Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World is a biographical work by Tracy Kidder. The book follows the life of physician, and anthropolgist Paul Farmer, with a focus on his work fighting Turberculosis in Haiti, Peru, and Russia. The book also touches on the stories of some of his fellow workers in the organization he started (Partners in Health), including Ophelia Dahl, Jim Kim, and Tom White.
- The Connection Between Life, Religion, and Medicine - Farmer, with the benefit of having an anthropologist background, recognizes the intertwined factors affecting the diseases he treats. One interesting example of this is when Farmer designs a study to disprove the idea brought forth by health professionals that many TB treatments given to Haitians failed because the patients stopped taking the pills too early out of of the belief that TB came from sorcery rather than microbes. Farmer took two groups of Hatian patients with TB; both groups received free treatment, but one group also received a monthly stipend for food, child care, and transportation to his medical facility. Although almost the entirety of both groups told him they believed TB came from sorcery, there was a 100% full recovery rate among the group with the stipend, compared to only 48% in the other group. This study demonstrated to him and his colleagues the importance of providing a holistic approach to treatments. An interesting side note as to why the Haitian's continued to take the pills even though they believed that sorcery was the cause was explained to Farmer by an elderly Hatian women. The English translation of what she said was "Honey, are you incapable of complexity?"
- The Concept of a Long Defeat - In the biography Mountains Beyond Mountains, Paul Farmer, doctor and anthropologist, interestingly describes himself as “fighting the long defeat”. Read more about what I thought about it here.
- The Hypocrisy of Money and Cost Efficiency - In the book, Farmer reflects on the hypocrisy regarding cost efficiency in first world vs. third world countries. Read more about it.
Little sleep, no investment portfolio, no family around, no hot water. On an evening a few days after arriving in Cange, I wondered aloud what compensation he got for these various hardships. He told me, "If you’re making sacrifices unless you’re automatically following some rule, it stands to reason that you’re trying to lessen some psychic discomfort. So, for example, if I took steps to be a doctor for those who don’t have medical care, it could be regarded as a sacrifice, but it could also be regarded as a way to deal with ambivalence. "He went on, and his voice changed a little. He didn’t bristle, but his tone had an edge: "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. "
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Farmer smiles at her, making the Haitian hand slap, the back of one hand into the palm of the other. "It’s a cross we must carry, "he says. The nurse stalks out. He looks over at me. "You can’t sympathize with the staff too much, or you risk not sympathizing with the patients. "
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Farmer liked to tell his Harvard 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. "And the rewards are so great for just those simple things !"Of course, this meant that some patients waited most of a day to see him and that he rarely left his office before dark.
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He seems to be, and besides, he’s left-handed, and to my eyes left-handers at work have always looked adroit.
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Wild cries erupt from the child: "Li fe-m mal, mwen grangou !"Farmer looks up, and for a moment he’s narrating Haiti again. "She’s crying, ‘ It hurts, I’m hungry. ’ Can you believe it? Only in Haiti would a child cry out that she’s hungry during a spinal tap. "
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Just recently, a TB patient from a village called Morne Michel hadn’t shown up for his monthly doctor’s appointment. So — this was one of the rules — someone had to go and find him. The annals of international health contain many stories of adequately financed projects that failed because"noncompliant" patients didn’t take all their medicines. Farmer said, "The only noncompliant people are physicians. If the patient doesn’t get better, it’s your own fault. Fix it. "A favorite Doktè Paul story in the village of Kay Epin was of the time, many years back, when Farmer had chased a man into a field of cane, calling to him plaintively to come out and let him treat him. He still went after patients occasionally. To inspire the staff, he said, and to give him a break from his office. So he was going to Morne Michel himself and was taking me with him. "Beyond mountains there are mountains. "The proverb appeared to describe the location of Morne Michel, the most distant of all the settlements in Zanmi Lasante’s catchment area. At breakfast on the appointed day, Farmer told the women in the kitchen his intentions. "Ooooo !" they cried. One said, "Morne Michel? Polo, do you want to kill your blan? "
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He had problems with groups that on the surface would have seemed like allies, that often were allies in fact, with for example what he called"WL’s"— white liberals, some of whose most influential spokespeople were black and prosperous. "I love WL’s, love ’ em to death. They’re on our side, "he had told me some days ago, defining the term. "But WL’s think all the world’s problems can be fixed without any cost to themselves. We don’t believe that. There’s a lot to be said for sacrifice, remorse, even pity. It’s what separates us from roaches. "
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We started on again, Farmer saying over his shoulder, "And if it takes five-hour treks or giving patients milk or nail clippers or raisins, radios, watches, then do it. We can spend sixty-eight thousand dollars per TB patient in New York City, but if you start giving watches or radios to patients here, suddenly the international health community jumps on you for creating nonsustainable projects. If a patient says, I really need a Bible or nail clippers, well, for God’s sake !"
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So maybe I’d learned something. Not enough to suit Farmer, I suspected. Education wasn’t what he wanted to perform on the world, me included. He was after transformation.
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He had a knack for aphorism. "Medicine is a social science, and politics is nothing but medicine on a large scale. "It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation. "Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community. "The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them. "This last was Farmer’s favorite. Virchow put the world together in a way that made sense to Farmer. "Virchow had a comprehensive vision, "he said. "Pathology, social medicine, politics, anthropology. My model.
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"What is anthropology exactly? "He told her, in effect — I am using words he would put in print in an article about a year and a half later — that anthropology concerned itself less with measurement than with meaning. As in mastering a language, one had to learn not just the literal meanings of words but also their connotations, and to grasp those one had to know the politics and economic systems and histories of a place. Only then could you really understand an event like the mango lady’s death.
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Before she’d met Paul, Haiti had seemed merely vivid — terrible and strange. The worm a full foot long that she’d seen wriggling out of a baby’s anus in the hospital where she first worked. The numberless children with diarrheal diseases. The daily national anthem ceremony in front of the presidential palace, where by decree everyone had to stop and face the tinny music or suffer the wrath of the macoutes. Now she had someone to translate Haiti to her. In the process Paul laid out a comprehensive theory of poverty, of a world designed by the elites of all nations to serve their own ends, the pieces of the design enshrined in ideologies, which erased the histories of how things came to be as they were. And he knew the details for Haiti, a catastrophe covered with the fingerprints of the Western powers, most of all those of France and the United States.
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Before she left Haiti, late that spring, she told him she was going home to do premedical studies. She was going to become a doctor, too. "Good, "he said earnestly. He had finished his own premed work. "You know what you should do? Make flash cards. "
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I said, ‘ There’s got to be some way to get her some blood. ’ Her sister was beside herself. She was sobbing and crying. The woman had five kids. The sister said, ‘ This is terrible. You can’t even get a blood transfusion if you’re poor. ’ And she said, ‘ We’re all human beings. ’"
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The nurses were saying, "Poor Paul. What a sweet young man. "And he knew what the doctors were thinking: "He’s new here, he’s green, he’s naïve. "Remembering this years later, he was still framing his retort: "Yeah, but I got staying power. That’s the thing. I wasn’t naïve, in fact. "
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He’d been taught that an ethnographer should observe, not try to change what was being observed. But practiced in that way, anthropology seemed"impotent" in the face of"everyday problems of adequate nutrition, clean water, and illness prevention. "It’s clear by the end of the essay that anthropology now interested him less as a discipline unto itself than as a tool for what he called"intervention. "He had settled not for a synthesis between observing and acting, but for doctoring and public health work that would be partly guided by anthropology.
Note-Chapter 8 - Page 83
Anthropology should be action not just observation
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Its uses were obvious. A doctor who knew nothing about local beliefs might end up at war with Voodoo priests, but a doctor-anthropologist who understood those beliefs could find ways to make Voodoo houngans his allies. A doctor who didn’t understand local culture would probably mistake many patients ’ complaints for bizarre superstitions, or at best be utterly baffled — by the female complaint called move san, lèt gate, for instance. The condition was said to be brought on by sezisman, that is, by a surprise or by someone’s frightening action. Move san, "bad blood, "could follow, and produce in turn lèt gate, a condition in which a nursing mother’s milk was spoiled or stopped flowing. None of this would be mysterious to a young ethnographer-a doctor who, like Farmer, was willing to puzzle out the social meanings of the syndrome. Farmer would write, "The most striking thing about move san disorder is the lurid extremity of its symbolism: two of the body’s most vital constituents, blood and milk, are turned to poisons. The powerful metaphors serve, it may be inferred, as a warning against the abuse of women, especially pregnant or nursing ones. "
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Farmer entered Harvard Medical School in the fall of 1984. He was only twenty-four. Then again, he told me once, "I was fully formed at twenty-three. "He meant, I think, that by then he had his philosophy and worldview in order, and knew that he wanted to marry them to action, first of all in Cange.
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The combination of Harvard and Haiti had begun to form a new kind of belief in Farmer. He would tell me years later: "The fact that any sort of religious faith was so disdained at Harvard and so important to the poor — not just in Haiti but elsewhere, too — made me even more convinced that faith must be something good. "
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And if the landless peasants of Cange needed to believe that someone omniscient was keeping score, by now Farmer felt the need to believe something like that himself. In the peasant phrase, an unnecessary death was"a stupid death, "and he was seeing a lot of those. "Surely someone is witnessing this horror show? "he’d say to himself. "I know it sounds shallow, the opiate thing, needing to believe, palliating pain, but it didn’t feel shallow. It was more profound than other sentiments I’d known, and I was taken with the idea that in an ostensibly godless world that worshiped money and power or, more seductively, a sense of personal efficacy and advancement, like at Duke and Harvard, there was still a place to look for God, and that was in the suffering of the poor. You want to talk crucifixion? I’ll show you crucifixion, you bastards. "
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He would say, some years later, that he had"faith, "then add, "I also have faith in penicillin, rifampin, isoniazid, and the good absorption of the fluoroquinolones, in bench science, clinical trials, scientific progress, that HIV is the cause of every case of AIDS, that the rich oppress the poor, that wealth is flowing in the wrong direction, that this will cause more epidemics and kill millions. I have faith that those things are true, too.
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He had distilled the contents of his medical texts onto index cards. He had great piles of them, thousands of flash cards. On one side he’d have written, in an elegant, left-handed script, a question such as"What’s gout got to do with lysosomes? "and he’d have added the symbols for musical notes around the words, indicating that the question should be sung. The question side of a card might read, for example, "Show me, sir, the lesions in Horner’s syndrome, & oculomotor nerve paralysis. And what the divvil’s an Argyll Robertson pupil? "The answers on the back often included drawings — many of them lovely, Ophelia thought — in that case a drawing of the neural pathways of the eye
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Farmer was learning about the great importance of water to public health, and he was conceiving a great fondness for technology in general, also scorn for"the Luddite trap. "He liked to illustrate the meaning of that phrase with the story of the time when he came back to Cange from Harvard and found that Père Lafontant had overseen the construction of thirty fine-looking concrete latrines, scattered through the village. "But, "Farmer asked, "are they appropriate technology? "He’d picked up the term in a class at the Harvard School of Public Health. As a rule, it meant that one should use only the simplest technologies required to do a job.
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The first microscope in Cange was a real one, which he stole from Harvard Medical School. "Redistributive justice, "he’d later say. "We were just helping them not go to hell. "
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He would write, "The establishment of a school may seem a bit out of place given the homelessness, landlessness, and hunger of many of the water refugees. But it appears that they themselves did not feel that way. "Children flocked to the new facility. One peasant woman explained, "A lot of us wondered what would have happened if we had known how to write. If we had known how to write, perhaps we wouldn’t be in this situation now. "And a school could serve as a place for teaching lessons about health and for providing free meals to malnourished children without injuring their dignity. To build a school was to unite the practical and the moral. Farmer would say, "Clean water and health care and school and food and tin roofs and cement floors, all of these things should constitute a set of basics that people must have as birthrights. "
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When Farmer was back in Boston, doing his internship at the Brigham, White would drive over at lunchtime and buy sandwiches at the restaurant inside the hospital. He and Farmer would eat them in White’s car. One day White asked Farmer, who looked pale as usual, "You eatin ’ enough? "Oh, I’m fine, "said Farmer. "Need any money? "No, "said Farmer. "Well, maybe forty dollars? "White happened to have a wad of hundred-dollar bills in his pocket. He tossed one into Farmer’s lap. "You look hungry to me. "Saying this, he felt impelled to reach in his pocket again. He tossed another hundred to Farmer. "Please, for God’s sakes, eat, "he said, and to emphasize the point, he gave Farmer yet another hundred. Farmer looked down at the loot. "Now I can tell you what happened last night. "He’d gone to the home of an AIDS patient whom he had treated at the Brigham and found out the man was about to be evicted. "I signed my check over to him. "Jeez, Paul, don’t you think that’s kind of impractical? "Farmer smiled. "Well, "he said. "God sent you today. "White often found himself running errands in Boston for projects in Cange, picking up things like sinks and loading them into the trunk of his Mercedes. ( One load of sinks was for a new clinic. The first clinic turned out to have been badly designed. White paid to have it rebuilt. He did this quietly, not asking for credit. "Not even a plaque with his name on it, "said Farmer. ) One time when they were together in Boston, White said, "You know, Paul, sometimes I’d like to chuck it all and work as a missionary with you in Haiti. "Farmer thought for a while, then said, "In your particular case, that would be a sin. "
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They were months of nearly constant work. By early afternoon Paul would still be seeing patients, and famished herself, she’d go to his office in the clinic. "You’re not hungry? All you had was coffee at six this morning. "He’d agree to come up the hill to the kitchen with her, but usually reluctantly, she felt.
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In previous years, before Baby Doc’s forced departure, the peasants had rarely dared to talk politics. Now, as a saying went, baboukèt la tonbe — the muzzle had fallen off. Farmer would later write, "Not only were the villagers talking about subjects previously forbidden, they were talking about old subjects in new ways. "They were no longer merely asking if infant diarrhea was caused by germs but asking whether the germs were caused by dirty water. And didn’t dirty water come from the neglect of feckless, greedy governments?
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They talked about issues such as political correctness, which Jim Kim defined as follows: "It’s a very well-crafted tool to distract us. A very self-centered activity. Clean up your own vocabulary so you can show everybody you have the social capital of having been in circles where these things are talked about on a regular basis. "( What was an example of political correctness? Some academic types would say to Jim and Paul, "Why do you call your patients poor people? They don’t call themselves poor people. "Jim would reply: "Okay, how about soon-dead people? ")
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They talked about the insignificance of"cultural barriers"when it came to the Haitian peasant’s acceptance of modern Western medicine: "There’s nothing like a cure for a disease to change people’s cultural values. "
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They talked about appearance: "The goofiness of radicals thinking they have to dress in Guatemalan peasant clothes. The poor don’t want you to look like them. They want you to dress in a suit and go get them food and water. Comma. "
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In ten days in a hotel room, he wrote 220 pages, most of the draft of a book he would eventually call The Uses of Haiti. It is, I think, the best of Farmer’s books, certainly the most passionate, essentially a history of American policy toward Haiti. The history, that is, as if written in collaboration with a Haitian peasant. The perspective is interesting. One learns, for instance, that the United States tried to help the French put down the Haitian revolution in the 1790s and, during the time of American slavery, refused to recognize Haiti and practiced gunboat diplomacy there. Also that, during the American occupation, the U.S. Congress had reconstituted the modern Haitian army and helped to finance it right up until the time when it deposed Aristide; that the head of the junta’s death squads, whose minions had murdered Chouchou, had been trained at Fort Benning’s School of the Americas; that some of the junta’s henchmen and officers in the Haitian army also worked for the CIA; that while formally deploring the coup, Washington, with the help of a generally compliant mainstream American press, was busily denouncing Aristide, even manufacturing lies about him, and maintaining a leaky embargo that seemed calculated to preserve appearances but not to drive the junta out of power. In the book, a number of heroes don’t look so fine. The French revolutionaries, whose idea of fraternité didn’t include the slaves in St. Domingue, and the Haitian "mulattoes" who went to France to aid those revolutionaries in the hope that they could win the right to own slaves themselves. Woodrow Wilson, who presided over the American invasion of Haiti. Even FDR, who once boasted that, while serving as assistant secretary of the navy, he had written the Haitian Constitution of 1918. ( There were others on this list whom Farmer often mentioned elsewhere: the former American slave and great abolitionist Frederick Douglass, who eagerly served as American ambassador to Haiti, in effect representing the Monroe Doctrine there. And Mother Teresa, who came to Haiti in 1981, during the time of Baby Doc, and, as one historian put it, "gushed" over the profligate dictator and his widely hated wife, Michele, who had looted millions from the Haitian treasury for her worldwide shopping sprees. Mother Teresa said Michele had taught her a lesson in humility and marveled at the closeness of the first lady to her people. )
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During a show in Fort Lauderdale, a caller said, referring to the boatloads of refugees who were fleeing the poverty and violence in Haiti and trying to get to Florida, "We can’t have Haitians coming into our country. "Why not? "Farmer said. "My family are boat people. "The host, understandably, didn’t get it. "Dr. Farmer, are you Haitian? "Several times, and especially after the general yelled at him, he thought, "Screw this. I want to go back to my clinic. "He returned the day after Aristide was reinstated as president, in mid-October 1994.
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A simple epidemiological map, a map based on what makes people sick and what kills them, and in what numbers and at what ages, could be coded in two colors. One would stand for populations who tend to die in their seventies, mainly from illnesses that seem like inevitable accompaniments to the aging of bodies. The other color would stand for groups who, on the average, die ten and even forty years earlier, often from violence and hunger and infectious diseases that medical science knows how to prevent and to treat, if not always to cure. On this map, the line dividing the two color-coded parts of humanity — what Farmer called the"great epi divide"(epi being short for epidemiological) — would partition many countries, many cities. Most of Haiti would wear the color of ill health, but parts of the hills above Port-au-Prince would be a patch of well-being. The map of the United States, by contrast, would depict a healthy nation speckled with disease. In Boston’s Mission Hill neighborhood, right next to the Brig-ham, for instance, infant mortality is higher than in Cuba. In New York City’s Harlem, a famous study from 1990 showed, death rates for males between the ages of five and sixty-five were higher than in Bangladesh.
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Farmer liked to say that tuberculosis made its own preferential option for the poor. The aphorism contained a certain literal truth. According to the best current estimates, about two billion people, one-third of humanity, have TB bacilli in their bodies, but the disease tends to remain latent. It multiplies into bone-eating, lung-consuming illness in only about 10 percent of the infected. The likelihood of getting sick increases greatly, though, for those who suffer from malnutrition or various diseases, especially from HIV, itself by now predominantly a disease associated with poverty. Usually, active TB feeds on the lungs and spreads itself from them, sneezes and coughs like the wind to its seeds. People who live in crowded peasant huts and urban slums and shantytowns and prisons and homeless shelters stand the best chances of inhaling the bacilli, of having their infections expand into active disease, and in some settings, of getting just enough treatment to make their TB drug-resistant
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There were many frustrations, small and large, many occasions when Jim felt insulted. Paul would tell him: "Remember, serving the poor in Carabayllo is more important than soothing your own ego. It’s called eating shit for the poor. "This sort of advice was always tonic for Jim. He’d feel as though catastrophe loomed, he’d call Paul and tell him about the problem, and Paul would say sympathetically, "Yeah, I remember something like that happened three times in Cange. "
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At the Brigham, a friend of theirs named Howard Hiatt was asking himself much the same question. Hiatt was in his seventies and a personage in medicine — a former dean of the Harvard School of Public Health and former chief of medicine at Beth Israel Hospital, now a professor at Harvard Medical School. He was charged, among other duties, with lending advice and assistance to young doctors pursuing unconventional careers. Paul and Jim were among his favorites, and they were making him nervous. Where, he wondered, were they getting their second-line drugs? How in the world were they paying for them? Then one day the president of the Brigham stopped Hiatt in a corridor. "Your friends Farmer and Kim are in trouble with me. They owe this hospital ninety-two thousand dollars. "Hiatt looked into the matter. "Sure enough. Paul and Jim would stop at the Brigham pharmacy before they left for Peru and fill their briefcases with drugs. They had sweet-talked various people into letting them walk away with the drugs. "He was amused, all in all. "That’s their Robin Hood attitude. "
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"Better to ask forgiveness than permission. "That had been Father Jack’s favorite saying. It was Farmer’s rule of thumb. When he and Jim had first resolved to take on Carabayllo’s epidemic, he had gone to Tom White and said, "Just buy the drugs for ten patients. We promise there won’t be more. "Even then Farmer had known this was what he called"a fib. "He had come back many times since to ask White for more money. White shared in the general nervousness. He wanted to leave this life without a nickel, he often said. As the number of patients grew, he began to wonder if Paul and Jim would upset his calculations. "For a while there, I thought they’d spend all my money before I died. "But he never turned them down.
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He didn’t put much work aside for Peru, not his duties in Haiti or his service at the Brigham or his teaching at Harvard or his growing number of speaking engagements. He just added Peru to his itinerary. Often he’d make two-day trips. He’d leave Cange before dawn and drive to Port-au-Prince. Sometimes he’d get stuck in traffic and, turning the truck over to a Haitian assistant, climb out and jog the last half mile to the airport. He’d catch the early flight to Miami, then fly on to Lima, arriving in Carabayllo late the same night. Starting early the next morning, he’d stride up and down the dusty hills with the Harvard student doctors or with one of the Socios nurses, visiting patients in their shacks. Later, when the local TB authorities had warmed up a bit to Socios, the patients were brought to the Jack Roussin Center, and he saw them there in a small room with a table and a concrete floor. That way he could see a larger number. He’d work until it was time to leave for the airport. He’d take the night flight to Miami, catch the early morning plane to Port-au-Prince, and arrive back in Cange by afternoon. He spent about twenty-two of the forty-eight hours just traveling, longer if flights got delayed or canceled, or Zanmi Lasante’s truck broke down, or an accident blocked the stretch of Highway 3 up Morne Kabrit, or rain had made the streams that crossed that road impassable. Farmer hadn’t been feeling well when he gave his speech in Chicago, in February 1997. He felt worse when he got to Boston to spend a month of service at the Brigham. "I must be exhausted, "he remembered thinking. "Everyone told me something like this would happen. "He prided himself on being a fast diagnostician, but he took his time on his own case. He kept on working, and his symptoms got worse. He reviewed them: nausea, vomiting, fatigue, night sweats. "Oh, my God, "he thought. "I’ve got MDR.
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He woke up there in the middle of the night bathed in sweat, thinking, "If I do have MDR, I’ve exposed all my patients to it. "He went to a radiologist friend, swore him to secrecy, and had his chest X-rayed. He studied the film. It was normal. He called Didi in Paris at least once a day. She told him over the phone, "You must go to a doctor. "Look, I am a doctor. Let me finish the month at the Brigham and go to Haiti. Then I’ll rest. "
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"Jim, I’m coming up to your unit. I need fluids. "Then Farmer lay down in his suit in one of the rooms on Jim’s floor, feeling rather cheerful. After the IV nurse rehydrated him, he got off the bed and joined the infectious disease specialist he was training, a young woman. "Marla, "he told her, "I feel worse. Let’s do rounds early. "Marla was usually impatient with him. She’d interrupt his constant in-hospital socializing, saying, "Farmer, shut up. Let’s get working. "Now she said, "You’re psycho. Let someone take over for you. "Marla, I finish today. "She went away scowling. He went into a patient’s room, and was in the midst of diagnosing a case of acute prostatitis — it was obvious — when Marla returned. Her face looked blanched, he thought. "Paul, your liver functions are so high the machine couldn’t do them. They had to dilute it. "All right. I give up. "He went back to the room in Jim’s unit, got into a johnny, and surrendered himself to illness.
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Speaking of his bout of hepatitis, Farmer told me, "If I get sick, it’ll be nearly fatal. "He was drawing a contrast between himself and the world’s poor. A generous thought, but his habit of disregarding his health hardly seemed like a way of expressing"pragmatic solidarity. "Given the responsibilities for other lives he’d taken on, it seemed to me he’d done the opposite
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He was walking fast. Then, all of a sudden, he stopped. A family of three stood in the hallway up ahead. A little boy and his mother and father. The mother was slender and wore a skirt and a T-shirt with a picture of Mickey Mouse on the front. She hung back, half-hidden around a corner, while the father came forward. Farmer and the father opened their arms simultaneously and bear-hugged each other. ("In my culture we don’t shake hands, "Farmer was always telling me, trying to reform me in this way, too, I’d begun to feel. ) Hurriedly, he asked for news of the child. The little boy was chubby, obviously healthy. He stood close to his father. When Farmer crouched down and held out his arms, the child came forward on his own stubby legs, in a rolling, waddling gait, giggling as he advanced headlong toward Farmer, then turning around and waddling back toward his father. A happy-looking dance. "Christian ! Look at you !" cried Farmer. His face had turned bright red. He wore the wild-looking grin with which he greeted old friends. He turned to me. "This was a terrible case, "he said in a low voice, in English.
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All his life, it seemed, Jim had been jumping at the next new thing, the bigger and better thing. Perhaps this was the residue of growing up in Muscatine with a cosmopolitan mother. "You’re not Korean, you’re careen, "Ophelia told him once. Jim himself said, "I tend to feel a problem’s solved once I’ve thought it through. "Then again, he was fond of overstatement, even when talking about himself. After all, he’d stuck with PIH for a decade by now, and done a lot of its most menial chores along the way. What Jim had, above all, was enthusiasm. He’d weigh facts against possibilities as if the two were equivalent. A lot of students had joined PIH after hearing him talk. Change the world? Of course, they could. He really believed this, and he really believed that"a small group of committed individuals"could do it. He liked to say of PIH, "People think we’re unrealistic. They don’t know we’re crazy. "
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Even Jim’s strongest ally there got frightened when various eminent TB experts wrote to Geneva saying they couldn’t countenance the elevation of second-line antibiotics to the essential drugs list. Some wrote that the plan wouldn’t work. Others believed that if it did and prices fell, the drugs would become too widely available. This worry had substance. In the real world, many places lacked even rudimentary health services, and others had clinics and hospitals staffed by the ignorant, the careless, the lazy. In the real world, some doctors and nurses peddled drugs on black markets, desperate patients sold their antibiotics to buy food, and stupid pharmacists mixed first-line TB drugs with cough medicine. Start distributing the second-line, the so-called reserve, antibiotics in settings like those and you’d breed resistant strains that no drugs could cure.
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They had similar diets, too. Dr. Farmer doused everything he ate with salt. Dr. Kim liked to say, "There are only two kinds of plants, stir-fryable and non. "Not having had a chance to talk face-to-face in a while, they celebrated the occasion by ordering pizza.
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A lot of Farmer had rubbed off on Jim. Over the years their philosophical views had become virtually indistinguishable, especially on that set of notions which, it seemed to them, international health had adopted as scripture. Jim told me once, "There have been fundamental frame shifts in what human beings feel is morally defensible, what not. The world doesn’t bind women’s feet anymore, no one believes in slavery. Paul and I are anthropologists. We know that things change all the time. Culture changes all the time. Advertising people force changes in culture all the time. Why can’t we do that? People in international health sit back and say, ‘ Will things change for the better? Who knows? But these Paul Farmers, they’ll drop out, and when they do, we stalwarts will still be here figuring out the best way to spend two dollars and twenty-seven cents per capita for health care. ’"
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"Resources are always limited. "In international health, this saying had great force. It lay behind most cost-effectiveness analyses. It often meant, "Be realistic. "But it was usually uttered, Kim and Farmer felt, without any recognition of how, in a given place, resources had come to be limited, as if God had imposed poverty on places like Haiti. Strictly speaking, all resources everywhere were limited, Farmer would say in speeches. Then he’d add, "But they’re less limited now than ever before in human history. "That is, medicine now had the tools for stopping many plagues, and no one could say there wasn’t enough money in the world to pay for them.
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Jim had an alternate vision, of course. In it, PIH would become an instrument for expanding the resources to treat TB, and in the process save itself. They had halted the spread of MDR in the shantytowns of northern Lima. Now they’d propose a project to wipe it out all over Peru. Then they’d go international. They’d show the world that it was possible to beat back that dread disease, and they’d show the world how to do it. And if MDR, then why not AIDS?
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For over a year, Jim had been courting what he called"big-shot donors. "None was bigger than the Gates Foundation. It had an endowment of roughly $ 22 billion, and it planned to spend about half the income, about $ 550 million a year, on projects to improve global health. Howard Hiatt had introduced Jim and Paul to the foundation’s senior science adviser, a man named Bill Foege, one of the people responsible for the eradication of smallpox, known to favor unconventional approaches to supposedly impossible problems. Foege had encouraged them. So Jim started putting a grant proposal together. He met up with Paul again, this time in Moscow. They sat on the edges of their beds in a room at the Holiday Inn and talked about how much money to ask for. They argued a little. Paul thought two million dollars, maybe four. "No, "Jim said. "We’re going to ask for forty-five million. "They’d never get that much, said Paul. Borrowing one of Paul’s favorite gambits in debate, Jim said, "On what data exactly do you base that statement? "
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It wasn’t as though Farmer didn’t want to do all he could to cure the world of poverty and disease. He just had his own ideas on how to go about it. Actually, he seemed to be the only person who understood the plan fully. A young assistant of his once said to him, in exasperation, that he had no priorities. That wasn’t true, he replied. Patients came first, prisoners second, and students third. But you could see how the assistant might have felt lost in the details.
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And when he was traveling, Creole e-mails flooded his account. I went with him once from Cange to the U.S. on a fund-raising trip of a day and a half. When we got back to Miami, en route to Haiti, and he checked his e-mail, this message was waiting for him, from one of the staff at Zanmi Lasante: Dear Polo, we are so glad we will see you in a mere matter of hours. We miss you. We miss you as the dry, cracked earth misses the rain. "After thirty-six hours? "Farmer said to his computer screen. "Haitians, man. They’re totally over the top. My kind of people. "
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These days his life had one central logistical problem. Ophelia defined it succinctly: "Wherever he is, he’s missing from somewhere. "Farmer’s solution for now was sleeping less and flying more. Early in 2000 I tagged along with him on what he called"a light month for travel. "
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"Who’s paying your way? "I asked. The church group, the Cuban government, and the Soros Foundation, he answered. He smiled. "Capitalists, commies, and Jesus Christers are paying.
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When he was younger, Farmer used to come and go from Cange in jeans and a T-shirt, until he realized this upset his Haitian friends, who always dressed up to travel. Then Père Lafontant told him that if he was going off to represent them to the world, he should wear a suit. Farmer owned two but had loaned one to a friend. He preferred the black one anyway, because it allowed him, for example, to wipe the fuzz off the tip of his pen onto his pants leg while writing up orders at the Brigham, catch a night flight, say to Moscow or Lima, and still look presentable when he arrived.
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I was looking around in my mind for a consoling way to view the roadside sights and also, frankly, for something likely to impress Farmer. A fragment from my religious education bubbled up. I said, "If you’ve done it unto the least of them, you’ve done it unto me. "Matthew twenty-five, "said Farmer. "Inasmuch as you have done it unto the least of these my brethren, you have done it unto me. "He went on, paraphrasing, "When I was hungry, you fed me. When I was thirsty, you gave me something to drink. When I was a stranger, you took me in. When I was naked, you gave me clothes. When I was sick, when I was in prison, you visited me. Then it says, Inasmuch as you did it not, you’re screwed. "He smiled, swerving around another giant rut in the road.
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We went outside. The truck wouldn’t start. The passengers from Cange and I climbed out and pushed. The engine caught. We climbed back in. "So much for the white knight making his departure, "said Farmer. "When I was sick, when I was in prison, when I needed clothes, you gave me, et cetera. We got those covered. "He went on, "One thing that comes back to me, with all this cost-efficacy crap, if I saved one patient in my whole life, that wouldn’t be too bad. What did you do with your life? I saved Michela, got a guy out of jail. So I’m lucky. "He added, "To have a chance to save a zillion of them, I dig that.
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When we landed in Miami, Farmer surveyed the cabin. He figured about 20 percent of our fellow passengers had never flown before. He could point them out — the very thin ones, the ones with callused hands and faces, the men who looked self-consciously dressed up, as if for the first time, the women in dresses that were covered with ruffles. "We’re about to see something horrible. "What? "The escalators. "He stood near the top of the first. A while ago he had gone to the airport administration to ask them to do something about the problem, but evidently they hadn’t listened. Every fourth or fifth Haitian would come to a stop at the head of the escalator and look down at the moving stairs. They’d pause as if at the edge of deep water, and then start to run, trying to match the speed of their legs with the apparent speed of the stairs. "Don’t run. Hold on to the rail, "Farmer called in Creole to an elderly-looking woman about to tip over. She regained her balance. He turned to me, his face grim again. "The more ruffles, the more stumbles. "
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Ophelia thought that Paul had a fairly complex personality, built of oppositions — a need for frenzied activity that verged, she thought, on desperation, and a towering self-confidence oddly combined with a hunger for affirmation. He was always asking, "How am I doin ’? "and if she didn’t praise him, he’d be hurt. She thought she understood; he took on more than he could fix, so of course he wanted reassurance. And yet he also seemed"terribly simple. "She thought he had never experienced true depression, a freedom so enviable she almost resented it. "I’ve never known despair and I don’t think I ever will, "he wrote me once. It was as if in seeking out suffering in some of the world’s most desperate locales, he made himself immune to the self-consuming varieties of psychic pain. He’d told me back in Haiti, "I may be a more sunny, cheerful person than you. No one believes that I’m cheerful because of what I say and write, but I only say and write those things because they’re true. "He was often sad, of course, but it didn’t take much to cheer him up.
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That night in the hotel, Farmer got up to go to the bathroom and, not wanting to wake me, left the lights off. He smashed his toe into a suitcase in the dark. When we got up at 4: 00 A.M., the toe had turned purple. He diagnosed a fracture but limped along through the terminal without complaint, his computer bag over a shoulder, his latest wallet — a plastic shopping bag — in one hand and in the other his suitcase. It contained just a smattering of clothes — only three shirts for two weeks — but was jammed full with slides for lectures and with presents for his Cuban hosts. "Do you think I like wearing the same shirt five days in a row? "he once asked me. I thought that at times he probably did. At times he’d seem to say that if the world weren’t in such terrible shape and its leaders would only do their jobs, he wouldn’t have to suffer such discomforts. But complaint didn’t seem to be his usual mode. He said the choice between, for instance, carrying extra shirts and carrying medicines was easy. "The trick is, "he said, "to keep your body clean and change your underwear. "I would learn that he had many such tricks. "Traveler’s tip number one thousand seventy-three. If you don’t have time to eat, and there’s no other food on the plane, a package of peanuts and Bloody Mary mix are six hundred calories. "
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One time he got in an argument about Cuba with some friends of his, fellow Harvard professors, who said that the Scandinavian countries offered the best examples of how to provide both excellent public health and political freedom. Farmer said they were talking about managing wealth. He was talking about managing poverty. Haiti was a bad example of how to do that. Cuba was a good one.
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When we got to our hotel, Farmer said, "I can sleep here. Everyone here has a doctor. "He lay down on his bed and within a few minutes he was asleep.
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He told them he dreamed of a new kind of"triangle, "doctors from Cuba and money from France coming together in Haiti. He was of course playing on the term triangular trade, the trade that had created the French slave colony that had turned into Haiti.
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The ambassador told Farmer, "Yes, we too are going to help with the Haitians. "Polite and worthless promises maybe, but Farmer in the role of supplicant seemed artfully ingenuous. Assume that each new promise was real and obtain as many as possible, to increase the odds that one or two might be real. And he’d follow up with calls, letters, e-mails, and if those didn’t bring results, they still might produce a little shame, which might increase the chances that the next promise would be real.
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Farmer asked the audience to remember the days when expert opinion had retailed all sorts of nonsense about who caught HIV and why, the days when to be Haitian was to be part of a"risk group. "He and his staff had designed a study in Cange, he said, to try to get at the local facts. Two hundred women were involved, half infected with HIV, half not. Almost none in either group had been exposed to risks often mentioned in expert commentary — intramuscular injections, blood transfusions, intravenous drug use. Around Cange, Farmer noted, the peasants ’ vocabulary didn’t even contain a word for illicit drugs, which virtually no one there could afford anyway. And none of the women had been especially promiscuous; on average, they’d had sexual relations with two different men, consecutively not concurrently, practicing"serial monogamy. "Between the groups of women, only two differences stood out. Unlike the uninfected, many of the ones with AIDS had worked as servants in Port-au-Prince. Obviously, domestic service hadn’t given them HIV, but it did describe their economic desperation — working for Haiti’s elite was rarely pleasant or remunerative. Uniformly, the infected women named that kind of desperation, deep poverty and illiteracy, as their reason for having taken what appeared to be the real risk for AIDS, which was cohabiting with truck drivers or soldiers. "Why those two groups of men? "Farmer asked from the podium. Were they known to be sexier than other Haitian men? Of course not. What they had were steady jobs, in an economy where an official unemployment rate of 70 percent probably understated the case. Truck drivers were mobile and could keep women in many ports. And soldiers, back in those days of military rule, had wielded a special coercive power over every peasant. Up at the podium, Farmer went on with the story: After the study was done, he returned to the United States and logged on to MEDLINE. He entered"AIDS, "and the names of thousands of studies came up on his computer screen. Then he entered"AIDS and women, "and only a handful of studies appeared. "And when I crossed ‘ AIDS, women, and poverty, ’ the message said, ‘ There are no studies meeting those specifications. ’"
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From time to time he worked on his new book, Pathologies of Power. He had a bound typescript of the rough draft. It contained a chapter comparing the two ways in which AIDS had been managed on the island of Cuba — the Cuban approach and the American quarantine of HIV-positive Haitian refugees, conducted in the early nineties on the Guantánamo naval base. In the room Farmer read aloud from a book by a respected American political scientist who had also compared the two quarantines, calling them roughly equivalent. "It makes my blood boil, "said Farmer. He didn’t approve of quarantine for AIDS. "Quarantine has never been shown to be an effective measure in controlling sexually transmitted diseases, "he said. He went on, "Both Guantánamo and Cuba’s AIDS sanitorium were quarantines. But it’s a lie to say they weren’t different. "
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He had traveled more than anyone I knew, and seen fewer of the brochure sights. He’d never been to Machu Picchu in Peru. He’d never gone to the Bolshoi in Moscow. He didn’t go sightseeing in Cuba either. On this trip, most of what he saw of old Havana he glimpsed through the windows of Dr. Pérez’s Lada.
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Then, all of a sudden, he said to me, "If you’re going to write about Che, it should be your own opinion. Not mine. "Why is that? "I asked. "You now know more about his exhumation than ninety-nine percent of Americans. And also how the Cubans feel about him. The man who dug him up was practically in tears. "He was giving me the stare. "I may be sentimental, "he went on, "but I’m not a goofball. I’m a hard-bitten, clinic-building, MDR-treating mother. "Then, it seemed, he got to the heart of the matter: what I was going to write about Cuba, especially about him in Cuba. "When others write about people who live on the edge, who challenge their comfortable lives — and it has happened to me — they usually do it in a way that allows a reader a way out. You could render generosity into pathology, commitment into obsession. That’s all in the repertory of someone who wants to put the reader at ease rather than conveying the truth in a compelling manner. I want people to feel unhappy about Lazarus and all the others who are shafted. Otherwise why would I have you with me? I don’t have a lot at stake in how you depict me. I’ve been yelled at by generals and denounced by people who don’t have any data when I have a shitload. It does no harm to me, but plenty to my patients. If the very warm reception of me in Cuba is portrayed as because I’m thought to be a sycophantic ally of Cuba, then the Cuban doctors ’ concern for the poor of Haiti would be lost. "
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He said patients came first, prisoners second, and students third, but this didn’t leave out much of humanity. Every sick person seemed to be a potential patient of Farmer’s and every healthy person a potential student. In his mind, he was fighting all poverty all the time, an endeavor full of difficulties and inevitable failures. For him, the reward was inward clarity, and the price perpetual anger or, at best, discomfort with the world, not always on the surface but always there. Sensing this, I’d begun to be relieved of the shallower discomforts I sometimes felt in his company, that I’d felt keenly back in the airport in Cuba. Farmer wasn’t put on earth to make anyone feel comfortable, except for those lucky enough to be his patients, and for the moment I had become one of those.
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He remembered, "The mother was seizing. I said, ‘ Hurry ! ’ Everything was going okay. Then the baby was born, and it was dead. A full-term, beautiful baby, and I started to weep. I had to excuse myself and go outside. I wondered, What’s going on? Then I realized I was crying because of Catherine. "He had imagined her in the place of the stillborn child. "So you love your own child more than these kids, "he said to himself. He went on: "I thought I was the king of empathy for these poor kids, but if I was the king of empathy, why this big shift because of my daughter? It was a failure of empathy, the inability to love other children as much as yours. The thing is, everybody understands that, encourages that, praises you for it. But the hard thing is the other. "I thought about this for a while, attempting to frame my question delicately. Finally, I just tried to disassociate myself from it: "Some people would say, Where do you get off thinking you’re different from everyone and can love the children of others as much as your own. What would you say to that? "Look, "he replied. "All the great religious traditions of the world say, Love thy neighbor as thyself. My answer is, I’m sorry, I can’t, but I’m gonna keep on trying, comma. "
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Before he went to bed, he phoned his mother in Florida, to ask her to give him a wake-up call at 7: 00 A.M. here in Paris. Didi shook her head. "We have an alarm clock, "she said to me, but she was smiling. I counted time zones. His mother would have to be up at 1: 00 A.M. to make the call. I wondered if she minded, but she told me some months later, "I just think it’s so cool that at forty he still does that. I’d miss it if he didn’t. "
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"I have been working in Haiti for almost twenty years, ever since I was a young chap, and some years ago I was asked by the state of Massachusetts to be a TB commissioner, and I said, ‘ What the hell do we do? ’ I was in Haiti and I had a couple of MDR-TB patients and I took sputums and I brought them to Boston. And I took them into the lab and I wrote, ‘ Paul Farmer, State TB Commissioner. ’ I wanted them to process my samples from Haiti and they did and never asked any questions, so I did it more and more and then I did it with sputums from Peru, and of course, eventually they asked me why. I said, ‘ Massachusetts is a great state, it has a big TB lab, lots of TB doctors, lots of TB nurses, lots of TB lab specialists. It lacks only one thing. Tuberculosis. ’"The chief of the Russian doctors — a colonel — laughed. A woman doctor said gravely, "We have lots of TB and no labs. "
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The goal was to improve the lives of others, not oneself. "It’s not about the quest for personal efficacy, "as Paul himself liked to say. Besides, frank imitations would fail. What PIH-ers should take from Paul wasn’t a manual for their own lives but the proofs he’d created that seemingly intractable problems could be solved. "Paul has created technical solutions to help the rest of us get to decency, a road map to decency that we can all follow without trying to imitate him, "Jim told me, explaining the message on the wall. "Paul is a model of what should be done. He’s not a model for how it has to be done. Let’s celebrate him. Let’s make sure people are inspired by him. But we can’t say anybody should or could be just like him. "
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It is so easy, at least for me, to mistake a person’s material resources for his interior ones.
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"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. "
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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. "
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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 thinking ’? "
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I am aware of other voices that would praise a trip like this for its good intentions, and yet describe it as an example of what is wrong with Farmer’s approach. Here’s an influential anthropologist, medical diplomat, public health administrator, epidemiologist, who has helped to bring new resolve and hope to some of the world’s most dreadful problems, and he’s just spent seven hours making house calls. How many desperate families live in Haiti? He’s made this trip to visit two. I think of the wealthy friend of Howard Hiatt’s who balked at contributing to PIH because, while he knew about Farmer’s work in Haiti and considered it impressive, he doubted anyone could reproduce it. I’ve heard variations on that theme. Farmer and Kim do things that no one else can do. Zanmi Lasante won’t survive Farmer. Partners In Health is an organization that relies too much on a genius. All the serious, sympathetic critiques come down to these two arguments: Hiking into the hills to see just one patient or two is a dumb way for Farmer to spend his time, and even if it weren’t, not many other people will follow his example, not enough to make much difference in the world. But standard notions of efficiency, notions about cost-effectiveness, about big people performing big jobs, haven’t worked so well themselves. Long ago in North Carolina, Farmer watched the nuns doing menial chores on behalf of migrant laborers, and in the years since he’s come to think that a willingness to do what he calls"unglamorous scut work" is the secret to successful projects in places like Cange and Carabayllo. "And, "he says, "another secret: a reluctance to do scut work is why a lot of my peers don’t stick with this kind of work. "In public health projects in difficult locales, theory often outruns practice. Individual patients get forgotten, and what seems like a small problem gets ignored, until it grows large, like MDR. "If you focus on individual patients, "Jim Kim says, "you can’t get sloppy. "
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From somewhere in the valley below us comes the sound of drums. I recall the time I spent here in the central plateau with the American soldiers, and I remember the sound of Voodoo drums wafting into the army barracks in Mirebalais at night and how unsettling it was to some of us sitting there, in all its mystery. I’m sure we’d have felt different if we’d known we were probably hearing ceremonies to cure the sick. For myself, right now, I like the sound, like so many hearts beating through a single stethoscope.