by Tracy Kidder
Ordinarily Farmer’s skin is pale, with a suggestion of freckles underneath. Now it reddens instantly, from the base of his neck to his forehead. “You’ve already given me a lot. Stop it!”
Ti Ofa smiles. “I am going to sleep well tonight.”
“Okay, neg pa”—“my man”—says Farmer.
Then it’s time for rounds, first by flashlight down the paths to the hospital, and through the dimly lit main ward, where the beds are filled by adults, and then, with trepidation, to the Children’s Pavilion upstairs, where there always seems to be a baby with the sticklike limbs, the bloated belly, the reddish hair of kwashiorkor, a form of starvation. Just a week or so ago, on his first morning back in Cange, Farmer had lost a baby to meningitis, in its ghastly purpura fulminans presentation, the small vessels bleeding into the baby’s skin, making a rash of purple spots. And, only days later, another baby, from beyond Zanmi Lasante’s catchment area, died of tetanus.
Farmer lingers beside the crib of a little girl with wasted arms and a torso bloated by pleural effusion—caused by extrapulmonary TB. She lies on her side. He reaches in and strokes her shoulder, saying softly, almost singing, in English, “Michela wants to give up, but we’re not going to let her, are we? No, we’re not going to let her.”
Then he walks back up the hill, to the TB hospital, saving this visit for last, he says, because just now everyone up there is getting better. Most of the patients have gathered in one room and are sitting on the beds watching a soccer game on a wavy, snowy TV screen. “Look at you bourgeois people watching TV!” Farmer says.
The patients laugh. One of the young men looks up at him. “No, Doktè Paul, not bourgeois. If we were bourgeois, we would have an antenna.”
“It cheers me up,” Farmer says on the way out. “It’s not all bad. We’re failing on seventy-one levels, but not on one or two.” Then it’s back down the hill and out the gate and across Highway 3 to his house.
Night in the mostly unelectrified central plateau is vast. Roosters are crowing—they crow here at all hours—and a warm wind rustles the leaves of the trees that surround Farmer’s little patio, lit by battery power. It feels like the cabin of a small boat at sea, a cozy enclosure, where Farmer now sets to work on speeches and grant proposals, assisted by a young member of Partners In Health, a PIH-er in Farmer’s vernacular, sent from Boston for this purpose.
He holds a huge stack of medical studies on his lap. After a time, he puts them aside. “I’m not into this, guys.” He takes me on a survey of his grounds. It’s clear that a proper guest has to accompany him. “This is called hortitorture,” he says. He recites the names of the trees, vines, shrubs, flowers that he’s planted here over the years. I count about forty different species. Finally, in the dim light from the patio, he studies a new fern that has just come up. “It’s just vibrant and happy and healthy. The way a patient should be.”
The word, patient, is like a bell. He goes back to work on the pile of clinical studies. Minutes later Ti Jean, Zanmi Lasante’s chief handyman, appears out of the dark, summoning him back across Highway 3.
In a bed by the door of the hospital lies a moaning thirteen-year-old girl, just arrived by donkey ambulance. Two young Haitian doctors—one is just an intern—stand beside her bed, eyes half-lowered, lips pursed, as Farmer makes the Haitian hand slap, saying, “Doktè-m yo, doktè-m yo, sa k’ap pase-n?”—“Doctors, doctors, what’s going on with you?” His voice sounds plaintive, not angry, as he lectures: You do not administer an antibiotic to a person with meningitis until you have done a spinal tap and know the variety of meningitis and thus which drug will work.
Then he does the job himself, the young doctors looking on, holding the girl down.
“I’m very good at spinal taps,” he’s told me. He seems to be, and besides, he’s left-handed, and to my eyes left-handers at work have always looked adroit. The veins stand out on Farmer’s thin neck as he eases the needle in. Wild cries erupt from the child: “Li fe-m mal, mwen grangou!” Farmer looks up, and for a moment he’s narrating Haiti again. “She’s crying, ‘It hurts, I’m hungry.’ Can you believe it? Only in Haiti would a child cry out that she’s hungry during a spinal tap.”
CHAPTER 4
Soon after I arrived to visit him in Cange, Farmer said he’d be my Virgil here. I think that, when it came to Haiti, he viewed almost everyone as a potential subject for education, or reeducation. No other country in the world had been subjected to as much “idiotic commentary,” he said, and it would have been hard to argue the point, given the fact that, for instance, the name of Haiti’s indigenous religion had long since become the synonym for crazy ideas and sheer luridness.
Farmer liked to tell a story about his own education in Haiti, a story about the relation between medicine and beliefs in sorcery. Back in 1988, a woman from Zanmi Lasante’s catchment area had died of tuberculosis while he was in Boston recovering from a badly broken leg. When he returned to Cange, several of the staff told him the woman wouldn’t have died if he’d been on hand. They meant this as a compliment. He converted it to self-reproach. He wanted a medical system that functioned in his absence. He gave everyone in the woman’s family jobs at Zanmi Lasante and called a series of staff meetings to figure out what was wrong with their system for treating TB.
The staff had a lively debate. Zanmi Lasante’s community health workers, who lived among the peasant farmers, who had been until recently mostly peasant farmers themselves, spoke about the economic impediments to treatment, pointing out that the poorest patients tended to fare worst, certainly in part because of malnutrition. One health worker recited a Haitian saying: “Giving people medicine for TB and not giving them food is like washing your hands and drying them in the dirt.” But most of the Haitian professionals on the staff—the doctor, the nurses, the technicians—offered explanations that laid the blame in the minds of the patients, the kinds of explanations one often reads in scholarly journals. Once they felt better but long before they were cured, patients stopped taking their pills, the professionals said, and patients did this in part because they didn’t believe TB came from microbes but believed it was sent to them by enemies, via sorcery.
Farmer felt intellectually torn. The health workers’ theory amounted to a description of the kind of socioeconomic arrangement that he called “structural violence.” But he was also an anthropologist in training, schooled in the importance of the kinds of cultural beliefs that the professionals cited. So he designed a study. He was still a student at Harvard. The study was like a class he created and then attended as a pupil.
He selected two groups of TB patients. During the study, each group got free treatment, the same they would have received at the Brigham. But one group got other services as well, including regular visits from community health workers and small monthly cash stipends for food and child care and transportation to Cange. Farmer hiked to the many villages of the patients, visiting all of them in their huts. This took weeks. “A hundred chatty Haitians,” he would say. “Don’t try this at home.” He asked all of them, among other questions, if they believed TB came from sorcery, and all but a very few in both groups said that they did. And yet, when the results came in, the cure rates for the two groups were dramatically different. Of the patients who had received only free medicine, a mere 48 percent were cured. By contrast, everyone in the group that received the cash stipends and other services made a full recovery. Whether a patient believed that TB came from germs or sorcery didn’t seem to have made any difference at all.
Farmer felt puzzled. “I expected to buy into the idea that what’s in people’s minds affects their behavior and the outcomes,” he told me. And he was at a loss for explanations, until he began reinterviewing the patients and called on one of his favorites, a sweet, rather elderly woman. When he had first interviewed her, about a year before, she’d taken mild offense at his questions about sorcery. She’d been one of the few to deny she believed in it. “Polo, cheri,” she had said, “I’m no
t stupid. I know tuberculosis comes from people coughing germs.” She’d taken all her medicines. She’d been cured.
But now, a year later, when he asked her again about sorcery, she said that of course she believed in it. “I know who sent me my sickness, and I’m going to get her back,” she told him.
“But if you believe that,” he cried, “why did you take your medicines?”
She looked at him. He remembered a small sympathetic smile. The smile, he thought, of an elder explaining something to a child—in fact, he was only twenty-nine. “Cheri,” she said, “eske-w pa ka kon-prann bagay ki pa senp?” The Creole phrase pa senp means “not simple,” and implies that a thing is freighted with complexity, usually of a magical sort. So, in free translation, she said to Farmer, “Honey, are you incapable of complexity?”
And then of course it dawned on him that he knew plenty of Americans—he was one himself—who held apparently contradictory beliefs, such as faith in both medicine and prayer. He felt, he said, as though he hung in the air before his patient, “suspended by her sympathy and bemusement.”
The study was for him a command—to worry more about his patients’ material circumstances than about their beliefs. From then on, all TB patients in the catchment area received the full package of services. Each continued to get what is called directly observed therapy, a community health worker on hand to be sure the patient took the medicines on schedule, and each got the monthly cash stipend—the equivalent of about five American dollars—to pay for extra food, child care, and transportation to a monthly doctor’s appointment at Zanmi Lasante. The program had worked well, indeed, couldn’t have worked better. They hadn’t lost a single patient in twelve years, and Farmer wasn’t about to change any of the rules.
Just recently, a TB patient from a village called Morne Michel hadn’t shown up for his monthly doctor’s appointment. So—this was one of the rules—someone had to go and find him. The annals of international health contain many stories of adequately financed projects that failed because “noncompliant” patients didn’t take all their medicines. Farmer said, “The only noncompliant people are physicians. If the patient doesn’t get better, it’s your own fault. Fix it.” A favorite Doktè Paul story in the village of Kay Epin was of the time, many years back, when Farmer had chased a man into a field of cane, calling to him plaintively to come out and let him treat him. He still went after patients occasionally. To inspire the staff, he said, and to give him a break from his office. So he was going to Morne Michel himself, and was taking me with him.
“Beyond mountains there are mountains.” The proverb appeared to describe the location of Morne Michel, the most distant of all the settlements in Zanmi Lasante’s catchment area. At breakfast on the appointed day, Farmer told the women in the kitchen his intentions. “Ooooo!” they cried. One said, “Morne Michel? Polo, do you want to kill your blan?”
She meant me, of course. She wasn’t being rude. The women in the kitchen called even Farmer a blan—usually they called him ti blan mwen, meaning “my little white guy.” But a blan isn’t necessarily white-skinned; one might say, every blan becomes white by virtue of being a blan. The African American medical student Farmer had brought here some months back, for instance. Some people at Zanmi Lasante had wondered if he was Farmer’s brother, and later some had mistaken another visiting black American student of Farmer’s for the first one, and when Farmer teased them about this, one of the staff had said—Farmer swore this was true—“All you blan look alike.”
Farmer drove the first leg in the pickup truck, south down National Highway 3, past two-roomed huts with metal roofs and little granaries on stilts—built, he explained, to keep food safe from animals, but rats still ate about a third of harvests—and stunted-looking pigs and goats and scrawny yellow dogs. Smiling for a moment, he said that Haitian peasants had a lot of sayings: that they’re the only farmers with land so steep they break their legs in their cornfields, that their dogs are so skinny they have to lean against trees in order to bark. Soon a reservoir came into view, a mountain lake far below the road. The scene looked beautiful, blue waters set among steep, arid mountainsides. And, if you saw with peasant eyes, Farmer said, the scene looked violent and ugly, a lake that had buried the good farmland and ravaged the highlands.
He parked beside the ruin of a small cement factory. Plants were growing helter-skelter high up on the rusted structure. A hundred yards away stood a concrete buttress dam. These days, when he wasn’t in Haiti, he gave a lot of speeches, sometimes several in one day, and in every one I heard, he talked about the dam. It appeared in all the books he had published by 2000 and in the books that he had helped to write and edit, and also in many of his journal articles—forty-two of those by then. As a scholar and writer, Farmer had taken his greatest pains to assert the interconnectedness of the rich and poor parts of the world, and the dam was his favorite case study.
It stops up Haiti’s largest river, the Artibonite. It’s called the Péligre Dam and the impounded waters behind it, the Lac de Péligre. The U.S. Army Corps of Engineers had planned it. Brown & Root of Texas, among others, built the structure in the mid-1950s during the reign of one of Haiti’s American-supported dictators, with money from the U.S. Export-Import Bank. It was advertised as “a development project,” and no doubt some of the people behind its creation believed it a gift to Haiti. But no one seems to have given much thought to the peasant farmers who lived in the valley upstream.
The project was intended to improve irrigation and to generate power. It wasn’t as though the peasants of the central plateau didn’t need and want modern technology, Farmer said. But, as they themselves often remarked, they didn’t even get electricity or water for their land. Most didn’t get money either. In fact, the dam was meant to benefit agribusinesses downstream, mostly American-owned back then, and also to supply electricity to Port-au-Prince, especially to the homes of the numerically tiny, wealthy Haitian elite and to foreign-owned assembly plants. Since the flooding of the valley, many peasant girls and boys from Cange, children of what Farmer called “the water refugees,” had left home looking for work in the capital, where they cooked and cleaned and stitched Mickey Mouse dolls and baseballs, more than a few of them nowadays returning home with AIDS.
When Farmer first saw this piece of Haiti and began to ferret out its history, old-timers talked longingly to him about the days before the water rose, when families lived on farms beside the river and everyone had enough to eat and something left over to sell. Some remembered being warned that their land was going to be submerged. But the river had always flowed by, and they’d examined the dam in progress, and they couldn’t believe that a mere wall of concrete could hold back their river. One of the old people of Cange remembered seeing the water rising and suddenly realizing that his house and goats would be underwater in a matter of hours. “So I picked up a child and a goat and started up the hillside.” Families had hurried away, carrying whatever they could save of their former lives, turning back now and then to watch the water drown their gardens and rise up the trunks of their mango trees. For most, there was nothing to do but settle in the steep surrounding hills, where farming meant erosion and widespread malnutrition, tending nearer every year toward famine. And for years there were wailings and curses and loud arguments among old neighbors, fighting over titles to the land that was left.
Things got worse. Even after the dam, most peasants still had their black, low-slung Creole pigs, which they kept like bank accounts, to pay for things such as school tuition. But in the early 1980s, they lost those as well. Alarmed about an outbreak of African swine fever in the Dominican Republic, afraid that it might threaten the American pork industry, the United States led an effort to destroy all the Creole pigs in Haiti. The plan was to replace them with pigs purchased from Iowa farmers. But these were much more delicate, much more expensive to house and feed, and they didn’t thrive. Many peasants ended up with no pigs at all. When school started the year after the sla
ughter, enrollments had declined dramatically, throughout the country and around Cange.
We walked across the top of the dam. The railings were rusted, the concrete flaking. To our right the roiled waters of the Artibonite rushed away, and to our left a few small canoelike vessels plied blue, placid waters. It looked almost like a tropical resort. Farmer walked briskly along. A small juvenile escort followed him for a time. Local people heading the other way smiled when they saw him and said, “Bonjou, Doc mwen”—“Good morning, my Doc.” There were clouds then sun then clouds again, and a gentle breeze. I felt vigorous and cheered by borrowed popularity.
On the other side of the dam, a footpath—loose dirt and stones—went straight up. Farmer had a slipped disk from eighteen years of traveling Highway 3. His left leg had been surgically repaired after he’d been hit by a car back in 1988, and it turned out at a slight angle—like a kickstand, one of his brothers said. He had congenital high blood pressure and mild asthma, which developed after he’d recovered from a possible case of tuberculosis. But when I got to the top of that first hill, sweating and panting, he was sitting on a rock, writing a letter to an old friend, a contributor to Partners In Health whose spouse had recently died. It was the first of many hills.
We passed smiling children climbing steep rocky paths that I had to clamber up on all fours. They were carrying water, in pails and plastic jugs that once held things like paint, oil, and antifreeze. The full containers must have weighed half as much as the children did, and the children had no shoes. We passed beside many patches of millet, the national staple, which seemed to be growing out of rocks, not soil, and small stands of banana trees and, now and then, other tropical species, Farmer pausing to apply the Latin and familiar names—papaw, sour-sop, mango—a gloomy litany because there were so many fewer of each variety than there should have been.