Mountains Beyond Mountains

Prompted by a 16-year-old friend, we’ll call her “Stacy”, I recently finished reading Mountains Beyond Mountains, a Tracy Kidder book that was excerpted in New Yorker magazine some years ago. Jeff Sachs and Peter Singer sit in comfort in the U.S. and say that other people really should do something to help the world’s poor. The subject of the book, Paul Farmer, is the rare American who has dedicated his life, no questions asked, to helping those in need, specifically those who are sick, regardless of how inconveniently located they are.

The book chronicles Farmer’s journey from a childhood spent in a converted bus parked in a Florida trailer park to Duke University on scholarship, to Haiti and Harvard Medical School, and eventually to a life floating among the world’s airports, clinics, and conferences. Through hard work and force of personality, Farmer has managed to build a modern clinic in a remote and desperately poor corner of Haiti. He has revolutionized the treatment of drug-resistant tuberculosis in Peru and Russia. The book, published in 2003, does not chronicle Farmer’s successful foray into HIV therapy for Rwandans.

Stacy was inspired by this book and other chronicles of Dr. Farmer’s achievements. I, on the other hand, could not imagine enduring the sacrifices described in the book: filthy food, Hepatitis A, all-day walks in stifling heat and humidity to reach patients in villages without road access, millions of miles of commercial airline flights, and hardly ever seeing his wife and children (who live in Paris). If this is what it takes to change the world, then don’t hold your breath waiting for change, because there probably won’t be another guy like Farmer in our lifetime.

Farmer and Kidder share a political philosophy up to a point. Farmer believes that it is immoral for someone to earn a fat salary and then spend it all on himself rather than living modestly and donating the surplus to the poor. Kidder states that Haitians are poor because it is to the advantage of powerful Americans and rich Haitians to keep them poor and illiterate. Somehow there are guys in Washington and New York who get richer as a consequence of Haitians getting poorer. Due to indifference if not hostility towards the peasantry, the government of Haiti has shirked its responsibility to build roads, educate the inhabitants, provide jobs, deliver drinking water, etc. Neither Kidder nor Farmer consider whether it would be feasible for the best-intentioned group of bureaucrats to bring prosperity to Haiti. Haiti is home to 9 million people in a country the size of Maryland, which makes it the most densely populated country in the Western Hemisphere (source). The per-capita GDP is $800 per year. Individual Haitians have cut down all of the forests and burned them or used them for building materials. If you wanted to create a case study to prove Jared Diamond’s points in Collapse, it would be hard to construct a better example than Haiti. The land supported a modest population of Taino Indians very nicely, but it could not support 9 million humans even if the natural resources were intact. If you distributed Haiti’s wealth equally among all Haitians, they would still be among the world’s poorest people.

How would a government collect tax revenues from people who are subsistence farmers? Who would want the job of running a government in Haiti? Haiti is so poor that the traditional dictatorial approach of stealing from the common people isn’t practical. It turns out that the only people who have been interested in the job recently were those who figured out that they could siphon off foreign aid dollars. Only a saint would be willing to take on the project of governing honestly and, in fact, Haiti was governed for a time by a Catholic priest, Jean-Bertrand Aristide. Folks’ initial optimism faded when the man’s earthly nature took over. The priest succumbed to the temptations of women and took a young American wife, Mildred Trouillot. Then he allegedly started pocketing millions of dollars in foreign aid (perhaps the wife needed to return to her native New York City to shop, thus proving the old adage that “Behind every successful man is the woman who made it necessary”). Now he lives very comfortably in South Africa with Mildred and their two daughters.

Where Farmer and Kidder part intellectual company is on a trip to Cuba. Farmer thinks it might be the world’s best country because everyone has equal access to high quality medical care (Cuba has 6.4 doctors per 1000 people; the U.S. has 2.4). Farmer acknowledges that Cuba is poor, but he blames that fact on the U.S. Kidder won’t go along with Farmer’s unqualified admiration for Fidel Castro and Che Guevara (a doctor who loved to personally execute traitors to the cause), but his opposition seems mostly based on prejudice against a country labeled “Communist.” Kidder does not find anything specific about Cuba to criticize. Neither Farmer nor Kidder pointed out that Cuba might be doing better than Haiti partly because it has more than three times as much land per person, a big advantage in a primarily agricultural economy (Cuba’s population growth rate is 0.23 percent per year; Haiti’s is over 1.8 percent). Farmer relaxes in Cuba, partly because he cannot get Internet access to retrieve his hundreds of importuning emails; Kidder blames this on the U.S. trade embargo. More importantly, there aren’t a lot of sick people waiting for treatment. “I can sleep here,” Farmer said. “Everyone here has a doctor.”

As with many non-fiction works, the complete book is less powerful than the shorter New Yorker article. The magazine article followed Farmer to Haiti where he was making a huge difference in one region. The book has him bouncing around a dozen countries, each of which has seemingly intractable problems and people dying due to insufficient and/or improper medical care. Farmer in the article is the hero of thousands of Haitians; Farmer in the book is bailing out the ocean with a teacup. After reading the article one thinks “That desperately ill Haitian kid walked out of the clinic”; after reading the book one thinks “With no education or skills, how is that Haitian kid ever going to get a job?”

I thought that perhaps I was being too cynical. Stacy, after all, is ready to dedicate the 80-or-so years she has left on this planet to helping the unfortunate. Perhaps her friends and hundreds of thousands more from her generation feel the same way. I asked. “Most of them are too busy nagging their parents to buy them cars.” Cars? Aren’t her friends mostly teenagers who live in Manhattan? What kind of cars? Where would they keep them? Where would they drive? “They get Lexus convertibles. Their parents pay $550 per month for a garage space. They drive to the Hamptons on some weekends.”

[If your teenager can manage without a Lexus, you can feel confident donating money to Partners in Health, Farmer’s non-profit organization, which spends roughly 95 percent of its money on program services. PIH has been selected by Bill and Melinda Gates for some large grants, and is rated highly by GiveWell. The org’s Form 990 for 2008 reveals that Farmer himself received no salary (he gets paid separately as a Harvard Med School professor and physician). The CEO of the $52 million/year organization received less than $75,000 per year in total compensation (compare to Carnegie Hall or WGBH); the highest paid employees earn between $67,000 and $80,000 per year.]


  1. Fred Hanson

    December 6, 2009 @ 10:49 pm


    Thank you for such an in-depth review of the book and the life and for your usual fascinating perspective.

  2. philg

    December 6, 2009 @ 11:28 pm


    Thanks, Fred. Normally a “I liked this posting” comment doesn’t fit the moderation policy, but I guess yours will have to do because we haven’t heard from anyone who has read the book and has something else to add.

  3. Bob T

    December 8, 2009 @ 6:59 pm


    I have read the book and since it seems Phil is requesting comments, I’ll jump in. Of course Farmer deserves our admiration. He has made a difference to thousands of lives, he’s in the Mother Teresa mold. He walks his talk and people like that don’t come along every day.

    But ironically, he is treating the symptoms and not the cause. The country is not a viable organism, as Phil pointed out. How does it support 9 million? What can they produce that they can sell? Is their sole revenue generation ability taking in foreign aid? How is that sustainable or desirable? I’m not trying to be heartless, just practical.

    You could fix all their medical care issues and you’d still have a completely non-functional country, right? Perhaps everything cannot be fixed.

  4. Stephen

    December 9, 2009 @ 11:24 am


    Well exactly. The problem with poor countries is not that there are not enough doctors willing to sacrifice everything to treat their inhabitants, or that there are not enough people willing to give money to them. People all over the world try to make life better for themselves and their children, and their failure or success depends to a large extent on their degree of freedom, economic perhaps more than political.

    If you want to give money to poor people, an organisation like Kiva, which makes micro-loans to people who need the money to grow their tiny businesses makes much more sense than giving to charities that see their aid siphoned off into Swiss bank accounts by dictators who would rather take the sure path of kleptocracy than the uncertain path of development and taxation to ensure their luxurious lifestyles.

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