where they go over strategy. Alex believes that the people they will meet
with are totally insignificant. They all are involved in turf wars: WHO, the World Bank, the Soros Foundation, and
even PIH. Alex thinks that what matters is the Russian split between the Ministry of Health, which deals with all
Russians, and the Ministry of Justice, which deals with the prisons. There are too many shadowy connections in
the Ministry of Health, which he thinks wants the money to prop up their crumbling system. The Ministry of
Justice may not be pure, but its intentions are correct. They know the prisons are an “epidemiological pump,”
spreading TB among the prisoners and then releasing them into the general population to further spread the
disease. Purifying the prisons will clean society. Unfortunately, the World Bank is inclined to give them only 20%
of the money while both Farmer and Goldfarb want 50%. Alex feels they’ll fail in their request, so he’s ready with
Plan B: fail at getting most of the money and resort to raising hell to get the attention of private money.
Farmer must convince the World Bank that they need 50% of the loan not only for medicine, but also for better
conditions in the prisons, including increased amounts of food for the sick. The bank argues that it isn’t
cost-efficient, but then privately tells Farmer to call it vitamins in the proposal, and it will go through. In the end,
the World Bank agreed that the Ministry of Justice will receive half the money.
Farmer and Alex love each other and are fast friends, but they argue incessantly, especially over prisoners. Alex
sees them as just bad people who are merely epidemiologically important. To Farmer, they are all people in need,
albeit with about 10% who are every bad. He asks Kidder later of he thinks he is crazy to feel that way about
prisoners. Kidder says no, but points out that some of them have done terrible things. Farmer says he knows that,
but he forgives them. Kidder says forgiving everyone is a fight Farmer can’t win. To which Farmer
Notes
The fight in Russia is one which takes Farmer away from the places he really wants to be, but one which is
necessary, not just for the patients, but also for the attention of the world on the needs of the poor. He is a clinician
at heart, but will be a bureaucrat if he has to.
PART V – O for the P
CHAPTER
24
Summary
In July 2000, the Gates Foundation gives Partners In Health and a cohort of other organizations $45 million to
wipe out MDR-TB in Peru, virtually everything Jim Kim had asked for. The grant is intended to last five years and
Jim plans to cure 80% of the patients, which will then give Peru control of the dread disease, and the world will
have proof that countrywide control is possible. Farmer is pleased with the grant but frets that other people who
support PIH will think the charity doesn’t need their money anymore. As a result, he begins to speak to all his old
allies and supporters to tell them in no uncertain terms that they “are not dismissed.”
The greatest problem for PIH at this point is just paying the bills since foundations tend to narrow the focus of
their giving. Also, he still has the problem of obtaining money for drugs for Haiti when every potential giver
insists that Haiti fails to meet “sustainability criteria.” That is, once the disease is under control, the patients
cannot afford to pay for drugs to sustain the program. Fortunately, the Soros Foundation, Tom White, and the
selling of their headquarters in Boston help sustain the program in Cange. Furthermore, Friends of Harvard
Medical School and the Brigham also provide support, and Farmer persuades Harvard to give them office space in
a pair of old brick buildings on Huntington Avenue. Of course, this means adding newcomers to the staff which
Ophelia is expected to accommodate. On one visit to the new offices, Kidder sees a sign taped to the wall which
reads, “If Paul is the model, we’re golden.” Upon looking closer at it, he sees the word golden is on another piece
of paper taped over another word which now reads, “If Paul is the model, we’re f*****.” It’s not meant to sound
as harsh as it does, but merely to emphasize to all staffers that no one can be Paul Farmer, and if the poor have to
wait for a lot of people like Paul to come along before they receive good health care, they are totally f*****. The
same quirkiness also still remains in the new offices, such as Paul’s suitcases lying open all over the floor and
everyone running in various directions following his orders, what Ophelia calls “little hurricanes.” Furthermore,
there is still the great frugality of the organization, running on just 5% of its budget, although Ophelia does pay
overtime when necessary. She just doesn’t tell Paul.
PIH has also expanded its organization into Siberia as a result of Alex Goldfarb. He involved himself in some
political problems by helping Boris Berezovsky, a KGB agent, to escape assassination and flee Russia with his
Swiss bank accounts. This assures that Goldfarb will be unable to return to Russia for while, and as a result, PIH is
needed in Siberia. Paul assigns Jim to the managerial chores of that project. Unfortunately, a month later, Jim has
still not gone to Russia, and Paul has a fit in the middle of a Cambridge restaurant. He accuses Jim of only wanting
to attend the Bolshoi, and then they argue over the fact that Jim always picked up Paul when he arrived in Haiti,
but that Paul had never once picked up Jim. The point is Paul wants Jim there yesterday, and Jim knows he has an
important meeting to attend first, and Russia will wait. Ophelia is glad these temper tantrums happen when they
are away from patients, and she says that this one is nothing compared to some Paul has had. Outside the
restaurant, Paul puts his arm around Jim’s shoulder, and Jim does the same to him. Just that quickly, the argument
is over.
Kidder flies to Siberia with Jim a few weeks later. The city of Tomsk had once been a thriving one, but now is
suffering over and above its MDR-TB problems. In addition, because of Goldfarb’s antics with politics, Jim has to
find a way to smooth over suspicions that they are foreign spies. Ironically, at the opening banquet of the meetings
with the generals who run the prisons, it is karaoke that makes everyone friends. Jim begins by singing The next
morning, Jim leaves, and Paul arrives. The generals already know Farmer, and relationships warm immediately
with lots of toasting to each side. The funny side of this evening is the drunken local oligarch, who owns the hotel
where they’re meeting and oil and gas fields as well. He wanders in and out of the meeting and even proposes his
own toasts. When the meeting is breaking up, the oligarch comes out of a side room naked but for a towel around
his waist. He is followed by a buxom woman in high heels, looking greatly alarmed. Paul watches them intently,
smiling gleefully. He says, “The Rooskies are my kind of people.”
As they are leaving Tomsk, Kidder asks Paul why he had gone to Paul White for $150,000 to help a few dozen
patients when larger amounts of the drugs would soon be on their way. Paul’s answer, “Project managers can
afford to wait for low prices, but not all patients can.” Kidder reflects as the flight continues that this approach
toward money is completely impractical, and yet it appears to be working.
Paul is traveling more than ever, and Kidder is forced to keep in touch with him by e-mail. Of course, he still
returns to Brigham for month long tours of service. It is here that he practices on all sorts of strange cases that
seem to really fulfill him. For example, he is brought in on a case of a man with “lightning gangrene of the penis,”
who is being recommended for hospice care. Farmer just says, “He’s going to walk out of here,” and a month
later, he does. He also cures a young man with toxic shock who two weeks after Paul sees him is still suffering
from a severe fever. Paul tells the caregivers that the next two week won’t be a picnic, but the worst is over, and
he is right once again. He is even consulted by telephone by someone who is treating a monkey!
Howard Hiatt, who has been lobbying Paul for a long time to give up Haiti and work at employing troops on
world-wide campaigns, finally visits Cange, and once he sees Zanmi Lasante, he is full of trying to replicate what
Paul has done there. He now understands why Haiti means so much to Paul. In August 2001, Paul publishes an
article in Lancet, describing the treatment and prevention program in Cange. As a result, PIH receives nearly 100
requests for advice and information from health consultants and charities on every continent. Paul’s reaction to all
this is slightly more realistic than those who would praise him, “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.”
The Global Fund is a brand new institution financed by governments and foundations. It wants to raise many
billions of dollars annually to fight the world’s three great pandemics. By spring of 2002, it has only achieved a
fraction of the goal, but has already received applications for grants. It approves one from PIH Haiti to direct a
thorough AIDS treatment and prevention program throughout the central plateau. It is hoped that this will serve as
a model for projects in Haiti’s other districts and in very poor countries. However, in addition to the daunting task
this promotes, politics emerges when the United States attempts to block aid to Haiti’s government. They have a
longstanding and institutional fear of President Aristide, as well as general weariness with Haiti’s problems. Paul’s
response is short, but succinct, “Lunacy is what it is.” The results are the closing of many other clinics that no
longer have the funds to stay open, which then puts an additional burden on Zanmi Lasante. Nonetheless, PIHers
manage to implement a program to prevent transmission of AIDS from pregnant mothers to their babies. They’ll
have to travel by donkey, bike, motorcycle and jeep, but they do what they have to. The Global Fund then releases
$14 million for the central plateau, payable over five years and to go mainly for anti-HIV drugs, for hiring Haitian
workers, and for fixing up the public clinics that already exist in the region. It’s really just enough to get them
started, but Farmer weeps with elation. He vows to spend even more time in Haiti, but he still continues traveling
everywhere. Once, on his return to Boston, he tells Ophelia that he hears two sets of voices in his ears: the one
from the world saying, “This meeting’s important;” and the one from Haiti saying, “My child is dying.” It seems
to Kidder that he doesn’t have a plan for his life as much as he has a pattern. He is like a compass, with one leg
swinging around the globe and the other planted in Haiti.
Notes
This chapter reinforces the realization on the part of the reader that Paul Farmer is not just an amazing man, but
one who no one can ever imitate. He spends little time with his family and barely sleeps all in the name of patient
care. He serves the world and never stops loving and serving Haiti.
CHAPTER
25
Summary
This chapter is essentially about a boy named John who like a few previous patients at Zanmi Lasante is in need of
care that even Farmer’s clinic cannot provide. He has swellings in his neck that Farmer determines are cancerous.
However, the diagnosis needs to be confirmed in Boston. Serena Keonig, a Brigham doctor, finds an oncologist at
Massachusetts General who will make the diagnosis for free. Of course, he needs a sample of John’s tissue and
blood, and so Farmer sends a Haitian surgeon that he knows to be competent to do the biopsy for $1000. The trip
takes the surgeon twelve hours, because it’s raining, creating mud and swollen streams. The biopsy itself lasts
until dawn. Farmer flies the samples himself to Boston, and Serena takes them to Mass General. The news is bad:
John has nasopharyngeal carcinoma, a very rare cancer. It is often fatal, but if caught in its early stages, 60 to 70
percent have been cured.
The plan is to treat John in Haiti, but Serena is told by an oncologist that it will kill the child to do it there. So
Serena and Farmer agree that they’ll try to bring the boy to Boston. Serena begs and cajoles the administration in
Boston until they agree to do all the treatment for free. The next hurdle becomes the documents needed to get him
out of Haiti and into America. He has no birth certificate, so Serena makes up names for his parents and even finds
him a Creole-speaking resident in pediatrics from Mass General to accompany him on the flight.
Serena brings two suitcases with her to Haiti – one filled with stuffed animals and toys for the pediatric ward in
Cange and one filled with medicines she thinks they might need to get John to the United States. She also carries a
plastic bag filled with water and two goldfish for Farmer’s fish pond in Cange. Farmer wouldn’t be there when
they arrive, but he has full confidence in Serena and the other caregivers. The plan is to get John a visa when they
arrive in Port-au-Prince, drive to Cange, and bring him back on a first class commercial flight the next day. The
first part of the plan unwinds smoothly thanks to Ti Fifi Farmer’s, best and oldest Haitian friend. She has already
managed to get John a Haitian passport, and the American consulate grants the visa at once. The road on the way
to Cange is worse than ever, and when the finally arrive, Kidder feels like the hospital isn’t quite as clean, the air
is hotter, and the flies are heavier. He then realizes that it just doesn’t seem the same, because Farmer isn’t there.
The next part of the plan becomes a nightmare. It is no longer possible to fly John commercially because of how
much sicker he has become. He has to be constantly suctioned or the tumors in his neck and nose will suffocate
him. Furthermore, he is emaciated even though Farmer has him on a feeding tube. Nonetheless, they all think he
deserves his fighting chance. They wonder if they can hire a helicopter to fly him out, but it will cost $20,000. So,
Serena and Ti Fifi head back to Port-au-Prince the next morning. They are in and out of traffic jams all day going
back and forth from the airport to Ti Fif’s home, to the office of a friend, and more. The medevac flight from
Port-au-Prince to Boston is easy to arrange, but it costs $18, 540, so Serena wants to clear it with Farmer. In their
e-mails, Farmer seems worried about the expense and the precedent it might set. Serena wants to just go ahead and
say she paid for everything, but Ti Fifi won’t allow anything to proceed without Paul’s approval. Finally, Paul
okays the expense, and now the difficulty of getting the boy down Highway 3 is the next problem. He will die on
the road without suction, and the only machines they have are electric. The thought then is to hire an ambulance
which has its own suction equipment on board. This search takes them to a private ambulance company run by a
man named Ralph who is willing to try the road to Cange. The ambulance breaks down twice even with Ralph and
his friends doing everything they can to keep it going. It’s then decided to borrow Ralph’s suction equipment and
take the boy down the mountain by truck. Ralph is agreeable to drive, and they hook the ambulance’s suction
equipment to the cigarette lighter of the truck. Three of those going along with the truck agree to ride in the back
in the rainstorm at night, including Kidder and Serena.
Even though Ralph drives very slowly over the bad road, it is excruciatingly painful for John, but finally they
arrive in Port-au-Prince where a Learjet awaits them. When they arrive in Boston, Kidder is amazed when their
driver tells them it will be rough driving, because there are bad roads between the airport and Mass General. If that
driver could only know Haiti, he would never have said that. The pediatric team is swift and deft and gets John
into a bed. One of the interns lectures Serena about John’s state, wondering if they haven’t been feeding him.
Serena begins to try to explain, but fortunately is saved by the entrance of Dr. Alan Ezekowitz, the head of
pediatrics, who has heard the intern’s comments and tells her, “Well, this boy is a challenge. But I’ve cured sicker
kids . . . We can always do better can’t we?” This subtle rebuke quiets the intern.
The next afternoon, Serena calls Kidder and says that a formidable group of physicians have examined John and
discovered that he has one solid tumor growing back into his spinal column and the roof of his mouth. He’s going
to die, and now she questions why she brought him to Boston. She can quickly answer her own question: Isn’t it
better that he can have a private room without flies on his face to die? Isn’t it better that he is treated by people
who are trained to help him die comfortably and that his mother has a private place to grieve? And so John
receives first rate care and is never again in apparent pain. All the PIHers take turns staying in his room with him
to help with his care. His mother finally arrives, and he is satisfied. Serena sets up her apartment as hospice care
and a couple of days after John is moved there, he simply doesn’t wake up. They are all glad he didn’t have to die
in Haiti, but displeased that his extraction from Haiti took so long that it actually contributed to his death. Other
consequences are surprising: Serena feared there wouldn’t be offers of free care from Boston after that, but just the
opposite occurred when Paul convinces Dr. Ezekowitz to take a few of their patients each year; also there isn’t a
precedent set for the people of Haiti who don’t demand the same care for their own children. They are just happy
someone cares about them. As for Kidder, he wonders if the whole thing isn’t an object lesson in the futility of
Farmer’s enterprise.
Notes
This entire chapter is a metaphor for the disaster named Haiti and Kidder is right to wonder if all of Paul Farmer’s
attempts to change the medical care for poor people are nothing more than an exercise in futility.
CHAPTER
26
Summary
This chapter begins in December, two months after the medevac flight of John to Boston, and Kidder has returned
with Farmer to the other side of the epi divide. As they are driving toward Cange, they see a bumper sticker ahead
of them which translates from the Creole to, “Lord, a word on all this.” It makes Farmer laugh. He tells Kidder
that his e-mails are now up to 200 a day, but he’s still managing them. He knows “something’s gotta give, but . . .
he’s not burning out.” Once they arrive at his Ti Kay, and he changes into his Cange clothes, they sit outside on
the bower and are joined by Ti Jean, the man who serves as Farmer’s “chief of staff, “ because he is his main local
male confident. This man wishes that they would fix National Highway 3 so that Zanmi Lasante can receive
100,000 patients, because it is their vocation to receive them. He also believes that people turn themselves into
animals for shifty reasons or else sorcerers turn them into animals as punishment. Pail calls it a “giant morality
play, a commentary on social inequality, almost invariably.” Ti Jean notes that Paul’s fish pond cost a lot of
money, but he approves of it since it makes the doctor happy. If he only saw patients, he might not be happy. He
says the doctor is a nestless bird in all his travels, but that since Haiti is his base, it can be called his nest.
Kidder summarizes at this point for the reader the outcomes of many of the patients he has introduced throughout
the novel, like Ti Ofa, the young man with AIDS, who wanted to give Farmer a chicken or a pig. Now he has
gained eight pounds and is doing much better. A few months back, a little boy named Alcante came into the clinic
with scrofula and was given first-line drugs that wiped out his infection. He was the kind of child that takes
strangers by the hand, and he was also very beautiful looking. As a result, Farmer kept him at the clinic two weeks
longer, calling him “a P.O.P.” or prisoner of Paul. The rest of his family was eventually brought in, and his father
was found to have TB.
So, now that the boy has gone home, Paul is anxious to see how the family truly lives, by taking a hike to his
home in a town called Casse. Ti Jean, a pharmacist, and Kidder go along with him, and as usual, Paul doesn’t even
seem winded on the long trek. Kidder, however, has a few moments of chest pain that Paul decides is only
heartburn, but it shows how good a shape Paul is in. They also stop along the way to speak with other patients
Farmer has been concerned about. While at the home of an elderly couple, a grandchild appears with his two toys:
his thumb in his mouth and a stone tied to a string. Paul laughingly calls it “Rocks R Us” which suddenly sends
them into gales of laughter. When they leave, he comments that they came to see Grandpa, but discovered that
Grandma had blood pressure problems, too. According to Farmer, “This is a good cast of the net. They came to
see Papa and got Grandma, too. Just in time. Before she got run over by a reindeer!” More laughter.
Kidder has been trying for awhile to ask Farmer about John, the boy who died of the terrible throat tumor, but has
been unable to couch it in just the right way. Now he has his opportunity to question Paul about it when the doctor
talks about triage. Kidder asks whether the $20,000 was a huge expense that might have gone for something with a
better outcome than death. He assures Farmer he doesn’t mean this disrespectfully; he just wonders how he feels.
This begins a long explanation that Farmer says he feels pressured to give all the time, but because it takes so long
to explain, he just refuses to do it very often. He begins by summing up that he has “fought his whole life a long
defeat.” He says he is doing it, and he brings other people in to do it, but he won’t give up, because sometimes he
feels like he is winning. He says that all the PIHers want to be on the winning team, but not at the risk of turning
their backs on the losers. So they fight the long defeat. He also uses the example of the young attending physician
who makes $100,000 a year, five times as much as it cost to bring John to America, and yet it is often people like
him who question the use of $20,000 to help just one child. He says he has to limit how much time he puts in
explaining all this or it will just suck his soul dry. Eventually, the long walk gets to Kidder who has run of water
he can drink, and so Farmer searches a village until he finds oranges and then Cokes to restore his hydration.
Not long after, they all come to Alcante’s home, and no sooner does Farmer see the boy’s impoverished hut with
its old banana bark and rag roof than he knows that money will have to be forthcoming to help this family and stop
the tide of TB that is probably incubating in the 10 people who live there. To Farmer it is all so unfair, especially
in light of people who live outside of this poverty, who want to give money for better drinking water, but only if
the poor show they really want it. So Farmer continues his hikes, saying that if seven hours is too long to walk for
two patients, you’re saying that their lives matter less than some others’, and that the thought that some lives
matter less is the root of what’s wrong with the world. He says this person is sick and he is a doctor, an idea that
taps into the universal anxiety and the ambivalence some of those fortunate ones feels about their place in the
world. To Ophelia, his walks are the best part about him, because they are small gestures which do add up. He is a
one person with great talents who has come to exert a great force on the world, just because of the craziness, the
sheer impracticality, of half of everything he does, including the hike to Casse.
Now, as they are readying to leave for Zanmi Lasante, the sunset makes Farmer realize it won’t be safe for Kidder
to walk the rest of the way. So, he borrows a young man and his motorcycle to take the pharmacist back to get the
truck for the rest of them. They then begin to walk toward the route where the truck will come. Along the way, Ti
Jean tells Farmer not to speak to anyone on the road, because they may be demons. That makes Paul comment that
a people who believe that you should take medicines and then see a Voodoo priest, use their religion as a means of
driving away illness. It gives the sounds of the drums in the distance an entirely different, less frightening, feel for
Kidder. Kidder finally reaches the point where he can go no further, and they sit down on the side of the road,
waiting for the truck under a star-filled sky unaffected by electric lights, and Kidder thinks the sound of the drums
is like the beating of so many hearts under a single stethoscope.
Notes
This final chapter is a kind of summarization where Kidder seems to finally get exactly what Paul Farmer is all
about. He is a genius who just happens to believe that he has lived his whole life as a long defeat. He may die and
the Haitian people will still be poor and dying in the thousands because of TB and AIDS. However, he will
AFTERWAR
D Summary
In June of 2002, seven years after Father Jack Roussin’s death, WHO adopted new prescriptions for dealing with
MDR-TB to which Jim Kim wrote, “The world changed yesterday.” The prices of second line antibiotics
continued to drop, and the Russian Ministry of Health had finally agreed to the terms of the World Bank’s loan
– $150 million to fight the epidemic throughout the country.
The fear of 100 million HIV infections by the year 2010 had galvanized much of the world in spite of prominent
voices, like the United States, that still argued that AIDS could not be defeated in impoverished places.
Jim Kim became the senior advisor to the new director of WHO in 2003 and the example of Zanmi Lasante
continued to grow with Cange as the destination for global policy makers and American politicians.
The Global Fund money was delayed, but Farmer chose not to wait, instead using $2 million borrowed from a
commercial bank in Boston to begin the program throughout the central plateau. The plan is to beef up the smaller
clinics around the area by dispatching teams of Haitian and American doctors and technicians to three towns. It
was a nightmare, but within a month, they were up and running.
Haiti was still bleeding away like topsoil and the whole situation was rotten, but according to Farmer, there are
still spots of hope. Electricity came to Cange, and they finally have a transfusion post at Zanmi Lasante. As for
Zanmi Lasante, they have over two hundred health care workers, a dozen nurses, and twelve doctors. They care
for over 3,000 AIDS patients, providing retrovirals to over 350, and they have the equipment and trained
personnel to do their own high-tech AIDS diagnostics. Father Lafontant has managed to build another operating
room, and they have seen their first open-heart surgeries performed by teams from Brigham and South Carolina.
Kidder is attempted to ask Farmer if this is appropriate use of technology – not to hear the answer, just to hear him
say it!
Notes
This afterward sums up what Paul has now accomplished in about 20 years in Haiti. The achievements are
unbelievable, but Kidder and the reader know that they will not stop him from continuing to try to win.
OVERALL ANALYSES
CHARACTER
ANALYSIS
Paul Farmer - It would be difficult to analyze this great man in just a paragraph when the whole book was written
to show what he has achieved in his life. However, there are some important aspects of his character to remember.
First, he believes he can win the long defeat, his way of saying that he can overcome impossible odds to save the
poor of the world. Second, he believes he can give up time with his family and put the guilt aside, because it’s his
job to help the poor and the very ill. Third, he believes in the simple mantra: He is sick and I am a doctor. He was
born for the work he does and is obligated to do it. Last, he can put aside his anger at a world that isn’t doing its
job of helping the poor and ill, because he has no time for the anger. He must do his work which also includes
lobbying the world and shaking it up in order that it pays attention to what it wants to forget.
Tracy Kidder - He is the author of this book, but he is also one of its main characters, because it is he who must
document what he sees by living and working with Paul Farmer. He is a bit of realist and a pessimist who
constantly wonders why Farmer continues his work in the face of almost certain defeat. It’s only at the end when
he finally realizes that Farmer’s determination to win over the long defeat is what makes him great. It goes back to
the axiom that having tried is just as important as winning.
Ophelia Dahl - Being the daughter of famous people, you might expect Ophelia Dahl to have been perfectly
content to live her life among the wealthy. But her family faced a great deal of adversity as well, and so it is not
unusual that she found herself in Haiti helping Paul Farmer. She didn’t like it there, but she stayed and worked
alongside him to achieve the goals he set for himself. They became lovers, but she wise enough to know that she
could never be his wife, because his life was so disjointed. She wouldn’t be able to stand knowing that she
wouldn’t see him for long periods of time, so she realized that their relationship would always be characterized as
a deep and abiding friendship.
Jim Yong Kim - He is the Korean-American doctor who grew up to be a good athlete, valedictorian of his class,
and a more than competent doctor. He falls in love with the work that Farmer is doing in Haiti and like him,
devotes much of life working among and caring for the poor. Eventually, he sees how Partners In Health could set
up the same model as Cange in Carabayllo in Peru. He finds he has a gift for the bureaucratic side of medical care
and eventually gets $45 million to help eradicate TB in Peru. By 2002, he has become the senior assistant to the
Director of WHO, a position that will allow him to help steer money to those who need it most.
PLOT STRUCTURE ANALYSIS
The novel is divided into twenty-six chapters beginning with the first time Kidder met Farmer in 1994 when the
United States had invaded Haiti to place Aristide back in power. Then, he does some flashback into Paul’s life
followed by a chronological presentation of Paul’s work through 2002. The story is told as a narrative argument,
focusing on the struggle of Dr. Farmer to find social justice for the less fortunate people of the world. It makes a
compelling argument regarding the distribution of wealth in the world and emphasizes that a small group of
people that are committed to a change, can bring about change in the world.
THEMES - THEME ANALYSIS
The poor deserve decent health care and living conditions
The first theme – the poor deserve decent health care and living conditions – is the very essence of this book. The
entire documentation of the work of Paul Farmer reflects this idea, one which will probably never be completely
attained, but which is well worth the fight to attain it. Farmer learns in his work that it starts with the individual
patient and ends with the wealthy individual who chooses to close his eyes to the misery around him. It is a
constant struggle, but if even one person’s life is changed as a result, it is worth the struggle and despair.
The Long Defeat
Kidder comes to realize that Farmer has spent his entire life trying to win the long defeat. This means that the
doctor knows that his goal of bringing medicine and better living conditions to all the poor is probably not
attainable, but trying and wanting to win are everything. Farmer is realistic and idealistic at the same time. That’s
what makes his determination so worth imitating.
The fortunate of the world turning their backs on the poor and needy
The theme of the fortunate of the world turning their backs on the poor and needy is evident throughout the book.
It is the one aspect of life that angers Paul to the point that he has to try to put the anger aside in order to try to
overcome this attitude. In his thinking, if everyone just did his job – caring for those less fortunate than he is –
then the world would change overnight. Of course, this is a pipe dream, but he still strives to make it come true by
lobbying the wealthy and powerful to do their part to at least eradicate the great pandemics like TB and AIDS.
The importance of trying to imitate Paul Farmer even though no one can ever be like him
The final theme, the importance of trying to imitate Paul Farmer even though no one can ever be like him, is not
loudly emphasized, but is present, nonetheless. Paul Farmer is such a unique character that being just like him is
impossible. However, wanting to at least imitate his work is goodness and a blessing for those who need our help.
If more and more would just try, how much better the world would be.
AUTHOR’S STYLE
Tracy Kidder is very truthful and forthcoming in his attempt to document the work of Paul Farmer. There is no
need for him to gloss over the man’s character in any way, because the truth speaks loudly enough. He does
attempt to show Farmer both symbolically and metaphorically at times as a way to explain what you can’t really
know without knowing the man personally. He brings us instead a word picture of greatness in the making.
RISING ACTION
The rising action begins when Tracy Kidder meets Paul Farmer while he embedded with American troops in Haiti
in 1994 and ends with his final realization that Paul Farmer is a man who has spent his life trying to win over the
long defeat.
FALLING ACTION
The reader learns at the end that Farmer is ultimately a clinician who very much loves working with and changing
the lives of his individual patients. We see this in his eleven hour trek over the hills of Haiti to see the home life of
a child he cured of scrofula. It’s more than the curative antibiotics for him. It’s all about knowing how his patient
lives and preventing further illness. We also see in the falling action the outcomes of several of Farmer’s goals
presented in an Afterward.
POINT OF VIEW
The point of view is first person, told from Kidder’s viewpoint. This allows the reader to personally experience
how Kidder himself learns and grows from his experiences with Farmer at the same time documenting the life
work of a great man.
OTHER
ELEMENTS
FORESHADOWIN
G
There are several literary devices that pop up at various times in the story. One of the most prevalent ones is
foreshadowing which frequently presents clues of something that will happen later in the novel. Some examples
of foreshadowing include:
1
Farmer and an American sergeant have a somewhat circuitous conversation with Farmer expressing his
concern that the American government’s plans for fixing Haiti would aid business interests but do nothing to
relieve the suffering of the poor. This foreshadows that Farmer’s life work is fighting for the poor.
2
The entire opening chapter is foreshadowing the kind of man Kidder is going to tell the reader about – Dr.
Paul Farmer, a true humanitarian.
3
After his study of Virchow, Farmer came to have a moral understanding of public health. This
foreshadowed where his life would lead him.
4
Ophelia knew Farmer’s aims were clear: he had come here to do ethnology – learning about a culture, not
though books and artifacts, but from the people who had inherited and were making culture. He was going to
specialize in medical ethnology to learn everything he could about morbidity and mortality in the most
disease-ridden country in the hemisphere. This foreshadows the remainder of the book for the reader.
5
After someone complains to the authorities of Peru that Farmer claimed that the Peruvian TB program was
killing patients, Farmer, at least, feels his protest had been lodged and the higher authorities have noticed. This
foreshadows his willingness to take on the highest authorities to protect the poor.
6
The mother of a boy Farmer cures of TB in Peru approaches him and says in Spanish, “I want to say many
thanks.” Then, Farmer, with great humility, replies in Spanish as well, “For me, it is a privilege.” This
foreshadows what Kidder learns about Famer: none of what he does is about him, but rather the people he serves.
IRONY
Another important element is irony – when something happens, or is seen, or is heard that we may know, but the
characters do not, or that appears opposite of what is expected. Some examples of irony include:
1
Farmer argues with the American sergeant that it makes no sense to apply principles of constitutional law
to a country that has no functioning legal system. So they come to a stalemate – one is a “redneck” arguing for due
process while the other is a champion of human rights arguing for preventative detention.
2
Farmer explains that he had come to Captain Carroll to warn him. The Haitians in the area were upset with
Carroll’s decision about Nerva Juste and had challenged the doctor to stop and talk to the soldier. Ironically, as
they were passing the army compound, the got a flat tire and Farmer had commented that “you have to listen to
messages from angels.”
3
His Haitian colleagues had told Farmer that the patients must pay user fees of about eighty cents a day.
However, Farmer has his own rule: every patient must pay the eighty cents, except for women, children, the
destitute, and anyone who us seriously ill. So everyone has to pay except for almost everyone!. And no one is
allowed to be turned away.
4
Farmer and his entourage pass smiling children, carrying water in buckets that had once held paint, oil,
and antifreeze.
5
Farmer’s comment on his childhood was, “The way I tell myself the story is a little too neat. I’d like to be
able to say that when I was young I lived in a trailer park, picked fruit with Haitians, got interested in migrant farm
workers, and went to Latin America. All true, but not the truth. We’re asked to have tidy biographies that are
coherent. Everyone does that. But the fact is, a perfectly discrepant version has the same ending.”
6
Kidder finds the sights of Cuba lovely after the deep and destitute vision of Haiti while Farmer can finally
sleep, because everyone here has a doctor.
7
There is a Haitian phrase, ”looking for life, destroying life.” Farmer explained it as an expression they
used if a poor woman selling mangoes falls off a truck and dies. In other words, trying to keep her family alive,
she sells mangoes, only to die when she falls off the mango truck.
8
When Farmer and Goldfarb held a press conference to announce their findings about TB in Russia, it was
the same day that the Special Prosecutor released his report on the Monica Lewinsky scandal, so few reporters
showed up.
9
When they sit down to eat in Russia, Farmer tells an interesting story: he had been named the TB
commissioner for the state of Massachusetts, and so every time he needed lab resources, he went back there,
because Massachusetts has a lot of TB labs, lots of TB doctors, lots of TB nurses, lots of TB lab specialists. What
Massachusetts doesn’t have is TB. That’s the irony for Russia.
10
Kidder sees a sign taped to the wall in Bostoon which reads, “If Paul is the model, we’re golden.” Upon
looking closer at it, he sees the word golden is on another piece of paper taped over another word which now
reads, “If Paul is the model, we’re f*****.” It’s not meant to sound as harsh as it does, but merely to emphasize
the irony to all staffers that no one can be Paul Farmer, and if the poor have to wait for a lot of people like Paul to
come along before they receive good health care, they are totally f*****.
11
Ironically, at the opening banquet of the meetings with the Russian generals who run the prisons, it is
karaoke that makes everyone friends.
12
Serena calls Kidder and says that a formidable group of physicians have examined John and discovered
that he has one solid tumor growing back into his spinal column and the roof of his mouth. Ironically, they worked
like fools and spent a lot of money to get him to Boston and now he’s going to die.
MOTIFS
Another important element is a motif which is a recurring element used to develop a literary work. There is one
major motif in this book:
1. Farmer is portrayed as a kind of priest of a belief system he calls liberation theology. That is, he believes that he
is there to bring a better life to as many people as he can and he is the minister who serves them. Like a
priest who is married to the church, Farmer is married to Haiti.
QUOTATIONS - IMPORTANT QUOTES AND ANALYSIS
The following quotations are important at various points of the story (Random House, New York, 2003):
1. “That guy’s a fuckin’ saint.” (pg. 16; This comment is made by a homeless man named Joe in Boston who
only wants to take his AIDS medication and drink a six-pack of beer every day. Farmer gets him the beer.)
2. “I feel ambivalent about selling my services in a world where some can’t buy them. You can feel ambivalent
about that, because you should feel ambivalent. Comma.” (pg. 24; Farmer said this when Kidder asked him if he
shouldn’t be compensated for what he does.)
3. Farmer “narrates Haiti.” (pg. 28; This is how describes his explanations which bring forth his drawing of a
moral about the suffering of the Haitian poor as well as the world’s poor.)
4. “Only in Haiti would a child cry out that she’s hungry during a spinal tap.” (pg. 32; This comment emphasizes
the sod plight of the poor in Haiti.)
5. “Are you incapable of complexity?” (pg.35; An old woman makes this comment to Farmer to emphasize that
the problems of the poor are not written in black and white.)
6. Farmer says that to understand Russia, Cuba, the Dominican Republic, Boston, or Sri Lanka, you just have to be
on the top of that hill in Haiti. (pg. 44; This comment makes the reader understand that all poverty can be
understood if only you would stand on a hill in Haiti.)
7. Farmer’s comment on his childhood was, “The way I tell myself the story is a little too neat. I’d like to be able
to say that when I was young I lived in a trailer park, picked fruit with Haitians, got interested in migrant farm
workers, and went to Latin America. All true, but not the truth. We’re asked to have tidy biographies that are
coherent. Everyone does that. But the fact is a perfectly discrepant version has the same ending.” (pg. 54; Farmer
sums up the irony that a somewhat abusive childhood would still produce a doctor.)
8. “Physicians are the natural attorneys of the poor, and the social problems should be largely resolved by
them.” (pg. 61; This saying by Virchow was one of Paul’s favorites.)
9. “In the end, I hope you know that as part of my histology you can never be replaced.” (pg. 67; This is the final
comment Ophelia makes in her letter to Paul explaining that she can’t marry him.)
10. “Accidents happen. Sure. But not every bad thing that happens is an accident. There was nothing accident
about the wretchedness of the road . . . or the over-loaded truck . . . of the desperation of a peasant woman who
had to get to market to make a sale, because otherwise her family would go hungry.” (pg. 73; This is Paul’s
explanation of the death of the Mango Lady.)
11. The Haitians believed that the rest of the world was wrong for “screwing them over, and that someone,
someone just and perhaps omniscient, was keeping score.” (pg. 78; This is why religion is so important to the
poor of Haiti.)
12. “Redistributive justice – we were just helping them not to go to hell.” (pg. 90; This is Paul’s justification for
stealing a microscope from Harvard Medical School.)
13. Ophelia knew Paul loved her, but for her, relations were strained: “Te strain of living with a fellow who was in
love with something else, something that I could never compete with, even if I wanted to.” (pg. 101; This is
Ophelia’s explanation for why she ultimately couldn’t marry Paul.)
14. “Perhaps this is a singular chance to change Haiti.”
(p. 109; This was what Farmer wrote in his diary Aristide declared his candidacy for president of Haiti.)
15. “The rocks in the water are going to find out how the rocks in the sun feel.” (pg. 110; Aristide declared this in
one of speeches; it was a spin-off of a Haitian proverb.)
16. Jim Kim quotes Margaret Mead who said, “Never underestimate the ability of a small group of committed
individuals to change the world.” Jim then responds to that quote by saying, “Indeed, they are only ones who ever
have.” (pg. 164; This is one of the speeches Jim makes to appeal for money to help Peru.)
17. The sights of Haiti remind Kidder of Matthew 25 which says, “Inasmuch as you have done it unto the least of
my brethren, you have done it unto me.” (pg. 185; Kidder is reminded of how little most of us who proclaim to
be good Christians actually follow what Jesus said.)
18. “Look! Only ninety miles from Haiti and look! Trees! Crops! It’s all so verdant! At the height of the dry
season! The same ecology as Haiti’s and look!” (pg. 193; This is Farmer’s excited comments as they land in
Cuba.)
19. “Knowing that this splendor came from the suffering of my ancestors.” (pg. 211; This was Paul’s wife Didi’s
comment when he asked her if she thought Paris wasn’t the most beautiful city in the world. The French had
brought slaves to Haiti from Africa.)
20. “Embracing a continuity and interconnectedness that excluded no one seemed like another of Farmer’s
peculiar liberties. It came with a lot of burdens, of course, but it also freed him from the efforts that many people
make to find refuge and distinction from their pasts, and from the mass of their fellow human beings.” (pg. 219;
Kidder makes comment about Farmer’s willingness to doctor wherever he’s needed.)
21. “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.” (pg. 257; This is Paul’s reaction to his projects being exemplars in an
article in Lancet.)
22. Paul tells Ophelia that he hears two sets of voices in his ears: the one from the world saying, “This meeting’s
important;” and the one from Haiti saying, “My child is dying.” (pg. 260; Paul explains his feeling of being torn in
so many directions.)
23. “Lord, a word on all this.” (pg. 280; This is a bumper sticker on the back of a truck in Haiti and seems to sum
up the seeming despair of an entire country.)
24. Paul begins his explanation of why he allowed all the money to be spent on John by summing up that he has
“fought his whole life a long defeat.” (pg. 288; This is what Kidder finally realizes motivates Farmer – winning
over the long defeat.)
25. “The world changed yesterday.” (pg. 299; Jim Kim writes this to Kidder when WHO finally adopted new
prescriptions for dealing with MDR-TB.)
SYMBOLISM / MOTIFS / METAPHORS / IMAGERY / SYMBOLS
Other elements that are present in this novel include symbols and metaphors. Symbols are the use of some
unrelated idea to represent something else. Metaphors are direct comparisons made between characters and ideas.
There many symbols and metaphors used by the author such as:
1. Boston’s Brigham and Women’s Hospital symbolizes outside help for the poor.
2. Kidder, the author, has arrived in Haiti to see Farmer’s oeuvre. He is met at the Port-au-Prince airport by a
four-wheel-drive pickup and rides on a two-lane paved road until he comes to the other side of the Plaine du
Cul-de-Sac. There, the truck moves steadily upward, while pitching and rolling, along a road that seems little more
than a dry riverbed. Along the way, he sees many arid mountains and villages of wooden huts, trucks of various
sizes and a lot of foot traffic, beggars, ox carts being pulled by men, few trees, and no electricity after the town of
Péligre. The trip is only 35 miles long, but lasts three hours. Finally, kidder’s truck pulls up to a tall concrete wall
where a sign reads, “Zanmi Lasante,” or Partners In Health. It is a very dramatic sight in the all but treeless, baked
brown landscape. There are tall trees beside courtyards, walkways, and walls, an ambulatory clinic and a women’s
clinic, a general hospital, a large Anglican church, a school, a kitchen which prepares meals for 2000 people a day,
and a brand new building to treat tuberculosis. Inside, the building has tiled floors, clean white walls, and
paintings by Haitian artists. This is a metaphor for all of Haiti where Zanmi Lasante is hope in the midst of
despair.
3. Farmer’s use of the word comma at the end of a sentence symbolizes the word that would follow the comma –
asshole. Kidder understands that Farmer isn’t calling him an asshole, but instead is referring to third parties who
feel comfortable with the current distribution of money and medicine in the world. And implication is that you
aren’t one of those. Are you?
4. A moaning thirteen-year-old has arrived by donkey ambulance. Paul must give her a spinal tap and when he
inserts the needle, she cries out in Creole that it hurts and she is hungry. This is a metaphor for the entire country
that cries out for food.
5. The truck was carrying people and mangoes to market and because it was overloaded, it couldn’t master the
turn. The people stand beside the road in shock while one of the women lies dead on a bed of the fruit, a piece of
corrugated cardboard laying over her. This is metaphor for the country which often faces death in search of life.
6. Farmer was struck by his memories of the tin roofs he’d seen in Mirebalais which were emblems of poverty.
The roofs in Cange screamed misery.
7. Farmer, will be Kidder’s Virgil – tutoring him in the complexities of Haiti. He symbolizes the great
philosopher.
8. The Péligre dam is a subject that Farmer has discussed in all of his books and many of his journal articles. It
symbolizes the misery of the central plateau part of which was destroyed when the dam was built.)
9. Chouchou Louis is a metaphor for Haiti. In a moment of freedom, he speaks disparagingly about his country
and is then beaten to death. In the same way, Haiti rises up to grab freedom momentarily and then is beaten back
into submission.
10. The “epi line” is a shortened version of the epidemiological line, an idea which symbolizes those who receive
good health care and live fairly well to those who die in poverty.
11. DOTS-plus symbolizes the knowledge that TB can be treated by the tradition protocols while also treating the
more serious MDR-TB.
12. Farmer carries two pictures of children with him: one is of Catherine and the other is of a Haitian child with
kwashiorkor. The second picture is a symbol of all the people suffering from TB and perhaps his willingness to try
to love them all equally.
13. The entire chapter about John is a metaphor for the disaster named Haiti – not enough or no medicines to help
a child struck ill and too great a difficulty getting him out of Haiti to save his life.
14. A good cast of the net is a metaphor for fishing, something Farmer often uses both positively as here and
negatively when talking about the lack opportunities for Haitians.
15. Farmer is the single stethoscope under which beat many hearts.
Another element that is very dominant in this novel is imagery – the employment of figures of speech, vivid
descriptions, or mental pictures in writing or speech. Much of the imagery in this book comes from the language
Farmer uses. Some examples include:
1
Farmer’s use of the word comma at the end of a sentence. It stands for the word that would follow the
comma – asshole. Kidder understands that Farmer isn’t calling him an asshole, but instead is referring to third
parties who feel comfortable with the current distribution of money and medicine in the world. And implication is
that you aren’t one of those. Are you?
2
A “dismount” is a term used in Farmer’s family when they became interested in gymnastics during the
Olympics. To them and to Farmer, a dismount is the term meaning the end of the conversation.
3
Bwats (French boîtes or boxes) are Paul’s way of referring to his checklist he makes for each day’s chores
he wants to complete.
4
“H of G or hermeneutic of generosity,” means whether Farmer looks upon something in a generous light,
just the way he feels about Kidder.
5
Farmer has a strange lexicon, a language that the PIHers have picked up on and follow perfectly. For
example, when his brother Jeff misspelled Haitians as Hatians, Farmer began to shorten it to “Hateans or Hats”
and their country became “Hatland.” The French were “Fran-chayze” and their tongue “Fran-chayze language.”
The Russians were “Rooskies.” Farmer calls himself “white trash” and even though he has the utmost respect for
women, he still calls them “chicks.” People of the same race and gender who suffer because of it have “different
degrees of shaftedness or hose-edness.” To commit a “seven-three” was to use seven words when three would do,
and “ninety-nine one hundred” was quitting on a nearly complete job, something he hated more than anything
else.
6
O for the P refers to the options available to the poor.
7
PIHers are people who work for Partners In Health.
IMPORTANT / KEY FACTS SUMMARY
•
Title: Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World
•
Author: Tracy Kidder
•
Date Published: 2003
•
Meaning of the Title: It refers to the main character’s determination to bring health and happiness to the
poor and comes from the Haitian proverb, Beyond Mountains There Are Mountains.
•
Setting: Boston and Cambridge, Massachusetts; Cange, Mirebalais, and Port-au-Prince, Haiti; Lima, Peru;
Tomsk, Siberia, Russia; Paris, France from 1982 through 2003.
•
Protagonist: Dr. Paul Farmer
•
Antagonists: Poverty and the lack of caring from people who could help end it.
•
Mood: The mood is often troubling and dark, but there are so many lights of hope along the way that
reader can’t help but feel uplifted by the end.
•
Point of View: The point of view is first person, told from Tracy Kidder’s viewpoint. This allows the
reader to personally experience how Kidderlearns and grows from his experiences with Paul Farmer.
•
Tense: The story is told in the past tense.
•
Rising Action: The rising action begins when Tracy Kidder meets Paul Farmer while he embedded with
American troops in Haiti in 1994 and ends with his final realization that Paul Farmer is a man who has spent his
life trying to win over the long defeat.
•
Exposition: The author tells us the story of Dr. Paul Farmer, a man who would cure the world. We follow
him through his years in Haiti and both his successes and failures there as well as in Peru, Cuba, and Russia.
•
Climax: The climax occurs when the author realizes that what Farmer is all about is winning over the long
defeat.
•
Outcome: Many of Farmer’s goals come true, but there is still the sense that he knows he has much more
to do.
•
Major Themes: The poor deserve decent health care and living conditions; the long defeat; the fortunate
of the world turning their backs on the poor and the needy; and the importance of trying to imitate Paul Farmer
even though no one can ever be like him.
VOCABULARY LIST
Part I: Dokté Paul ambulatory (adj.): of, relating to, or adapted for walking; capable of walking; not
bedridden ambivalence (n.): the coexistence of opposing attitudes or feelings, such as love and hate, toward a
person, an object, or an idea; uncertainty or indecisiveness as to which course to follow annals (n.): a
chronological record of the events of successive years anthropology (n): the scientific study of the origin, the
behavior, and the physical, social, and cultural development of human beings august (adj.): inspiring awe or
admiration; majestic; venerable for reasons of age or high rank. austere (adj.): severe or stern in disposition or
appearance; somber and grave balmy (adj.): soothing; mild and pleasant beatification (n): the act of appearing to
be angelic, exalted, or blessed bemusement (n): bewilderment or confusion; the state of being engrossed in
thought bourgeois (n): a person belonging to the middle class bureaucrat (n.): an official who is rigidly devoted
to the details of administrative procedure candor (n.): frankness or sincerity of expression; openness; freedom
from prejudice; impartiality causality (n.): the principle of or relationship between cause and effect circuitous
(adj.): being or taking a roundabout, lengthy course citadel (n.): a fortress in a commanding position in or near a
city constrain (v.): to keep within close bounds; confine; to inhibit or restrain; hold back copse (n.): a thicket of
small trees or shrubs; a coppice cosmology (n.): the particular way a person sees the world and its
interconnectedness; the astrophysical study of the history, structure, and constituent dynamics of the universe
daguerreotype (n.): an early photographic process with the image made on a light-sensitive silver-coated metallic
plate denunciation (n.): the act or an instance of condemning, especially a public condemnation or censure
desultory (adj.): moving or jumping from one thing to another; disconnected; occurring haphazardly; random
discourse (n.): verbal expression in speech or writing; verbal exchange; conversation dubious (adj.): fraught
with uncertainty or doubt; undecided; arousing doubt; doubtful ebullience (n.): zestful enthusiasm efficacy (n.):
power or capacity to produce a desired effect; effectiveness encomium (n.): warm, glowing praise; a formal
expression of praise; a tribute ensorcellment (n.): enchantment; bewitchment; a spell or the state of being under
the influence of a spell fastidious (adj.): possessing or displaying careful, meticulous attention to detail ferret (v.):
to drive out, as from a hiding place; expel; to uncover and bring to light by searching freighted (adj.): burdened;
loaded down with something harangue (n.): a long, pompous speech, especially one delivered before a gathering;
a speech or piece of writing characterized by strong feeling or expression; a tirade inculcate (v.): to impress
(something) upon the mind of another by frequent instruction or repetition; instill indignation (n.): anger aroused
by something unjust, mean, or unworthy inordinate (adj.): exceeding reasonable limits; immoderate; excessive;
not regulated; disorderly junta (n.): a group of military officers ruling a country after seizing power; a council or
small legislative body in a government, especially in Central or South America laconic (adj.): using or marked
by the use of few words; terse or concise litany (n.): a repetitive or incantatory recital obstetrics (n.): the branch
of medicine that deals with the care of women during pregnancy, childbirth, and the recuperative period following
delivery oeuvre (n.): a collection of works, usually artistic in nature; the sum of the lifework of an artist, a writer,
or a composer plaintive (adj.): expressing sorrow; mournful, sad, or melancholy prodigious (adj.):
impressively great in size, force, or extent; enormous; extraordinary; marvelous proselytize (v.): to induce
someone to convert to one's own religious faith; to induce someone to join one's own political party or to espouse
one's doctrine roil (v.): to displease or disturb; vex; annoy sojourn (v., n.): to reside temporarily; a temporary
stay; a brief period of residence stentorian (adj.): extremely loud subvert (v.): to destroy completely; ruin; to
undermine the character, morals, or allegiance of; corrupt; to overthrow completely summary (adj.): performed
speedily and without ceremony tertiary (adj.): third in place, order, degree, or rank trepidation (n.): a state of
alarm or dread; apprehension; an involuntary trembling or quivering tuberculosis (n.): an infectious disease of
human beings and animals caused by the tubercle bacillus and characterized by the formation of tubercles on the
lungs and other tissues of the body, often developing long after the initial infection vernacular (n.): the use of
language in a particular trade or profession; the everyday language spoken by a people as distinguished from the
literary language Virgil (n.): a Roman poet who guided Dante through the underworld in Dante’s Inferno Part
II: The Tin Roofs of Cange affluent (adj.): generously supplied with money, property, or possessions;
prosperous or rich antebellum (adj.): belonging to the period before a war, especially the American Civil War
aphorism (n.): a tersely phrased statement of a truth or opinion; an adage arbitrary (adj.): determined by
chance, whim, or impulse, and not by necessity, reason, or principle ardent (adj.): expressing or characterized by
warmth of feeling; passionate bawdy (adj.): humorously coarse; risqué; vulgar; lewd bedraggled (adj.): wet; limp;
soiled by or as if by having been dragged through mud; being in a condition of deterioration; dilapidated bibulous
(adj.): given to or marked by the consumption of alcoholic drink; very absorbent, as paper or soil brackish (adj.):
having a somewhat salty taste, especially from containing a mixture of seawater and fresh water Buchenwald (n.):
a village of central Germany near Weimar. It was the site of a Nazi concentration camp during World War II
cadre (n.): a nucleus of trained personnel around which a larger organization can be built and trained: cavort (v.):
to bound or prance about in a sprightly manner; caper; to have lively or boisterous fun; romp coalesce (v.): to
grow together; fuse; to come together so as to form one whole; unite constituent (n.): something or someone that
is a part of a whole, a group; a component convalescence (n.): gradual return to health and strength after illness;
the period needed for returning to health after illness cosmopolitan (adj.): at home in all parts of the world or
conversant with many spheres of interest; pertinent or common to the whole world countenance (n.): appearance,
especially the expression of the face; the face or facial features depredation (n.): damage or loss; ravage; a
predatory attack; a raid derelict (adj.): neglectful of duty or obligation; remiss deserted by an owner or keeper;
abandoned; run-down; dilapidated disparage (v.): to speak of in a slighting way; belittle; to reduce in esteem or
rank dissident (v., n.): disagreeing, as in opinion or belief; one who disagrees; a dissenter distillation (n.): the
reduction of matter (or ideas, or theories, etc.) to its purest form egregious (adj.): conspicuously bad or offensive
endemic (adj.): prevalent in or peculiar to a particular locality, region, or people epidemiology (n.): the branch
of medicine that deals with the study of the causes, distribution, and control of disease in populations epiphany
(n.): a sudden, profound realization about the essence or meaning of something exacerbate (v.): to increase the
severity, violence, or bitterness of; aggravate expatriate (v., n.): to remove (oneself) from residence in one's
native land; one who has taken up residence in a foreign country exultant (adj.): marked by great joy or jubilation;
triumphant feckless (adj.): lacking purpose or vitality; feeble or ineffective; careless and irresponsible fetid (adj.):
having an offensive odor goad (n., v.): an agent or means of prodding or urging; a stimulus; to prod or urge with
or as if with a long pointed stick gradient (n.): a rate of inclination; a slope; an ascending or descending part; an
incline grandiose (adj.): characterized by greatness of scope or intent; grand; characterized by feigned or affected
grandeur; pompous herpetology (n.): the branch of zoology that deals with reptiles and amphibians idyllic (adj.):
simple and carefree implacable (adj.): impossible to pacify, calm, or appease kwashiorkor (n.): severe protein
malnutrition, especially in children after weaning, characterized by lethargy, growth retardation, anemia, edema,
potbelly, depigmentation of the skin, and loss of hair or change in hair color languish (v.): to be or become weak
or feeble; lose strength or vigor; to exist or continue in miserable or disheartening conditions; to remain
unattended or be neglected lassitude (n.): a state or feeling of weariness, diminished energy, or listlessness
liberation theology (n.): a school of theology, especially prevalent in the Roman Catholic Church in Latin
America, that finds in the Gospel a call to free people from political, social, and material oppression lucrative
(adj.): producing wealth; profitable Luddite (n.): one who opposes technical or technological change lurid (adj.):
causing shock or horror; gruesome; marked by sensationalism macerate (v.): to cause to become lean, usually by
starvation; emaciate; to make soft by soaking or steeping in a liquid malign (v.): to make evil, harmful, and often
untrue statements about; speak evil of misappropriate (v.): to take, procure, or steal wrongfully or dishonestly;
embezzle mnemonic (adj., n.): relating to, assisting, or intended to assist the memory; a device, such as a formula
or rhyme, used as an aid in remembering mordant (adj.): bitingly sarcastic; incisive and trenchant; bitingly
painful omniscient (adj.): having total knowledge; knowing everything onerous (adj.): troublesome or
oppressive; burdensome ostensible (adj.): represented or appearing as such, usually with an ulterior or hidden
motive palliation (n.): the relieving or soothing of the symptoms of a disease or disorder, without effecting a cure
pathology (n.): the scientific study of the nature of disease and its causes, processes, development, and
consequences; a departure or deviation from a normal condition perfunctory (adj.): done routinely and with little
interest or care personae non gratae (n.): people who are fully unacceptable or unwelcome, especially to a
foreign government pittance (n.): a meager monetary allowance, wage, or remuneration; a very small amount
polymath (n.): a person of great or varied learning pragmatic (adj.): dealing or concerned with facts or actual
occurrences; practical proclivity (n.): a natural propensity or inclination; predisposition; a tendency to be a
certain way profligate (adj.): recklessly wasteful; wildly extravagant prophylaxis (n.): prevention of or
protective treatment for disease recrimination (n.) the act of countering one accusation with another; a
countercharge regale (v.): to provide with great enjoyment; entertain; to entertain sumptuously with food and
drink; provide a feast for reticent (adj.): inclined to keep one's thoughts, feelings, and personal affairs to oneself;
restrained or reserved in style reticulate (v.): to make a net or network of; to mark with lines resembling a
network salient (adj.): projecting or jutting beyond a line or surface; protruding. 2. Strikingly conspicuous;
prominent sardonic (adj.): scornfully or cynically mocking skein (n.): A length of thread or yarn wound in a
loose, elongated coil; something suggesting the coil of a skein; a complex tangle surreptitious (adj.): obtained,
done, or made by clandestine or stealthy means; acting with or marked by stealth terra firma (n.): solid ground;
dry land throes (n.): a condition of agonizing struggle or trouble trollop (n.): a woman regarded as slovenly or
untidy; a slattern; a strumpet Part III: Médicos Aventureros accoutrements (n.): accessories; ancillary
items of equipment or dress; military equipment other than uniforms and weapons allocation (n.): the setting apart
for a special purpose; designation; distribution according to a plan; allotment aplomb (n.): self-confident
assurance; poise ba·cil·lus n. pl. ba·cil·li (-sl) Any of various bacteria, especially a rod-shaped bacterium.
ceviche (n.): raw fish marinated in lime or lemon juice with olive oil and spices and served as an appetizer
consternation (n.): a state of paralyzing dismay declaim (v.): to deliver a formal recitation, especially as an
exercise in rhetoric or elocution; to speak loudly and vehemently; inveigh demur (v.): to voice opposition; object
dissemination (n.): the act or process of scattering widely, as in sowing seed; distribution; promulgation gambit
(n.): a maneuver, stratagem, or ploy, especially one used at an initial stage insurrection (n.): the act or an
instance of open revolt against civil authority or a constituted government latent (adj.): present or potential but
not evident or active milieu (n.): an environment or a setting mor·tal·i·ty t) n. pl. mor·tal·i·ties Death,
especially of large numbers; heavy loss of life: the mortality wrought by an epidemic. Or 2. Death rate.
pal·li·a·tive adj. Relieving or soothing the symptoms of a disease or disorder without effecting a cure. OR n.
One that palliates, especially a palliative drug or medicine. paradigm (n.): a conceptual framework; an example
that serves as pattern or model provocative (adj.): capable of arousing or holding interest; capable of arousing or
holding interest; controversial quixotic (adj.): caught up in the romance of noble deeds and the pursuit of
unreachable goals; idealistic without regard to practicality; capricious; impulsive refusenik (n.): a Soviet citizen
who has been denied the right to emigrate rhetoric (n.): the art or study of using language effectively and
persuasively; skill in using language effectively and persuasively; a style of speaking or writing, especially the
language of a particular subject stalwart (n.): one who is physically and morally strong; one who steadfastly
supports an organization or a cause stanch (v.): to stop or check the flow of (blood or tears, for example); to stop
the flow of blood from (a wound); to check or allay synergy (n.): the interaction of two or more agents or forces
so that their combined effect is greater than the sum of their individual effects; cooperative interaction among
groups, especially among the acquired subsidiaries or merged parts of a corporation, that creates an enhanced
combined effect temperate (adj.): exercising moderation and self-restraint; moderate in degree or quality;
restrained. unequivocal (adj.): admitting of no doubt or misunderstanding; clear and unambiguous utilitarian
(adj.): of, relating to, or in the interests of utility; exhibiting or stressing utility over other values; practical
vivisection (n.): the act or practice of cutting into or otherwise injuring living animals, especially for the purpose
of scientific research
Part IV: A Light Month for Travel abstraction (n.): the act or process of making a real problem or
situation hypothetical or unreal, or of considering something apart from reality or its concrete existence;
something thought of in this way acumen (n.): quickness, accuracy, and keenness of judgment or insight
adulterate (v.): to make impure by adding extraneous, improper, or inferior ingredients au pair (n.): a young
foreigner who does domestic work for a family in exchange for room and board and a chance to learn the family's
language burgeon (adj.): to begin to grow or blossom Chekhov (n.): Russian writer whose dramas and stories
often concern the inability of human beings to communicate with one another. coercive (adj.): characterized by
or inclined to force others to act or think in a certain way by use of pressure, threats, or intimidation
commensurate (adj.): of the same size, extent, or duration as another; corresponding in size or degree;
proportionate concurrent (adj.): happening at the same time as something else; operating or acting in conjunction
with another condescension (n.): patronizingly superior behavior or attitude; behavior in which a person treats
others as if they are inferior diminutive (adj.): extremely small in size; tiny embargo (n.): a government order
prohibiting the movement of merchant ships into or out of its ports; a prohibition by a government on certain or all
trade with a foreign nation endeavor (n.): a conscientious or concerted effort toward an end; an earnest attempt;
purposeful or industrious activity; enterprise epicurean (adj.): devoted to the pursuit of pleasure; fond of good
food, comfort, and ease euphemism (n.): the act or an example of substituting a mild, indirect, or vague term for
one considered harsh, blunt, or offensive exhumation (n.): the removal of bodies from a grave; disinterment facile
(adj.): done or achieved with little effort or difficulty; easy; arrived at without due care, effort, or examination;
superficial fiat (n.): an arbitrary order or decree fodder (n.): raw material, as for artistic creation; a consumable,
often inferior item or resource that is in demand and usually abundant supply gewgaw (n.): a decorative trinket; a
bauble gulag (n.): a network of forced labor camps in the Soviet Union; a forced labor camp or prison, especially
for political dissidents hermeneutic (adj.): interpretive; explanatory iconoclast (n.): one who attacks and seeks
to overthrow traditional or popular ideas or institutions indigent (adj.): experiencing want or need; impoverished
lexicon (n.): a stock of terms used in a particular profession, group, subject, or style; a vocabulary
megalomaniacal (adj.): suffering from a psychopathological condition in which delusional fantasies of wealth,
power, or omnipotence predominate pandemic (adj.): widespread; general; epidemic over a wide geographic
area peripatetic (adj.): walking about or from place to place; traveling on foot periphery (n.): a line that forms
the boundary of an area; a perimeter; an edge or border preponderant (adj.): having superior weight, force,
importance, or influence recalcitrant (adj.): marked by stubborn resistance to and defiance of authority or
guidance remunerative (adj.): yielding suitable recompense; profitable supplicant (n.): a person who asks for
humbly or earnestly, as by praying; a person who makes a humble entreaty to or beseeches sycophantic (adj.):
appearing to be a servile self-seeker who attempts to win favor by flattering influential people verdant (adj.):
green with vegetation; covered with green growth; green in hue
STUDY QUESTIONS - MULTIPLE CHOICE QUIZ
1
Kidder first meets Paul Farmer a.) at a church in Cange. b.) at an American army base. c.) at a meeting
about TB in Russia.
2
Paul’s childhood was unique because a.) he lived in church. b.) he lived on a bus, c.) he lived in a trailer.
3
The peasants think Paul is a.) a Voodoo priest. b.) a god. c.) a saint.
4
Paul calls his religion a.) liberation theology. b.) Voodoo theology. c.) Modified Christianity.
5
Ophelia refuses to marry Paul, because a.) he is undependable b.) he will always be the kind of husband
she needs. c.) he is married to Haiti.
6
Ophelia’s responsibility at PIH is a.) to manage the money. b.) to manage the nurses. c.) to manage Paul’s
schedule.
7.) A sign of better circumstances for the Haitians is
a.) banana bark roofs.
b.) tin roofs.
c.) stone roofs.
8.) Paul’s wife lives in
a.) Port-au-Prince.
b.) Cange.
c.) Paris.
9.) When the military controlled Haiti, this junta was run by
a.) Jean-Bertrand Aristide.
b.) the Duvaliers.
c.) the United States.
10.) To be president of Haiti, Jean-Bertrand Aristide gave up
a.) a wealthy life.
b.) marrying the woman he loved.
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c.) the priesthood.
11.) Two programs that PIH ventured into were curing TB in a.) Peru and Russia. b.) Cuba and Russia.
c.) Cuba and Peru.
12.) Paul loved everything about trying to eradicate poverty, but his favorite activity
was: a.) clinicals. b.) lab work. c.) research.
13.) Paul attended and spoke at many meetings and impressed the crowd by a.) his black suit. b.) his deep
compassion for the poor. c.) his impeccable state of preparedness.
14.) Paul was known for his treks which were a.) long walks over many hours to see doctors. b) long walks
over many hours to see people with money. c.) long walks over many hours to see patients.
15.) When Paul spoke of the O for the P, he was referring to a.) oil for the poor. b.) outcomes for the poor.
c.) options for the poor.
ANSWER KEY
1.) b. 2.) b. 3.) b. 4.) a. 5.) c. 6.) a. 7.) b. 8.) c. 9.) b. 10.) c. 11.) a 12.) a. 13.) b. 14.) c. 15.) c.
ESSAY TOPICS - BOOK REPORT IDEAS
1. Describe the program that Paul sets up in Cange which he calls Zanmi Lasante.
2. Describe the belief system that Paul calls liberation theology. How is like a priest of this belief system.
3. Explain the relationship between Paul and Ophelia. How does it finally end up and why?
4. Discuss Paul’s childhood with details of his relationship with his father. How does it mold him into the man he
becomes?
5. After his father dies, Paul finds a letter the man had written to him. Why does it make him cry? How might this
have helped him become the man he did?
6. What does Paul mean when he says, while standing on a hill in Haiti, in order to understand Cuba, Peru, and
Russia, you have to stand on that hill in Haiti?
7. What is the significance of the sign hanging in the PIH headquarters in Boston which on the top says, “To know
Paul is to be golden,” but underneath says, “To know Paul is to be f*****?”
8. How is Jim Kim just like Paul and yet very different?
9. Why do you think Kidder spent an entire chapter of his book telling the story of the young boy named John who
is taken to Boston only to die?
10. Paul says he has spent his entire life working on the long defeat. What does he mean and how is this
representative of the kind of man he is?
COMMENT ON THE STUDY OF LITERATURE
The study of literature is not like the study of math or science, or even history. While those disciplines are based
largely upon fact, the study of literature is based upon interpretation and analysis. There are no clear-cut answers
in literature, outside of the factual information about an author's life and the basic information about setting and
characterization in a piece of literature. The rest is a highly subjective reading of what an author has written; each
person brings a different set of values and a different background to the reading. As a result, no
In this study guide, we have tried to give an objective literary analysis based upon the information actually found
in the novel, book, or play. In the end, however, it is an individual interpretation, but one that we feel can be
readily supported by the information that is presented in the guide. In your course of literature study, you or your
professor/teacher may come up with a different interpretation of the mood or the theme or the conflict. Your
interpretation, if it can be logically supported with information contained within the piece of literature, is just as
correct as ours; so is the interpretation of your teacher or professor.
Literature is simply not a black or white situation; instead, there are many gray areas that are open to varying
analyses. Your task is to come up with your own analysis that you can logically defend. Hopefully, these
booknotes will help you to accomplish that goal.
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