Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World

The two fly to Cuba, where Farmer notes the healthier ecosystem in comparison to its Caribbean neighbor. While Farmer sees flaws in every ideology, he appreciates the communist nation’s excellent medical system and framework for “managing poverty.” They attend an AIDS conference with the goal of obtaining AIDS antiretroviral drugs, permission to send two Cange residents to a Cuban medical school, and an aid commitment from a French ambassador. Farmer gives two talks on AIDS-TB coinfections and the source of AIDS in Haiti. While first-world observers blame the AIDS outbreak on drugs and promiscuity, Farmer notes that illicit drug use is too expensive for most Haitians and that Haitian women rarely have more than two partners in their lifetimes. Rather, the most stable occupations for their husbands are truck drivers, who can keep multiple partners in different cities, and soldiers, who can abuse their power for sex. Eliminating inequalities for women is vital to stopping AIDS.

In his downtime, Farmer writes grants, papers, and the book Pathologies of Power, which compares Cuba’s well-coordinated and relatively humane AIDS response, leading to fewer infections and deaths, to the American effort at the Guantanamo Bay prison, which a federal judge shut down for squalid conditions. As they visit Cuba’s quarantine site with Infectious Disease Institute head Jorge Pérez, Kidder feels that Farmer is uncritical, ignoring the realities of the pandemic’s early days. When Kidder suggests that the Cubans are nice to Farmer because he attacks US foreign policy, Farmer retorts that he receives good treatment everywhere and later warns Kidder that an article that vilifies him will ultimately harm his patients. While Kidder feels that the “scolding” embodies all his issues with the doctor, they agree to continue their trip together, and Farmer cares for Kidder after he develops diarrhea.

The two stay in Paris for the birthday of Farmer’s daughter. The doctor recounts his initial thrill of showing the city to his wife, only for her to mention that this beauty is possible because of the exploitation of her ancestors. He also discusses how he cried upon delivering a stillborn baby after imagining his own daughter in the baby’s place, calling it a “failure of empathy” that he expresses sorrow for his child’s life above others (213). He keeps both a picture of his daughter and a picture of a child with kwashiorkor, or severe starvation, on him.

Kidder notes that his long separations from his family are an emotional kink in his armor and that Farmer expects much from coworkers but is quick to forgive. PIH members are familiar with his shorthands, use of flippant terms that reflect Farmer’s disdain of identity politics, and seem like a special club. However, Farmer insists on strict sourcing in his papers to prevent criticism, and he tells Kidder that calling Haiti and France separate worlds ignores the link between one’s success and the other’s suffering.

Farmer partners with the Soros Foundation’s Russian TB program after critiquing its DOTS-only approach. He sees Russia as a chance to increase the profile of MDR treatment efforts as a Doctors Without Borders effort only cured 46% of treated patients in a prison colony. Farmer befriends Alex Goldfarb, welcomes philanthropist George Soros’s willingness to fund projects, and accepts an unpaid consultancy with the World Bank.

Farmer and Kidder travel to Moscow’s central prison, Matrosskaya Tishina. Many arrested prisoners stay in the maze-like complex for a year before a trial, thus getting exposed to TB, and prisoners with AIDS get longer sentences. Farmer considers the situation catastrophic but commends the doctors. He tells a colonel that he considers himself a physician first rather than an American, noting that it’s easy for privileged nations to consider themselves democracies.

Farmer must convince the World Bank to give the Ministry of Justice 50% of its anti-TB loan both to support the most affected and to prevent spread to outside communities. He also must control the outspoken Goldfarb. Farmer earns praise for his understanding of the TB crisis and gets food into the budget by labeling it as “vitamins.” The Ministry of Justice obtains half of the loan, with a $30 million first installment and a projected $100 million in the future. Farmer is not worried about misuse of the funds. Kidder tells Farmer that he’s a great guy, but Farmer finishes his sentence by saying that he would be nothing without his clinic.