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A Conversation with Tracy Kidder About Mountains Beyond Mountains

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Tracy Kidder was tired and a bit slaphappy. We laughed often and digressed frequently, though in the interview that follows I've mostly cut what was superfluous. It so happens that Kidder had hung out with Paul Farmer two nights before and was still recovering. "That guy -- he did it to me again," Kidder intoned with mock irritation of the globetrotting doctor who only sleeps about two hours a night. Farmer is the subject of Kidder's 2003 bestseller Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure The World, the very book I wanted to talk about with him. More than any other of Kidder's distinguished titles, it revolves around issues of social justice and faith.

Based on Kidder's voluminous notes from having traveled with and researched his subject for three years, Mountains Beyond Mountains details Farmer's astonishing accomplishments, starting with his graduating near the top of his class from Harvard Medical School after having barely attended classes because he was already spending most of his time in Haiti trying to bring health care to the poorest of the poor. With a career that begins like that, the reader wonders what will become of him, and as the answers unfold they evoke incredulity, excitement, and often a resounding "Bravo!"

The good doctor goes on to form an organization, Partners In Health, which is determined to redress the inequitable distribution of health care throughout the world. He and his associates proceed to do just that in a myriad of creative and ingenious ways. Begun on a shoestring in 1987, the organization was receiving multi-million dollar grants by the time Kidder finished the book, and best of all, Farmer and his friends were still doing things their way. Their "whatever it takes" approach, influenced by liberation theology, affirms that each human life is precious and equally deserving of care.

Kidder confided to me that he thinks Mountains Beyond Mountains is his best book. Considering that he has produced one book since, and six previously -- for which he has received the Pulitzer Prize, the National Book Award, and the Robert F. Kennedy Award -- I found this self-assessment interesting. Perhaps an author cannot help but feel at a zenith when he has, as Kidder puts it in the interview, "stumbled onto something extraordinary:" A subject that challenges him to muster all his authorial skill to do it justice. In Kidder's case, that involved bringing Farmer's own pursuit of justice for the poor to life on the page. The result is an absorbing multi-layered narrative in which Farmer emerges as a kind of postmodern Albert Schweitzer whose humanitarian ambitions are as limitless as the starry Haitian sky under which he works.

Mark Klempner: What made you want to devote a book to Dr. Paul Farmer and his organization, Partners In Health?

Tracy Kidder: I had met him in 1994 and found him intriguing, but I think the decisive moment was when I saw his health center in Haiti for the first time in 2000.You travel from the airport along this horrible road where you mostly notice the absence of things: Electricity, arable land, even trees. And after three hours of witnessing unremitting misery all around you --people without food, without shoes-- you come to this verdant citadel that provides high-quality medical services to everyone for miles around, regardless of their ability to pay. I remember feeling that if it was possible for this to be here, then anything was possible.

MK: In your previous books, you portrayed people who were close to home, such as the teacher in Among Schoolchildren who was based not far from where you live in Western Massachusetts. But Farmer is mostly based in Haiti, and while you were researching the book, he was rapidly expanding the work to other far-flung places.

TK: As a way of getting to know him, he invited me to come along with him for "a light month of travel." And as he was sketching out to me where we were going to go, I inwardly gulped. It did turn out to be a lot of travel, with many flights starting before dawn and ending after dark, but I felt it was a privilege to be around him. A priest friend of mine who once said to me, "When you cross the path of a certain kind of person, you ought to really pay attention." Farmer was one of those persons. But even at the time, I didn't fully realize the significance of what I was seeing. For instance, he and his staff were developing protocols to treat multi-drug resistant tuberculosis that ended up being adopted all over the world.

MK: One of my favorite sentences in the book is when you have tagged along with him to an important panel on international health, and you write: "It's easy to drift away on the voices, imagining colors in the accents -- pinks and purples from the Caribbean and the Indian subcontinent, black and white from Japan -- and forget that what is really going on is the writing of prescriptions that may affect the lives of billions."

TK: Yes, the scope of this book was much bigger than any I'd taken on before, and somehow felt more important.

MK: There is also a lot of religion and spirituality in Mountains Beyond Mountains, though it is presented in an understated way.

TK: That parallels Farmer, who is also understated when it comes to religion. Yet his personal history vis-à-vis religion struck me as really important. It took me a while to realize that, and to begin to try to get at it. It is very important to him, but initially I think it was very important because it was so important to his patients. But then something took hold.

I don't go to church very often, but I came away from this project with a real respect for religious beliefs. The most important conversation I had with him along these lines was the one that comes at the end of the book when he talks about "the long defeat," a phrase he probably picked up from reading Camus. But his rendering of its meaning struck me as fundamentally religious. You do things as confidently as possible, you try to win your victories, but you're making common cause with the losers: The poor, the destitute, the vulnerable. So inevitably some of your efforts are going to fail, or maybe most of them, or maybe all of them. But you don't quit because of that; you don't change sides because of that. So it points back to why you do what you do in the first place, and the answer has got to have something to do with faith and justice.

I think we're living in the most meretricious age ever --I mean ever. And Mountains Beyond Mountains is about a man whose values differ radically from those that currently prevail. That might be one reason why tons of colleges have inflicted this book on their incoming freshmen. (laughter)

MK: I can see how students would find Farmer's gutsy idealism exciting. The appeal of Mountains Beyond Mountains is such that secular readers can get into it, impressed by his medical and humanitarian accomplishments; religious progressives like me get knocked out by it; and even religious conservatives can engage with it, saying, "He's healing the sick, feeding the hungry, sheltering the homeless, and visiting the prisoners."

TK: Right --if only he didn't say fuck so often. (laughter)

MK: The profanity makes you feel you're dealing with a real person, not some goody-goody. It seems to me that the people who have done the most good in the world have not been goody-goody at all, but rather very passionate about what they're doing to the point of being confrontational with defenders of the status quo.

TK: Farmer certainly fits that description, and one of his great gifts is to have a constitutional aversion to conventional wisdom of any sort. And despite the privations and punishing schedule, in some ways he has a truly enviable life: He doesn't have to live with ambivalence -- and that's really important. To wake up in the morning and know what you're doing and why you're doing it, and not to feel the least bit of ambivalence about it.

MK: To put it in more popular terms, we could say that he knows his purpose, and that his purpose is morally irreproachable. In the book, it's pretty clear that he gets the most satisfaction from doctoring, even if -- and perhaps especially if -- he has to hike a long ways to get to a patient, or even to chase a patient into a field to get him to take his medicine.

TK: Yes, Farmer gets enormous pleasure from being a doctor, and a lot of that is the altruistic impulse, which some people don't think exists. But they're wrong.

I once had a conversation with a psychiatrist friend of mine who stated flatly that altruism doesn't exist. So I said, "All right. What if I agreed with you? You would still have to acknowledge that there is a difference between that kind of selfishness that leads to slaughtering six million Jews and the kind of selfishness that leads a doctor to save millions of lives." She couldn't argue that.

But I do believe altruism exists, and you can see it in him. Maybe in the long run in some psychological way it's self-serving, but I don't really care. It was very beautiful to see -- it really was. Everyone who watches him with his patients always finds it moving.

He also loves animals, and he loves to grow things, and he's enormously knowledgeable about reptiles and lizards. So what's that about? This is a person who is really in love with the world and who, in proportion, is offended by the horrible flaws in it.

MK: What about the millions of materially affluent Americans who don't really have any purpose in life, who can't imagine that the work they are doing makes any kind of meaningful contribution, who have to live every day with, as you put it, ambivalence? Would Farmer recognize that this too comprises a variety of poverty, albeit spiritual poverty?

TK: I think Farmer is aware of the soullessness of our culture, and, in fact, he's given a way out for a fairly large and growing number of people: He does all the work, all we have to do is make a donation. Then we can all feel better. (laughter)

MK: What impact has the book had on him and his organization?

TK: He was already on his way to being awfully well known in three disciplines -- infectious disease, medical anthropology, and epidemiology -- so it's not as though I put Paul Farmer on the map. But I've heard it's had a pretty big impact on his organization. Apparently a number of the recent major donors first heard about Farmer from my book. And I'm delighted about that.

MK: After reading the big picture of what he's trying to do, I came away from the book wanting Farmer to win, I was cheering for him, and I can see how by writing a check I'd be connecting myself with someone who is doing something really vital. As a religious person, I would have to say that what he's doing is holy work.

TK: And he's living a life that is pretty free of hypocrisy. Religions command us to do these things, but we don't. And he does. He showed me more reasons for despair than I had ever seen before, or had ever imagined. And yet, being around him, and the whole crew, was exhilarating. Because I got to see with my own eyes what this small group of people were able to do.

MK: His willingness to devote all his resources and abilities to helping the poor and the sick --usually the same thing, when you look at the world picture-- has prompted some people to call him a saint.

TK: The problem with describing a contemporary as a saint is that it can be a way of dismissing a person. If you're set apart by God, you really aren't like us, and so we can just stand apart and admire you. And any thought that we can do the same thing goes out the window.

The truth is that what he's doing was really hard to do at the beginning when he had almost no support and the whole body of conventional wisdom among the international health community was against him. But it's somewhat different now, and people like Farmer, and the others -- Ophelia Dahl, Jim Kim, Tom White -- have made it a little easier.

For instance, treating multi-drug resistant tuberculosis in poor countries was almost impossible when they started, but now that Partners In Health has driven the prices of the drugs down by more than 90 percent and they've developed protocols for how to treat it . . . I don't know how many countries it is now, maybe thirty or forty countries, who have adopted those prescriptions. The staff of Partners In Health not only told people how to do it, and proved that it could be done, but they also made it possible for much larger numbers of hospitals to try to do it. So things have opened up now somewhat, and the notion that he's some kind of saint whose efforts cannot be replicated -- because he puts too much love and personal attention into what he is doing -- has proven to be false.

MK: The classic archetype of the hero is someone who faces great adversity and overcomes it, and Farmer certainly fits the bill there. But in tales of saints, the protagonist usually overcomes great temptation and it strikes me that Farmer, as portrayed in your book, doesn't seem to know temptation. For example, when he won the MacArthur "Genius" grant and was awarded $220,000, he just signed the check over to the accountant at Partners In Health to start a new research arm of the organization, and it didn't seem to occur to him to spend any of it on himself.

TK: Only early on, when he first left the jury-rigged houseboat in the bayou on which he and his family had been living and started attending Duke University did he seem tempted by the idea of wealth and status for a short time. He isn't very interested in things that interest most people. He doesn't care about not having a car. He likes comfort and a good meal when they occasionally come his way, but he doesn't need or crave them. He doesn't see money as an end in itself, but just as a means to get things done.

I sometimes wondered if the adoration of the Haitians tempted him to some sort of pride or grandiosity, such as when those he was treating would call him a god. But he's too good an anthropologist to not understand that they've been systematically deprived of modern medicine, and when you come along and give them pills that make them well, that's the way they're going to react.

So you're right: he doesn't seem to have faced any major temptations. But if I were to write his life as a novel, I would slip some vivid temptation scenes in there. (laughter)

MK: What is Farmer up to these days?

TK: It so happens he was just in town and I heard him speak to a bunch of high school students. It was a brilliant speech, one that left them feeling that they could play a powerful role in repairing the world. He also really got them laughing.

MK: I thought some of the things he says in the book are hilarious -- like the acronyms he's constantly coming up with, such as TBMIs, "transnational bureaucrats managing inequality" to identify the stodgy people who control international health. And then referring to their clever arguments about why things have to stay the same as "well formed stool."

TK: Yes, he can be very funny, and he's always at his funniest when he's talking about really serious things.

MK: What has happened with Partners In Health since the book came out?

TK: It's amazing: They now have nine sites in Haiti, including four hospitals complete with operating rooms, and they've got AIDS under control in the entire central plateau of Haiti. I mean Haiti is still in desperate shape, but this is something good that's happened there, and they're continuing to expand. They now have about three thousand staff members of Partners In Health in Haiti, almost all Haitian, and a total of about five thousand worldwide.

And they've begun work in Rwanda, and are now deeply involved in an effort to improve the health care in that entire country. Meanwhile, they're working in Lesotho in Southern Africa -- which has one of the worst AIDS epidemics in the world with about one quarter of the adult population infected -- and in Malawi, and they're still working in Peru and Russia, and they have an AIDS project in Boston based on the Haitian model. So they're really all over the place, and it's kind of wonderful. You always fear that when an organization has this kind of success that it will lose its soul, but I can't see any evidence of that. It's pretty neat.

When I was writing the book, I thought it was not my place to proselytize for Partners In Health, but now that it's out there, I feel, "Why not?" I look back and see that I stumbled onto something extraordinary and I'm absolutely convinced that this is a really important organization, and one that has nothing to hide.

MK: Do you feel you were able to get to the truth of what makes Farmer tick, and how his organization has been able to gain so much traction for their idealistic principles?

TK: The little t truth. The big T truth doesn't belong to us.

Mark Klempner is a historian, social commentator, and author of The Heart Has Reasons: Holocaust Rescuers and Their Stories of Courage. He can be contacted through his website www.hearthasreasons.com. This interview originally appeared in The Social Edge.