Study Guide Mountains Beyond Mountains by Tracy Kidder

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Farmer tells Kidder soon after he arrives in Haiti that he, Farmer, will be Kidder’s Virgil. That’s because he views everyone as a potential subject for education. He tells him about his own education concerning the relation between medicine and beliefs in sorcery. He had been in Boston recovering from a broken leg when one of his patients died of TB. When he returned, he was told by the staff that she wouldn’t have died if he had been there. Their intended meaning was complimentary, but Farmer converted it to self-reproach. He wanted a medical system that continued to work in his absence.

So Farmer calls a staff meeting to figure out what is wrong. Some of the staff points out that the poorest patients fare worst, but many of the staff point out that failure with a patient can often be placed on his mindset: once he feels better, he stops taking his medicine which then inevitably leads to setbacks. Farmer is intellectually torn over the possible reasons and so designs a study. He selects two groups of TB patients. Both groups receive the same treatment for free, but one of the groups also receives other services, such as visits from health care workers and monthly cash stipends. Farmer visits all the patients personally to monitor their care. When the study ends, only 48% of the group who only received free medicine is cured, while in the group that received extra services, everyone fully recovers. So whether a patient believes that his illness comes from germs or sorcery makes no difference at all in his recovery. Farmer is at a loss to why the study comes out the way it does, until he interviews a sweet, rather elderly woman who asks him, “Are you not capable of complexity?” That’s when Farmer realizes that this is no different than the dynamic he sees in America where people rely both on medicine and prayer. Thus, the study becomes a command to him to worry more about his patients’ material circumstances than about their beliefs. So the money he receives for his clinic also is used for extra health care workers and cash stipends. As a result, he hasn’t lost a single patient in twelve years.

A patient from a village called Morne Michel has not shown up for his monthly appointment, so Farmer, believing that one of his rules is to find a patient when he doesn’t appear, decides to go into the countryside. To him, the noncompliant one is the doctor who doesn’t fix a patient who doesn’t get better. As a result, Farmer decides to go to Morne Michel and take Kidder with him. On the day he sets out, he tells the women in the kitchen where he and kidder are going. They admonish him that such a trip will kill his “blan,” a term referring to Kidder. Actually the term has a complicated meaning such as “white person,” but also anyone from outside Haiti, even black Americans. The Haitians think they all look alike!

The trip is long and difficult. Their first stop is an abandoned cement factory which sits beside a concrete buttress dam. This dam is a subject that Farmer has discussed in all of his books and many of his journal articles. To him, it is the perfect example of what’s wrong in Haiti. In the 1950’s, under one of Haiti’s many dictators who was supported by the USA, the dam was built by the US Army Corps of Engineers under the pretext of improving irrigation and generating power. In reality, the peasants who were supposed to benefit from the project received nothing but the loss of their homes and property. In fact, the dam had always been intended to help agribusinesses downstream, mostly American-owned, and also to supply electricity to Port-au-Prince and to the homes of the Haitian wealthy.

As a result, the young soon left the countryside and moved into the cities. The old reminisce about what the countryside looked like before the dam. They describe the experiences of running from the rising water and then fighting over who owned the scabby land that was left. After that, they even lost their pigs in the 1980’s when American fears of swine flu invading their own pigs led to Haiti destroying the Creole pigs. Even supplying the peasants with American pigs didn’t work, because they couldn’t survive the rigors of the Haitian countryside.

Farmer and Kidder walk across the top of the dam, being greeted all along the way by the locals. Then, they find a footpath that moves straight up. Even with Farmer’s bad back, he makes it to the top of the first hill before Kidder. It is the first of many hills. They pass smiling children, carrying water in buckets that had once held paint, oil, and antifreeze. They pass patches of millet, the national staple, and small stands of banana trees. On a fair number of the trees that are still standing are political graffiti, which is one way, Kidder believes, that the poor here avoid hopelessness. They pass women washing clothes in a rivulet of a gully. Farmer explains that they are a fastidious people in spite of their poverty. He also comments on their smiling faces that are evident even though they’re very aware of their own misery. He says there’s a WL (white liberals) line that says, “They’re poor but happy.” He even has problems with groups who appear to be his allies, because even though he loves them, he is angry that they believe all the problems of poverty can be fixed without any personal costs.

Kidder notices that many of the people he passes are wearing second-hand American clothes. The people call these “Kennedys,” because President Kennedy had sponsored a program for Haiti that sent machine oil among other things to the country. The people thought the machine oil was cooking oil, and so came to apply the name Kennedy to goods of inferior quality.

The two men continue their trek with Kidder sweating buckets and Farmer as dry as a bone. About three hours after they began, they arrive at the hut of the patient who hadn’t shown up for his appointment. When Farmer asks him if he dislikes his TB medication, the man replies with an emphatic yes, because he wouldn’t be here without it. However, he hadn’t received his standard cash stipend and so hadn’t come in to the clinic. Farmer is satisfied that he has resolved the problem, and they begin the long journey back, slipping and sliding this time down the hills. When Kidder asks him what his reply would be if other health care workers were unwilling to make the same effort he is, Farmer says he would reply, “F*** you,” his way of saying that they are responsible for assuring an “outcome-oriented view of TB.”

They soon come to a cock-fighting pit where two chairs are found for both men and where Farmer is soon surrounded by all the women of the men participating in the match. They admire him and want to talk to him, because he is the first physician who has ever provided them with gynecological or obstetric help. Once they set out again, it is mostly downhill, but there are still a few hills to climb. At the top of one, Farmer stops as if to admire the view. It is beautiful, but Kidder now sees it as more than just picturesque - perhaps he now knows the truth that lies within these hills. Farmer says that to understand Russia, Cuba, the Dominican Republic, Boston, or Sri Lanka, you just have to be on the top of that hill. He seems to be joking, but Kidder understands now that viewing this drowned land of the poorest people is a lens on the world. However, he fears to voice his ideas, because he doesn’t want to disappoint Farmer.



In this chapter, Kidder begins to learn the great lessons that Farmer teaches: there is a definite link between poverty and poor health; behind the beauty of the hills is the truth about the poorest of the poor; WL stands for more than white liberals, but also for anyone who champions Farmer’s cause without any personal sacrifice.


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