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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.
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.”
“But WL’s think all the world’s problems can be fixed without any cost to themselves. We don’t believe that. There’s a lot to be said for sacrifice, remorse, even pity. It’s what separates us from roaches.”
We walked on. I noticed, as I had around Cange, that many people we passed wore clothes from America, brand-name running shoes that had seen much better days and baseball caps and T-shirts bearing the logos of professional sports teams and country clubs.
“Sure,” I said. “But some people would ask, ‘How can you expect others to replicate what you’re doing here?’ What would be your answer to that?” He turned back and, smiling sweetly, said, “Fuck you.”
Education wasn’t what he wanted to perform on the world, me included. He was after transformation.
He allowed that growing up as he did also probably relieved him of a homing instinct. “I never had a sense of a hometown. It was, ‘This is my campground.’ Then I got to the bottom of the barrel, and it was ‘Oh, this is my hometown.’ ” He meant Cange.
Farmer returned home less and less during his last years at Duke, but it wasn’t as though he still intended, if he ever had, to trade in his old life for something fancier. “He had to get out from under his father,” Ginny explained. “Back home everything would revert to the old order.”
When P.J. had learned he’d been accepted at Harvard Medical School, he’d called home from Haiti to tell his parents, and the Warden had said, “Oh yeah, we knew you’d get in.” It had been, at moments anyway, a difficult relationship.
Virchow would write, “My politics were those of prophylaxis, my opponents preferred those of palliation.”
“The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.”
But he wasn’t mainly impelled by politics or religion, he’d say. He felt more curious about the world than outraged. He had the sense that the truth about events in places like El Salvador lay hidden from most Americans.
By now he had certainly progressed, as he would put it, from curiosity to indignation. But curiosity remained.
These circumstances all had causes, and the nearest ones were the continuing misrule of the Duvaliers and the long-standing American habit of lavishing aid on dictators such as Baby Doc, who used the money to keep himself and the Haitian elite in luxury and power and spent almost nothing on things like roads and transportation.
He’d come here to do ethnography, the kind of anthropology he most admired—learning about a culture, not through books and artifacts but from the people who had inherited and were making culture. His special field was going to be medical ethnography. He wanted to learn everything about morbidity and mortality in the most disease-ridden country in the hemisphere. He’d write about what he discovered and in this way, he told her, “lend a voice to the voiceless.” He’d also be a doctor. He wasn’t sure which branch of medicine he’d choose. Maybe psychiatry. In any case, he’d be a doctor to poor people. Maybe he’d end up working in Africa or an American inner city.
Aristide said, as Farmer remembered his words, “People read the Gospel as if it pertained to another place and time, but the struggles described there are in the here and now. The oppression of the poor, the abuse of the vulnerable, and the redemption that comes with fighting for what is right—what ideas could be more relevant in our dear Haiti?”
Perhaps it is a universal tendency to view the deaths of strangers philosophically.
For Farmer, and for Jim and Jaime, there was a larger principle involved. A TB epidemic, laced with MDR, had visited New York City in the late 1980s; it had been centered in prisons, homeless shelters, and public hospitals. When all the costs were totaled, various American agencies had spent about a billion dollars stanching the outbreak. Meanwhile, here in Peru, where the government made debt payments of more than a billion dollars every year to American banks and international lending institutions, experts in international TB control had deemed MDR too expensive to treat.
He was charged, among other duties, with lending advice and assistance to young doctors pursuing unconventional careers. Paul and Jim were among his favorites, and they were making him nervous. Where, he wondered, were they getting their second-line drugs?
You can’t use fluoroquinolones or ethambutol at high doses in kids. Where did this come from? Fluoroquinolones cause cartilage damage in immature beagle pups. High-dose ethambutol is associated with optic neuritis and loss of color vision in a small proportion of adults, but kids can’t report loss of color vision, so it shouldn’t be used. This was a big part of the discussion, and here was a child literally wasting away, his flesh and bones consumed by MDR, in front of our eyes.” Farmer proposed an “empiric” regimen—a regimen based on his best guesses—which consisted of high-dose ethambutol and four second-line drugs, including a fluoroquinolone. To get official approval, he told the Peruvian doctors that he’d discussed the matter with every world-renowned expert, and studied the pediatric literature. This was true. He didn’t say that the pediatric literature contained nothing at all about treating MDR. “It was a matter of merely applying infectious disease knowledge,” he would tell me.
Farmer looked away, just a quick glance to left and right. I’d seen him do this in patients’ rooms at the Brigham—look at the patient, then glance up at the TV for a moment, then return, as if disconnecting so as to reconnect fully. He gazed at the woman and pursed his lips and said softly in Spanish, “For me, it is a privilege.”
“On what data exactly do you base that statement?”
Farmer said they were talking about managing wealth. He was talking about managing poverty. Haiti was a bad example of how to do that. Cuba was a good one.
Polite and worthless promises maybe, but Farmer in the role of supplicant seemed artfully ingenuous. Assume that each new promise was real and obtain as many as possible, to increase the odds that one or two might be real. And he’d follow up with calls, letters, e-mails, and if those didn’t bring results, they still might produce a little shame, which might increase the chances that the next promise would be real.
“I have a hermeneutic of generosity for you because I know you’re a good guy. Therefore I will interpret what you say and do in a favorable light. Seems like I’m the one who should hope for as much from you.”
Other small AIDS-treatment and-prevention programs were under way in poor countries, but Zanmi Lasante’s was the only one in an impoverished rural area that chose its patients solely on medical grounds and not on their ability to pay, the only one that provided expert care and treatment for free.
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.”
So he’s gonna die. He’s getting excellent care, but there’s still a bit of why did you bring him? Why? Because, A, he’s a human being, and B, because I didn’t know he couldn’t be treated, and C, why shouldn’t he have a comfortable way to die, why shouldn’t his mother have a private room without flies on her face to grieve in? Can we not have him in a place where people are trained in palliation? Isn’t palliative care important? And a place where his mother can grieve in private instead of an open ward with flies all over her face?”
Watching the PIH-ers extract John from Cange, I had at moments, in my darkest thoughts, worried that the event might have more to do with them than with John, more to do with proving the organization’s capacity for heroics than with saving a child. But then I thought: An idea like that would never have occurred to me if John had been my son. You do all you can for a patient. If I were seriously ill myself, I wouldn’t find that policy unreasonable.
He knows something about medicine and shares Farmer’s scorn for notions that there’s special virtue in a culture’s old technologies, in the idea for instance that herbal remedies are generally to be preferred over manufactured drugs. He is also one of Farmer’s chief informants on local beliefs.
“I don’t want to misrepresent it,” I say. “Your PIH-er wasn’t saying you shouldn’t have brought John to Boston. Only that it was a shame you had to spend so much, given what else you could do with twenty grand.” “Yeah, but there are so many ways of saying that,” he replies. “For example, why didn’t the airplane company that makes money, the mercenaries, why didn’t they pay for his flight? That’s a way of saying it. Or how about this way? How about if I say, I have fought for my whole life a long defeat. How about that? How about if I said, That’s all it adds up to is defeat?” “A long defeat.” “I have fought the long defeat and brought other people on to fight the long defeat, and I’m not going to stop because we keep losing. Now I actually think sometimes we may win. I don’t dislike victory. You and I have discussed this so many times.” “Sorry.” “No, no, I’m not complaining,” he says. “You know, people from our background—like you, like most PIH-ers, like me—we’re used to being on a victory team, and actually what we’re really trying to do in PIH is to make common cause with the losers. Those are two very different things. We want to be on the winning team, but at the risk of turning our backs on the losers, no, it’s not worth it. So you fight the long defeat.” He pauses. “How you feelin’? Is that chest pain gone?” I