Mountains Beyond Mountains: Part IV

One day in 2000 I met with Howard Hiatt in his Brigham office. He told me, “Paul and Jim had mobilized the TB tribe to accept drug-resistant TB as a soluble problem,” but victory over MDR was far from assured.

One day in 2000 I met with Howard Hiatt in his Brigham office. He told me, “Paul and Jim had mobilized the TB tribe to accept drug-resistant TB as a soluble problem,” but victory over MDR was far from assured.

When those in the central plateau staged a rebellion—refusing to be treated as slaves—their insurrection was put down violently by Marine-supervised Haitian police, not unlike the French masters had done to their ancestors.

I was narrating Haiti on my own, in my mind, as I looked out the windshield. The past seemed to blend seamlessly with the present. The view of emaciated beggars and barefoot children lugging containers of water never changed much.

I was narrating Haiti on my own, in my mind, as I looked out the windshield. The past seemed to blend seamlessly with the present. The view of emaciated beggars and barefoot children lugging containers of water never changed much.

Remembering my religious education, I said to him, “If you’ve done it unto the least of them, you’ve done it unto me.”
“Matthew twenty-five,” Farmer picked up. ‘“Inasmuch as you have done it unto the least of these my brethren, you have done it unto me.’”

Our first stop was a jail in a Port-au-Prince suburb. An unchecked bwat on Farmer’s list of things to do read “Prison extraction.”

Farmer had already arranged for a lawyer. He was stopping at the jail so the father could speak to his son. Inside, the cell where the young man languished was unlit. There were at least thirty men in the shadows, crowded together, and a fierce stench was wafting out at us. The son stood at the bars and talked to his father. Farmer passed on the news to the boy about the lawyer, delivering hope amid all the squalor.

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.

He got to work, writing thank-you notes to PIH contributors. Finishing five, he mentally checked off a bwat, which cheered him. But his mood was volatile that day. He could easily lapse into self-criticism, particularly if there was someone, especially a child, whose life he thought he could have saved in Cange.

He got to work, writing thank-you notes to PIH contributors. Finishing five, he mentally checked off a bwat, which cheered him. But his mood was volatile that day. He could easily lapse into self-criticism, particularly if there was someone, especially a child, whose life he thought he could have saved in Cange.

“I’ve never known despair and I don’t think I ever will,” he wrote to 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 emotional pain that came more typically to the rest of us.

I remarked on his sleepless nights, his hundred-hour weeks, and his incessant travel as he hobbled along. He said, “The problem is, if I don’t work this hard, someone will die who doesn’t have to. That sounds megalomaniacal. I wouldn’t have said that to you before I’d taken you to Haiti and you had seen that it was manifestly true.”

I remarked on his sleepless nights, his hundred-hour weeks, and his incessant travel as he hobbled along. He said, “The problem is, if I don’t work this hard, someone will die who doesn’t have to. That sounds megalomaniacal. I wouldn’t have said that to you before I’d taken you to Haiti and you had seen that it was manifestly true.”

When our plane descended toward Havana, Farmer grew excited as he peered out the window. “Look! Only ninety miles from Haiti, and look! Trees! Crops! It’s all so verdant. At the height of the dry season! The same ecology as Haiti’s, and look!”

On our ride into Havana, I got my first glimpse of a political billboard, an enlarged version of the famous photograph of the Marxist revolutionary Che Guevara wearing a beret.

It was a poor country, in part because the United States maintained its trade embargo, and because the Soviet Union, once it collapsed in the late eighties, no longer provided financial subsidies. Yet its public health system allowed all Cubans virtually free medical care.

It was a poor country, in part because the United States maintained its trade embargo, and because the Soviet Union, once it collapsed in the late eighties, no longer provided financial subsidies. Yet its public health system allowed all Cubans virtually free medical care.

He found that the peasants’ vocabulary didn’t even have a word for illicit drugs, which almost no one could afford anyway.

We visited Eduardo’s modest house. On the bureau was a snapshot of Farmer.

I was listening to the Farmer who honestly believed that he could never do enough. When he combined that attitude with a righteous indignation about how the world treated the poor, his conviction was hard to ignore.

Like Pérez, Farmer didn’t like social inequality. He believed in social justice medicine. He championed a preferential option for the poor. And he didn’t want to see his beliefs mischaracterized, or his work ridiculed in the book I was writing. There was vehemence in his voice, and I felt I was its object, as if I had already ridiculed Dr. Pérez.

I was getting weary of his constant righteousness and the sense I was in some way a great disappointment to him.

In addition to “H of G,” “ID,” “WL,” and “O for the P,” Farmer used scores of other abbreviations and slang in his daily speech and emails. Jim and Ophelia had invented some of the lexicon, and the expressions had filtered into the PIH culture.

To commit “a seven-three” was to use seven words when three would do, and a “ninety-nine one hundred” meant quitting on a nearly completed job. The terms could seem impolite to an outsider, but they reflected Farmer’s sense of humor, his quick mind, and his prejudice for brevity.

To me, however, the inner circle of PIH seemed like a club, or even a family, which was deeply opposed to the concept of insiders and outsiders. Farmer called it “the most inclusive damn club in the world, being full of people with AIDS, WLs galore, tons of students, church ladies, and lots of patients, and it’s a club that grows and never shrinks.”

“There is no relation between the massive accumulation of wealth in one part of the world and abject misery in another.” He looked at me. He’d made me laugh. “You know I’m being funny about something serious,” he said.

He often caught me off guard with his humor, and it seemed to relax him to make me and others laugh. He could quote lines from his favorite comedies, like Caddyshack, or poke fun at someone who was too pretentious or willfully ignorant.

He often caught me off guard with his humor, and it seemed to relax him to make me and others laugh. He could quote lines from his favorite comedies, like Caddyshack, or poke fun at someone who was too pretentious or willfully ignorant.

Farmer had written the Soros Foundation a terse letter stating why their DOTS-only regimen was bound to fail.

Entering Matrosskaya Tishina, I found a confusing maze of cell blocks, low doorways, endless tunnels, dingy corridors, and ancient metal staircases.

The men gathered around Farmer, airing their grievances about the Soviet justice system, which they accused of giving longer sentences to anyone who had HIV or AIDS.

Farmer stood beside a bed, his arm resting on the mattress of an upper berth.

Their prison hospital X-ray machines were in a decrepit state, and there was a chronic shortage of even first-line antibiotics.

A certain World Bank official implied that Alex’s brashness and outspokenness turned off many people.

Alex continued with his attack, not just on members of the World Bank but on the World Health Organization bureaucrats stationed in Moscow, who he said resented PIH and the Soros Foundation. Adding to the complexity and jealousy, according to Alex, the Soros Foundation itself contained competing factions with different points of view about Russia.

Alex reveled in all this conflict, I thought. I could understand why he was perceived as an agitator by some World Bank members.

Farmer seemed to say that diplomacy, charm, and sound argument backed by hard data could unite all factions against their common enemy, TB.

Jim Kim had the finesse and diplomatic skills to deal with bureaucrats and large organizations such as WHO and the World Bank.

My thoughts were a bit hazy, and I sensed my voice was a little slurred. I began to pose a hypothetical question, which I thought expressed insight into Farmer’s itinerant, nomadic life. “You’re a great guy,” I said, putting a hand on his shoulder. “But without your clinical practice—”
He interrupted. He said, “I wouldn’t be anything.”