by Tracy Kidder
They headed upstairs, to visit Joe.
Farmer moved through the Brigham in a long-legged stride, making intermittent headway. He’d pause to receive a hug from a nurse’s aide, then to exchange quips in Haitian Creole with a janitor. Then his beeper would go off. Answering the page, he’d greet the hospital operator—whichever of the dozen or so came on line—and quickly ask about her blood pressure, or her husband’s heart condition, or her mother’s diabetes. Then he’d have to stop at a nurses’ station to answer an e-mail about a patient, then to answer a question from a cardiologist. Finally, stethoscope around his neck and singing in creative German, “We are the world. We are das Welt,” Farmer led the infectious disease team to the patient’s door. Then everything slowed down.
Joe lay on his covers, dressed in blue jeans and a T-shirt, a small man with scarred and wiry arms and prominent collarbones. He had an unkempt beard and unruly hair, and when he smiled nervously at the doctors trooping in, I saw he still had most of his teeth but probably wouldn’t for long. Farmer introduced himself and the members of his team. Then he sat down at the head of Joe’s bed, on a corner of the mattress, folding himself half around Joe in an agile way that made me think of a grasshopper. He leaned over Joe, gazing down at him, pale blue eyes behind little round lenses. For a moment, I thought Farmer might climb into bed with him. He placed a hand on Joe’s shoulder instead and stroked it.
“Your X ray looks good. I think it’s probably pneumonia. A little bit of pneumonia. Let me ask you, how’s your stomach? Do you have any gastritis these days?”
“I’m eatin’ everything in sight of me. Everything in front of me I eat.”
Farmer smiled. “You need to gain some weight, my friend. You’ve lost some weight.”
“I didn’t eat much when I was outside. I didn’t eat much at all. Messin’ around, doin’ this, doin’ that.”
“Talk to us a little bit. We’re in infectious disease, and we don’t think it’s tuberculosis. Before I say that, though, any exposure to anybody with TB?”
Joe didn’t think so, and Farmer said, “I think we should go ahead and make a recommendation that you not be isolated. We’re ID, right? ID says hi. I think you don’t need to have a negative airflow room and all that.”
“Nah. A fella’s in a boat by himself, y’know. People come in with masks on their heads and wash their hands all the time.”
“Yeah,” said Farmer, adding, “but washing the hands is good, though.”
This day was the first on which I’d seen him at work, and it seemed to me just then that his part in the case was closed. Fancy specialist is called in to answer a question. For once, it is vanishingly simple, at least for the specialist. He answers it, makes some small talk with the patient, then departs. But Farmer was still sitting on Joe’s bed, and he seemed to like it there.
They talked on and on. Judging from the resident’s earlier report, she had asked many of the same questions as Farmer. But Joe was responding with greater candor now. He and Farmer talked about Joe’s regular doctor, whom Joe liked, and about the fact that Joe had taken antiretroviral medicines for his HIV, but only erratically, Joe confessed, and Farmer explained that he might well have acquired resistance to some of those drugs and probably shouldn’t risk taking others until he found himself in a position to take them faithfully. They talked about drugs and alcohol, Farmer warning him against heroin.
“But really the worst ones are alcohol and cocaine. We were saying downstairs during rounds, we were kinda joking around, saying, Well, we should tell him to smoke more marijuana, because that doesn’t hurt as much.”
“If I smoke marijuana, I’ll create an international incident.”
“Not in the hospital, Joe.” The two men laughed, looking at each other.
They talked about his HIV. “Your immune system’s … pretty … good, you know. Workin’ pretty well. That’s why I’m a little worried that you’re losing weight, you know. Because you’re not losing weight on account of HIV, I bet. You’re losing weight because you’re not eating. Right?”
“Yeah, that’s right.”
“Yeah,” said Farmer softly. The way he stared at Joe’s face just then seemed both intent—as if there were no one else in the world—and also focused elsewhere. I thought in his mind he might be watching Joe from a high window, as Joe went about what are known in social work as the activities of daily living, which in his case would mean scoring some narcotics on a corner, then heading off to his favorite bridge or underpass for camping.
In the midst of all this, another person entered the room, a medical student whom Farmer had invited to join him on rounds. Farmer introduced her. Joe had asked all the other doctors where they’d gone to school. Now he asked the newcomer in his Boston accent, “Are you a Hah-vahd graduate, too?”
“Am I?” she said. “Yes.”
“Wow,” said Joe. He turned back to Farmer. “I got some people from high places lookin’ at me, huh?”
“She’s a hotshot,” Farmer said. And the conversation resumed. “So tell us now, Joe, how can we help? Because we know how the system works here. You come in here, you like us, we like you, you’re very nice to us, we’re very nice to you, and I think you feel like people here treat you right at home.”
“I feel kinda lonesome in this room!” said Joe.
“That’s true. And we’re going to recommend that you get out of this,” said Farmer. “So here’s my heavy question for you. Heavy but good.”
“What you can do for me.”
“Yeah!”
“You ain’t gonna believe what I’m gonna say. You ain’t ready for this,” said Joe.
“I’ve heard it all, my friend.”
“I’d like to have an HIV home where I could go to …”
Farmer was gazing down at him again. “Yeah.”
“Sleep and eat, watch television, watch games. I’d like somewhere I could go where I can drink a six-pack.”
“I understand.”
“I’d like to go somewhere where I wouldn’t get in trouble, maybe have a couple too many beers, as long as I’m doin’ what they tell me, and I’m home on time and I don’t mess around, y’know.”
“Sure.”
“And I don’t drive everybody crazy, runnin’ out the doors and everything, y’know. Somewhere I could maybe even have a bottle of wine for dinner or something.”
“Yeah,” said Farmer. “I can see your point.” He pursed his lips. “So I’ll tell you what. I’ll look around, and you’re going to be here probably a couple of days, and you know I don’t think it’s that crazy an idea at all, what you said. Is it better to be out on the street using?”
“Freezing to death,” added Joe.
“Freezing to death,” said Farmer. “Or inside having a six-pack of beer or some wine with dinner? I know what I would want. The other thing is, if you have a place to stay, you could take medicines, if you want to take medicines.”
“Yeah,” said Joe, dubiously.
A few days later on the message board outside the door of the Brigham’s social work department, a cryptic handwritten message appeared. It looked like this:
Beneath this someone had scrawled: “Why do I know Paul Farmer wrote this?”
Friends of Farmer’s had found a homeless shelter for Joe, but of course the social workers had reminded Farmer that shelters forbade drinking, and for good reason, too. He was still pleading Joe’s case, just to keep his promise, I supposed, not expecting to win the argument.
Farmer was on service at the Brigham on Christmas. He spent part of the day visiting patients outside the hospital. He brought them all presents, including Joe—who got a six-pack of beer, disguised in wrapping paper.
Joe seemed glad to see him, as well as the present. As Farmer was leaving the shelter, he heard Joe say to another resident, just loudly enough to make Farmer wonder if Joe meant for him to overhear, “That guy’s a fuckin’ saint.”
It wasn’t the first time Farmer had heard
himself called that. When I asked him his reaction, he said that he felt like the thief in Hawthorne’s novel The Marble Faun, who steals something from a Catholic church and, before making his escape, dips his hand in holy water. “I don’t care how often people say, ‘You’re a saint.’ It’s not that I mind it. It’s that it’s inaccurate.”
This was seemly, I thought, resisting beatification. But then he told me, “People call me a saint and I think, I have to work harder. Because a saint would be a great thing to be.”
I felt a small inner disturbance. It wasn’t that the words seemed immodest. I felt I was in the presence of a different person from the one I’d been chatting with a moment ago, someone whose ambitions I hadn’t yet begun to fathom.
Farmer finished up his service at the Brigham and went to Haiti on New Year’s Day 2000. We had an exchange of e-mails. He had sent me a copy of his latest book, Infections and Inequalities, a prodigiously footnoted discourse with case studies of individual patients to illustrate its main themes—the connections between poverty and disease, the maldistribution of medical technologies in the world, and “the immodest claims of causality” that scholars and health bureaucrats had offered for those phenomena. At times, it seemed that the author could hardly contain his anger. He described giving antibiotics to an impoverished TB patient, then wrote: “When she received them, she soon began to respond—almost as if she had a treatable infectious disease.” The Paul Farmer who had written that book didn’t seem much like the Paul Farmer who worked at the Brigham. This one was shouting on every page. I wrote to thank him for the book and added that I planned to read his previous two. “I’m reading your oeuvre,” I wrote.
By e-mail he replied: “Ah, but that is not my oeuvre. To see my oeuvre you have to come to Haiti.”
CHAPTER 3
Farmer had sent a truck, a sturdy four-wheel-drive pickup, to the Port-au-Prince airport, and I was driven north away from the capital on a two-lane paved road. On the other side of the Plaine du Culde-Sac, though, at the foot of a wall of mountains, the road turned into something like a dry riverbed, and the truck began pitching and rolling, scaling its way up the cliff—look down over the edge and you saw a boneyard of truck bodies. No one talked much from then on, not even the friendly, chatty Haitians in the front seat.
On maps of Haiti, the road we traveled, National Highway 3, looks like a major thoroughfare, and indeed it is the gwo wout la, the only big road across the central plateau, a narrow dirt track, now strewn with boulders, now eroded down to rough bedrock, now, on stretches that must have been muddy back in the rainy season, baked into ruts that seemed designed to torture wheels, hooves, and feet. It wound through arid mountains and villages of wooden huts. It forded several streams. Trucks of various sizes, top-heavy with passengers, swayed in and out of giant potholes, raising clouds of dust, their engines whining in low gear. A more numerous traffic plodded along on starved-looking donkeys and on foot. Here and there beggars stood on the banks of the road, rubbing concave bellies with one hand while holding out inverted straw hats. Here and there boys with hoes smoothed out little patches of roadway, making shows of their diligence, then lifting their hands in the hope of reward. One noticed absences. An oxcart and no ox, only a man pulling it. Scant trees, especially after Mirebalais. No power poles after the town of Péligre.
The trip, of only about thirty-five miles, lasted three hours and seemed longer by far. It was dark when, at the top of another steep and rocky incline, in the village of Cange, the truck’s headlights lit up a tall concrete wall, then a gate in the wall and a sign beside it that read ZANMI LASANTE, Creole for “Partners In Health”—on the sign there was also a picture, of four open hands reaching in from the cardinal points of the compass, all the fingers touching. Then the truck turned in at the gate, and the relief of smooth pavement followed. So I felt Farmer’s oeuvre before I saw it.
In daylight, in an all but treeless, baked brown landscape, Zanmi Lasante makes a dramatic appearance, like a fortress on its mountainside, a large complex of concrete buildings, half covered with tropical greenery. Inside the walls, the world turns leafy. Tall trees stand beside courtyards and walkways and walls, artful constructions of concrete and stone, which mount the forested hillside, past an ambulatory clinic and a women’s clinic, a general hospital, a large Anglican church, a school, a kitchen that prepares meals for about two thousand people daily, and, near the top, a brand-new building for the treatment of tuberculosis. The medical complex contains two laboratories. There is running water, and you can hear a big generator churning out electricity. The buildings have tiled floors and clean white walls and ceilings, and paintings by Haitian artists, the soothing kind, full of color, which reimagine the tropical paradise that the journals of Christopher Columbus describe.
The morning after I arrived, I followed Farmer on his rounds through this place, for the first of many times. The general routine was always the same. His day begins around dawn, in the lower courtyard beside the ambulatory clinic. At night I would see in the moonlight the shapes of perhaps a hundred people sleeping there on the ground. In the morning, there are twice as many, people of all ages, the women in dresses and head wraps, the older men in straw hats, and many in shoes that are falling apart, all waiting to see a doctor or nurse.
As Farmer comes in through the gate, dressed in his Haiti clothes—black jeans and a T-shirt—a part of the crowd advances on him. An old man who needs money for food, a woman with a letter she wants him to take to the United States, a young man who has been seen by another doctor here but wants to be examined by Farmer and is calling to him, “I have many things I want to discuss with you, Doktè Paul.” Mainly, Farmer searches the crowd for people in urgent need. A nurse has already found one of those, a pretty young woman with her hand wrapped in a towel. The nurse calls to Farmer. He walks over, peels back the towel, and looks in at the hand.
“It’s gangrene,” he says to me. “Smell it.”
He gives the nurse instructions for cleaning the wound. His face looks grim as the nurse leads the woman away. “Her hand was injured fifteen days ago. I wonder if she knows what’s coming, you know. As if they didn’t have enough problems. Even their minor injuries go unattended.”
It usually takes him an hour to make his way through the courtyard. He has almost reached the other side when a small, elderly man approaches, takes off his straw hat, and says in Creole, “I am looking for a man named Doktè Paul.”
Farmer smiles. “Do you know Doktè Paul, Father?”
“No,” says the old man. “But I was told to seek him out.”
One of the staff takes the man by the arm. “Let’s see if we can find Doktè Paul.” As she leads him away toward another doctor, Farmer finally escapes, a lanky figure striding up the shaded concrete path toward the kitchen and the little room above it where every morning, before patients, he sends and receives e-mail via a satellite phone.
I may as well say that from the moment I saw Zanmi Lasante, out there in the little village of Cange, in what seemed to me like the end of the earth, in what was in fact one of the poorest parts of the poorest country in the Western Hemisphere, I felt I’d encountered a miracle. In Haiti, I knew, per capita incomes came to a little more than one American dollar a day, less than that in the central plateau. The country had lost most of its forests and a great deal of its soil. It had the worst health statistics in the Western world. And here, in one of the most impoverished, diseased, eroded, and famished regions of Haiti, there was this lovely walled citadel, Zanmi Lasante. I wouldn’t have thought it much less improbable if I’d been told it had been brought by spaceship.
My first week in Cange I met a peasant farmer who had brought a sick child to the hospital—by donkey, on a trek of twelve miles along Highway 3. I asked him if he’d felt relieved when he got to Cange and the medical complex. I needn’t have bothered. He looked surprised at the question and simply said, “Wi!” There were a handful of other clinics and hospitals in the region, b
ut none were well-equipped and some were downright unsanitary, and everywhere patients had to pay for medicines, and even the gloves that would be used to examine them, and very few people in the central plateau could pay much of anything. At Zanmi Lasante, too, patients were supposed to pay user fees, the equivalent of about eighty American cents for a visit. Haitian colleagues of Farmer’s had insisted on this. Farmer was the medical director, but he hadn’t argued. Instead—this was often his way, I would learn—he had simply subverted the policy. Every patient had to pay the eighty cents, except for women and children, the destitute, and anyone who was seriously ill. Everyone had to pay, that is, except for almost everyone. And no one—Farmer’s rule—could be turned away.
Perhaps a million peasant farmers relied on Zanmi Lasante. At the moment, about a hundred thousand lived in its catchment area, the area served by its community health workers, seventy in all. Some patients came great distances, as distance is measured in a country of ruined roads and villages served only by footpaths—from Port-au-Prince and Haiti’s southern peninsula, and from towns along the border with the Dominican Republic, speaking Spanish. Most came from the central plateau, on the battered, overloaded passenger trucks that navigated Highway 3. Many came on foot and by donkey. Now and then out on the road, a bed moved slowly toward the front gate, a bearer at each corner, a patient on the mattress.
Sometimes Zanmi Lasante’s pharmacy muddled a prescription or ran out of a drug. Now and then the lab technicians lost a specimen. Seven doctors worked at the complex, not all of them fully competent—the staff was entirely Haitian, and Haitian medical training is mediocre at best. But Zanmi Lasante had built schools and houses and communal sanitation and water systems throughout its catchment area. It had vaccinated all the children, and had greatly reduced both local malnutrition and infant mortality. It had launched programs for women’s literacy and for the prevention of AIDS, and in its catchment area had reduced the rate of HIV transmission from mothers to babies to 4 percent—about half the current rate in the United States. A few years back, when Haiti had suffered an outbreak of typhoid resistant to the drugs usually used to treat it, Zanmi Lasante had imported an effective but expensive antibiotic, cleaned up the local water supplies, and stopped the outbreak throughout the central plateau. In Haiti, tuberculosis still killed more adults than any other disease, but no one in Zanmi Lasante’s catchment area had died from it since 1988.