by Tracy Kidder
How could a just God permit great misery? The Haitian peasants answered with a proverb: “Bondye konn bay, men li pa konn separe,” in literal translation, “God gives but doesn’t share.” This meant, as Farmer would later explain it, “God gives us humans everything we need to flourish, but he’s not the one who’s supposed to divvy up the loot. That charge was laid upon us.” Liberation theologians had a similar answer: “You want to see where Christ crucified abides today? Go to where the poor are suffering and fighting back, and that’s where He is.” Liberation theology, with its emphasis on the horrors of poverty and on redressing them in the here and now, its emphasis on service and remediation, seemed to fit the circumstances of Haiti. And it suited Farmer temperamentally because, for all his scholarship and interest in theories, his strongest impulses were pragmatic. He only seemed like a nerd. He would tell me years later, with undeniable accuracy, “I’m an action kind of guy.”
Looking back at this first year of living in Haiti, Farmer would speak of the feeling that many things in his mind coalesced into a vision of his life’s proper work. But, he’d insist, this happened in stages, not all at once. “For me, it was a process, not an event. A slow awakening as opposed to an epiphany.” Then he remembered an incident from the time he spent in Léogâne. Repossessing it, he said that perhaps there had been an epiphany after all.
Working as a medical volunteer at the Hôpital St. Croix in Léogâne, he got to know a young American doctor. “He loved the Haitians,” Farmer said. “He was a very thoughtful guy.” The man had worked in Haiti for about a year. Now, in a few days, he was going back to the United States. “I realized, hearing him talk, that something had happened to me already,” Farmer said. “I wasn’t feeling judgmental. Haiti was something he was seeing that he could leave and erase from his mind, and I was thinking, Could I do that? He was leaving Haiti, really leaving in body and mind, and I realized I was going to have trouble with that.”
“Isn’t it going to be hard to leave?” he asked the young doctor.
“Are you kidding? I can’t wait. There’s no electricity here. It’s just brutal here.”
“But aren’t you worried about not being able to forget all this? There’s so much disease here.”
“No,” the doctor said. “I’m an American, and I’m going home.”
“Right. Me, too,” said Farmer.
He thought about that conversation all the rest of the day and into the evening. “What does that mean, ‘I’m an American’? How do people classify themselves?” He understood the doctor’s position, but he didn’t really know his own. The only thing he knew for sure was that he would become a doctor himself.
Later on that night, a young woman arrived at the hospital, pregnant and in the throes of malaria. “She had a very high parasitemia,” Farmer remembered. “Bad malaria. She went into a coma, and you know—I didn’t know the details then, I do now because it’s my specialty—she needed a transfusion, and her sister was there. So there was no blood and the doctor told her sister to go to Port-au-Prince to get her some blood, but he said that she would need money. I had no money. I ran around the hospital, and I rounded up fifteen dollars. I gave her the money and she went away, but then she came back and she didn’t have enough for both a tap-tap and the blood. So meanwhile the patient started having respiratory distress and this pink stuff started coming out of her mouth. The nurses were saying, ‘It’s hopeless,’ and other people were saying, ‘We should do a cesarean delivery.’ I said, ‘There’s got to be some way to get her some blood.’ Her sister was beside herself. She was sobbing and crying. The woman had five kids. The sister said, ‘This is terrible. You can’t even get a blood transfusion if you’re poor.’ And she said, ‘We’re all human beings.’ ”
The words—tout moun se moun—seemed like the answer to the question he’d asked himself earlier that day. Was being an American a sufficient identity unto itself? “She said that again and again,” he remembered. “We’re all human beings.”
The woman and her unborn baby died. Afterward, the sister lavished thanks on Farmer. And of course this made him feel more acutely his failure at emergency fund-raising. He was obviously upset, and the doctors and nurses seemed to focus their attention on him. The nurses were saying, “Poor Paul. What a sweet young man.” And he knew what the doctors were thinking: “He’s new here, he’s green, he’s naïve.” Remembering this years later, he was still framing his retort: “Yeah, but I got staying power. That’s the thing. I wasn’t naïve, in fact.”
Or perhaps he was, a little. He decided to raise money to buy the hospital its own blood-banking equipment. He wrote to his relatives and the parents of his friends from Duke. He was seeing dreadful things in Haiti, he wrote. He described the project. Many checks arrived. In the end, he collected a few thousand dollars. He was elated. He wrote to Ophelia, “I’m off to Léogâne for a meeting with the director of Hôpital St. Croix to discuss BIG PLANS.” But not long afterward, Ophelia received another letter: “My stint down here at the hospital isn’t turning out exactly as I thought it would. It’s not that I’m unhappy working here. The biggest problem is that the hospital is not for the poor. I’m taken aback. I really am. Everything has to be paid for in advance.”
The central imperative of liberation theology—to provide a preferential option for the poor—seemed like a worthy life’s goal to him. Of course, one could pursue it almost anywhere, but clearly the doctrine implied making choices among degrees of poverty. It would make sense to provide medicine in the places that needed it most, and there was no place needier than Haiti, at least in the Western Hemisphere, and he hadn’t seen any place in Haiti needier than Cange. He didn’t stick around in Léogâne to see the blood bank get installed. He’d found out that the hospital would charge patients for its use. He told me he had these thoughts, as he headed back toward the central plateau: “I’m going to build my own fucking hospital. And there’ll be none of that there, thank you.”
When he returned from Léogâne to the central plateau, Farmer went to work for a while at Père Lafontant’s clinic in Mirebalais. It resembled a lot of the clinics he’d seen in his months of exploring Haiti. Patients waited in a line for a visit with the lone doctor, who didn’t bother to get their medical histories or give them real physical exams. “A perfunctory exchange with a doctor who’d rather have been anywhere else but there,” Farmer would remember. “Then the patients took their filthy corncob-stoppered bottles to the ‘pharmacy’ and paid to have them glug-glug filled up, with cough medicine and vitamins. A sorry spectacle, which included, at times, the staff yelling at the patients for bringing really, really filthy bottles.”
With Père Lafontant’s blessing, Farmer began to focus on the wretched, dusty squatter settlement up the road in Cange. It was a big moment in his life. “Going up to Cange, which was back then a truly awful place compared to Mirebalais, was for me, bizarrely, a relief. No clinic at all was a relief! Not because there wasn’t an urgent need for a clinic in Cange. I just knew I couldn’t work in a clinic like that one in Mirebalais, which was, I had learned, altogether representative of other clinics for poor Haitians. And I also knew, I hope, that it wasn’t about how I felt or how the hapless Haitian doctor felt. It was about the patients and their awful outcomes.”
Cange needed a clinic, a hospital, a community health system. In Farmer’s conception, the facilities should provide services to the destitute for free, and those services should meet the real needs of the place and of individual patients. So the first step was to find out exactly what the needs were. Farmer began modestly, with a preliminary health census. He enlisted five Haitians, all about his age, all of whom had gone at least as far in school as the first year of junior high, and they went from hut to hut through Cange and two neighboring villages, tallying up the numbers of families, recent births and deaths, and the apparent causes of morbidity and mortality. That first survey was rather informal, but it confirmed what Farmer had already suspected. Mortali
ty among infants and juveniles was “horrific.” He learned, too, about the central importance of “maternal mortality”—how the deaths of mothers, common events in those squatter settlements, led to skeins of catastrophes in families, to hunger and prostitution, to disease and other deaths.
This first survey was just a small beginning, a piece of an apprenticeship in public health and medicine and also anthropology. In Cange in early 1984, Farmer had another memorable encounter with malaria, in its way as instructive as the one back in Léogâne. The patient was a young woman. Her father decided to have her treated by a local houngan, a Voodoo priest, but after a lot of discussion, the mother agreed to let Farmer and a Haitian doctor treat her with chloroquine as well. She recovered. In an essay which he titled “The Anthropologist Within,” Farmer wrote that, in the aftermath of that case, he’d wondered obsessively about the role anthropology should assume in his life. He’d been taught that an ethnographer should observe, not try to change what was being observed. But practiced in that way, anthropology seemed “impotent” in the face of “everyday problems of adequate nutrition, clean water, and illness prevention.” It’s clear by the end of the essay that anthropology now interested him less as a discipline unto itself than as a tool for what he called “intervention.” He had settled not for a synthesis between observing and acting, but for doctoring and public health work that would be partly guided by anthropology.
Its uses were obvious. A doctor who knew nothing about local beliefs might end up at war with Voodoo priests, but a doctor-anthropologist who understood those beliefs could find ways to make Voodoo houngans his allies. A doctor who didn’t understand local culture would probably mistake many patients’ complaints for bizarre superstitions, or at best be utterly baffled—by the female complaint called move san, lèt gate, for instance. The condition was said to be brought on by sezisman, that is, by a surprise or by someone’s frightening action. Move san, “bad blood,” could follow, and produce in turn lèt gate, a condition in which a nursing mother’s milk was spoiled or stopped flowing. None of this would be mysterious to a young ethnographer-doctor who, like Farmer, was willing to puzzle out the social meanings of the syndrome. Farmer would write, “The most striking thing about move san disorder is the lurid extremity of its symbolism: two of the body’s most vital constituents, blood and milk, are turned to poisons. The powerful metaphors serve, it may be inferred, as a warning against the abuse of women, especially pregnant or nursing ones.”
In the course of his research on move san, lèt gate, he consulted a local Haitian woman, asking her about the herbal remedies for the condition. She gave him the information and then told him, in effect, “Surely you are collecting these leaves in order to better understand their power and improve their efficacy.” This was a lesson reiterated. The people of Cange weren’t interested in having their suffering merely scrutinized; he should be interested in both research and action.
Farmer was probably fortunate—certainly he thought so—to have done some work in anthropology and medicine and public health in Haiti before he studied those disciplines at Harvard. He had a gift for academic pursuits, but Haiti ensured that his taste for them would be limited.
Farmer entered Harvard Medical School in the fall of 1984. He was only twenty-four. Then again, he told me once, “I was fully formed at twenty-three.” He meant, I think, that by then he had his philosophy and worldview in order, and knew that he wanted to marry them to action, first of all in Cange. He didn’t linger in Cambridge. He stayed around Harvard just long enough to get oriented and to gather up textbooks, which he took with him back to the central plateau.
At the medical school, the first two years of the curriculum consisted mainly of large lecture courses. Often, Farmer would show up in Cambridge just in time for lab practicums or exams. Then he’d go back to Haiti. It wasn’t as though no one noticed. By the second year, his classmates had nicknamed him Paul Foreigner. But while this kind of commuting by a student was almost certainly unprecedented, it would have been hard for any professor to disapprove. The young man was trying to bring medicine to people without doctors. Besides, his grades were excellent, some of the best in his class.
CHAPTER 9
The combination of Harvard and Haiti had begun to form a new kind of belief in Farmer. He would tell me years later: “The fact that any sort of religious faith was so disdained at Harvard and so important to the poor—not just in Haiti but elsewhere, too—made me even more convinced that faith must be something good.”
And if the landless peasants of Cange needed to believe that someone omniscient was keeping score, by now Farmer felt the need to believe something like that himself. In the peasant phrase, an unnecessary death was “a stupid death,” and he was seeing a lot of those. “Surely someone is witnessing this horror show?” he’d say to himself. “I know it sounds shallow, the opiate thing, needing to believe, palliating pain, but it didn’t feel shallow. It was more profound than other sentiments I’d known, and I was taken with the idea that in an ostensibly godless world that worshiped money and power or, more seductively, a sense of personal efficacy and advancement, like at Duke and Harvard, there was still a place to look for God, and that was in the suffering of the poor. You want to talk crucifixion? I’ll show you crucifixion, you bastards.”
When Ophelia went back to the central plateau to work with Paul, in the summer of 1985, she saw that, when he dressed up now in Haiti, he often wore a large wooden cross hanging outside his shirt. But the apparatus only reinforced a quality of “priestliness” that she’d sensed in him before, and that quality was far from thorough. He would say, some years later, that he had “faith,” then add, “I also have faith in penicillin, rifampin, isoniazid, and the good absorption of the fluoroquinolones, in bench science, clinical trials, scientific progress, that HIV is the cause of every case of AIDS, that the rich oppress the poor, that wealth is flowing in the wrong direction, that this will cause more epidemics and kill millions. I have faith that those things are true, too. So if I had to choose between lib theo, or any ology, I would go with science as long as service to the poor went along with it. But I don’t have to make that choice, do I?”
He’d never cared much about the religious dogma he’d been taught as a child, and he didn’t believe in most of it now. He would say, for instance, “I’m still looking for something in the sacred texts that says, ‘Thou shalt not use condoms.’ ” He was still the very young man who would challenge Ophelia to mango-eating contests that turned into slimy food fights, and he was quite willing to ignore the injunctions about chastity that the bishop had uttered at his confirmation in Florida years ago. Indeed, he was happy to skip church services in order to violate those injunctions. Ophelia remembered the afternoon when she “gave” herself to him—she chuckled at the term. It was a Sunday. They were in Mirebalais and got caught in a rainstorm, and ran back to Père Lafontant’s rectory. The building was empty because everyone else was in church, and in Haiti church services tend to last a long time. Moreover, most Haitians don’t like being out in the rain. “You knew that, until it ended, no one would be coming,” she said. “We took a shower together.” She remembered the sound of the rain on the roof, the smell of the smoke from the fire out in the courtyard lit for Sunday dinner. The moment, she said, still stood in her memory as the most romantic of her life.
She spent the whole summer in Haiti with Paul. In the evenings, over coffee, she’d help him with his formal medical education. She’d try to help, that is. He had distilled the contents of his medical texts onto index cards. He had great piles of them, thousands of flash cards. On one side he’d have written, in an elegant, left-handed script, a question such as “What’s gout got to do with lysosomes?” and he’d have added the symbols for musical notes around the words, indicating that the question should be sung. The question side of a card might read, for example, “Show me, sir, the lesions in Horner’s syndrome, & oculomotor nerve paralysis. And what the divvil’s an Argyll
Robertson pupil?” The answers on the back often included drawings—many of them lovely, Ophelia thought—in that case a drawing of the neural pathways of the eye.
Ophelia looked through the stack of index cards for a question that Paul might answer wrong, hoping he would. It felt good to be able to read him the correct answer, as if she was actually helping. “Okay, P.J., what’s dystrophic calcification?”
“When abnormal deposition of calcium salts takes place in necrotic tissues, it’s known as dystrophic calcification.” He’d lift a finger in the air. “Of course, it’s not caused by hypercalcemia.” He’d smile. “Metastatic calcification is associated with hypercalcemia, however.”
She’d stare at the back of the index card, trying not to look let down. “Right! Very good, P.J.”
They walked to villages from time to time. On the way he’d point out plants. “Indigo,” he’d say, and then with an eager smile, “What’s the Latin name?”
He’d been doing this since she’d first met him. At moments, she wondered if he was trying to make her feel uneducated. “No, you twit, of course not,” she thought. “He just likes to say the names. It’s one of his ideas of fun.”
But it was hard to avoid comparing herself with him. At almost every hut they visited, food would appear, a great deal of it unsavory to both of them—items from what Paul called “the fifth food group”—and, making faces at each other when their hosts weren’t looking, they pretended to munch happily on things like meat-filled pastries that smelled like sweat. Then one time their hosts presented each of them with what looked like a fried egg afloat in pig fat and gristle, and she took a bite and almost gagged on it. When the hosts turned away for a moment, she handed her plate to Paul, whispering, “Here, you eat it.” He took the plate and slurped the contents down. Then he looked at her and smiled. “B minus,” he said. On the way back they laughed about the incident, and yet of all the times she’d eaten things that she could hardly bear to look at, this one occasion when she failed the test stood out for her.