Coming down a steep trail in one of the hills around Cange, she lost her footing momentarily. There were Haitians nearby. “Watch your step!” someone called to her in Creole. She felt the muscles in her jaw flex. Did they think she was a weakling? An elderly man came up to her and offered her his walking stick. “No, I’m fine!” she said. Paul’s face looked stern. “Don’t refuse something like that,” he said to her emphatically. “It’s an incredible gift.” Of course he was right. Her cheeks burned.
They slept in different quarters in Cange—the patriarch of the place was, after all, a priest. One night, about to turn in, she decided that tomorrow she’d get up earlier than Paul. She set her alarm clock for five. She woke to the sound of his voice, singing up to her from the courtyard below her window, and she lay in bed thinking, “I just want to do something better than him. For a moment.”
Paul had expanded and refined the health census he’d begun around Cange in 1983. He’d found a book that described a census done in a rural part of India, and he used it as a manual. Ophelia worked on gathering data. This meant walking from village to village, sometimes with Paul, more often with the local youths he had recruited, who knew the ways, down gullies and up mountainsides, along paths half-covered in underbrush. The heat felt “enormous.” Her face would turn bright red, but her Creole greatly improved, and every trip seemed important and wrenching. She’d go to a tiny two-room hut, a chair would appear, and the peasants would offer her a drink and talk about their pain and misery while she took notes. She would ask them when they were born, and they would tell her what president had been in power at the time, or date their births to before or after the dam. Ophelia would ask, “How many live here?” and the mother or father of the house would reel off names, sometimes as many as eleven, and Ophelia would look up and see slivers of sky through the banana-bark roof and think about the rainy season. She’d see the metal cups on the stilts of their small granaries and think, “Rats.” She noted a distinctive smell inside the crowded huts. “Not smelly socks stinky, but the close smell of people in poverty. Many hungry people breathing.”
Sometimes she went to houses where people were dying, and often, especially in Cange among the water refugees, these were children in the throes of one or another of the diarrheal diseases. To get water, the people of Cange had to climb down a steep eight-hundred-foot hillside. They’d dip their calabash gourds or recycled plastic jugs in the stagnant reservoir, then carry them back up the hill, and of course they’d want to make that water last. So it would sit in the jugs or gourds uncovered for days.
The solution came from a team of Haitian and American engineers. The Americans were members of the church group from the Episcopal Diocese of Upper South Carolina who had been helping out Père Lafontant for years. A sparkling underground river burst out near the base of the eight-hundred-foot hill. Before the dam, it had been a main source of local drinking water. The engineers devised a plan to use the force of that river to carry its own water in a pipe up to communal water spigots that would be constructed in Cange. Almost as soon as this was accomplished, Ophelia remembered, infant deaths began dropping.
Farmer was learning about the great importance of water to public health, and he was conceiving a great fondness for technology in general, also scorn for “the Luddite trap.” He liked to illustrate the meaning of that phrase with the story of the time when he came back to Cange from Harvard and found that Père Lafontant had overseen the construction of thirty fine-looking concrete latrines, scattered through the village. “But,” Farmer asked, “are they appropriate technology?” He’d picked up the term in a class at the Harvard School of Public Health. As a rule, it meant that one should use only the simplest technologies required to do a job.
“Do you know what appropriate technology means? It means good things for rich people and shit for the poor,” the priest growled, and refused to speak to Farmer again for a couple of days.
Lafontant was also supervising the construction of a clinic in Cange—the South Carolinians had put up the money. The facility would have a laboratory, of course. Farmer got hold of a pamphlet about how to equip labs in third world places published by the World Health Organization. It made modest recommendations. You could make do with only one sink. If it wasn’t easy to arrange for electricity, you could rely on solar power. A homemade solar-powered microscope would serve for most purposes. He threw the booklet away. The first microscope in Cange was a real one, which he stole from Harvard Medical School. “Redistributive justice,” he’d later say. “We were just helping them not go to hell.”
The enterprise in Cange and the surrounding villages was essentially the creation, from scratch, of a public health system, with Père Lafontant as the construction boss—amazing how quickly and durably he got things built in a place without electricity, stores, or a serviceable road. Increasingly, the vision for this health system came from Farmer. A lot of the plan was straightforward, steps that any school of public health would recommend. He’d begun with the census because that was the way to identify problems and to begin building records and to create a baseline against which future censuses could measure how well the new system was working. He planned for the creation of what he called a “first line of defenses” out in the communities. These would include vaccination programs, protected water supplies and sanitation, and at the heart of the defenses, a cadre of people from the villages trained to administer medicines and give classes on health, to treat minor ailments and recognize the symptoms of grave ones like TB, malaria, typhoid. He imagined his project for women—gynecological services, health education, and family planning—to reduce local maternal mortality. What the first line of defenses failed to prevent would be handled at the second line—at the new Clinique Bon Sauveur in Cange, which Farmer imagined would someday have a hospital beside it.
To many people in public health, such an array of projects would have seemed ambitious enough, indeed too much to hope for in a place as impoverished as Cange. But by 1985 Farmer had grown impatient with standard definitions of public health. The great burdens of disease in Cange were just a symptom of a general deprivation, he’d say to Ophelia. He’d tell her, “We have to think about health in the broadest possible sense.”
This notion came in part from Lafontant. He had built the first school in Cange back in the late 1970s. It had a thatched roof; classes that didn’t fit inside were held under a mango tree. In the early 1980s, with money from South Carolina, Lafontant had erected a much larger building, two stories tall, on a small plateau on the hillside above Highway 3. To Farmer the building looked “faintly grandiose,” looming above the shacks of Cange. He would write, “The establishment of a school may seem a bit out of place given the homelessness, landlessness, and hunger of many of the water refugees. But it appears that they themselves did not feel that way.” Children flocked to the new facility. One peasant woman explained, “A lot of us wondered what would have happened if we had known how to write. If we had known how to write, perhaps we wouldn’t be in this situation now.” And a school could serve as a place for teaching lessons about health and for providing free meals to malnourished children without injuring their dignity. To build a school was to unite the practical and the moral. Farmer would say, “Clean water and health care and school and food and tin roofs and cement floors, all of these things should constitute a set of basics that people must have as birthrights.”
All this would require money beyond what the South Carolinians could provide. Farmer had only limited experience as a fund-raiser. In 1985, though, he got lucky.
Two years before, late in 1983, he’d gone to Boston for his standard preadmissions interview at Harvard and had visited a charity named Project Bread. He’d asked the organization for a few thousand dollars to build a bread oven in Cange. He’d often heard Père Lafontant say that Cange needed a bakery.
It had been an easy sell. Farmer was told that the charity had a donor who had asked that his money go to feed poor peo
ple in Haiti.
“Who is he?” Farmer asked.
“He’s an anonymous donor.”
The bread oven was built, not far from the school, in the summer of 1984. Early the following year, a Harvard Medical School publication printed Farmer’s essay “The Anthropologist Within.” Soon afterward the director of Project Bread contacted Farmer. The bread oven’s anonymous donor had read the article. “I’d like to meet this kid,” the donor had supposedly said. “He sounds like a winner.”
“If he wants to meet me, tell him to come to Haiti,” Farmer replied.
He had been told that the donor’s name was Tom White, and that the man owned a heavy-construction firm in Boston. Farmer imagined portly Republicans smoking stogies and cutting back-alley deals with the Massachusetts Bay Transit Authority, keeping the unions out. Farmer went to pick up White at the François Duvalier Airport. The person he found waiting there in the hot wind was a pink-faced man in his sixties, dressed in polyester golfing clothes, including the plaid pants. White had brought along a roll of cash, which he had soon distributed among beggars, not an obnoxious act in Farmer’s philosophy but hardly a sufficient one. Farmer narrated Haiti in the truck on the way to Cange, and White seemed appropriately horrified, but Farmer was still wary of him and didn’t try to hide the fact.
He was only twenty-five and not, he would admit, “fully formed” when it came to dealing with potential donors. Inside the jouncing truck the conversation turned to American politics. White remarked, “Well, I didn’t vote for Reagan.”
“What do you mean?” said Farmer.
“I didn’t vote for Reagan.”
“So you voted against your own interests?” asked Farmer.
“Is that a sin?” said White.
Remembering that moment, White told me, “So he went from being cool to very warm.” White went on, “He was fresh as hell to me, but I liked him, because if you said boo and he didn’t think boo was right, he’d tell you. He was way ahead of me, on service to the poor.”
The next time Farmer returned to Cambridge, Tom White took him to lunch, and they had an argument about guilt. White said he thought it was a useless emotion. On the contrary, Farmer said, it could be quite helpful. White had gotten divorced from his first wife. He had made a very generous voluntary settlement with her, and footed all the bills for his children’s keep and education. His second marriage—to a woman with six children of her own—was hardly the conventional rich man’s. Nonetheless, he said, he felt very guilty about the fact of his divorce.
This wasn’t what Farmer had in mind. What he endorsed, he said, was the guilt some rich people felt toward the poor, because it could cause them to part with some of their money. And they ought to feel guilty besides.
Actually, White had been giving away money for years, to Catholic charities and needy friends, even before he’d had much of his own. He grew up in an Irish Catholic household devastated by his father’s drinking, and at an early age became what he called “the go-to guy” in his family. He’d had a colorful-sounding life. College at Harvard, where he majored in Romance languages, and then the army, where he became, reluctantly at first, the aide to General Maxwell Taylor, commander of the 101st Airborne Division. White parachuted into Normandy the night before D-Day and later into Holland. Though he would say he didn’t regret participating, he came away with a hatred for war, and though he liked Taylor personally and admired the general’s courage, he learned to dislike the tendency of the powerful to view human beings as pins on a map. Also to dislike the perquisites of power—through seeing a young paratrooper crushed by his own pack, overweight with unnecessary items he carried for the general.
After the war, White had built his father’s construction company into what was now the largest in Boston. He had been the intimate of cardinals, had served on the boards of nine institutions, and had sat with the presidential party at JFK’s inauguration. But he felt uncomfortable among most of the rich and famous, and generally shunned the press. He told me, cryptically, that he had been depressed at various times in his life. Also that he’d had “a low self-image,” adding, “But in my business all you had to be was low bidder.” When I asked him what had caused him to place large bets on Farmer, on a medical student in his twenties, White said, “He appealed to me immediately. So intelligent, so dedicated to his work.” He thought for a time. “I really can’t explain it. I probably was also looking for somebody to hang my hat with.”
Certainly Haiti upset White. He found the road to Cange especially offensive. “Jogging along that damn road,” he’d say. He never traveled it without thinking, “This would be so damn easy to fix.” He remembered his first view of kwashiorkor. “There was a kid with red hair and a bloated belly, and I said right away, ‘Put in a feeding program here.’ ” White found it easy to imagine himself a Haitian. A child with big eyes and a memorable smile, encountered in a dirt-floored hut, made him feel like bringing over the company bulldozers. “For Christ’s sake,” he’d say to Farmer or Père Lafontant. “Put a tin roof on and pour a concrete floor. I’ll give you the money. Holy shit.”
When Farmer was back in Boston, doing his internship at the Brigham, White would drive over at lunchtime and buy sandwiches at the restaurant inside the hospital. He and Farmer would eat them in White’s car. One day White asked Farmer, who looked pale as usual, “You eatin’ enough?”
“Oh, I’m fine,” said Farmer.
“Need any money?”
“No,” said Farmer. “Well, maybe forty dollars?”
White happened to have a wad of hundred-dollar bills in his pocket. He tossed one into Farmer’s lap. “You look hungry to me.” Saying this, he felt impelled to reach in his pocket again. He tossed another hundred to Farmer. “Please, for God’s sakes, eat,” he said, and to emphasize the point, he gave Farmer yet another hundred.
Farmer looked down at the loot. “Now I can tell you what happened last night.” He’d gone to the home of an AIDS patient whom he had treated at the Brigham and found out the man was about to be evicted. “I signed my check over to him.”
“Jeez, Paul, don’t you think that’s kind of impractical?”
Farmer smiled. “Well,” he said. “God sent you today.”
White often found himself running errands in Boston for projects in Cange, picking up things like sinks and loading them into the trunk of his Mercedes. (One load of sinks was for a new clinic. The first clinic turned out to have been badly designed. White paid to have it rebuilt. He did this quietly, not asking for credit. “Not even a plaque with his name on it,” said Farmer.)
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.”
CHAPTER 10
In a photograph that Ophelia took in the mid-1980s, Paul appears in shorts, five or ten pounds heavier than in the coming decades—thin but not remarkably so. He crouches, his hands still smoothing the dirt around a seedling he’s just planted, on the once barren hillside above Highway 3, where each time she returned Ophelia found another young grove of trees, another new building or two. She came back every summer, from 1985 until 1989. They were months of nearly constant work. By early afternoon Paul would still be seeing patients, and famished herself, she’d go to his office in the clinic. “You’re not hungry? All you had was coffee at six this morning.” He’d agree to come up the hill to the kitchen with her, but usually reluctantly, she felt.
From time to time she longed to get away from that desolate region. She’d talk Paul into trips to Port-au-Prince, always feeling “sort of scummy” for taking him away. She would tell him, “This is about getting things for the clinic.” Before they left she’d grab a handful of his index cards. The drive was a little less than three hours back then. When, as often happened, they punctured a tire or broke a spring and had to wait for repairs,
they would sit by the road and she would quiz him. And they would in fact buy medicines and equipment and more flora for Paul to plant around the growing medical complex on the hillside in Cange.
At the end of one of those weekends, they were driving down Delmas Street on their way out of Port-au-Prince, and Ophelia was thinking of the long, hot walks ahead of her in Cange, and of how wonderful it was to return from them and drink a Diet Coke. “I’d love to get some Diet Coke,” she said.
Paul said, “We don’t have time. We can’t do it.”
She understood that he wanted to get back to Cange and that making the stop would mean not just a twenty-minute delay but also walking past the beggars into a supermarket that served the Haitian elite. But at the moment, his words nettled her. He seemed to be saying that if he and the peasantry could get along without things like Diet Coke, so could she. “He was so sure about some things,” she remembered. “The frustrating thing was, he usually was right.” In the car, she started in on him, accusing him of self-righteousness. She didn’t let up. Finally, he slammed on the brakes, reached across her, and pushed open her door. “Get out!” he yelled, and called her a foul name. She didn’t obey. She sat rigidly in her seat, feeling both offended and also exultant, smiling inwardly, thinking, “Yes! I got to you. You have this human quality. You’re flawed.”
Another trip to Port-au-Prince stood out in her memory. It was in 1986, not long after Baby Doc left Haiti, an event that marked the end of the Duvaliers’ reign, which was being followed by what dissident Haitians called Duvalierism without Duvalier, with the Haitian army generally taking on the dictatorial role. All that summer there had been signs of unrest, still rather disorganized: impromptu roadblocks made of burning tires, peasants demonstrating in Mirebalais. A lot of peasants, it seemed, had imagined their lives would improve when Baby Doc left. Now they were protesting the continuation of the status quo. There was, for Ophelia, “a feeling in the air that things could erupt at any moment.” She and Paul went to Port-au-Prince for the weekend and were staying at the house that the Lafontants kept in the city. They’d driven downtown on an errand. When they came outside, it seemed to Ophelia that the street had become unusually still, and amid the normal sour odor of the capital she smelled burning tires, “the smell of something being burned that shouldn’t be.” But kids had taken the keys from their car. While Paul was negotiating with them to get the keys back, Ophelia stared down the street, at its intersection with a larger avenue. Suddenly she saw what in Haiti is known as a kouri, literally a run—a stampede of people passing the intersection, and then large Haitian army trucks with mounted guns in close pursuit. She heard shots. The aftermath of a political demonstration, clearly. In a moment demonstrators came running down the street, surrounding their car and all the others that were trying to back and fill and get away from there. She and Paul opened the doors to let in some of the wounded. Meanwhile, she began having stomach cramps. “P.J., let’s get out of here!”