MOUNTAINS BEYOND MOUNTAINS SUMMARY

CHAPTER SUMMARIES WITH NOTES AND ANALYSIS

PART I - Doktè Paul

CHAPTER 1

Summary

This chapter explains how the author came to meet Dr. Paul Edward Farmer. Two weeks before Christmas 1994, in a market town in the central plateau of Haiti called Mirebalais, the author is sitting with an American Special Forces captain named Jon Carroll at a Haitian army outpost. He is in Haiti to report on American soldiers, 20,000 of which had been sent to reinstate the country's democratically elected government and to strip away power from the military junta that had deposed it and ruled cruelly for three years. With only eight men, Captain Carroll is temporarily in charge of approximately 150,000 Haitians spread across one thousand square miles. Political violence has all but disappeared except for one particularly grisly murder: a few weeks back, American soldiers had fished the headless corpse of the assistant mayor of the town from the river. A rural sheriff named Nerva Juste, a frightening figure to most of the people of the area, had been arrested by Captain Carroll, but was released for lack of evidence or witnesses. The release of Juste was a source of great frustration to Captain Carroll, but because the US government had determined that they would not be in the business of "nation building," he was given no tools to properly govern the area he now controlled.

As the chapter begins, Captain Carroll is advised that he has five visitors: four Haitians with one American friend. The American steps forward to explain that his name is Paul Farmer, and he is a doctor working in a local hospital. Captain Carroll asks Farmer if he has any medical needs and that he himself has even bought medicines when needed. However, Farmer's concern is who cut off the head of the assistant mayor. Carroll answers that he doesn't know for sure, but Farmer says that in that small area it is very hard not to know the answer. The two men then have a somewhat circuitous conversation with Farmer expressing his concern that the American government's plans for fixing Haiti would aid business interests but do nothing to relieve the suffering of the poor. He says he is on the side of the poor but it is still unclear which side the American soldiers are on, especially in light of Nerva Juste's release. The author realizes that Farmer knows Haiti better than Carroll does, and he's trying to impart the fact that the Haitians are losing confidence in the Captain. However, Carroll becomes riled at Farmer's criticisms and raises his voice to say that when he has enough evidence he'll slam the man, but until he does, he's not going to stoop to the level of those who make summary arrests. Farmer argues that it makes no sense to apply principles of constitutional law to a country that has no functioning legal system. So they come to a stalemate - one is a "redneck" arguing for due process while the other is a champion of human rights arguing for preventative detention.

The author stays with the soldiers for several weeks and then meets up with Farmer again on the flight home. Kidder proceeds to have an in-depth conversation with Farmer about the murder of the assistant mayor in which the doctor explains that he had come to Captain Carroll to warn him. The Haitians in the area were upset with Carroll's decision about Nerva Juste and had challenged the doctor to stop and talk to the soldier. Ironically, as they were passing the army compound, the got a flat tire and Farmer had commented that "you have to listen to messages from angels."

Kidder also gets Farmer to tell him about his life. The doctor is 35 and graduated from Harvard Medical School and also has a Ph.D in anthropology. He works in Boston for four months of the year, living in a church rectory in a poor neighborhood. The rest of the year he works without pay in Haiti, doctoring peasants who had lost their land to a hydroelectric dam. He had sneaked back into Haiti when the junta was in power by paying a small bribe.

After the plane lands, Kidder speaks to Farmer again in a small coffee shop and a few weeks later, he takes him to dinner in Boston, hoping the doctor could help him make sense of what he is writing about Haiti. Kidder is very impressed with Farmer's enthusiasm about the island nation and how he clearly enjoys living among the poor. However, after their dinner, Kidder loses touch with the doctor. In the interim, he comes to take on the same the belief as the soldier that there's not much they can do to alleviate the extreme poverty in Haiti, which appears in what he writes about the country. It's only when he thinks about Farmer that he comes to have a different view of the island. He knows that this view will be hard to share, because it implies a definition of a term like "doing one's best." In the meantime, Kidder sends monetary donations to which Farmer sends a handwritten thank-you note each time. Then, the author hears that Farmer is working in international health, notably with tuberculosis, but they don't meet again until 1999 when Kidder calls the doctor and Farmer names the place.

Notes

This entire opening chapter is foreshadowing of the kind of man Kidder is going to tell the reader about - Dr. Paul Farmer, a true humanitarian. His willing to do his best among the poor and downtrodden everywhere is about to unfold to the reader.

CHAPTER 2

Summary

The setting of this chapter is Boston's Brigham and Women's Hospital whose great works and fame make people feel stilled in its presence. Kidder is gathered with Dr. Farmer and his team in radiology where they are discussing the cases for the day. Dr. Farmer is now 40 years old and dresses, like the "big-shot" he is, in formal attire. He still spends most of his time in Haiti, but he is also a very important professor of both medicine and medical anthropology at Harvard Medical School as well as being an attending physician on Brigham's senior staff. They are discussing a patient who has recently been treated for a parasite in the brain. Farmer elicits opinions of his staff about whether to continue treatment for infection. He listens carefully, but it is evident that he is in charge. He calls a female parasitologist, an old, close colleague, whom he calls "pumpkin." He tells her they are going to treat the patient. This is part of a typical ordinary day for Farmer and his staff. They have dealt with six cases all of which are somewhat of a puzzle, until the last patient who they are concerned may have TB as a result of being HIV positive. They head upstairs to see the patient, and along the way, Kidder is impressed by Farmer's demeanor: he speaks to everyone in a personal manner and stops at various places to do small office duties and help other physicians.

Kidder is further impressed by how Farmer deals with the patient, named Joe. Joe is a drug addict and often doesn't take his medication or eat properly. Farmer curls right on the bed to the point that Kidder thinks he's going to climb in with the man. He is very close and personal with the guy to show how much he cares. The patient tells him he want to have a home to go to where he can have a six-pack of beer a day and someone to make sure he eats and takes his medicine. On the outside, he is too distracted by finding drugs and a warm place to sleep to take care of himself. Farmer stares at Joe's face intently as if he and his patient are the only ones in the world, and he promises Joe he will do everything he can to fulfill his wish. A few days later, on a message board outside the door of Brigham's social work department is the message: "Joe OUT: cold, their drugs, ½ gal. vodka; IN: warm, our drugs, 6 pack Bud." Beneath this message are the words, "Why do I know Paul Farmer wrote this?" A homeless shelter is found, but they forbid alcohol, understandably, which doesn't deter Farmer from pleading his patient's case.

On Christmas, when he is on duty, Farmer wraps a six pack of Bud as a present for Joe, and when they leave the patient, Kidder overhears him say, "That guy's a fuckin' saint." When Kidder asks him how he reacts to these kinds of comments, the doctor says that he doesn't mind that they say that, it's just that he feels it's inaccurate, and it makes him think he has to work harder to live up to the label. Kidder feels his own inner disturbance to this comment. It isn't that the words seem immodest to him; it's that he feels he's in the presence of a very different person, whose ambitions he hasn't yet begun to fathom.

Farmer finishes his service at Brigham and returns to Haiti on New Year's Day. He sends Kidder a copy of his latest book, Infections and Inequalities, in which he makes connections between poverty and disease. In it, Farmer can hardly contain his anger at how the necessary drugs don't make it to the patients. He isn't at all like the teaching doctor at Brigham. He shouts on every page. Kidder e-mails him that he loves the book and is going to read his previous ones as well - his oeuvre (body of work). Farmer tells him that those books are not his oeuvre. To see his oeuvre, Kidder has to go to Haiti.

Notes

This chapter reinforces the type of doctor Farmer is. To Kidder, he is like a split personality: he is a calm, caring laid-back doctor who goes the extra mile for his patients. In his book, he is an angry physician, shouting out the needs of his patients and how the poor suffer more, because they're poor and don't have access to necessary care. Kidder seems intrigued and even somewhat disturbed about what he will see in Paul Farmer in the future.

CHAPTER 3

Summary

Kidder, the author, has arrived in Haiti to see Farmer's oeuvre. He is met at the Port-au-Prince airport by a four-wheel-drive pickup and rides on a two-lane paved road until he comes to the other side of the Plaine du Cul-de-Sac. There, the truck moves steadily upward, while pitching and rolling, along a road that seems little more than a dry riverbed. Along the way, he sees many arid mountains and villages of wooden huts, trucks of various sizes and a lot of foot traffic, beggars, ox carts being pulled by men, few trees, and no electricity after the town of Péligre. The trip is only 35 miles long, but lasts three hours. Finally, kidder's truck pulls up to a tall concrete wall where a sign reads, "Zanmi Lasante," or Partners In Health. It is a very dramatic sight in the all but treeless, baked brown landscape. There are tall trees beside courtyards, walkways, and walls, an ambulatory clinic and a women's clinic, a general hospital, a large Anglican church, a school, a kitchen which prepares meals for 2000 people a day, and a brand new building to treat tuberculosis. Inside, the building has tiled floors, clean white walls, and paintings by Haitian artists.

The morning after Kidder arrives, he goes on the first of many times with Farmer on his rounds. It begins at dawn and there are many, many people waiting to see him. A large number are there just to ask Farmer to help them in ways that are not really medical or urgent, so he searches the crowd for people in real need. One is a young woman with her hand in a towel. She has waited fifteen days before seeking medical care for a severe wound and now she is has gangrene. He is frustrated that even minor injuries go untended and then more severe consequences are the result. The woman will probably lose her hand.

Kidder explains to the reader that when he arrived at Zanmi Lasante, he came to what seemed to him the end of the earth. It is the poorest part of the one of the poorest nations in the world, but he feels he has encountered a miracle. The people make the equivalent of one dollar a day or less, the country has lost most of its trees and a great deal of its soil, it has one of the worst health statistics in the Western world, and yet in one of the most impoverished regions of the world is this lovely, walled citadel called Zanmi Lasante. Other clinics treat patients there, but none are as well-equipped, and the patients do not have to pay at Farmer's clinic like in the others. His Haitian colleagues had told Farmer that the patients must pay user fees of about eighty cents a day. However, Farmer has his own rule: every patient must pay the eighty cents, except for women, children, the destitute, and anyone who us seriously ill. So everyone has to pay except for almost everyone!. And no one is allowed to be turned away.

In addition to the excellent medical care the clinic provides, it also had built schools, houses, sanitation systems and water systems in the catchment area. What's more, in a country where the greatest killer is TB, there has not been one death from it in Farmer's catchment area since 1988. The money for Zanmi Lasante is funneled through the public health charity called Partners In Health with headquarters in Boston. The bills are small by American standards, so that Kidder's local hospital in Massachusetts treats about 175,000 patients with an annual operating budget of $60 million, while Zanmi Lasante treats the same number of patients for about $1.5 million. Much of what they receive is from donated drugs and charitable contributions.

Farmer himself contributes a great deal to Zanmi Lasante, also. He had received from the MacArthur Foundation a so-called genius grant of $220,000. He had donated the entire sum to Partners In Heath for a research branch for the organization. He personally makes about $125,000 a year from Harvard and the Brigham, but all his paychecks for honorariums or royalties also go to Partners In Health. Now he is married to a Haitian woman named Didi Bertrand and has a daughter born in 1998. They moved from the basement of Partners In Heath's headquarters and live in a small apartment in Eliot House at Harvard when they are in America. While they are in Haiti, they stay at the clinic. However, these days Farmer doesn't see much of his family, because Didi is finishing her studies in anthropology in Paris. When told he should spend more time in Paris, Farmer says, "But I don't have any patients there." So he spends four months in Boston and the rest of the time in Haiti and has traveled to so many places where doctors are needed that he has traveled more than three million miles by airplane. He has a small house similar to a ti kay that peasants live in only with an indoor bathroom (without hot water). Whenever Kidder looks into Farmer's little house, he is amazed to see that his bed remains unused. Farmer claims that he sleeps about four hours a day, but later he confesses that he just can't sleep, because there's always someone who's not receiving treatment when he does.

Once, Kidder wonders aloud what compensation Farmer receives for all his sacrifices. Farmer, with an edge to his voice, responds, "I feel ambivalent about selling my services in a world where some can't buy them. You can feel ambivalent about that, because you should feel ambivalent. Comma." This is Kidder's first experience with Farmer's use of the word comma at the end of a sentence. It stands for the word that would follow the comma - asshole. Kidder understands that Farmer isn't calling him an asshole, but instead is referring to third parties who feel comfortable with the current distribution of money and medicine in the world. And implication is that you aren't one of those. Are you?

Kidder follows Farmer into his office where Farmer says that now the objective is to stay put. The patients then come to him: an elderly man being treated for pulmonary TB who is blind, but wears glasses. He had said he wanted them, so Farmer saw to it that he received them; a younger man called Lazarus by Farmer who had been wasting away from AIDS and TB and had gone from 90 pounds to 150 in Farmer's care; a woman who looked healthy and well, but only a few months before, her father had been saving to buy her a coffin; a lovely-looking young woman being treated for drug-resistant TB and now is in the midst of a sickle-cell crisis; a man with gastritis in late middle age which Farmer explains could mean thirty years old since 25% of Haitians die before they reach the age of forty; a sixteen-year-old boy too weak to walk because of an ulcer; and a very small elderly-looking woman who had developed TB of the spine before Farmer could treat her. Farmer is especially solicitous of her needs and calls her "mother." Then a very pregnant woman enters cheerily calling all the men in the clinic her husbands. She is infected with HIV and has been exposed to TB.

While Farmer deals with this last patient, Kidder examines the yellow legal pad lists taped on the wall. There is a task to be completed written on every line of each of three pages. When he gets a task done, he checks a box he has drawn beside it. This seems to give the doctor inordinate pleasure when he sees he's getting a lot done. There are sixty imperatives on the list such as sending sputum samples to Boston. One tantalizing item reads, "Sorcery consult." This refers to the deep belief in the Haitian culture that someone can be made ill through sorcery. It is called "maji" and all Haitian doctors know how to deal with it. Because Farmer has such a gift for healing, the people think he is a god and that he works with both hands - science and magic. Farmer is embarrassed and amused by these kinds of consults, but on a serious note, he explains that the beliefs of the people evolved in the absence of effective medicine, so they have developed an alternative cause for illnesses they don't understand. Of course, the allegation of sorcery itself can cause problems, like the boy whose mother refuses to speak with him, because she believes he used "maji" to kill his brother.

All these interpretive discourses he has with Kidder Farmer calls "narrating Haiti." Normally, the doctor can be silent during his rounds or at the least, reticent about benign conversation, so Kidder eggs him on in order to get him to "narrate Haiti," which brings forth his drawing of a moral about the suffering of the Haitian poor as well as the world's poor. He often pauses for a reaction, "You feelin' me?" As for Kidder himself, he finds he can't muster a sufficient response internally. He feels sorry for so many Haitian children, who often die of something as common as measles, but he knows he can never feel sorry enough to satisfy Farmer. It sometimes makes him feel annoyed with Farmer.

Farmer teaches his students that to be a good clinician, you must never let a patient know that you have problems, too, or that you're in a hurry. He says that the rewards are so great for simple things. Of course, this means that he seldom leaves his office before dark. A young man named Ti Ofa comes in as a chronic infectious patient. Because the clinic doesn't have the equipment to measure viral loads and CD4 counts, Farmer knows only from long experience that Ti Ofa is in the endgame of his AIDS infection. Even though it is exorbitantly expensive and no doubt a waste of resources, Farmer has started patients like Ti Ofa on new antiviral drugs. The man is embarrassed by his situation, but accepts the drugs and promises to take them faithfully. He tells Farmer that just talking to him makes him feel better.

The end of the day brings more rounds, this time of the Children's Pavilion where there are babies with kwashiorkor, a form of starvation. Farmer has recently lost a baby to meningitis and another to tetanus. He croons softly to a baby girl named Michela who he refuses to give up on even though she is bloated with pleural effusion. The last stop is the TB hospital where the patients are sitting on the beds in one room watching a soccer game on TV. He jokes and teases them, which cheers him up. He points out to Kidder that they're failing on 71 levels, but not on one or two. The day ends on Farmer's little patio lit by battery power. He puts a pile of medical studies on his lap to read, but decides he's not into that and instead takes Kidder along, while he surveys the plant life he has nurtured over the years. The, he goes back to his studies for awhile. Even that is interrupted when he is called back to the clinic for a moaning thirteen-year-old who has arrived by donkey ambulance. He must give her a spinal tap and when he inserts the needle she cries out in Creole that it hurts and she is hungry. Farmer is amazed and "narrates Haiti" again, "Only in Haiti would a child cry out that she's hungry during a spinal tap.

Notes

This chapter shows the reader how Farmer spends his days and how dedicated he is to each and every patient. They love him and call him a god, bring him gifts like pigs or chickens. However, none of these accolades are what motivates this man. It is the thought that there is some patient in need that keeps him going.

CHAPTER 4

Summary

Farmer tells Kidder soon after he arrives in Haiti that he, Farmer, will be Kidder's Virgil. That's because he views everyone as a potential subject for education. He tells him about his own education concerning the relation between medicine and beliefs in sorcery. He had been in Boston recovering from a broken leg when one of his patients died of TB. When he returned, he was told by the staff that she wouldn't have died if he had been there. Their intended meaning was complimentary, but Farmer converted it to self-reproach. He wanted a medical system that continued to work in his absence.

So Farmer calls a staff meeting to figure out what is wrong. Some of the staff points out that the poorest patients fare worst, but many of the staff point out that failure with a patient can often be placed on his mindset: once he feels better, he stops taking his medicine which then inevitably leads to setbacks. Farmer is intellectually torn over the possible reasons and so designs a study. He selects two groups of TB patients. Both groups receive the same treatment for free, but one of the groups also receives other services, such as visits from health care workers and monthly cash stipends. Farmer visits all the patients personally to monitor their care. When the study ends, only 48% of the group who only received free medicine is cured, while in the group that received extra services, everyone fully recovers. So whether a patient believes that his illness comes from germs or sorcery makes no difference at all in his recovery. Farmer is at a loss to why the study comes out the way it does, until he interviews a sweet, rather elderly woman who asks him, "Are you not capable of complexity?" That's when Farmer realizes that this is no different than the dynamic he sees in America where people rely both on medicine and prayer. Thus, the study becomes a command to him to worry more about his patients' material circumstances than about their beliefs. So the money he receives for his clinic also is used for extra health care workers and cash stipends. As a result, he hasn't lost a single patient in twelve years.

A patient from a village called Morne Michel has not shown up for his monthly appointment, so Farmer, believing that one of his rules is to find a patient when he doesn't appear, decides to go into the countryside. To him, the noncompliant one is the doctor who doesn't fix a patient who doesn't get better. As a result, Farmer decides to go to Morne Michel and take Kidder with him. On the day he sets out, he tells the women in the kitchen where he and kidder are going. They admonish him that such a trip will kill his "blan," a term referring to Kidder. Actually the term has a complicated meaning such as "white person," but also anyone from outside Haiti, even black Americans. The Haitians think they all look alike!

The trip is long and difficult. Their first stop is an abandoned cement factory which sits beside a concrete buttress dam. This dam is a subject that Farmer has discussed in all of his books and many of his journal articles. To him, it is the perfect example of what's wrong in Haiti. In the 1950's, under one of Haiti's many dictators who was supported by the USA, the dam was built by the US Army Corps of Engineers under the pretext of improving irrigation and generating power. In reality, the peasants who were supposed to benefit from the project received nothing but the loss of their homes and property. In fact, the dam had always been intended to help agribusinesses downstream, mostly American-owned, and also to supply electricity to Port-au-Prince and to the homes of the Haitian wealthy.

As a result, the young soon left the countryside and moved into the cities. The old reminisce about what the countryside looked like before the dam. They describe the experiences of running from the rising water and then fighting over who owned the scabby land that was left. After that, they even lost their pigs in the 1980's when American fears of swine flu invading their own pigs led to Haiti destroying the Creole pigs. Even supplying the peasants with American pigs didn't work, because they couldn't survive the rigors of the Haitian countryside.

Farmer and Kidder walk across the top of the dam, being greeted all along the way by the locals. Then, they find a footpath that moves straight up. Even with Farmer's bad back, he makes it to the top of the first hill before Kidder. It is the first of many hills. They pass smiling children, carrying water in buckets that had once held paint, oil, and antifreeze. They pass patches of millet, the national staple, and small stands of banana trees. On a fair number of the trees that are still standing are political graffiti, which is one way, Kidder believes, that the poor here avoid hopelessness. They pass women washing clothes in a rivulet of a gully. Farmer explains that they are a fastidious people in spite of their poverty. He also comments on their smiling faces that are evident even though they're very aware of their own misery. He says there's a WL (white liberals) line that says, "They're poor but happy." He even has problems with groups who appear to be his allies, because even though he loves them, he is angry that they believe all the problems of poverty can be fixed without any personal costs.

Kidder notices that many of the people he passes are wearing second-hand American clothes. The people call these "Kennedys," because President Kennedy had sponsored a program for Haiti that sent machine oil among other things to the country. The people thought the machine oil was cooking oil, and so came to apply the name Kennedy to goods of inferior quality.

The two men continue their trek with Kidder sweating buckets and Farmer as dry as a bone. About three hours after they began, they arrive at the hut of the patient who hadn't shown up for his appointment. When Farmer asks him if he dislikes his TB medication, the man replies with an emphatic yes, because he wouldn't be here without it. However, he hadn't received his standard cash stipend and so hadn't come in to the clinic. Farmer is satisfied that he has resolved the problem, and they begin the long journey back, slipping and sliding this time down the hills. When Kidder asks him what his reply would be if other health care workers were unwilling to make the same effort he is, Farmer says he would reply, "F*** you," his way of saying that they are responsible for assuring an "outcome-oriented view of TB."

They soon come to a cock-fighting pit where two chairs are found for both men and where Farmer is soon surrounded by all the women of the men participating in the match. They admire him and want to talk to him, because he is the first physician who has ever provided them with gynecological or obstetric help. Once they set out again, it is mostly downhill, but there are still a few hills to climb. At the top of one, Farmer stops as if to admire the view. It is beautiful, but Kidder now sees it as more than just picturesque - perhaps he now knows the truth that lies within these hills. Farmer says that to understand Russia, Cuba, the Dominican Republic, Boston, or Sri Lanka, you just have to be on the top of that hill. He seems to be joking, but Kidder understands now that viewing this drowned land of the poorest people is a lens on the world. However, he fears to voice his ideas, because he doesn't want to disappoint Farmer.

Notes

In this chapter, Kidder begins to learn the great lessons that Farmer teaches: there is a definite link between poverty and poor health; behind the beauty of the hills is the truth about the poorest of the poor; WL stands for more than white liberals, but also for anyone who champions Farmer's cause without any personal sacrifice.

PART II - The Tin Roofs of Cange

CHAPTER 5

Summary

This chapter is Kidder's research into how Farmer's background caused him to make the choices he made. His parents came from western Massachusetts, and Paul was born in the mill town of North Adams in 1959, the second of six children, three boys and three girls. He looks mostly like his mother who had quit college early to marry and be a mother. His father was a big man and a ferociously competitive athlete known as Elbows to people with whom he played basketball. His daughters called him the Warden, because he wouldn't allow them to use make-up, have boyfriends, or stay out late.

Because his father was a restless sort of man, he left his steady job as a salesman in Massachusetts and moved his family to Birmingham, Alabama in 1966. It would be some of the happiest years for the family, especially Ginny, Paul's mother, because they lived in a house and even had an automatic washing machine. They even bought, at public auction, a large bus for family vacations. They named it the Blue Bird Inn. Paul flourished here as well, being placed in gifted classes in school and even subjecting his siblings to his "herpetology class." He went to Catholic Church, but didn't feel engaged, pointing out that his books caught his attention more. He even likened War and Peace to The Lord of the Rings.

When sales work disappointed the Warden, he turned to teaching, but the atmosphere in Alabama in the 1960's worried him and Ginny, so he found a job in the public schools of Florida, and the family moved there in 1971. Unfortunately, the beloved washing machine wouldn't fit in the bus, and it would be many years before Ginny saw another one. They parked the bus at a campground, and it became their home. Ginny was forced to take a job at a local Winn-Dixie, and she also was expected in their "traditional home" to do all the wifely duties as well. However, she insisted on reading aloud to her children and pushing the concept of education on them all. Years later, she herself would graduate from Smith College. The family remained in the campground for five years where Paul learned to concentrate in the midst of all kinds of noise and where he used a tent after an accident in the bus forced the family out until repairs were made.

Once, when funds were low, the Warden decided they would pick citrus, but Paul pointed out that white people didn't pick citrus. His father's only response was, "Yeah? I'll give you white people." This would be Paul's first experience with Haitians for they were the ones who usually picked citrus.

Because the pay picking the fruit was so meager, the Warden decided to quit that project after a few days. Instead, he bought an old boat and fixed it up and renamed it The Lady Gin after his wife. He declared that it would be a source of revenue in the area of commercial fishing and so the family set out on their first voyage. They got caught in a major storm, and Ginny rose up against her husband for once and demanded they throw the generator overboard as an extra anchor. The experience turned out alright, but the danger they were in didn't faze the Warden at all. Paul said later, "But the thing was - it was a strange feeling - you knew he didn't know what he was doing, but you also felt the security. That he would get us out of the situation. That nothing was really going to beat him." Nonetheless, future voyages were limited to staying moored on an uninhabited bayou on the Gulf Coast called Jenkins Creek. Paul continued to flourish here, because he loved the nature that surrounded him. He even saved money from his part-time jobs to landscape the area around the boat. This life, of course, was the hardest on Paul's mother: working all day and caring for the family all night, having to deal with a refrigerator that was much too small, washing clothes at a laundromat and washing themselves and their dishes in the brackish water of the bayou, stealing their drinking water from an outdoor spigot at a convenience store, and living with vehicles that often broke down and were embarrassing to look at.

Farmer's comment on his childhood was, "The way I tell myself the story is a little too neat. I'd like to be able to say that when I was young I lived in a trailer park, picked fruit with Haitians, got interested in migrant farm workers, and went to Latin America. All true, but not the truth. We're asked to have tidy biographies that are coherent. Everyone does that. But the fact is, a perfectly discrepant version has the same ending." In spite of this truth, his upbringing was good for both Paul and his siblings. They grew up well, albeit choosing to live in houses, and became successful people. His childhood especially helped Farmer prepare for a traveling life, sleeping anywhere, including a dentist's chair, and never having needed a sense of a hometown. Cange in Haiti became his hometown. His childhood also helped him score a full scholarship to Duke University.

At Duke, Paul failed to score all A's his first semester, because he plunged into every organization and cultural event he could. For the first two years there, his family feared he was turning into a preppy, which the Warden quickly dispelled when he told his son that a preppy can still clean the bilge. Eventually, however, he saw that this wasn't the life for him, even quitting his fraternity, because they wouldn't admit anyone who wasn't white. He also returned home less and less in his final two years, because he needed to get out from under his father. All the Farmer children craved their father's approval, but the man made it hard to get. He never allowed Paul to see any pride in his achievements out of fear he'd make his head swell. Also, the Warden had been forced to move the family once again, this time to a trailer that the two youngest sisters called the Star Road State Prison. None of the children wanted to live near there, so they all began to drift away.

Paul did share certain qualities with his father, above all their intense focus on a goal. The Warden died a few years later in July, 1984, while playing a pick-up game of basketball. He evidently had a heart attack at the young age of 49. Paul brought home a girlfriend soon after his father's death, and they explored the Blue Bird Inn while he was there. He discovered an old letter that his father had written him saying, "I just want you to know how proud I am." Paul sat there holding the letter and sobbing his heart out. He had finally received his father's approval.

Notes

This chapter is not only revealing of what molded Paul's character but it is also very touching. It helps the reader understand what made Paul the man he is. His childhood was not easy, but he adapted and flourished within it. And it's easy to see that it provided him with the tools to accomplish his oeuvre.

CHAPTER 6

Summary

Paul was described by his college friends as a guy who made friends easily and had a photographic memory for facts about each one. He talked to everyone he met and was open to late night food fights and singing Broadway songs while walking across the campus.

After his first semester, Paul started getting all A's. He also spent one summer and fall in Paris where he lived with a family that needed an au pair. He went frequently to political demonstrations and took four courses, among which was the last anthropology class taught by the great Claude Lévi-Strauss. By the time he returned to Duke, he read, wrote, and spoke French fluentlym and he had claimed as his personal mentor Rudolf Virchow, a German polymath who had been dead for the better part of the century.

Virchow isn't very well-known in the medical world, but he is considered the "principal architect of the foundations of scientific medicine." He made important contributions in oncology and parasitology, coined at least 50 medical terms in use today, and helped define the field of medical anthropology. He published more than two thousand papers and dozens of books. He was sent by the German government to Upper Silesia to report on an epidemic called relapsing fever. His report included a prescription for "full and unlimited democracy" as a means to help cure the epidemic. The government fired him. His aphorisms after such experiences included, "Physicians are the natural attorneys of the poor, and the social problems should be largely resolved by them," a favorite of Farmer's. Farmer made no secret of his admiration for Virchow. He said, "Virchow had a comprehensive vision. Pathology, social medicine, politics, anthropology. My model."

After his study of Virchow, Farmer came to have a moral understanding of public health. He also became interested in current events after the murder of Archbishop Oscar Romero by a right-wing death squad in El Salvador. After this, his understanding of Catholicism changed radically when he saw Catholic prelates preaching against the oppression of the poor rather than the perils of premarital sex. He came to believe that there was so much more to countries like El Salvador that people in the United States knew. He later met a Belgian nun named Julianna DeWolf who was working with United Farm Workers. She was fearless, radical, and committed to the farmers of Haiti. Paul called women like her "the church ladies" and was very impressed by what they were willing to do on behalf of migrant workers. His discovery through her of the misery of the Haitians led to an article of over 6,000 words about those farmers laboring in the fields near Duke University, called "Haitians Without a Home."

After graduating summa cum laude from Duke, Farmer joined protests at Krome Detention Center where American Immigation officials were allowing Cuban immigrants entrance and sending Haitians back. He became interested in all things Haitian including its violent history and its ongoing struggle between great and terrible, between good and evil. He had won a one thousand dollar prize at Duke and figured it would be plenty to last him when he went to Haiti. In the meantime, he applied to both Harvard and Case Western Reserve where he could get a joint degree as a doctor-anthropologist. He figured his time in Haiti would help him know if that's what he really wanted.

In 1983, when Farmer landed, Haiti was still controlled by the Duvalier family. It had been controlled by the dictator Papa Doc Duvalier from 1957 until his death in 1971. Now it was controlled by his son, Baby Doc, who had declared himself President for Life. The tourist areas were patrolled by the tontons macoutes , the Duvaliers' Praetorian Guard so Haiti seemed an exotic destination. But Farmer knew the interior would be different. Using his friendship with a member of the Mellon family on Pittsburgh, he hoped to get on the staff of the Hôpital Albert Schweitzer. Unfortunately, there was no opening, so Farmer looked into other situations, including Eyecare Haiti which had mobile outreach clinics and a base for their operations out in the central plateau in the town of Mirebalais. Farmer headed there.

Notes

This chapter explains the circumstances that led Paul Farmer to realize there is a moral understanding to public health and that his talents would be better employed on behalf of the poor of Haiti.

CHAPTER 7

Summary

This chapter is written from the viewpoint of Ophelia Dahl, the young lady with whom Paul fell in love and wanted to marry. It begins with a letter from her to him, explaining why she couldn't marry him. She loved him very deeply and was as committed as possible to him, but she felt she couldn't be the kind of wife he deserved, because the very qualities that drew her to him also caused her to resent him. He was just too committed to the poor, his schedule is limitless and his massive compassion for others would leave little room for her. She tells him, however, "In the end, I hope you know that as part of my histology you can never be replaced."

Ophelia was the daughter of the actress Patricia Neal and her writer husband, Roald Dahl. She came from England to Haiti in 1983 to please her father and with the rather vague intention of doing good works. She was only eighteen and was working as a volunteer at the Eye Care house in Mirebalais when Paul Farmer arrived.

Mirebalais was the country home of Madame Max Adolphe, the warden of Fort Dimanche, the prison where the Duvaliers sent their enemies, likened by one historian to Buchenwald. She was now the national chief of the tontons macoutes. Mirebalais, because it was a place of some significance, had a teleco, and Ophelia had gone there to call home after a letter from her father indicated troubles at home. Unfortunately, the teleco was unable to connect her call, and she headed back to the Eye Care house feeling glum and homesick. On her way back, she saw Paul standing on the balcony of the Eye Care house, calling him a "pale and rangy fellow." They sat down together after introductions in the common room, and she found herself telling this perfect stranger some of her deepest feelings. He seemed close to ideal as a listener, not only listening intently, but offering ways to help her cope. She asked herself how he could know at only age 23 what would comfort her. He also described his own family, making her laugh, and she described the team at the Eye Care house. He was so sincerely grateful for her telling him all she did that she was amazed at his compassion.

Later, they went out together with the team in the Land Rover. He brought his tape recorder, camera, and a notebook to practice his anthropology which prompted her to ask him many questions. He did nerdy things, but was also extremely enthusiastic. He asked the peasants he met just as many questions as Ophelia asked him. After that trip, he began mastering Creole with enviable speed, soon passing Ophelia's skills in the language. On the way back from the trip to the countryside of a few days time, the Rover came around a corner beside a cliff and came across a truck accident on the side of the road. The truck was carrying people and mangoes to market and because it was overloaded, it couldn't master the turn. The people stand beside the road in shock while one of the women lies dead on a bed of the fruit, a piece of corrugated cardboard laying over her. This memory would become fixed in Ophelia's brain, including the sight of Paul staring out the window, very, very silent.

Over the next month or so Ophelia and Paul saw each other almost every day. He lived in a huge old ruin of a mansion in Port-au-Prince and they often went there to be together. It was there he composed a poem called "The Mango Lady" and dedicated it to her:

We start, eyes drawn reluctantly back Over baskets, to the dead mango lady Stretched stiff on her bier of tropical fruit. She is almost covered by a cardboard strip, Like the flag of her corrugated country, A flimsy strip too thin to hide the wounds.

In the process of their relationship, Ophelia realized that he was subtly educating her. She knew if he made a cryptic or broad statement that it was best not to challenge him, but instead ask him to tell her more. One of the questions she asked was, "What is anthropology exactly?" He defined it as being less concerned with measurement than meaning. To grasp it, one had to know the politics, economic systems, and the histories of a place. Only then could you understand an event like the mango lady's death. What he meant was: "Accidents happen. Sure. But not every bad thing that happens is an accident. There was nothing accident about the wretchedness of the road . . . or the over-loaded truck . . . of the desperation of a peasant woman who had to get to market to make a sale, because otherwise her family would go hungry." He blamed this anthropology on the Duvaliers and the American government that supported them. Now she had someone to translate Haiti for her. He could lay out a comprehensive theory of poverty where the world is designed by the elite of all nations to serve their own ends and which erased the histories of how things came to be as they were. His aims were clear: he had come here to do ethnology - learning about a culture, not though books and artifacts, but from the people who had inherited and were making culture. He was going to specialize in medical ethnology to learn everything he could about morbidity and mortality in the most disease-ridden country in the hemisphere. She said after hearing him talk about what he wanted to accomplish that she reached a point where she realized that world had just been revealed to her and that things would never quite be the same again. She told him that when she went home in the spring that she was entering premed herself. They promised to write.

Paul was ardent in his requests for letters, but Ophelia, for a time, didn't write back. She wasn't sure why, because she hated the thought that she might never see him again. One day, she went to lunch with her father and Graham Greene, Paul's favorite writer. He inscribed his book to her, "To Ophelia, who knows the real Haiti." She wondered, if he really thought that of her, what would he have made of Paul Farmer?

Notes

Seeing Paul Farmer through the eyes of someone other than the author, Tracy Kidder, brings more emphasis to the great compassion and empathy Paul had for the poor and down-trodden. It also brings into greater clarity why a woman like Ophelia would be unable to make a life with a man like him. As wonderful as he is, he is first committed to his patients and has little of any commitment left for someone who loves him.

The story of the Mango Lady is a metaphor for Haiti itself as seen in Paul's poem. She is the country dying in the midst of circumstances created by the wealthy and the elite.

CHAPTER 8

Summary

Soon after Ophelia left Haiti, Paul first saw Cange. He was still searching for a place to do his work when he met up with a Haitian Anglican priest named Fritz Lafontant. He was running a rudimentary one-doctor health clinic in Mirebalais. He also had built schools, organized community councils, and programs for adult literacy in several small towns, including Cange. He went with the priest one day by truck and was struck by the beautiful greenness of Haiti in the spring; that is, until he passed the dam and saw the barren, dry area around it. Most of the dwellings were crude hovels with banana-bark thatched roofs patched with rags to stop the leaking. Farmer was struck by his memories of the tin roofs he'd seen in Mirebalais which were emblems of poverty. The roofs in Cange screamed misery.

Farmer kept traveling through Haiti, hitching rides with whoever would take him. He came down with dysentery, probably from eating foods sold on the street. An American public health expert told him, as he lay in a grubby hospital in Port-au-Prince, that if he got any sicker, she would have to take him back to America. At the same time he was telling her no, his heart was saying yes. After he recovered, his determination to understand what Haiti needed returned, and he continued to travel around the country asking questions of the peasants. He knew that the scholarly texts were wrong. He came to realize by living there that a minor error in one setting of power and privilege could have an enormous impact on the poor in another setting. That could be seen in the Creole pig eradication and the dam at Péligre.

Farmer also became interested in liberation theology. It was a powerful rebuke to the hiding away of poverty. The peasants didn't follow doctrines that encouraged them to accept their plight in life and anticipate the afterlife. Instead, they believed that the rest of the world was wrong for "screwing them over, and that someone, someone just and perhaps omniscient, was keeping score." Religion was the one thing they still had. The peasants also believed that God gives humans everything they need, but he leaves it up to them to divvy up the goods. This is also the tenet of liberation theology which demands that we redress the horrors of poverty in the here and now with service and remediation. This fit Farmer perfectly, because as he said of himself, "I'm an action kind of guy." This was further emphasized to him through two events: in one, an American doctor, who loved the Haitians and loved caring for them, was returning to the States, ecstatic to be going home. He said he was an American and that's where he belonged. Farmer wondered about the idea of saying, "I am an American;" in the second, a woman and her baby died of malaria because there was no blood or money to buy it. Her sister sobbed that it was terrible that you couldn't get a blood transfusion when you were poor. She says, "We are all human beings." As a result, he wrote his relatives asking for donations for blood-banking equipment. He happily received a thousand dollars and turned it over to the hospital for the equipment they needed, but he wrote to Ophelia that things hadn't turned out as he had thought: the hospital was not for the poor, because when a blood transfusion was needed, they were still demanding payment in advance. Farmer decided he would build his own hospital.

It was a relief to Paul to discover that there was no clinic at all in Cange. Not because he didn't feel they needed one, but because he knew he couldn't work on one like that of Mirebalais. It was all about the patients and their awful outcomes, and he wanted a clinic that reflected that. He began with a modest health census. Hiring four young Haitians who had at least finished the 7th grade, he sent them to two neighboring villages, going hut-to-hut, tallying up the numbers of families, recent births and deaths, and the apparent causes of morbidity and mortality. It confirmed what Farmer already suspected - the mortality rates were horrific and the deaths of mothers, common events in this squalid area, led to "skeins of catastrophes in families, to hunger and prostitution, to disease and other deaths."

Farmer also learned from another experience how cooperation with the beliefs of the people was important to meeting their needs. A woman with malaria was treated by a local hougan, a Voodoo priest, because her father insisted, but after Farmer explained his role in healing, her mother agreed for her to be treated with chloroquine, and she recovered. Farmer reiterated what he learned in an essay entitled "The Anthropologist Within." He stated that when he had learned that an ethnographer should observe and not try to change anything within a culture, he knew that this made anthropology impotent. To him, it was a tool rather than a discipline unto itself, a tool for intervention. A doctor-anthropologist who understood the religion would find a way to make the hougan his ally rather than fighting his methods. Furthermore, he knew the people of Cange weren't interested in having their suffering merely scrutinized; they wanted both research and action.

Farmer entered Harvard Medical School in 1984 at the age of twenty-four. However, he didn't linger there just studying and learning. He would take off for Haiti, then showing up at Harvard just in time for lab practicum and exams and avoiding basic lecture courses. Being a commuter like this didn't cause any disapproval from his professors who understood that he was trying to bring medicine to people. Besides, his grades were the best of his class.

Notes

When Farmer spends time in Haiti, he formulates his own philosophy about how his love of both medicine and anthropology can become tools to help the people who most sorely need it.

CHAPTER 9

Summary

The combination of Harvard and Haiti brought Farmer back to his religious belief. He had come to accept the peasant view that there was Someone keeping score. He said that in such a godless world that worshiped money and power, the only place to find God was in the suffering of the poor. When Ophelia returned to Haiti, Paul had taken to wearing a large crucifix outside his shirt which enhanced his "priestliness," a characteristic she had sensed in him before. He proclaimed that he had faith in God, but also in science, and he would have to choose science if it were the only service to the poor. He was just glad he didn't have to choose.

He and Ophelia became lovers, and she spent the whole summer with him. She helped him with his formal education by quizzing him with his self-designed flashcards, which she found as amazing as he was. They also walked through the villages where they would continue to take down information at every hut, and where she tried very hard to do something better than he did. She was frustrated by it, but far from angry, that she just couldn't outdo him! During her wanderings with him, she suffered greatly from the heat, but her Creole began to improve immensely. She was also amazed at the strange smell in every hut - not a smelly socks stinky - a smell of people living too closely in poverty.

One of the greatest problems in Cange was the drinking water the people gathered in calabash gourds or recycled plastic jugs. It was retrieved from the stagnant reservoir, and people often left it uncovered for days as well. So a team of Haitian and American engineers from a South Carolina church group devised a plan to use the force of an underground river to carry its own water in a pipe up to communal spigots. After it was built, infant deaths began dropping. Father Lafontant had also constructed thirty fine, clean latrines as well as supervising the building of a clinic. Farmer stole a microscope from Harvard for this clinic. He said, "Redistributive justice - we were just helping them not to go to hell."

Paul himself began to plan for what he called "first line defenses" out in the community. What the first line didn't prevent the Clinique Bon Sauveur would. He was impatient for it to happen, but understood that all of his plans would require money far beyond the means of the South Carolinians. In 1983, he had gone to Boston for his pre-admission testing at Harvard and had asked an organization called Project Bread for money to build a bread oven in Cange. They had willingly given him the money, explaining that an anonymous donor had earmarked some of their money for Haiti. The following year his article "The Anthropologist Within" was published at Harvard and Paul learned that the anonymous donor had read it and wanted to meet him. Paul said to tell the man to come to Haiti.

Paul found out the donor was the owner of a heavy-construction company and that made Farmer war that he was an anti-union Republican working out unfair deals in back alleys. To his delight, however, the man, named Tom White, came to Haiti and Farmer soon discovered that he was far from the typical construction businessman. He had been giving away money for years and had always had a deep feeling about the needs of the poor. He also had a great deal of influence politically in Boston and knew and associated with famous people. He didn't like the attitudes of the rich, however, and was more than upset by what he saw in Haiti. That's when he began giving money to help with Paul's plans.

When Farmer came home to Boston, White would bring sandwiches to him at lunch and they'd eat in his car. One day, White became perturbed at how pale Farmer looked and asked him if he was eating properly. He pulled out a wad of hundred dollar bills and began pulling one after another out and throwing them at Paul. Paul finally admitted that he had given his entire check to an AIDS patient who was being evicted. When White asked him if he didn't think it was kind of impractical, Paul said, "Well, God sent you today." White also told Paul that sometimes he'd like to chuck it all and work as a missionary in Haiti. To that, Paul replied, "In your particular case that would be a sin."

Notes

This chapter especially exemplifies that there are no coincidences. Just when Paul seems to need help or money to further his plan, something or someone comes along to make sure they are fulfilled. Father Lafontant, Tom White, the Bread project, and the engineers from South Carolina are part of the motif which reflects the peasants' idea that there really is Someone keeping score.

CHAPTER 10

Summary

Ophelia came back to Haiti every summer from 1985 through 1989. They were months of nearly constant work. From time-to-time, she longed to get away from the desolate region where they worked and convinced Paul to take a trip into Port-au-Prince on the pretext that they needed medical supplies. She'd take along a pile of his flashcards in case they'd end up broken down, as was often the case. However, it wasn't enough to satisfy Paul who wanted to get back to Cange. Once, she wanted to stop along the way at a supermarket, which was used only by the elite, for a case of Diet Coke. Paul refused, saying they didn't have time to do it. It would mean only a twenty minute delay, but it would also mean walking by the beggars at the market. She knew he was right, that she could get along without the Coke, but she lashed out at him, calling him self-righteous. He became so angry that he slammed on the brakes and ordered her out of the car, calling her a foul name at the same time. She refused to get out, feeling offended, but she also smiled inwardly and exalted that she had finally found a human flaw in him.

On another trip to Port-au-Prince, they arrived after Baby Doc had left Haiti, and the peasantry was rebelling, because the military was acting like it was life as usual, just a different dictatorship. The smell of burning tires filled the air, and at one point, their car was trapped when some kids stole the car keys. Then, a military truck came screaming down the street after a huge crowd of protestors, firing indiscriminately into the crowd. Paul got her to the house where they were staying, but he went back into the crowd again and again, helping the wounded and viewing the action. Once they returned to Cange, they saw changes there as well. They people were now openly talking about politics and how the government could be blamed for dirty water and the resulting illnesses and death. These events and the smell of burning tires would be an abiding part of Ophelia and Paul's lives for years to come.

In 1988, Ophelia came to Boston to live with Paul, who had now entered the phase of medical school called clinical rotations. Paul rarely missed a day of these clinical labs, but Haiti was never far from his thoughts. He asked Ophelia to help him bring resources to the country, and he also turned to Tom White again. Together, the three of them, plus another friend named Todd McCormack, created an organization called Partners In Health (Zanmi Lasante). This organization would solicit contributions, make them tax-free and funnel them to Haiti. White himself put up one million dollars as "seed money." This became Paul's Catholic Church. He expanded the group a few months later with a fellow Harvard anthropology and medical student, a Korean-American named Jim Yong Kim. They would spend many hours together, even into the wee hours of the morning, discussing such ideas as political correctness, the significance of cultural barriers, appearance, and medicine addressing the symptoms of poverty. They believed anything was possible. Among other things, PIH decided to build a school in Cange called Kay Epin (House of Pines). Because there wasn't much in the way of trees, Ophelia's father gave a large sum of money to plant some.

On one evening in 1988, Farmer was rushing around with last-minute errands in Cambridge, before leaving the next morning for Haiti, when he stepped off a curb into the path of a car. His knee was shattered, and so instead of going to Haiti, he went to Mass General for surgery. He spent three weeks in the hospital and then was discharged to the apartment he shared with Ophelia. Setting up housekeeping with Paul was a difficulty that Ophelia hadn't anticipated. She knew he loved her, but for her, relations were strained: "the strain of living with a fellow who was in love with something else, something that I could never compete with, even if I wanted to." Even before the accident, it was difficult when he left for Haiti, but afterwards, when he couldn't go, he became very restive, and they argued frequently over his recovery. Finally, he said, "I'm going to Haiti. They don't mind looking after me there." That was December 10, 1988, and Ophelia knew something had irrevocably changed. A couple of years later, he proposed to her, but she found it hard to say no and impossible to say yes. He was hurt and angry and said, "If I can't be your husband, I can't be your friend. It would be too painful."

For a time after that, Ophelia received word about Paul only through Jim Kim. However, she hated being separated from him. More than ever, he seemed like a person to believe in. he was proof that it was possible to put up a fight. Because she knew he had a weakness for forgiving people, she decided to remain a part of PIH and his life. She gradually filtered back in, taking on the organization's finances. As for her relationship with Paul, within a few years, they seemed perfect to her: no one could make him laugh like her and he could tell her anything. So she said to herself, "Being his wife would have been no bargain. But to be his friend is simply wonderful."

Notes

This chapter reinforces how the relationship between Ophelia and Farmer gradually evolved from one of a couple on the verge of marrying to a deep and abiding friendship. Ophelia knew he was really in love with Haiti and helping the poor and so has to find a way to be with him that doesn't mean a marriage. This also reinforces the motif of Farmer as a kind of priest to what he so firmly believes and that he is married to Haiti.

CHAPTER 11

Summary

In December 1988, Farmer returned to Cange in a wheelchair, and while his leg mended, he launched his study to improve TB treatment in the central plateau. Meanwhile, big events were happening in the country. Several un-elected governments attempted to take power, but invariably the country was under the control of the military. As a result, a great popular movement seemed to be gaining momentum. The peasants and the people in the slums had embraced what they called dechoukaj, which meant the uprooting of every visible symbol of the Duvalier family and the tontons macoutes. There was violence on all sides, but the Haitian military was particularly brutal. Catholic churches became the center of the popular revolt, and the most important priest among them was Jean-Bertrand Aristide.

Farmer decided to go to mass at St. Jean Bosco, the church where Aristide presided, to hear the priest speak. The crowd was rapt at his words when he applied the poverty and suffering of the Gospel to what they were suffering in their "dear Haiti." Farmer remembered thinking that he had been looking all over for the progressive liberation theology church, and now he had finally found it. He joined the crowd moving forward to meet the priest, and after that, the two became friends. They didn't see much of each other in 1988, because of their commitments and because Aristide was busy surviving a series of assassination attempts, including the fire-bombing of his church arranged by the mayor of Port-au-Prince.

Farmer was working on his Ph.D. thesis in anthropology which he entitled "AIDS and Accusation." AIDS had arrived in Haiti in 1985, and he would catalogue what he called the "geography of blame." Haiti had been assigned the role of scapegoat in the eyes of American health officials. They insisted that the virus had originated in Africa, come to Haiti, and then to the United States. Farmer had marshaled a host of epidemiological data which proved that the virus had come to Haiti from the US, most assuredly through American, Canadian, and Haitian-American sex tourists who could buy assignations for a pittance in the slums called Carrefour. The accusations that Haiti had visited AIDS on America had done incalculable harm to the fragile economy of the country and to the poor Haitians themselves. The thesis he wrote was to be "an interpretative anthropology of affliction," combining evidence from ethnography, history, epidemiology, and economics. He would use Cange as his example, renaming it Do Kay to protect it. Standing up above the town, he was reminded of all the failures and deaths he had experienced there, but he could also see the successes: communal water fountains, communal latrines, the public health project, the greenhouse, the artisans' workshops, and the Clinique Bon Sauveur. It had grown from 107 families to 178 households, and now nearly all the roofs were made up tin. It was no longer a miserable encampment of refugees , but just a typical extremely poor Haitian village.

Farmer received his Ph.D and his M. D. simultaneously in the spring of 1990. His thesis won a prize and was accepted for publication. He had been protected by numerous physicians at the medical school in his unorthodox attendance habits, and they hadn't hurt his educational standing. What's more, his experiences in Haiti as a virtual doctor made his acceptance by Brigham and Women's Hospital into their residency program less than surprising. He and Jim Kim both received a split clinical residency to spend half their time in Haiti and half in the United States.

By 1990, it seemed possible that Haiti would have a real national election. It wouldn't happen without a fight. Because the military had the country tightly controlled. Farmer himself was threatened by unknown voices over the phone. When there was an audible clicking sound with each call, he climbed the roof and discovered a crude bugging device and happily kicked it to pieces. He hadn't played a visible role in the politics of Haiti so he could only assume he was being targeted because he had been seen with Aristide. Once, Aristide had shown up at Zanmi Lasante with a truckload of flour for his orphanage. His truck wouldn't start, so they had loaded the flour into one of the clinic trucks which then broke down in a large puddle in the road. With the thought of the horror of the roads in Haiti on his mind, he said to Aristide, "In the newspapers, it says you're going to be a candidate for president. I guess they don't know you very well, because you would never run for president." Aristide was noncommittal, but a week later, he declared his candidacy. It angered Paul at first, but then he realized that Aristide was the man the people wanted and he thought, "Perhaps this is a singular chance to change Haiti."

Soon Farmer was ardently rooting for Aristide. On Election Day, many foreign observers oversaw the counting of the ballots, and Aristide won 67 percent of the vote, while 12 other candidates took 33 percent. Now, as Aristide said in one of his speeches in a revision of an old Haitian proverb, "The rocks in the water are going to find out how the rocks in the sun feel." To Farmer, it wasn't Aristide who was the real victor, but instead the people of Haiti who had braved massacre and death to vote and reclaim their country. He had never felt so moved.

In the summer of 1991, Farmer returned to Brigham full of hope for his adopted country. Rumors of coups abounded, but there were no longer military checkpoints on the roads and a revitalized Haitian Ministry of Health had begun collaborating with Zanmi Lasante on AIDS-prevention work in the central plateau. Also, the money was now available to build a real hospital in Cange.

On September 29, 1991, Farmer got Jim Kim to cover for him and decided to take a short trip back to Haiti for a meeting about the new hospital. A Haitian refugee in America drove the cab that took him to the airport and told him there was trouble again "down there." Farmer refused to believe it, but when he arrived at Miami, the sign above the check-in desk for Port-au-Prince said cancelled. He stayed in Miami to see if flights resumed and watched CNN stupefied to see that the Haitian army had deposed Aristide. Even when the flights resumed, he couldn't return, because the junta had placed his name on a persona non grata list. Finally, Father Lafontant bribed a Haitian army colonel to expunge his name from the list, and Farmer got a flight out. He made it through immigration without incident and drove to Cange through two military checkpoints.

Two days later, he was called away by a woman who said the local authorities had beaten her husband and he was dying. Farmer had seen a lot in Haiti, but this case impacted him more deeply than anything he had ever seen there. The man, whom Farmer called Chouchou Louis to protect his family, had made a disparaging remark about the road of the country. Unbeknownst to him, inside the truck he was riding was a soldier dressed in plain clothes. At the next checkpoint, he was taken inside an official building and beaten severely. They let him go, but his name was added to their blacklist. Eventually, he came out of hiding and sneaked back home. He was met by a local section chief and an attaché. They beat him again and what was left of him absolutely appalled Farmer. Paul recorded all his wounds and eventually wrote a report called "A Death in Haiti" for Amnesty International. After the man died, Farmer took a different way back to the clinic out of fear for his own life. Later, Paul told some of his students that he took pains not to remember Chouchou even though he described his death several times in print. He told Tracy Kidder that to him, "He died in the dirt."

Notes

This chapter is bittersweet, because it expresses the hope Farmer has that change will finally come to Haiti through the efforts of Jean-Bertrand Aristide. For awhile, Haiti is changed and the Health Ministry takes steps to help the poor, but the dream is crushed when the military deposes the man and the violence begins again. In this sense, Chouchou Louis is a metaphor for Haiti. In a moment of freedom, he speaks disparagingly about his country and is then beaten to death. In the same way, Haiti rises up to grab freedom momentarily and then is beaten back into submission.

CHAPTER 12

Summary

Ophelia visited Cange during the rule of the junta in the early 1990's. She had felt nervous there in the early years, but now she felt living there was worse. Paul also took many chances, acting rude to the soldiers at checkpoints and refusing to take down the iron sculpture in the clinic supporting Aristide. The soldiers began poking around at Zanmi Lasante, and Ophelia worried that they would come in and massacre them. Iron Pants (a generic name for a strong woman in Haiti) comforted Ophelia by telling her, "We'll defend this place with our lives." However, Ophelia wondered what they would use as weapons: pots and pans?

Farmer continued his frequent commute between Boston and Cange. One time, Farmer got $10,000 from Tom White and smuggled it in to the underground, pacifist movement. When Jim Kim cautioned him to be careful, Farmer actually screamed in frustration and anger. He fretted about everything, especially what he would do if the soldiers came in and arrested a patient. He even tried to defy soldiers who told him to say, "Long live the Haitian army," at one of the checkpoints. He eventually said it, but only when a rifle was pointed at him. A soldier actually came into the compound one day, and Farmer told him he couldn't bring a gun in there. The man demanded from Farmer, "Who are you to tell me what to do?" Farmer's answer saved him, "I'm the person who's going to take care of you when you get sick." The soldier knew that only at Zanmi Lasante could he get good medical care, too.

Farmer received a MacArthur grant in the summer of 1993. He was depressed by it, because it was meaningless in the face of the junta's control. The body count continued to grow there. Three of Farmer's closest friends were murdered, and Farmer retreated to Quebec City, one of his favorite places, and began the draft of a book he would call The Uses of Haiti. He wrote as if in collaboration with a Haitian peasant and revealed the history of American policy all the way back to the 1790's and up to the present day where the American position was openly against the junta while privately unwilling to drive it out of power. People considered heroes were not so heroic in his book, including Woodrow Wilson, FDR, the CIA, and even Mother Theresa, who openly embraced the so-called good works of Michele, the wife of Baby Doc Duvalier.

When it seemed like the Clinton administration might support the restoration of Aristide, Farmer wrote an editorial in the Miami Herald in which he said, "Should the US military intervene in Haiti? We already have. Now we should do so in a way to restore democracy." The editorial was mentioned in Haiti on government radio, and the soldiers came looking for Farmer. Fortunately, he was back in Boston, but now he was formally expelled from the country. At the same time, he heard that another friend had been murdered, and he became almost inconsolable.

That summer, 1994, he spent as much time as could lecturing people about Haiti in small towns in Maine, Texas, Kansas, and Iowa. He also went on radio talk shows and challenged anyone who said they couldn't allow the Haitians to come into our country. Finally, in mid-October, 1994, Aristide was reinstated, and Paul returned to Haiti the day after.

The three years of military rule had nearly decimated the country, especially its health system. All the programs they had set in place were suspended, once the clinic had been briefly shut down, patients were afraid to come there for help, the ones who did come were victims of assaults by soldiers, cases of typhus and measles were up, the number of patients with AIDS had increased by 60% and much of the staff had resigned or were afflicted with a lassitude. However, to Farmer, the situation was far from hopeless, and he was glad to be back.

Farmer was now 35 years old and on the rise in both medicine and anthropology. PIH now had permanent headquarters in a building in Cambridge. It was involved in many programs not only in Haiti, but also other areas of poverty around the world. However, Farmer felt that they were still just a small public charity and that they should reign themselves to a somewhat marginal status. Little did he know that a big change in PIH was about to begin. They were about to become players in international health.

Notes

This chapter describes how Farmer dealt with the military junta both before and after he was expelled from the country. He lost many friends, but ultimately never lost hope that he could return and help the people who meant so much to him.

PART III - MEDICOS AVENTUREROS