It is December, two months after John’s transportation to Boston. Kidder is in Boston, preparing to travel to Cange with Farmer for one of the last times. In Cange, Kidder speaks with Ti Jean, Farmer’s “chief of staff” at Zanmi Lasante. Ti Jean talks about local custom and superstition, and he shares Farmer’s respect for hard work and selflessness. Jean tells Kidder that Farmer’s “nest” is in Haiti—though he travels all over the world, Haiti is his base. At Zanmi Lasante, Kidder learns, many of the people who teach disease prevention classes are former patients of Farmer, some of whom suffered from MDR.
In the last chapter of the book, Kidder returns to the obvious benefits and successes of Zanmi Lasante. While it hasn’t yet succeeded in wiping out poverty in Haiti, it’s certainly saved many lives. One good measure of the value of Zanmi Lasante in Haiti is the fact that many former patients come back to the hospital to work. Farmer has saved many of their lives, and they want to repay him and further the good he’s done for their community. (It’s also true that working at Zanmi Lasante provides a steady job.)
Kidder mentions a boy named Alcante, who came to Zanmi Lasante with a sever case of scrofula—an infectious disease. After Farmer treated Alcante for the disease, he made a full recovery. Afterwards, Alcante’s entire family journeyed to Zanmi Lasante for treatment. As a show of respect and understanding, Farmer decided to walk all the way from Zanmi Lasante to the family’s home, in the town of Casse.
The book begins and ends with a long journey across Haiti (it was on such a journey that Kidder learned the Haitian proverb that gives the book its title). These walks convey the extent of Farmer’s devotion to his patients: although any other doctor wouldn’t bother to show respect by walking to Alcante’s house (surely treating his illness is respect enough), Farmer does so in order to learn about his patients, to become a better doctor, and simply because it seems like the right thing to do for this patient in this moment.
Kidder describes the long walk that he and Farmer make to Casse, accompanied by Ti Jean. The hike is even longer than the one he took with Farmer to Morne Michel, years before. Halfway through the hike, Farmer stops to make a house call. He arrives at the house, which shelters an elderly-looking couple. Inside, he greets a feeble-looking old man who’s had a stroke recently. Farmer examines the man and his wife, both of whom have high blood pressure. As Farmer proceeds, a group of small children gather in the doorway and point at him—he’s a legend.
Farmer’s fame and prestige in Haiti are beyond all doubt in this scene. He’s helped many thousands of families and is a revered figure, but still doesn’t seem to have let this fame go to his head.
After leaving the house, Kidder tries to ask Farmer a question he’s been formulating for a while—ever since John’s death. He points out that Farmer can never treat every sick person on the planet—there simply isn’t enough time. How, Kidder asks, can Farmer compare suffering—how can he decide which suffering should be treated immediately? Farmer tries to answer Kidder’s question. He brings up the concept of “triage”—a word that was first used to describe how French military doctors decided whom to treat on the battlefield. Triage can also refer to the hospital practice of beginning by treating the patients in the gravest danger. It is this second definition of triage that’s influenced Farmer throughout his life.
Kidder finally formulates the question that he’s been trying to ask ever since meeting Farmer: how does a doctor with limited time and resources decide how best to practice medicine? Because it’s impossible to take care of everyone, doctors—Farmer included—must choose which patients to consult with. This is, to say the least, a difficult decision, and Kidder has been struggling to understand it for some time now. From what we’ve seen, Farmer’s strategy is to focus on those whose need is greatest: in the sense that they’re seriously ill, that their case is urgent and presented to Farmer at a particular moment, and that they live in a poverty-stricken country.
Farmer discusses John’s death with Kidder. It’s certainly possible to question Serena’s decision to move John to Mass General, spending almost 20,000 dollars in the process. And yet it’s wrong, Farmer insists, to fault PIH itself for spending too much money—it makes more sense to criticize the airplane company for charging so much for a medical flight, or to criticize the first-world doctors who draw enormous salaries for providing basic treatment. Asking why PIH spent 20,000 dollars to save a boy’s life, Farmer concludes, is the wrong question—it obscures the real, much more uncomfortable issue: why cash for saving the lives of children is in such short supply.
Farmer doesn’t exactly answer Kidder’s question. Instead, he dismisses it as a “red herring”—a distraction from the truth. The point is that questions about triage or “finite resources” always carry the implication that there’s too little time and money. In reality, Farmer suggests, there’s more than enough time and money to care for the poor—it’s just that most people waste a disproportionate amount of money and time, and never devote their resources to helping others. Even the hypothetical well-paid doctor that Farmer discusses is part of the problem by this measure. Farmer has no clear solutions for this problem, but essentially he’s saying that we think about economic value in an entirely skewed way—someone might pay thousands (or millions) of dollars for a car, a gemstone, or unnecessary plastic surgery, but still consider it a waste to spend far less money to save a child’s life.
Kidder and Farmer continue walking through Casse. After many hours, they arrive at Alcante’s home. Alcante and his family are delighted to see Farmer. Farmer reminds Kidder of a PIH worker who, years before, claimed that he would only install a water project in Casse if the people showed him that they “really wanted it.” Farmer finds this conditional approach to healthcare outrageous: a good doctor knows what’s best for his patients, whether they’re aware of it or not. As Kidder listens, he considers that Farmer, a world-renowned doctor, still makes house calls. He’s spent 7 hours with 2 families—2 out of millions.
A good doctor, Farmer claims, must also be a good leader—almost like a parent. In other words, Farmer isn’t simply negotiating a “contract” with his patients: he’s helping them whether they understand the treatment or not. The very notion of making charity work conditional, Farmer adds, is often a way for people in the First World to rationalize their own indifference to the suffering of others. The implication of this mindset is that Third World people don’t appreciate or desire good healthcare, and therefore don’t deserve it.
Kidder remembers a wealthy donor who abruptly stopped donating to Farmer and PIH, on the basis that while Farmer was a great doctor, his nonprofit model simply wasn’t sustainable. The donor pointed out that nobody could replicate what Farmer had done, and moreover, Farmer wasted too much time on individual patients, when his efforts would have been better spent on holistic planning. Kidder is sympathetic to this point of view. And yet he also agrees with Farmer that it’s narrow-minded: by saying that Alcante and his family are too far from Zanmi Lasante to be cared for, one would be placing a relative value on human life. Once, Ophelia told Kidder that Farmer’s ”small gestures,” such as his house calls, “add up” over time.
As the book approaches an ending, Kidder has a major insight about healthcare ethics. Arguments for cost-effectiveness and limited resources have practical grounds, but it’s also almost impossible to make these arguments without betraying some bias, whether it’s the bias of the First-World citizen or that of the ignorant cynic. Because there is no way to “stand outside the system,” Farmer maintains, the best course of action is to focus on the here and now (as liberation theology teaches), and try one’s best to help all sick and suffering people, one at a time, to the best of one’s ability.
Farmer and Kidder return to Zanmi Lasante. There, Ti Jean has been supervising patient care in Farmer’s absence. Ti Jean gave one patient medicine, but also told him to see a Voodoo priest. Farmer points out that the vast majority of Voodoo ceremonies are designed to eliminate illness—a fact that has “eluded all the many commentaries on Voodoo.” As Kidder considers this fact, he thinks of the drums and chants of a Voodoo ritual, and realizes that it’s not as foreign as it seems initially: it’s just an attempt to cure the sick.
In the final section of the book, Kidder clarifies Farmer’s position on the ethics of medicine with an elegant example. It’s impossible to weigh the cost-effectiveness of healthcare without betraying some cultural or racial bias. Understood in this way, part of Farmer’s goal in curing the people of the Third World is to eliminate some of the social and economic inequalities that separate them from the First World. In other words, Farmer isn’t just curing Haitians—he’s showing the rest of the world that Haitians’ aren’t somehow inferior or destined to always live in poverty. This is reflected in the Haitians’ tradition of Voodoo. Although Voodoo may seem like an alien tradition to many Westerners, it’s rooted in the same values that all human beings cherish and celebrate: the importance of life, health, and happiness.