ALSO BY TRACY KIDDER
Home Town
Old Friends
Among Schoolchildren
House
The Soul of a New Machine
FOR HENRY
AND TIM KIDDER
Dèyè mòn gen mòn.
Beyond mountains there are mountains.
HAITIAN PROVERB
… And right action is freedom
From past and future also.
For most of us, this is the aim
Never here to be realised;
Who are only undefeated
Because we have gone on trying …
T. S. ELIOT, “THE DRY SALVAGES”
CONTENTS
PART I
Doktè Paul
PART II
The Tin Roofs of Cange
PART III
Médicos Aventureros
PART IV
A Light Month for Travel
PART V
O for the P
Afterword
Acknowledgments
Selected Bibliography
CHAPTER 1
Six years after the fact, Dr. Paul Edward Farmer reminded me, “We met because of a beheading, of all things.”
It was two weeks before Christmas 1994, in a market town in the central plateau of Haiti, a patch of paved road called Mirebalais. Near the center of town there was a Haitian army outpost—a concrete wall enclosing a weedy parade field, a jail, and a mustard-colored barracks. I was sitting with an American Special Forces captain, named Jon Carroll, on the building’s second-story balcony. Evening was coming on, the town’s best hour, when the air changed from hot to balmy and the music from the radios in the rum shops and the horns of the tap-taps passing through town grew loud and bright and the general filth and poverty began to be obscured, the open sewers and the ragged clothing and the looks on the faces of malnourished children and the extended hands of elderly beggars plaintively saying, “Grangou,” which means “hungry” in Creole.
I was in Haiti to report on American soldiers. Twenty thousand of them had been sent to reinstate the country’s democratically elected government, and to strip away power from the military junta that had deposed it and ruled with great cruelty for three years. Captain Carroll had only eight men, and they were temporarily in charge of keeping the peace among 150,000 Haitians, spread across about one thousand square miles of rural Haiti. A seemingly impossible job, and yet, out here in the central plateau, political violence had all but ended. In the past month, there had been only one murder. Then again, it had been spectacularly grisly. A few weeks back, Captain Carroll’s men had fished the headless corpse of the assistant mayor of Mirebalais out of the Artibonite River. He was one of the elected officials being restored to power. Suspicion for his murder had fallen on one of the junta’s local functionaries, a rural sheriff named Nerva Juste, a frightening figure to most people in the region. Captain Carroll and his men had brought Juste in for questioning, but they hadn’t found any physical evidence or witnesses. So they had released him.
The captain was twenty-nine years old, a devout Baptist from Alabama. I liked him. From what I’d seen, he and his men had been trying earnestly to make improvements in this piece of Haiti, but Washington, which had decreed that this mission would not include “nation-building,” had given them virtually no tools for that job. On one occasion, the captain had ordered a U.S. Army medevac flight for a pregnant Haitian woman in distress, and his commanders had reprimanded him for his pains. Up on the balcony of the barracks now, Captain Carroll was fuming about his latest frustration when someone said there was an American out at the gate who wanted to see him.
There were five visitors actually, four of them Haitians. They stood in the gathering shadows in front of the barracks, while their American friend came forward. He told Captain Carroll that his name was Paul Farmer, that he was a doctor, and that he worked in a hospital here, some miles north of Mirebalais.
I remember thinking that Captain Carroll and Dr. Farmer made a mismatched pair, and that Farmer suffered in the comparison. The captain stood about six foot two, tanned and muscular. As usual, a wad of snuff enlarged his lower lip. Now and then he turned his head aside and spat. Farmer was about the same age but much more delicate-looking. He had short black hair and a high waist and long thin arms, and his nose came almost to a point. Next to the soldier, he looked skinny and pale, and for all of that he struck me as bold, indeed downright cocky.
He asked the captain if his team had any medical problems. The captain said they had some sick prisoners whom the local hospital had refused to treat. “I ended up buyin’ the medicine myself.”
Farmer flashed a smile. “You’ll spend less time in Purgatory.” Then he asked, “Who cut off the head of the assistant mayor?”
“I don’t know for sure,” said the captain.
“It’s very hard to live in Haiti and not know who cut off someone’s head,” said Farmer.
A circuitous argument followed. Farmer made it plain he didn’t like the American government’s plan for fixing Haiti’s economy, a plan that would aid business interests but do nothing, in his view, to relieve the suffering of the average Haitian. He clearly believed that the United States had helped to foster the coup—for one thing, by having trained a high official of the junta at the U.S. Army’s School of the Americas. Two clear sides existed in Haiti, Farmer said—the forces of repression and the Haitian poor, the vast majority. Farmer was on the side of the poor. But, he told the captain, “it still seems fuzzy which side the American soldiers are on.” Locally, part of the fuzziness came from the fact that the captain had released the hated Nerva Juste.
I sensed that Farmer knew Haiti far better than the captain, and that he was trying to impart some important information. The people in this region were losing confidence in the captain, Farmer seemed to be saying, and this was a serious matter, obviously, for a team of nine soldiers trying to govern 150,000 people.
But the warning wasn’t entirely plain, and the captain got a little riled up at Farmer’s denunciation of the School of the Americas. As for Nerva Juste, he said, “Look, that guy is a bad guy. When I do have him and the evidence, I’ll slam him.” He slapped a fist into his hand. “But I’m not gonna stoop to the level of these guys and make summary arrests.”
Farmer replied, in effect, that it made no sense for the captain to apply principles of constitutional law in a country that at the moment had no functioning legal system. Juste was a menace and should be locked up.
So they reached a strange impasse. The captain, who described himself as “a redneck,” arguing for due process, and Farmer, who clearly considered himself a champion of human rights, arguing for preventive detention. Eventually, the captain said, “You’d be surprised how many decisions about what I can do here get made in Washington.”
And Farmer said, “I understand you’re constrained. Sorry if I’ve been haranguing.”
It had grown dark. The two men stood in a square of light from the open barracks door. They shook hands. As the young doctor disappeared into the shadows, I heard him speaking Creole to his Haitian friends.
I stayed with the soldiers for several weeks. I didn’t think much about Farmer. In spite of his closing words, I didn’t think he understood or cared to sympathize with the captain’s problems.
Then by chance I ran into him again, on my way home, on the plane to Miami. He was sitting in first-class. He explained that the flight attendants put him there because he often flew this route and on occasion dealt with medical emergencies on board. The attendants let me sit with him for a while. I had dozens of questions about Haiti, including one about the assistant mayor’s murder. The soldiers thought that Voodoo
beliefs conferred a special, weird terror on decapitation. “Does cutting off the victim’s head have some basis in the history of Voodoo?” I asked.
“It has some basis in the history of brutality,” Farmer answered. He frowned, and then he touched my arm, as if to say that we all ask stupid questions sometimes.
I found out more about him. For one thing, he didn’t dislike soldiers. “I grew up in a trailer park, and I know which economic class joins the American military.” He told me, speaking of Captain Carroll, “You meet these twenty-nine-year-old soldiers, and you realize, Come on, they’re not the ones making the bad policies.” He confirmed my impression, that he’d visited the captain to warn him. Many of Farmer’s patients and Haitian friends had complained about the release of Nerva Juste, saying it proved the Americans hadn’t really come to help them. Farmer told me he was driving through Mirebalais and his Haitian friends were teasing him, saying he didn’t dare stop and talk to the American soldiers about the murder case, and then the truck got a flat tire right outside the army compound, and he said to his friends, “Aha, you have to listen to messages from angels.”
I got Farmer to tell me a little about his life. He was thirty-five. He had graduated from Harvard Medical School and also had a Ph.D. in anthropology from Harvard. He worked in Boston four months of the year, living in a church rectory in a poor neighborhood. The rest of the year he worked without pay in Haiti, mainly doctoring peasants who had lost their land to a hydroelectric dam. He had been expelled from Haiti during the time of the junta but had sneaked back to his hospital. “After the payment,” he said, “of an insultingly small bribe.”
I looked for him after the plane landed. We talked some more in a coffee shop, and I nearly missed my connecting flight. A few weeks later, I took him to dinner in Boston, hoping he could help make sense of what I was trying to write about Haiti, which he seemed glad to do. He clarified some of the history for me but left me wondering about him. He had described himself as “a poor people’s doctor,” but he didn’t quite fit my preconception of such a person. He clearly liked the fancy restaurant, the heavy cloth napkins, the good bottle of wine. What struck me that evening was how happy he seemed with his life. Obviously, a young man with his advantages could have been doing good works as a doctor while commuting between Boston and a pleasant suburb—not between a room in what I imagined must be a grubby church rectory and the wasteland of central Haiti. The way he talked, it seemed he actually enjoyed living among Haitian peasant farmers. At one point, speaking about medicine, he said, “I don’t know why everybody isn’t excited by it.” He smiled at me, and his face turned bright, not red so much as glowing, a luminescent smile. It affected me quite strongly, like a welcome gladly given, one you didn’t have to earn.
But after our dinner I drifted out of touch with him, mainly, I now think, because he also disturbed me. Writing my article about Haiti, I came to share the pessimism of the soldiers I’d stayed with. “I think we should have left Haiti to itself,” one of Captain Carroll’s men had said to me. “Does it really matter who’s in power? They’re still gonna have the rich and the poor and no one in between. I don’t know what we hope to accomplish. We’re still going to have a shitload of Haitians in boats wanting to go to America. But, I guess it’s best not even to try and figure it out.” The soldiers had come to Haiti and lifted a terror and restored a government, and then they’d left and the country was just about as poor and broken-down as when they had arrived. They had done their best, I thought. They were worldly and tough. They wouldn’t cry about things beyond their control.
I felt as though, in Farmer, I’d been offered another way of thinking about a place like Haiti. But his way would be hard to share, because it implied such an extreme definition of a term like “doing one’s best.”
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. Over the next five years, I mailed some small sums to the charity that supported Farmer’s hospital in Haiti. He sent back handwritten thank-you notes on each occasion. Once, from a friend of a friend, I heard he was doing something notable in international health, something to do with tuberculosis. I didn’t look into the details, though, and I didn’t see him again until near the end of 1999. I was the one who made the appointment. He named the place.
CHAPTER 2
Outside the Brigham and Women’s Hospital in Boston, you’re aware of a relative urban quiet. A Wall Street of medicine surrounds you: the campus of Harvard Medical School and the Count-way Medical Library, Children’s Hospital, Beth Israel Deaconess, Dana-Farber Cancer Institute, the Brigham. The buildings look imposing packed together, and even awesome when you let yourself imagine what’s going on inside. Chest crackings, organ transplants, molecular imagings, genetic probes—gloved hands and machines routinely reaching into bodies and making diagnoses and corrections, so much of human frailty on the one hand and boldness on the other. One feels stilled in the presence of this enterprise. Even the Boston drivers, famously deranged, don’t honk much when passing through the neighborhood.
The Brigham occupies one side of Francis Street and envelops, like a city around a Roman ruin, the renovated Victorian lobby of the old Peter Bent Brigham, a relic of the history of Boston medicine. The modern entrance, a towering atrium with marble floors, lies a quarter of a mile away, at the end of a shiny corridor called the Pike—short for turnpike—flanked by banks of elevators, clinical departments to the right and left, inpatient wards on floors above, operating rooms below (forty, not counting the ones in obstetrics), dozens of laboratories in all directions, and mortal dramas everywhere. It’s a medical mall, a teaching hospital and a full-service hospital and a tertiary care facility, a hospital to which other hospitals forward their most difficult cases. Crowds move up and down the Pike, in white uniforms and street clothes, carrying bouquets of flowers, trailing the sound of many mingled conversations.
Four floors down in radiology, Dr. Farmer and his team had staked out a quiet spot, an empty windowless room, and were discussing the last of their cases for the day. Farmer had recently turned forty. Perhaps his hair had receded slightly since I’d last seen him, five years ago. He looked a little thinner, too, and was much more formally attired. He wore wire-framed glasses with little round lenses, and a black suit, and a necktie, cinched up tight. He was still spending most of his time in Haiti, but he was also a big-shot Boston doctor now, a professor of both medicine and medical anthropology at Harvard Medical School, and an attending specialist on the Brigham’s senior staff. Looking at him, sitting with two of his students, young doctors in white coats, I imagined a nineteenth-century daguerreotype—the austere, august professor of medicine in a stiff high collar and a waistcoat. That impression didn’t last.
He and the young doctors discussed a patient who had recently been treated for a parasite in the brain. The man had become hydrocephalic, and the neurosurgeons had implanted a shunt to drain off the fluid. There was no evidence of further infection, but should the patient be treated for one, just to be safe? “What do you think?” Farmer asked his team, and they batted the question around, and Farmer mostly just listened, though it was clear he was in charge.
After a few minutes, the team agreed: they should treat the patient. Then the phone rang. Farmer picked it up and said, “HIV central. How can we help?”
The caller was a female parasitologist, an old close colleague of Farmer’s, offering her view on the hydrocephalic patient. “Worm Lady!” Farmer exclaimed. “How are you, pumpkin? Oh, I’m fine. Listen, it’s scandalous to say, but we don’t agree. We want to treat his ass. ID says treat. Love, ID.”
These last two lines were a saying of his. I’d heard him use it earlier in the day, and I’d worked it out for myself. ID stood for “Infectious Disease,” his specialty. And the command was uttered as if in a letter, and generally meant that he wanted to treat a patient at once, rather than wait for further tests. Clearly, he liked the soun
d of the words. He seemed to be having a very good time, and from the reactions of his students, small smiles and shakes of the head, which they didn’t try to hide from him, I figured that none of his sayings or his jokes or his general ebullience was new for today.
This day—a day in mid-December 1999—had so far been quite ordinary, at least by Brigham standards. Farmer and his team had dealt with six cases, each something of a puzzle, except for the next-to-last case of the day, which seemed rather simple. The resident on the team, a young woman, presented the facts to Farmer, reading from her notes: A thirty-five-year-old man (I’ll call him Joe). HIV-positive. Smoked a pack of cigarettes a day. Usually drank half a gallon of vodka. Also used cocaine, both intravenously and by inhalation. Recently overdosed on heroin. Had a chronic cough which five days ago increased, became productive—yellow-green sputum but no blood—and was accompanied by deep chest pain. He had lost twenty-six pounds over the last several months. The radiologists reported a possible right lower lobe infiltrate on his chest X ray—possible tuberculosis, they thought.
The tools for uncovering tuberculosis belong to an older era in medicine, and the diagnosis can be tricky, especially in someone with HIV. Certainly, Joe was a likely target for TB. Of all the infections that can come crowding into a person with HIV disease, TB was the most common worldwide. The disease was rare in Boston, indeed throughout the United States, except in the kinds of places where Joe lived—in homeless shelters and jails and on the streets and under bridges. But in spite of his HIV infection, Joe’s immune system was still mostly intact. And he didn’t have the classic symptoms of TB, which are fever, chills, and night sweats. “He has terrible teeth,” said the resident. She added, “He’s a nice guy.”
Farmer said, “Let’s go see the X ray, shall we?”
They went to another room and put Joe’s chest X ray up on a lighted viewing screen, and Farmer stared, for less than a minute, at the spot where the radiologists thought they saw an infiltrate. Then he said, “That’s it? It’s rather underwhelming.”