The Doctor and his Boswell: Farmer, left, and biographer Kidder. Chris Hildreth.
The Doctor and his Boswell: Farmer, left, and biographer Kidder. Chris Hildreth.

Islands of Decency

Dialogue on Healing
March 31, 2005

During fall semester, Duke Magazine and the Office of Student Affairs sponsored the fourth Duke Magazine Campus Forum, featuring a public conversation with Paul Farmer and Tracy Kidder. Farmer '82 is a physician, infectious-disease specialist, and the subject of Kidder's book Mountains Beyond Mountains, which was the summer reading assignment for the Class of 2008.

Farmer has won Duke's Humanitarian Award, a MacArthur Foundation "genius award," and the Heinz Foundation Award. The nonprofit organization he co-founded, Partners In Health, which operates in Haiti, Peru, Russia, Cuba, and Mexico, has changed international health practices, proving the efficacy of delivering modern medicine in resource-poor settings and advocating for access to decent health care as a basic right of the world's poorest and most marginalized people.

Kidder has won the Pulitzer Prize, the National Book Award, and the Robert F. Kennedy Award. Besides Mountains Beyond Mountains, he is the author of The Soul of a New Machine, House, Among Schoolchildren, Old Friends, and Home Town.

The following is an edited version of their conversation, which took place in a packed Page Auditorium on September 29, 2004. The event was the culmination of a four-day campus visit, during which Farmer met with first-year medical students and took part in discussions on global health with campus leaders, including Duke Medical Center's new chancellor, Victor Dzau. Kidder sat in on a journalism class and gave a reading in the Rare Book Room in Perkins Library.

On Partners In Health

kidder: In the time I spent on the road with Paul, I was introduced to more reasons for despair than I'd ever imagined. The problems in places like Haiti and urban slums of Latin America and prisons in Siberia are truly horrifying. But, traveling with him was not just the most exhausting experience of my life, it was also the most exhilarating and the most hopeful.

I had become accustomed to skipping over stories about the AIDS pandemic, for instance, in the newspaper. It seemed too big, too complicated, too expensive a problem ever to be solved. And here was this guy and this group of people, Partners In Health, saying, "No, it's not too big. It's not too expensive. It's not too complicated. And here's the proof." A skeptical person like me looks into the statistics. And this was a group that hadn't lost a single patient to an uncomplicated case of tuberculosis in--I think it was twelve years at that time.

The other side of that, of course, is that the message was daunting. Because if, in fact, we have all the tools and the money to take on AIDS and TB throughout the world--at the moment [Partners In Health] is treating AIDS patients in Haiti, one of the most difficult settings you can imagine, for, I believe, around $20 a year per AIDS patient--then it can be done everywhere. And so, we're left with a choice--a choice about the kind of world we want to live in, it seems to me. And I, frankly, don't want to live in a world in which we let mass extinctions occur.

On "his" book

farmer: I can't tell you how many people have said to me, "Oh, I just love your book." And I think, "Oh, you mean Uses of Haiti?" I know they never mean that. They always mean his book, which is kind of annoying. [Laughter]

Okay, I won't be bitter, because, fortunately, I have some skills that he does not. And some of them I acquired right here--a lot of them.

Since many of you are probably freshmen, I know that you were forced to read this book. Which, actually, I also know is a farce. I know most of you didn't read it. Because even though you were [told] to, you just didn't. That's called the resistance--the weapons of the weak.

So, I don't imagine that you've all read this book written by Tracy. And I know that you've not read my [six] books, because I see the sales figures. But, my mother has read my books, and she is of the opinion that my books are as good as or better than Tracy's book.

Campus foray: Farmer talks with students

Campus foray: Farmer talks with students. Jim Wallace.

On the impact of his undergraduate years

farmer: The last time I was here at Duke, a number of people asked me, "How did you end up doing what you are doing?" And I said, "Well, I can't answer for the others who do this work, but I can tell you that I got started on this road as an undergraduate." All of it: Haiti, medicine, medical anthropology, social-justice work. It all started for me right here. And I really only wanted to come here after I saw the place. I said, "This is the most beautiful place I've ever seen in my life. I want to go here." And I'm not sure that I even bothered applying anywhere else.

I told Tracy --we had this long discussion, "Would he write this book? Would he not?" And he said, "Well, how did you get involved in this?" And I said, "Well, when I was at Duke I met a bunch of patients who were migrant farm workers, and I--it was very compelling to me." And most people would just be polite and say, "Oh, that's interesting." But he would say, "In what way compelling?" And I'd say, "Well, I mean, I thought that their working conditions were terrible." He said, "Well, compared to what?" And I said, "Well, I don't know. I mean, they were living in all these crowded quarters and in buses. And there were slavery charges brought against the growers that year--1981." He said, "Slavery charges?" I said, "Yeah, slavery charges." And I said, "You know, I wrote an article about this." He said, "Did you now?"

kidder: I never said "Did you now?" [Laughter]

farmer: Well, something along those lines. So, he, you know, being a researcher, decides he's going to find out whether I really wrote an article about this. And he found it.... And you told me it was how many words long?

kidder: 13,000--something like that.

farmer: It was very long. And it was called "Haitians Without a Home." It wasn't in The Chronicle, because The Chronicle has strict deadlines. It was in Aeolis or Tobacco Road, one of those publications. And so, I looked back at that fifteen, twenty years later, and I thought, Well, you see, there is some coherence in life. There are claims of causality that one might make. And so, that's why I'm addressing you undergraduates--you freshmen--tonight.

On using privilege wisely

farmer: This is a really fantastic time in a fantastic place. It's not a good time in the world, I don't think. I just came from Haiti where a natural disaster, which we all know to be completely not a natural disaster, just killed a couple of thousand people. There are other natural disasters occurring in our land around us. And so, I don't think it's a great time for the world. And I've been thinking a lot about it as a doctor and as an anthropologist: What is it, really, that's happening in the early twenty-first century?

And I'm not really optimistic or happy about that. But, I'm optimistic and happy about you and this place and other places like it. Islands of decency.

Duke may be in a forest of 8,000 acres, and you may be able to live in your own self-contained world as I did when I was an undergraduate here. I never ventured into Durham.

You know, find out about the rest of the world while you're here. While you have this protected time. Find out about the rest of North Carolina. Find out about sub-Saharan Africa and Central America and the rest of the great world. Find out about power and how it works. We're in a very dicey time.

The Haitians believe that we Americans have unprecedented and perhaps unmerited power. I mean, largely unmerited power, but there you have it. And I hope to spend some of the time I have left here talking to students and recommending that, regardless of what path they take--and many of you will go into law or medicine or teaching or do graduate programs of some sort--that they make sure to take a measure of our privilege and decide how to use it wisely. Thank you.

[The discussion is opened to the audience for questions]

audience member: I'm a junior here. And I didn't actually get to read your book. So, frankly, I don't know a whole lot about you. But--

farmer: It's not my book. I don't care.

Campus foray: Kidder signs books

Campus foray: Kidder signs books. Les Todd.

audience member: I was just curious if any of your spiritual or religious beliefs affected the path that you chose to take?

farmer: I wish I could tell you--as many in this room no doubt can--that their spiritual convictions led them to do the things that they do--the good things. (One assumes that spiritual values should not, in general, lead you to do bad things, like bomb urban areas. But hey, go figure.) But I can't. I can only say that I regained spiritual values by following this path, and it was a hard battle for me. You're asking a very personal question. It's okay. This is just a couple thousand of our closest friends. I was raised Catholic. But, it wasn't really very meaningful to me, frankly, as a young adult here, until I started on this path of engagement with the world. And then you needed spirituality. You needed some sort of faith, in a way, to understand all the things you were seeing. I mean, a twenty-two-year-old mother dying of malaria.

audience member: My name is Rebecca and I'm a medical student from UNC. And my question is this. What advice would you give to a young person as you look out on the sea of faces, many under thirty--

farmer: I don't talk to Tar Heels. [Laughter] I'm kidding, Rebecca. Come on.

rebecca: What advice would you give to a person who is seeking to use their life in such a way as to maximize the potential positive impact on the health of the poor?

farmer: How do you help to help the poor? It's a great question. I've met people who are so talented, say, as basic scientists that you'd never want to say, "You know, you should leave the lab and go do primary health care in Haiti or eastern North Carolina." That would be a mistake. Because you'd have squandered that person's great gift.

But, I think, what you ask is really a moral question. What are we going to do to remediate inequalities of access to care for people living in poverty? I think we need to pull in a lot more people--doctors, nurses, social workers. We need community health workers. But, we also need deans and chancellors and basic scientists and policymakers and historians and people in the arts and social sciences. If we were to pull together some sort of coalition of people, and say, "Well, you know, the idea of decent health as a right is a good idea," then we wouldn't have 40-million Americans without health insurance. Nor would we have 40-million more poorly insured. To say nothing of the bottom billion in the world, who really can't expect to know modern medicine at all. So, I say keep aiming--keep the moral goal the same, but permit yourself to follow your heart and what it is you would like to do.

audience member: Hello. I'm a Duke graduate, 1995, and currently a resident in internal medicine, and I'll be doing my fellowship in infectious diseases next year. I was just wondering what you both learned about yourselves from doing this project that has won you both so much acclaim and fame?

kidder: I don't know.

farmer: He could testily reply, "Hey, I won a Pulitzer Prize well before I met him." But go ahead.

kidder: Well, you know, one of the things I learned is to pay attention, and I know I wasn't actually paying attention to a lot of things. But, I don't want to join the collective amnesia that I think that a lot of Americans share toward the suffering that's really all around us.

The other one though is, don't try to reproduce a life like Paul Farmer's. That's not the point. I think the point is to take heart from the example that he--and certainly, his colleagues at Partners In Health--provide us. Which is, that individuals--small groups of people--can actually improve the world.

farmer: There's a big text by [Gerald] Mandell, the "infectious-disease text." It weighs about thirty-five kilos.

kidder: How many pounds is that?

farmer: Two point two times thirty-five. Anyway--

kidder:He's not a mathematician.... Listen. I've got to tell this story. This is too much. He was testifying in court in New York, trying to save the life of a Haitian who was about to be deported. And the judge was trying to figure out when something or other had happened to this guy. And the guy said it was when Thurman Munson, the catcher of the New York Yankees, died in the plane crash. And afterwards, Paul kept saying, "Well, who was this Thurman Gunson?" It was clear to me that this young man, who was not an American citizen, although he had been in the United States for a long time, was much more American than Paul. So, really. And any talks of kilos--I mean, come on.

farmer: Victor [Dzau], speak up for me. We're supposed to talk in kilos. Anyway, back to what I learned. I read President Brodhead's inaugural speech. And I know, very well, your new chancellor who you stole from us. And what's exciting to me is, if we can now do what we've been called to do by your president and, as an alum, by my president, if we can tie these together--for example, we can say okay, now, we want management scientists from the business school to help the people from infectious diseases to deliver anti-retroviral care to the Duke-affiliated project in Tanzania. And then, we're going to have the epidemiologists assess the impact of X, Y, or Z. And then, we're going to have social scientists help us to understand the impact of integrating prevention and care. I mean, imagine the project without that interdisciplinary tying together.

And I think that's what I've learned by being around Tracy. Why would I learn that from him? Because when you're used to being around sub-specialists and you're traveling with someone who is not a sub-specialist--is not a TB expert, not an HIV expert--they're going to ask you questions about why you're making decisions that you're making. And it was a good experience. It was painful in a way. Not because he was whining about the travel schedule--that was painful. But because he'd say, "Why did you make this choice?" He didn't say, "Why did you let this person die, and save this person?" In a way, though, it felt like that. And that, for me, was an instructive process. I learned a lot about what it is we do and how we can do it better.

audience member: Hi, I'm a freshman and I'm just kind of wondering, like, a lot of your work with PIH and the World Health--

farmer:You're not allowed to say "like." [Laughter] Okay?

audience member: All right. A lot of your work was to lower health-care costs especially with tuberculosis drugs. And I was just wondering how that work could be translated into the United States.

farmer: Well, we're the most powerful and affluent and technologically advanced nation in human history. And we have great tertiary medical centers like the one about a few hundred yards from here. They're the best in the world. I don't doubt it. However, we have serious deficiencies--and I think this is what you're getting at--in our delivery of medical services. When I was at the medical school, the majority of what I saw in the emergency room was African Americans living 200 yards from a hospital who had high blood pressure or another primary health-care problem that should not have been managed in an emergency room.

And then, the numbers. We spend more of our gross national product--I think the number may be 14 percent--on health care than any other nation. Now, the question is, is it to deliver the best possible care? And the answer is, clearly, No.

We can deliver some of the best tertiary care--probably the best tertiary care in the world. But, what we need as a society to ask is, Do we have a plan that can lead us forward, so that we can have universal access to basic health care for our country?

And the answer is, We do not have a plan, and we do not have the political will currently in place to even move forward a little bit. In fact, what we're doing is moving backwards now.