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Fall 2009
Special Edition Vol. 2 of 5

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Dr. Paul Farmer with a patient

courtesy of Partners in Health

Dr. Paul Edward Farmer, the subject of Tracy Kidder’s book Mountains Beyond Mountains, works in one of the most impoverished areas of Haiti to provide medical care.


Mountains Beyond Mountains

Excerpt courtesy of the author, Tracy Kidder

The Common Reading Convocation with Pulitzer Prize winning author Tracy Kidder was held Sept. 14 at Brubaker Auditorium. In the first keynote lecture of the Centennial year, Kidder shared his experiences involved in researching and writing his non-fiction book Mountains Beyond Mountains, the common reading text for 2009 10 first-year students at Messiah College. The excerpt that follows is Kidder’s account of Dr. Paul Edward Farmer, a Harvard-educated doctor working in Haiti. Farmer has dedicated his life to improving the lives of others in that country

I may as well say that from the moment I saw Zanmi Lasante, out there in the little village of Cange, in what seemed to me like the end of the earth, in what was in fact one of the poorest parts of the poorest country in the Western Hemisphere, I felt I’d encountered a miracle. In Haiti, I knew, per capita incomes came to a little more than one American dollar a day, less than that in the central plateau. The country had lost most of its forests and a great deal of its soil. It had the worst health statistics in the Western world. And here, in one of the most impoverished, diseased, eroded, and famished regions of Haiti, there was this lovely walled citadel, Zanmi Lasante. I wouldn’t have thought it much less improbable if I’d been told it had been brought by spaceship.

My first week in Cange I met a peasant farmer who had brought a sick child to the hospital by donkey, on a trek of twelve miles along Highway 3. I asked him if he’d felt relieved when he got to Cange and the medical complex. I needn’t have bothered. He looked surprised at the question and simply said, “Wi!” There were a handful of other clinics and hospitals in the region, but none were well-equipped and some were downright unsanitary, and everywhere patients had to pay for medicines, and even the gloves that would be used to examine them, and very few people in the central plateau could pay much of anything. At Zanmi Lasante, too, patients were supposed to pay user fees, the equivalent of about eighty American cents for a visit. Haitian colleagues of [Dr. Paul Edward Farmer’s] had insisted on this. Farmer was the medical director, but he hadn’t argued. Instead this was often his way, I would learn he had simply subverted the policy. Every patient had to pay the eighty cents, except for women and children, the destitute, and anyone who was seriously ill. Everyone had to pay, that is, except for almost everyone. And no one Farmer’s rule could be turned away.

Perhaps a million peasant farmers relied on Zanmi Lasante. At the moment, about a hundred thousand lived in its catchment area, the area served by its community health workers, seventy in all. Some patients came great distances, as distance is measured in a country of ruined roads and villages served only by footpaths from Port-au-Prince and Haiti’s southern peninsula, and from towns along the border with the Dominican Republic, speaking Spanish. Most came from the central plateau, on the battered, overloaded passenger trucks that navigated Highway 3. Many came on foot and by donkey. Now and then out on the road, a bed moved slowly toward the front gate, a bearer at each corner, a patient on the mattress.

Sometimes Zanmi Lasante’s pharmacy muddled a prescription or ran out of a drug. Now and then the lab technicians lost a specimen.

“I can’t sleep. There’s always somebody not getting treatment. I can’t stand that.”

—Dr. Paul Farmer, co-founder of Partners in Health, an organization providing healthcare to the developing world

Seven doctors worked at the complex, not all of them fully competent — the staff was entirely Haitian, and Haitian medical training is mediocre at best. But Zanmi Lasante had built schools and houses and communal sanitation and water systems throughout its catchment area. It had vaccinated all the children, and had greatly reduced both local malnutrition and infant mortality. It had launched programs for women’s literacy and for the prevention of AIDS, and in its catchment area had reduced the rate of HIV transmission from mothers to babies to 4 percent — about half the current rate in the United States. A few years back, when Haiti had suffered an outbreak of typhoid resistant to the drugs usually used to treat it, Zanmi Lasante had imported an effective but expensive antibiotic, cleaned up the local water supplies, and stopped the outbreak throughout the central plateau. In Haiti, tuberculosis still killed more adults than any other disease, but no one in Zanmi Lasante’s catchment area had died from it since 1988.

The money for Zanmi Lasante was funneled through a small public charity that Farmer had founded — Partners in Health, with headquarters in Boston. The bills were small by American standards. Farmer and his staff of community health workers treated most tuberculosis patients in their huts and spent between $150 and $200 to cure an uncomplicated case. The same cure in the United States, where most TB patients were hospitalized, usually cost between $15,000 and $20,000.

My local hospital in Massachusetts was treating about 175,000 patients a year and had an annual operating budget of $60 million. In 1999 Zanmi Lasante had treated roughly the same number of people, at the medial complex and out in the communities, and had spent about $1.5 million, half of that in the form of donated drugs. Some of the cash came from grants but most of it from private donations, the largest from a Boston developer named Tom White, who had given millions over the years. Farmer contributed, too, though he didn’t know exactly how much.

I became aware of the logistical facts of Farmer’s life only gradually, so they didn’t seem completely unusual until I totaled them up. In 1993, the MacArthur Foundation had given him one of its so-called genius grants — in this case some $220,000. He’d donated the entire sum to Partners in Health, to create a research branch for the organization — the Institute for Health and Social Justice, he called it. He made about $125,000 a year from Harvard and the [Brigham and Women’s Hospital,] but he never saw his paychecks or the honoraria or royalties, both fairly small sums, that he received for his lectures and writings. The bookkeeper in PIH headquarters cashed the checks, paid his bills — and his mother’s mortgage — and put whatever was left in the treasury. One day in 1999, Farmer tried to use his credit card and was told he’d reached his limit, so he called the bookkeeper. She told him, “Honey, you are the hardest-workin’ broke man I know.”

Back when he was a bachelor, he’d stayed in the basement of Partners in Health headquarters during his sojourns in Boston. Four years ago he’d married a Haitian woman, Didi Bertrand. He saw no reason to change their Boston living quarters, but when their daughter was born, in 1998, his wife insisted it was time to move. Now they had an apartment in Eliot House at Harvard, which they used when in Boston. But they weren’t often there. These days, Didi and their two-year-old spent the academic year in Paris, where Didi was finishing her own studies in anthropology. Several friends had told Farmer he should spend more time with them. “But I don’t have any patients in Paris,” he’d say. It was obvious that he missed his family. When I was with him in Haiti, he called them at least once a day, from the room with the satellite phone. In theory, he spent four months in Boston and the rest of the year in Cange. In fact, those periods were all chopped up, by trips to places where he did have patients. Years ago he’d gotten a letter from American Airlines welcoming him to their million-mile club. He’d traveled at least two million miles since.

He had a small house in Cange, the closest thing in his life to a home, perched on a cliff across the road from the medical complex. It was a modified ti kay, a replica of the better sort of peasant house, with a metal roof and concrete floors and exceptional in that it had a bathroom, though without hot water. Many times when I looked inside his house, his bed appeared unused. He told me he slept about four hours a night but a few days later confessed, “I can’t sleep. There’s always somebody not getting treatment. I can’t stand that.”


Kidder gives lecture at Messiah College

Author Tracy Kidder

Walter P. Calahan

Pulitzer Prize-winning author Tracy Kidder

Pulitzer Prize-winning author Tracy Kidder delivered the first keynote lecture of the Centennial year Sept. 14 at Brubaker Auditorium and shared his personal experience researching and writing Mountains Beyond Mountains, the common reading text for Messiah’s first-year students. The non-fiction narrative captures two global health crises tuberculosis and AIDS from the eyes of Dr. Paul Farmer, a physician dedicated to improving the health of some of the poorest people on the planet. Alana Woods ’13, who attended the event, says that Kidder’s book and lecture greatly affected her.  “Kidder gave insight into the despicable living conditions of men and women around the world... . It gives me hope that I, like Paul Farmer, can channel my passions with the strength and will of God,” says Woods, “and make even one step toward a better world.”  

Pulitzer Prize-winning author Tracy Kidder signs copies of his book Mountains Beyond Mountains following his lecture Sept. 14 at Brubaker Auditorium.


Click here to listen to a podcast of Kidder’s lecture. 


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