By now I felt I was getting a sense of how Farmer put together experience and philosophy. In trying to control TB and AIDS in the central plateau, he had ended up wrangling, not much with third world myths, like beliefs in sorcery, but usually with first world ones, like expert theories that exaggerated the power poor women had to protect themselves from AIDS. This was Cuba, of course, the hemisphere’s small, lonely iconoclast. The amphitheater, about half full, gave him a long, loud round of applause.
Farmer told me he’d like to hang out at the conference, but he spent less time there than in our hotel room, lying on his bed, a pillow behind his head, a pillow under his knees, his computer on his lap. Once in a while he’d begin to doze, then jump up and pace the floor, swinging his arms, saying to himself, “Come on, Pel. Come on.” He typed away. At the proposal for UNAIDS, at a different grant proposal for obtaining antiretroviral medicines for Zanmi Lasante (you could never seek out too many sources of funding when you didn’t have funding), at a countereditorial he’d been asked to write in response to an editorial questioning the wisdom of treating MDR-TB in Russia. “Who’s it for?” I asked.
“The Journal of Tuberculosis and Lung Disease,” he said, typing away. “I’m sure you get it at home.”
From time to time he worked on his new book, Pathologies of Power. He had a bound typescript of the rough draft. It contained a chapter comparing the two ways in which AIDS had been managed on the island of Cuba—the Cuban approach and the American quarantine of HIV-positive Haitian refugees, conducted in the early nineties on the Guantánamo naval base. In the room Farmer read aloud from a book by a respected American political scientist who had also compared the two quarantines, calling them roughly equivalent. “It makes my blood boil,” said Farmer.
He didn’t approve of quarantine for AIDS. “Quarantine has never been shown to be an effective measure in controlling sexually transmitted diseases,” he said. He went on, “Both Guantánamo and Cuba’s AIDS sanitorium were quarantines. But it’s a lie to say they weren’t different.”
He had interviewed some of the Haitians quarantined on Guantánamo, and from them heard stories of wretched treatment at the hands of the U.S. military—of food with maggots in it, of compulsory blood tests and compulsory injections of the long-acting contraceptive Depo-Provera—its effects can last up to eighteen months—of beatings when they protested. One didn’t have to take the Haitians’ word for all of this. In 1993 an American federal judge had described the quarantine in harsh terms and ended it, ruling it unconstitutional.
The other quarantine of HIV patients in Cuba, the Cuban government’s, had been conducted in a place called Santiago de las Vegas. It lay about an hour’s drive from Havana. Dr. Pérez had played a big part in its history. He took us there in his battered Russian Lada sedan.
I enjoyed looking out at the countryside, all colored for me by contrast with Haiti’s—the electric power wires, the irrigated fields. We turned off the highway onto a narrower paved road, and after a while Dr. Pérez announced, “We are arriving now to the concentration camp. You will see the concentration camp we have here.” That was what the AIDS sanatorium had been called in a New York Times op-ed.
On the right lay the grounds of what had clearly been a grand estate. We turned down the drive. A bare-chested, heavily muscled young man wearing a black beret was coming out the gate on a bicycle. “Please stop,” said Farmer to Pérez’s driver. Then Farmer jumped out and called to the bicyclist, “Eduardo!” And Eduardo did a double take, climbed off his bike, grinning, then enveloped Farmer in a hug. He was a former Cuban soldier who had contracted AIDS in Africa, a patient of Pérez’s. Farmer had met Eduardo on a previous trip and had doctored him a little. I never heard Farmer complain of having too many patients, and it seemed clear that he couldn’t feel comfortable anywhere not having any at all. So in Cuba he borrowed some from Pérez.
Farmer climbed back in, and we drove on, up to an old hacienda. A wealthy Cuban had owned it, and fled during the revolution. The interior was high-ceilinged, many-roomed. Stains darkened the walls here and there, but the place wasn’t exactly shabby. It had the feeling of a defrocked place, where you’d find a gray filing cabinet in a spot designed for a mahogany highboy.
During lunch in the headquarters building, Dr. Pérez told us his version of the history of the sanatorium. He said that he and his boss, Gustavo Kouri, were giving Fidel Castro a report about malaria in Africa when Castro asked, “What are you going to do to stop AIDS from entering Cuba?”
Pérez went on: “Gustavo said, ‘AIDS has no importance.’ Then Fidel tugged his beard and said, ‘You don’t know what you’re talking about. It’s going to be the disease of the century, and it is your responsibility, Gustavo, to stop AIDS from spreading in Cuba.’ ”
The Cuban authorities had decided to quarantine people infected with HIV at this old hacienda, under military discipline—first soldiers and then a combustible mixture of soldiers and homosexual men, nastiest no doubt for the gay inmates, although everyone was well-fed and got medical treatment. When Pérez took over a few years later, he let in visitors, had the tall surrounding wall torn down—“Because reporters came here and they were climbing trees”—and little by little changed the rules, first allowing patients to leave on passes once they’d shown they could be trusted to practice safe sex, and eventually lifting the quarantine altogether. Pérez said he’d imagined that all the patients would leave at that point, but only 20 percent did, in part because conditions at the sanatorium were generally better than elsewhere.
Dr. Pérez led us on a tour of the patients’ quarters, little houses and apartments set among gardens and palm trees. The settlement looked like a working-class American suburb. We visited the patient Eduardo’s house—three little rooms. On the bureau stood a snapshot of Farmer. Paul spotted it and stared, his face turning red. When he recovered, he said to Eduardo, “I see you’re still smoking cigarettes.” Eduardo offered him the pack, and Farmer pushed it aside, laughing. “No. I was about to say you should quit.”
The tour resumed. Farmer kept remarking on how pleasant and peaceful these quarters were, and finally I said to him, “I find them kind of depressing.”
“Really?” He seemed surprised. “Compared to what I grew up in, it’s pretty nice. They have gas stoves, air-conditioning, electricity, TV.” Actually, it wasn’t the sanatorium’s housing that troubled me. I felt that Farmer was suspending his usually sharp critical judgment. I thought he was looking only for things to praise. So I was doing the opposite. Maybe I just wanted an argument. He didn’t, clearly. He let the subject drop.
As we walked around, I told myself it was too easy to pass judgment now on the way various societies had responded to AIDS in the first panicky years of a terrifying public health emergency. And it was probably facile to compare the responses of the United States and Cuba. The countries were so different in size and complexity. But I had to wonder if I would have felt the same reserve if the outcomes had been reversed. By 2000 the overall rates of HIV infection and deaths from AIDS were dropping in the United States, but infections and deaths had claimed a much larger percentage of the population than in Cuba, and HIV had become mainly a heterosexual disease concentrated among the American poor. Cuba, meanwhile, had the lowest per capita incidence of HIV in the Western Hemisphere—its HIV statistics were probably among the most accurate in the world, for the simple reason that, in Cuba, testing wasn’t optional and millions had been tested. On an island of 11 million, only 2,669 had tested positive as of 2000. The virus had progressed to AIDS in 1,003 of those people, and 653 had died. Only five children had caught HIV from their mothers, and all those children were still alive. Because Cuba had acted quickly to clean up its blood supply, only 10 people had contracted HIV from transfusions. One could argue that the U.S. embargo had protected the island, but then again, back at the start of the epidemic Cuba had engaged in a lot of commerce with Africa.
We drove back toward Havana. Pérez sai
d he’d gotten a call that morning from the Barbados embassy. They wanted him to see the daughter of the ambassador. “But I don’t know even who she is. They phoned me five times yesterday. Anyway, I am with Paul Farmer today.”
Farmer and Pérez seemed to share one favorite recreation, which was visiting patients. When Pérez came to Boston, he liked to go on rounds with Farmer. Not long after we’d arrived in Havana, Farmer had asked, “Are we going to see some patients, Jorge?”
“Well, of course.”
Pérez also took him to meet Cuba’s chief forensic pathologist, the person who had led the team that had found Che Guevara’s secret grave in Bolivia—or claimed to have found it, some would say. The pathologist stood up at his desk to tell the story, in a loud voice, at moments practically declaiming, recounting how they had done mathematical modeling, employed their own Cuban archaeologist, soil chemist, geologist, and botanist, and how, after searching for three hundred days, they had finally come upon the bones and identified them and sneaked them back to Cuba. “We were finding heroes. I was finding my heroes. As a researcher, as a scientist, and because of the revolution, we were proud. It is very important for the revolution. It is a mixture. That and doing your job.”
We went to dinner at Pérez’s house, which was about as large and well-furnished as a unit in a decent American housing development—Farmer made sure I noticed that Pérez’s driver ate with the family. Another night we had dinner in a restaurant said to have been one of Hemingway’s favorites—there were probably almost as many of those in Havana as in Key West—men with guitars surrounding the table to sing “El Comandante,” the mournful ballad of Che. At the hotel Farmer got to do variations of hortitorture. There were some cockatoos in a cage in the lobby. Going in and coming out, he always stopped to gaze at them. “They’re Psittaciformes, by the way. I know that because they’re associated with a disease called psittacosis.” The hotel also had a fish tank and several small fish ponds, over which he’d bend his lanky torso, naming species. “Blue gourami, black molly, neon tetra, orange barb.”
Cuba really was a holiday, by his standards. In almost every other place where he worked, in Siberia, in the central plateau of Haiti, in the northern slums of Lima, in Chiapas under siege, he could send and receive e-mail. But in Cuba, because of the embargo, he was cut off from his usual electronic routine. He’d pay for this later, but for the moment he was relieved of the requests and duties that e-mail brought him every day, anywhere else but in Cuba.
He had traveled more than anyone I knew, and seen fewer of the brochure sights. He’d never been to Machu Picchu in Peru. He’d never gone to the Bolshoi in Moscow. He didn’t go sightseeing in Cuba either. On this trip, most of what he saw of old Havana he glimpsed through the windows of Dr. Pérez’s Lada. A city like a tarnished heirloom, pleasing—from the outside looking in, at least—in the half decay of its sculpted cornices, arcades, and porticoes, and loveliest in the warm, windy evenings, when the waves crashed against the seawall, raining spray on lovers along the Malecón. But it was as if Farmer had built himself an alarm system by which every pleasant thing set off a recording saying, “You’re forgetting Haiti.” He stared out at the monumental banyan trees along a route that Pérez’s driver took, and said softly, “I’ve worked eighteen years in Haiti, and everything has gotten worse.”
“We haven’t done enough yet in Haiti,” he told me at one point.
“What about Zanmi Lasante?”
“Zanmi Lasante is an oasis, the best thing of its kind in Haiti. But it’s not as good as here. The Cubans would have done a better job.”
Again and again during our stop in Cuba, Farmer had marveled at the attentions lavished on him. Dr. Pérez had a hospital and a conference to run, and he had to entertain a surefire Nobel Prize–winner-to-be in Luc Montagnier. And yet he’d spent a large part of every day and all his evenings with Farmer. One night in the hotel room, Farmer looked up from his computer and asked me what I thought accounted for this.
It seemed to me that he rarely asked a question for which he didn’t have the answer. So, to keep the peace, I should have tried to find the one he had in mind. Instead, I told Farmer I imagined that the Cubans liked his published attacks on American policy in Latin America, his frank admiration of Cuban public health and medicine, his efforts to create connections between Harvard and Cuba. I added, “And Jorge constantly introduces you by saying, ‘He is my friend.’ ”
I looked over and found Farmer’s pale blue eyes fixed on me. The Farmer stare. It could make you think he was examining an X ray of your soul or, if you were irritated with him, that he imagined he was examining one. My eyes wanted to look away, and I wasn’t going to let them.
“I get the same reception everywhere,” he said. “I’m stupefied by the way the Russians receive me, and I hate their wacky system. Why is it the same across all these radically different settings? I think it’s because of Haiti. I think it’s because I serve the poor. Love, ID.”
I had the impression he was angry, disappointed, and a little hurt. A potent combination. And then he went back to work, and I lay in bed trying to read, and in a little while he said, “Whatchya thinkin’ over there?” and I felt I was forgiven, and though I wasn’t sure for what, this was a relief. It didn’t last.
When we got to the airport and learned our flight back to Miami was delayed five hours, we went to a little restaurant on the premises, and Farmer settled in, opening his computer. He called in Spanish to the waitress behind the counter, “Dear lady?” She had her back to us. Without turning, she replied, “Dígame, mi amor”—“Speak to me, my love.” Farmer laughed. He said to me, “You have to love a country where people do that.”
The flight delay hadn’t fazed him. In fact, I was thinking, he was apt to be most cheerful when facing adversities, small ones anyway. Then, all of a sudden, he said to me, “If you’re going to write about Che, it should be your own opinion. Not mine.”
“Why is that?” I asked.
“You now know more about his exhumation than ninety-nine percent of Americans. And also how the Cubans feel about him. The man who dug him up was practically in tears.” He was giving me the stare.
“I may be sentimental,” he went on, “but I’m not a goofball. I’m a hard-bitten, clinic-building, MDR-treating mother.” Then, it seemed, he got to the heart of the matter: what I was going to write about Cuba, especially about him in Cuba.
“When others write about people who live on the edge, who challenge their comfortable lives—and it has happened to me—they usually do it in a way that allows a reader a way out. You could render generosity into pathology, commitment into obsession. That’s all in the repertory of someone who wants to put the reader at ease rather than conveying the truth in a compelling manner. I want people to feel unhappy about Lazarus and all the others who are shafted. Otherwise why would I have you with me? I don’t have a lot at stake in how you depict me. I’ve been yelled at by generals and denounced by people who don’t have any data when I have a shitload. It does no harm to me, but plenty to my patients. If the very warm reception of me in Cuba is portrayed as because I’m thought to be a sycophantic ally of Cuba, then the Cuban doctors’ concern for the poor of Haiti would be lost.”
He went on in this way for a time. “If I say that Santiago de las Vegas looks like a nice hacienda with a lot of labs and medical facilities, I’m a tool of the Cuban oppressors.” He took up the cause of Dr. Pérez: “Jorge is chief doctor of the Infectious Disease Institute, director of the sanatorium, chair of the national AIDS program, visiting professor in many countries, on the board of directors, by fiat, mine, of our program at Harvard. He has the ear of the president and the minister of health. He’s at the pinnacle of power in Cuban medicine and he lives like a lower-middle-class American, and he doesn’t care. I have no generic liking for modest living. What I like is that Jorge believes this is right. He doesn’t like social inequality. He believes in social justice medicine. That moves me. I hate
to see that ridiculed. I hate it.”
There was vehemence in his voice, and I felt I was its object, as if I had already ridiculed Dr. Pérez. I’m sure I felt offended, and maybe I felt hurt—though I’d hardly have admitted this at the moment. Farmer’s emotional side lay close to the surface, and, as Ophelia said, his emotions were usually sympathetic. He cried openly over patients, and the memories of patients. He greeted everyone in his wide circle with blushing elation. I was no less immune than most people to his warmth. Now he seemed to be withdrawing it, and I felt the chill. Was he saying he’d rather not travel with me anymore? Well, then, the feeling was mutual. This guy kept the cybernetic equivalent of a bumper sticker on his computer, a screen saver that read, “Seek Justice.” For me, at the moment, suddenly, the tone of this expressed all my problems with him.
He began to talk about our next destination, Russia. He said it wasn’t as important as Haiti.
“Well, do you think I shouldn’t come along with you?” I said. I tried to make my tone nonchalant. I’m not sure I succeeded.
He looked surprised. “No, no. It’s important.”
The scolding, if that’s what it was, ended then. He said our conversation had just been the “dismount” of our time in Cuba. The term was one the Farmer family had borrowed from Olympic gymnastics, which they’d watched together on TV on the boat, his buxom sister Peggy throwing out her chest in imitation of the stance the diminutive female athletes would take when they finished their routines. All the interns, residents, and fellows who worked with Farmer at the Brigham knew the term. “Okay, let’s do the dismount,” he would say, and they’d begin wrapping up discussion of a case.