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Tracy KidderMountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World
Nonfiction | Biography | Adult | Published in 2003A modern alternative to SparkNotes and CliffsNotes, SuperSummary offers high-quality Study Guides with detailed chapter summaries and analysis of major themes, characters, and more.
Part 3Chapter Summaries & Analyses
Part 3: “Médicos Aventureros”
Chapters 13-14 Summary
A “great epi divide” exists between regions—even neighborhoods—where tuberculosis is nonexistent and those where poverty allows TB and AIDS to flourish (125). Five anti-TB drugs are available, but advanced nations stopped researching in that discipline years ago even as multi-drug resistant (MDR) strains develop among poor, often Black and female patients who could not complete their proper regimens.
Paul Farmer prefers keeping Partners in Health a small foundation, but Jim Yong Kim starts an independent project, Socios en Salud, in Lima’s Carabayllo district with Father Jack Farmer, a charismatic preacher and PIH advisor, to create a replicable healthcare model for slums worldwide. PIH deals with administration conflicts and antagonistic revolutionaries, but Farmer feels that tuberculosis won’t be a problem due to Peru’s WHO-endorsed TB control program. Father Jack, however, contracts TB and dies a month later. His sample shows resistance to five first-line drugs.
Farmer, Kim, and project director Jaime Bayona search for the origins of the MDR strain. They find witnesses and records detailing patients who did not get better from treatment due to contracting an MDR strain or a treatment disruption that enabled the bacteria to develop resistance.
Chapters 15-16 Summary
Kidder travels with Farmer to Carabayllo, finding a largely Andean migrant population in search of food and resources. Farmer uses his credentials as a Massachusetts TB commissioner to process samples from 10 MDR patients. Through tests and in-person diagnosis, he concludes that the strains’ cause is the treatment regimen itself. The WHO’s DOTS strategy provides free treatments and orders a repeat of the regimen if the patient doesn’t get better. This encourages the development of drug-resistant TB strains, and many patients must pay for expensive second-line antibiotics on their own. The secondary drugs have a cure rate of just 60%, a two-year treatment regimen, and difficult side effects.
Believing that they can’t ignore the issue, Farmer tailors Cange’s TB program to fit the needs in Carabayllo. The program faces challenges from PIH workers who want more pay and Peruvian authorities who do not want a scandal around their renowned, hard-won program. They insist that PIH follow “las normas” and only take patients after they complete two rounds of DOTS treatment, which is often too late.
To get around local resistance, Farmer speaks at an international TB conference and outlines the myths of MDR-TB, noting that the cost to treat the disease in developing countries is cheaper than if a strain becomes active in the United States. Beliefs that MDR strains are less contagious or that DOTS doesn’t need revisions are also “wishful thinking.”
Chapters 17-19 Summary
Farmer marries Didi Bertrand, the daughter of a Cange schoolmaster, in 1996, and they have their first child shortly after. The Carabayllo project’s costs go out of control as it costs up to $20,000 to treat one patient. Howard Hiatt, a confidant at the Brigham, learns that Farmer and Kim have “borrowed” $92,000 of drugs, with Tom White paying the costs afterward. Stretched over three countries, Farmer ignores his own health problems until he develops a severe case of hepatitis A, which Kidder considers irresponsible.
Kidder returns to Peru with Farmer as the program becomes successful and political hostility subsides. They see a child running through the hospital who overcomes MDR-TB thanks to an aggressive-but-unproven regimen from Farmer. He then examines a girl with resistance to all five first-line drugs. It’s clear that the father and doctors already know it’s an MDR strain and only need Farmer’s approval to skip the second DOTS regimen.
At a 1998 special meeting of tuberculosis experts in Boston, WHO TB program head Arata Kochi introduces a DOTS-plus program that would incorporate PIH’s protocols. Meanwhile, Alex Goldfarb, head of the Soros Foundation’s TB program in Russia, notes that 100,000 prisoners have active TB with limited resources to treat them. Goldfarb bristles against idealistic suggestions to ignore costs or do pilot projects, noting that the Russian public would not support a program that treats MDR-TB in 500 prisoners over a general one that treats 5,000 civilians.
Kim promotes PIH’s Peru operations as a replicable model that can rely on philanthropy instead of political aid. It defies cost-effectiveness analyses that claim MDR treatment isn’t possible in poor countries. In addition, WHO leaders do not know that many TB drug prices remain high despite expired patents. Farmer attempts to convince drug manufacturers to compete to lower prices, while Kim convinces the WHO to classify second-line treatments as essential drugs with a Green Light Committee to regulate use. Hiatt and Farmer also convince Eli Lilly to donate drugs to Haiti for publicity. Through these efforts, the MDR-TB treatment costs drop from $15,000 to $1,500. The results encourage Kim to focus on policy, court major donors like the Bill and Melinda Gates Foundation, and use PIH to promote TB treatment globally.
Part 3 Analysis
This part’s title translates to “adventurous medics,” which is the derisive term that Peruvian medical authorities give to Partners in Health’s cage-rattling endeavors. This section focuses on PIH’s global expansion as well as political and financial barriers in medicine.
One issue is whether PIH should expand at all, as Farmer envisions the organization as small and focused on Haiti, which certainly still needs help. This view contrasts with that of Jim Yong Kim, who wants a project to pursue his own interests. In contrast to Farmer, Kim prefers management and is more receptive to outside ideas. Despite Farmer’s misgivings, he still adds Peru to his packed itinerary as Peru’s challenges have implications for other developing nations. MDR-TB strains usually arise because of incomplete treatment—common in a country with medical strikes against President Alberto Fujimori’s austerity program and attacks by the communist Shining Path movement. However, the DOTS system, once endorsed by Farmer himself, is contributing to the problem by continuing an ineffective treatment for too long.
As a newcomer to international TB control, PIH faces a medical establishment with interests in maintaining the status quo. Peru’s authorities struggled to secure funding for the project, so they don't want a scandal to damage their world-renowned program. Kidder describes a situation In which an intern watches a patient die because she can’t provide alternative treatment until after DOTS treatment is complete, and Farmer must provide in-person approval to override this protocol. Farmer makes his case to international committees but has limited clout in this area and faces hostile audiences.
Then there is the cost of treatment. Farmer notes the hypocrisy that Peru pays billions of dollars per year in international loans but developed nations consider medical aid for it too expensive. PIH notes that funding MDR-TB treatments now would be much cheaper than during a global epidemic, when a drug that costs $8.80 in France can rise to $21 in Peru and $29.90 in the United States. Farmer pressures drug manufacturers to compete by presenting accurate-but-misleading statistics, with one representative seeing through them but promising support out of disgust that no one else would. Meanwhile, Kim works with the WHO to add second-line medications to the essential drugs list even though they are by nature not essential. This requires a council that can ensure that buyers follow treatments and do not exasperate problems.
The fight to prevent a global MDR-TB epidemic has parallels to the 2020 Covid-19 pandemic, which involved a novel, life-threatening respiratory disease with no treatment. Like the great epi divide that Kidder describes in Chapter 13, the Covid-19 positivity and death rates were higher in Black, Latino, and low-income neighborhoods in the United States, where most people work jobs that they cannot complete from home. At the beginning of the pandemic, African American deaths nationally were nearly two times greater than expected based on their share of the population. (Godoy, Maria. “What Do Coronavirus Racial Disparities Look Like State by State?” National Public Radio, 30 May 2020, www.npr.org/sections/health-shots/2020/05/30/865413079/what-do-coronavirus-racial-disparities-look-like-state-by-state.) As pharmaceutical companies developed and manufactured vaccines, developed nations hoarded available doses. While the United States was vaccinating one in four people by April 2021, Doctors Without Borders reported that developing countries were only vaccinating 1 in 500 people. (Kelly, Mary Louise. “Poor Nations Left Behind in Coronavirus Vaccine Rollout.” National Public Radio, 14 Apr. 2021, www.npr.org/2021/04/14/987371978/poor-nations-left-behind-in-coronavirus-vaccine-rollout.)
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