Mountains Beyond Mountains
February 13, 2008
One of the benefits of participating in a book club is reading books you would not have selected on your own. Sometimes those books can be provocative and rewarding.
February's book club selection, Mountains Beyond Mountains, was both. A New York Times "Notable book" and Reader's Circle selection, this 304-page nonfiction narrative by Tracy Kidder is the kind of book that will have you thinking about its ideas for weeks or months after you finish it.
(CAUTION: POTENTIAL SPOILERS AHEAD)
It is a profile of Dr. Paul Farmer, a Harvard trained tuberculosis specialist who has spent his life bringing first-world medical treatment to some of the earth's poorest people. Tracy Kidder does a good job presenting this story. Although he seems too smitten by the doctor at the book's beginning, he gains perspective as the narrative goes on. By the end of the book the reader has a nuanced view of this impressive and complicated healer. It is the view that Kidder seems to have. And that's okay. Because Kidder, we realize, is more like us than Dr. Farmer is.
Dr. Paul Farmer is a very unusual doctor. Completely dedicated to his patients, he is happy to travel miles and miles in rural Haiti to visit patients that can't come to him. He works tirelessly, lives frugally, writes books, makes speeches, argues his cause and travels more than 250,000 miles a year to raise money and public awareness for people who can't afford the kind of medical care that most first-world citizens consider normal.
Starting with nothing but a few thousand dollars and an indomitable will, he flew to Haiti as a young medical student. He established a small clinic in Cange, a rural area that had no access to doctors. From that meager beginning he went on to develop several other successful clinics in other parts of the world. He also developed a method of treating tuberculosis patients who were resistant to the most common forms of treatment. In pursuing his career, he attracted apostles - a wealthy man who was happy to "get rid" of his fortune by donating to the doctor's mission as well as dozens of doctors, nurses and volunteer workers who believed, as he did, that the poor deserve the same medical treatment as the rich.
This is particularly true, Dr. Farmer believes, when the patient is suffering from a life-threatening disease (such as tuberculosis) that can be cured. In an interesting passage about the concept of triage - the medical term for deciding which patients gets treated first and/or treated at all and which patients get treated later and/or ignored completely - the reader is presented with the fundamental moral issue that permeates the book:
A woman from the city of Hinche, "eschewing the dreadful public hospital there," brought her son John to Farmer's clinic. The boy had swelling in his neck and a high white cell count. One of Farmer's doctors decided he needed emergency treatment, but the kind that could only be given in a first-world hospital. She found an oncologist at Massachusetts General Hospital who agreed to diagnose the boy for free. She took tissue and blood samples and Farmer flew them with him to Boston. The diagnosis was bad. John had nasopharyngeal carcinoma, a very rare and deadly cancer. If caught early, however, it had a 60% to 70% cure rate.
At first Farmer thought the boy could be treated in Haiti, but as time passed he got quickly worse. The only chance to save his life was to fly him to Boston and have the procedure done there. Since commercial airlines would not carry someone looking as dreadful as John did, they decided to medieac him there - transportation that cost the clinic $20,000. The account of taking him to Port-au-Prince where the Lear jet waited was harrowing. A storm was raging. The ambulance broke down several times. And the machine that was keeping John breathing was hooked up to the cigarette lighter. By sheer force of will, they got John to the jet and from there everything went smoothly.
Everything except the outcome. His disease had spread too far. In a few short weeks, he was dead.
The $20,000 spent on John did not save his life. Yet it would have saved several lives - possibly dozens - if it had been used locally, to treat Haitians whose ailments were less advanced.
Thus the question of triage: given limited resources, what is the most humane way of helping the sick and the poor?
Does everybody have an equal right to the best medicine money can buy? Farmer thinks so. When there is a chance to cure someone, as there was with John, there is also a moral imperative to do everything you could. He has a term for this. He calls it an AMC - an area of moral clarity.
Other health practitioners - most health practitioners in fact - have a different idea. They advocate triage -- using what resources you have to help the most people you possibly can. It is morally better, they would argue, to let John die - even if he might have been cured - if the money spent on John could cure several Johns who didn't need to be medevaced to the United States.
Dr. Farmer spends a good deal of his time arguing this issue when he attends medical forums or meets with international aid groups or courts wealthy people and organizations for funds. His view is that everybody should do what he does: abandon the desire for personal gain and safety. Commit to the notion that we should treat everyone and anyone with the same care and giving that we would give ourselves or our own children.
Dr. Farmer doesn't have a good answer for the economic criticism of his mission: that what he is doing can't be done universally. By spending so much on one dying child, you deprive others of their right to live.
He doesn't have an answer but he is sure he is doing the right thing. He feels it most convincingly when he is hiking miles, mountain over mountain, to help his poor patients. He feels it as a moral certainty then. So he keeps pushing, even though he knows that at some level his mission (of eradicating unnecessary death among the poor) cannot succeed.
Kidder's depiction of Dr. Farmer shows him to be a complicated man: caring but myopic, intelligent but naive, idealistic and zealous, moral and arrogant. But despite his flaws, Dr. Farmer presents a challenge to the thoughtful reader: What is my moral responsibility? How much should I do?
The president of my book club was so inspired by this account that he decided to establish some sort of medical or anti-poverty program in Latin America. He didn't want to simply give money to existing programs. He wanted to get involved, like Dr. Farmer, and see what kind of difference he could make.
I would not have read this book if it had not been mandated by my book club. Yet I'm glad I did. It has already given me some interesting thoughts:
- My friend Ella, who believes that all "overly wealthy people" should give up their "extra" money to the poor. What is an "overly wealthy" person to Ella? Anyone who is wealthier than she. She considers her personal fortune, about $2 million as near as I can guess, to be adequate but also necessary. When she makes her point I can't help but think that the money she wants to give away is mine, not hers.
- Should a rich man stop working and spend his life administering to the poor? Or does it do more good to keep working and thus be able to contribute large sums of money to those, like Dr. Farmer, who need money to do their work?
- Are areas of moral clarity real? Or are they selfish, smug delusions? I have had moments when I was sure that what I was doing was good. Some of those moments involved giving large sums of money to people in need. About half of the time that money didn't help matters. That left me wondering whether I shouldn't have triaged it better by giving it out, in smaller doses, to people who might have used it better.
- At one point in the book Dr. Farmer finds himself crying over the fate of a young patient. He realizes that he got so emotional because he saw his own daughter in that little girl. To Dr. Farmer, this is a flaw in his character. He wants to care as much for "The least of his brethren" that he does for "the most." But nature mandates that we care more for our offspring than we do for anything else. That is an instinct that preserves our species. Can something so fundamental to our nature be wrong, as Dr. Farmer thinks? I am not sure. I do believe that civility, if not civilization, is advanced by expanding one's selfish instinct to preserve his lineage. But I also think that there is something healthy about that too.
- On the one hand, Dr. Farmer's strategy is obviously impossible to execute globally. There is simply not enough money in the world to do what he does. On the other hand, it seems to an outside observer (not just to him) that he is doing something good and should be admired for it. What, if anything, does this mean?
- Nothing works against poverty and disease. Despite all our efforts - including the efforts of the Dr. Farmers in the world, these human scourges persist.
- One of the reasons that it is impossible to eradicate poverty is because we don't really understand what it is. We see it as something fixed and static. We think, "There are a hundred trillion dollars worth of poverty in the world and two hundred trillion dollars of wealth." If we can redistribute that wealth then poverty would be gone. But what if poverty, like wealth, was not something fixed and static? What if poverty was a result or a product instead? What if poverty can be produced just as readily as wealth? Then it would be obvious that it can't be eliminated. Even if we got rid of whatever existed today, there would be more poverty tomorrow. (This last is a thought I think I should expand on.)
- Even if it is impossible to eliminate poverty, our instinct to fight it seems natural, even instinctive. The impulse to help the poor is just as fundamental as the impulse to make ourselves rich.
posted by M. Masterson @ 8:56 AM,