The old man’s wife says she wants her blood pressure checked, too. Kneeling beside her, Farmer says in English, “She’s sixty-two. Going on a hundred,” adding, as if to himself, “We are far from the Brigham, my friend.” The woman’s pressure is high, too, he says. I, meanwhile, am trying to think of what Farmer said to me a year ago about the profound difference between being bedridden in a nice house outside Boston and mat-ridden in a hut like this, but I can’t stop thinking at the same time about the little pain that has been flitting around behind my left nipple, on and off ever since that first cliff climb.
Finally, I tell Farmer about the pain. Then I apologize, and he says, “Don’t be silly. Tell me more about it.” He asks me a dozen questions, and says he thinks I just have heartburn. “But if it gets worse, you have to tell me. You don’t want to see Alcante that bad. Promise?”
Several small children have come to the doorway. They stand there, peering in. Farmer says to them, speaking of the sad-looking woman of the house, “You love her a lot? Do you tell her? Don’t lie to me now.” The children giggle. The old woman smiles. Farmer nods toward a naked toddler in the doorway. “Look at his toy.”
The child is sucking the thumb of one hand. In the other, he holds a piece of coarse hemp string. A rock is tied to the end of it.
“Rocks ‘R’ Us,” says Farmer, and I laugh. I can’t stop. Farmer starts laughing, too, saying, “Now I’m going to have chest pain. God is going to strike me dead.” He says that he’s going to give me half a beta-blocker just in case, and still I can’t stop laughing.
“God is going to strike me dead,” he says again. “For drinking more than my share of water, for not living humbly, for my bad sense of humor. It’s your fault. I’m playing to my audience.”
But, I think, he hasn’t drunk any water yet.
He gives the couple their pills and instructions. Good-byes are always long in Haiti. When we get outside, Farmer says, “This was a bel kout nas, a good cast of the net. We came to see Papa and got Grandma, too. Just in time. Before she got run over by a reindeer.”
I’ve heard him use the fishing metaphor many times. When a sick person is discovered by accident, he usually says he’s made a lucky catch. As if Zanmi Lasante didn’t have enough patients already.
“Is there a long way still to go?” I ask, as we walk on.
“Oh, yeah! This is a quarter of the way there.”
“A quarter?”
Since the death of the boy John, I’ve been trying to form my question for Farmer about that case. I remember a remark he made to me a year ago in these hills: “You should compare suffering. Which suffering is worse. It’s called triage.”
The term comes from the fourteenth-century French trier, “to pick or cull,” and was first used to describe the sorting of wool according to its quality. In modern medical usage, triage has two different meanings, nearly opposite. In situations where doctors and nurses and tools are limited, on battlefields, for instance, one performs triage by attending first to the severely wounded who have the best chance of survival. The aim is to save as many as possible; the others may have to die unattended. In the peacetime case, however, in well-staffed and well-stocked American emergency rooms, for example, triage isn’t supposed to imply withholding care from anyone; rather, it’s identifying the patients in gravest danger and giving them priority.
Farmer has constructed his life around this second kind of triage. What else is a “preferential option for the poor” in medicine? But Haiti more nearly resembles a battlefield than a place at peace. Walking behind him, I say there must always be situations here where the choice to do one necessary thing also means the choice not to do another—not just to defer the other but not to do it.
“All the time,” he says.
“Throughout your whole career you’ve had to face this, right?”
“Yes. I do it every day. Do this instead of that. Every day all day long, that’s all I do. Is not do things.”
So, I ask, what about the case of John? What about the twenty thousand dollars that PIH spent on the medevac flight to get him out of Haiti? Not long after John died, a PIH-er, a relatively new one, said to me that she couldn’t help thinking of all the things they could have done with that twenty thousand dollars. What is his response to that? “I don’t mean this at all critically,” I add, hurrying along behind him.
“Come on,” he says over his shoulder. “I’m not hypersensitive. But we’ve already discussed this, so many times. I’m just failing to do a good job or you’re not convinced. Maybe I’ll never convince you that the choices we make are good ones.”
I don’t want to nettle him. For one thing, he’s both my guide and my doctor for today. But I recognize his tone of voice. He’s not really irritated. He’s just delivering a preamble, warming up his argument.
He continues, talking over his shoulder to me as we walk on. “Let me say a couple of things about this particular case, if you like. One is, remember of course that John was referred to Boston as dying of a treatable tumor, a very rare tumor. He wasn’t referred to Mass General before we knew what he had. So when he was referred, it was for free care because he had such a rare thing and it was treatable, and the predicted cure rate was sixty to seventy percent. All right. Good enough. That was what the decision was made on. And there was no way for us to find out that John didn’t have locally invasive disease without metastases, because it required a diagnostic test that we can’t do here. So the other thing is, the bottom line is, why do we intervene as aggressively as we can with that kid and not with another? Because his mother brought him to us and that’s where he was, in our clinic.”
“I wondered when Serena and Carole came to get him, if you’d have decided to bring him after all, if you’d been there. He was so emaciated.”
“The emaciation wouldn’t have stopped me. If I’d seen him and seen how far he’d gone downhill, I wouldn’t have stopped the process. Why? On what grounds? We didn’t know until he got to Boston that the cancer had invaded his vertebrae.”
We climb another cliff, and I am breathing too hard to speak. After a short pause, he says, “I have to tell you, though, I’m a little troubled by these comments from the new PIH-er. Because I have to work with these people. The last thing I want to do is expend my energy trying to convince my own co-workers. Now I have to, of course. But I don’t like it. The Haitians have a lot to say about inviting the wrong people into your midst, you know.”
“I don’t want to misrepresent it,” I say. “Your PIH-er wasn’t saying you shouldn’t have brought John to Boston. Only that it was a shame you had to spend so much, given what else you could do with twenty grand.”
“Yeah, but there are so many ways of saying that,” he replies. “For example, why didn’t the airplane company that makes money, the mercenaries, why didn’t they pay for his flight? That’s a way of saying it. Or how about this way? How about if I say, I have fought for my whole life a long defeat. How about that? How about if I said, That’s all it adds up to is defeat?”
“A long defeat.”
“I have fought the long defeat and brought other people on to fight the long defeat, and I’m not going to stop because we keep losing. Now I actually think sometimes we may win. I don’t dislike victory. You and I have discussed this so many times.”
“Sorry.”
“No, no, I’m not complaining,” he says. “You know, people from our background—like you, like most PIH-ers, like me—we’re used to being on a victory team, and actually what we’re really trying to do in PIH is to make common cause with the losers. Those are two very different things. We want to be on the winning team, but at the risk of turning our backs on the losers, no, it’s not worth it. So you fight the long defeat.” He pauses. “How you feelin’? Is that chest pain gone?”
I am overheated, but that little flitting pain hasn’t come again.
Farmer continues, “And most of the time when people ask about triage, most of the time they’
re asking not with open hostility but deep distrust of our answer. They already have the answer. And that of course is the energy-draining process, because you understand that a substantial proportion of the questions are asked in a, you know, in a very, what’s the word?”
“With an animus?”
“Yeah.”
He’s silent as we scrabble down a hilly section of the trail. At the bottom, he resumes. “The salary of a first-world doctor. How about that? Talk about all the money that could have been spent on other things, what about a doctor’s salary?”
I laugh. “I hadn’t thought of that.”
“Well, of course. See, the truly humble think of that before they say the other. I’m not truly humble. I’m trying to be humble. So let me ask you another question. What is it that makes people not think that? Why doesn’t a young American doctor say, ‘Gee, my salary is five times what John’s airplane ride cost. And I’m twenty-nine or thirty-some years old.’ If you say that stuff out loud, you sound like an asshole. Whereas if you say the other stuff, you just sound thoughtful. Now what’s wrong with that? What’s wrong with this picture? If you say, Well, I just think how much could have been done with twenty thousand dollars, you sound thoughtful, sensible, you know, reasonable, rational, someone you really want on your side. However, if you were to point out, But a young attending physician makes one hundred thousand dollars, not twenty, and that’s five times what it cost to try to save a boy’s life—that just makes you sound like an asshole. Same world, same numbers, same figures, same currency. It’s just, you know, I never have been able to figure it out. I mean, I’ve figured it out, but I realize now it takes so much time to get to that point, to explain it, without offending someone. So what are you thinkin’?”
“I like the line about the long defeat,” I tell him.
“I would regard that as the basic stance of O for the P,” he replies. “I don’t care if we lose, I’m gonna try to do the right thing.”
“But you’re going to try to win.”
“Of course! We’re not, you know, masochistic. And then all the victories are gravy, you know? The other option is to be jaded because you’ve been fighting a defeat for eighteen years, and trying to stop it, at least save the elbow joint for Kenol, you know.” He’s referring to a current patient, a boy back in Cange whose hand got caught in a sugarcane press—a “low medieval device,” Farmer called it—and ended up with gangrene. In the end, his arm had to be amputated above the elbow joint. (After the operation, he said he wanted a radio. Farmer bought him one on his latest Miami day. Zanmi Lasante will send him to school.)
“How’s your chest?” Farmer asks.
It feels all right, in fact. But there is only one mouthful of water left in my jug, and Farmer has said he’d prefer that I not drink the unfiltered water Ti Jean is carrying. So, for the moment, I think I’d rather be thirsty.
Farmer goes on, “If we could identify losers like John, and not waste our time and energy on them, then we’d be all good, as they say in the States. Right? But the point of O for the P is that you never do that. You never risk that. Because before you turn your back on someone like John you have to be really really sure, and the more you learn about John’s family the more you realize that the whole family, their whole—I mean, they’re basically extinct, right? He was the last kid. They’re extinct. His mother’s bloodline is just gone. It sounds Darwinian, but you know what I mean. Shit, man, how can you be an O for the P doc and be willing to take that risk without all the data you can get? Every patient is a sign. Every patient is a test. Like this guy we just saw. The guy’s living in dirt, the guy who needs Canadian crutches? You realize how much shit I’d get for that, Canadian crutches in rural Haiti?”
“Because they’re not appropriate technology?”
“Yeah. Now you can see the critiques revealed for what they are. But I have to limit the amount of time I put into explaining all that or it just sucks your soul dry. If I spent all my time arguing, No, this man needs Canadian crutches and a roof and a floor. I mean, if you’re only defensive. If you say, Fuck you, man, I already built a thousand houses in this country, how many have you built? That doesn’t go anywhere either. But that’s the very doctor they’d be criticizing, one who’s already done his housing fellowship and his practicum in blah blah blah. If you spend all your time arguing about that stuff, defending yourself, you don’t get your work done. It must mean something that Ti Jean doesn’t talk about things like appropriate technology.”
We are walking, Farmer has said, through what used to be rebel territory, during both Haiti’s slave days and the years when the U.S. Marines occupied the country. It seems different from the areas near Cange. The farmyards and even the hilltops look a little more fertile, a little less bereft of soil and trees. But the land is just as crowded. We have been trudging through deep country, far from anything that could even be called a road, and yet there’s hardly been a moment when other people haven’t been in sight or just around the next turn in the trail.
We’ve forded one big river—pigs rooting in the banks, chunks of earth falling into the water, and irrationally, I felt as though I should catch the soil in my arms and put it back. I’m not sure how many hours we’ve been walking. It must be at least four. We’ve crossed ridge after ridge, and we’re still encountering the works of PIH. Some are inanimate—a school that Zanmi Lasante built out here in the mountains—but mostly they’re patients. I’ve lost count of their numbers, and we’re still running into them. There are the fairly healthy-looking ones who say to Farmer in Creole, “Hi, my Doc,” or “How’s my Doc’s little body today?” And patients who are works in progress. The most memorable for me is a girl whose neck and chest were burned some time ago. It looks as if the flesh on the lower part of her face had melted and then hardened into a beard of skin, the strands of the beard attaching her jaw and chin to her chest and shoulders more and more tightly as she’s grown. Never mind the grotesque scarring, in another year or so, her mouth will be pulled permanently open. Unless she gets to a plastic surgeon. Farmer has been trying to arrange the necessary operations in the United States. “It’s a bwat,” he says.
“We getting close to Casse?” I ask.
“Well, you don’t want to know just yet.” He smiles. He stops and points to a hilltop in the distance. “Wait’ll we get over that ridge. Then I’ll break it to you. Khyber Pass. Ruby Ridge. I’m sorry. Lord of the Rings, Redhorn Pass. Smell this. It’s campêche.”
I drank my last sip of water some time ago, and I’m feeling slightly dizzy as we continue on. My mouth has grown so dry that I croak when I try to speak.
Farmer has noticed. He starts calling out, “Do you have oranges?” at every farmyard we pass. I end up sitting with my back against a tree, devouring six oranges, one right after the other. And when we finally reach Casse, a brown and dusty, dirt-street market town, constructed of wood and corrugated metal, Farmer feeds me Cokes.
“I can’t tell you how much better I feel.”
“Hydration,” he says.
Zanmi Lasante’s local health worker—a barefoot woman in a dress—shows us the way to Alcante’s house. (Farmer waited for her to find us. He didn’t ask the strangers in Casse for directions. “Because they’re Hats, there would be no shortage of wrong answers. You learn that in year three or four.”) Another half hour’s walk and we arrive at the farm, which consists of a stand of millet, a cook shack with a three-rocks fireplace, and a hut made of what is known as wattle and daub—that is, dried mud and sticks. The roof is old banana bark, patched all over with rags.
“Alcante!” says Farmer. “I’m happy to see you.”
“And I’m delighted to see you!” says the shiny little boy. He calls to his sisters, emerging from the hut, “Are there any more chairs here? We need more chairs.”
“The little social director,” Farmer says to me. “He’s just so …” His voice trails off. He grins.
Alcante’s father was shaving when we arriv
ed—with a painted shard of glass for a mirror and a razor blade and no soap or water. He finishes the job. Gradually, the rest of the family emerges from the hut, and I am reminded of the routine at the circus in which an apparently endless stream of people comes out of a tiny car. I estimate the hut to be about ten feet by twenty, and I count ten souls who live in it. Farmer gazes at the hut. “Well, I guess I don’t need to do a house inspection.” He stares at it some more. “On a scale of one to ten, this is a one.”
A long chat ensues. From it Farmer draws a variety of lessons for me. Of the several cases of TB in this family, only the father’s was detectable by sputum smear. That is, his was the only case that involved the lungs and was contagious, the only epidemiologically significant case, the only kind of case that DOTS addresses. “So here’s a house full of TB, where you only have one case according to the DOTS system,” says Farmer. “The rest had extrapulmonary disease, which doesn’t count. It can kill ya but it doesn’t count.” He adds, and for a moment he is back in Peru, “We never wanted to get rid of las normas, we just wanted to extend them, and add some flexibility.”
There’s also a sociopolitical lesson to draw, of course: “Look at Alcante’s family. It’s intact, the kids are bright and clever, and the father can’t walk. And they just can’t make it. It’s fucking unfair. The woman who said to me years ago, Are you incapable of complexity? That was an epiphany for me. Are you going to punish people for thinking TB comes from sorcery? It’s like the guy on our own team, a nice guy, who said he would help with a water project in a town here, but only if the people really showed they wanted it. What if that standard had been applied to me when I was a kid, before I knew that water could carry organisms that made people sick?”