Mountains Beyond Mountains

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Note: all page and citation info for the quotes below refers to the Random House edition of Mountains Beyond Mountains published in 2009.
Chapter 1 Quotes

The world is full of miserable places. One way of living comfortably is not to think about them or, when you do, to send money.

Related Characters: Tracy Kidder (speaker)
Page Number: 8
Explanation and Analysis:

At the beginning of the novel, Tracy Kidder (the author) offers some harsh truths about the state of the Western world. For most of the people who live in developed, first-world countries, the easiest course of action is to carry on with one's own personal problems and affairs, and ignore the millions of starving human beings around the world—people whose lives could be drastically changed for the better with just a fragment of the wealth or resources most Westerners enjoy daily.

In short, the rich countries of the world have to perform some complicated mental gymnastics to avoid becoming overcome with guilt at their own passivity: no moral, prosperous human being, Kidder insists, can think about the world's poverty and disease without guilt. Instead, most people either ignore the problem or do the bare minimum, and send some money now and then in the hopes that it will improve the problem slightly.

Against this backdrop of ignorance, passivity, and sheer laziness, Kidder introduces us to Doctor Paul Farmer—a man who refuses to play along with his peers in America. Instead of ignoring the world's problems, Farmer tries to use his intelligence and medical training to eliminate them altogether, one problem at a time.


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Chapter 2 Quotes

As Farmer was leaving the shelter, he heard Joe say to another resident, just loudly enough to make Farmer wonder if Joe meant for him to overhear, “That guy’s a fuckin’ saint.”

Related Characters: Tracy Kidder (speaker), Joe (speaker), Doctor Paul Farmer
Page Number: 16
Explanation and Analysis:

At several points in the book, characters will compare Paul Farmer to a saint. Here, Joe, a man who's been sent to a medical shelter in Boston, calls Farmer a saint for taking such good care of his patients, going far beyond the minimum requirements even for a doctor.

When Joe calls Farmer a saint, he means that Farmer devotes huge amounts of his time and energy to helping other people whom he's never met before. Yet throughout the book, Farmer insists that he's not a saint at all—on the contrary, he claims, he's just doing "his part" to help others. Farmer is so used to spending 20 hours a day caring for the sick that he considers himself just an average, decent human being—he's just doing what any intelligent, trained person should be doing to help alleviate the vast suffering in the world. One disturbing implication of Farmer's claim that he's not a saint is that we as readers—or anyone with education, wealth, time, or other resources—aren't doing remotely enough with our own gifts. It's easy for us to believe that Farmer is a saint because it absolves us of some of our own guilt at not doing more to help people in need—only a superhuman or saint could do what Farmer does. The troubling part is when we think that Farmer is just a normal human, doing what all normal people ought to do.

Chapter 3 Quotes

He made about $125,000 a year from Harvard and the Brigham, 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 at 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.

Related Characters: Tracy Kidder (speaker), Doctor Paul Farmer
Page Number: 23
Explanation and Analysis:

Kidder notes some irony here: although Farmer contributes more to society than almost anyone (he literally saves lives almost every day), he's not rewarded for his actions with money or property. Instead, Farmer sends most of his income to other people. He's learned to live so simply that he has no use for extra cash.

The fact that Farmer doesn't feel any need to spend money makes us wonder—what motivates his quest to help the sick? Does he get any pleasure from doing so, or does he see it as a duty? While Farmer clearly gets a sense of joy and comfort from knowing that he's important to other people, he's also so regimented and rigorous in his routine as a doctor that he seems to treat curing the sick as a basic obligation, not a joy. Strange as it might seem, Farmer doesn't really enjoy his work—"enjoy" is the wrong word. Rather, Farmer seems to treat charity as the cornerstone of a normal, moral life—a life that few people emulate, however.

Chapter 4 Quotes

And then of course it dawned on him that he knew plenty of Americans—he was one himself—who held apparently contradictory beliefs, such as faith in both medicine and prayer. He felt, he said, as though he hung in the air before his patient, “suspended by her sympathy and bemusement.”

Related Characters: Doctor Paul Farmer (speaker), Tracy Kidder (speaker)
Page Number: 35
Explanation and Analysis:

In this quotation, Dr. Farmer travels to Haiti, where he researches the Haitians' beliefs concerning religion and science. Farmer discovers that many Haitians believe in Voodoo, a complex set of religious rituals. In the past, American doctors have concluded that the Haitian belief in Voodoo trumps any American efforts to introduce medicine in the country—and so they felt that there was no point in giving the Haitians pills if they don't believe that pills can cure disease. Farmer's insight is that a belief in religion doesn't preclude the belief in science and medicine. Indeed, plenty of Americans—including some of the American doctors who decided to stop shipping medicine to Haiti—believe in both Christianity and antibiotics simultaneously.

Farmer's insight here illustrates a disturbing form of racism. Americans, in Farmer's view, are looking for an excuse to dehumanize and deny help to Haitians. In their search for an excuse, they construct a shallow and condescending portrait of the typical Haitian—a narrow-minded individual who's incapable of believing in science and religion simultaneously. The implication of this portrait is that Haitians are less intellectually advanced than Americans (no one would ever question an American's ability to believe in God and science at once). In short, Farmer's predecessors' actions illustrate the condescension of many Western charity organizations, and the unfortunate eagerness of the people in power to deny their help to those in need.

Chapter 5 Quotes

By then Farmer had quit his fraternity. He wrote them that he couldn’t belong to an all-white organization. (“I received quite a frosty reply,” he would say, in a tone of voice that implied this still surprised him.) He’d come to admire his father’s distaste for putting on airs.

Related Characters: Tracy Kidder (speaker), Doctor Paul Farmer
Page Number: 56
Explanation and Analysis:

In order to get a better understanding of Dr. Farmer, Kidder focuses on Farmer's past. Even in college, we're told, Farmer showed signs of being a remarkably forward-thinking, progressive person. Although it was the norm at the time for white fraternities to exclude black students, Farmer didn't hesitate to quit his fraternity when he realized that it was a racist organization.

Farmer's decision to quit his fraternity for its poor racial politics illustrates his refusal to play along with racist "groupthink," an instinct that continues throughout his career as a doctor. Again and again, Farmer ignores the "common wisdom" about charity in Haiti or South America—i.e., that there's no point in helping the Haitians or South Americans because it doesn't make financial sense. One reason Farmer ignores other people's advice about nonprofit work is that he sees this advice as an extension of American racism and indifference to people of other cultures—a form of racism he's been avoiding at least since his experience with his college fraternity. Just as his frat excluded blacks, the powerful charities of the U.S. have an unfortunate tendency to buy into the myth that white Americans will always be better than their neighbors to the south. Farmer finds this latent racism disgusting.

Chapter 6 Quotes

But independence had been followed by nearly two hundred years of misrule, aided and abetted by foreign powers, especially France and the United States. (From 1915 to 1934, the U.S. Marines had occupied and run the country.) To Farmer, Haiti’s history seemed, indeed, like The Lord of the Rings, an ongoing story of a great and terrible struggle between the rich and the poor, between good and evil.

Related Characters: Tracy Kidder (speaker), Doctor Paul Farmer
Page Number: 63
Explanation and Analysis:

In this quotation, Farmer shows Kidder that he's both realistic and idealistic about his charity work. He explains how Haiti continues to suffer from the foreign policies initiated by Europe and later the U.S. Few people know that the United States ruled Haiti by military force during the 20th century—during this time, Farmer argues, American troops weakened Haiti's economy, leading to structural problems in the country that continue to cause poverty and disease to this day. Farmer's realism about the dangers of foreign policy, particularly American foreign policy, make him wary of accepting help from the American government or large American charities. Instead of partnering with organizations that have hurt Haiti in the past, Farmer works largely by himself, and accomplishes a great deal as a result.

But at the same time, Farmer's view of Haitian life is extremely idealistic: a life-and-death battle between the forces of evil (the U.S. and Europe) and the forces of good (the people of Haiti). The notion that American foreign policy accomplishes nothing but evil is just as naive as the notion that it causes only good. Farmer seems to need to believe in certain "useful" fictions, such as that of America's wickedness, in order to carry out his work. His belief in the idea that America is purely "evil," even if it's not entirely true, motivates him to work harder and perhaps leads him to accomplish more for his patients.

Chapter 7 Quotes

For a long time I thought I could live and work in Haiti, carving out a life with you, but now I understand that I can’t. And that’s simply not compatible with your life—the life you once told me you would like to lead even ten years ago.

Related Characters: Ophelia Dahl (speaker), Doctor Paul Farmer
Page Number: 66
Explanation and Analysis:

For many years as a young man, Dr. Farmer is romantically close with a fellow charity worker, Ophelia Dahl. But as he spends more and more time working with his patients, Farmer struggles to spend time with Ophelia. He makes it clear that he'll only be able to pursue a relationship with Ophelia if she can get used to a life of constant travel and work. In this quotation, Ophelia writes Farmer a letter in which she tells him that she can no longer pursue a relationship with him: she's just not ready for the life he wants to lead.

Ophelia's letter reminds us how difficult Farmer's life is—contrary to what he always claims. There are few people who could spend their entire lives traveling the world, meeting with hundreds of strangers a day, and devoting incredible amounts of time to dangerous or thankless tasks. Indeed, Ophelia's letter establishes the basic sacrifice that a "saint" like Farmer must make. Farmer must choose between his family—a small group of people with whom he's very close, such as Ophelia—and his profession—a life spent circling through a huge group of patients, none of whom he's very close with. While most people choose to give most of their love and attention to the small number of people in their immediate family, Farmer takes a different path. Ironically, in choosing a career that, on the surface, seems incredibly noble and loving, he shies away from love for a family—a basic form of love that almost every human being expresses.

Chapter 8 Quotes

He was already attracted to liberation theology. “A powerful rebuke to the hiding away of poverty,” he called it. “A rebuke that transcends scholarly analysis.” In Haiti, the essence of the doctrine came alive for him. Almost all the peasants he was meeting shared a belief that seemed like a distillation of liberation theology: “Everybody else hates us,” they’d tell him, “but God loves the poor more. And our cause is just.”

Related Characters: Doctor Paul Farmer (speaker), Tracy Kidder (speaker)
Page Number: 78
Explanation and Analysis:

In this passage, Farmer gives an eloquent explanation of liberation theology, the strain of Catholicism that defines his approach to charity work in Haiti. In many conventional interpretations of Christianity, poverty should be ignored altogether, because it's unimportant in the "grand scheme of things" (no point worrying about your paycheck on Earth when you're going to Heaven for eternity, anyway). Farmer disputes this interpretation, arguing that it's vitally important to focus on improving life on Earth, here and now. To allow the people of Haiti to live in poverty is, in essence, to support suffering and misery—an obvious violation of the spirit of Christianity. Armed with liberation theology, Farmer devotes huge amounts of his time to working with the poorest Haitians, recognizing that their need for medical attention is great.

A doctor who knew nothing about local beliefs might end up at war with Voodoo priests, but a doctor-anthropologist who understood those beliefs could find ways to make Voodoo houngans his allies. A doctor who didn’t understand local culture would probably mistake many patients’ complaints for bizarre superstitions.

Related Characters: Tracy Kidder (speaker)
Page Number: 83
Explanation and Analysis:

In addition to his training as a doctor, Farmer is also a kind of anthropologist, who has focused on the Voodoo customs of Haiti for many years. Farmer recognizes that many of the patients he visits in Haiti suffer from bizarre-sounding symptoms that, to many American doctors, sound like mere superstitions, reflecting the ubiquity of Voodoo in the country. As Farmer sees it, however, it's the job of a good doctor to take the Haitians' belief in Voodoo seriously. Farmer recognizes that some of the Haitians' complaints are legitimate, even if they're wrapped in the language of Voodoo. An untrained American doctor could easily ignore a legitimate medical problem, assuming that it was imagined.

In general, Farmer's thoughts suggest that the duty of a good doctor is to understand the culture of his patients, since the study of the human body is an important part of any culture. More importantly, Farmer suggests that American racism—the glib dismissal of Voodoo as primitive or superstitious, for example—is getting in the way of proper patient care.

Chapter 9 Quotes

On the way back they laughed about the incident, and yet of all the times she’d eaten things that she could hardly bear to look at, this one occasion when she failed the test stood out for her.

Related Characters: Tracy Kidder (speaker), Doctor Paul Farmer , Ophelia Dahl
Page Number: 87
Explanation and Analysis:

In this passage, Ophelia Dahl describes an episode from her travels in Haiti when, accompanied by her lover, Farmer, she was offered a traditional Haitian dish. Ophelia politely refused the dish, not realizing that her politeness would be interpreted as rudeness. Farmer irritably corrected Ophelia, showing that he was far more familiar with Haitian culture than she. Ophelia continues to remember this episode for many years. In her mind, it proves that she'll never be an important part of Farmer's life; on the contrary, she'll always be less relevant than his patient care.

A further implication of the passage is that Ophelia feels like a outsider in Haiti because of her privileged life in the United States and England. Ophelia, the wealthy daughter of the famous author Roald Dahl, is occasionally uncomfortable in Haiti because she's reminded of how lucky she was to be born to wealthy, white, Western parents. Incidents like the one described in the passage push Ophelia further away from Farmer while also exacerbating her "white guilt."

One time when they were together in Boston, White said, “You know, Paul, sometimes I’d like to chuck it all and work as a missionary with you in Haiti.” Farmer thought for a while, then said, “In your particular case, that would be a sin.”

Related Characters: Tracy Kidder (speaker), Tom White (speaker)
Page Number: 95
Explanation and Analysis:

In this passage, one of Farmer's key allies, a man named Tom White, discusses the possibility of going to Haiti to be a one-on-one charity worker. White is a wealthy man who donates millions of dollars of his own money to ensure that Farmer can continue practicing medicine in Haiti. When Farmer says that White's decision to move to Haiti would be a sin, he's saying that White is far more valuable to the world as a donor to nonprofit work than he would be as a missionary on the ground.

Farmer's observation shows an awareness of the importance of strategy and resource allocation in nonprofit work: there are some people who work best as donors and some people who work best as one-on-one doctors. At the midpoint of his career, Farmer excels at the latter: while he thinks of the "big picture" as much as possible, he prefers the thrill of curing an individual patient's illness.

Chapter 10 Quotes

Some people said that medicine addresses only the symptoms of poverty. This, they agreed, was true, and they’d make “common cause” with anyone sincerely trying to change the “political economies” of countries like Haiti. But it didn’t follow, as some self-styled radicals said, that good works without revolution only prolonged the status quo, that the only thing projects like Cange really accomplish is the creation of “dependency.”

Related Characters: Tracy Kidder (speaker), Doctor Paul Farmer , Jim Yong Kim
Page Number: 100
Explanation and Analysis:

Paul Farmer and his friend, Jim Yong Kim, are thoughtful people who think deeply about the merits of their own work. One question Kim and Farmer ask each other frequently concerns the long-term effects of their work—is it possible that by treating disease, they're only making the Haitians more dependent on American aid, thereby keeping Haiti subservient to a foreign power? In other words, why doesn't Farmer train Haitian doctors to treat their own people—in time, wouldn't this be a better use of his time than continuing to treat hundreds of patients a day?

For now, Kim and Farmer insist that their work does more than merely creating a cycle of dependency. Just because Farmer spends hours treating Haitians doesn't mean that Haitians will always look to the U.S. for help and medical care. Indeed, by treating Haitians' medical problems, Farmer is enabling the Haitians to spend more time building their own businesses, running for political office, reforming education systems, etc. Healthy people can accomplish more than sick people, after all. Nevertheless, the fact that Farmer and Kim are considering the big-picture, long-term effects of their actions in Haiti proves their devotion to nonprofit work and all its implications. 

Chapter 11 Quotes

He’d write about how the Centers for Disease Control, a federal U.S. agency, had gone so far as to identify Haitians as a “risk group,” along with several other groups whose names began with h—homosexuals, hemophiliacs, and heroin users—and about the incalculable harm all this had done to Haiti’s fragile economy and to Haitians wherever they lived. In his thesis, he’d marshal a host of epidemiological data to show that AIDS had almost certainly come from North America to Haiti.

Related Characters: Tracy Kidder (speaker), Doctor Paul Farmer
Page Number: 106
Explanation and Analysis:

Farmer is one of the world's foremost researchers on the subject of AIDS, the deadly virus that continues to kill millions around the world by weakening humans' immune systems. Farmer notices that American government officials have identified Haitians as a "risk group" for AIDS—in other words, Haitians are (supposedly) very likely to have AIDS, meaning that by associating with Haitians, other people are risking contracting AIDS themselves.

As Farmer argues, the U.S. government's treatment of Haiti is just an extension of racism. There is little convincing evidence that Haiti is any more of a risk group for AIDS than the U.S. itself—indeed, the evidence suggests that Americans are more at risk for carrying AIDS than Haitians! The reason that Haiti has been placed on the "risk list," Farmer suggests, is that Haitians have already been treated as dirty, animalistic, second-class, and, in general, subhuman. Like so much of America's medical policy toward Haiti, Farmer implies, the government's decision to place Haitians on the "risk list" is racism masquerading as prudence.

Chapter 12 Quotes

In early 1994, just before The Uses of Haiti came out, Farmer wrote an editorial for The Miami Herald. The gist of it was: “Should the U.S. military intervene in Haiti? We already have. Now we should do so in a new way, to restore democracy.”

Related Characters: Doctor Paul Farmer (speaker), Tracy Kidder (speaker)
Page Number: 117
Explanation and Analysis:

In his editorial for the Herald, Farmer clarifies his thoughts about the nature of America's involvement with the United States. In doing so, he distances himself both from establishment thinkers who believe that American foreign policy is an inherent good, and far-left thinkers who reject the concept of foreign aid altogether. As Farmer argues here, America has been intervening in Haiti for decades. America's goal has always been to suppress the Haitian economy and keep it dependent on America's power. In 1994, however, a new opportunity has presented itself: a large, democratic movement is coming into power. America, Farmer argues, can do some good for once: it can use its military power to foster a strong, stable society by ensuring that democratic elections are held in Haiti.

As Farmer acknowledges elsewhere, there are many who believe that American foreign intervention of any kind is harmful to the foreign country in question, because it increases the country's dependence on American generosity. Farmer has always rejected these facile arguments, because they're just an excuse to let the inhabitants of third-world countries suffer. Farmer believes that foreign intervention can be a force for good, provided that it's done well.

Chapter 15 Quotes

The motion of his mind toward root causes had always excited him. He loved the challenge of diagnosis and all its accoutrements—the stains on the microscopic slides, the beautiful morphologies of the creatures under the lens. But what he called “the eureka moment” had a bad aftertaste this time. Later he would tell me, “God, I’d hate to ever feel triumphant about something so rotten.”

Related Characters: Doctor Paul Farmer (speaker), Tracy Kidder (speaker)
Page Number: 140
Explanation and Analysis:

In this quotation, Farmer sheds some light on his own psychology: what motivates him to devote his entire life to medicine? And what goes through his mind when he works with a patient?

As Farmer explains, he feels a special thrill when he diagnoses a patient with a serious viral disease. But this thrill immediately causes Farmer guilt and shame—how could he possibly feel happy about a virus that causes human beings so much misery?

In general, the passage suggests that Farmer doesn't really think of his work as a doctor as pleasurable at all—what little pleasure he does feel on the job vanishes almost immediately, as Farmer takes in the gravity of the situation. Instead of practicing medicine for his own gratification, Farmer does it out of a more abstract sense of duty: his faith in liberation theology encourages him to devote himself to other people, whether he enjoys it or not, and he can never fully savor his more abstract, aesthetic appreciation of diagnoses without also considering the real-world, human cost of his work.

Farmer and Kim began collecting a number of official WHO statements. Some put the case more plainly: “In developing countries, people with multidrug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries.” For Farmer […] there was a larger principle involved. A TB epidemic, laced with MDR, had visited New York City in the late 1980s; it had been centered in prisons, homeless shelters, and public hospitals. When all the costs were totaled, various American agencies had spent about a billion dollars stanching the outbreak. Meanwhile, here in Peru, where the government made debt payments of more than a billion dollars every year to American banks and international lending institutions, experts in international TB control had deemed MDR too expensive to treat.

Related Characters: Tracy Kidder (speaker), Doctor Paul Farmer , Jim Yong Kim
Page Number: 141
Explanation and Analysis:

This long passage illustrates the hypocrisy in the way the Western world studies and treats diseases. As Kidder describes it, there was an outbreak of tuberculosis in Boston and Peru almost at the same time. The U.S government provided huge sums of money to ensure that the people of Boston wouldn't suffer any more than they absolutely had to. And yet when the time came to treat tuberculosis in Peru, American medical officials—including some of the same people who'd supported TB treatments in Boston—insisted that TB was too expensive to treat in Peru.

The hypocrisy of the medical establishment is clear here. If the sick are American citizens, who share a culture and a heritage with the medical officials, then no sum of money is too high to treat them. It's only when the patients are strangers—people who speak a different language, or have a different skin color than the medical officials—that cost becomes a factor at all. As Farmer argues, even to ask the question, "Is this treatment worth it?" is to treat a patient as a second-class human being, something to be measured in terms of economic value rather than basic human dignity.

Chapter 18 Quotes

Then Goldfarb spoke up again, his voice calm and acidic. “I want to share with you a simple reality. I have six million dollars. With three million dollars I can eemplement DOTS for five thousand Russian prison inmates. And assuming that ten percent have MDR-TB, forty-five hundred will be cured and five hundred will go down with MDR-TB and die. And there’s nothing much you can do. So. I have a choice. And my choice is to use another three million dollars to treat the five hundred with MDR-TB, or go to another region and treat another five thousand. I’m working with leemited resources. So my choice is not involved in the human rights of five hundred people, but five hundred people versus five thousand people.

Related Characters: Alex Goldfarb (speaker), Doctor Paul Farmer
Page Number: 162
Explanation and Analysis:

In this passage, Dr. Alex Goldfarb, a medical researcher who does important work with Russian prison inmates, makes a surprisingly eloquent argument for why—contrary to what Farmer has always maintained—the question, "is this worth it?" is sometimes a necessity for medical officials.

Goldfarb explains that he has a limited amount of money, with which he can either treat a small number of Russian prisoners who have a particularly deadly strain of TB, or treat a large number of different Russian prisoners who have a more manageable kind of TB. Goldfarb seems to believe that the best course of action is to treat the larger number of prisoners with the more common form of TB, even though doing so would mean letting the other Russian prisoners die of diseases that—technically—could be cured.

The scenario Goldfarb describes is very different from the ones Farmer has used to illustrate the hypocrisy of the medical community. Farmer is quick to criticize Western doctors for reducing the lives of "undesirable" people (prisoners, Haitians, Africans, etc.) to dollars and cents, effectively treating these people as second-class human beings. But Goldfarb doesn't fit into this critique at all. Rather, Goldfarb is sincerely interested in treating as many lives as possible—and for this reason, it's crucial to equate lives with dollars and cents. In the end, Goldfarb supports saving more lives, leaving other people to die. While his decision might seem harsh and inhuman, it's motivated by a sincere belief in the value of human life—not the cynical dismissal of human life, as Farmer would say.

Chapter 19 Quotes

As sometimes happened, Paul seemed to know what Jim was thinking. “What do you want to do now?” he asked. There was warmth in the question, Jim felt, a real invitation for him to come clean. “Political work is interesting to me, and it has to be done,” he said. “I prefer it to taking care of patients. It’s O for the P on an international scale.”

Related Characters: Doctor Paul Farmer (speaker), Jim Yong Kim (speaker)
Page Number: 174
Explanation and Analysis:

In this quotation, Farmer and Kim—two old, like-minded friends—part ways on the question of how they can best take care of the sick and impoverished. As Kim sees it, his talents would be put to the best use on a high-level, administrative level. Kim is a world-renowned expert on nonprofit policy: he's not necessarily the best one-on-one doctor, but he knows how to use resources efficiently, address the root causes of a problem, and put together a team of great doctors. Kim is, in short, an experienced, talented medical researcher who's ready to graduate to the next level.

Although Farmer respects Kim's ambitions of working in politics or high-level administration, he doesn't share these ambitions. Although Farmer is just as intelligent and far-thinking as Kim, he refuses to move on to administrative work, because his true passion (his calling, really) is patient care. It may seem strange that such a brilliant man would prefer working with individual patients (surely Farmer could accomplish more as a political leader than he could meeting with individual TB victims). But even if Farmer could accomplish more by pursuing a political career, he refuses to lose touch with his "roots" as a doctor. He's motivated by something entirely different than practicality, or even passion—he thinks it's his duty to continue practicing medicine.

Chapter 20 Quotes

Farmer was forty now, and he had the credentials to operate in the way Hiatt envisioned, on a purely executive level. In academic circles his reputation had grown. He was about to become a tenured Harvard professor. He was near the head of the line for the big prizes in medical anthropology; some of his peers were now saying that he’d “redefined” the field.

Related Characters: Tracy Kidder (speaker), Doctor Paul Farmer , Howard Hiatt
Page Number: 182
Explanation and Analysis:

In this passage, Kidder makes it clear that Farmer could retire or step into a cozy academic position—if he wanted to. Farmer has spent decades caring for patients, reorganizing the nonprofit world, and advising the next generation of charity workers. He has, in short, accomplished more in 20 years than most people could accomplish in a lifetime.

But in spite of his success as a humanitarian doctor, Farmer refuses to slow down the pace of his life. He continues to travel constantly in order to help as many patients and advise as many nonprofits as possible. Farmer's health and contentment are never a factor, and even when he's deliriously tired, he continues to work. By this point in Kidder's book, Farmer's drive is expected (if still not totally comprehensible)—if Farmer were seriously thinking about retiring at the age of 40, there's no way he would have been so productive in the previous 20 years.

Chapter 21 Quotes

He distrusted all ideologies, including his own, at least a little. “It’s an ology, after all,” he had written to me about liberation theology. “And all ologies fail us at some point. At a point, I suspect, not very far from where the Haitian poor live out their dangerous lives.” Where might it fail? He told me, “If one pushes this ology to its logical conclusion, then God is to be found in the struggle against injustice.

Related Characters: Doctor Paul Farmer (speaker), Tracy Kidder (speaker)
Page Number: 195
Explanation and Analysis:

Farmer takes a moment to clarify his thoughts on politics and philosophy. Although he's passionate about his belief in liberation theology—the Catholic belief in the importance of solving the concrete, real-world problems of human beings—Farmer acknowledges that any system of beliefs is always flawed in some way. In other words, he concludes, there's no system of thought that can tell us what to do in all cases—there will always come a point, particularly in an impoverished place like Haiti, where humans have to use their instincts to decide on the "right" thing to do.

Farmer's observations about the failure of "ologies" are important, because they help clarify why he's so devoted to helping the sick through individual consultations. In part, Farmer refuses to settle into a comfortable administrative position (chair of a major nonprofit, president of a medical society, etc.) because he doesn't want "ology" to guide his decision-making processes. By meeting with the sick one-on-one, Farmer reminds himself that no abstract belief system can fully solve humans' problems—only hard work and a strong sense of duty can make the world healthier.

It still seemed to me that he took a stance all too conveniently impregnable. He embodied a preferential option for the poor. Therefore, any criticism of him amounted to an assault on the already downtrodden people he served. But I knew by now he wasn’t simply posing. I felt something about him that I’d later frame to myself this way: He said patients came first, prisoners second, and students third, but this didn’t leave out much of humanity. Every sick person seemed to be a potential patient of Farmer’s and every healthy person a potential student. In his mind, he was fighting all poverty all the time, an endeavor full of difficulties and inevitable failures.

Related Characters: Tracy Kidder (speaker), Doctor Paul Farmer
Page Number: 210
Explanation and Analysis:

In this quotation, Kidder voices some of his frustration about Farmer and Farmer's attitude toward healthcare. Kidder can't help but suggest that Farmer is being a little disingenuous when he claims to be a kind of savior devoting his life to helping the poor and the sick. The problem with such a life, Kidder claims, is that it's immune from all criticism—Kidder can't disagree with Farmer without feeling that he's also somehow hurting the poor and sick people whom Farmer helps.

In part, Kidder's objections to Farmer sound like frustration with his own passivity—as Kidder himself acknowledges, he feels guilty whenever he's around Farmer, because Farmer could put any humanitarian to shame, let alone a wealthy writer like Kidder. At the same time, Kidder seems to have a valid point: Farmer isn't critical enough in his attitude toward patient care. By refusing to ever think of patient care as a matter of dollars and cents, Farmer is overly idealistic.

Chapter 25 Quotes

“Well, this boy is a challenge. But I’ve cured sicker kids.” Serena laughed nervously. She said, “Well, now he’s in Man’s Greatest Hospital.” That was what Mass General people called the place, playing on its initials, MGH. Dr. Ezekowitz chuckled. “As soon as we start to believe that, we won’t be.” He turned to the young intern. “Isn’t that right? We can always do better, can’t we.”

Related Characters: Serena Koenig (speaker), Dr. Alan Ezekowitz (speaker), John
Related Symbols: John’s Treatment
Page Number: 276
Explanation and Analysis:

In the penultimate chapter of the book, Kidder focuses on a single patient of Farmer's—a patient whom, in Kidder's mind, sums up the strengths and weaknesses of Farmer's approach to medicine. The patient in question is John, a Haitian youth who's suffering from an extremely painful facial tumor. At great expense, Farmer's nonprofit rushes John to the Massachusetts General Hospital. There, a young intern chastises Serena Koenig—the woman responsible for making the call to bring John to Boston in the first place—for leaving John so malnourished.

By saying, "We can always do better," Dr. Ezekowitz is subtly chastising his intern for her rude comment. Essentially, Ezekowitz is admitting that no hospital is perfect, whether it's in Boston or Haiti. To judge a patient for being poorly cared for, as the intern has done, is to pretend that one's own hospital needs no improvements. Therefore, Ezekowitz's statement is optimistic: like Farmer, he believes that healthcare is always improving, grounded in doctors' sincere desire to help the sick. Ezekowitz's words are particularly inspiring since they follow Koenig's nerve-wracking, controversial decision to spend thousands of dollars to fly John to Boston for more care. Although the chances of curing John are extremely low, Ezekowitz seems to support Koenig's decision. No matter how much it costs, or how unlikely the possibility of a cure might be, doctors need to work together to help those in need, always doing a little bit better.

“Can we not have him in a place where people are trained in palliation? Isn’t palliative care important? And a place where his mother can grieve in private instead of an open ward with flies all over her face?”

Related Characters: Serena Koenig (speaker), John
Related Symbols: John’s Treatment
Page Number: 277
Explanation and Analysis:

After John is transported to the hospital in Boston, he's treated for his facial cancer, but ultimately dies. Serena Koenig, the doctor who made the choice to fly John to Boston, is devastated by John's death. In part, she's saddened by the death of a patient. But more generally, she's beginning to question her decision to spend tens of thousands of dollars on flying John out of Haiti for a treatment that ultimately didn't change John's fate at all. Serena tries to rationalize her decision by arguing that even she didn't succeed in saving John's life, she at least improved his quality of life in the final hours.

Kidder doesn't offer his opinion on whether or not Serena did the right thing by choosing to fly John to Boston—he leaves it up to us to decide. John's treatment cost a lot of money, and therefore might detract from Farmer's ability to treat other patients in the future. And yet John was also a young boy who desperately needed better medical treatment—even if his treatment was expensive, Farmer would argue, it's not up to us to decide which lives are worth expensive treatments and which lives aren't. 

The next time I was in Cange, I asked Zanmi Lasante’s chief handyman, Ti Jean, what the people in the region were saying about the case. He told me that everyone talked about it. “And you know what they say? They say, ‘Look how much they care about us.’”

Related Characters: Tracy Kidder (speaker), Ti Jean (speaker)
Related Symbols: John’s Treatment
Page Number: 278
Explanation and Analysis:

In this scene, Kidder receives an important piece of evidence. One reason that Koenig's decision to fly John out of Haiti for additional treatments was so controversial was that, according to some doctors, flying Haitians out of the country for medical care would encourage others to ask for the same treatment—soon, every Haitian patient would be demanding an airplane. As this quotation makes clear, the Haitians don't demand that "special" treatment at all. On the contrary, they consider the airplane an incredible gesture for John, but don't ask for it again.

The quotation is important because it dispels some myths about the supposed "cycle of dependency." Some people argue that the efforts of humanitarians in Haiti are useless in the long run, because they encourage Haitians to rely on free medical services or aid from other countries—an unstable situation for any country. Farmer has always argued that arguments for the "cycle of dependency" border on racism: they offer dubious logic in order to support the old, prejudicial idea that people in third-world countries shouldn't receive the generosity of the United States. Whether or not one agrees with Farmer that dependency arguments are racist, this quotation certainly suggests that dependency arguments are wrong.

Chapter 26 Quotes

If you say, Well, I just think how much could have been done with twenty thousand dollars, you sound thoughtful, sensible, you know, reasonable, rational, someone you really want on your side. However, if you were to point out, But a young attending physician makes one hundred thousand dollars, not twenty, and that’s five times what it cost to try to save a boy’s life—that just makes you sound like an asshole. Same world, same numbers, same figures, same currency.

Related Characters: Doctor Paul Farmer (speaker)
Related Symbols: John’s Treatment
Page Number: 289
Explanation and Analysis:

Farmer offers Kidder one final explanation of why arguments for efficiency are immoral. There are some people (cynics, in Farmer's opinion) who would argue that John's treatment in Boston was a colossal waste of money, since it cost thousands and didn't save John's life. Kidder's point, however, is that these arguments place an unfair burden on the lives of third-world citizens. No first-world person would ever have to argue for why she "deserves" healthcare—the only relevant argument would be that doctors have a moral duty to help the sick. It's only when we bring up third-world people that the question of of cost-efficiency is brought up in the first place. Furthermore, Farmer argues, focusing on the cost-efficiency of treatment is the wrong issue. It would be better to focus on the ludicrous amounts of money spent on other, non-life-saving issues and professions, not the relatively small amounts of money that good doctors spend on sick patients in Haiti.

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