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Study Guide Mountains Beyond Mountains by Tracy Kidder

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MOUNTAINS BEYOND MOUNTAINS ONLINE STUDY GUIDE

 

CHAPTER 3

 

Summary

Kidder, the author, has arrived in Haiti to see Farmer’s oeuvre. He is met at the Port-au-Prince airport by a four-wheel-drive pickup and rides on a two-lane paved road until he comes to the other side of the Plaine du Cul-de-Sac. There, the truck moves steadily upward, while pitching and rolling, along a road that seems little more than a dry riverbed. Along the way, he sees many arid mountains and villages of wooden huts, trucks of various sizes and a lot of foot traffic, beggars, ox carts being pulled by men, few trees, and no electricity after the town of Péligre. The trip is only 35 miles long, but lasts three hours. Finally, kidder’s truck pulls up to a tall concrete wall where a sign reads, “Zanmi Lasante,” or Partners In Health. It is a very dramatic sight in the all but treeless, baked brown landscape. There are tall trees beside courtyards, walkways, and walls, an ambulatory clinic and a women’s clinic, a general hospital, a large Anglican church, a school, a kitchen which prepares meals for 2000 people a day, and a brand new building to treat tuberculosis. Inside, the building has tiled floors, clean white walls, and paintings by Haitian artists.

The morning after Kidder arrives, he goes on the first of many times with Farmer on his rounds. It begins at dawn and there are many, many people waiting to see him. A large number are there just to ask Farmer to help them in ways that are not really medical or urgent, so he searches the crowd for people in real need. One is a young woman with her hand in a towel. She has waited fifteen days before seeking medical care for a severe wound and now she is has gangrene. He is frustrated that even minor injuries go untended and then more severe consequences are the result. The woman will probably lose her hand.

Kidder explains to the reader that when he arrived at Zanmi Lasante, he came to what seemed to him the end of the earth. It is the poorest part of the one of the poorest nations in the world, but he feels he has encountered a miracle. The people make the equivalent of one dollar a day or less, the country has lost most of its trees and a great deal of its soil, it has one of the worst health statistics in the Western world, and yet in one of the most impoverished regions of the world is this lovely, walled citadel called Zanmi Lasante. Other clinics treat patients there, but none are as well-equipped, and the patients do not have to pay at Farmer’s clinic like in the others. His Haitian colleagues had told Farmer that the patients must pay user fees of about eighty cents a day. However, Farmer has his own rule: every patient must pay the eighty cents, except for women, children, the destitute, and anyone who us seriously ill. So everyone has to pay except for almost everyone!. And no one is allowed to be turned away.


In addition to the excellent medical care the clinic provides, it also had built schools, houses, sanitation systems and water systems in the catchment area. What’s more, in a country where the greatest killer is TB, there has not been one death from it in Farmer’s catchment area since 1988. The money for Zanmi Lasante is funneled through the public health charity called Partners In Health with headquarters in Boston. The bills are small by American standards, so that Kidder’s local hospital in Massachusetts treats about 175,000 patients with an annual operating budget of $60 million, while Zanmi Lasante treats the same number of patients for about $1.5 million. Much of what they receive is from donated drugs and charitable contributions.

Farmer himself contributes a great deal to Zanmi Lasante, also. He had received from the MacArthur Foundation a so-called genius grant of $220,000. He had donated the entire sum to Partners In Heath for a research branch for the organization. He personally makes about $125,000 a year from Harvard and the Brigham, but all his paychecks for honorariums or royalties also go to Partners In Health. Now he is married to a Haitian woman named Didi Bertrand and has a daughter born in 1998. They moved from the basement of Partners In Heath’s headquarters and live in a small apartment in Eliot House at Harvard when they are in America. While they are in Haiti, they stay at the clinic. However, these days Farmer doesn’t see much of his family, because Didi is finishing her studies in anthropology in Paris. When told he should spend more time in Paris, Farmer says, “But I don’t have any patients there.” So he spends four months in Boston and the rest of the time in Haiti and has traveled to so many places where doctors are needed that he has traveled more than three million miles by airplane. He has a small house similar to a ti kay that peasants live in only with an indoor bathroom (without hot water). Whenever Kidder looks into Farmer’s little house, he is amazed to see that his bed remains unused. Farmer claims that he sleeps about four hours a day, but later he confesses that he just can’t sleep, because there’s always someone who’s not receiving treatment when he does.

Once, Kidder wonders aloud what compensation Farmer receives for all his sacrifices. Farmer, with an edge to his voice, responds, “I feel ambivalent about selling my services in a world where some can’t buy them. You can feel ambivalent about that, because you should feel ambivalent. Comma.” This is Kidder’s first experience with Farmer’s use of the word comma at the end of a sentence. It stands for the word that would follow the comma - asshole. Kidder understands that Farmer isn’t calling him an asshole, but instead is referring to third parties who feel comfortable with the current distribution of money and medicine in the world. And implication is that you aren’t one of those. Are you?

Kidder follows Farmer into his office where Farmer says that now the objective is to stay put. The patients then come to him: an elderly man being treated for pulmonary TB who is blind, but wears glasses. He had said he wanted them, so Farmer saw to it that he received them; a younger man called Lazarus by Farmer who had been wasting away from AIDS and TB and had gone from 90 pounds to 150 in Farmer’s care; a woman who looked healthy and well, but only a few months before, her father had been saving to buy her a coffin; a lovely-looking young woman being treated for drug-resistant TB and now is in the midst of a sickle-cell crisis; a man with gastritis in late middle age which Farmer explains could mean thirty years old since 25% of Haitians die before they reach the age of forty; a sixteen-year-old boy too weak to walk because of an ulcer; and a very small elderly-looking woman who had developed TB of the spine before Farmer could treat her. Farmer is especially solicitous of her needs and calls her “mother.” Then a very pregnant woman enters cheerily calling all the men in the clinic her husbands. She is infected with HIV and has been exposed to TB.

While Farmer deals with this last patient, Kidder examines the yellow legal pad lists taped on the wall. There is a task to be completed written on every line of each of three pages. When he gets a task done, he checks a box he has drawn beside it. This seems to give the doctor inordinate pleasure when he sees he’s getting a lot done. There are sixty imperatives on the list such as sending sputum samples to Boston. One tantalizing item reads, “Sorcery consult.” This refers to the deep belief in the Haitian culture that someone can be made ill through sorcery. It is called “maji” and all Haitian doctors know how to deal with it. Because Farmer has such a gift for healing, the people think he is a god and that he works with both hands - science and magic. Farmer is embarrassed and amused by these kinds of consults, but on a serious note, he explains that the beliefs of the people evolved in the absence of effective medicine, so they have developed an alternative cause for illnesses they don’t understand. Of course, the allegation of sorcery itself can cause problems, like the boy whose mother refuses to speak with him, because she believes he used “maji” to kill his brother.

All these interpretive discourses he has with Kidder Farmer calls “narrating Haiti.” Normally, the doctor can be silent during his rounds or at the least, reticent about benign conversation, so Kidder eggs him on in order to get him to “narrate Haiti,” which brings forth his drawing of a moral about the suffering of the Haitian poor as well as the world’s poor. He often pauses for a reaction, “You feelin’ me?” As for Kidder himself, he finds he can’t muster a sufficient response internally. He feels sorry for so many Haitian children, who often die of something as common as measles, but he knows he can never feel sorry enough to satisfy Farmer. It sometimes makes him feel annoyed with Farmer.

Farmer teaches his students that to be a good clinician, you must never let a patient know that you have problems, too, or that you’re in a hurry. He says that the rewards are so great for simple things. Of course, this means that he seldom leaves his office before dark. A young man named Ti Ofa comes in as a chronic infectious patient. Because the clinic doesn’t have the equipment to measure viral loads and CD4 counts, Farmer knows only from long experience that Ti Ofa is in the endgame of his AIDS infection. Even though it is exorbitantly expensive and no doubt a waste of resources, Farmer has started patients like Ti Ofa on new antiviral drugs. The man is embarrassed by his situation, but accepts the drugs and promises to take them faithfully. He tells Farmer that just talking to him makes him feel better.

The end of the day brings more rounds, this time of the Children’s Pavilion where there are babies with kwashiorkor, a form of starvation. Farmer has recently lost a baby to meningitis and another to tetanus. He croons softly to a baby girl named Michela who he refuses to give up on even though she is bloated with pleural effusion. The last stop is the TB hospital where the patients are sitting on the beds in one room watching a soccer game on TV. He jokes and teases them, which cheers him up. He points out to Kidder that they’re failing on 71 levels, but not on one or two. The day ends on Farmer’s little patio lit by battery power. He puts a pile of medical studies on his lap to read, but decides he’s not into that and instead takes Kidder along, while he surveys the plant life he has nurtured over the years. The, he goes back to his studies for awhile. Even that is interrupted when he is called back to the clinic for a moaning thirteen-year-old who has arrived by donkey ambulance. He must give her a spinal tap and when he inserts the needle she cries out in Creole that it hurts and she is hungry. Farmer is amazed and “narrates Haiti” again, “Only in Haiti would a child cry out that she’s hungry during a spinal tap.

 

Notes

This chapter shows the reader how Farmer spends his days and how dedicated he is to each and every patient. They love him and call him a god, bring him gifts like pigs or chickens. However, none of these accolades are what motivates this man. It is the thought that there is some patient in need that keeps him going.

 

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