Mountains Upon Mountains - Paul Farmer

Two epigraphs introduce Mountains Beyond Mountains. The first is the Haitian proverb "Beyond mountains there are mountains." 

• It may be interpreted to mean when one problem is solved, another appears and must be dealt with. It also may be interpreted to mean life offers boundless opportunities.

The second epigraph is from a poem by T.S. Eliot, "The Dry Salvages":

 And right action is freedom / From past and future also / For most of us, this is the aim / Never here to be realized; Who are only undefeated / Because we have gone on trying 

• Together, these epigraphs sum up Paul Farmer's life work. The poor of Haiti present him with endless challenges to which he responds with unflagging determination, ministering to the malnourished and diseased with the goal of making a difference, one patient at a time.

Farmer, working in Haiti since about 1984, points out the gross injustices plaguing Haiti and its people and the role that the US and other Western power have had in the ensuing chaos and poverty. Haiti has been and remains the poorest nation in the world.

• In 1946 a U.S. military school called the Latin-America Center—Ground Division was established in the Panama Canal Zone, then controlled by the United States. Initially, only U.S. soldiers studied there. However, the focus of instruction shifted over time to bilingual instruction of Latin American military personnel. The goal of this instruction was to strengthen Latin American forces while promoting American ideals. In addition to military training and education, instruction at the school sought to instill democratic values and to foster respect for human rights.
• The school was renamed again in 1963. Now the U.S. Army School of the Americas (SOA), the facility had overseen the training of thousands of Latin American military personnel. In 1984, the school relocated to Fort Benning, Georgia. In addition to traditional training for war operations, courses included training for non-traditional missions, such as peace-keeping and combatting drug trafficking and terrorism.
• Over the years the SOA gained critics after some attendees became notorious for human rights abuses in Latin America. For example, according to Paul Farmer, a high official of the military junta that overthrew President Aristide's legitimate government trained at the SOA. In 1996 it came to light that some school instruction supported brutal and unethical methods of combatting rebels and revolutionists in Latin America. The SOA was shut down in 2000.

Farmer's interest in the social aspects of health stems from his studies in medical anthropology. 

• This field of study delves into the social, political, cultural, biological, and linguistic (language-related) factors affecting health and wellbeing within communities. 
• Medical anthropology examines how these factors influence the spread and treatment of illnesses. 
• It looks at illness from all angles, including human behavior, cultural norms, nutrition, and conditions shaping medical practices.
• Example of his 24/7 dedication to improving the lives of his patients: Joe

Zanmi Lasante, Paul Farmer's medical complex in Cagne (one of the prooest places on earth), is like a walled oasis; "a fortress on its mountainside." A picture emerges of poverty, malnourishment, and want in this region of Haiti. The need for a clean, modern medical facility and the broad range of services it offers becomes clear during Kidder's first week of rounds with Farmer. 

Farmer has a compassionate and holistic way of dealing with each patient and his or her sickness. Creole for "Partners in Health," Zanmi Lasante features tree-shaded courtyards and walkways, specialty clinics, a general hospital, and a new building for the treatment of tuberculosis. There is also an Anglican church, a school, and a kitchen set up to feed 2,000 people daily. The complex is clean, with running water and electricity.

• Rounds begin at dawn. Outside the ambulatory clinic, patients are gathered to seek medical help. Farmer looks among the throng for those who are in urgent need. He then retreats awhile to a small room above the kitchen to receive and transmit emails by satellite phone. Then it is on to his office in the Thomas J. White Tuberculosis Center, where Farmer begins to minister to patients suffering from TB and coexisting illnesses, like AIDS.
• Zanmi Lasante is the cleanest, best-equipped medical facility in the region. No one is ever turned away for inability to pay. 
• About a million peasant farmers depend on its services, and 100,000 live in a catchment area—an area served by Zanmi Lasante's staff of 70 community health workers. 
• Within this catchment area, Zanmi Lasante has built schools and houses, put in community sanitation and water systems, vaccinated the children. and lowered malnutrition and infant mortality rates. 
• The number of HIV cases had been greatly reduced, and since 1988, no one in the catchment area had died from Haiti's most prevalent disease, tuberculosis.

In 1995 Farmer married Didi Bertrand, a Haitian woman (who he was married to until his death two years ago). Their daughter was born two years later. During the academic year, mother and daughter live in Paris where Didi studies anthropology. While in Haiti, Farmer lives alone in a small house in Cange. When the family is together in Boston, they share an apartment in Eliot House at Harvard.

• Any money Farmer makes from grants, lectures, writings, or his work at Harvard and Brigham goes directly to the Boston-based public charity Partners in Health, founded by Farmer. The rest of the funding for Zanmi Lasante comes from private donations. 

Sorcery and the indigenous religion called voodoo play a role in the diagnosis and treatment of illnesses. 

• Farmer says Haitian culture "has evolved in the absence of effective medicine." As a result people believe sorcery is the origin of sickness. When they see medicine cure people, they attribute godlike powers to the healer—in this case, Farmer.
• Farmer underscores the power of this religion, practiced mostly by Haitian peasants, in his story of the mother who believes her son, through sorcery (magic), sent the illness that killed his brother. This fixed belief adds to her suffering, and the accusation deeply wounds her surviving son. 
• Farmer notes Haitians have "an exquisite openness to being injured by words." Further poisoning the situation is jealousy based on economic inequality. The son lives better than his mother, so in her view, cares nothing for her. He must have sent the killing sickness. Traditional medicine cannot address such beliefs, but insights provided by medical anthropology can help a physician such as Farmer blend science with "the magic necessary to remove ensorcellments," meaning enchantments.

Farmer fights for high-quality medicine for the world's poor. 

• A young man, Ti Ofa, is nearing the final stage of AIDS. 
• Farmer insists on treating him with the latest and very costly antiretroviral drug denied to the poor anywhere else in the world. 
• Farmer is determined to find the money to pay for this level of therapy. He rejects those that say they won't follow protocol.

The 13-year-old patient in the midst of a painful spinal tap cries out that she is hungry. 

• Farmer says only in Haiti would the pain of hunger surpass the pain of this procedure. The causes of hunger in Haiti are long-term and complex. 
• Their roots are historic, beginning with the country's start as a colony of enslaved people dominated by France. Since then, international influences, even well-meaning ones, have continued to impact the tiny nation.  
• Haiti exports what it produces while it becomes increasingly dependent on the import of necessities, such as rice. These are often overpriced and unaffordable for the poor.
• Internal problems have also plagued Haiti since its independence more than 200 years ago. Over time, corrupt dictators have illegally grabbed the land from the peasantry, who depend on it for farming. Now, most farming land is owned by the government and leased out to farmers, who then struggle to make a living. Adding to this problem are poor farming practices that have led to soil erosion and deforestation. Natural disasters, such as hurricanes and epidemics, periodically contribute to the misery. Abject poverty seals the fate of the hungry and remains inescapable as long as the social, economic, and political structure of Haiti remains unchanged. Well-meaning charitable foundations can only offer temporary relief.

Historical Foundation of Philosophy

In 1988, while still a student at Harvard but working in Haiti, Farmer learned about the relationship between cultural beliefs in sorcery and the treatment of illnesses like tuberculosis. More importantly, he learned successful treatment required a full package of services. 

• Patients thrived when they received medicine as well as visits from a community health worker and a monthly cash stipend for extra food, childcare, and transportation to doctor's appointments.
• For 12 years Farmer has kept to this treatment program and has not lost a single patient to TB. 
• Deep in the mountains, they at last reach Morne Michael (Dam reservoir)and find the young patient. His missed appointment was caused by a mix-up in instructions, and he had received no cash stipend to fund the journey. However, he has been taking his TB medication faithfully (Farmer keeps track of and checks up on his patients)
• Farmer wants to transform how the world views the poor. 

The Péligre Hydroelectric Dam was planned by the U.S. Army Corps of Engineers and completed in 1956. It was assembled by an international team. 

• The dam is one of the only sources of electricity for Haiti and was intended to bolster the country's industrial expansion. 
• Another promised benefit was controlled irrigation downriver from the dam, which would assist farmers and enhance crop production. 
• Nevertheless, by the time Kidder's visits Haiti, the dam has fallen into disrepair and is operating at only one-third capacity. Drought and a shortage of oil to run the power plant contribute to the problem. The power being supplied is intermittent and unstable.
• Families displaced by the dam's flooding resettled in the hills, where inept farming efforts led to soil erosion and deforestation. They reaped no benefits from the dam—neither water nor electricity. 
• As conditions worsened many of the displaced left for the capitol city of Port-au-Prince. There they found the promised electricity illuminating wealthy people's homes, but most found no solution to their own destitution. The cycle of generational poverty continues.
• The Péligre Dam symbolizes the clash between progress and humanity that produces poverty worldwide and creates suffering within the most vulnerable groups. It is advancement and investment in the future—well-intended or not—but it fails to consider the human cost.

Personal History: Paul Farmer's Childhood/Influences

• Liberation theology is a religious movement that arose in the second half of the 20^th century. It blends Roman Catholicism and social activism on behalf of the poor. First emerging in Latin America, its doctrine holds that God and the Bible, to be truly understood, must be experienced and interpreted from the perspective of the poor. His father was a member of the lay clergy

• Farmer was very dedicated to his Christian religion and what he beleived were its most important tenets. This faith-based advocacy is what appealed to Farmer. He recognized that the poor, of all people, benefit most from faith and the hope and help it inspires.
• Liberation theology demands practitioners to confront social issues and strive for positive change. 

• Liberation Catholics form small, local faith-based communities and address social problems, such as hunger or lack of clean of water. These communities are often led by laypersons, not clergymen.
• Unconventional upbringing: He was raised in a refurbished bus and an unseaworthy boat 
• He learned outward appearances are not what count; they are not true benchmarks of a person's worth. 
• While his father did not allow the children to feel prideful, he would not permit them to feel ashamed of their lower standard of living. 
• As a result Farmer can appreciate and enjoy nice things but can easily do without them. 
• The children were also taught the value of work, including manual labor. The boys and their father labored beside migrant workers, picking fruit to earn money. 
• The children also were encouraged to strive for excellence in their education. When Farmer brought home an "A" on a test, his father would ask if anyone got an "A+". He won a full scholarship to Duke University.

Education and Mentors:

• Farmer went to study in Paris with anthropologist Claude Lévi-Strauss. Lévi-Strauss's work inspired a methodology called structuralism, which seeks to analyze the components of the human experience from birth until death and to understand their relationships. Understanding the structure of the human experience and how it is built is a useful tool for social anthropologists, who study human societies and how they develop. Farmer would weave these principles to his medical philosophy and approach to treating disease among the poor.
• An even greater influence on Farmer was the life and work of Rudolf Virchow. Virchow was a prominent physician and pathologist—a scientist who studies the causes and effects of disease. 
• He was also an anthropologist as well as a political activist and social reformer. He worked for public health improvements such as better standards of meat inspection, sewage disposal, hospital designs, and school hygiene.
• Virchow believed in taking preventative measures against disease rather than waiting until people got sick. This methodology appealed to Farmer and was fundamental to his approach in wiping out diseases in Cange and elsewhere. 
• Social anthropology applied to medicine sees patients in a holistic light. Patients are more than a set of symptoms or a disease; they are part of a social structure that influences the acquisition of an illness and the course of its cure. 

Contributions:

• During Farmer's first visit to Haiti, his philosophy, world view, and life goals coalesce into an intent to serve the nation's poor. Haiti's economics demand people pay for health services before treatment. This is often impossible for the poor, so they must go without. For most, the outcome is predictably catastrophic. Farmer witnesses the death of a Haitian woman who likely would have been saved by a simple blood transfusion—had she been able to pay for it. She leaves behind five children. This is how the cycle of poverty persists and grows worse.
• In 1989 Farmer writes his Ph.D. thesis in anthropology: "AIDS and Accusation." Farmer sees Haiti as a scapegoat in the debate about the origins of HIV. In his paper, he theorizes the origins will not be found in Africa or Haiti, as some experts have concluded. In Farmer's view, HIV has most likely originated in North America and spread to Haiti by American, Canadian, and Haitian American sex tourists.
• May 1995, Farmer's mentor from Boston, Father Jack, contracts TB in the slums of Peru, and it proves to be resistant to treatment. His death devastates Farmer and sparks fear TB may not be under control in Lima at all. The only way Father Jack could have caught the disease was from someone else in Carabayllo. From there, it might easily spread—or be spreading already—to the capital city. This sends him to Peru to eradicate TB. He concludes that interrupted and incomplete treatment of TB results in a stronger strain of the disease developing and being transmitted to others. 
• he finds the therapy's failure springs from the official guidelines for TB therapy prescribed by the World Health Organization (WHO). Based on a 20-year-old study, WHO endorses trying again if a first round of therapy fails. The same drugs are used; the regimen is simply strengthened. 
• he emphasizes that bringing better health care to the poor is not just a matter of raising money and building hospitals. It involves understanding and carefully dealing with the nuances of politics where other agendas may directly or indirectly conflict with the needs of the sick.

Jim Kim  and Farmer are relentless in his pursuit of a way to lower drug prices. Groups with similar goals, including the International Dispensary Association (IDA) and Doctors Without Borders, notice PIH's success in Haiti and Peru and get involved.

• Like PIH, IDA and MSF exemplify Margaret Mead's philosophy: "Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has."

• Finally, in Farmer's global view, there are no barriers to be breached between the wealthy and the poor. They are part of the same world, and whatever seems to divide them is an illusion. Those who take refuge in their affluence cannot escape the universal continuity and interconnectedness the ties them to those in abject misery. Farmer sees no reasons why the flow of wealth cannot and should not be redirected towards those in need.

• He has redefined "what can be done and what is reasonable to do in medicine and public health." His ideas are spreading.