Mountains Beyond Mountains
Treating the Ills of Poverty
by Tracy Kidder
Amnesty Now, Amnesty International,
[In the dirt-poor, politically roiling
Haiti, Dr. Paul Farmer treats the rural poor and confounds the
public health establishment. His prescription includes expensive
medicine, new schools, communal water systems, and long-trek house
From the moment I saw the Zanmi Lasante
Hospital, out there in the little village of Cange, in what seemed
to me like the end of the earth, in what was in fact one of the
poorest parts of the poorest country in the Western Hemisphere,
I felt I'd encountered a miracle.
In Haiti, I knew, per capita incomes came
to a little more than one American dollar a day, less than that
in the central plateau. The country had lost most of its forests
and a great deal of its soil. It had the worst health statistics
in the Western world. And here, in one of the most impoverished,
diseased, eroded, and famished regions of Haiti, there was this
lovely walled citadel, Zanmi Lasante. I wouldn't have thought
it much less improbable if I'd been told it had been brought by
spaceship. In fact it had been "brought" by Paul Farmer,
a Harvard-trained American doctor who
My first week in Cange I met a peasant
farmer who had brought a sick child to the hospital-by donkey,
on a trek of 12 miles along Highway 3. I asked him if he'd felt
relieved when he got to Cange and the medical complex. I needn't
have bothered. He looked surprised at the question and simply
said, "Wi. " There were a handful of other clinics and
hospitals in the region, but none were well-equipped and some
were downright unsanitary, and everywhere patients had to pay
for medicines, and even the gloves that would be used to examine
them, and very few people in the central plateau could pay much
of anything. At Zanmi Lasante, too, patients were supposed to
pay user fees, the equivalent of about 80 American cents for a
visit. Haitian colleagues of Farmer's had insisted on this. Farmer
was the medical director, but he hadn't argued. Instead-this was
often his way, I would learn- he had simply subverted the policy.
Every patient had to pay the 80 cents, except for women and children,
the destitute, and anyone who was seriously ill. Everyone had
to pay, that is, except for almost everyone. And no one-Farmer's
rule-could be turned away.
Perhaps a million peasant farmers relied
on Zanmi Lasante. At the moment, about 100,000 lived in its catchment
area, the area served by its community health workers, 7o in all.
Some patients came great distances, as distance is measured in
a country of ruined roads and villages served only by footpaths-from
Port-au-Prince and Haiti's southern peninsula, and from towns
along the border with the Dominican Republic, speaking Spanish.
Most came from the central plateau, on the battered, overloaded
passenger trucks that navigated Highway 3. Many came on foot and
by donkey. Now and then out on the road, a bed moved slowly toward
the front gate, a bearer at each corner, a patient on the mattress.
Sometimes Zanmi Lasante's pharmacy muddled
a prescription or ran out of a drug. Now and then the lab technicians
lost a specimen. Seven doctors worked at the complex, not all
of them fully competent-the staff was entirely Haitian, and Haitian
medical training is mediocre at best. But Zanmi Lasante had built
schools and houses and communal sanitation and water systems throughout
its catchment area. It had vaccinated all the children, and had
greatly reduced both local malnutrition and infant mortality.
It had launched programs for women's literacy and for the prevention
of AIDS, and in its catchment area had reduced the rate of HIV
transmission from mothers to babies to 4 percent-about half the
current rate in the United States. A few years back, when Haiti
had suffered an outbreak of typhoid resistant to the drugs usually
used to treat it, Zanmi Lasante had imported an effective but
expensive antibiotic, cleaned up the local water supplies, and
stopped the outbreak throughout the central plateau. In Haiti,
tuberculosis still killed more adults than any other disease,
but no one in Zanmi Lasante's catchment area had died from it
A crowd of perhaps 30 or 40 waits in the
hall, some sitting on benches, some milling around.
A man whom Farmer refers to as Lazarus,
who arrived some months ago on a bed frame carried by relatives,
wasted by AIDS and TB to about go pounds, now weighing in at about
150, cured of TB and his AIDS arrested thanks to medications.
A healthy-looking young woman whose father,
only a month ago, was saving up for her coffin.
A lovely-looking young woman being treated
for drug-resistant TB, now in the midst of a sickle-cell crisis
and moaning in pain. "Okay, doudou. Okay, cherie," Farmer
coos. He orders morphine.
A man with gastritis in late middle age.
In Haiti, Farmer told me, that could mean 30 years old, since
25 percent of Haitians die before they reach 40. "It's because
there's a near famine here," Farmer says while examining
A 16-year-old boy too weak to walk, who
weighs only 6 0 pounds. Farmer diagnoses an ulcer. "His body's
gotten used to starvation. We're gonna buff him up. " Farmer
hefts a can of the dietary supplement Ensure. "This is good
stuff So we'll give him a couple hundred dollars of Ensure, and
I'll take great pleasure in violating the principle of cost-efficacy."
Through the louvered windows high on the
wall behind his desk, I see stars shivering in the warm night.
A sad-faced young man takes his seat beside Farmer and stares
down at his own feet, shod in ragged running shoes, splitting
at the heels. His name is Ti Of a. He has AIDS.
No one else, not at this time, is treating
impoverished Haitians with the new antiretroviral drugs. Indeed,
before Farmer, almost no one in any poor country is treating poor
people who have the disease. Even some of Farmer's friends in
the Haitian medical establishment have told him he's crazy to
take on AIDS this way in Cange, and certainly many experts in
international health would agree. Leaving aside all other objections,
the new AIDS drugs could cost Zanmi Lasante about $5,000 a year
per patient. Nonetheless, Farmer had started some patients on
Even more controversial was Farmer's commitment
to treat not only the diseases that racked his patients' bodies,
but also those that devastated their communities: the socioeconomic
ills or "structural violence" as he called it. One health
worker at Cange recited a Haitian saying: "Giving people
medicine for TB and not giving them food is like washing your
hands and drying them in the dirt."
Thus, all TB patients in the catchment
area received the full package of services. Each continued to
get what is called directly observed therapy, a community health
worker on hand to be sure the patient took the medicines on schedule,
and each got the monthly cash stipend- the equivalent of about
five American dollars- to pay for extra food, child care, and
transportation to a monthly doctor's appointment at Zanmi Lasante.
The program had worked well, indeed, couldn't have worked better.
They hadn't lost a single patient to TB in 12 years.
Just recently, a TB patient from a village
called Morne Michel hadn't shown up for his monthly doctor's appointment.
So-this was one of the rules-someone had to go and find him. The
annals of international health contain many stories of adequately
financed projects that failed because "noncompliant"
patients didn't take all their medicines. Farmer said, "The
only noncompliant people are physicians. If the patient doesn't
get better, it's your own fault. Fix it." A favorite Dokte
Paul story in the village of Kay Epin was of the time, many years
back, when Farmer had chased a man into a field of cane, calling
to him plaintively to come out and let him treat him. He still
went after patients occasionally. To inspire the staff, he said,
and to give him a break from his office. So he was going to Morne
Michel himself, and was taking me with him.
Beyond mountains there are mountains."
The proverb appeared to describe the location of Morne Michel,
the most distant of all the settlements in Zanmi Lasante's catchment
Farmer drove the first leg in the pickup
truck, south down National Highway 3, past two-roomed huts with
metal roofs and little granaries on stilts-built, he explained,
to keep food safe from animals, but rats still ate about a third
of harvests-and stunted-looking pigs and goats and scrawny yellow
dogs. Smiling for a moment, he said that Haitian peasants had
a lot of sayings: that they're the only farmers with land so steep
they break their legs in their cornfields, that their dogs are
so skinny they have to lean against trees in order to bark. Soon
a reservoir came into view, a mountain lake far below the road.
The scene looked beautiful, blue waters set among steep, arid
mountainsides. And, if you saw with peasant eyes, Farmer said,
the scene looked violent and ugly, a lake that had buried the
good farmland and ravaged the highlands. He parked beside the
ruin of a small cement factory. Plants were growing helter-skelter
high up on the rusted structure. A hundred yards away stood a
concrete buttress dam.
These days, when he wasn't in Haiti, he
gave a lot of speeches, sometimes several in one day, and in every
one I heard, he talked about the dam. It appeared in all the books
he had published by 2000 and in the books that he had helped to
write and edit, and also in many of his journal articles-42 of
those by then. As a scholar and writer, Farmer had taken his greatest
pains to assert the interconnectedness of the rich and poor parts
of the world, and the dam was his favorite case study.
It stops up Haiti's largest river, the
Artibonite. It's called the Peligre Dam, and the impounded waters
behind it, the Lac de Peligre. The U.S. Army Corps of Engineers
had planned it. Brown & Root of Texas, among others, built
the structure in the mid-1950s during the reign of one of Haiti's
American-supported dictators, with money from the U.S. Export-Import
Bank. It was advertised as "a development project,"
and no doubt some of the people behind its creation believed it
a gift to Haiti. But no one seems to have given much thought to
the peasant farmers who lived in the valley upstream.
The project was intended to improve irrigation
and to generate power. It wasn't as though the peasants of the
central plateau didn't need and want modern technology, Farmer
said. But, as they themselves often remarked, they didn't even
get electricity or water for their land. Most didn't get money
either. In fact, the dam was meant to benefit agribusinesses downstream,
mostly American-owned back then, and also to supply electricity
to Port-au-Prince, especially to the homes of the numerically
tiny, wealthy Haitian elite and to foreign-owned assembly plants.
Since the flooding of the valley, many
peasant girls and boys from Cange, children of what Farmer called
`'the water refugees," had left home looking for work in
the capital, where they cooked and cleaned and stitched Mickey
Mouse dolls and baseballs, more than a few of them nowadays returning
home with AIDS.
When Farmer first saw this piece of Haiti
and began to ferret out its history, old-timers talked longingly
to him about the days before the water rose, when families lived
on farms beside the river and everyone had enough to eat and something
left over to sell. Some remembered being warned that their land
was going to be submerged. But the river had always flowed by,
and they'd examined the dam in progress, and they couldn't believe
that a mere wall of concrete could hold back their river. One
of the old people of Cange remembered seeing the water rising
and suddenly realizing that his house and goats would be underwater
in a matter of hours. " So I picked up a child and a goat
and started up the hillside."
Families had hurried away, carrying whatever
they could save of their former lives, turning back now and then
to watch the water drown their gardens and rise up the trunks
of their mango trees. For most, there was nothing to do but settle
in the steep surrounding hills, where farming meant erosion and
widespread malnutrition, tending nearer every year toward famine.
And for years there were wailings and curses and loud arguments
among old neighbors, fighting over titles to the land that was
Things got worse. Even after the dam,
most peasants still had their black, low-slung Creole pigs, which
they kept like bank accounts, to pay for things such as school
tuition. But in the earIy 1980S, they lost those as well. Alarmed
about an outbreak of African swine fever in the Dominican Republic,
afraid that it might threaten the American pork industry, the
United States led an effort to destroy all the Creole pigs in
Haiti. The plan was to replace them with pigs purchased from lowa
farmers. But these were much more delicate, much more expensive
to house and feed, and they didn't thrive. Many peasants ended
up with no pigs at all. When school started the year after the
slaughter, enrollments had declined dramatically, throughout the
country and around Cange.
We walked across the top of the dam. The
railings were rusted, the concrete flaking. To our right the roiled
waters of the Artibonite rushed away, and to our left a few small
canoe-like vessels plied blue, placid waters. It looked almost
like a tropical resort. Farmer walked briskly along. A small juvenile
escort followed him for a time. Local people heading the other
way smiled when they saw him and said, "Bonjou, Doc mwen."
(Good morning, my Doc.) There were clouds then sun then clouds
again, and a gentle breeze. I felt vigorous and cheered by borrowed
On the other side of the dam, a footpath-
loose dirt and stones-went straight up. Farmer had a slipped disk
from 18 years of traveling Highway 3. His left leg had been surgically
repaired after he'd been hit by a car back in 1988, and it turned
out at a slight angle-like a kickstand, one of his brothers said.
He had congenital high blood pressure and mild asthma, which developed
after he'd recovered from a possible case of tuberculosis. But
when I got to the top of that first hill, sweating and panting,
he was sitting on a rock, writing a letter to an old friend, a
contributor to Partners In Health whose spouse had recently died.
It was the first of many hills.
We passed smiling children climbing steep
rocky paths that I had to clamber up on all fours. They were carrying
water, in pails and plastic jugs that once held things like paint,
oil, and antifreeze. The full containers must have weighed half
as much as the children did. We passed many patches of millet,
the national staple, which seemed to grow out of rocks, not soil,
and small stands of banana trees and, now and then, other tropical
species, Farmer pausing to apply the Latin and familiar names-papaw,
soursop, mango-a gloomy litany because there were so many fewer
of each variety than there should have been.
Many aid experts from prosperous places
gladly expressed hopelessness on the Haitians' behalf, Farmer
would say. By this point on our hike, I too was guilty. The houses
we passed in the mountains were much worse than most of the ones
They had dirt floors and roofs made of
banana fronds, which, Farmer pointed out, leaked in the rainy
season, turning the floors to mud. We passed a group of women
washing clothes in the rivulet of a gully. "lt's Saturday,"
said Farmer. "Washing day. I guess the Maytag repairman didn't
come." Haitians, he said, are a fastidious people. "I
know. I've been in all their nooks and crannies. But they blow
their noses into dresses because they don't have tissues, wipe
their asses with leaves, and have to apologize to their children
for not having enough to eat."
"Misery," I said. But this would
not suffice. He was on a roll.
"And don't think they don't know
it," he said, and referring to white liberals added, "There's
a WL line-'They're poor but they're happy' line. They do have
nice smiles and good senses of humor, but that's entirely different."
Like many of his remarks, this one gave me pause.
Just when you thought you had the hang
of his worldview, he'd surprise you. He had problems with groups
that on the surface would have seemed like allies, that often
were allies in fact, with, for example WL's, some of whose most
influential spokespeople were black and prosperous. "l love
WL's, love'em to death. They're on our side," he had told
me some days ago, defining the term. "But WL's think all
the world's problems can be fixed without any cost to themselves.
We don't believe that. There's a lot to be said for sacrifice,
remorse, even pity. It's what separates us from roaches."
We went on, deeper and deeper into the
mountains, Farmer leading the way. We chatted front to back. I
was drenched in sweat. I couldn't see even signs of perspiration
on his neck-his pencil neck as friends of his called it. Many
people waved to him-the lifted hand motionless, the fingers fluctuant,
like the legs of insects on their backs.
"Do you see how Haitians wave? Don't
you love it? You dig?" he said to me, waving back with his
fingers. The trail wound across barren, steeply folded mountainsides.
I had thought that I was fairly fit, but at the top of every hill,
Farmer would be waiting for me, smiling and making excuses for
me when I apologized-I was 14 years older; I wasn't used to the
The one-way trip to Morne Michel usually
took him two hours. About three hours after we'd set out, we arrived
at the hut of the noncompliant patient, another shack made of
rough-sawn palm wood with a roof of banana fronds and a cooking
fire of the kind Haitians call "three rocks."
Farmer asked the patient, a young man,
if he disliked his TB medicines. "Are you kidding?"
he replied. "I wouldn't be here without them." It turned
out that he'd been given confusing instructions the last time
he was in Cange, and he hadn't received the standard cash stipend.
He hadn't missed any doses of his TB drugs, however. Good news
for Farmer. Mission accomplished. He'd made sure that the patient's
cure wasn't being interrupted.
We started back. I slipped and slid down
the paths behind Farmer. " Some people would argue this wasn't
worth a five-hour walk," he said over his shoulder. "But
you can never invest too much in making sure this stuff works."
"Sure," I said. "But some
would ask, 'How can you expect others to replicate what you're
doing? 'What would be your answer to that?"
He turned back and, smiling sweetly, said,
"F* *k you." Then, in a stentorian voice, he corrected
himself: "No. I would say, 'The objective
is to inculcate in the doctors and nurses
the spirit to dedicate themselves to the patients, and especially
to having an outcome-oriented view of TB.'" He was grinning,
his face alight. He looked very young just then. "In other
words, 'F* *k you."'
We started on again, Farmer saying over
his shoulder, "And if it takes five-hour treks or giving
patients milk or nail clippers or raisins, radios, watches, then
do it. We can spend $68,000 per TB patient in New York City, but
if you start giving watches or radios to patients here, suddenly
the international health community jumps on you for creating nonsustainable
projects. If a patient says, I really need a Bible or nail clippers,
well, for God's sake!"
The rest of the way back was mostly a
descent, but there were still some slopes to climb. I straggled
up out of another ravine and as usual found Farmer waiting for
me. He stood at the edge of a cliff, gazing out. I walked over
to him. The view from where he stood was immense.
Scrims of rain and clouds and swaths of
sunlight swept across the yellow mountains in front of us and
the yellow mountains beyond those mountains and over the Lac de
Peligre. The scene, I realized, would have looked picturesque
to me before today. So maybe I'd learned something. Not enough
to suit Farmer, I suspected. Education wasn't what he wanted to
perform on the world, me included. He was after transformation.
I offered him a slightly moist candy,
a Life Saver from my pocket. He took it, said, "Pineapple,
which, as you know, is my favorite," and then went back to
He was staring at the impounded waters
of the Artibonite. They stretched off to the east and west and
out of sight among the mountains.
From here the amount of land the dam had
drowned seemed vast. Still gazing, Farmer said, "To understand
Russia, to understand Cuba, the Dominican Republic, Boston, identity
politics, Sri Lanka, and Life Savers, you have to be on top of
The list was clearly jocular. So was his
tone of voice. But I had the feeling he had said something important.
I thought I got it, generally. This view of drowned farmland,
the result of a dam that had made his patients some of the poorest
of the poor, was a lens on the world. His lens. Look through it
and you'd begin to see all the world's impoverished in their billions
and the many linked causes of their misery. In any case, he seemed
to think I knew exactly what he meant, and I realized, with some
irritation, that I didn't dare say anything just then, for fear
of disappointing him.
For more on Partners in Health: www.pih.org
Tracy Kidder is author of The Soul of
a New Machine, House, Among Schoolchildren, Old Friends, Home
Town, and most recently, Mountains Beyond Mountains, Healing the
World: The Quest of Dr. Paul Farmer, 2003, from which this article
is adapted. He won the Pulitzer Prize and National Book Award,
among other literary prizes. was challenging standard preconceptions
of public health for the world's poor.