by Tracy Kidder
The Global Fund, which Sachs helped to create, was a brand-new institution, financed by governments and foundations. The hope was to raise many billions of dollars annually to fight the world’s three great pandemics. By the spring of 2002, it had collected pledges for only a fraction of the goal. Nevertheless, the fund had begun receiving applications for grants and approved, among others, Haiti’s application, which PIH had helped to write. According to the plan, Zanmi Lasante would direct a thorough AIDS-treatment and-prevention program through most of the central plateau. The project would, it was hoped, serve as a model for similar projects in Haiti’s eight other departments and in other very poor countries.
Every part of the task looked daunting, and politics promised to make the job both harder and more pressing. When President Aristide’s government had been restored in 1994, a host of nations and international development banks had pledged their help in rebuilding Haiti. But contributions were already dwindling by the time of Aristide’s reelection, in late 2000. Now the United States was leading a concerted effort to block aid to Haiti’s government—not just American aid but also grants and loans from other sources, including loans from an international agency that would have financed an increase in the supplies of potable water and improvements in roads, education, and the public health system. The stated reasons for this policy were various and changeable. The real reasons probably included longstanding institutional fear and distrust of Aristide, a hope that Haitians might blame him for the country’s continuing decline, and general weariness with Haiti’s problems. Farmer wrote to me, about the blocked loans: “I think, sometimes, that I’m going nuts, and that perhaps there is something good about blocking clean water for those who have none, making sure that illiterate children remain so, and preventing the resuscitation of the public health sector in the country most in need of it.” He added, “Lunacy is what it is.”
In Cange at least, the effects of dwindling aid seemed plain. By 2002 the public clinics out in the central plateau had all but shut down for lack of cash. Impoverished peasant families had nowhere to go but Cange. They were flocking to Zanmi Lasante in overwhelming numbers, four times as many as just two years before. Patients filled every hospital bed at the complex, and every reclining chair, and every space on the floors. In effect, the people of the central plateau were begging Zanmi Lasante to do the same thing as the Global Fund asked.
Just to enact one part of the plan, just to extend Zanmi Lasante’s program for preventing transmission of HIV from mothers to babies, looked as difficult as the nationwide MDR project in Peru, and that project ranked among the most complex health interventions ever undertaken in a poor country. Only 20 percent of women in rural Haiti received any medical care. An estimated 5 percent had HIV. To find them, Farmer’s team, a group of PIH and Zanmi Lasante doctors and health workers and Haitian government employees, would have to undertake AIDS education among about half a million peasants who were scattered throughout a mountainous region of about four hundred square miles. They’d have to establish labs and testing centers in a place where the principal roads were nearly impassable even in good weather. (“As for transportation,” Farmer wrote to PIH-ers, “we believe it’s gonna be donkey & bike & motorcycle & jeep.”) They’d have to train lab technicians to run those centers, in places that had only intermittent electricity or none, and hire and train many additional community health workers to deliver prophylactic drugs twice a day for nine months to each infected pregnant woman and for a week to each newborn baby. Because breast milk can transmit the virus, each mother would have to be provided with infant formula for at least nine months, and because the formula would have to be mixed with local water, Farmer’s team would have to clean up the water supplies in dozens of places.
The Global Fund money—$14 million for the central plateau, paid out over five years—would go mainly for anti-HIV drugs and for hiring Haitian health workers and for fixing up the few public clinics that already existed in the region. But treating and preventing HIV would also mean treating and preventing tuberculosis. And when they set up clinics to treat those two diseases, people would come to them with other ailments, with broken legs and machete wounds, with typhoid and bacterial meningitis. A PIH project couldn’t refuse to treat people who didn’t have the right diseases. So they’d have to spread facsimiles of the medical complex in Cange throughout the vast, mountainous, famished Département du Centre, and if they were lucky and frugal, $14 million would get them started.
But Farmer was elated. When he got word about the Global Fund money, he wrote to me, “I feel like weeping. The Haitians so deserve this.” He wrote that he would study his schedule and cancel whatever he could so as to spend more time in Haiti. A few weeks later he was in Tomsk, visiting patients and checking out the program there. Not long after that, he was in Barcelona, addressing the annual international conference on AIDS.
Once, arriving in Boston, exhausted after another of his light months for travel, Farmer told Ophelia that he heard two sets of voices. At one ear he heard friends and allies saying he should concentrate on the big issues of world health and, at the other ear, the groans of his Haitian patients: the voice of the world saying, “This meeting’s important,” and the voice of Haiti saying, “My child is dying.” Once in a while, cramped in an airplane seat, he had talked to me about retiring to Cange, about wanting to stay put there and be “just a country doctor.” I didn’t fully believe him. For as long as he could manage the travel, I thought, he’d be leaving Haiti for places like Tomsk and Lima, to doctor individual patients and to do his part fighting plagues and inequities in health, practicing his own combination of wholesale and retail medicine. But he’d always return to Cange. It seemed to me that he didn’t have a plan for his life so much as he had a pattern. He was like a compass, with one leg swinging around the globe and the other planted in Haiti.
CHAPTER 25
The transit between Cange and Boston used to jar Farmer back when he was a young medical student. He’d leave peasant huts full of malnourished babies and, arriving in Miami Airport, overhear well-dressed people talk about their efforts to lose weight. The trip was unsettling in either direction. One day he’d be inside the teaching hospitals of Boston, receiving instruction in the highest current standards of medical care, and the next morning he’d be climbing out of a tap-tap, his face gray with dust, into the squatter settlement in the parched high ground above the dam, where there was no medicine, let alone standards of care. In time he learned to make the transition more calmly. “After a while I realized I could do just as good a job treating my patients without getting angry,” he told me. By then, I think, he was transmuting anger into something that felt better, a dream of ending the disparities, at least the medical ones, that separated Boston and Cange.
The dream seemed impossible, of course, but he still held to it. “I don’t mean we should do bone-marrow transplants in Cange, but proven therapies,” he’d say in lectures. “Equity is the only acceptable goal.” He had made progress. Zanmi Lasante now had decent facilities, including a good operating room, always sparkling clean. But it still lacked a lot of high-tech equipment. There was no blood bank, no CT scanner. Farmer intended to fix those deficiencies and more, someday. In the meantime, on occasion, when he couldn’t bring Boston medicine to Cange, he’d bring a patient from Cange to Boston.
In early 2000, PIH had flown a young man named Wilnot to the Brigham. He had a rare congenital heart defect, which a team of surgeons fixed, waiving their fees. Several months later, near the beginning of August, a woman from the city of Hinche, eschewing the dreadful public hospital there—floors of rotting wood, an open sewer out back, no medicine without cash—brought her son by tap-tap over the road to Zanmi Lasante. The boy’s name was John. Like their deaths, the births of most Haitian peasants go unrecorded, so John’s exact age was uncertain. He was probably eleven or twelve. He and his mother were all that remained of their immediate family. John’s father and his three si
blings had all died during the past few years, apparently of various ailments. When asked what he thought those had been, Farmer adapted a mordant line from Graham Greene’s The Comedians. “Haiti,” he said. “They died of Haiti.” John’s mother called her life “a series of catastrophes.” Though far from unprecedented, the family history lent John’s case a special urgency. The clinical facts made it singular.
John had swellings in his neck, which at first glance resembled scrofula—cervical lymphadenitis, TB in the lymph nodes of the neck, fairly common in Haiti. But with scrofula the nodes feel squishy. John’s felt hard to Farmer’s touch. And the proportion of white cells in his blood was much higher than usually seen in extrapulmonary TB. Farmer suspected some sort of cancer.
A diagnosis that would take a few hours in Boston can take weeks when made between Haiti and Boston. Serena Koenig, a Brigham doctor in her early thirties, had arranged for Wilnot’s operation and the fund-raisers that had paid for his travel and hospital stay. Now Serena found an oncologist at Massachusetts General Hospital who agreed to make the diagnosis for free. Of course, the oncologist needed a sample of tissue from John. Obtaining the tissue involved a tricky surgical procedure, one that Farmer didn’t feel he should perform himself, if he had a choice. He sent word to a Haitian surgeon in Mirebalais, one he knew to be competent. The surgeon agreed to come to Cange, for several thousand dollars, a very large fee in Haiti. It was raining in the central plateau, and fetching the surgeon meant braving the mud and swollen streams between Mirebalais and Cange. The trip took twelve hours. The biopsy lasted until dawn. Farmer was scheduled to fly to Boston that morning. He brought John’s blood and tissue samples with him, and Serena took them to Mass General in a plastic shopping bag. Zanmi Lasante didn’t have the equipment to preserve the specimens in frozen sections, so they’d been placed in formaldehyde. This meant that the diagnosis itself took four days instead of just one.
The news was bad. John had nasopharyngeal carcinoma, a very rare cancer, constituting less than 1 percent of all childhood malignancies. If caught early, however, 60 to 70 percent could be cured.
At first Farmer thought they could treat John in Haiti, adminstering the chemotherapy in Cange. He got Serena to obtain the regimen from her contacts at Mass General. She was about to start buying the drugs—cisplatin, methotrexate, leucovorin—when an oncologist friend in Boston told her, “Serena, if you want to kill this child, there are less painful ways to do it.” In fact, only a handful of hospitals in the United States had the right equipment and experience to deal properly with John’s illness. So Serena and Farmer agreed they’d try to bring the boy to Boston. Farmer was very busy, of course, and had to follow a lot of the case from a distance. Serena did almost all the work. The hospital bill for John would come to something like $100,000. Serena begged and cajoled nonstop for three weeks. Finally, the authorities at Mass General agreed to take the case for free.
But by now a month had passed since John’s mother had brought him to Cange. Serena still had to put together a pile of documents, for Mass General and for the American consulate in Haiti so that she could get a visa for John. She didn’t even know John’s parents’ first names. There was no more time to lose, so Serena made up names—Jean Paul and Yolande. Serena didn’t speak Creole, and she figured that since John had never traveled beyond the central plateau he was bound to be scared, flying to America without his mother. She knew a Haitian American, a resident in internal medicine and pediatrics at Mass General and the Brigham, named Carole Smarth. Carole had spent parts of her childhood in Haiti, she spoke Creole fluently, and she was a friend of PIH—she’d worked for a few weeks at Zanmi Lasante. She agreed to go to Cange with Serena and help fetch John to Boston.
Serena called Farmer, who was traveling. She was afraid John might have grown much sicker in the past month and she asked Farmer what circumstances would keep them from bringing John to Mass General.
“No circumstances,” Farmer said. “It’s his only chance.”
“What will I say if I’m asked why we’re doing this?”
“That his mother brought him to us,” said Farmer. “And we’re doing everything we can to help him.”
Serena’s first sight of Haiti had horrified her. Zanmi Lasante had moved her. The whole experience of bringing Wilnot to Boston had changed her life, she felt. She was still employed by the Brigham and Harvard Medical School, but now spent most of her free time working for Paul and Jim.
PIH-ers weren’t all alike, of course, but many had impressive academic credentials, many were religious, the majority were female, and a lot of those were, as Ophelia said, “rather good-looking.” The full description fit both Serena and Carole. As I hurried along with these two young doctors through Logan Airport, I noticed a lot of people glancing our way.
Serena had brought two suitcases, one full of stuffed animals and toys for the pediatric ward in Cange. Carole had brought a gigantic bag, a bag of Haitian-returning-from-the-United-States proportions. It was filled with medicines she thought they might need to get John safely through the trip. Carole also carried a plastic bag filled with water. Two shebunkins were finning around inside, goldfish for Farmer’s new fish pond at his house in Cange. He’d asked that some be brought, if it wasn’t too much trouble.
He wouldn’t be there when we arrived. He had to go to Europe for a scientific meeting; the head of Soros’s foundation had asked him to go, and he’d felt he couldn’t refuse. Right now he was in a German castle, of all places. But his young colleagues were certifiably first-rate doctors from two of the world’s best teaching hospitals, and it looked to me as though they’d thought of everything. Serena had been too busy with arrangements to sleep last night. Now she ran through the whole list of what she’d done and was still reciting it when we got on the plane.
The plan was to get John a visa on arriving in Port-au-Prince, drive on to Cange, and bring him back to Boston the next day—in first class, with Carole sitting beside him. Farmer, always saving money so there would be more money to spend, had insisted by e-mail that they not buy first-class tickets but use some of his own vast store of frequent-flyer miles.
The first part of the plan unwound smoothly, largely because of Ti Fifi, one of Farmer’s best and oldest Haitian friends, the person whom, above all, he could count on to get a thing done in Haiti. The Haitian Godfather, Farmer called her. Ti Fifi was small and quiet, usually smiling. When she met us at the airport, she said she’d managed to get John a Haitian passport. First, she’d had to manufacture a birth certificate. Serena said, “If you get him another one, could you make his mother’s name Yolande?”
Everyone laughed. I myself felt a lack of reserve that should have made me nervous. I felt as if I were slipping into a holiday mood, embarked on another vicarious moral adventure, which looked as though it would be painless. The American consulate granted the visa at once. Then, late in the afternoon, we headed north toward Cange, in the Zanmi Lasante truck.
Nearly a year ago I’d seen a sign at the foot of Morne Kabrit where the paving gave out, a sign that announced the imminent rehabilitation of National Highway 3. Now rust from the fastenings dripped down the face of the sign, but it was still in better shape than the road. Some rocks had been moved around at the foot of the mountain, but not an inch of the track had been smoothed or paved, and all the earthmoving equipment was gone, except for one machine parked about a third of the way up the slope, on its way to becoming a relic.
“What happened?” I asked Ti Fifi.
She shrugged. She’d heard that the European and South American contractors had either wasted all the money or stolen it.
A battered old truck had turned over on the road up the mountain, blocking the way. There was a traffic jam of tap-taps and camions, the truck’s carcass at the center and a crowd milling around it. After a lot of arguing and failed attempts, in which a few people nearly got crushed, the crowd rolled the truck off to one side of the road. All that took a while. It was after da
rk when we turned in at Zanmi Lasante’s gate and I felt again the relief of smooth pavement, by now a familiar pleasure, a secure feeling, which this time didn’t last. Serena and Carole went right up to the Children’s Pavilion. The place felt different from the last time I’d been there. The hospital didn’t look quite as clean or the walls as white, and the air inside seemed hotter, the flies thicker. But I don’t think anything had changed in fact. I think it was just that Farmer wasn’t there. The hospital seemed less reliable without him. And the sight of John in his bed shocked me.
In photographs taken a month before, he had looked merely sick. Now his legs and arms were emaciated. You could see all the bones in them, and his knee and elbow joints looked outsize, with the flesh shrunk away. He’d been given a tracheotomy. A round peg to accommodate a feeding tube was fixed in the front of his neck, on either side of which bulb-shaped lumps of flesh stood out. The swellings forced his tongue from his mouth. He was shifting around, clearly trying to find a way to take the pressure off his neck. He made a gurgling sound—secretions clogging his airways. A nurse suctioned them out with an electrical device. On top of everything else, he was running a fever.
I couldn’t look at him again right away. I glanced around the room instead, and found myself staring at a baby with kwashiorkor in the crib near the stairs. Her eyes looked immense, like the eyes of a frightened woodland creature. I looked at John’s mother, a dark-skinned, very thin woman. She sat on the side of the bed, staring at nothing, it seemed, no expression at all on her face. I looked at Serena and saw that she, too, was looking away—gazing at the wall above John’s bed, her lips pursed. She was silent for a long moment, which seemed to stretch into minutes. Then she thrust her hands through her hair and said, “Okay, we need to know why he has a fever, what meds he’s on.” She started leafing through John’s records, and Carole went to John’s bedside.