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
Cost-Efficiency vs. the Value of Life Quotes in Mountains Beyond Mountains
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.
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.”
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.”
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.”
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.
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.
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.”
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.
“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.”
“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?”
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.’”
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.