Farmer has always found the flight from Haiti to Boston strange, Kidder reports. When he arrives in Boston he sees well-dressed people complaining about the most superficial of problems—a far cry from the poverty and suffering of Haiti.
It’s hard for someone like Farmer, who’s spent most of his adult life surrounded by poverty and misery, to adjust to the scale of most Americans’ lives: their problems simply don’t matter by comparison.
In 2000, Kidder explains, PIH flies a Haitian child named John from Cange to Boston for treatment for a rare facial cancer, nasopharyngeal carcinoma. The process of diagnosing John requires several trips to and from Haiti, over the course of several weeks. Farmer’s assistant, Serena Koenig, arranges an emergency medical visa for John, so that he can exit and enter Haiti without a problem. Farmer thought that he could conduct most of John’s treatment in Haiti, with Serena’s help and with shipments of treatment drugs from Boston. In the end, however, Serena decides that it is better to conduct the surgery in Boston, not Haiti. Preparing for the treatment costs nearly 100,000 dollars, but with much difficulty, Serena is able to convince Mass General to waive its fee. In order to do this, she’s forced to make up family information for John. Although John’s parents have checked him into Zanmi Lasante, and visit him periodically, Serena is forced to invent names for John’s parents while filling out paperwork (since she doesn’t know their real names, and doesn’t want to wait for their next visit).
The story of John’s experience with facial cancer will take up the majority of this chapter, and will provide Kidder with one of his most fascinating (and disturbing) case studies for the efficacy and morality of Farmer’s medical philosophy. To begin with, Kidder makes it perfectly clear how much money Boston is spending on John’s life: the equivalent of hundreds of thousands of dollars. But for the time being, there isn’t a real ethical conundrum in John’s treatment: although the drugs used to treat John may be expensive, we get the sense that they’re overpriced (we already know from the chapters about MDR-TB that drugs can be 20 times as expensive as they “should” be). Even more basically, Kidder doesn’t suggest that there’s any reason why a boy’s life shouldn’t be worth 100,000 dollars of treatment. The only “rule-breaking” in this passage comes when Serena invents contact info for John—a victimless crime (which also reminds us of how Farmer broke the rules by sneaking beer into the homeless shelter).
While Farmer attends a Soros conference in Europe, Serena prepares to fly John out to Mass General for a full treatment for his cancer. Kidder sees John lying in bed, and is shocked by his appearance—his limbs are terrifyingly thin and emaciated, and he makes a sickly gurgling sound when he breathes. Serena prepares for an ambulance to drive John from Zanmi Lasante to the airport—a form of transportation that, along with the medevac flight from Port-au-Prince to Boston, costs more than 18,000 dollars. In the days leading up to the car ride and flight, John’s condition deteriorates, so that it’s unclear if he’ll be able to survive a long flight to Boston. Serena is unsure whether or not she should proceed with her plan. She emails Farmer asking for advice, and Farmer replies, very promptly, that he’ll be in Boston in 24 hours, but that he thinks Serena should “consider other possibilities” in the meantime. Serena interprets this to mean that news of the flight will set an expensive precedent for future Haitian patients: everyone will want to be flown to the U.S.
Kidder conveys the crisis of John’s treatment: the leadership is disorganized (Farmer, the clear leader of Zanmi Lasante, is gone, and Serena Koenig isn’t sure what to do in his absence), the treatment is very expensive, and a decision needs to be reached very, very quickly. The short timespan of this chapter allows Kidder to focus on the split-second ethical decisions that doctors have to make. One important factor in Serena’s decision is that of precedent: she reasons that flying John to Boston may cause greater harm and disorganization in the long term, because other Haitians will expect the same level of treatment. In general, Serena seems to naturally think as Farmer does—she should do whatever is necessary to save a patient’s life at that moment—but she also makes herself think in the utilitarian terms of costs and benefits in the long run.
Serena decides to arrange for an ambulance to drive John to the airport, even though John’s condition is uncertain. She reasons that she can prevent the flight from becoming a precedent for Haitian patients by saying that she paid for it herself. The ambulance service is extremely unreliable, and on the road to the airport, the ambulance breaks down. John needs a “suction device” to ensure that he can breathe properly during the car and plane rides. Without this device, his facial tumors would suffocate him.
This is one time when summary simply can’t do justice to the text. Kidder spends pages and pages going step-by-step through the process of moving John to Boston: it’s agonizing to read these pages, because we see how difficult it’s going to be to save his life. By focusing so intently on the moving process, Kidder makes us see the extent of the world’s inequality: in the U.S., it would be inconceivable for a medical evacuation to last more than an hour—but in Haiti, it’s a miracle such an evacuation lasts less than an hour.
The driver of the ambulance decides to arrange for another truck to drive John to the airport. Serena and the other hospital technicians hook up John’s suction device to the truck’s battery, and they drive off toward the airport. John is in great pain during this ride, not least because the road is extremely rocky and bumpy. After hours of driving, during which the car stops several times, John, Serena, and Kidder make it to the airport.
It’s physical torture for John to have to be in a car when he’s already in so much agony. It’s also psychological torture for Serena and the other medics to have to sit with John this whole time. During their long ride to the airport they must be grieving his suffering while also agonizing over the decision they’ve already made, questioning whether it was really a good idea to fly John out to Boston in the first place.
Kidder reports that John survives his medevac flight to Boston, helped by his suction device the entire time. When the group lands in Boston, the ambulance driver tells Kidder, “There’s a lot of bad road between here and Mass General,” a statement that, Kidder later realizes, is hilariously funny, considering what John has just been through.
The ambulance driver’s warning about the bumpy road reads like the punch line to a dark joke. But it also suggests the different levels of difficulty the First World faces compared to the Third World’s problems: what seems like a big problem in the U.S. (i.e., a bumpy road) wouldn’t even register as a problem in Haiti.
The ambulance drives John to the pediatric wards of Mass General, and the team has John in bed very quickly. Farmer, who’s agreed to meet Serena in Boston, tells Serena that she did the right thing by bringing John to Boson. A medical intern at Mass General criticizes Serena because John is so malnourished. Dr. Alan Ezekowitz, the head of pediatrics, subtly chastises this intern by saying, “This boy is a challenge. But I’ve cured sicker kids,” and adding, “We can always do better, can’t we?”
There are two important exchanges in this section: first, Farmer confirms that Serena did the right thing by bringing John to Boston—a huge validation for Serena, who must have been wondering, “What will Farmer say?” throughout the flight. Second, an intern who has faced none of Serena’s challenges criticizes Serena’s treatment of John. This seemingly reflects the cynicism and pessimism of the medical establishment, and also reminds us that healthcare is always, at its core, made up of flawed and limited human beings. From the perspective of an intern in Brigham, Zanmi Lasante has failed to take care of its patients—despite Farmer’s best efforts, children like John are still malnourished. Ezekowitz’s rejoinder to his intern is then also important because it reflects his (and Farmer’s) optimism: even if he can’t eliminate all of John’s problems, he can do his best.
The medical team at Mass General proceeds with treating John. They identify tumors in John’s nasal area and spine—extremely painful. Gradually, they realize that there’s nothing they can do to save John’s life: he’s going to die. Serena nods, and whispers, “He’s getting excellent care.” She explains that there was value in bringing John to Boston, even if his life couldn’t be saved: he got excellent care, and he will at least be able to die in a room where his mother can grieve without “flies all over her face.”
In this heartbreaking sequence, we can’t help but ask, “Was it worth it to bring John to Boston?” One could say this is the “acid test” for one’s feelings on healthcare. The intern who scoffed at Serena would probably say no—the process was a waste of time, money, and energy. But Farmer and (presumably) Ezekowitz would argue otherwise: even if they couldn’t save John, they improved his quality of life by giving him a clean, warm place to spend his final moments, and at least they tried their best instead of giving up for the sake of cost-efficiency.
A few days later, John’s mother arrives on another flight. She’s able to see her son just before the end of his life. Shortly after John’s death, Farmer offers her a job at Zanmi Lasante, which she accepts. Months after the incident, the Haitians aren’t mobbing Zanmi Lasante with demands for transportation to the U.S.—on the contrary, Farmer’s assistant Ti Jean reports that the Haitians merely say, “Look how much they care about us.” Moreover, Mass General waives medical fees for several other Haitian children in the months after John’s death, and Serena is able to arrange for them to be flown up to Boston. Thus, John’s death in Boston could be said to have a silver lining.
In the end, Farmer and Ezekowitz’s point of view seems partly vindicated: contrary to what some had worried, the Haitians aren’t mobbing Zanmi Lasante with demands for special treatment like John had. The usual arguments for the “cycle of dependency” simply aren’t true, at least in this case: instead of expecting the best possible healthcare, the Haitians are still grateful to have any healthcare whatsoever.
Kidder is unsure how he feels about John’s treatment. In a sense, he thinks of it as a lesson in the impossibility of Farmer’s project—a symbol of its futility.
Kidder refuses to make up his own mind about John’s death, and in this way, he’s allowing each reader to reach his or her own decision about the value of human life, cost-effectiveness, and cycles of dependency.