The summer after submitting primary applications to medical school is too late to still be searching for a reason to be a doctor. The Association of American Medical Colleges (AAMC) and its titular associated medical colleges have constructed a labyrinthian admissions process to get to know (and make sure that you know) your reasons for pursuing a medical education. One third of the way into the process is too late to not know. In May 2024, shortly after submitting my AAMC primary application, I walked into a used bookstore hoping to find a compelling reason to have embarked on the path down which I had just taken the first step. In two books by Tracy Kidder, Mountains Beyond Mountains (2003) and Rough Sleepers (2024), I found the reason I was looking for as well as a deep-seated uncertainty about it.

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     Before taking big steps in my life, I have always looked to books to inform my decisions: Kurt Vonnegut’s Bluebeard before declaring a second major in Studio Art, Robert Caro’s The Power Broker while moving to New York City, Oliver Sacks while writing my neuroscience dissertation. My literary wayfaring guides before applying to medical school were Dr. Siddartha Mukherjee’s Emperor of All Maladies and Dr. Paul Kalanithi’s When Breath Becomes Air. Dr. Mukherjee’s enduring prose about humanity's relationship to cancer galvanized my commitment to advancing medical research, and Dr. Kalanithi’s narrative and journey crystallized my interests in neurosurgery. Still, I couldn't help but be swept up in the undercurrents of inequality that lie beneath cancer, surgery, and wider health systems. In absolute terms, the cancer burden of low and middle-income countries (LMICs) outstrips that of high-income countries (HICs). Paradoxically, but not unsurprisingly, cancer treatment is overwhelmingly concentrated in HICs, with 2-5 radiotherapy machines per 1000 patients in HICs and only 0-2 per 1000 patients in LMICs.1 Domestically, a 2019 systematic review of surgical disparities in the United States found significant and deep inequalities which predictably fell on racial/ethnic, insurance status, and income lines.2 All doctors, and those hoping to one day be doctors, practice against this backdrop of fundamental inequality.

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     A central tenet of the National Institute of Health—American College of Surgeons Symposium on Surgical Disparities Research is “No quality without access.”3 Picking up the works of Tracy Kidder, I needed role models who had cut through the inequalities of global and domestic healthcare to show that it could be possible for me too. Mountains Beyond Mountains and Rough Sleepers were a double feature of role models that showed me that the path to health equity isn’t just possible, but an urgent call every prospective doctor needs to hear. What we do after that is up to us.

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Mountains Beyond Mountains 

Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World tells the story of Dr. Paul Farmer and how he came to dedicate his life to the cause of accessible quality healthcare in the most underserved regions of the world. The book charts Dr. Farmer’s journey through his medical anthropology education to starting a clinic in Haiti to eventually helping start Partners in Health (PIH) and its global health mission. Dr. Farmer first visited Haiti to work in the tiny Haitian village of Cange at the tail end of the US-backed Jean-Claude Duvalier dictatorship. Returning to the country during his MD/PhD at Harvard Medical School, Dr. Farmer began to set the groundwork for the development of Zanmi Lasante (“Partners in Health” in Haitian Creole) and an extensive health system of community health spokes revolving around a hospital complex in Cange. As the book continues, the reader is brought along as Dr. Farmer’s focus expands towards the AIDS epidemic in Haiti, multi drug-resistant tuberculosis (MDR-TB) in Peru, MDR-TB in the Russian prison system, and eventually the world. By the end of the book in 2004, Dr. Paul Farmer had already earned the moniker “The Man Who Would Cure the World.” Of course, the work of PIH continues to this day, stepping up during the Ebola and COVID crises and partnering with the national governments of Rwanda and Sierra Leone. In fact, it was through PIH’s work in radically reducing maternal mortality in Sierra Leone that I first came to be introduced to the story of Dr. Farmer and Mountains Beyond Mountains. 

In the book, Kidder dances around the question of potential influences that lead to Dr. Farmer’s passion for serving the underserved. Circumstances such as growing up poor in Florida and working similar field jobs as Haitian migrants are introduced as noteworthy but not influential. Kidder mentions them seemingly as journalistic points of interest, coincidences too apropos to ignore. A much more direct influence on a young Farmer would be liberation theology, a Catholic ideology which took hold in the Latin American revolutionary political atmosphere of the 1980’s. Adherents to liberation theology hold that caring for the spiritual and physical needs of the poor and underserved is a preeminent obligation. Paul Farmer would take the liberation theological phrase, “a preferential option for the poor,” and distill it into an unofficial slogan for PIH: an “O for the P.” 

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     An “O for the P” is a radical departure from the sociopolitical status quo, and in the world of healthcare it feels to many like a utopian pipe dream. Health care technologies, to the extent that they are distributed to the poor, fall woefully short of the need especially in rural areas. Mountains Beyond Mountains tells a story of a young Paul Farmer in Cange asking a local priest if the new concrete latrines were “appropriate technology” - a buzzword in international aid. The priest replied, “Do you know what appropriate technology means?... It means good things for rich people and shit for the poor.” Serious economists have long since dispelled the notion of a trickle-down economics as an effective means for distributing wealth; why do we still adhere to the fantasy of trickle-down healthcare? 

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     On the surface, technological advancements seem to have “trickled down” before. The advent and subsequent dissimilation of refrigeration technologies have dramatically moved the needle on medicine storage and delivery (though establishing medical cold chains in poor countries remains a critical goal of global health advocates). However, the work of Dr. Farmer and PIH draws attention to all the ways healthcare innovations can also “trickle up.” PIH’s role in establishing robust contact tracing networks in Sierra Leone during the Ebola crisis gave them the expertise to consult with the state of Massachusetts on similar contact tracing during the COVID pandemic. This direction of progress, from poor regions “up” to the rich, shouldn’t be considered a feat of defying gravity. The idea of “high ground” and “low ground” in medicine is only made real when we regard it as such. By rejecting the notion that poor countries’ health should be held to lower standards than rich countries, Mountains Beyond Mountains flattens the topography of global medicine. In turn, it raises the bar for all aspiring physicians.

 

Rough Sleepers 

Rough Sleepers: Dr. Jim O’Connell’s Urgent Mission to Bring Healing to Homeless People trades the global scope of Mountains Beyond Mountains for a more intimate glimpse into the lives of Boston’s homeless and those who take on the mission of healing them. Through Kidder's account, we see the personal struggles of Dr. Jim O’Connell and the unrelenting challenges faced by his patients, especially the chronically homeless. These are the so-called “rough sleepers” who die at 10 times the rate of the housed. What began as Dr. Jim's 1-year role overseeing a homeless health clinic developed into a lifelong journey into getting to know (and, often, tragically losing) the city’s homeless. Kidder weaves the narrative through the changing landscape of healthcare policy and an increasingly gentrified city as Boston’s homeless navigate AIDS, drug epidemics, and bitter winters. 

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     Like Dr. Farmer building out from Zanmi Lasante as a central hub, Rough Sleepers documents the Barbara McInnis House medical respite facility and the weekly free clinic established by the Boston Health Care for the Homeless Program presided by Dr. Jim. Revolving around this system is the tremendous social support trying to find housing for the patients and the nighttime outreach van on whose route Dr. Jim becomes a kind of microcelebrity to the unhoused. Getting to know the homeless population of Boston throughout the career of one doctor paints an unflinching picture of the social and medical needs of people that are so often ignored. 

 

     Rough Sleepers is a book that ages you. The book charts the course of work done over 40 some-odd years and seemingly all of them are felt as the story’s figures rotate through. The attrition is felt both in the stories of the many rough sleepers we get to know, whose truncated life expectancies accelerate their narratives, as well as the book’s healthcare and social workers, like Barbara McInnis, for whom the medical facility is named and whose passing leaves an indelible impact. It’s impossible to not get sucked into the portraits painted by Kidder and Dr. Jim: the two homeless former professors who still held academic debates over the rare coffee, the chronically homeless person who pitched a tent in the living room of their first apartment provided by the program. Enmeshed in this “system of friends” is the story of Tony Columbo, a character at the center of a circle of chronically homeless persons that Dr. Jim affectionately calls his “old classics.” Tony’s relationship with Dr. Jim defines the second act of Kidder's book and reflects the humanity that is missing in so many approaches to treating the homeless. The tragedy of Rough Sleepers, then, is not just the ways Tony was failed but how that failure persists in our policies. 

 

     Policy and politics also takes the spotlight in much of Rough Sleepers messaging. While Mountains did not shy away from dense policy discussion, it was often couched in the academic realm of global health circles or national NGO policy. By 2024, Tracy Kidder pulls no punches and centers Boston’s housing and carceral policies, the importance of schmoozing the right politicians for support, and the ever-looming threat of defunding (felt at its pinnacle during the Trump-era attempts to repeal the Affordable Care Act, a lifeblood to the Health Care for the Homeless Program). Even so, Rough Sleepers also challenges certain well-meaning progressives such as myself in its discussion of “Housing First” initiatives which holds that unconditional permanent housing is the first step, not a destination, in addressing America’s

homelessness crisis. Dr. Jim highlights, however, that these initiatives fall short without an emphasis on supportive housing first. This is perhaps best exemplified in the story of the chronically homeless person who pitched a tent in their “Housing First” provided apartment and later left voluntarily due to the overwhelming loneliness. 

 

     Ultimately, this nuance is the product of proximity. Tracy Kidder does not have unique access to some truth about the world that is denied to everyone else. Instead, he provides a level of sustained care and interest, as well as a commitment to asking hard questions, that starts to chart a path through the bleak reality for hundreds of thousands of Americans (though the difficulty of getting an accurate statistic for even the number of homeless is discussed in Rough Sleepers). The book isn’t abounding in its optimism, but in highlighting the kinds of organizations, people, policies, and patients at the center of our urgent moment, we are left with something else. To any member of a community that includes the homeless (ie. everyone), Rough Sleepers shows that, as Dr. Jim put it, “This is what we do while we’re waiting for the world to change.” 

 

Searching for Meaning 

Part five of Rough Sleepers is titled, “Searching for Meaning.” Plumbing these two books by Tracy Kidder, I found myself searching for meaning across their similarities and differences. Here were two books that elevate Harvard-educated doctors to be models of virtuous service and dedication to improving the lives of countless patients. Much emphasis is placed on the personal nature of this care: Dr. Farmer’s day-long hike to make sure one patient was keeping up with their medication, Dr. O’Connell’s auspicious start in a clinic where he is told to set down his stethoscope and instead work washing the patients’ feet. The lessons seem straightforward: doctors need to practice social medicine, or the idea that health care must also treat the social, economic, political, and environmental ailments of their patients. 

 

     In both cases, however, Kidder winds down his reporting with the notion that the work, rather than being sole individuals who graced their patients during their tenures, succeeded mostly by setting up durable systems. My copy of Mountains opens with a short obituary to Dr. Farmer, who passed away in Rwanda in 2022, and by the end of Rough Sleepers, Dr. Jim has slowed down his nonstop work pace. But these organizations, communities, and models persist long after retirement and death. PIH and Boston Health Care for the Homeless Program are both active and expanding, and so are the countless organizations like them. 

 

     What are the roles of role models in medicine? I thought I was reading about Dr. Farmer and Dr. Jim because I wanted a step-by-step guide to pursue medicine the way they had. But it turns out that the question of how the two doctors got to and through their education is not the focus of Kidder’s journalism (parts of chapters 5-8 of Mountains Beyond Mountains and chapter 1 of Rough Sleepers, for those curious). The playbook across the two books can be boiled down to: 

1. Be predisposed towards concern for those with less. 

2. Be introduced to a way of treating them. 

3. Commit entirely. 

The books serve less as an instructional manual because it understands that Dr. Farmer, Dr. Jim, and those working with them are not exceptional because they found a path others hadn’t. Kidder writes that the thing setting these doctors apart is not the moment they broke from a traditional MD career path (when Dr. O’Connell delays and ultimately turns down a prestigious oncology fellowship at Sloan Kettering), but their steadfast determination every day after. 

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     “If Paul is the model, we’re f*****.” Kidder writes that this phrase was on a sign in a new PIH employee’s office. Reading it, I couldn’t help but feel that of course Paul Farmer was the model. After all, I had decided to read these books in the first place to find a model of a fulfilling life as a doctor. The sign in the PIH office is a warning to aspirants who share my mentality. It’s a mindset I’ve seen echoed in other reviews of Kidder's work, like a 2021 student article in The Stanford Daily which concludes, “At our age, around this time of year, Farmer was buying his first plane tickets from North Carolina to the hospital he would staff in Port-au-Prince.”6 But this kind of thinking is exactly why, if Paul is the model, we’re f*****. Instead, Kidder writes, “What PIH-ers should take from Paul wasn’t a manual for their own lives but the proofs he’d created that seemingly intractable problems could be solved.” In the end, any conversation about improving health equity in the world that starts with how I become a better doctor has already started off on the wrong foot. Or, as Paul himself would say, “It’s not about the quest for personal efficacy.” 

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     If after this double feature of Tracy Kidder’s books one is not left with an enduring sense of agency, what is the intended impact of this reporting? For me, I put down Mountains Beyond Mountains and Rough Sleepers with a much more difficult sense of empowerment: I came away with a realization that the lives led by the heroes of these books is, in a word, possible. In a 1994 essay, Kidder wrote, “I think that the nonfiction writer's fundamental job is to make what is true believable.”7 Kidder’s reporting is a Pandora’s Box of moral responsibility. It’s not that everyone who reads them will take the selfless leap into a lifetime of fiercely passionate service, but there is also no returning to the blissful inertia that propelled me and others like me into medicine before reading these books. Doubtlessly, there are still those who read these stories and return to their paths of mainstream, lucrative, comfortable (and, yes, still vitally important) medical professionals, but they will do so with clear knowledge of their choice. As one Dr. Farmer aphorism holds, “Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community.” 

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     It’s a cheap thrill to be told what to do, which steps to follow, to be the kind of good person - good doctor - that you want to be. But Tracy Kidder instead delivers a tougher pill to swallow, one which nourishes all the more. His books ask everyone who wishes to do good in this world: Look at what these doctors have been able to do, and at all that is left to be done. Now what are you going to do?