Mountains Beyond Mountains Paperback – August 31, 2004

Mountains Beyond Mountains is Tracy Kidder's novel-like non-fiction book about Dr. Paul Farmer, an American doctor who dedicates his life to doctoring the world's poorest and sickest.Dr. Farmer spends his entire life traveling the world, working at the highest levels of the WHO and other health organizations, but also on the ground -- treating the poor one-on-one. Dr. Farmer became a controversial figure in world medicine, primarily as the result of his stance on two issues...#1, Dr. Farmer feels compelled to provide direct one-on-one care to patients, including patients in places among the most remote and destitute in the world. In Haiti, it is not uncommon for him to hike for an entire day to reach one patient who failed to make a scheduled appointment at Dr. Farmer's clinic. His usual reasons for these treks are simply so he can ensure a patient is OK and doesn't miss a necessary dose of medicine.But is this the best use of time for someone uniquely gifted in researching, planning, and guiding disease eradication on a world-wide scale? To many, the answer is "no," and to them, it's irresponsible for Dr. Farmer to spend so much time with individual patients. However, Paul Farmer feels a compulsion to treat the sick. He is driven to it by the core of his being. Further, he believes policies with the best chance of transforming conditions on a large scale, are those that arise from exposure to patients on a small scale.#2, Dr. Farmer eschews conventional "cost efficacy" principles by investing whatever it takes to treat a patient or group of patients. For example, the recommended tuberculosis treatment strategy for poor populations was a program called DOTS. Part of the DOTS philosophy was to dedicate all resources to treating standard strains of tuberculosis because non-standard strains, known as TB-MBR, are resistant to the more common medications and can cost ten times as much to treat.When Dr. Farmer first started treating TB patients, he went against the grain of the entire world health community by not factoring cost efficacy into the equation when determining whether or how to treat TB-MBR patients. Dr. Farmer's scientific reasons for this approach are explained in the book, but even without the science, it's clear that if sick people are in front of Paul Farmer, he's going to treat them without regard to whether the costs will impact resources for treating other (potentially much larger) groups of patients.Tracy Kidder personalizes the cost efficacy argument by illustrating a case where Dr. Farmer decided to spend $20K treating a near terminal patient from a remote region of Haiti despite a low chance for success. With that $20K, so many other lives could have been improved and even saved, so how can Dr. Farmer in good conscience have made his decision?In this review, I won't delve much more into the anecdote. It is told powerfully by Kidder in the book. I sympathize greatly with the moral principle on which Dr. Farmer's detractors base their criticism. However, the book and Dr. Farmer issue a strong challenge, one that is both troubling and empowering when we consider the "proper" use of world resources.First, why is the $20K used to save a poor patient associated with the $20K that could potentially be used to treat other poor patients? Why not consider the salary of the average doctor or surgeon? Why not lament that by paying surgeons $200K instead of $220K, we could help so many of the poor and sick? In other words, although it's a natural convention to associate the $20K in the former paradigm, it's ultimately a contrived association. Further, when we make that association, it belies how we value the life of a poor person versus the life of someone more like ourselves. Would anyone question spending $20K to airlift out a teenager injured and trapped in a skiing accident?These are troubling questions that cause us to consider our own biases and more importantly to consider the values we place on human lives, and whether there is really room for relativity in such assessments.I think Dr. Farmer's frame of reference stems in part from how he views humanity, and in particular how he views the poor. But more profoundly, he doesn't prescribe to a scarcity mindset. Most of us in the world, including me, have an instinct to view resources as scarce. Therefore allocating resources to one person or project by its definition means limiting resources to another. However, is that really true? Contemplating the magnitude of the world's resources and our human potential, are those limits real or imagined?Recently I read an argument saying that the energy "crisis" is a figment of our imagination that stems from a collective viewpoint based on scarcity. Because we believe in scarcity so strongly, we accept a view of energy as fossil fuel resources, which by their nature, imposes a limit (due to both the amount of fossil fuels available and the limit placed by the pollution their use causes). But if instead of a collective scarcity mindset, if we shared a collective abundance mindset, we would realize the potential of many greater and greener energy sources.Therefore, Dr. Farmer's unwillingness to compromise on the care of an individual patient inspires me on both the intimate level of one life, and on the broad level of what adopting an abundance mentality can mean for all our lives.Reading Mountains Beyond Mountains left me feeling both inspired, as described above, and deeply challenged. I spend most of my time blissfully and perhaps purposely ignorant of the massive amount of suffering in the world. Dr. Paul Farmer demonstrates the potential positive impact we can have on these conditions as individuals. In a few weeks or a couple of months, will I let this book shift to the recesses of my consciousness or will I accept the challenge to contribute more fully to the world? Even if I choose the latter, I have neither the energy nor the compulsion to rush off to the far reaches of the world and sacrifice my life as Paul Farmer has sacrificed his. What does that say about me and would a desire to strike a balance be nearly equivalent to copping out altogether?In this review, I sketched themes that were meaningful to me. However, I cannot do justice to the book, in which Tracy Kidder weaves these themes and others together, in much greater detail and with the movement of grand story telling. I encourage you to read the book and hope you are similarly thought-provoked and moved by it.

Mountains Beyond Mountains should be offered to every pre-medical and medical student. Even if none of us can do what Dr Farmer has done, we should know that it was done and all the possibilities for each of us that entails.

Tracy Kidder is the master journalist, like a clear window on the world. Long ago I read The Soul of a New Machine and liked it, but didn't think too much about it. The brilliance of Kidder's style is so make you feel like you are there, really feel what the subject is about, without any distortion positive or negative.What an amazing subject for this work: Dr. Paul Farmer. This guy is just amazing! As a college student, he travels to Haiti to dedicate himself to the poor. He attends Harvard while spending 8 months a year in Haiti building his own hospital there. He gets a PhD in Anthropology at the same time he gets his MD, the latter not surprising given that he already has 6 years of intense clinical experience dealing directly with life and death situations. You would expect such a person to take on airs, maybe be a big proud of himself, maybe even be motivated by the 'big bucks' so clearly available in a rich city. Dr. Farmer appears to be vying for a "saint" award. Kidder makes you feel like you are there sitting in the same room, and it is no big deal.To say this book is inspiring is badly understating it. Look at what you can do if you hold true to your ideals! It is humbling as well. Dr. Farmer is my age, and I can't help drawing parallels with my own life, and there is no way I could do a fraction of what he is done. Yet I don't need to: it is satisfying to know that there are people like him in the world.There is so much to learn from the book. Never give in, and never give up! His daily accomplishments are so small, and yet at the same time so profound and consistent. It is all about "caring". If you care about your friends, your neighbors, your family, and - yes - the rest of the world, how can you not love a person who literally saves people on a daily basis? Are we seeing a saint walking among us? One has to wonder.This is a story that needs to be told. It reminds me a lot of Three Cups of Tea. If only we could motivate others to do the same -- if only we could motivate ourselves to do the same -- the world could be a better place. How refreshing to read about a real superhero.While continuing to work in Haiti, he started to investigate Lima Peru, where there was a disturbing trend: people with Tuberculosis that was resistant to 4, maybe even 5 of the top antibiotics. He goes there and finds that in general Peru is competently following a program in strict accordance to WHO standards. The problem was the WHO guidelines! How to raise this issue without alienating the world's most important health organization, or the officials in Peru. At the same time, what can be done about drugs with inflated costs putting them out of reach of these poor patients?His travels take him to the prisons in Russia, which has a an extreme problem with TB as well. Prisoners are easy to study and monitor. He points out that the prisons are like a pump that cycles TB into the general population with prisoners who stay a few years and bring the disease back with him. You almost cheer when he gets a grant from the Gates foundation to develop a modified procedure to battle MDR-TB.He does not do any of this all by himself. There are a lot of truly dedicate people who recognize his talent and follow/help him all along the way. Kidder manages to capture many of these people as well. At still, Farmer's real talent is to be the catalyst that makes it all come together. It might be better to say it all flows around him...In the end, his success is due to one simple talent, and he says it best in his own words: "I like people." It is hard not to like him back.

Truly amazing work from someone who could have had a comfortable living in Boston or anywhere but decided to help the needy… in one of the worlds most difficult places, Haiti… its a story about history, caring, and absolute and destitute people… governed by corrupt politicians who are supported by western governments….. but forget that, the story is about humanity, helping people and caring… Paul is a true hero.

Amazing book-difficult to believe there are people who are so committed and driven to do good for the people-wherever they are. It shows to see people as human not based on colours. Instead of calculating everything as cost vs benefits, we should meet the requirements of every individual. Paul Farmer demonstrate that few committed individuals with high ideals can change the world. He also demonstrates the importance of working with people accepting their cultural beliefs.Tracy kidder- this is the first book I read from him. I never felt there is any need to take a break! I am planning to read more of his books.

I work in primary health care in the UK and have lived through the times when HIV related illness emerged and TB reappeared as a significant public health problem so this book is of great interest to me professionally and at a personal level with a parallel career in a totally different setting. I found it challenging in thinking 'what might have been' but at the same time familiar - holding that paramount concern for the patient in front of you and the desire to be the best advocate for their care. I think I got to understand the psyche of Dokte Paul, but I am left wondering about the relationships within his own nuclear family. I found it a very good read.

A must read for anyone interested in medicine and public health. Very inspiring story.

I adored this incredible book, and I’m absolutely obsessed with Farmer after reading it. More than just one man though it really sparks thought about global health and social policy and the idea that the poor don’t deserve the health options that the rich have. It is incredibly well researched and I’ve come away knowing more than I ever imagined I would about Haiti, and TB.

Not yet finished, but really enjoying this inspirational book. Recommend for anyone studying tropical medicine/nursing or has a desire to make a difference in low resource countries