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Chapter 23
Themes
Key
LitCharts assigns a color and icon to each theme in Mountains Beyond Mountains, which you can use to track the themes throughout the work.
Cost-Efficiency vs. the Value of Life
Saintliness
America, Imperialism, and the First World
Science, Magic, and Religion
Nonprofits, Politics, and Compromise
Summary
Analysis
In July of 2000, the Gates Foundation gives PIH a grant of 45 million dollars to wipe out MDR-TB in Peru in the next 5 years. Jim Kim, who’s overjoyed with this development, plans to eliminate at least 80 percent of cases of MDR. Farmer is also delighted, though he worries that news of the Gates Foundation’s generosity will result in less money being given to PIH by other donors.
The chapter begins on an optimistic note: with the Gates Foundation’s endowment, Jim Kim seems to have a good shot at achieving his goals. As usual, Farmer doesn’t allow himself to linger on a success, but immediately moves on to the next problem that needs addressing.
Themes
Although Farmer will be traveling to Peru to help out with the new Gates endowment, he continues to supervise Zanmi Lasante in Haiti. In spite of the generosity of the Soros Foundation, Farmer still needs to find long-term sources of funding for Haiti—Tom White’s money is almost gone, and other individual donations to PIH in Haiti are too irregular.
Farmer needs to balance his commitments to his Haitian patients with his duties as the head of a major international nonprofit, PIH. Basically, he needs to temporarily neglect his house calls and find new donors.
Themes
Although PIH has more money than it ever did before, the company remains remarkably frugal. PIH works out of the same tiny office in Boston, and spends only 5% of its budget on administering itself—the other 95% goes to patient services. There are about 50 people working for PIH in Boston, 400 in Haiti, and 120 in Peru. PIH has also expanded to Siberia, thanks largely to Alex Goldfarb’s actions. Goldfarb displeased the Soros Foundation by vocally supporting (and giving aid and comfort to) a former KGB agent who’d been ordered and refused to assassinate the Russian oligarch Boris Berezovsky. Because Goldfarb worked with the Soros Foundation, the Foundation found itself mired in a political controversy in Russia. Soros decided to pull out of Russia for the foreseeable future, and asked Farmer and PIH to replace his organization.
In a bizarre turn of events, Goldfarb’s involvement with the KGB agent causes a vast “domino effect,” culminating in the Soros Foundation’s decision to pull out of Russia. It’s a mark of the fragility of the nonprofit world that the slightest association between one of its members and a specific political cause—in this case, Goldfarb and the KGB’s agenda—can spoil the Soros Foundation. Organizations like Soros’s put so much effort into being non-controversial and apolitical that the slightest disturbance in the status quo can topple them. We’ve seen this before with Farmer and his connection with Aristide in Haiti.
Themes
Shortly after the Soros Foundation appoints the PIH its successor, Jim Kim tells Farmer that he’s unable to come to a meeting in Russia, as he has another meeting to attend at the Rockefeller Foundation in Bellagio. Farmer is furious, and he tells Kim that there’s “real work” to be done in Moscow. Kim, Farmer, and Ophelia argue, and Kidder is amazed—he can’t remember seeing Farmer lose his temper before. Later, Ophelia tells Kim that Farmer’s outburst is “nothing” compared to some of his others. But Kidder is unlikely to see any of these, she explains, because Farmer never gets angry when his anger could endanger the success of PIH.
Farmer’s definition of “real work” doesn’t cohere with Kim’s, or (probably) ours. But for Farmer, real work involves real interactions with real people, rather than interactions with politicians and bureaucrats deciding how to move money around. What Farmer sometimes fails to appreciate (or tolerate) is that “real work,” by his definition, is only possible with the money and help of bureaucrats from the Rockefeller Foundation and its peers. Farmer’s close relationship with Tom White was all about personal relationships, but in reality non-profit work is more often about playing a political game.
Themes
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A few weeks after his argument with Farmer, Jim Kim flies to Siberia, and Kidder goes with him. They travel into the town of Tomsk, which has had a severe MDR-TB problem for many years. There, Jim Kim attends a banquet in honor of PIH’s new role in Russian health. Farmer is supposed to fly into Russia to join the banquet, but his assistant is unable to obtain a visa for him in time, and he’s delayed several days. After the banquet, Kim and some of his colleagues (including the wardens of Russian prisons) go karaoke singing.
Despite Farmer’s outburst, here we see the good work that Kim is capable of doing at the political level—by making inroads with politicians and bureaucrats, he’s essentially eradicated TB in an entire community. As frivolous as karaoke night might seem, it’s because of frivolities like this that Kim is able to build good relationships with the rich and powerful—people who might seem shallow or immoral to Farmer, but who are necessary for the funding of Farmer’s work.
Themes
The next morning, Jim Kim leaves Russia and Farmer arrives. He spends his day examining MDR patients, and attends another banquet in the evening. The next day, he and Kidder fly to Paris. On the plane, Farmer tells Kidder that he’s been arguing with Tom White, from whom Farmer wants to raise 150,000 dollars for PIH. Farmer argues that it’s best to act fast and treat suffering Russian prisoners, while White points out that the cost of treatment will fall greatly in only a few months, and thus PIH would be better off waiting before it treats any patients. Farmer insists that it’s best to eliminate as much suffering as possible, as soon as possible.
This is a good illustration of the limitations of Farmer’s critique of cost-effectiveness. While it’s perfectly clear that at times, arguments for cost-effectiveness veil racism and bigotry (the implication is that some lives matter more than others), in this particular case, it doesn’t seem unreasonable to delay treatment for a few months if the end result will be a vastly more successful program, run by the same well-meaning people at PIH. Farmer’s rule of thumb here is noble and high-minded, but there are times when it interferes with the greatest number of people getting the best possible treatment—i.e., the intuitive measure of good healthcare.
Themes
Farmer travels more than ever, Kidder notes, and for a while Kidder communicates with him mostly by email. Farmer travels to Mexico, as well as Haiti, Boston, Paris, Peru, and Russia, giving diagnoses, delivering speeches, and treating the sick. Dr. Hiatt visits Farmer in Haiti, and notes that health conditions in Zanmi Lasante are every bit as high as they are at Brigham.
As frustrating as Farmer’s idealistic view of the value of life can be at times, it’s undeniably resulted in some stellar healthcare. Hiatt’s assessment of Zanmi Lasante is only the latest evidence of this.
Themes
Farmer now turns to the project of fighting AIDS around the world. There have been antiretroviral AIDS drugs since the late 90s, but there’s an intense debate about how best to use these drugs. Some say that prevention, rather than medical treatment, is the most effective (and cost-effective) strategy, while others argue that it’s immoral not to provide those suffering from AIDS with drugs that could save their lives. Farmer maintains that there is no real distinction between prevention and treatment—as with so much of the medical “consensus,” it reflects the first world’s disdain or ignorance of the third world.
The distinction between healthcare and treatment, as Farmer conveys it, is really a distinction between bad doctoring and good doctoring. A good doctor, like Farmer, doesn’t only examine his patients for their symptoms. Rather, he or she uses knowledge of a patient’s life and culture to makes a diagnosis designed to eliminate the causes of their suffering, not just its immediate manifestations.
Themes
Kidder notes that Farmer has already made the acquaintance of the influential economist Jeffrey Sachs, who founded the Global Fund, a prominent institution devoted to fighting AIDS. With the aid of PIH, the Global Fund develops a plan to spend 14 million dollars to fight AIDS in Haiti, via the Zanmi Lasante facilities. This project is extremely difficult, since at the time the U.S. was making it difficult for Haiti to accept aid of any kind. Nevertheless, the Global Fund succeeds in establishing large AIDS treatment centers at Farmer’s hospital—centers that are visited by tens of thousands of Haitians. By treating HIV and AIDS, the Global fund also indirectly treats tuberculosis and even typhoid. Farmer is overjoyed by the success of this plan in Haiti—when Kidder discusses the matter with him, Farmer is weeping.
Farmer’s notion of helping patients as soon as possible (rather than waiting for supposedly better treatment down the line) has a few interesting consequences. One consequence is that Farmer treats any success in treating patients—i.e., any improvements in their quality of life—as a victory. While a cynic would quickly become bogged down in the enormity of Haiti’s poverty and suffering, Farmer treasures every healed patient (inspired in part by his study of Catholicism and liberation theology). While Haiti is far from “healed,” Farmer is proud of the work he has done there, and is able to see the small victories alongside the enormity of total suffering.
Themes
