The world is full of miserable places. One way of living comfortably is not to think about them or, when you do, to send money.
As Farmer was leaving the shelter, he heard Joe say to another resident, just loudly enough to make Farmer wonder if Joe meant for him to overhear, “That guy’s a fuckin’ saint.”
He made about $125,000 a year from Harvard and the Brigham, but he never saw his paychecks or the honoraria or royalties, both fairly small sums, that he received for his lectures and writings. The bookkeeper at PIH headquarters cashed the checks, paid his bills—and his mother’s mortgage—and put whatever was left in the treasury. One day in 1999, Farmer tried to use his credit card and was told he’d reached his limit.
And then of course it dawned on him that he knew plenty of Americans—he was one himself—who held apparently contradictory beliefs, such as faith in both medicine and prayer. He felt, he said, as though he hung in the air before his patient, “suspended by her sympathy and bemusement.”
By then Farmer had quit his fraternity. He wrote them that he couldn’t belong to an all-white organization. (“I received quite a frosty reply,” he would say, in a tone of voice that implied this still surprised him.) He’d come to admire his father’s distaste for putting on airs.
But independence had been followed by nearly two hundred years of misrule, aided and abetted by foreign powers, especially France and the United States. (From 1915 to 1934, the U.S. Marines had occupied and run the country.) To Farmer, Haiti’s history seemed, indeed, like The Lord of the Rings, an ongoing story of a great and terrible struggle between the rich and the poor, between good and evil.
For a long time I thought I could live and work in Haiti, carving out a life with you, but now I understand that I can’t. And that’s simply not compatible with your life—the life you once told me you would like to lead even ten years ago.
He was already attracted to liberation theology. “A powerful rebuke to the hiding away of poverty,” he called it. “A rebuke that transcends scholarly analysis.” In Haiti, the essence of the doctrine came alive for him. Almost all the peasants he was meeting shared a belief that seemed like a distillation of liberation theology: “Everybody else hates us,” they’d tell him, “but God loves the poor more. And our cause is just.”
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.
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.
One time when they were together in Boston, White said, “You know, Paul, sometimes I’d like to chuck it all and work as a missionary with you in Haiti.” Farmer thought for a while, then said, “In your particular case, that would be a sin.”
Some people said that medicine addresses only the symptoms of poverty. This, they agreed, was true, and they’d make “common cause” with anyone sincerely trying to change the “political economies” of countries like Haiti. But it didn’t follow, as some self-styled radicals said, that good works without revolution only prolonged the status quo, that the only thing projects like Cange really accomplish is the creation of “dependency.”
He’d write about how the Centers for Disease Control, a federal U.S. agency, had gone so far as to identify Haitians as a “risk group,” along with several other groups whose names began with h—homosexuals, hemophiliacs, and heroin users—and about the incalculable harm all this had done to Haiti’s fragile economy and to Haitians wherever they lived. In his thesis, he’d marshal a host of epidemiological data to show that AIDS had almost certainly come from North America to Haiti.
In early 1994, just before The Uses of Haiti came out, Farmer wrote an editorial for The Miami Herald. The gist of it was: “Should the U.S. military intervene in Haiti? We already have. Now we should do so in a new way, to restore democracy.”
The motion of his mind toward root causes had always excited him. He loved the challenge of diagnosis and all its accoutrements—the stains on the microscopic slides, the beautiful morphologies of the creatures under the lens. But what he called “the eureka moment” had a bad aftertaste this time. Later he would tell me, “God, I’d hate to ever feel triumphant about something so rotten.”
Farmer and Kim began collecting a number of official WHO statements. Some put the case more plainly: “In developing countries, people with multidrug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries.” For Farmer […] 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.
Then Goldfarb spoke up again, his voice calm and acidic. “I want to share with you a simple reality. I have six million dollars. With three million dollars I can eemplement DOTS for five thousand Russian prison inmates. And assuming that ten percent have MDR-TB, forty-five hundred will be cured and five hundred will go down with MDR-TB and die. And there’s nothing much you can do. So. I have a choice. And my choice is to use another three million dollars to treat the five hundred with MDR-TB, or go to another region and treat another five thousand. I’m working with leemited resources. So my choice is not involved in the human rights of five hundred people, but five hundred people versus five thousand people.
As sometimes happened, Paul seemed to know what Jim was thinking. “What do you want to do now?” he asked. There was warmth in the question, Jim felt, a real invitation for him to come clean. “Political work is interesting to me, and it has to be done,” he said. “I prefer it to taking care of patients. It’s O for the P on an international scale.”
Farmer was forty now, and he had the credentials to operate in the way Hiatt envisioned, on a purely executive level. In academic circles his reputation had grown. He was about to become a tenured Harvard professor. He was near the head of the line for the big prizes in medical anthropology; some of his peers were now saying that he’d “redefined” the field.
He distrusted all ideologies, including his own, at least a little. “It’s an ology, after all,” he had written to me about liberation theology. “And all ologies fail us at some point. At a point, I suspect, not very far from where the Haitian poor live out their dangerous lives.” Where might it fail? He told me, “If one pushes this ology to its logical conclusion, then God is to be found in the struggle against injustice.
It still seemed to me that he took a stance all too conveniently impregnable. He embodied a preferential option for the poor. Therefore, any criticism of him amounted to an assault on the already downtrodden people he served. But I knew by now he wasn’t simply posing. I felt something about him that I’d later frame to myself this way: He said patients came first, prisoners second, and students third, but this didn’t leave out much of humanity. Every sick person seemed to be a potential patient of Farmer’s and every healthy person a potential student. In his mind, he was fighting all poverty all the time, an endeavor full of difficulties and inevitable failures.
“Well, this boy is a challenge. But I’ve cured sicker kids.” Serena laughed nervously. She said, “Well, now he’s in Man’s Greatest Hospital.” That was what Mass General people called the place, playing on its initials, MGH. Dr. Ezekowitz chuckled. “As soon as we start to believe that, we won’t be.” He turned to the young intern. “Isn’t that right? We can always do better, can’t we.”
“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?”
The next time I was in Cange, I asked Zanmi Lasante’s chief handyman, Ti Jean, what the people in the region were saying about the case. He told me that everyone talked about it. “And you know what they say? They say, ‘Look how much they care about us.’”
If you say, Well, I just think how much could have been done with twenty thousand dollars, you sound thoughtful, sensible, you know, reasonable, rational, someone you really want on your side. However, if you were to point out, But a young attending physician makes one hundred thousand dollars, not twenty, and that’s five times what it cost to try to save a boy’s life—that just makes you sound like an asshole. Same world, same numbers, same figures, same currency.