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Mountains Beyond Mountains by Tracy Kidder


Rating: (Highly Recommended)


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Over the Top

I’ve been reading Tracy Kidder’s books since his Pulitzer-prize winning The Soul of a New Machine, more than twenty years ago. Kidder’s latest book, Mountains Beyond Mountains, introduces readers to the remarkable life of Dr. Paul Farmer. Farmer received both a medical degree and a doctorate in anthropology from Harvard, while shuttling back and forth between Haiti and Boston. In Haiti, he formed an entity called Partners in Health (Zanmi Lasante in Creole). Farmer received a MacArthur genius grant for his work in creating a community based tuberculosis treatment program. From the two decades of his work in Haiti, Farmer became an international expert in communicable disease, and the effect treatment thereof.

Here’s an excerpt from the beginning of Chapter 4 that also explains the title (pp. 33-36):

Soon after I arrived to visit him in Cange, Farmer said he'd be my Virgil here. I think that, when it came to Haiti, he viewed almost everyone as a potential subject for education, or reeducation. No other country in the world had been subjected to as much "idiotic commentary," he said, and it would have been hard to argue the point, given the fact that, for instance, the name of Haiti's indigenous religion had long since become the synonym for crazy ideas and sheer luridness.

Farmer liked to tell a story about his own education in Haiti, a story about the relation between medicine and beliefs in sorcery. Back in 1988, a woman from Zanmi Lasante's catchment area had died of tuberculosis while he was in Boston recovering from a badly broken leg. When he returned to Cange, several of the staff told him the woman wouldn't have died if he'd been on hand. They meant this as a compliment. He converted it to self-reproach. He wanted a medical system that functioned in his absence. He gave everyone in the woman's family jobs at Zanmi Lasante and called a series of staff meetings to figure out what was wrong with their system for treating TB.

The staff had a lively debate. Zanmi Lasante's community health workers, who lived among the peasant farmers, who had been until recently mostly peasant farmers themselves, spoke about the economic impediments to treatment, pointing out that the poorest patients tended to fare worst, certainly in part because of malnutrition. One health worker recited a Haitian saying: "Giving people medicine for TB and not giving them food is like washing your hands and drying them in the dirt." But most of the professionals on the staff—the Haitian doctors and nurses and technicians—offered explanations that laid the blame in the minds of the patients, the kinds of explanations one often reads in scholarly journals. Once they felt better but long before they were cured, patients stopped taking their pills, the professionals said, and patients did this in part because they didn't believe TB came from microbes but believed it was sent to them by enemies, via sorcery.

Farmer felt intellectually torn. The health workers' theory amounted to a description of the kind of socioeconomic arrangement that he called "structural violence." But he was also an anthropologist in training, schooled in the importance of the kinds of cultural beliefs that the professionals cited. So he designed a study. He was still a student at Harvard. The study was like a class he created and then attended as a pupil.

He selected two groups of TB patients. During the study, each group got free treatment, the same they would have received at the Brigham. But one group got other services as well, including regular visits from community health workers and small monthly cash stipends for food and child care and transportation to Cange. Farmer hiked to the many villages of the patients, visiting all of them in their huts. This took weeks. "A hundred chatty Haitians," he would say. "Don't try this at home." He asked all of them, among other questions, if they believed TB came from sorcery, and all but a very few in both groups said that they did. And yet, when the results came in, the cure rates for the two groups were dramatically different. Of the patients who had received only free medicine, a mere 48 percent were cured. By contrast, everyone in the group that received the cash stipends and other services made a full recovery. Whether a patient believed that TB came from germs or sorcery didn't seem to have made any difference at all.

Fanner felt puzzled. "I expected to buy into the idea that what's in people's minds affects their behavior and the outcomes," he told me. And he was at a loss for explanations, until he began reinterviewing the patients and called on one of his favorites, a sweet, rather elderly woman. When he had first interviewed her, about a year before, she'd taken mild offense at his questions about sorcery. She'd been one of the few to deny she believed in it. "Polo, cheri," she had said, "I'm not stupid. I know tuberculosis comes from people coughing germs." She'd taken all her medicines. She'd been cured.

But now, a year later, when he asked her again about sorcery, she said that of course she believed in it. "I know who sent me my sickness, and I'm going to get her back," she told him.

"But if you believe that," he cried, "why did you take your medicines?"

She looked at him. He remembered a small sympathetic smile. The smile, he thought, of an elder explaining something to a child—in fact, he was only twenty-nine. "Cheri," she said, "eske-w pa ka konprann bagay kipa senp?" The Creole phrase pa senp? means "not simple," and implies that a thing is freighted with complexity, usually of a magical sort. So, in free translation, she said to Farmer, "Honey, are you incapable of complexity?"

And then of course it dawned on him that he knew plenty of Americans—he was one himself—who held apparently contradictory beliefs, such as faith in both medicine and prayer. He felt, he said, as though he hung in the air before his patient, "suspended by her sympathy and bemusement."

The study was for him a command—to worry more about his patients' material circumstances than about their beliefs. From then on, all TB patients in the catchment area received the full package of services. Each continued to get what is called directly observed therapy, a community health worker on hand to be sure the patient took the medicines on schedule, and each got the monthly cash stipend—the equivalent of about five American dollars—to pay for extra food, child care, and transportation to a monthly doctor's appointment at Zanmi Lasante. The program had worked well, indeed, couldn't have worked better. They hadn't lost a single patient in twelve years, and Farmer wasn't about to change any of the rules.

Just recently a TB patient from a village called Morne Michel hadn't shown up for his monthly doctor's appointment. So—this was one of the rules—someone had to go and find him. The annals of international health contain many stories of adequately financed projects that failed because "noncompliant" patients didn't take all their medicines. Farmer said, "The only noncompliant people are physicians. If the patient doesn't get better, it's your own fault. Fix it." A favorite Dokte Paul story in the village of Kay Epin was of the time, many years back, when Farmer had chased a man into a field of cane, calling to him plaintively to come out and let him treat him. He still went after patients occasionally. To inspire the staff, he said, and to give him a break from his office. So he was going to Morne Michel himself, and was taking me with him.

"Beyond mountains there are mountains." The proverb appeared to describe the location of Morne Michel, the most distant of all the settlements in Zanmi Lasante's catchment area. At breakfast on the appointed day, Farmer told the women in the kitchen his intentions. "Ooooo!" they cried. One said, "Morne Michel? Polo, do you want to kill your blan?"

She meant me, of course. She wasn't being rude. The women in the kitchen called even Farmer a blan—usually they called him ti blan mwen, meaning "my little white guy." But a blan isn't necessarily white-skinned; one might say, every blan becomes white by virtue of being a blan. The African American medical student Farmer had brought here some months back, for instance. Some people at Zanmi Lasante had wondered if he was Farmer's brother, and later some had mistaken another visiting black American student of Farmer's for the first one, and when Farmer teased them about this, one of the staff had said—Farmer swore this was true—"All you blan look alike."

Kidder’s powers of observation, fine writing, and storytelling skills all come together in Mountains Beyond Mountains. This is a finely written book by a talented writer about an amazing person who’s changing the world. Treat yourself to reading Mountains Beyond Mountains.

Steve Hopkins, December 22, 2003


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The recommendation rating for this book appeared in the January 2004 issue of Executive Times

URL for this review: Beyond Mountains.htm


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