Mountains Beyond Mountains

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Cost-Efficiency vs. the Value of Life Theme Analysis

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Cost-Efficiency vs. the Value of Life Theme Icon
Saintliness Theme Icon
America, Imperialism, and the First World Theme Icon
Science, Magic, and Religion Theme Icon
Nonprofits, Politics, and Compromise Theme Icon
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Cost-Efficiency vs. the Value of Life Theme Icon

In Mountains Beyond Mountains, Dr. Paul Farmer devotes enormous amounts of resources to caring for sick people, especially in impoverished parts of the world like Peru and Haiti. Tracy Kidder keeps coming back to the same question, then: Is this worth it? At times, Farmer and his nonprofit organization, Partners in Health (PIH) have to spend huge amounts of money on individual patients—amounts that, Kidder can’t help but think, might be better spent caring for multiple other patients. On one occasion, Farmer approves extremely expensive vaccinations for a rare strain of tuberculosis (TB) in Lima; another time, PIH spends 20,000 dollars on an airplane ride for a boy named John, who suffers from cancer. Why spend 20,000 dollars on treatment for a rare cancer in one child when the same sum could pay for lifesaving healthcare for hundreds of other patients?

Over the course of Kidder’s book, Farmer doesn’t answer Kidder’s question so much as he dismisses it as a red herring—a distraction from the real issue. To complain about cost-efficiency in PIH, Farmer argues, is to rationalize the status quo in the world, whereby wealthy people, living mostly in wealthy countries like the U.S., have all the power. In the case of John’s cancer, for example, the question shouldn’t be, “Why spend 20,000 dollars on one plane ride?” Rather, it should be, “Why does a medical flight to save the life of a child cost 20,000 dollars?” or, more generally, “Why doesn’t the U.S., the wealthiest country on the planet, invest more of its money in curing diseases around the world?”

Kidder it finds it difficult to agree with Farmer at first. But he acknowledges that in part he’s reluctant because Americans are conditioned to think in terms of cost-efficiency when they discuss healthcare in other countries. Nobody would talk about cost-efficiency, Farmer points out, if there were an outbreak of tuberculosis in Boston—the assumption would be that as many American lives as possible should be saved, regardless of the costs. Cost-efficiency arguments, then, always come with the sinister undertone that individual lives—usually the lives of people who live far away, in a very different culture—are somehow second-rate. For Farmer, the best demonstration of this principle is the TB treatment program in Peru. For years, it was agreed that it was too expensive to treat rare, drug-resistant strains of TB. Over the course of several years, however, Farmer was able to drive down the costs of treating these strains by more than 95 percent. In the case of Peru, cost-efficiency was an alibi for indifference: before Farmer, medical bureaucrats could treat TB cheaply, but they didn’t feel any great need to do so.

Paul Farmer’s entire career could be considered a rebuttal to the arguments for cost-efficiency. In order to balance out what he sees as the indifference of the Western medical establishment to the world’s suffering, Farmer devotes his life to hands-on work with patients around the world—work that’s rooted in his respect for the inherent value of a human life, independent of efficiency arguments.

Cost-Efficiency vs. the Value of Life ThemeTracker

The ThemeTracker below shows where, and to what degree, the theme of Cost-Efficiency vs. the Value of Life appears in each chapter of Mountains Beyond Mountains. Click or tap on any chapter to read its Summary & Analysis.
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Cost-Efficiency vs. the Value of Life Quotes in Mountains Beyond Mountains

Below you will find the important quotes in Mountains Beyond Mountains related to the theme of Cost-Efficiency vs. the Value of Life.
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 9 Quotes

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 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 21 Quotes

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.