Friday, January 30, 2009

"Mountains Beyond Mountains"

Mountains Beyond Mountains by Tracy Kidder

Book Review by Teresa Friedlander (copyright 2007)

Every once in a while, I read a book that changes the way I see the world, and Mountains Beyond Mountains is such a book. This book is primarily the story of Paul Farmer, MD, a Harvard professor and infectious disease specialist, who waged war on multiple fronts against antibiotic-resistant tuberculosis. Mountains Beyond Mountains is additionally an autobiographical narrative of the author’s experience while documenting the life and work of Dr. Farmer. This book is also a love story: the biographer’s love for his subject and the subject’s love for the world he inhabits.

The title comes from a Haitian proverb: “Beyond mountains there are mountains”. This is a perfect metaphor for the never-ending series of obstacles Dr. Farmer faced and surmounted in his work with some of the poorest people in the world. Tuberculosis is a disease which thrives where sanitation is a luxury. In most cases it is easily treated with antibiotics, however a new strain has emerged which is stronger than existing medicines. In Haiti, where there is little sanitation and no money for public health, this disease has reached epidemic proportions. Life for many Haitians is, in the words of Thomas Hobbes, “nasty, brutish, and short”.

Haiti’s troubles date back to when Christopher Columbus landed on the island he named Hispaniola and triggered the extermination of the Arawak Indians. France and Spain split the island and the French developed their half – now Haiti – into a slave colony. The slaves revolted in 1791 and the country has been in turmoil ever since. Once covered with lush tropical rainforests, Haiti is now a mountain of mud and misery. Infant and maternal mortality rates are among the highest in the world, and one fourth of the population dies before age 40. AIDS is a leading cause of death. Over the past century, the United States has made attempts to help Haiti, but these efforts in the eyes of most Haitians have been misguided. As one Haitian saying goes: “Giving people medicine … and not giving them food is like washing your hands and drying them in dirt”.

Something about Haiti, despite how tragic and desperate a place it is, got inside the heart of Dr. Paul Farmer and inspired him to be a catalyst for change there. Farmer’s childhood was anything but ordinary. His family was poor and itinerant and dominated by a father whom the six siblings called “The Warden”. They were at times homeless, living out of a bus and a boat. In spite of this upbringing, Paul Farmer excelled as a student. He graduated from Duke University and Harvard Medical School, but never forgot where he came from; he loved everyone he met regardless of their circumstances or station in life. While at Duke, Farmer studied the work of medical anthropologist, Rudolf Virchow, “the principal architect of the foundations of scientific medicine”. Virchow documented how social upheaval leads to “overcrowding, poor hygiene, and malnutrition” which in turn creates breeding grounds for epidemics. Virchow’s vision of creating a healthy world shaped Farmer’s view: “Pathology, social medicine, politics, anthropology. My model.”

During his years at Duke, Farmer met a nun, Sister Julianna DeWolf, who championed migrant farm workers, many of whom were Haitians. Through Sister Julianna, Farmer met many more Haitians and observed the wretched conditions in which they lived. He became a student of Haiti and by the time he graduated from Duke – summa cum laude – Farmer was hooked. The culture fascinated him: its music, art, and religious practices. Voodoo and Christianity had blended as had the French and African languages of the former slaves. In 1983, Paul Farmer arrived in Port-au-Prince on a grant from Duke while waiting to hear if he had been accepted into medical school. He entered Harvard in 1984, gathered his text books and returned to Haiti. In spite of only showing up for labs and exams he was among the top students in his class.

All the while Farmer commuted between Harvard and Haiti, he also performed a survey of health statistics in and around the city of Cange. He collected data on births, deaths, and living conditions. This research showed the direct correlation between clean water and infant mortality. Farmer’s beliefs coalesced and he would say “Clean water and health care and school and food and tin roofs and cement floors, all of these things should constitute a set of basics that people must have as birthrights.” And so, step by step, Dr. Farmer set about making this vision a reality for the citizens of Haiti – climbing one mountain after another.

The difference between Paul Farmer and other doctors who have lived in Haiti is that while they could leave, return to the United States and never look back, Farmer knew he couldn’t. No matter where he was on earth, his heart would remain in Haiti and he would return. Many of his patients died and he frequently felt like a failure even though their deaths were inevitable given the circumstances. Farmer came to realize what the Haitians already intuited: that simply providing medical care wasn’t enough. Successful medicine in Haiti would require a more comprehensive approach: better housing and nutrition, clean water, and community-based healthcare.

Farmer’s biographer, Tracy Kidder, followed him around the world on his quest for funding for his comprehensive plan as well as basic medicines and supplies for his clinic. According to Kidder, Farmer was tireless and always cheerful and positive. He could sleep in a dentist’s chair and feel it was an improvement over other places he had slept. Farmer constantly traveled back and forth between Boston, where he is now a professor of medicine, and Haiti, where he treats patients. He went to Russia to study tuberculosis epidemics there. Farmer developed recommendations for preventing and treating antibiotic resistant tuberculosis which the World Health Organization eventually adopted.

What makes Paul Farmer so remarkable, beyond his brilliance and effectiveness, is his love for humanity. This love continues to drive him to care for the poorest of the world’s poor. He would be saintly except he has a wicked sense of humor and isn’t particularly religious. Just the same, he succeeds in Haiti where others have failed because he accepts that faith – voodoo, Christian, or medical – is necessary to healing. He also accepts with grace and appreciation whatever he is given to eat and drink regardless of risk to his own health. And he is selfless. He once he signed over his paycheck to a patient who was facing eviction. Paul Farmer didn’t starve, however; his friends took care of him.

Living our comfortable lives in the United States of America, it is easy to forget that a few hundred nautical miles southeast of us is a land of unimaginable poverty. We take clean water for granted and even if we have no health insurance, we can visit a clinic or emergency room and receive decent medical care. Mountains Beyond Mountains opened my eyes not only to how desperate the human condition can be but also how the human spirit can triumph over such desperation. Paul Farmer fell in love with Haiti and Haitians because of their spirit and serenity in the face of starvation and squalor, disease and death. These people are not blind to their plight or accepting of it; they know that their country is the end of the world. Just the same, they celebrate life’s joys and share what little they have with their guests.

Tracy Kidder is a Pulitzer Prize winning writer and Vietnam veteran who lives in Massachusetts and Maine. He comes across as enjoyable a character as the subject of Mountains Beyond Mountains. Farmer and Kidder developed a close friendship during their time together and Kidder’s recounting of this side of the story makes it even more enjoyable to read. Kidder’s writing is engaging and descriptive and the book moves at a fast pace. If you are interested in science, medicine, anthropology, or just want to read a good story, this is a great book. If you care about the future of the human race, this book is a must read.

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