He received his MacArthur grant in the summer of 1993, when it seemed that the junta might always be in power. He went to the awards ceremony in Chicago but soon afterward went back to his hotel room—hiding, as he thought of it, and watching the news from Haiti on TV. He was sitting in his room feeling wretched, thinking, “Big deal, I just got a MacArthur. Oh, great. My star’s ascending as the Haitians’ sets,” when he heard voices outside. Haitians! Of course. Who was more likely to be cleaning hotels in the States? He went out and chatted with them, which cheered him up a little.
In Haiti, the body count kept growing. Three close friends of Farmer’s had been murdered. He asked Ophelia to give him some money, and he went to Quebec City, his favorite of all cities—he’d always loved snow. In ten days in a hotel room, he wrote 220 pages, most of the draft of a book he would eventually call The Uses of Haiti. It is, I think, the best of Farmer’s books, certainly the most passionate, essentially a history of American policy toward Haiti. The history, that is, as if written in collaboration with a Haitian peasant.
The perspective is interesting. One learns, for instance, that the United States tried to help the French put down the Haitian revolution in the 1790s and, during the time of American slavery, refused to recognize Haiti and practiced gunboat diplomacy there. Also that, during the American occupation, the U.S. Congress had reconstituted the modern Haitian army and helped to finance it right up until the time when it deposed Aristide; that the head of the junta’s death squads, whose minions had murdered Chouchou, had been trained at Fort Benning’s School of the Americas; that some of the junta’s henchmen and officers in the Haitian army also worked for the CIA; that while formally deploring the coup, Washington, with the help of a generally compliant mainstream American press, was busily denouncing Aristide, even manufacturing lies about him, and maintaining a leaky embargo that seemed calculated to preserve appearances but not to drive the junta out of power.
In the book, a number of heroes don’t look so fine. The French revolutionaries, whose idea of fraternité didn’t include the slaves in St. Domingue, and the Haitian “mulattoes” who went to France to aid those revolutionaries in the hope that they could win the right to own slaves themselves. Woodrow Wilson, who presided over the American invasion of Haiti. Even FDR, who once boasted that, while serving as assistant secretary of the navy, he had written the Haitian Constitution of 1918. (There were others on this list whom Farmer often mentioned elsewhere: the former American slave and great abolitionist Frederick Douglass, who eagerly served as American ambassador to Haiti, in effect representing the Monroe Doctrine there. And Mother Teresa, who came to Haiti in 1981, during the time of Baby Doc, and, as one historian put it, “gushed” over the profligate dictator and his widely hated wife, Michele, who had looted millions from the Haitian treasury for her worldwide shopping sprees. Mother Teresa said Michele had taught her a lesson in humility and marveled at the closeness of the first lady to her people.)
In the United States, there was talk that the new Clinton administration might send troops to put Aristide back in power—albeit with conditions, such as accepting plans for “structural economic adjustment.” 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 editorial was mentioned in Haiti, on government radio. Farmer was said to have slandered the Haitian government. Soldiers came looking for him, to escort him out of the country. But he was already in Boston. He was formally expelled again, this time with a finality that even bribery couldn’t undo—“I would have expelled me, too, were I them.” He moped around the PIH office. Ophelia bought him a guitar, and he actually took some lessons, until the news came that yet another friend had been assassinated in Haiti. Jim half-carried Farmer home, weeping and puking, from a bar that night. The next day Farmer gave away his guitar.
For the rest of the summer of 1994, he lectured about the situation in Haiti to anyone who would listen, in small towns in Maine and Texas, Kansas and Iowa, usually staying at the houses of “church ladies.” He testified before a congressional committee along with some nuns—but most of the congressmen were asleep. He debated an American general. “I basically just let it rip,” he said later. “ ‘The Haitian situation is not understandable unless you know that the U.S. created the Haitian army. Blah, blah, blah, infectious disease.’ ” The general’s main response was to yell at him: “Paul, you’re totally out in left field!”
Most of the sources Farmer had used in his book were American government documents. He’d imagined that he could merely say he was a doctor and he had written about things he’d either seen with his own eyes or had looked up, and he’d be believed. He was well-received in some quarters, but usually not on the radio. During a show in Fort Lauderdale, a caller said, referring to the boatloads of refugees who were fleeing the poverty and violence in Haiti and trying to get to Florida, “We can’t have Haitians coming into our country.”
“Why not?” Farmer said. “My family are boat people.”
The host, understandably, didn’t get it. “Dr. Farmer, are you Haitian?”
Several times, and especially after the general yelled at him, he thought, “Screw this. I want to go back to my clinic.” He returned the day after Aristide was reinstated as president, in mid-October 1994.
The three years of military rule in Haiti had resembled a war, and like every war produced a public health disaster. The United Nations estimated that about eight thousand people got killed, most of them murdered by the Haitian army and its paramilitaries. Many boat people, perhaps thousands, drowned while trying to get away, and more died than on the Titanic when a leaky old ferry named the Neptune had sunk. But deaths from drowning and gunshots and torture probably made up just a fraction of the total. There was no telling precisely how much public health had deteriorated by the time military rule ended, but Farmer could make some guesses, based on the wreckage he returned to in Cange.
Somehow Père Lafontant had managed to get the new hospital built. But all Zanmi Lasante’s projects in the villages around Cange had been interrupted—its programs for women’s literacy, for vaccinating children, for sanitation and clean water, for distributing condoms and other AIDS-prevention measures. Partners In Health had financed a movie about HIV. Patients created the script, which depicted a truck driver and a soldier romancing several female victims. It was being shown to a crowd in a village school when soldiers walked in and shut down the projector. Not the wisest thing, during the reign of a military junta, to show a movie that blames AIDS on soldiers. Zanmi Lasante had put the movie away for the duration.
In the region, only Zanmi Lasante had dared to treat people who had been beaten or shot. The army had shut down the clinic once, briefly. The place was marked. Afraid to be seen there, afraid to travel at all, lest they end up like Chouchou, many patients hadn’t come until they’d grown very ill. Many had simply stayed away. The number of patients fell by half during those years, yet the clinic recorded an annual doubling of injuries from assaults—including four rapes committed by soldiers and attachés—a large increase in typhoid, and twenty-two times more cases of measles than the average before the coup. The years of military rule had exacerbated the chronic malnutrition, and tuberculosis had risen markedly in the region. The junta had focused most of its terror on the urban slums, because some of Aristide’s most ardent support was concentrated in them, and the slums were also at the center of Haiti’s AIDS epidemic. Hundreds of thousands fled back to the countryside. At Zanmi Lasante, in 1993, the number of patients with AIDS had increased by about 60 percent.
Several of the staff had resigned in fear. Farmer wrote that “paralysis” and “lassitude” afflicted almost all the medical personnel who stayed on. They missed meetings or canceled them, abandoned research, found excuses for not resuming the interrupted projects. Haitian doctors, he’d long ago
discovered, learned early to accept all sorts of deficiencies—shortages of medicines, filthy hospitals. Perhaps it is a universal tendency to view the deaths of strangers philosophically. Haitian doctors had better cause for this failing than most others in medicine. Not surprisingly, they tended to shrug when patients died from ailments like measles or tetanus or TB. Farmer had put some of his best efforts into teaching his staff to expect more of themselves. Now many were shrugging again.
But the situation was far from hopeless, and he was glad to be back.
Farmer was thirty-five now, on the rise in both medicine and anthropology. He had won his MacArthur. He was an infectious disease fellow in training at one of the world’s best teaching hospitals, an assistant professor in medical anthropology at Harvard, and the author of two books and about two dozen articles. He seems to have looked forward to a great deal more of the same, and he seems to have imagined that his main jobs now, and PIH’s as well, were to repair Zanmi Lasante and keep expanding it.
Partners In Health had changed their offices twice since 1987. They had finally acquired their own small headquarters building in Cambridge—the idea had been Jim Kim’s, the money Tom White’s. The staff there numbered only about a dozen, a little less than half volunteers, the rest underpaid employees. They managed an AIDS-prevention program for Haitian teenagers in Boston and, in the rundown neighborhoods right next to the Brigham, a program for providing medical and social services to people who weren’t getting any. They supported, with small sums and advice, a few public health projects in far-flung places, such as Chiapas in Mexico, and their research branch, dedicated to criticizing the status quo in international health, was assembling a book about the special worldwide vulnerability of impoverished women to AIDS. (Women, Poverty, and AIDS, it was called. Hearing the title, a friend of Farmer’s said, “That’s what I like about your books, Paul. They have such cheerful subjects.”) One could hardly have called PIH Paul’s Catholic church anymore, but for all their cosmopolitan outlook, they were still just a small public charity with a substantial medical complex in Haiti, and Farmer seems to have felt they were going to stay that way. In PIH’s 1993 annual report, he’d written that they should never change their mission or soften their message in order to broaden their appeal. Accordingly, he wrote, they should resign themselves “to a somewhat marginal status.”
But, in fact, a big change in PIH was about to begin. They were about to become players in international health.
CHAPTER 13
A simple epidemiological map, a map based on what makes people sick and what kills them, and in what numbers and at what ages, could be coded in two colors. One would stand for populations who tend to die in their seventies, mainly from illnesses that seem like inevitable accompaniments to the aging of bodies. The other color would stand for groups who, on the average, die ten and even forty years earlier, often from violence and hunger and infectious diseases that medical science knows how to prevent and to treat, if not always to cure. On this map, the line dividing the two color-coded parts of humanity—what Farmer called the “great epi divide” (epi being short for epidemiological)—would partition many countries, many cities. Most of Haiti would wear the color of ill health, but parts of the hills above Port-au-Prince would be a patch of well-being. The map of the United States, by contrast, would depict a healthy nation speckled with disease. In Boston’s Mission Hill neighborhood, right next to the Brig-ham, for instance, infant mortality is higher than in Cuba. In New York City’s Harlem, a famous study from 1990 showed, death rates for males between the ages of five and sixty-five were higher than in Bangladesh.
Meager incomes don’t guarantee abysmal health statistics, but the two usually go together. Many of the groups of people living on the wrong side of the great epi divide have brown or black skin. Many are female. What they all have in common is poverty. Absolute poverty, the lack of almost every necessity—clean water and shoes, medicine and food—in a place like Haiti. Relative poverty in a place like New York.
For Farmer and Jim Kim and many others interested in the distribution of disease, tuberculosis vividly illustrated the great epi divide, its contours, its causes, its effects. Improperly treated, or not treated at all, TB is dreadful and lethal, usually devouring the lungs but also sometimes other organs, and sometimes the bones. Fortunately, an array of good and inexpensive “first-line” TB drugs existed. They had to be administered over the course of months—usually six to eight months—but then they cured virtually every case. Thanks in part to those antibiotics, tuberculosis had all but vanished from the rich parts of the world. But the disease still plagued the poor parts to a degree most Americans and many western Europeans would find hard to credit. At the end of the twentieth century, TB was still killing about two million people a year, more adults than any other infectious disease, except for AIDS, and TB shared what Farmer called “a noxious synergy” with AIDS, since an active case of one often makes a latent case of the other active, too. In poor countries, TB was the most common proximate cause of death among people who died with AIDS. And yet, because tuberculosis mainly afflicted the poor side of the epi divide, the industrial nations and pharmaceutical companies had all but abandoned the search for new technologies to fight it. The tools for diagnosing the disease were antique; no large campaign had been launched to find a fully effective vaccine; and the newest of the antituberculous drugs had been developed twenty-five years ago.
Farmer liked to say that tuberculosis made its own preferential option for the poor. The aphorism contained a certain literal truth. According to the best current estimates, about two billion people, one-third of humanity, have TB bacilli in their bodies, but the disease tends to remain latent. It multiplies into bone-eating, lung-consuming illness in only about 10 percent of the infected. The likelihood of getting sick increases greatly, though, for those who suffer from malnutrition or various diseases, especially from HIV, itself by now predominantly a disease associated with poverty. Usually, active TB feeds on the lungs and spreads itself from them, sneezes and coughs like the wind to its seeds. People who live in crowded peasant huts and urban slums and shantytowns and prisons and homeless shelters stand the best chances of inhaling the bacilli, of having their infections expand into active disease, and in some settings, of getting just enough treatment to make their TB drug-resistant.
A person with active TB of the lungs harbors hundreds of millions of bacteria, enough to ensure that a small number will be mutants impervious to anti-TB drugs. In a patient who gets only one antibiotic or inadequate doses of several, or who takes the medicines erratically or for too short a time, the drug-susceptible bacilli may die off while the drug-resistant mutants flourish. The patient becomes a site of rapid bacterial evolution, with drugs supplying the selective pressure. In the gravest cases, patients end up infected with bacilli that can’t be killed by the two most powerful drugs. Medical science reserves a special name for tuberculosis of that sort—multidrug-resistant TB, MDR by abbreviation. It is a scary disease, and a serious problem wherever it appears, but worst, of course, in the places with the fewest resources to deal with it.
Multidrug-resistant TB tends to arise where wealth and poverty are mingled, where poor people get some treatment but not enough. It arises only infrequently in places of nearly universal poverty like Haiti, where most people don’t get treated at all. But by the mid-1990s Farmer had dealt with several cases of MDR in Cange. The first had appeared during the time of the junta. He remembered the feeling of dread that washed over him when he realized what his patient had. And dread was justified; the young man died.
Farmer blamed himself, but the fact was that treating MDR was tricky under the best of circumstances, and for a while, during the time of the junta, he simply couldn’t get the necessary medicines to Cange. Since the death of that patient, he’d assembled the resources to fight the disease at Zanmi Lasante, both the tools and the procedures. He was curing most of the cases that appeared sporadically in Cange when, i
n 1995, MDR claimed a close friend who had been living in a shantytown on the outskirts of Lima, Peru.
CHAPTER 14
For several years during medical school, Farmer had boarded at St. Mary of the Angels, a parish run by a priest known as Father Jack. Farmer camped in a room under the eaves of the rectory. The church was in Roxbury, one of Boston’s run-down neighborhoods, largely African American. In the musty, dim, low-ceilinged sanctuary, gospel music surrounded the Mass, and sermons had the feel of revival meetings. Jack Roussin, the priest, a beefy man with a florid complexion, would declaim on poverty and injustice, voices in the congregation calling out amens.
Jack was the kind of priest whom nervous bishops call “a character.” He mediated arguments among neighborhood gangs, led candlelight vigils against drug dealing, carried signs in front of the State House protesting cuts in welfare. In his spare time, he liked to tell off-color stories and tease the young medical student upstairs. When Farmer began practicing vivisection—dog lab it was called at the medical school—he had a long talk with Jack about his misgivings, working on a creature he was going to have to kill. The next morning Farmer awoke to what sounded like fingernails scratching on his door, then imitations of whinings, finally a few howls. Ophelia stayed at the rectory sometimes. She’d muss up the sheets in the room the nuns assigned her, then cross herself as she crept up the stairs to Paul’s garret. Father Jack pretended not to notice, but he’d talk about Farmer’s previous girlfriends in front of Ophelia just to see Paul blush. When Farmer created Partners In Health, he put Father Jack on the board of advisers.