John and Rosianna discuss Mountains Beyond Mountains by Tracy Kidder. This episode was originally released to subscribers in October 2019.
“The idea that some lives matter less is the root of all that is wrong with the world.” - Dr. Paul Farmer
In this episode, John Green and Rosianna Halse Rojas discuss the late Dr. Farmer’s work, Partners in Health’s mission, and the tuxedo problem. You can read more about Life’s Library’s work with Partners in Health at https://pih.org/hankandjohn.
This episode was originally released to subscribers in October 2019. The Life’s Library Discord and subscriptions are now closed after a wonderful three years of reading together. Check out past books at www.lifeslibrarybookclub.com, Twitter, and Instagram.
Life’s Library logo by Bethany Mannion.
John Green: Hello and welcome to the Life's Library podcast. I'm joined today by Rosianna Halse Rojas. This is John Green, by the way. Hi, Rosianna.
Rosianna Halse Rojas: Hi, how's it going?
John: I'm doing well. We're here to talk about Mountains Beyond Mountains, Tracy Kidder's book about the formation of Partners in Health and the career of Paul Farmer.
Rosianna: Do you think that Tracy Kidder himself wrote the subtitle to Mountains Beyond Mountains, which on my copy is the Quest of Dr. Paul Farmer, A Man Who Would Cure the World? It seems very dramatic.
John: Yeah, it seems to me that that was like one of 35 subtitles that Tracy Kidder submitted to the editor.
Rosianna: Right?
John: And that ended up being the subtitle and he kind of cringed every time he saw it for the rest of his life. I think he's still alive, actually.
Rosianna: I feel like it's the kind of thing that you were just like, yep. I'll let you put that on my book.
John: Yeah, totally. I mean—you always—you tend to want to win the title fight—
Rosianna: Right.
John: —really, really badly in a way that makes you think, well, it's all right if I lose the subtitle fight.
Rosianna: Well, Mountains Beyond Mountains is kind of the perfect title for this.
John: It's a great title. And it's a great book. I mean, this book changed my life when I first read it. And most books that changed your life, change your life for three weeks, you know?
Rosianna: Right.
John: But this book changed my life in an ongoing way and really awakened me to two facts. First, that—because I was not making myself in any way close to the suffering of poor people, I was not feeling it.
Rosianna: Right.
John: And I was—and I didn't feel an obligation to do anything. And second, that change was possible.
Rosianna: Can you talk a bit about when you first read it? Do you remember like where you are when you were?
John: Yeah, it was not too long after I'd given up on becoming a minister.
Rosianna: Okay.
John: And so I was working at Booklist and, you know, I'd given up on becoming a minister, but I still really loved liberation theology, which is at the center of this book and a lot of Partners in Health's thinking about how to serve people who are vulnerable and who are in need. And, at least according to my reading of the Gospels, also at the center of a lot of the New Testament, or at least what indirect information we have about the life and teachings of Jesus.
Rosianna: Right.
John: And so that really moved me. There's this thing in philosophy that I remember hearing about that Kaveh Akbar reminded me about—the poet Kaveh Akbar reminded me about recently when we were together. I think it's called like the tuxedo problem, if I remember correctly.
Rosianna: Okay.
John: And the idea is this: if you're walking home from dinner one night and you're wearing a tuxedo and you hear a child who is drowning call out to you, you will—almost everyone almost all of the time will forget about the tuxedo and run into the water and save the child.
Rosianna: Okay.
John: But we all have tuxedos that are sitting—like I personally have a tuxedo that right now is sitting in my closet doing nothing that could be turned into capital or indeed could never have been purchased.
Rosianna: Right.
John: And could—and that capital could have been devoted to helping a child who is in desperate need or helping someone who is in desperate need. And when we are close to suffering, we try to do something about it. And we find that in fact, often we can do something about it and when we are not close to suffering, we buy tuxedos.
Rosianna: Right. That's kind of the question of urgency and emergency that, I don't know, that just reframes the way we look at need and where need should go.
John: Right.
Rosianna: And something I really appreciated about the book, especially right now, kind of where all our conversations are now, there's so much talk about how we should give and what's the best way to give and looking at it in a very cerebral, cold way that is, I think, very different from suffering. Very distant from suffering, I mean, to me personally,
John: Yeah, I think that there's a lot in the effective altruism movement that's important, right? Like I think that there are things that are important about trying to do good and understanding that different kinds of investment do different kinds of good.
Rosianna: Yeah, I don't mean just that though. I feel like in the way that we kind of give overall, even personally, like—I wasn't familiar with that movement at all. But in just kind of seeing among—yeah, for myself and among friends and things, it's very distant because also there's this constant feeling that you don't have anything to give and you can't give in ways that seem meaningful—
John: Right.
Rosianna: —because the ways that seem meaningful have been, you know, these huge donations from individuals or huge donations from foundations. Like that's what's really celebrated in our culture. But not, you know, not as celebrated in the same way other things are celebrated, too. So it kind of functions at all these different levels where when I was reading it, I found—something I found really compelling and moving and also quite difficult at times about the book is that it really challenged all the different excuses I've—I don't know, I've found myself making over the years for my different kinds of interactions with need and with giving. Yeah.
John: Yeah.
Rosianna: Does that make sense?
John: Yeah, we make excuses—I shouldn't say we, I should say I—I make excuses about corruption. I make excuses about not knowing whether it's going to serve the most good or not knowing whether it's going to be the most efficient and the book kind of destroys each of those in turn.
Rosianna: Yeah.
John: And also I make the excuse that I need money to take care of my family and to give my kids the opportunities, the support that they need to succeed and all that stuff, you know? And all of that is true, but it is also true that I am wearing a tuxedo and there is a child crying out for help.
Rosianna: I mean, that's such a good analogy, though. What a great way to think about the whole...yeah, the whole problem of it. And we should say, also, that we're recording this after the Q and A with Dr. Paul Farmer and Ophelia Dahl and Todd McCormack, which was such a...yeah, such an incredible thing that they took their time to come and talk to everyone on the Discord.
John: Yeah. It was really wonderful to hear from them and they are so funny and charming. And they're a little bit—because I think they've, you know, known each other for thirty years and they've been through so many intense experiences together, they're a little bit of like a three-person comedy team.
Rosianna: Yeah, definitely. They know each other in that deep way where they just constantly dig at each other.
John: Um, yeah. Like they can tease each other without hurting each other's feelings, which for me is like the central benefit of longitudinal friendship, you know? I need that, but in a way that doesn't hurt my soul.
Rosianna: Right, feels safe.
John: But yeah, it was so nice to hear from them and they were so generous with their time. You know, I mean, obviously they're extraordinarily busy. If there's one takeaway from Mountains Beyond Mountains, it's that Paul Farmer is very busy.
Rosianna: Oh, boy. Yes. I felt quite stressed actually, at points. Even just reading about his emails.
John: Yeah. You know, when we were in Sierra Leone, one thing I thought was brought up in some of the discussions in some of the shelves that I think is really important and interesting is that this narrative centers on Paul Farmer. And one of the reasons why Dr. Farmer has been so successful is because he—by virtue of where he was born and where he was educated and the life that he's had—he's able navigate between these worlds. You know, between the world of raising money from Americans and the world of delivering healthcare in Haiti. And I think at the end of the book, Tracy Kidder made the point that if Paul Farmer had been writing this story, he would have made it much more about collaboration and much more about—especially the Haitian healthcare workers who are really the lifeblood of that hospital and end of that project.
Rosianna: Yeah.
John: But it made me think about this doctor I met in Sierra Leone, a Sierra Leonean doctor named Dr. Bailor Barrie. Who's really the Dr. Paul Farmer in some ways of PIH Sierra Leone. And he's the same way, like he is always on the phone. He's, you know, he's always practicing medicine. All the time to everyone, you know, and I'm just astonished by the capacity of those people.
Rosianna: Yeah, and I loved where they—when he goes to Cuba and they talk about him wanting to go in the rounds and just always just wanting to go in the rounds with the doctors, always looking for new patients.
John: Yeah. And I think at one point Tracy Kidder was like, when I became his patient, I felt what it's like to be his patient.
Rosianna: Yeah.
John: You know, the minute you have a health concern, he becomes your doctor and you become his patient. And that's obviously a setting in which he really thrives.
Rosianna: But I think you also point to something that I had been thinking about a lot, which was what—the kind of stories that we want to read and the kinds of stories that we want to hear. Like we want to hear about that individual who's extraordinary and Dr. Paul Farmer is extraordinary. But what I really liked to hear over the course of the book also is that there are these moments where you hear about these other individuals who are amazing as well. And they're amazing because they work with one another. I loved that very, very sad portion of the book where it talks about Serena, who was advocating to fly this boy—I think his name was John?
John: Yeah, his name is John, yeah.
Rosianna: Yeah, off the island to get treatment in Massachusetts and that kind of level of advocacy and those moments where you spent time with a different person in the story reminds you that even though Tracy Kidder is spending all this time and all this focus on Dr. Farmer, kind of trying to almost work out what makes him tick and push all the different boundaries of him, really, you do get a sense that this is a collaborative effort full of extraordinary people. Who are also not extraordinary in the sense that they are superheroes—they're extraordinary in the sense of what they choose to do with their time and the way they do their work.
John: Yeah. I thought that part of the book was very moving and, you know, typically in these stories—in stories about, you know, nonprofits that are kind of celebratory, the boy in that story lives.
Rosianna: Right.
John: And there are lots of stories that Tracy Kidder could have told about kids who were seriously ill, who lived. And he, in fact, he tells a few in passing, but he focused on that story about a boy who dies and I found that very important and moving and challenging. I like that the book doesn't narrowly say, you know, this is the best way, but instead presents the extremely complicated and difficult and human story of trying to build healthcare systems and trying to get people access to healthcare in incredibly difficult circumstances.
Rosianna: Yeah. Yeah, I agree because I felt like he could have chosen a story about a child who lived and then had the question of like, what was the point or the value of flying someone out for this? But that question is all the more real and hard to grapple with and also, I know, also desperate in the context of what's just happened. Like you have also, as the reader, become close to this child and the course of a few pages. And then there's questions that exist. Like what happens—I feel like sometimes from afar, we can all ask questions about, well, what's the point? And they're important questions, but I think sometimes the way we ask them is quite flippant about, well, what's the point of this? Or couldn't it have been done in this way? And the book also does a good job of explaining the places where those kinds of questions are—need to be asked in some ways, especially in like the global health policy, but how you can't have them without separate—you can't have them completely separate from the one-on-one patient experience. Like you can't have them separate from the doctor-patient.
John: Yeah, you can't separate them from human need, right.
Rosianna: Yeah.
John: And that's a lot of what was happening in the conversations about treating multidrug-resistant tuberculosis. And so it seemed impossible, but one of the reasons it seemed impossible is because no one was doing it.
Rosianna: Right.
John: And now I think it costs—I think it's literally 99% reduced cost to treat multidrug-resistant TB versus what it was when PIH started doing it in Peru. And what that tells me is that sometimes the most cost-effective things, you know, the things that can have the most transformative impact are not immediately apparent.
Rosianna: Yeah.
John: And one of the challenges that the global health community has, and that people who are interested in and passionate about trying to find the best ways to support global health initiatives have is that sometimes—what is easy to measure is not what is most important. And sometimes we need to figure out how to do something, rather than assuming that we can't do it. Antiretroviral therapy is another example. It was just assumed that we—it couldn't be done in extremely poor communities and that was wrong. And if ten years or five years earlier, or ten years earlier, we had accepted that that was wrong. We had known that that was wrong. Hundreds of thousands of people who died wouldn't have died. And if we'd waited another ten years, millions of people who haven't died would have died and understanding that—this is—obviously you have to allocate resources smartly. You have to think about how to allocate them. But this is a human story. And I know this stuff is complicated and it's difficult and I don't think that there are easy answers, but I think assuming there are easy answers or that it is easy to measure outcomes is a mistake.
Rosianna: Yeah. It comes down to—well, for me, it felt like it came down to—even that sounds like so simplistic. "It comes down to this, me the authority on global health."
John: Right.
Rosianna: But for me it also—it felt so much came down to value and whose lives we think have value—
John: Yeah.
Rosianna: —whose lives are worth saving and the different ways we measure that or generalize about that.
John: Yeah.
Rosianna: Yeah, it was just devastating. I mean, I hadn't heard about either—well, either of the big tuberculosis outbreaks that are mentioned in this. Like specifically Peru, and then also Russia. Like I hadn't heard about that at all. And that, you know, that's not that long ago, really.
John: No, and I mean, tuberculosis is still a leading cause of death. I mean, we visited a MDR-TB center in Sierra Leone that's supported by Partners in Health. And, you know, for now the only way to get treatment, if you have MDR TB, is—you have to live at the facility. And that's how it works.
Rosianna: Wow.
John: But it is a way to get treatment and, you know, it's a way to get cured eventually. And—so there's a lot of hope in that, because until recently there was no—if you had MDR TB, you received, you know, quote unquote supportive care, until you died. And that was the case in every poor country or—and even in many middle income countries, like Russia. That was the case until PIH began to treat people. And then was able to make the argument that it could be done. And in fact, that they had like higher rates of people sticking with the treatment regimen than even many settings in rich countries.
Rosianna: Yeah. Yeah, because it—I mean, it was just so telling to me that I have always associated TB with like, Victorian times, because—
John: Yeah.
Rosianna: —in my context, that is what it is. Like it's a Victorian illness that's almost a punchline in—like it sounds horrible to say, having just read this, but it's like a punchline. Oh, you're in bed and you're suffering from TB and it's kind of in that so past context, it feels so distant as we keep saying, it's so distant from you. It's so different from your context. And then—
John: Right, yeah. I mean, it's something that killed 19th century poets and Brontë sisters, right? Like that's how we mostly construct TB, but it's also one of the biggest health problems in the world. And part of—I think part of what allows those of us who live in rich countries to feel distant from those health emergencies is that we don't think that they are coming to us, right? Like we don't worry about malaria. We don't worry about typhoid or cholera. We don't worry about tuberculosis because those diseases have largely been eradicated from most rich countries. And we don't worry about Ebola until Europeans or Americans start to get Ebola or somebody contracts Ebola and comes to the United States. And then it is front page news.
Rosianna: Yeah.
John: And then there are tens of millions of aid dollars suddenly flowing in to West Africa to treat the Ebola epidemic. And then the Ebola epidemic ends or at least Europeans stop getting it. It fades from the news. The money goes away and the healthcare system has not been meaningfully strengthened and 15% of Sierra Leone's healthcare workers have died of Ebola. And so—and there's no real lasting investment. And so there's no way to improve the weakened healthcare system, which means that future emergencies are both inevitable and they're going to be much worse than they otherwise would be.
Rosianna: Yeah. And I—it was such a good insight into how they're able to get the funding for their work is in part, by having to make the case that this illness could affect you. This could—
John: Right.
Rosianna: —get into this rich country. This could affect you specifically. It's not like it—is what it was saying. And that the fact that that case has to be made is so frustrating, but you also—I also at least understand not why, because it's frustrating that it's why, but there's an understanding of how you have to kind of play to some degree on the terms that have been laid out in the table. And then meanwhile, on the side, manage to do the work that you need to do. I don't know how—I'm not phrasing that well. But somehow—
John: No, I know exactly what you mean though. Like it—this is a huge challenge that there is distance in terms of empathy, you know?
Rosianna: Yeah.
John: And that's natural, it's normal, it's healthy. If we felt the death of all 155,000 people who are going to die today on Earth, the way that we would feel the death of someone in our family, we would be consumed by grief at all times. And if we felt the joy of every birth, you know, like it would be completely—we wouldn't be able to function. And so I think it's natural and normal that there are limits to empathy. What I think isn't natural and isn't inevitable is for us to feel like some human lives matter more than others.
Rosianna: Yeah.
John: Like I think at the end of the book, Tracy Kidder writes that the founding idea of Partners in Health is that the world's problems come from the belief that some human lives matter more than others. And I completely agree with that. I think whether it's climate change or healthcare or extractive resource capitalism, we don't act like all human lives have equal value and if we did, we would act differently.
Rosianna: Yeah. Yeah, I really agree with that. Oh, I mean, there were some also—lighter parts—a couple of lighter parts in the book that I really loved, including just the small personal detail that Dr. Farmer gets a wake up call from his mother when he travels—
John: Yeah.
Rosianna: —even when it’s 1am. I love that and I still love—and this isn't really lighter, but I think it's something that we all really clung onto from the Discord and also just as we were reading—was that line, "Honey, are you incapable of complexity?" Which is just—
John: Yeah.
Rosianna: —what a gift of a line.
John: Yeah, and a line that I want to hold onto for the rest of my life, right?
Rosianna: Yeah.
John: Like, I mean, there's so many things in my own life like that, where I want to dismiss other people's superstition, or I find it frustrating that other people are trying to ascribe meaning to things that I'm convinced are meaningless. But, I mean, where do I get off? You know, like, when I see it a tails-up penny and think, oh, that's it, I'm doomed for sure. Today's going to be a bad day. We all—you know—we are magical thinkers. The human brain is a weird myth-oriented place. And I don't think there's any—like, fully eradicating that.
Rosianna: Yeah.
John: And I also—the great thing about that line, about "Are you incapable of complexity?" is that it argues—inherent to it, I guess, for me, is the argument that we don't need to eradicate that from our brains. We only need to eradicate the parts that are unhelpful or inaccurate or lead us toward, you know, increasing injustice or whatever. It made me feel better, honestly, about my obsession with heads-up pennies. Because it made me think like, you know, as long as this isn't making the world worse.
Rosianna: Right.
John: Uh, I don't know.
Rosianna: Yeah, and I—again, really flagged to me like how much that becomes an excuse for not doing something.
John: Right.
Rosianna: Like, oh, well they believe this, so we can't do that. And it's so us and them again.
John: Yeah.
Rosianna: But yeah, it's kind of like someone saying like, oh, we can't have a national health service here because all of these people believe that whatever they're wearing on the day of the ballgame will affect the outcome of this match.
John: [laughs]
Rosianna: It's like that.
John: Yeah.
Rosianna: Yeah.
John: And also—yeah, all these things become excuses, right? And instead of looking at root causes, we end up using those excuses to shut down the parts of us that otherwise would be really deeply challenged by confronting the reality of massive structural inequality in our world.
Rosianna: On that note, I mean, obviously a big part of these conversations is a level of cultural awareness and cultural sensitivity, and also understanding the colonial histories of certain countries. Like you talked wonderfully about the resource extraction in Sierra Leone and how that's—that video is up, right? I don't—
John: It's not up, I don't think—
Rosianna: Oh.
John: —but maybe it will be by the time this is done.
Rosianna: Oh, sorry!
John: I did write it, though—
Rosianna: I can say it's something different.
John: —and Rosianna's read the script. It's about why Sierra Leone is poor and how the poverty of Sierra Leone can't be disconnected from the wealth in other places.
Rosianna: But—sorry for the spoiler—I do think that even there is, I don't know, that's just a level of using even that fear, which is a very valid fear of not understanding and respecting and appreciating the different power structures at work and the colonial histories, especially as a British person, I think about matters a lot, but also as a Mexican person, I think about this a lot from a slightly different perspective, about not being aware of that power and of course, of that white savior narrative of someone coming in and imposing a different way of doing things, but then also taking the glory of it. I think those are all important conversations to have, but it is also important to think about how sometimes, at least it feels like in contemporary times, that again becomes an excuse of some form or can be used an excuse of some form to qualify inaction or—
John: Yeah.
Rosianna: —dismissal and that's something I was thinking about a lot.
John: Yeah, I thought that the Life's Library community asked this question really well of the founders of PIH and I loved their answer, which was long and I don't remember all of it, but the first part was a two word sentence. How do you deal with post-colonialism and with the challenges of coming into communities that—where you aren't and their first answer was with humility.
Rosianna: Yeah.
John: And, that to me, is correct. And then also with deep partnerships and beginning by listening instead of by talking. And also, I do think it is really important to be aware of the fact that you can do real harm. You know, you can stomp on existing things that are working and you can shut those out by virtue of your size and your wealth when you're a big donor. And you can also do harm in lots of other ways. When you have power, your unintended consequences also have lots of power. And it's very important to be aware of that, but that's actually one of the things I really like about PIH—you know, is in Sierra Leone, 96% of PIH's employees are Sierra Leonean and the emphasis—at this point, I think it might be even higher than that—the emphasis that I saw, and certainly that they have by reputation is on listening and coming to these problems from a place of humility and from a place of listening and understanding that people know what their problems are.
Rosianna: Yeah.
John: You just have to listen.
Rosianna: Yeah. And then—I cut you off earlier, were you about to say?
John: Oh, I was—it was about—just to give one example of this. When we were in Sierra Leone, we traveled around for half a day with a community health worker named Ruth who makes house calls to people who have chronic illnesses, usually HIV or tuberculosis or both. And Ruth asks her patients, did you take your medicine yesterday and have you taken it today? Whereas like my psychiatrist, you know, like every 12 weeks, will be like, have you been taking your medication? Which is a vague question that always receives a vague answer. Like Ruth is able to ask her patients, have you taken your medication today? Which is a specific question that usually gets a specific answer. But we were with one woman who seemed very ill. And she said she hadn't taken her medication. And Ruth asked, what's preventing you from taking your medication or what's standing in your way? And the woman said, well, you know, when I take it, without any food, I get really sick, I throw up—which is very common with anti-retroviral—certain anti-retroviral medications. And then Dr. Barrie, the Sierra Leonean doctor I mentioned earlier, was with us and Dr. Barrie said, drink water with a little bit of sugar in it. If you haven't been able to eat—because this woman didn't have food, she wasn't able to eat. And he said, if you drink water with sugar in it, it'll make it easier when you take the medication. It'll keep your stomach from hurting. That's advice that, you know, doctors coming in from Harvard might not know to give.
Rosianna: Yeah.
John: And—but because of the deep partnership with the Ministry of Health, with physicians who are already running clinics and working in Sierra Leone, that's information that that patient is able to get and is able to internalize into her life. And then the other thing is that Ruth is able to say, because of PIH's model, Ruth is able to say, this woman can't take her medicine because she doesn't have food. So we need to give her money to buy food.
Rosianna: Right.
John: Because that is part of health care.
Rosianna: Yeah, that's part of the treatment.
John: That is part of the treatment for this woman's HIV, is that she needs to be able to have a little bit of food in the middle of the day so that she can take her medication.
Rosianna: I mean, there's that remarkable portion at the end of the book where they have that very, very long walk.
John: Yeah.
Rosianna: Very, very long walk. And then they go to a home and, you know, see that it needs concrete floors and a tin roof and that's part of the care too. Like the idea that you can separate that from healthcare—having read this book now seems absurd. Like, of course you can't separate it. And we talk about it sometimes and—in sometimes, you know, of clean water, which is of course very important and other big things, but then it's all the little things as well. The little things that are in themselves big that are a central part of healthcare and how we think about it.
John: Yeah. Yeah, we've kind of been trained to think about either ors, you know. To think about either clean water or vaccines, either electricity or better staffed clinics. And one thing I liked a lot about the way Dr. Farmer in the book pushes back against that way of thinking is that he's correctly arguing that there are plenty of resources available in the world for both and. We imagine Sierra Leone as a very poor country because the people who live there are very poor, but it is not an objectively, very poor country. It is objectively a very wealthy country. It's rich in natural resources. It's rich in arable land. It's impoverished. It's a country that has had its wealth taken from it and as a result, the people there are poor. But there are plenty of resources on Earth. You know, there are plenty of human resources. There are plenty of financial resources to take a healthcare system that has nine or ten dollars per person per year to spend on healthcare and change that to nineteen or twenty dollars, which is the difference between—or if it's well allocated and spent well—is the difference between thousands of women dying every year in pregnancy and childbirth for no reason, other than the fact that they are pregnant, to seeing that reduced by eighty or ninety percent.
Rosianna: Yeah.
John: The resources are there, they're just allocated horribly. Like there are more doctors—for context, there are more doctors in the building where I currently am recording this podcast right now than there are in the nation of Sierra Leone.
Rosianna: Wow, really?
John: Yeah.
Rosianna: Oh my god.
John: It's about 160 to 150.
Rosianna: Wow. Yeah, the past years about not having the resources, like the idea of a resources always being limited and you've got to be realistic about it and what we can't spend—like that really feels like it goes back to that question of whose lives do we value and what was it? Let me find it. It says, strictly speaking all resources, everywhere were limited, pharma would say in speeches. Then he'd add, but they're less limited now than ever before in human history. Yeah, I don't know.
John: Yeah.
Rosianna: It just feels like, again, like another one of those things I just hear over and over again and kind of had assumed to be true.
John: Yeah.
Rosianna: Like there was—that there was some limit on it and that things couldn't be done and so inherent in that is some dismissal of a life, or hundreds of people's lives, or hundreds of thousands of people supplies or millions of lives—
John: Right.
Rosianna: —because there's that thing of like, well, we can't help, but it's almost not our fault because the natural structure of resources has not fallen in favor of us helping. Yeah.
John: Right, but yeah, and I agree that it's just unnatural. And I mean, having said all of this, I want to be clear that I am not—I have not sold my tuxedo either metaphorically or literally. I think I need to. And I'm trying to figure that out. But I also—like a lot of people reading this book, I kept thinking like, well, that's great if you're a saint, but I'm not, you know. I love fancy things. Like I have a horrible, horrible love of fancy things. And—
Rosianna: Right, but I—you know—
John: Yeah, and so I think I—I think—
Rosianna: —he likes a good bottle of wine.
John: I love a good bottle of—I mean, that's the least of it, but yeah, I do love a good bottle of wine.
Rosianna: No, but I was saying Dr. Farmer does, too.
John: Oh.
Rosianna: Yeah.
John: Yeah, yeah. But I—
Rosianna: But there is that great tension, the book also of like, Tracy being scared of having him be disappointed in him or—
John: Yeah.
Rosianna: —you know, that fear of disappointing him in some way through what he's done or what he said. And then those times when he does push back and get angry at him.
John: Yeah. So I just think like, I'm not trying to come at this from the perspective of someone who's doing a good job, because I want to be clear that I'm not doing a good job and really, it's much harder for someone who's making $10 to donate $2, than it is for someone with lots of money to donate lots of money. Which is one of my ongoing annoyances with things being named after rich people, which is one of the the one of the rants that Rosianna has heard from me a million times. But like, I'm so tired of seeing the such and such school of such and such, you know?
Rosianna: Yeah.
John: Because it didn't hurt you to give that a hundred million dollars. Like it wasn't hard. All you—you went from being a billionaire to being a billionaire. Like you went from infinite resources to infinite resources. And I really don't want anything ever named after me. I really—not because I'm humble—I'm definitely not. I'm a complete narcissist. It's not that. I just don't want to go to hell.
Rosianna: I just—I was just remembering when I was living in Indianapolis, you see the same names over and over again on different things.
John: Oh, five names.
Rosianna: Yeah. Over and over again. And I thought that that was so bizarre and so funny. And then I came back to London and I realized that it's the exact same thing here. You just see the same—
John: Yeah.
Rosianna: —you see the same names. And of course, there have been certain names that have got more publicity lately.
John: Yeah.
Rosianna: But you just see them everywhere. And for some reason, I was like, oh, how quaint. Indianapolis has the same five rich families. No, we do too. It's just different scales.
John: Yeah, and I should say that I'm very grateful to those five rich families.
Rosianna: Right.
John: It's like, you could do nothing and, and God knows, lots of people do.
Rosianna: But it does—it goes back to this thing of this—the person who gives and who gives most importantly is the person who gives this grand amount of wealth, regardless of what percentage of their income that is, regardless of whether they were born into that wealth or not—it is—yes, it's very important that that wealth has been given. But at the same time, I think it comes back to that tension I have with how we talk about giving in contemporary culture.
John: Yeah. Yeah, I totally agree. I think we need to make an emphasis on how many people are part of the project that we're doing in Sierra Leone instead of just how much money's being raised, you know—
Rosianna: Yeah.
John: —because really, it's true that money is extremely important. And you know, donations are what pay for Ruth's salary and many other community health workers in Sierra Leone and doctors and nurses and medicines and all kinds of things. But it's also true that if we were all paying attention to the needs of the of people in extreme poverty and trying to listen to their voices and trying to find ways to amplify their voices so that they can be heard. Like if we were all doing that—if that were the focus of our international global attention, the problem would end.
Rosianna: Yeah.
John: Like maternal mortality in Sierra Leone would decline by 90% very quickly because inevitably our resources end up going where our attention goes. And so when our attention is turned to this disaster or that disaster, our resources go there, which is very important—disaster response is super important, just like it's super important for the five wealthy families in Indianapolis to fund infrastructure projects and you know, all the stuff that we need to be a good city. But where we put our attention, in the end, helps dictate where we put our resources. And right now very, very little attention goes to the problems of the people who are the most vulnerable and the most marginalized because we literally don't hear their voices, right? They aren't on Facebook. They aren't on Twitter. They aren't on Reddit. I mean, when I was in Sierra Leone, I had this idea of how do we amplify people's voices? How do we hear directly from people? Well, like you can't give someone a video camera. Because a) they don't need a video camera, right?
Rosianna: Yeah.
John: That's not on the list of central needs and b) there's no way to upload video. So it doesn't matter. Unless you're in Freetown. The internet is way—you know, like I thought that I was gonna make a video in Sierra Leone. I ended up having to take off Tuesday. I got there and I was immediately like, oh my god, what was wrong with me that I thought that was going to be easy?
Rosianna: Right.
John: Like what's been hardwired into my brain incorrectly that I thought I was going to be in Koidu Town in western Sierra Leone and have no problem uploading a six gigabyte file onto the internet.
Rosianna: Because that's the number one priority. Yeah.
John: Right. Yeah, exactly. It was so—it was immediately clear to me that that's not—yeah, it's not a short term goal for the government of Sierra Leone. Nor should it be.
Rosianna: Yeah. Well, I feel like that's a good note to end it on, really. I don't really know what a good note to end it on would be, but I—
John: Yeah.
Rosianna: It was just—I mean, I felt like for me, so much of this would—the beginning of a conversation or a way of thinking about things of reading this book and kind of the middle of it, too, because it slots in very well with a lot of the conversations we've been having on the Discord and on your YouTube channel and across the past few years. I was remembering the first book we read for —was it the Blurbing Book Club? Oh, god, the one about Rwanda.
John: Oh, We Wish to Inform You That Tomorrow We Will Be Killed With Our Families. Rosianna: Yes. Yeah. That came up a lot in my head as I was reading this.
John: Yeah. I mean, and if you look at the last ten years in Rwanda, where Partners in Health has a cancer center—in fact, I met a boy in Sierra Leone who was treated for cancer in Rwanda and is now fine. You know, a boy like John in some ways—the boy in this book—whose cancer was identified earlier and who was able to get the treatment that he needed and now is in school and is at the top of his class and just an amazing, amazing kid. That was inconceivable in Rwanda a decade ago.
Rosianna: Yeah.
John: But you know, it's actually—I think Rwanda has the fastest increase in life expectancy over the last decade in human history.
Rosianna: Wow.
John: If I remember correctly. Don't quote me on that.
Rosianna: Okay. Everyone google it.
John: Yeah. Yeah, I'm sure somebody will point out to me that I'm incorrect, but I heard that somewhere.
Rosianna: So it must be true.
John: Oh, god, the welcome to 2019.
Rosianna: Yeah.
John: But yeah, thank you for reading this book with us. Obviously this one means a lot to both Rosianna and me, and we really appreciate you reading this book with us and we appreciate whether you're on this journey with us as fellow donors or as attentive people or if you're just passing by, we really appreciate it. For the last several years, this has been the focus—increasingly the focus of my non-professional life and I think that's only going to grow. And so hopefully our community will be able to follow what's happening with PIH Sierra Leone over the next several years and see what happens when you invest in a major way in trying to help people to have better healthcare options.
Rosianna: Yeah. Well, thank you very much for picking the book, John.
John: Yeah, I look forward to reading your pick.
Rosianna: Yes. Slightly different. It's called The Summer Book. That's the next one, I think.
John: It's perfect. It's just what I need. I need a summer book.
Rosianna: Yeah. Just in autumn.
John: Especially because it's getting dark.
Rosianna: Yeah, it's getting so dark!
John: This morning was the first morning I woke up and like, it was dark. Fully dark. And I was like, oh, I have to take the kids to school in the dark. For six more months.
Rosianna: Yeah. I've been feeling real sad about that in the mornings, I have to say. Although at night I just go to bed really early now, so. I went to bed at eight last night.
John: That sounds lovely.
Rosianna: It was great.
John: That sounds lovely.
Rosianna: Yeah.
John: All right, well, it's great to talk with you and thanks again to everybody for reading with us.
Rosianna: Thanks, everyone. Goodbye!
John: Bye.