Book Review

Mountains Beyond Mountains

N Engl J Med 2003; 349:1877-1878November 6, 2003

Article

Mountains Beyond Mountains
By Tracy Kidder. 317 pp. New York, Random House, 2003. $25.95. ISBN: 0-375-50616-0

Paul Farmer is a 44-year-old specialist in infectious diseases and an attending physician at the Brigham and Women's Hospital in Boston. His biographer, Tracy Kidder, read his book on the connections between poverty and disease — Infections and Inequalities — and wrote to him, “I'm reading your oeuvre.” “Ah, but that's not my oeuvre,” Farmer replied. “To see my oeuvre you have to come to Haiti.”

Indeed, Farmer founded a hospital and health center, Zanmi Lasante, in Cange, Haiti, hours from the capital and at the end of a gutted road in a region destitute even by Haiti's standards, as part of an extensive community-based health network linked to a hospital, Clinique Bon Sauveur (see FigureDr. Paul Farmer in Cange, Haiti.). For more than 20 years, Farmer has spent many months every year there, often taking care of patients himself and continually improving the treatments offered by the clinic. These now include antiretroviral drugs. Lasante is supported by a foundation based in Boston called Partners in Health, which is headed by Ophelia Dahl and largely financed by Tom White, the philanthropic owner of a large Boston construction firm.

There is more. Through his patients in Cange, Farmer became interested in multidrug-resistant tuberculosis. From Haiti, he exported treatment of multidrug-resistant tuberculosis to Peru and then to Siberia, achieving cure rates comparable to those in the United States. Through the Institute for Health and Social Justice (the research and education division of Partners in Health) and his associate Jim Yong Kim, he started a movement to lower prices for the second-line drugs necessary to treat resistant tuberculosis and successfully lobbied the World Health Organization for changes in treatment recommendations for tuberculosis.

Readers may have heard some of this story before (Farmer has received a MacArthur award and the American Medical Association's Dr. Nathan Davis Award) and may have wondered, as I did, where he came from and how one man could accomplish so much. Kidder traces Farmer's trajectory, starting with his unconventional childhood, which included living in a bus and on a leaky boat. He was given a scholarship to Duke, where he majored in anthropology and worked alongside poor Haitian farm workers in North Carolina's tobacco fields. After graduation he spent a year in Haiti, where he met Ophelia Dahl, and then went to Harvard Medical School. While in medical school and during his residencies and fellowships, he spent more time in Cange than in Boston.

How does Farmer do it? Kidder provides some explanations: he works nonstop, hardly sleeps, sees his wife and child for a day or so every few months, inspires an uncommon degree of devotion and enthusiasm among collaborators and potential donors, and tolerates planes and airports for days on end. In addition, the Boston medical establishment has bent rules and regulations to accommodate his needs.

Convincing? Maybe. There remains something miraculous about Paul Farmer. Should one go out and buy Mountains beyond Mountains? By all means. Not only it is it an enjoyable book, but it is also very likely that a part of the $25.95 spent in purchasing it will find its way back to Haiti. That is more than can be said about many books. In addition, readers looking for a worthwhile charity to support may be inspired to send some money to Partners in Health.

Bernard Hirschel, M.D.
Hôpital Cantonal, 1211 Geneva 14, Switzerland
bernard.hirschel@hcuge.ch