Hiatt looked into the matter. “Sure enough. Paul and Jim would stop at the Brigham pharmacy before they left for Peru and fill their briefcases with drugs. They had sweet-talked various people into letting them walk away with the drugs.” He was amused, all in all. “That’s their Robin Hood attitude.”
In fact, they’d only borrowed the drugs. Tom White soon sent the Brigham a check for the entire bill, along with a note saying he thought the hospital ought to be more generous toward the poor.
“Better to ask forgiveness than permission.” That had been Father Jack’s favorite saying. It was Farmer’s rule of thumb. When he and Jim had first resolved to take on Carabayllo’s epidemic, he had gone to Tom White and said, “Just buy the drugs for ten patients. We promise there won’t be more.” Even then Farmer had known this was what he called “a fib.” He had come back many times since to ask White for more money. White shared in the general nervousness. He wanted to leave this life without a nickel, he often said. As the number of patients grew, he began to wonder if Paul and Jim would upset his calculations. “For a while there, I thought they’d spend all my money before I died.” But he never turned them down.
To many seasoned managers of public health projects, what Farmer and Kim were doing would have looked quite reckless—like a stunt, as some would later insinuate. They didn’t have a guaranteed supply of drugs, only the determination to obtain the drugs and the charm to get away with borrowing. They were borrowing their laboratory services, too, from Massachusetts. They lacked proper institutional support. The weight of expert opinion stood against them. Their organization was small and it had other projects, in Haiti and Boston and elsewhere, and Peru put a strain on everyone.
Jim had to travel to Carabayllo at least once a month. Farmer had to go there slightly more often. He didn’t put much work aside for Peru, not his duties in Haiti or his service at the Brigham or his teaching at Harvard or his growing number of speaking engagements. He just added Peru to his itinerary.
Often he’d make two-day trips. He’d leave Cange before dawn and drive to Port-au-Prince. Sometimes he’d get stuck in traffic and, turning the truck over to a Haitian assistant, climb out and jog the last half mile to the airport. He’d catch the early flight to Miami, then fly on to Lima, arriving in Carabayllo late the same night. Starting early the next morning, he’d stride up and down the dusty hills with the Harvard student doctors or with one of the Socios nurses, visiting patients in their shacks. Later, when the local TB authorities had warmed up a bit to Socios, the patients were brought to the Jack Roussin Center, and he saw them there in a small room with a table and a concrete floor. That way he could see a larger number. He’d work until it was time to leave for the airport. He’d take the night flight to Miami, catch the early morning plane to Port-au-Prince, and arrive back in Cange by afternoon. He spent about twenty-two of the forty-eight hours just traveling, longer if flights got delayed or canceled, or Zanmi Lasante’s truck broke down, or an accident blocked the stretch of Highway 3 up Morne Kabrit, or rain had made the streams that crossed that road impassable.
Farmer hadn’t been feeling well when he gave his speech in Chicago, in February 1997. He felt worse when he got to Boston to spend a month of service at the Brigham. “I must be exhausted,” he remembered thinking. “Everyone told me something like this would happen.” He prided himself on being a fast diagnostician, but he took his time on his own case. He kept on working, and his symptoms got worse. He reviewed them: nausea, vomiting, fatigue, night sweats. “Oh, my God,” he thought. “I’ve got MDR.”
His wife, Didi, had begun her studies in Paris. So for now, when he was in Boston, Farmer still camped in the basement of the PIH building—PIH-ers called it “the cave.” He woke up there in the middle of the night bathed in sweat, thinking, “If I do have MDR, I’ve exposed all my patients to it.”
He went to a radiologist friend, swore him to secrecy, and had his chest X-rayed. He studied the film. It was normal.
He called Didi in Paris at least once a day. She told him over the phone, “You must go to a doctor.”
“Look, I am a doctor. Let me finish the month at the Brigham and go to Haiti. Then I’ll rest.”
He finally made the diagnosis on the morning of his last day of Brigham service. The night before, he’d turned down pizza, and that morning the smell of coffee nauseated him. Classic for hepatitis, he thought. Revulsion at foods you love. In the bathroom he saw that his urine was dark. “Oh, no. I do have hepatitis. Which kind? B? No, I’ve been vaccinated. Not C. I don’t do drugs. A? But how?” He’d discovered ceviche in Lima. Perhaps he had eaten some tainted fish.
When he got to the Brigham, he stopped at the lab and asked them to do tests on him at once. He stayed around to see the first result, his red blood count. “It’s way out of whack,” he thought. He felt dehydrated, so while the other lab results were still pending, he called Jim Kim on the house phone. Jim was back in Boston, too, managing a floor at the Brigham. “Jim, I’m coming up to your unit. I need fluids.” Then Farmer lay down in his suit in one of the rooms on Jim’s floor, feeling rather cheerful. After the IV nurse rehydrated him, he got off the bed and joined the infectious disease specialist he was training, a young woman. “Marla,” he told her, “I feel worse. Let’s do rounds early.”
Marla was usually impatient with him. She’d interrupt his constant in-hospital socializing, saying, “Farmer, shut up. Let’s get working.” Now she said, “You’re psycho. Let someone take over for you.”
“Marla, I finish today.”
She went away scowling. He went into a patient’s room, and was in the midst of diagnosing a case of acute prostatitis—it was obvious—when Marla returned. Her face looked blanched, he thought. “Paul, your liver functions are so high the machine couldn’t do them. They had to dilute it.”
“All right. I give up.” He went back to the room in Jim’s unit, got into a johnny, and surrendered himself to illness.
Hepatitis A is only rarely fatal, but his case was severe—Jim and some other doctors worried that he might need a liver transplant. Farmer was so sick for a time that he could hardly make his voice audible. Nevertheless, a few nights after he took to his hospital bed a young PIH-er got a call from him, a tiny, squeaky voice issuing instructions about drug procurement for Peru. When he got out of the hospital two weeks later, Ophelia sent him and Didi to a hotel in southern France, Paul’s first real vacation in years. Nine months later he had a daughter, named Catherine. So everything turned out all right.
But hearing him tell the story, I wondered at his recklessness. At the Brigham he’d been preaching the importance of hepatitis A vaccination, especially for middle-aged people. He told me, “I was embarrassed.” But only, it seemed, for failing to get the shot, not for ignoring his symptoms during an entire month. He hadn’t told Ophelia or his mother he was sick, and I wondered if that was because he knew they would try to make him stop working. Doctors are notorious for taking peculiar views of their own bodies. They tend to develop hypochondria in medical school and, once they get over it, if they do, tend to think they’re invulnerable. Many people refuse to set their work aside for matters of personal convenience. But Farmer seemed to be unwilling to set it aside for any reason. It was as if he couldn’t allow himself to be the one to set it aside. A force stronger than his own will had to intervene, like the car that had hit him back in 1988.
Speaking of his bout of hepatitis, Farmer told me, “If I get sick, it’ll be nearly fatal.” He was drawing a contrast between himself and the world’s poor. A generous thought, but his habit of disregarding his health hardly seemed like a way of expressing “pragmatic solidarity.” Given the responsibilities for other lives he’d taken on, it seemed to me he’d done the opposite.
On the other hand, at some point—I’m not sure exactly when—I realized that I’d become inclined to hold Farmer to a higher standard than I did most people, including myself. And, as a rule, to see him in action was to excuse hi
m.
The MDR project was making progress with patients, and the Peruvian TB doctors had noticed. Accordingly, Farmer and Kim were making progress with them.
One day, when it was clear that the project was succeeding, I followed Farmer to an appointment at the Children’s Hospital in downtown Lima. When he emerged from the noisy, smoky traffic jam in front of the hospital, a small entourage of Peruvian medical people rushed out to claim him, then hurried him past the men hawking toilet paper and balloons and newspapers, then past the armed guard at the front door. Farmer was, I figured from the fuss, médico aventurero no more around here. He looked worried, though. Or maybe I only imagined this, thinking he ought to be. He and Jim and Jaime had tried hard to establish collegial relations with the Peruvian medical establishment, and now, because of traffic, he’d kept a group of proud doctors waiting over an hour for him.
Farmer pulled a stethoscope out of the pocket of his rumpled black suit jacket and draped it over his neck as we entered a maze of narrow, concrete-walled corridors—the hospital’s tuberculosis wing. He was walking fast. Then, all of a sudden, he stopped.
A family of three stood in the hallway up ahead. A little boy and his mother and father. The mother was slender and wore a skirt and a T-shirt with a picture of Mickey Mouse on the front. She hung back, half-hidden around a corner, while the father came forward. Farmer and the father opened their arms simultaneously and bear-hugged each other. (“In my culture we don’t shake hands,” Farmer was always telling me, trying to reform me in this way, too, I’d begun to feel.) Hurriedly, he asked for news of the child.
The little boy was chubby, obviously healthy. He stood close to his father. When Farmer crouched down and held out his arms, the child came forward on his own stubby legs, in a rolling, waddling gait, giggling as he advanced headlong toward Farmer, then turning around and waddling back toward his father. A happy-looking dance. “Christian! Look at you!” cried Farmer. His face had turned bright red. He wore the wild-looking grin with which he greeted old friends. He turned to me. “This was a terrible case,” he said in a low voice, in English.
Nearly two years ago, a doctor from this hospital had called Jaime Bayona at Socios headquarters and said, “We have a child here you have to help us with.” By the time of that phone call, Christian had been lying in bed for months. Jen Furin, the Harvard medical student who worked with Sonya in Carabayllo, went to the hospital. The child she found there was three years old and weighed only about twenty-two pounds. He labored to breathe, and the oxygen mask had made sores around his nose. Tuberculosis had invaded both his lungs, it had begun eating his spine, and it had fractured the long bones of his legs. He had gone through the six months of standard short-course chemotherapy. Then the lab had cultured his TB and found it resistant to several drugs. Christian was being given those same drugs when Jen arrived. The doctors were obeying las normas, applying the WHO retreatment plan.
Jen had done most of the actual doctoring. Farmer had devised the regimen for Christian. He’d talked about the case to both Peruvian and American TB experts, but no one in the world knew much about treating children with second-line drugs. “Here was the received wisdom. You can’t use fluoroquinolones or ethambutol at high doses in kids. Where did this come from? Fluoroquinolones cause cartilage damage in immature beagle pups. High-dose ethambutol is associated with optic neuritis and loss of color vision in a small proportion of adults, but kids can’t report loss of color vision, so it shouldn’t be used. This was a big part of the discussion, and here was a child literally wasting away, his flesh and bones consumed by MDR, in front of our eyes.”
Farmer proposed an “empiric” regimen—a regimen based on his best guesses—which consisted of high-dose ethambutol and four second-line drugs, including a fluoroquinolone. To get official approval, he told the Peruvian doctors that he’d discussed the matter with every world-renowned expert, and studied the pediatric literature. This was true. He didn’t say that the pediatric literature contained nothing at all about treating MDR. “It was a matter of merely applying infectious disease knowledge,” he would tell me. He based the dosing on the drug manufacturers’ recommendations, which had nothing to say about children but advised the use of so many milligrams of drug per so many kilograms of body weight. He’d often done this with other pediatric illnesses in Haiti. He recommended a very aggressive course of second-line drugs for Christian. Too aggressive, said some of the American doctors he consulted. “Who, I might add, had never treated a baby with MDR.” The Peruvians had no experience with such cases either. They accepted Farmer’s recommendation. The child was clearly dying, and in agony. So why not try it?
Farmer had learned, through e-mail, that Christian was coming along well, but he hadn’t known how well until this moment in the hall at the Children’s Hospital. The child could actually run! Farmer grinned, and a blush spread from his high forehead and over his neck and, I imagined, down past his necktie toward his feet, as the child waddled around giggling in front of him and the father beamed down at the child and the mother peered out from around the corner, smiling, too.
Then it was over. Christian’s wasn’t the main case Farmer had been asked to consult on today. He was making this hospital visit on Jaime Bayona’s instructions, as a favor to a Peruvian TB doctor whose own daughter was sick. Farmer’s escorts shepherded him into an office—a whitewashed ceiling, concrete walls, a team of doctors, and a little girl in a dress. A string of X rays and CT films were mounted in a viewer along one wall, pictures of the interior of the little girl’s chest. Farmer made apologies for his lateness to the doctors, bowing a little at the waist, and then turned with them to the films. The little girl had pulmonary TB. “Infiltrates. Not good,” Farmer said in Spanish to the doctors.
He studied the report from the Massachusetts State Lab. It was unequivocal. I looked over his shoulder at the sheet of paper—a list of the five first-line antibiotics with the letter R for “resistant” next to each one. The child, the doctor’s daughter, had gone through DOTS and was now several months into the retreatment regimen. That is, she was being treated with all five of those same drugs.
“This is terrible,” Farmer murmured to me in English, from the side of his mouth.
He knelt down and listened through his stethoscope to the girl’s lungs. Then, smiling, he looked up at her father and said, “She has asthma. Just like me. She’s adorable, like my Catherine.” Then Farmer stood and began a long spiel in Spanish, directed to the little girl’s father and the other doctors. “I do not know more than this medical team, my esteemed colleagues here. She has wheezing and a worsening CT scan since February. It’s worrisome.” He reviewed the options. They could perform a new laboratory analysis, on the chance that the Massachusetts State Lab had made a mistake, even though it had a nearly flawless record, well-certified. Or they could wait and monitor the child’s condition, even though it was getting worse. Or they could trust the lab work, abandon the DOTS retreatment regimen, and begin giving her Farmer’s own favorite pediatric regimen of second-line drugs. He preferred this last course, he said. “This is my prejudice.” He smiled some more at the doctors. “As you know, from our experience together, working shoulder to shoulder.”
The room seemed full of strong feeling, covered with professional courtesy. The little girl’s father stood behind his daughter. He maintained a smile throughout. He kept his shoulders erect. He was trying hard, it seemed to me, to hold on to his professional composure. He was a TB doctor after all. But when Farmer spoke to him about his daughter, the man reached out to touch her shoulders, and he seemed to hold his breath. “He knew,” Jaime Bayona would tell me later. “He knew for months that she had MDR.” But the man hadn’t dared go against the national program’s strict normas. One could imagine his reasons. He would have been risking his job, and jobs like his were hard enough to come by in Peru that to risk it would be to risk the survival of his entire family. Jaime had taken matters into his own hands. He’d had the gi
rl’s sputum sent to Boston, circumventing the national lab, and when the results had come back, her father, an old friend, had begged Jaime—begged, Jaime insisted—that Farmer examine her. Because Farmer’s opinions had weight now with a lot of Peruvian doctors.
The father had known beforehand that Farmer would prescribe second-line therapy and so had the assembled doctors. (“They were just waiting for Paul to pronounce,” Jaime would say later on. Indeed, soon afterward the doctors would place the girl on Farmer’s regimen, and she would begin to recover, suffering few side effects.) So the consult was really just a charade. Farmer played out the rest of his part with aplomb. He promised to send his report and recommendations to the father by e-mail. He ticked off the reasons for optimism on his fingers. “It is possible she may still have rifabutin on her side. She’s in good shape. She has only a little lung damage. Her resistance isn’t total. We are ready to help you in any way that we can.”
Soon, with many thank-yous and bowings and scrapings and warmest wishes to their beautiful wives and distinguished husbands, Farmer departed.
On the way out of the hospital he said, speaking of the little girl, “The child is wheezing and has a worsening CT. She’s on all five first-line drugs and she’s resistant to all of them. And I had to say, ‘I wonder why she isn’t getting better,’ and go through the pathophysiology. Instead of saying, ‘What’s the matter with you people?’ They don’t want to believe in MDR. The delicate thing is, you want to make progress with them. Insult them and forget it. They want to do the right thing. They’re just following instructions from on high.”