Mountains Beyond Mountains

  “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?”

  CHAPTER 20

  “Paul and Jim mobilized the world to accept drug-resistant TB as a soluble problem,” Howard Hiatt told me one day in 2000, in his office at the Brigham. This was no small matter, he believed. “At least two million people a year die of TB. And when those people who die include large numbers of people with drug-resistant strains, as will happen unless a very big and good program gets established, it’s not going to be two million. That number could be increased dramatically.”

  And MDR was only a part of an enormous problem in the world’s health. TB and AIDS loomed over the new millennium. Add the malaria pandemic into the projections, and it seemed obvious that the world faced public health catastrophes on a scale not seen for centuries, since the eras of plague in Europe or the near extinctions of indigenous peoples in the Americas. Farmer, Hiatt seemed to say, should be solely engaged in the battle against those scourges, and at a level commensurate with their size. “The six months a year that Paul’s looking after patients one-on-one in Haiti, if that time were converted to a major program for treating prisoners with TB in Russia and other eastern European countries, or malaria around the world, or AIDS in southern Africa—it doesn’t matter where or what because you know he’ll do important things. Because look at what he’s done with only part of his time on MDR. Look what he’s done with his skills and his political acumen! I have been urging him to take the role of consultant in Haiti and spend most of his time on worldwide projects.”

  Farmer was forty now, and he had the credentials to operate in the way Hiatt envisioned, on a purely executive level. In academic circles his reputation had grown. He was about to become a tenured Harvard professor. He was near the head of the line for the big prizes in medical anthropology; some of his peers were now saying that he’d “redefined” the field. As for his standing in clinical medicine, he’d become one of the doctors whom medical schools, in Europe as well as in the United States, invite to their campuses to deliver the lectures known as grand rounds. At the Brigham the surgeons had recently asked that he lecture to them, a signal honor not often granted to a mere medical doctor. He also sat on a number of councils in international health, and he’d made his views heard. But he didn’t seem disposed to abandon any side of his work, including seeing patients one-on-one in Haiti.

  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.

  I liked to sit and watch him at his e-mail, in Cange and on airplanes and in airport waiting rooms. He had a way of moving a finger around in the air when he was thinking of how to make a point, and when he felt someone else had sniffed out a good one, he’d tap the side of his nose with an index finger. The e-mail itself was interesting to me. It conveyed some sense of his practice, a taste of its extent. In early 2000 he was receiving about seventy-five messages a day. He seemed to welcome most of them, and to have invited many. He answered the great majority.

  There were consults on MDR patients in Peru, which he had to read and respond to carefully; worried and worrisome messages about projects in which PIH was involved, in Russia and Chiapas and Guatemala and Roxbury; affectionate greetings and requests for advice from priests and nuns and anthropologists and health bureaucrats and fellow doctors, in Cuba, London, Armenia, Sri Lanka, Paris, Indonesia, the Philippines, South Africa; and always a few queries like this: “Just a wrench to throw in your head. How would you like to work in Guinea-Bissau?” There were requests for counsel and for letters of recommendation, from youngsters who had worked as volunteers at PIH and now wanted to go to medical school, and from young doctors and epidemiologists who had in one way or another enlisted in the PIH cause. There were questions from his infectious disease fellow at the Brigham, and from a doctor in Boston who had been consulting him on the care of an indigent HIV patient, and from favorite medical students. “What is the mechanism/pathophys of acute hearing loss associated with meningitis?” one wrote.

  Farmer answered promptly:

  good morning, david. the damage from bacterial meningitis is ultimately due to the host inflammatory response. white cells. so that purulent meningitides that go for the base of the brain cause an almost mass-like inflammation there. now what courses under the base of the brain? the cranial nerves. and what do they do? permit little girls to hear. and what happens to them when they are surrounded with mass-like gelatinous inflammation (pus?) they get pinched. and they get anoxic. there goes hearing, and often ability to open both eyes, etc. even hydrocephalus is often due to inflammatory debris blocking the foramina. … it’s anatomy, my friend. anatomy and pus. it’s always anatomy and pus.

  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.”

  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.”

  We had spent two weeks in Cange, and in the midst of them had taken a quick trip to visit the church group in South Carolina. Now we were heading to Cuba for an AIDS conference. We’d spend the week after that in Moscow on TB business, with a stop in Paris en route.

  “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.”

  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.

  We left Zanmi Lasante for the airport around dawn. Ten Cangeois climbed on board, cramming themselves into the cab of the truck and among the suitcases in the open bed in the rear. Farmer, dressed in his suit, issued a bunch of last-minute requests and instructions to the staff who came to see him off, and got into the driver’s seat—he suffered from motion sickness, and being at the wheel lessened his nausea—and the truck, like a small boat leaving its harbor, departed the smooth pavement of the complex and began lurching down National Highway 3.

  It was early. We hadn’t eaten breakfast. My back felt wrenched already. I was narrating Haiti on my own, in my mind, bouncing up and down in the cab of the truck. This so-called road had been built early in the twentieth century, during the first American occupation of Haiti. The U.S. Marines had supervised its construction. To get the job done, they’d revived an institution known as the corvée, a system of conscript labor that dated back to slavery days. The peasants o
f the central plateau staged an insurrection, which the Marines put down violently. In a book Farmer had shown me, there was a photograph of a conscripted and presumably recalcitrant roadworker who had been disciplined by the Marine-supervised Haitian gendarmes. In the photograph, the man lies on the ground with both hands cut off.

  Sights along this roadside were less dramatic now but brutal enough for 6:00 A.M.—the emaciated beggars, the barefoot children lugging water. Through the jouncing windshield, I saw a thin man in a straw hat on a starving Haitian pony. He was mounted on a traditional Haitian saddle, made of straw, designed, it would seem, to abrade the backs of donkeys and ponies until they bled. He was kicking the pony’s protruding ribs, hurrying, I imagined, to get to work on some rocky, infertile piece of local farmland so his children could have at least one meal today. 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.

  The conversation was desultory, and the ride uneventful, until we came to the descent of Morne Kabrit, the view opening below us of the once fertile and now alkalized Cul-de-Sac Plain and beyond it Port-au-Prince. This was the most dangerous part of the road, kwazman territory. Farmer defined the term for me: “When you encounter another truck or something like that boulder we just glanced off and it ain’t good, that’s a kwazman.” The aftermath of a kwazman lay up ahead, a truck turned onto its side along the inner edge of the road, not far from the spot where Paul and Ophelia had come upon the dead mango lady seventeen years before. Farmer stopped and peered at the wreck through the windshield. But there were no people around the wreck, no bodies on the ground this time. “It doesn’t look like anyone got hurt,” he said in English to me, then in Creole to the Cangeois in the back.

  One of the men replied, “Well, someone in that truck could have had a general curse on him, and he might have taken the occasion to die.”

  Farmer translated this for me and laughed and, still laughing, drove on. His first stop was the jail in Croix des Bouquets, a Port-au-Prince suburb. An unchecked bwat on his current list of things to do read, “Prison extraction.” One of the men in the back of the truck, a peasant farmer from Kay Epin, had a son who had left home to work as a security guard in the city; recently, the young man had been jailed on suspicion of murder. Farmer had already arranged for a lawyer. He was stopping at the jail so that the father could speak to his son.

  The sergeant at the desk said, “You’re not allowed in.” Farmer put a hand on the sergeant’s shoulder and talked his way past. The cell where the young man languished was unlit. In the shadows within you could see a crowd of at least thirty young men. Nearer the light, a dozen faces peered out through the bars. “Hi,” said Farmer.

  “Hi, Doc,” many voices replied. Several raised their hands and wiggled their fingers. A fierce odor came out—dried sweat, foul breath, urine, and shit. The son stood at the bars and talked to his father. Then the father stood back and gazed at his boy. Farmer spoke to the young man for a while, telling him about the lawyer.

  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.”

  After an errand downtown, he drove to the airport. The closer we got, the thicker the crowds of women and children hawking sodas and fruit and geegaws among the rubble by the side of the road. Up ahead Farmer spotted a broken-down car, the occupants outside and pushing. He drove around it. “Am I sinning? But Matthew twenty-five doesn’t say anything about …” He lifted his voice and sang: “When my car broke down, you gave me a push.” The traffic was snarled as usual. Crowds always thronged the airport when a big plane was coming or going, and most of the people seemed to have no business there except hope. It wasn’t just taxi drivers looking for fares who gathered at this seam in the world but children and old men and women leaning on sticks and people with missing limbs, all straining at the barricades, shouting and waving at the arriving passengers. On a wall of the main terminal Farmer spotted a sign in English, placed there for tourists during the last holiday season:

  BEST WISHES FOR THE CHRISTMAS

  AND HAPPINESS FOR THE NEW MILLENNIUM 2000

  Beneath this was a painting of a reindeer. “Oh,” said Farmer. “An example of the local fauna. The poor Haitians. God bless the Haitians. They try so hard.”

  My gloom lifted on the airplane, but Farmer, I was learning, found it hard to leave Haiti. “You and I, we can leave whenever we want. But most Haitians are never going to get to go anywhere, you know?” he’d said as we boarded. A little later, when the plane banked over the Bay of Port-au-Prince, he glanced out the window once, then turned his face away. For a minute or two the central plateau was laid out in the window beside him, a brown landscape dotted with just a little green, eroded mountainsides that looked like the ribs of starving animals, and rivers that stained the turquoise waters brown, bleeding the last of Haiti’s topsoil into the sea. “It bothers me even to look at it,” Farmer said, narrating Haiti for what would be the last time in a while. “It can’t support eight million people, and there they are. There they are, kidnapped from West Africa.”

  He went to work on thank-you notes to PIH contributors. Finishing five, he got to check off a bwat. This cheered him up. But then lunch was served, and I was about to start eating when I looked over and saw that his fold-down tray was empty. “Hey, where’s your meal?”

  “Maybe they know about the kid,” said Farmer. “That I failed to save her.”

  A little girl had died in the Children’s Pavilion last night, one he felt shouldn’t have. This was the first I’d heard of it. He’d stayed up all night, trying every trick he knew to save her.

  “I’m sorry,” I said.

  “There’s a lot of death in Haiti,” he answered. “Sometimes I get so fucking sick of it, babies dying …” His lunch had arrived by now. He ate some of it, then said, “Let’s go over the patients.” He went bed by bed through the TB hospital, the main hospital, the Children’s Pavilion. “And there’s the preemie who worried me because she’s no bigger than a peanut. But she looked fine.” He was smiling, finally. “For a tadpole.”

  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.”

  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.

  Miami Airport was his usual hub. Many business travelers rated it one of their least favorite. Not Farmer. Depending on its length, a layover there was either “a Miami day” or “a Miami day plus,” and both included a haircut from his favorite Cuban barber—they’d chat in Spanish—and the purchase of the latest issue of People magazine, the JPS. And then it was up to the Admirals’ Club, which he was in the habit of calling “Amirales.” There he’d take a hot shower, then stake out a section of lounge—this was “making a cave” or “getting caveaceous at Amirales”—and answer e-mail from a soft easy chair while sipping a glass of red wine. Today was a Miami day plus, which meant that, in addition to all those other exquisite pleasures, we stayed the night in the airport hotel.