Mountains Beyond Mountains: Chapter 26 Summary & Analysis

In the last chapter of the book, Kidder returns to the obvious benefits and successes of Zanmi Lasante. While it hasn’t yet succeeded in wiping out poverty in Haiti, it’s certainly saved many lives. One good measure of the value of Zanmi Lasante in Haiti is the fact that many former patients come back to the hospital to work. Farmer has saved many of their lives, and they want to repay him and further the good he’s done for their community. (It’s also true that working at Zanmi Lasante provides a steady job.)

The book begins and ends with a long journey across Haiti (it was on such a journey that Kidder learned the Haitian proverb that gives the book its title). These walks convey the extent of Farmer’s devotion to his patients: although any other doctor wouldn’t bother to show respect by walking to Alcante’s house (surely treating his illness is respect enough), Farmer does so in order to learn about his patients, to become a better doctor, and simply because it seems like the right thing to do for this patient in this moment.

Farmer’s fame and prestige in Haiti are beyond all doubt in this scene. He’s helped many thousands of families and is a revered figure, but still doesn’t seem to have let this fame go to his head.

Kidder finally formulates the question that he’s been trying to ask ever since meeting Farmer: how does a doctor with limited time and resources decide how best to practice medicine? Because it’s impossible to take care of everyone, doctors—Farmer included—must choose which patients to consult with. This is, to say the least, a difficult decision, and Kidder has been struggling to understand it for some time now. From what we’ve seen, Farmer’s strategy is to focus on those whose need is greatest: in the sense that they’re seriously ill, that their case is urgent and presented to Farmer at a particular moment, and that they live in a poverty-stricken country.

Farmer doesn’t exactly answer Kidder’s question. Instead, he dismisses it as a “red herring”—a distraction from the truth. The point is that questions about triage or “finite resources” always carry the implication that there’s too little time and money. In reality, Farmer suggests, there’s more than enough time and money to care for the poor—it’s just that most people waste a disproportionate amount of money and time, and never devote their resources to helping others. Even the hypothetical well-paid doctor that Farmer discusses is part of the problem by this measure. Farmer has no clear solutions for this problem, but essentially he’s saying that we think about economic value in an entirely skewed way—someone might pay thousands (or millions) of dollars for a car, a gemstone, or unnecessary plastic surgery, but still consider it a waste to spend far less money to save a child’s life.

A good doctor, Farmer claims, must also be a good leader—almost like a parent. In other words, Farmer isn’t simply negotiating a “contract” with his patients: he’s helping them whether they understand the treatment or not. The very notion of making charity work conditional, Farmer adds, is often a way for people in the First World to rationalize their own indifference to the suffering of others. The implication of this mindset is that Third World people don’t appreciate or desire good healthcare, and therefore don’t deserve it.

As the book approaches an ending, Kidder has a major insight about healthcare ethics. Arguments for cost-effectiveness and limited resources have practical grounds, but it’s also almost impossible to make these arguments without betraying some bias, whether it’s the bias of the First-World citizen or that of the ignorant cynic. Because there is no way to “stand outside the system,” Farmer maintains, the best course of action is to focus on the here and now (as liberation theology teaches), and try one’s best to help all sick and suffering people, one at a time, to the best of one’s ability.

In the final section of the book, Kidder clarifies Farmer’s position on the ethics of medicine with an elegant example. It’s impossible to weigh the cost-effectiveness of healthcare without betraying some cultural or racial bias. Understood in this way, part of Farmer’s goal in curing the people of the Third World is to eliminate some of the social and economic inequalities that separate them from the First World. In other words, Farmer isn’t just curing Haitians—he’s showing the rest of the world that Haitians’ aren’t somehow inferior or destined to always live in poverty. This is reflected in the Haitians’ tradition of Voodoo. Although Voodoo may seem like an alien tradition to many Westerners, it’s rooted in the same values that all human beings cherish and celebrate: the importance of life, health, and happiness.