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Mountains
Beyond Mountains (2004)
by Tracy Kidder Study
Guide Part One, “Dokte
Paul” pp. 1-45 Tracy
Kidder’s Mountains Beyond Mountains
tells the story of Paul Farmer and his unique approach to delivering health
care in places wracked by poverty. Farmer believes, simply, that all humans
deserve high-quality medical care regardless of their ability to pay. Kidder
chose to tell this story in the first person so that he could trace his own
struggle to accept Farmer’s radical approaches to dealing with the problem of
poverty. The action of the story really concerns the health care debate which
develops between Farmer and Kidder over the practicality of liberation
theology in the post-Cold War era. Liberation
theology- a movement in Christian theology which interprets the teachings of
Jesus Christ in terms of a liberation from unjust economic, political, or
social conditions. (Wikipedia) The
title of the book, Mountains Beyond Mountains, is taken from a
Haitian proverb that translates as “beyond mountains there are mountains.”
Why did Kidder use this as the title? What does it mean in terms of Paul
Farmer’s work? (Kidder) Kidder
opens Mountains Beyond Mountains with an account of a discussion
between Paul Farmer and a U.S. army captain who was commanding a small
peacekeeping force in Haiti in 1994. (3-4) Farmer and the captain initially
discuss a recent murder case in the area, and the captain claims that there
is little that he can do legally to put the suspected perpetrator, a local
thug named Nerva Juste
who belongs to a local death squad, behind bars. (Kidder) Farmer
argues that it makes little sense to observe principles of constitutional law
in a country that has no functioning legal system. What are the implications
of his assertion for American foreign policy? What else do we learn about Farmer’s philosophy from the opening chapter? (He speaks Creole; he grew up in a trailer park; he teaches medicine and medical anthropology at Harvard; he works in Haiti eight months out of the year) “The term "medical anthropology" has been used since 1963 as a label for empirical research and theoretical production by anthropologists into the social processes and cultural representations of health, illness and the nursing/care practices associated with these.” (Wikipedia) A medical anthropologist learns about a culture not from books or classes but from the people themselves. Chapter Two (9-17)
Boston 1999 What do we learn about Farmer’s medical philosophy from his treatment of “Joe”, the HIV positive substance abuser who is being treated for TB at Brigham and Women’s Hospital in Boston, where Farmer practices when he is in the states? Where would Joe like to go when he gets out of the hospital? In a reference to Farmer’s latest book Infections and Inequalities, Kidder focuses upon Farmer’s poorly disguised sarcasm when he refers to a TB patient in Haiti responding to antibiotics “almost as if she had a treatable infectious disease” (17). What is Farmer’s point? Chapter Three
(18-32) Zanmi Lasante
2000 Describe the Zanmi Lasante facilities that Farmer and Partners in Health had developed during the sixteen years since he first arrived in Haiti. What are some of the key accomplishments that the clinic had already achieved by 2000? How is the operation financed? How does Farmer justify spending so much money on the health of people who cannot pay? What is the principle of ‘cost efficacy’ in health care? Why does Farmer get annoyed when Kidder asks him about the personal sacrifices he has made in his career in order to build Zanmi Lasante? How does Farmer treat Ti Ofa when his HIV infection progresses into full blown AIDS? (How would he be treated in an American hospital?) Chapter 4 (33-44)
Sustainable Care? How would a traditional doctor regard the Vodou beliefs of the Haitian people? What is Farmer’s attitude towards these beliefs? How has his thinking been influenced by his training in medical anthropology? What did Farmer’s team discover was essential to their successful treatment of TB in the greater Cange community? How does this approach to care reflect Farmer’s belief that ‘structural violence’ is the fundamental cause of disease? Farmer believes that if a patient does not get better, it is the physician’s fault. How do the health workers at Zanmi Lasante implement this philosophy? Is this approach to health care ‘sustainable’? What makes the hydroelectric dam at Lac de Peligre on the Artibonite River a perfect example of the problems with US investment in Haitian infrastructure? How might this money have been better spent to benefit the people in this river valley? How did the US respond to the outbreak of African swine fever in the Dominican Republic? What were the consequences of this policy? What is the meaning of the Haitian term ‘Kennedys’? Part
Two: The Tin Roofs of Cange (45-121) Chapter 5
(47-58) Farmer’s Childhood and Family Which
characteristics of Farmer’s unusual family and upbringing would lend
themselves to his later career success? Chapter 6
(59-65) Duke University Who
is Farmer’s hero from the history of medicine? Why? By
whom was Farmer first introduced to the tenets of liberation theology? What
are the basic tenets of liberation theology? How do these beliefs differ from
traditional Catholicism? How do they differ from Marxism? Chapter 7
(66-76) Ophelia Dahl Farmer
describes the reasons for his decision to work in Haiti as the result of his
own interpretation of the causes of poverty. (73-74) Can you rebut this
interpretation of Haiti’s history? [The
] world [has been] designed by the elites of all nations to serve their own
ends, the pieces of the design enshrined in ideologies, which erased the
histories of how things came to be as they were. The catastrophe in Haiti is
covered with the fingerprints of the Western powers, most of all those of
France and the United States. (73) How
was Farmer drawn back to the religion of his youth by his experiences among
the poor of Cange? What did he find inspiring about
their lives? What
is the meaning of the Haitian proverb, “Bondye konn bay, men li pa konn separe.” What
problems did Farmer find with the clinics in which he first worked in Haiti?
How would his own clinic be different? How
is ethnography essential to his own approach to practicing medicine? What
particular information did Farmer discover about Cange
in the planning his clinic? How might this approach differ from that of an
international charitable agency? How
did Farmer work with the hungans to address the problem of maternal mortality in Cange? Chapter 9
(85-95) Harvard and Haiti How
does Farmer reconcile his religious beliefs (Haiti) with his devotion to
science (Harvard)? How
did American engineers finally solve the problem of water born diseases in Cange? Would typical American aid agencies regard this
project as an ‘application of appropriate technology’? What
first line ‘preventive’ measures did Farmer implement in Cange? Farmer
says “Clean water and health care and school and tin roofs and cement floors,
all of these things should constitute a set of basics that people must have
as birthrights.” Do
you agree? Should government be responsible for providing these basic rights
for their people? Could the Haitian government meet these challenges? To
whom did Farmer turn to find the money he would need to build Zanmi Lasante? Chapter 10
(96-103) Partners in Health How
do Farmer and his colleagues respond to criticism from the political left?
“Good works without revolution only prolongs the status quo. The only thing
projects like Cange really accomplish is creation
of dependency.” Who,
in addition to Farmer, are the key members of Partners in Health and what are
their functions? What do they mean when they describe the situation in Haiti
as an “AMC”? (100-101) Which
group in Haitian society led the opposition to Baby Doc during the 1980’s? Who
was Jean-Bertrand Aristide, and why did Farmer support him? What
story did Farmer publish in the Boston
Globe the year after the junta ousted Aristide? Chapter 12 (114-121)
Military Rule 1991-94 How
is Farmer able to wield influence with the potentially violent members of the
regime? What
is the thesis of the book on Haitian history, The Uses of Haiti,
that Farmer wrote at this time? Do you buy it? Part III Medicos Adventureos (125-177) What
factors account for the convergence of TB and AIDS on the poor side of the
‘great epi divide’? How
does poverty contribute to rising antibiotic resistance to TB? Does
investment in Farmer’s studies of MDR make economic sense? Chapter 14
(129-134) Lima, Peru How
did Partners in Health get interested in the Carabayllo
District of Lima, Peru? Why
did the Shining Path
guerillas blow up the Partners in Health pharmacy in Carabayllo?
How
was it that the Peruvian authorities were unaware that an epidemic of MDR had
broken out in Lima? Chapter 15
(135-141) The Problem with DOTS Why
would people move from the countryside to the arid slums on the hilly
outskirts of Lima? How
does Farmer solve the problem of poor laboratory and testing facilities
wherever he practices medicine? What
had the World Health Organization’s DOTS treatment plan for TB accomplished
worldwide since its inception? What,
according to Farmer’s theory, had gone wrong with the DOTS treatment plan for
TB in Peru? (138-140) What had caused
the ‘amplification of resistance’? How
do Farmer and his colleagues make the case that cost-effective policies
limiting treatment of MDR wind up costing health systems more in the long
run? Do you buy this argument? Chapter 16
(142-147) Changing the Drug Protocol Regimen What
average expense and cure rate did experts get at the best MDR treatment
facility in the United States? Why
were the Peruvian doctors who led the WHO treatment plan so reluctant to
allow Farmer and his doctors to treat MDR cases? How
did Farmer break down the following myths: a.
MDR is too expensive to treat in poor countries and
just detracts attention and resources from treating drug-susceptible disease. b.
DOTS alone will stop outbreaks of MDR. Chapter 17
(148-158) Funding the Change in Protocol Where
had Farmer found the drugs to treat the MDR patients in Peru? Public
health managers regarded what Farmer was doing as reckless: a.
They had no way of financing a regular supply of
drugs for their MDR patients. b.
They had no way of financing the testing required
to diagnose MDR. c.
Expert opinion in the TB field was against them. Would
you have financed them? What standard did Farmer in his colleagues use
instead? What
does Kidder think of Farmer’s response to coming down with Hepatitis A? Can
this criticism be applied to his philosophy of medicine as well? What
medical protocols did Farmer ignore when he prescribed second line MDR drugs
for Christian when he was a baby? (How did Farmer rationalize his decision?) What
is Farmer’s strategy for overcoming the Peruvian medical establishment’s
inflexible approach to TB treatment? What
additional expenses will be incurred worldwide if the DOTS program is
altered? What
is the MORAL of the story? By successfully treating a small number of MDR
cases at great expense, has Farmer made the case for significantly altering the
DOTS program which saved the lives of millions? Chapter 18
(159-164) Taking on the WHO Arata Kachi articulates the other side of the argument: “Don’t
let perfect be the enemy of good.” What is the ‘problem’ with Farmer’s
approach from the perspective of a doctor with international public health
experience? Look
at the problem of the Russian doctor responsible for treating TB in the
Russian prison system with a budget of six million dollars. (162) What
utilitarian choices will he be forced to make? Can Farmer rebut his logic? Do
you buy Jim Kim’s rationale for devoting such a substantial portion of the
PIH budget in Haiti to the treatment of MDR patients in Peru? (How many kids
in Haiti went hungry because of the program?) What standard must the PIH
people use when they make decisions like this one? Chapter 19
(165-177) Economics and Medical Care in 3rd World Countries Note
the articulation of the utilitarian argument (165): “The world has limited
resources. Nations whose resources are not just limited but scarce have to
make the best possible uses of what little they have. Other countries and
international institutions may help out, but if you want money from big
donors, if you want to be taken seriously, your proposals have to pass a cost
effectiveness analysis. You must calculate costs and try to quantify your
programs effectiveness.” Is
there a logical flaw to this reasoning? Must health care planning use a
universal baseline to determine costs? Will a program that is successful in
New York City also prove successful in an impoverished locale? Should
economic decision making (with its short term perspective) drive long term
health care decisions? What
variables are involved in bringing a drug to a mass market? (169) What decisions
at Eli Lilly (the pharmaceutical firm) made production of 2nd line
MDR drugs so expensive? What
was Jim Kim’s business strategy to get 2nd line MDR drugs
approved for the WHO DOT plus program? What
business conundrum did Jim Kim have to overcome? To lower the prices of
drugs, a lot of TB projects would need to use them, but for a lot of projects
to use them, the prices have to be lower (ie
generic production). How did he do it? How did Guido Bakker at IDA and the
group Doctors Without Borders come to his rescue? What
possible NEGATIVE MEDICAL consequences could result from a successful effort
to make 2nd line TB drugs widely available? What solution did Kim
and his team come up with? By
2000, how far had prices for 2nd line drugs to combat MDR dropped? What
is the moral of this story? How, in a world of limited resources and
bureaucracies which naturally favor incumbent policies, had Kim and Farmer
engineered a change which primarily benefitted poor people? Once
they had broken through, how did PIH plan to expand its services so that it
could continue to fund its operations in both Haiti and Peru? Part Four: A Light Month for Travel
(179-237) Chapter 20
(181-192) Farmer’s Days After
his breakthrough success convincing the World Health Organization to alter
its protocol on MDRs, Farmer was urged to leave his practice in Haiti behind
and take an executive role in the international effort to contain MDR. Why
did he turn these offers down? How instead did he put his fame to work on his
vision of practicing medicine for the poor? “Patients
come first, prisoners second, and students third.” (182) For
I was an hungred, and ye gave me meat: I was
thirsty, and ye gave me drink: I was a stranger, and ye took me in: Naked,
and ye clothed me: I was sick, and ye visited me: I was in prison, and ye
came unto me. Then shall the righteous answer him, saying, Lord, when saw we
thee an hungred, and fed thee?
or thirsty, and gave thee drink? When saw we
thee a stranger, and took thee in? or naked,
and clothed thee? Or when saw we thee sick, or in prison, and came
unto thee? And the King shall answer and say unto them, Verily I say unto
you, Inasmuch as ye have done it unto one of the least of these my
brethren, ye have done it unto me. (Matthew 25:35-40) Why
does Farmer find it so hard to leave Haiti? (188) Ophelia
Dahl describes Farmer as ‘terribly simple’, a man who has never experienced
true depression. Why is that? How
does Farmer rationalize continually working 100 hour weeks? (191) (That’s 14
hour days.) Chapter 21
(193-210) Cuba’s Health Care System Kidder
begins this chapter with Farmer’s exclamation about the verdant Cuban
countryside as their plane descends into Havana. “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!” (193) What is Kidder’s
point? Why is Farmer fond of Cuba? What
does Farmer despise about Marxism? What does he despise about ALL ideologies? What
does he mean when he says, “All -ologies fail us at some point. At a point, I suspect,
not very far from where the poor live out their dangerous lives.” (195) What
personnel problem did Farmer hope to solve in Cuba? How? How
does he hope to redefine ‘triangular trade’ for the 21st century? What
did Farmer’s study of HIV infection in women in Cange
reveal about the source of infection? How
did myths about HIV and AIDS influence the two different quarantines at
Guantanamo Bay and in Havana in the early nineties? What
choice did the Cuban government make which radically reduced the number of
AIDS cases in that country? At
the end of this chapter, Farmer confronts Kidder with his concerns about how this
visit will be represented in his book. Will he depict Farmer as a stooge of
the communists? Or will he affirm the successes of this government’s health
system? Farmer
suggests that the notion that a peasant revolution could ever succeed in
Haiti is ridiculous. He says instead that other people, richer people, will
have to perform that revolution for them? Is that ever going to happen? How
then should we regard his politics: “Patients come first, prisoners second,
and students third.” (182)? What
chink in Farmer’s moral armor is revealed when he visits his family in Paris?
Can we draw conclusions about his ideas from this failing? What
does ‘hermeneutic of generosity’ mean? Musing
about the parallel universe of wealth and power exhibited by Charles De
Gaulle Airport, Farmer describe his philosophy of
interconnectedness. What is the connection between the two worlds? What is
the worst sin, in Farmer’s view, that the rich can commit? Chapter 23
(220-237) Mission to Moscow How
had the tuberculosis epidemic in Russian prisons in 1997 begun to ‘amplify’
before Farmer got involved? How
did Farmer’s commitment to this project (despite his lack of time) serve
PIH’s mission and its financial needs? What
political point can be made by comparing the health systems in two socialist
countries: Cuba and (formerly) the Soviet Union? During
the toasting ceremony at the dinner with Russian prison doctors, Farmer
describes America less as a democracy then as a privileged nation. “The rich
can always describe themselves as democratic, but the sick people are not
among the rich.” What conclusion can you draw from this comment about
Farmer’s political views? Describe
the complex politics involved in the competition for control of the World
Bank/George Soros loan to Russia to treat its tuberculosis epidemic. After
securing the loan Farmer argues with his Russian friend Alex Goldfarb, the
head of the Russian Ministry of Justice. Goldfarb accused Farmer of being a
naïve sentimentalist, someone who cannot acknowledge that most people in
prison are bad, not just poor. He says, “You can just disregard things which
are unpleasant, and that is why you are not scientific. You disregard
reality.” (236) Is this criticism fair? Part Five: O for the P (239-301) Chapter 24
(239-260) AIDS Treatments in Impoverished Countries What
new challenges did Partners in Health face as it expanded its medical scope
to treat AIDS and its geographical scope to projects in Russia and Peru as
well as Haiti? Rather
than waiting to administer the low cost second-line antibiotics in Russia,
Farmer and Kim bought enough drugs at high prices to start treating a few
dozen MDR patients right away. How did they rationalize this financial
decision? What
approach to dealing with AIDS in impoverished countries had been the World Health
Organization’s approach even after antiretroviral drugs had become available?
What
treatment plan did Farmer propose in his plan to fight the epidemic
throughout rural Haiti? (259) Tell
the story of Zanmi Lasante’s
effort to save John, the ten year old boy suffering from TB and nasophayngeal carcinoma. How
much money did Farmer commit to this one patient? How much did it cost to
borrow the suction device, transport John from Cange,
and then treat him at Mass General in Boston? Can
such an outlay of funding be rationalized? What
was the response of the physicians at Mass General? What
was the response of Haitians when they learned of the trip? Chapter 26 (280-298) A Housecall in Haiti Describe
the stops Farmer makes enroute to Alcante’s hut in Casse. (Note
that this international expert is on a seven hour hike to treat two
patients.) From
whom did Farmer learn about the importance of doing anonymous, ‘scut work’? How
does Farmer respond to Kidder’s question about triage and John’s case? What
does he mean by ‘fighting the long defeat’? What is he making by comparing the
expense in John’s case to the salary of a young attending physician? (288-89) What
do you make of the criticism of Farmer and Partners in Health that suggest
that the organization will not survive Farmer and it cannot be replicated?
(294) Farmer’s
basic philosophy is to do what is best for the individual patient. Can you
argue against that model of health care? How
has Farmer changed the world in its approaches to the treatment of TB and
AIDS? Essay
Question: Evaluate Farmer’s approach to public health. Is it, finally, practical?
Should we rethink the health care debate in the United States with his
example in mind? |