MOUNTAINS BEYOND MOUNTAINS
DR. PAUL FARMER WITH ALCANTE JOSEPH,
AGE FIFTEEN, IN CANGE, HAITI,
OCTOBER 2001
THE QUEST OF DR. PAUL FARMER, A MAN WHO WOULD CURE THE WORLD
First published in Great Britain in 2013 by
PROFILE BOOKS LTD
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London EC1R 0JH
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First published in the United States of America in 2013 by
Delacorte Press, an imprint of Random House Children’s Books, New York
This work is based on Mountains Beyond Mountains: The Quest for Dr. Paul Farmer, a Man Who Would Cure the World © 2003 by John Tracy Kidder, published by Random House, an imprint of Random House Publishing Group
Copyright © by John Tracy Kidder, 2013
Frontispiece photograph courtesy of Moupali Das-Douglas, M.D.
Book design by Angela Carlino
The moral right of the author has been asserted.
All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the prior written permission of both the copyright owner and the publisher of this book.
ISBN 978 1 84765 885 2
FOR HENRY AND TIM KIDDER
INTRODUCTION
PART I: DOKTÈ PAUL
PART II: THE TIN ROOFS OF CANGE
PART III: MÉDICOS AVENTUREROS
PART IV: A LIGHT MONTH FOR TRAVEL
PART V: O FOR THE P
POSTSCRIPT: HAITI NOW
MOUNTAINS BEYOND MOUNTAINS
MOUNTAINS BEYOND MOUNTAINS is a book about a remarkable man, Dr. Paul Farmer. I met him in Haiti, that desperately poor country just a two-hour plane ride from the American mainland. He was spending a large part of his time there, among some of the poorest of the poor, treating their illness and, more important, creating a public health and medical system for them. He seemed to be performing all this difficult work for no personal reward except the satisfaction of doing it. Dr. Farmer could have worked in any number of hospitals in the United States, conducting important research, curing patients, and living a comfortable and respected life. What made him do otherwise? I wrote this book because I was curious about him and I thought his life would make for a good story. I didn’t write my book to make people believe in his cause. But well before the end of my research, I did believe.
I had been writing books and magazine articles for a number of years when I met Dr. Farmer. I was not the sort of journalist you see on television or in the movies. I didn’t cover the news; I didn’t put microphones in people’s faces or go to press conferences. Instead, I wrote about life as it is lived out of the spotlight, by people who are not celebrities. I wrote a book about a team of engineers designing a computer, one about a schoolteacher, another about the building of a house, and even one about some very old people in a nursing home. I wrote about “ordinary people,” but once I got to know them, I found that none were really ordinary. My most important technique for research was simply hanging out with my subjects. I would try to fit into their lives, to be as unobtrusive as possible, and I would try to understand them by watching what they did.
I hung out with Farmer, too. Although he was not famous when I met him, he was nobody’s idea of an ordinary person. He was already an important figure in medicine, public health, and medical anthropology, and he worked impossible hours in impossible circumstances. In one of the poorest parts of Haiti, he had built a modern facility that provided health care for people who were living and dying in abject poverty. He seemed never to sleep. He seemed to be loved and admired not just by his patients but by practically everyone who knew him.
I spent long stretches with him in Haiti and traveled with him internationally. Traveling with Farmer is not like being a tourist. I accompanied him to Russia, a country I had never visited before. On my own, I would have enjoyed touring the Kremlin and certainly would have gone out of my way to see a performance of the Bolshoi Ballet in Moscow. Instead we went to Moscow’s Central Prison, full of inmates ill and dying from tuberculosis, and then to an even more desperate outpost in Siberia. It was the same in Peru. Most Americans visiting there want to make the ascent to the ancient ruins of Machu Picchu. I would have liked that, too, but to travel with Farmer was to go directly into the tuberculosis-infected slums of Lima. None of this was much fun, to be honest. But it was spellbinding. And it was exhilarating to see how much Farmer and his small group of colleagues were able to accomplish, both in helping individual patients and in changing international health policies.
When you write about people in depth, you are always interested in how they grew up, what they were like as children. And usually you go looking for the evidence. For part of his boyhood Paul lived with his family in an old school bus, which they called the Bluebird Inn. After about five years of that, Farmer’s father, a great big man who was nicknamed “Elbows” by people who played basketball with him, moved the whole family onto a half-homemade, fifty-foot-long boat that was moored in a bayou in South Florida. The family had little money, but most of them relished their unorthodox lifestyle, at least when they looked back on it. It seemed as if, for a lot of the time, they had a lot of fun. At one point Paul’s father decided to earn his living as a fisherman, but he knew nothing about the ocean, or fishing. The experiment didn’t last long. Soon the boat rarely left its place in the bayou.
Paul was a brainy boy and he did well in school, even though he didn’t have a bedroom or a quiet place to do his homework. He went to Duke University on a full scholarship, and there discovered first wealth and then migrant farm workers toiling in the fields of North Carolina. Many were Haitian. He became interested in their lives because they seemed so different from the comfortable life he was leading at Duke, and so hidden from that lovely campus. He studied all things Haitian: the country’s religion, its art and music, its language, and its amazing history. Haiti is a country created by former slaves, kidnapped West Africans who threw off their extremely cruel French masters—at times they had to fight the English, too—and created their own republic. It’s the only place in the world where this happened, but it happened in 1804, when slavery still flourished here in the United States, and to make a very long and painful story short, Haitians have been punished ever since for claiming their freedom.
So Farmer imagined Haiti first, and then, after graduating from Duke, he made his first trip there. From that point on, he had a mission in life. By the time he got to medical school at Harvard, he was already working with friends to create the medical complex Zanmi Lasante, which is described in this book. Farmer’s early life couldn’t explain the man he became, but it was clear that he had learned something about poverty and how the world, when confronted with the poor, tends to look the other way.
Farmer is so gifted, so self-sacrificing, and so passionate about his cause that it is sometimes hard to believe he’s for real. That was part of my problem as a writer—how to make him believable to people reading my book. That’s why I chose to write about myself in this book—so that readers can see what it’s like to meet someone who operates on a much different level from the rest of us. At first Paul Farmer made me feel inadequate and even a little guilty. He was doing all these wonderful things to end suffering in the world. What was I doing? But he didn’t mean to make me feel that way, and I came to realize that he did not expect everyone to follow his path.
I hope that this young adult adaptation of Mountains Beyond Mountains will help a new generation to get a sense of the extent of global poverty and the challenges and opportunities it presents to those who want to help improve the world.
Farmer’s life looked very difficult to me at first, and it still looks exhausting and endlessly demanding. But it is also a life that is rich in rewards. I remember talking about all this to my editor, who said something about Farmer that I think is true: “His life looks hard, but it also looks enviable. When he wakes up in the morning, he doesn’t have all sorts of conflicting feelings about his life. He knows what he’s going to do and he believes it’s what he ought to do, what he was put on earth to do.” If there is a lesson to this book, that may be it—not that everyone should go out and try to cure the world, but that all our lives are richer for having purpose, for pursuing something larger than ourselves.
TRACY KIDDER
I FIRST MET Paul Edward Farmer two weeks before Christmas 1994. I was in Haiti as a journalist, writing about the presence of twenty thousand American soldiers there. The soldiers’ job was to reinstate the country’s democratically elected government, in the process stripping power from the junta—a government composed of military leaders—whose corrupt and cruel reign had gone on for three years. The evening I met Farmer, I was sitting on a second-story balcony of a military outpost, talking with U.S. Army Special Forces Captain Jon Carroll. The compound was a desperate-looking place. Concrete walls enclosed a weed-dotted parade field, a jail, and a mustard-colored barracks. The captain was stationed with eight American soldiers in Haiti’s rural central plateau, charged with keeping the peace for 150,000 Haitians, mostly peasants, spread over a thousand square miles.
The task seemed daunting if not impossible. The grisly murder of a popular local official—the assistant mayor had been beheaded and his body tossed in the Artibonite River—was making life even more complicated for Captain Carroll. The suspect most locals considered the killer was a member of the junta. He had been captured and briefly detained by the captain, only to be released by him for lack of physical evidence and reliable witnesses.
Carroll was shaking his head in frustration—about the crime and about all the challenges of peacekeeping—when an aide appeared and told him an American was waiting at the compound gate to see him.
There were in fact five visitors, four of them Haitian, but my gaze lingered on a tall, lanky white man in his mid-thirties as the group joined us on the balcony. The American introduced himself as Paul Farmer, a doctor who worked in a hospital in a nearby town called Mirebalais, helping poor people. Farmer had short black hair and a high waist and thin, long arms. His nose came almost to a point, upon which rested a pair of rimless glasses. Despite his pale and even delicate appearance, especially compared to the tanned and muscular Special Forces captain, there was something undeniably confident, even cocky, about him.
Farmer asked the captain if anyone in the compound needed medical attention. Carroll advised him that he had some sick prisoners the local hospital refused to treat, so he had ended up buying the medicine himself.
Farmer flashed a smile. “You’ll spend less time in purgatory,” he replied. Then he asked, “Who cut off the head of the assistant mayor?”
The conversation between the captain and the doctor went in circles. Carroll insisted he couldn’t be sure, but Farmer said that everyone in the region had a very clear idea who the killer was. I sensed that the doctor knew Haiti far better than the captain, and that he was trying to give him some important information. He suggested the murder suspect be arrested again, and this time held indefinitely. This was the practical thing to do, he hinted, to imprison the man rather than risk the anger of Haitians who were starting to lose confidence in Captain Carroll’s leadership. Farmer seemed to care less about the notion that someone should be considered innocent until proven guilty than about preserving a thin-edged calm in a jittery country. I found the two men’s views ironic. The captain, who described himself as “a redneck,” was arguing for due process. Farmer, who championed human rights and clearly was on the side of the poor, was arguing against it.
The captain couldn’t hide his overall pessimism. No matter what he did or didn’t do about the murder suspect, he said, nothing was going to change Haiti in the long term. The United States Army had ventured here before, in the early twentieth century, to restore order during another period of turmoil, only to leave and watch from a distance as the new government eventually collapsed. The same thing was going to happen when the army left this time, he predicted. Haiti would always be a desperately poor, corrupt, broken society. No one could fix it.
Farmer agreed with some of the captain’s points. Poverty and corruption were everywhere in Haiti, and the doctor had always been vocal about it. He thought the American government’s plan to stabilize the local economy might help the wealthy business class, but it would do nothing to ease the suffering of the vast majority of people. Haiti occupies the western third of the island of Hispaniola, in the Caribbean, while the more prosperous Dominican Republic, once ruled by Spain, governs the eastern two-thirds. Each country has a population of about ten million, which means that life is far more crowded in Haiti. In fact, Haiti is the poorest country in the Western Hemisphere. Workers in rural areas, which are home to two-thirds of the population, earn less than a dollar a day on average. Health care, education, and food security are sometimes nonexistent in the central plateau. In 1994, 25 percent of all Haitians who lived there died before they reached the age of forty.
Doktè Paul, as his Haitian friends called him, made it clear that he didn’t hold the captain or his men responsible for not being able to fix Haiti’s problems; he blamed United States foreign policy for being naive. He insisted that imposing political order on Haiti, no matter how much financial aid was provided, wouldn’t improve the problems of poverty and disease. These have their roots in the mid-eighteenth century, when the French government, which had claimed Haiti as its own, made Port-au-Prince, the capital, a major hub of slave trading. Most Haitians, who trace their ancestry to West Africa, have been exploited for 250 years, no matter what government was in power. First they were enslaved by their French masters. When they were finally freed, after a series of slave rebellions, their new masters were poverty, illiteracy, and lack of economic opportunity.
While the captain had good reason to be frustrated, Farmer, describing the work he was doing at Mirebalais, was saying something different. Even in a remote, understaffed, and underequipped hospital, if he did his best, a simple country doctor could improve the quality of life in Haiti. Of course, something told me that Farmer was more than a simple country doctor. Shaking the captain’s hand and offering an apology for what might have seemed like a lecture, he disappeared into the evening shadows. As his group departed, I noticed that he spoke fluent Creole, the local language, with his Haitian friends.
For the next few weeks I stuck with Captain Carroll and other military personnel, continuing to write my story, more sympathetic than Farmer had been to their mission of nation building. Like Farmer, the captain and his troops were giving their best effort. I might have forgotten my evening with Paul Farmer had he not appeared on the same flight with me from Port-au-Prince to Miami. We ended up sitting together, dissecting our evening with Captain Carroll and the fragile peace that had settled over Haiti. Farmer seemed to know everything about a country that baffled me on many levels, and his insights helped me with the article I was writing. As he opened up a little, I found his personal life equally interesting.
Farmer had graduated from Harvard Medical School and completed his residency in internal medicine there. He had gone on to do a fellowship in infectious diseases. Somehow he’d also made time at Harvard to earn a PhD in anthropology. For four months of the year he attended to patients in Boston at the Brigham and Women’s Hospital, and lived as a bachelor in a grubby church rectory in a poor neighborhood called Roxbury. For the other eight months he returned to the central plateau of Haiti, doctoring impoverished patients, many of whom had lost their land to a government hydroelectric dam project. He refused to take a salary for his work there. During the rule of the junta, he had been expelled from the country for his political views. Rather than stay safely away, Farmer bribed his way back in, to continue his work at the Mirebalais hospital.
My curiosity was piqued by his unusual life, and once back in the States, we kept in touch via email. A month later we hooked up in Boston, at a fancy restaurant with cloth napkins and good wine, which Farmer seemed to thoroughly enjoy. He struck me as incredibly happy with his life. I tried to understand how a Harvard-trained MD who could have enjoyed a successful, full-time private practice and a comfortable home in a Boston suburb preferred to spend most of his life with the forgotten poor. At one point I was sure he knew what I was thinking, as if others had asked him the same question. “I don’t know why everybody isn’t excited about it,” he suddenly responded, meaning his work in Haiti. He smiled, a glow lighting his face. That moment, if not the whole evening, affected me quite strongly, like a welcome gladly given, one you didn’t have to earn.
But after our dinner I found myself keeping a distance from Paul Farmer, mainly, I came to realize, because his optimism and happiness made me slightly uneasy. I wondered how anyone could give himself so selflessly to a forsaken land, refusing to be defeated by the considerable odds against him. Having finished my article on Haiti, I had come to share Captain Carroll’s pessimism. Haiti’s problems were impossibly deep and tangled. No one could solve them, including Farmer. Besides, the world was full of miserable places just like the central plateau, all of them hopeless. Most of my friends preferred not to think about the problems in developing countries, or if they did, they sent money.
Over the next five years I mailed small amounts to the charity that supported Farmer’s hospital near Mirebalais. He faithfully sent back handwritten thank-you notes. I wondered where he found the time. I was aware from media coverage that in addition to his work in Haiti and seeing patients in Boston, Farmer had begun working internationally in the field of tuberculosis. He traveled extensively, grabbed naps in airports, and, usually managing to find a computer, stayed in touch with old friends while making new ones. A very busy, determined man, running on high energy and idealism.
Perhaps my curiosity about Farmer had never gone away, and now I was more intrigued than ever. I wrote to him in Boston proposing that I write a magazine piece about him and his work. In December of 1999, we were together again.
MY APPOINTMENT WITH Farmer was at the Brigham and Women’s Hospital, a teaching affiliate of Harvard. The Brigham was part of a “medical mall” that included a teaching hospital, a full-service hospital, secondary-care facilities, and numerous physicians in private practice. The campus was impressive for what happened within its walls: chest crackings, organ transplants, molecular imagings, genetic probes, and virtually any other medical service known in the advanced world. With its distinguished reputation, this was where other hospitals in the country sent their most difficult cases, including people dealing with cancer, serious burns, psychiatric conditions, and infectious diseases. I joined Farmer on the Brigham’s radiology floor, in a quiet room where he was discussing various patients with younger doctors, mostly residents, who were his students. Farmer was now forty years old. His hairline had receded slightly, and he looked thinner than I remembered him. Today he was dressed appropriately for an important Boston physician, in a black suit and necktie, and as usual wore his rimless glasses.
He still spent most of his time in Haiti, but as an attending specialist on the Brigham’s senior staff, he was sought after frequently for his diagnoses of ID—infectious diseases. Farmer had become a recognized expert in the field, in good part because of his experiences in Haiti’s central plateau, where he treated HIV (human immunodeficiency virus), AIDS (acquired immunodeficiency syndrome), malaria, tuberculosis, hepatitis, and cholera. He had written scholarly articles on the history of various diseases, often focusing on their connection to poverty.
Farmer suddenly interrupted a discussion with his students by picking up a ringing phone. “HIV Central. How can we help you?” he chimed.
“Worm lady!” he exclaimed after a moment. “How are you, pumpkin? … Oh, I’m fine.”
The female doctor on the other end was a parasitologist, someone who studies how parasites, such as worms, invade and damage the body. She was a longtime colleague of Farmer’s, and she had questions about treating someone with hydrocephalus—an abnormal amount of fluid in the brain’s ventricles, or cavities—caused by a parasite. She asked if Farmer thought more tests would be appropriate.
“Listen, it’s scandalous to say, but we don’t agree. We want to treat his ass. ID says treat. Love, ID.”
He hung up, his face glowing again. Farmer’s whimsical tone didn’t mean that everything he said wasn’t completely serious. He wanted the doctor to begin treatment immediately, rather than subject the patient to further tests. He was having a very good time, as usual, and his students smiled back at him in approval. He seemed to enjoy the attention.
Farmer and his team had focused on six cases that afternoon, each something of a puzzle. He had methodically worked his way through all of them, step by step. A female resident on the team brought up the final case of the day, a thirty-five-year-old man (I’ll call him Joe) who was HIV-positive, smoked a pack of cigarettes and consumed half a gallon of vodka daily, used cocaine, and just recently had overdosed on heroin. He had lost twenty-six pounds over the previous few months and had a chronic cough accompanied by chest pain. An X-ray revealed a shadow on his lung.
Certainly Joe was a likely target for tuberculosis, Farmer agreed with the resident. Of all the infections that can come crowding into a person with HIV, TB was the most common worldwide. It was rare in the United States, however, even in the jails, in the homeless shelters, and under the bridges that Joe often called home. Also, he didn’t experience the fever, chills, and night sweats that usually accompanied TB. The resident offered that she liked Joe. “He’s a nice guy,” she said.
Farmer said, “Let’s go see the X-ray, shall we?”
Less than a minute after studying the film, he seemed convinced this was not TB. He headed with his team upstairs to see the patient.
Farmer’s long-legged strides might have carried him to Joe’s room with reasonable speed, but he stopped frequently to give or receive hugs from hospital staff, exchange quips in Creole with a Haitian janitor, and answer his beeper to discuss someone’s blood pressure, heart condition, or diabetes. Finally he led his team to Joe’s door while he sang in creative German, “We are the world. We are das Welt.”
Joe was isolated in a special room with negative airflow, just in case he did have TB, which can spread in the air and is highly contagious. He lay on his bed dressed in blue jeans and a T-shirt, a small man with scarred and wiry arms and prominent collarbones. He had an unkempt beard and unruly hair. Introducing himself, Farmer sat at the head of Joe’s bed, folding himself around the patient in an agile way that made me think of a grasshopper. For a moment, I thought Farmer might crawl into bed with him. Instead, he placed a hand on Joe’s shoulder and stroked it. Farmer had a way making almost anyone feel immediately comfortable in his presence.
He asked Joe a series of questions, listening carefully to his answers, all the while peering down at the man, pale blue eyes behind little round lenses.
“Your X-ray looks good. I think it’s probably pneumonia. A little bit of pneumonia,” said Farmer. “Let me ask you, how’s your stomach?” He asked if Joe suffered from gastritis, or inflammation of the stomach lining.
“I’m eatin’ everything in sight of me.”
Farmer smiled. “You need to gain some weight, my friend.”
“I didn’t eat much when I was outside. I didn’t eat much at all. Messin’ around, doin’ this, doin’ that.”
Just to be sure, Farmer asked Joe if he’d been exposed to anyone with TB. Joe said he didn’t think so.
“I think we should make a recommendation that you not be isolated,” Farmer replied. “We’re ID, right? ID says hi. I don’t think you need to have a negative airflow room and all that.”
They kept talking, longer than necessary for a specialist whose job was essentially to determine the problem, make small talk with the patient, and proceed with his rounds. Farmer remained perched on the bed. He explained that it was important for Joe to take his antiretroviral medicines faithfully so that his HIV wouldn’t develop into full-blown AIDS. They talked about drugs and alcohol, too, and Farmer warned him against heroin.
“But really the worst ones are alcohol and cocaine,” Farmer continued. “We were saying downstairs during rounds, we were kinda joking around, saying, ‘Well, we should tell him to smoke more marijuana, because that doesn’t hurt as much.’ ”
“If I smoke marijuana, I’ll create an international incident.”
Farmer blushed, as he often did. “Not in the hospital, Joe.” The two laughed, looking at each other.
Farmer talked about Joe’s HIV. “Your immune system’s pretty good, you know. Workin’ pretty well. That’s why I’m a little worried that you’re losing weight, you know. Because you’re not losing weight on account of HIV, I bet. You’re losing weight because you’re not eating. Right?”
“Yeah, that’s right.”
“Yeah,” Farmer said softly. The way he stared at Joe’s face seemed both intent—as if there were no one else in the world—and also focused elsewhere. I thought in his mind he might be watching Joe from a high window, as Joe went about what are known in social work as the activities of daily living, which in his case would mean scoring some narcotics, then heading off to his favorite underpass for camping.
Another person entered the room, a medical student whom Farmer had invited to join him on rounds. The room was getting crowded.
“I feel kinda lonesome in this room!” Joe said, gazing around.
“That’s true. And we’re going to recommend that you get out of this,” said Farmer. “So here’s my heavy question for you—”
“What you can do for me.”
“Yeah!”
“I’d like to have an HIV home where I could go to sleep and eat, watch television, watch games. I’d like somewhere to go where I can drink a six-pack. And I don’t drive everybody crazy, runnin’ out the doors and everything.”
“Yeah,” said Farmer. “I can see your point.” He pursed his lips. “So I’ll tell you what. I’ll look around. And you know, I don’t think it’s that crazy an idea at all, what you said.”
Farmer and his team eventually left the room, but only after it was clear Joe had been comforted and Farmer had earned his trust. A few days later, friends of Farmer’s found a homeless shelter for Joe, but of course the social workers had to remind Farmer that shelter rules forbade alcohol consumption. Just to keep his word, I suppose, Farmer still pleaded Joe’s case, not expecting to win the argument.
On Christmas, Farmer spent part of the day visiting patients outside the hospital. He brought them all presents, including Joe—who got a six-pack of beer, disguised in wrapping paper.
Joe seemed glad to see him as well as the gift. As Farmer was leaving, he heard Joe say to another resident, just loudly enough to make Farmer wonder if Joe meant for him to overhear, “That guy’s a saint.”
It wasn’t the first time Farmer had heard himself called that. When I asked him for his reaction, he replied, “I don’t care how often people say, ‘You’re a saint.’ It’s not that I mind it. It’s that it’s inaccurate.”
Then he added, “People call me a saint, and I think I have to work harder. Because a saint would be a great thing to be.”
I felt another inner disturbance. It wasn’t that I thought Farmer was being vain; rather, I felt I was in the presence of a different person from the one I had been chatting with a moment ago, someone whose ambitions I hadn’t yet begun to fathom.
A week later, on New Year’s Day 2000, Farmer was back in Haiti. He had sent me a copy of his latest book, Infections and Inequalities, which, in addition to examining the link between poverty and disease, took to task how developed nations such as the United States and those in Europe treated poor, essentially invisible countries such as Haiti. He accused certain governments, pharmaceutical companies, and public health policies of favoring the “maldistribution of medical technologies.” That meant that rich countries got the best medical care while poor ones were neglected. Corporate profits and ever-expanding markets were major reasons for this, he wrote in his book. I was seeing a very angry Paul Farmer, who didn’t seem much like the Paul Farmer who worked at the Brigham. This one was shouting on every page. I emailed to thank him for Infections and Inequalities and promised to read his earlier books.
“I’m reading your entire body of work,” I wrote.
By email Farmer replied, “Ah, this is not my real body of work. To see that, you have to come to Haiti.”
FARMER SENT A driver in a sturdy four-wheel-drive pickup to retrieve me from the Port-au-Prince airport. I had been invited to visit his clinic in the central plateau, in the village of Cange, called Zanmi Lasante. That is Creole for Partners in Health, an organization Farmer and some supporters had created in Boston to raise funds for his work in Haiti. Incredibly, the thirty-five-mile trip to Cange on National Highway 3 took more than three hours. Some stretches of road resembled a dry riverbed; other places were strewn with boulders or eroded down to rough bedrock. I would later learn that Farmer had suffered a slipped disk in his back from taking this bruising journey countless times.
As we lurched along, I saw beggars whose clothes were so tattered that I thought they’d disintegrate; villages of primitive wood huts; young boys working with hoes to smooth out patches of deeply rutted road, then opening their hands in the hope of a reward from people like me; and wobbly trucks top-heavy with passengers, impatiently swerving past oxcarts and donkeys as dust plumed in the air. I wondered when was the last time the government had tried to improve National Highway 3, but I wondered even more about the visible desperation of everyday lives.
We didn’t reach our destination until evening. Cange, with a population of about thirty thousand, might be described as the most impoverished, famished, and disease-ridden place in Haiti. The original village was submerged when a government dam was built in 1956. The residents immediately became squatters, scrambling up the steep hillsides to remake their homes and farms on land they didn’t own. In 1962, a Haitian Anglican priest named Fritz Lafontant built a primary school for local children. Later he built a small hospital near Mirebalais. The rest of the world, however, didn’t pay the central plateau much attention, even after the first case of AIDS here was diagnosed in 1986, and a dangerous epidemic followed.
In this baked, desolate, treeless landscape, scattered with small tin-roofed huts and dusty walking paths, we drove through a gate and onto smooth pavement. Caught in the sweep of our headlights, Zanmi Lasante appeared dramatically on a hill, like a mountainside fortress. I studied a complex of concrete buildings that were half covered with tropical greenery. I would discover that inside the complex, amid leafy trees and spacious walkways, were an ambulatory clinic and a women’s clinic, a general hospital, two laboratories, a large Anglican church, a school, a kitchen that prepared meals for about two thousand people daily, and a brand-new building called the Thomas J. White Tuberculosis Center. Tiled floors, white walls, and paintings by Haitian artists made the interiors inviting. The staff included Haitian doctors, nurses, a number of aides, and community workers, about 150 in all. A large generator in the compound provided electricity, and there was running water.
The day after I arrived, starting at dawn and ending well into the evening, I followed Farmer on his rounds, for the first of many times. The general routine was always the same. The clinic treated hundreds of people every day, who came sometimes from great distances, by foot, on donkey, or on the overcrowded passenger trucks on Highway 3. Dressed in jeans and a T-shirt, strolling into the main courtyard, Farmer was inevitably greeted by a crowd beseeching him not just for medical help but personal favors, such as delivering a letter for them to the United States, or procuring a pair of reading glasses or nail clippers or a wristwatch or just food. It took an hour to maneuver through the courtyard as he arranged treatment for the most serious cases. Then he retreated to a small room above the kitchen, where, before formally seeing patients, he sent and received emails via a satellite phone.
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