Service, Activism, and Mountains Beyond Mountains

By Professor Ron Krabill, Interdisciplinary Arts & Sciences, University of Washington, Bothell
Email: rkrabill@u.washington.edu

Here’s a good deed in progress, and a perfect example of the Farmer method. First, you perform what he calls “the distal intervention” and cure the family of TB. Then you start changing the conditions that made them especially vulnerable to TB in the first place.
– Tracy Kidder, Mountains Beyond Mountains, p. 293
The approach of charity further presupposes that there will always be those who have and those who have not.
– Paul Farmer, Pathologies of Power, p. 133

What can you learn from exploring this topic?

The University of Washington has chosen Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World, by Tracy Kidder, as the Common Book to inspire students to become scholars and active participants in shaping an equitable global society. What is required of an individual to engage with issues of importance, whether through service or activism, and what prevents such engagements?
The ethics and politics of community service are more complicated than they may seem at first glance. What is the value of community service to the servers and the served and who decides? What are the ethics of different approaches to service?
The relationships between service and activism are sometimes complementary and sometimes contentious. What are the assumptions behind each approach and their strengths and weaknesses?
Sometimes we choose to act alone on issues of importance to us; and sometimes we seek to have broader impact through building alliances in the service of a cause. What issues does the book raise around individual versus collective action for the common good?
Mountains Beyond Mountains is written by a white man from the United States about another white man from the United States who seeks to improve the lives of poor people of color in Haiti and other parts of the so-called Third World. What issues and assumptions regarding race, class and nationality in relation to service and activism are raised, both implicitly and explicitly, by the book?

Service

We use the term service in many different ways in our everyday language. Community service, military service, the service industry, civil service, and service-learning represent only the tip of the iceberg regarding how the term is utilized. Any time a term is used to cover such varied and sometimes conflicting concepts, it risks becoming emptied of meaning. Common to all these uses is an assumption that service is an action done to benefit someone else; beyond that, however, many different questions factor into whether a given act counts as service or not. This is even more true if we contemplate the relative meaning or value of different types of service. For example, is service more meaningful if it is done:

without financial compensation (e.g., volunteering)?
at risk to your own health and welfare (e.g., military service)?
for the benefit of strangers (e.g., philanthropy or international service work) or for those you know well (e.g., community building in your neighborhood)?
as part of an occupation (e.g., social work) or outside of your occupation (e.g., foster parenting)?
as part of a broader lifestyle commitment (e.g., environmentally sustainable living)?

Behind these questions lies a more fundamental question: in determining the meaningfulness of service, which matters more – the motivations of the person doing the serving or the value of that service for the person being served? In other words, are we primarily concerned with the attitudes and sacrifice of the server or the impact on the served? And to further complicate the issue, is it always (or ever) clear who is being served and who is doing the serving?
These tensions are readily apparent in Mountains Beyond Mountains. Kidder writes:

[Farmer] had described himself as “a poor people’s doctor,” but he didn’t quite fit my preconception of such a person. He clearly liked the fancy restaurant, the heavy cloth napkins, the good bottle of wine. What struck me that evening was how happy he seemed with his life. . . . The way he talked, it seemed he actually enjoyed living among Haitian peasant farmers. (7)

Kidder gives voice to the common assumption that someone who serves others as Farmer does could not possibly actually enjoy it, because it must be based on sacrifice rather than pleasure. The same person, carrying a presumably saintly disposition, cannot or should not enjoy both living in rural Haiti and eating at an upscale Boston restaurant.
Kidder’s presumptions grow from a common understanding of service that equates it largely with concepts of charity and noblesse oblige (the obligation of the nobility). As Farmer’s quote at the beginning of this study note suggests, this approach understands service as what the privileged do – whether out of obligation or kindness – to ease the suffering of the underprivileged. However, it does not challenge the division between the privileged and underprivileged; indeed, it actually reproduces and maintains it. Thus the server can feel good about doing a good deed or making a sacrifice while maintaining the structural (social, economic, cultural, political, etc.) privilege from which he or she benefits.
Many commentators have attacked this approach to service; one notable example is Ivan Illich’s short speech, “To Hell with Good Intentions” (1990), in which he addresses a group of American students preparing to travel to Mexico for a summer of community service. Illich tells the students that, while he respects their motivations, their impact on those they wish to serve will be profoundly negative in both social and cultural terms. He says that they will be able to provide relatively little material gain for those they hope to serve during their brief service work, while simultaneously acting as emissaries for an individualistic, consumerist culture that celebrates a level of wealth that the Mexicans with whom they work cannot possibly achieve. Through that process, Illich says, they will aggravate class divisions within the community they are serving and then disappear before the consequences of their visit become visible. Whether you agree with Illich’s claims or not, he raises the important point that those who serve, unless they make a lifelong commitment such as Farmer, are often unaware of the long term results of their service.
Although the approach to service of noblesse oblige is largely discredited among scholars and activists, it still carries a great deal of weight in U.S. society. For instance, community service and service-learning programs are often viewed as unassailably positive, with very little attention or critique regarding the particular ways in which those programs operate. Furthermore, service is often viewed as a politically neutral, and therefore politically safe, way of engaging students in their local communities.

Activism

In contrast, activism wears its political commitments on its sleeve. As a result, activism is rarely if ever viewed as politically safe, and certainly not neutral. While very few people would criticize Farmer’s direct service to his patients in Haiti, his activism around the World Health Organization, his embrace of liberation theology and its preferential option for the poor, and his challenges to structural violence become far more controversial. If “The Farmer Method” described by Kidder above includes “the distal intervention” of direct service, than “changing the conditions” of structural violence requires an activist engagement with political power.
Activism and social movements can take many forms: some are grassroots while others are driven by elite forces; some are supportive of the status quo while others seek moderate to radical change; some are driven by charismatic individuals like Farmer while others grow out of more collective leadership; some are aligned with the political left, others with the political right, and still others attempt to carve out alternatives to the left and right. What distinguishes common understandings of activism from those of service is their view that political engagement (in a broad sense) is necessary to effect positive social change. In other words, activist approaches tend to claim that direct service, while often positive and necessary, is not enough.
Farmer’s conceptualization of structural violence mirrors this claim by naming the solution to the challenges faced by Haitians and others not as individual treatment for particular patients but as “changing the conditions that made them especially vulnerable . . . in the first place.” But much of the power of Mountains Beyond Mountains, and indeed Farmer’s work, is in his insistence on personally participating in both direct service and structural activism. He recalls for Kidder his own overly-structural (and therefore abstract and distant from those being impacted) concerns around appropriate technologies in his first contact with Père Lafontant, who responded, “Do you know what appropriate technology means? It means good things for rich people and shit for the poor” (90). Later, Farmer is criticized for being too focused on direct service even by some of his supporters, such as Howard Hiatt, the former dean of the Harvard School of Public Health:

Farmer, Hiatt seemed to say, should be solely engaged in the battle against those scourges [pandemics], and at a level commensurate with their size. “The six months a year that Paul’s looking after patients one-on-one in Haiti, if that time were converted to a major program for treating prisoners with TB in Russia and other eastern European countries, or malaria around the world, or AIDS in southern Africa . . . I have been urging him to take the role of consultant in Haiti and spend most of his time on worldwide projects.” (181)

But Farmer and his colleagues seem to view his one-on-one doctoring as central to his understanding of the global pandemics. As Keith Morton (1995) claims, service and activism may best be understood not in juxtaposition to one another but rather in the ways each deepens our involvement in the other. Kidder echoes this, describing the approach of Partners in Health as follows:

In public health projects in difficult locales, theory often outruns practice. Individual patients get forgotten, and what seems like a small problem gets ignored, until it grows large, like MDR [multidrug resistance]. “If you focus on individual patients,” Jim Kim says, “you can’t get sloppy.” (294)

Farmer as a model of service and activism

If Mountains Beyond Mountains is intended to inspire us to take action to create a more just and equitable world, it does so through the compelling and charismatic character of Paul Farmer. But Farmer is also an extreme personality and emulating Farmer can seem, to put it mildly, daunting. “If Paul is the model,” as Kidder describes the posted exchange within Partners in Health, “we’re golden” or, alternately, “we’re f***ed” (243-44). By highlighting Farmer as an inspiration for motivating people to become involved with issues of importance, Kidder risks leading his readers to believe that, like Farmer, we need to operate on very little sleep, attend Ivy League schools, acquire not only one but two terminal degrees, and make an intense personal connection with nearly everyone we meet. In this context, the model quickly appears unattainable, leaving the reader with the choice of doing nothing at all in order to avoid being insufficient in his or her efforts. As Farmer himself says at one point, “I didn’t say you should do what I do. I just said these things should be done!” (244).
The tension between sufficient and ethical preparation for effective service and the desire to take action without being paralyzed waiting for the perfect time or training – what author Paul Loeb (1999) has described as “the perfect standard”– remains a central issue for the book. Again in Farmer’s words: “When others write about people who live on the edge, who challenge their comfortable lives – and it has happened to me – they usually do it in a way that allows a reader a way out. You could render generosity into pathology, commitment into obsession. That’s all in the repertory of someone who wants to put the reader at ease rather than conveying the truth in a compelling manner” (206-7).
Another risk to writing Mountains Beyond Mountains as a character study of Paul Farmer is the way in which it demotes other leaders in Partners in Health, such as Jim Kim, Ophelia Dahl, and Tom White, to mere supporting actors in the narrative force of Farmer. The risk here goes beyond devaluing the work of these leaders and toward creating an individualist model of social change. In other words, would Farmer be able to do what he does without the work of Kim, Dahl, White, and countless others in PIH and around the world? While the leadership of a charismatic individual such as Farmer is undeniably valuable in both service and activism, a focus on one type of leadership and spokesperson can keep others from getting involved because the roles they might be able to play outside of the spotlight are obscured.

Race, class, gender and nationality in relationship to service and activism

Highlighting Farmer’s individual efforts in Haiti not only emphasizes individual acts over collective efforts, it also has the potential to reinforce one of the fundamental assumptions of noblesse oblige: that service is a unilateral act performed by the privileged and received by the poor. The reality is that structural violence can be largely mapped onto divisions of race, class, gender, and nationality – what Farmer describes as the “great epi divide” (125). This does not mean, however, that the privileged have nothing to gain and the poor have nothing to give. Making that assumption, either consciously or otherwise, replicates not only noblesse oblige but also, on a more personal scale, many of the same dynamics as colonialism and postcolonialism on the national scale (see Amy Bhatt’s study note on postcolonialism). Likewise, a common assumption regarding activism is that one must come from the social group seeking change in order to participate. In this rubric, service becomes an action of the privileged and activism becomes an action of the dispossessed, further exacerbating the danger of viewing service as safe and good vis a vis the disruption and controversy generated by activism.
Choosing Farmer as an exemplar of service can thereby, without ever considering the issue explicitly, fit easily into a wider discourse wherein white men from the United States are the lynchpins to providing solutions to worldwide problems that disproportionately impact poor women and people of color outside of the United States. This critique should not be misunderstood as a criticism of either Farmer’s own work or the way in which he positions himself in relation to those with whom he works; indeed, the evidence in the book and elsewhere indicates that Farmer does an exceptional job of overcoming these divisions in both his political work and his direct service. Rather, this critique reminds readers to be vigilant toward the kinds of assumptions that can be easily made regarding who needs to be served and who can or should do the serving, as well as the supposition that the benefits of such an interaction flow in only one direction.

How, then, can we “become scholars and active participants in shaping an equitable global society”?

Recognizing the many issues surrounding service and activism, how then do we engage with issues of importance in ethical and valuable ways? How do we keep from being paralyzed by the enormity and complexity of global inequity and take action? Those working with PIH provide us with several possible answers. Kidder tells us that Farmer, Kim and Dahl would discuss how:

WL’s [white liberals] were forever saying, “Things aren’t that black and white.” But some things were plenty black and white, they told each other—“areas of moral clarity,” which they called AMC’s. These were situations, rare in the world, where what ought to be done seemed perfectly clear. But the doing was always complicated, always difficult. (101)

One part of “the doing” is to constantly and consistently challenge what is considered acceptable in terms of global inequity. Throughout Mountains Beyond Mountains, Farmer returns to the importance of asking the right questions (see, for example, 78, 133, 218, 289, 290). Many of these questions revolve around what is considered cost effective, reasonable, sustainable, or appropriate, as in one of the last stories in the book concerning the medevac flight of a Haitian child from Cange to Boston (260-98). Once the questions have shifted, the areas of moral clarity can be more easily seen and addressed. Farmer seeks to shift the discourse away from what costs are believed “reasonable” for alleviating poverty and poor health toward a rejection of the idea that poverty itself is acceptable. In response to Kidder’s off-hand comment that rural Haiti “seems like another world” from Charles de Gaulle airport, Farmer says, “But that feeling has the disadvantage of being . . . wrong” (218). In other words, he rejects the presupposition “that there will always be those who have and those who have not.”
As well as shifting the discourse on global inequity, Mountains Beyond Mountains is a profoundly hopeful book. It indicates that not only do “areas of moral clarity” exist, but that something can be done about them. While the doing may be difficult, it can still be done. One of the lasting questions the book asks of us, then, is to consider where we find hope and to challenge us to pursue that hope relentlessly. Consider what issues you are passionate about and then consider realistic strategies to approach those goals, utilizing well-known lists like Peter Singer’s “Ten Ways to Make a Difference” (1998) (excerpted from his book, Ethics into Action, available online), Saul Alinsky’s Rules for Radicals (1971), or Martin Luther King, Jr.’s steps and principles of nonviolence (available online through the King Center), all of which outline steps to take to bring about positive social change. Also be sure to visit the UW’s Carlson Leadership and Public Service Center for a myriad of opportunities to engage in community service and service-learning opportunities in and around Seattle, and seek out courses that incorporate service learning into their coursework.