Sunday, November 4, 2007

Mountains Beyond Mountains

Quotes from the book:

"Never underestimate the ability of a small group of committed individuals to change the world. Indeed, they are the only ones who ever have." - Margaret Mear (Jim Kim)

"Intelligence plus character--that is the true goal of education." - Martin Luther King, Jr.

Excerpts from the book:

I am aware of other voices that would praise a trip like this for its good intentions, and yet describe it as an example of what is wrong with Farmer's approach. Here's an influential anthropologist, medical diplomat, public health administrator, epidemiologist, who has helped to bring new resolve and hope to some of the world's most dreadful problems, and he's just spent seven hours making house calls. How many desperate families live in Haiti? He's made the trip to visit two.

I think of the wealthy friend of Howard Hiatt's who balked at contributing to PIH (Partners in Health) because, while he knew about Farmer's work in Haiti and considered it impressive, he doubted anyone could reproduce it. I've heard variations on that theme. (Paul) Farmer and Kim do things that no one else can do. Zamni Lasante won't survive Farmer. Partner in Health is an organization that relies too much on a genius. All the serious, sympathetic critiques come down to the two arguments: Hiking into the hills to see just one patient or two is a dumb way for Farmer to spend his time, and even if it weren't, not many other people will follow his example, not enough to make much difference in the world.

But standard notions of efficiency, notions about cost-effectiveness, about big people performing big jobs, haven't worked so well themselves. Long ago in North Carolina, Farmer watched the nuns doing menial chores on behalf of migrant laborers, and in the years since he's come to think that a willingness to do what he calls, "unglamorous scut work" is the secret to successful projects in places like Cange and Carabayllo. "And," he says, "another secret: a reluctance to do scut work is why a lot of my peers don't stick with this kind of work." In public health projects in difficult locales, theory often outruns practice. Individual patients get forgotten, and what seems like a small problem gets ignored, until it grows large, like MDR (multiple drug resistant TB). "If you focus on individual patients," Jim Kim says, "you can't get sloppy."

That approach has worked for PIH. And I can imagine Farmer saying he doesn't care if no one else is willing to follow their example. He's still going to make these hikes, he's insist, because if you say that seven hours is too long to walk for two families of patients, you're saying that their lives matter less them some others', and the idea that some lives matter less is the root of all that's wrong with the world. I think he undertakes what, earlier today, he called, "journeys to the sick" in part because he has to, in order to keep going. "That's when I feel the most alive," he told me once on an airplane, "when I'm helping people." He makes these house calls regularly and usually without blan [non-native] witnesses, at times when no one from Harvard of WHO [World Health Org] can see him kneeling on mud floors with his stethoscope plugged in. This matters to him, I think--to feel, at least occasionally, that he doctors in obscurity, so that he knows he doctors first of all because he believes it's the right thing to do.

If you do the right thing well, you avoid futility. His patients tend to get better. They all get comforted. And he carries off, among other things, images of them and their medieval huts. These refresh his passion and authority, so that he can travel a quarter of a million miles a year and scheme and write about the health of populations. Doctoring is the ultimate source of his power, I think. His basic message is simple: This person is sick, and I am a doctor. Everyone, potentially, can understand and sympathize, since everyone knows or imagines sickness personally. And it can't be hard for most people to imagine what it would be like to have no doctor, no hope of medicine. I think Farmer taps into a universal anxiety and also into a fundamental place in some troubled consciences, into what he calls "ambivalence," the often unacknowledged uneasiness that some of the fortunate feel about their place in the world, the thing he once told me he designed his life to avoid.

"The best thing about Paul is those hikes," Ophelia says. "You have to believe that small gestures matter, that they do add up." Earlier today Farmer said that he'd brought on others to fight "the long defeat." The numbers are impressive. They include priests and nuns and professors and secretaries and businessmen and church ladies and peasants like Ti Jean and also dozens of medical students and doctors, who have enlisted to work in places such as Cange and Siberia and the slums of Lima. Some of the students and doctors work for nothing, some earn much less than they could elsewhere, some raise their own salaries through grants. I once heard Farmer say that he hoped a day would come when he could do a good job just by showing up. It seems to me that time has already arrived. A great deal of what he's started goes on without him now, in Roxbury and Tomsk and Peru and, some of the year, in Haiti. Meanwhile, other definitions than the usual, of what can be done and what is reasonable to do in medicine and public health, have spread from him. They're still spreading, like ripples in a pond.

How does one person with great talents come to exert a force on the world? I think in Farmer's case the answer lies somewhere in the apparent craziness, the sheer impracticality, of half of everything he does, including the hike to Casse.

My goal personal goal, the end to which I seek, is to be to education in America what Farmer is to public health in Haiti.

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