Farmer spent an hour that evening locating the gate for our charter flight to Havana. He had a brand-new young assistant back in Boston, but it seemed that the assistant had joined Partners In Health to do social justice work, not to be a travel agent. This was a common sort of problem in the organization, as in any that relies heavily on volunteers and can’t pay its salaried employees much. When it came to managing personnel, Ophelia and Jim had at least one other special handicap. No one could be fired—Farmer’s rule—except for stealing or slapping a patient twice. The rule used to be one slap and you were out, but then an employee in Cange hit a patient, and rather than fire the guilty party, Farmer amended the rule. “Two slaps,” he insisted.
His young assistant deserved some sympathy. These days a seemingly endless line of people wanted some of Farmer’s time, and he didn’t like to turn anyone down. Farmer had a habit of complaining that he had no time off and then, when some was scheduled, of filling it with a meeting or a speaking engagement. No one had ever been able to order his affairs flawlessly. His last assistant, a woman in her thirties, had come close. But he had promoted her.
That night in the hotel, Farmer got up to go to the bathroom and, not wanting to wake me, left the lights off. He smashed his toe into a suitcase in the dark. When we got up at 4:00 A.M., the toe had turned purple. He diagnosed a fracture but limped along through the terminal without complaint, his computer bag over a shoulder, his latest wallet—a plastic shopping bag—in one hand and in the other his suitcase. It contained just a smattering of clothes—only three shirts for two weeks—but was jammed full with slides for lectures and with presents for his Cuban hosts. “Do you think I like wearing the same shirt five days in a row?” he once asked me. I thought that at times he probably did. At times he’d seem to say that if the world weren’t in such terrible shape and its leaders would only do their jobs, he wouldn’t have to suffer such discomforts. But complaint didn’t seem to be his usual mode. He said the choice between, for instance, carrying extra shirts and carrying medicines was easy. “The trick is,” he said, “to keep your body clean and change your underwear.” I would learn that he had many such tricks. “Traveler’s tip number one thousand seventy-three. If you don’t have time to eat, and there’s no other food on the plane, a package of peanuts and Bloody Mary mix are six hundred calories.” This morning I carried the presents that didn’t fit in his bag. He was very grateful. I think he felt obliged to keep getting presents until he had more than he could easily carry. Then he’d know he had enough.
I remarked on his sleepless nights, his hundred-hour weeks, his incessant travel, as he hobbled along.
He said, “The problem is, if I don’t work this hard, someone will die who doesn’t have to. That sounds megalomaniacal. I wouldn’t have said that to you before I’d taken you to Haiti and you had seen that it was manifestly true.” He added earnestly, “But I do want to get into better shape. I did my push-ups this morning.” He had, in fact, done a set of upward-facing push-ups between two chairs, so as to protect his toe.
Up ahead we could see the check-in point for the charter flight to Havana. You could tell from the piles of luggage, the boxes containing radios and kitchen appliances, the sacks full of things like disposable diapers. The scene resembled the ones at ticket counters serving flights to Haiti, except that the piles here weren’t as mountainous or the suitcases as dilapidated. One can guess a lot about the economic condition of a country by inspecting the baggage people carry there from the United States, the shopping mall for the poor countries of the world. This sort of scene, I think, was so commonplace to Farmer as not to be worth remarking on. For going on eighteen years he’d been performing for Haitians what are called commission, Creole for “I got some stuff for you to carry on the plane.” “They’re the story of Paul’s life,” Jim Kim told me. “ ‘I have an uncle who lives in Poughkeepsie, can you bring this mango to him?’ Or ‘Can you buy me a watch in the States? Can you buy me a radio and take this piece of bread to my aunt in Brooklyn?’ And Paul will say, ‘Sure.’ ”
After we checked in, we sat at an airport restaurant table, and Farmer worked on more thank-you notes. He was smiling, and I figured he was looking forward to Cuba, because he said, “No dead babies for a while.”
CHAPTER 21
When the plane descended toward Havana, Farmer stared intently out the window, making exclamations. “Look! Only ninety miles from Haiti and look! Trees! Crops! It’s all so verdant. At the height of the dry season! The same ecology as Haiti’s, and look!”
The Cuban doctor who was running the AIDS conference, an old friend of Farmer’s named Jorge Pérez, had sent a car for him. On the ride into Havana, I got my first glimpse of a Cuban political billboard, a gigantically enlarged version of the famous photograph of Che Guevara in a beret, and I was reminded that an American who found anything good to say about Cuba under Castro still ran the risk of being labeled a communist stooge. I knew Farmer was fond of Cuba, not mainly, I thought, for ideological reasons but because of its health statistics—statistics vetted by WHO and generally regarded as among the most accurate in the world.
Many things affect a public’s health, of course—nutrition and transportation, crime and housing, pest control and sanitation, as well as medicine. In Cuba, life expectancies were about the same as in the United States. Since its revolution Cuba had achieved real control over diseases still burgeoning ninety miles away in Haiti, such as dengue fever, typhoid, tuberculosis, AIDS. Later, accompanying Dr. Pérez on rounds at his hospital, the national infectious disease hospital, we would come to the room of a patient with malaria, and Pérez would announce that his young doctors had missed the initial diagnosis because they’d never seen a case of malaria before. And here was Farmer, who had stood, time after time for eighteen years, at the bedsides of Haitian peasants just arrived by donkey in the last throes of cerebral malaria—grandparents, mothers, fathers, children—already in convulsions.
“For me to admire Cuban medicine is a given,” Farmer said. It was a poor country, and made that way at least in part by the United States’ long embargo, yet when the Soviet Union had dissolved and Cuba had lost both its patron and most of its foreign trade, the regime had listened to the warnings of its epidemiologists and had actually increased expenditures on public health. By American standards Cuban doctors lacked equipment, and even by Cuban standards they were poorly paid, but they were generally well-trained, and Cuba had more of them per capita than any other country in the world—more than twice as many as the United States. Everyone, it appeared, had access to their services, and to procedures like open heart surgery. Indeed, according to a study by WHO, Cuba had the world’s most equitably distributed medicine. Moreover, Cuba seemed to have mostly abandoned its campaign to change the world by exporting troops. Now they were sending doctors instead, to dozens of poor countries. About five hundred Cuban doctors worked gratis in Haiti now—not very effectively, because they lacked equipment, but even as a gesture it meant a lot to Farmer.
One time he got in an argument about Cuba with some friends of his, fellow Harvard professors, who said that the Scandinavian countries offered the best examples of how to provide both excellent public health and political freedom. Farmer said they were talking about managing wealth. He was talking about managing poverty. Haiti was a bad example of how to do that. Cuba was a good one.
He had studied the world’s ideologies. The Marxist analysis, which liberation theology borrowed, seemed to him undeniably accurate. How could anyone say that no war among socioeconomic classes existed, or that suffering wasn’t a “social creation,” especially now, when humanity had developed a grand array of tools to alleviate suffering. And he was more interested in denouncing the faults of the capitalist world than in cataloging the failures of socialism. “We should all be criticizing the excesses of the powerful, if we can demonstrate so readily that these excesses hurt the poor and vulnerable.” But years ago he’d concluded that Marxism wouldn’t an
swer the questions posed by the suffering he encountered in Haiti. And he had quarrels with the Marxists he’d read: “What I don’t like about Marxist literature is what I don’t like about academic pursuits—and isn’t that what Marxism is, now? In general, the arrogance, the petty infighting, the dishonesty, the desire for self-promotion, the orthodoxy. I can’t stand the orthodoxy, and I’ll bet that’s one reason that science did not flourish in the former Soviet Union.”
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. But if the odds are so preposterously stacked against the poor—machetes versus Uzis, donkeys versus tanks, stones versus missiles, or even typhoid versus cancer—then is it responsible, is it wise, to push the poor to claim what is theirs by right? What happens when the destitute in Guatemala, El Salvador, Haiti, wherever, are moved by a rereading of the Gospels to stand up for what is theirs, to reclaim what was theirs and was taken away, to ask only that they enjoy decent poverty rather than the misery we see here every day in Haiti? We know the answer to that question, because we are digging up their bodies in Guatemala.”
For me, the first sights of communist Cuba were a great relief after Haiti. Paved roads and old American cars, instead of litters on the gwo wout la. Cuba had food rationing and allotments of coffee adulterated with ground peas, but no starvation, no enforced malnutrition. I noticed a group of prostitutes on one main road, and housing projects in need of paint and repair, like most buildings in Havana. But I still had in mind the slums of Port-au-Prince and the huts of the central plateau, and Cuba looked lovely to me.
When we got to our hotel, Farmer said, “I can sleep here. Everyone here has a doctor.” He lay down on his bed and within a few minutes he was asleep.
“I relish the break from Haiti,” Farmer told me when he woke up. “I mean, I feel guilty. I feel guilty leaving, but I’m going to try to raise money for Haiti while I’m here.” He was counting on Dr. Pérez for some help.
Pérez was in his mid-fifties. The top of his head reached roughly the altitude of Farmer’s bony shoulders. Farmer said that when he first laid eyes on Pérez, some years before, a very tall patient was wagging a finger in Jorge’s face, saying in Spanish, “Listen to me, you. I have a problem with you.” And Pérez was looking up at the man and nodding. Farmer said he remembered thinking, “That looks like a good doctor-patient relationship.” They’d been friends ever since.
Farmer was looking in Cuba, first of all, for money to stockpile antiretroviral drugs, enough to treat twenty-five patients with full-blown AIDS back in Cange—twenty-five patients for starters. At the AIDS conference he met a woman who might be able to help, if she would. She was in charge of the United Nations’ project on HIV/AIDS, UNAIDS, for the Caribbean. He lobbied her over several days. He gave her a copy of Infections and Inequalities, and inscribed it, “For Peggy McAvoy with a big hug of solidarity and with high hopes for your help in Haiti.” He said to me, “My subtlety. No one gives guilt trips like I give.” At the cocktail party, full of all sorts of medical dignitaries, he tried to close the sale, and it seemed as though he had, with a little help from Dr. Pérez, who approached and told Peggy, speaking of Farmer, “He is a friend of mine.” She asked Farmer for a written proposal. And Farmer said, his face bright, “Can I give you a kiss? Can I give you two?”
He also hoped to begin to solve one of Zanmi Lasante’s most persistent problems. All but one of the Haitian doctors who worked in Cange had their homes in Port-au-Prince, or abroad—in Canada or Florida or New Jersey. They were “middle-class Haitians,” Farmer explained. “And middle-class Haitians regard Cange as an uninhabitable place, nan raje, in the sticks.” To work out in the central plateau away from their families, where there was nothing to do but work and play Ping-Pong—Farmer had recently bought the doctors a Ping-Pong table—had proved too great a sacrifice for many over the years. Several, most recently his gynecologist, had gone to work in the States, and some of those had clearly gone to work for Farmer with that aim in mind, to be trained by Doktè Paul, then to emigrate, and he always felt obliged to help them leave. So he hoped to begin creating some doctors indigenous to Cange. He and his Haiti staff had picked out two local youths. Farmer hoped to send them to the huge new medical school that Cuba was opening for Latin American students.
He told Dr. Pérez about this plan, and Pérez arranged a private meeting between Farmer and the secretary of Cuba’s Council of State, a medical doctor named José Miyar Barruecos, known as Choumy. A distinguished-looking man, in his sixties I figured.
They talked for a while, and then in Spanish Farmer asked, “Can I send you two students this year?”
“From the U.S.?”
“No, Haiti.”
“Por supuesto,” said Choumy. “Of course.”
Luc Montagnier, the man generally credited with discovering the human immunodeficiency virus, was speaking at the conference. This meant of course that the French ambassador to Cuba would show up at some point. When he did, Farmer got his ear and also Montagnier’s. Looking on, I thought they seemed surprised, then impressed by Farmer’s French. He told them he dreamed of a new kind of “triangle,” doctors from Cuba and money from France coming together in Haiti. He was of course playing on the term triangular trade, the trade that had created the French slave colony that had turned into Haiti. He invited Montagnier to Cange, and after some hesitation Montagnier said he would come. The ambassador told Farmer, “Yes, we too are going to help with the Haitians.”
Polite and worthless promises maybe, but Farmer in the role of supplicant seemed artfully ingenuous. Assume that each new promise was real and obtain as many as possible, to increase the odds that one or two might be real. And he’d follow up with calls, letters, e-mails, and if those didn’t bring results, they still might produce a little shame, which might increase the chances that the next promise would be real.
Farmer also had formal duties in Cuba. He was scheduled to give two talks at the conference. “What are the subjects?” I asked.
“One speech is for clinicians, how to deal with HIV and TB coinfection,” he said. “The other is why life sucks.”
He began the second speech by saying, “Today I’m going to talk about the problem of a more important coinfection, which is poverty. Poverty and inequality.” Up on the screen in the ampitheater of Cuba’s infectious disease hospital, beside the tall, reedy fellow in the black suit, the blue waters of the Péligre Reservoir appeared. “Now, in this country where I have worked for eighteen years, the campesinos lost their land to a hydroelectric dam.”
Farmer asked the audience to remember the days when expert opinion had retailed all sorts of nonsense about who caught HIV and why, the days when to be Haitian was to be part of a “risk group.” He and his staff had designed a study in Cange, he said, to try to get at the local facts. Two hundred women were involved, half infected with HIV, half not. Almost none in either group had been exposed to risks often mentioned in expert commentary—intramuscular injections, blood transfusions, intravenous drug use. Around Cange, Farmer noted, the peasants’ vocabulary didn’t even contain a word for illicit drugs, which virtually no one there could afford anyway. And none of the women had been especially promiscuous; on average, they’d had sexual relations with two different men, consecutively not concurrently, practicing “serial monogamy.” Between the groups of women, only two differences stood out. Unlike the uninfected, many of the ones with AIDS had worked as servants in Port-au-Prince. Obviously, domestic service hadn’t given them HIV, but it did describe their economic desperation—working for Haiti’s elite was rarely pleasant or remunerative. Uniformly, the infected women named that kind of desperation
, deep poverty and illiteracy, as their reason for having taken what appeared to be the real risk for AIDS, which was cohabiting with truck drivers or soldiers.
“Why those two groups of men?” Farmer asked from the podium. Were they known to be sexier than other Haitian men? Of course not. What they had were steady jobs, in an economy where an official unemployment rate of 70 percent probably understated the case. Truck drivers were mobile and could keep women in many ports. And soldiers, back in those days of military rule, had wielded a special coercive power over every peasant.
Up at the podium, Farmer went on with the story: After the study was done, he returned to the United States and logged on to MEDLINE. He entered “AIDS,” and the names of thousands of studies came up on his computer screen. Then he entered “AIDS and women,” and only a handful of studies appeared. “And when I crossed ‘AIDS, women, and poverty,’ the message said, ‘There are no studies meeting those specifications.’ ”
Farmer extended a hand toward the screen behind him, now filled with a gigantically enlarged graph of the study from Cange. “There are reasons why people are uncomfortable talking about this. Fine. But if we want to stop AIDS, we better find out about this. Countries with the steepest grades of inequality and the greatest poverty have the biggest AIDS problems, and I’m sure Professor Montagnier would agree that while coinfections are important cofactors, they’re not as important as these. We need to erase social inequalities, and very few countries have done that.” He closed in one of his favorite ways, by quoting a peasant. “A woman in Cange said to me, ‘You want to stop HIV in women? Give them jobs.’ ”