18312: radtimes: Something Special in the World (fwd)

[Bob Corbett <corbetre@webster.edu>]

From: radtimes <resist@best.com>

Something Special in the World

http://www.theatlantic.com/unbound/interviews/int2004-02-03.htm

February 3, 2004

Tracy Kidder, the author of Mountains Beyond Mountains, on Paul Farmer, a
doctor who set out to make a difference

Tracy Kidder has long been known for his ability to extract the
extraordinary from the seemingly ordinary. The author of the nonfiction
bestsellers Home Town, House, Among Schoolchildren, Old Friends, and The
Soul of a New Machine, Kidder has chronicled the life's work of such
everyday citizens as a schoolteacher, a police officer, and a team of
computer engineers. His newest book, Mountains Beyond Mountains, features,
in his words, "the least ordinary ordinary person" he has ever known. At
the center of the story is Dr. Paul Farmer, a Harvard Medical School
professor and physician at Boston's Brigham & Women's teaching hospital.

As a young physician, Farmer set out to do the extraordinary. Equipped with
little more than an M.D./Ph.D. and an unshakable faith in God and in
himself, he traveled to Haiti—the Western Hemisphere's poorest nation—and
created a non-profit clinic he called Zanmi Lasante (Creole for "Partners
in Health"). Farmer worked tirelessly to treat Haiti's AIDS and
tuberculosis epidemics as well as common ailments like diarrhea and malaria
that often prove fatal in impoverished communities. In founding Zanmi
Lasante, Farmer brought Haiti's peasants not just basic medical care, but
clean water, food, shelter, and education. Above all, he brought hope to a
group of people whom the rest of the world had written off as hopeless. His
success over the years in improving the health-care situation in Haiti has
made him an influential shaper of policy at the World Health Organization,
and has earned him a MacArthur "Genius" grant.

Kidder met Farmer in 1994 on his first trip to Haiti while writing an
article for The New Yorker. Though he was initially perplexed by Farmer's
zeal in the face of so much despair, he realized what an intriguing
character he'd come across, and several years later decided to build a
story around him. He interviewed Farmer's friends, family, and coworkers,
followed him as he taught medical students in Boston and treated patients
in Haiti, and flew with him as he traveled around the globe to share his
expertise with the larger medical community. For the first time, Kidder has
inserted himself into one of his books, and his first-person narration
gives the reader a unique perspective on a seemingly saint-like character
working in inhumane conditions.

Tracy Kidder has been a contributing editor of The Atlantic since 1981, and
is the recipient of both a Pulitzer Prize and a National Book Award. We
spoke by telephone this fall.

—Dana Rousmaniere

You titled your book after the Haitian proverb "Dèyè mòn gen mòn," meaning
"beyond mountains there are mountains." Is this description of the Haitian
landscape also symbolic of the obstacles that Paul Farmer and the Haitian
people have faced, and continue to face?

Exactly. The proverb as I understand it means "beyond mountains, more
mountains." But I looked at it harder and saw a verb in there: "gen." I
think it's the verb "there are," or it could be "one gains"—beyond
mountains, one gains mountains. Haitians use the phrase in two different
ways: to say that there's no end to obstacles, and also to say that there's
no end to opportunities. I think those two meanings aren't inconsistent.
The phrase seemed to me to suggest the scale and difficulty, and something
about the spirit, of Farmer's work.

Haitians are the third most malnourished people in the world. In a recent
survey of potable water supplies in 147 countries, Haiti came in 147th. The
potable water supplies in a lot of villages are absent—or they were until
Farmer got there. It's just as bad as anything in Africa. There's no
electricity, and the roads—well, they just really shouldn't even be called
roads. It's a nightmare to work there. If you want to build something, you
often end up having to carry cement on a donkey. It's just dreadful.

All of your books have chronicled the lives of real people in real
situations, but this is perhaps the most intensely personal chronicle. The
subtitle of the book refers to "The Quest of Dr. Paul Farmer." Is it
difficult to capture someone else's quest?

It is—without any question. In the past, I've written about supposedly
ordinary people. Of course there's no such thing as an ordinary person.
Everybody walks around with the most complex structure in the known
universe on his or her shoulders. But Paul Farmer is the least ordinary
ordinary person I have ever met. And I think that his work is tremendously
important.

Can you talk about why you were drawn to this topic? Once you decided to do
the book, what was your goal? And why do you think Paul Farmer agreed to
let you write his story?

Maybe the best way to answer all those questions is to just tell a story. I
tell part of it in the book: I met Paul Farmer by accident on my first
visit to Haiti, when I was writing an article for The New Yorker. I had
been a soldier in Vietnam and I thought I'd seen the world, but I had never
seen anything like Haiti. It was shocking to me. I remember being hit by
the fact that every plane that came in was met by hordes of people. They
still are. Many of these people would be children in rags—I mean really in
rags, emaciated, and clearly malnourished, and you knew that if you just
gave each one of them a Haitian gourde—pennies in U.S. currency—it would
keep them from starving for one night. Then there was the stuff you'd see
in the countryside: women giving birth unattended by the side of the road,
old men coming up and saying, "Grangou, grangou," meaning "I'm hungry." It
was horrible.

So I was trying to find a way, both in writing the New Yorker article and
in thinking about Haiti, to reconcile the fact of Haiti with my own really
comfortable, pretty nifty life. I talked quite a bit with Farmer on the
plane ride and I went to dinner with him afterward hoping he would help
make sense of Haiti for me, and he was very helpful. But I came away with
this sort of soldier's pessimism, thinking, Why do we bother? I didn't
examine it much further. I didn't, for instance, stop to think, It's kind
of unseemly for a person in my position to be professing despair on behalf
of these millions of people who are in desperate shape. It's really
unseemly. It's worse than unseemly—it's awful. If they have hope, why
wouldn't I have some hope for them?

I didn't know everything about Paul Farmer's life, but I knew the rough
outlines. And he hadn't yet done some of the stuff that really put him on
the map. But I knew that this was someone worth writing about. I'm always
in the market for good stories and interesting people.

I didn't see Farmer again for over five years. I didn't pursue him. I think
now the reason is that I knew that if I did start hanging around with him,
he was going to disturb my peace of mind. But I started hearing more about
him, and it made me think, What's the matter with you? You've had fate put
you in Farmer's path, and you just turned away? So I went to see him
and—I've talked to colleagues of his about this—I don't think he wanted me
to write about him at all. It's not that he wasn't friendly—he was friendly
to everyone. But I don't think he's particularly self-aggrandizing, and I
think he understood pretty clearly the risks of doing this. There's a part
of him that would prefer to just be a country doctor. But his colleagues at
Partners in Health basically said, "Look, Paul. As always, we're in
desperate need of money, and we want this cause to be a little more widely
known. And we want these conditions—particularly the state of Haiti—to be
known more widely." So Farmer said—and I remember really gulping—"Here's my
schedule for January 2000." I remember looking at it and thinking, Oh, my
God! I don't know if I can do that. But he invited me to come along with
him for the month, and I sort of swallowed hard and said, "That's great."
So I did that, and then I wrote a profile of him for The New Yorker. And
then I said, "Well, I really ought to write a book about all this with him
at the center." He would have been glad to have me write a book just about
Partners in Health in which he was just one of many characters. But I
didn't know any way to write such a book that would be as engaging as a
book that was largely focused on him.

I'm really glad you mentioned that you knew the whole experience would
disturb your peace of mind. I just returned from traveling in some Third
World countries like Cambodia and India, and came back with the same
feeling of uncomfortableness in my own comfortable surroundings after
having seen people living in such deplorable conditions. You went back and
forth a lot between the U.S. and Haiti. How hard was it to acclimate on
either end? Has the uncomfortable feeling stayed with you, and if so, how
do you deal with it?

I understand exactly what you're saying, and it's something I haven't
resolved. I don't know that I ever will resolve it. Farmer's done it so
many times, between, say, the Brigham in Boston and the hospital in Cange
in Haiti. It's quite a contrast, although the contrast is getting smaller,
at least as far as medical facilities go. It jangled him tremendously most
of his life, and it still jangles him from time to time. I mean, every time
we would get on a plane to leave Haiti he felt terrible remorse. I usually
felt relief. When I'd come to Haiti, and particularly when I got to Zanmi
Lasante, I'd feel exhilarated—it was tremendous. But I'd also count the
days until we left. Maybe I shouldn't admit that, but the truth is that
it's hard. It was very hard for Farmer to acclimate himself on both ends. I
remember once flying with him from Haiti to Miami, and then getting on a
plane to Boston. As sometimes happens, they bumped Farmer up to first
class. Every flight attendant knows him on those American Airlines
routes—he's always willing to deal with medical emergencies on board. So
we're sitting in first class and drinking and having a good time, and
suddenly Farmer says, "It's nice to be back in the first world. It always
is." And there was that tone of remorse. He'd expand on it sometimes,
saying, "These people in Haiti, most of them will never get to go anywhere."

Did you feel that Paul Farmer portrayed himself accurately to you, or did
he simply put forth a persona that he was trying to gain publicity for?

How long can someone pretend to be someone he or she is not? I remember
this schoolteacher I wrote about saying to me, "For the first two weeks, I
was trying to make everything in the class perfect, and finally I realized
that that wasn't happening and I just gave up." It's very different if
you're interviewing a State Department official, and you know you're
getting smoke blown at you.

I've been around Farmer a lot. I've watched him give speeches. I've watched
him with other people. I've traveled extensively with him. It's not so hard
to get to know someone if you spend a lot of time with him or her and you
take good notes and pay attention. It may be that, like with your spouse or
something, you get to know that person less well the more time you spend
with them. But when you're doing this with the intent of trying to write
about someone, you don't let the familiar become too familiar. I think the
hard thing, and the crucial thing—in order to write the kinds of books that
I like to write—is to try to capture a reflection of the person on the
page. It's hard, but if you can't do it, then you really haven't got much
of an engine for the stories you're telling.

It seemed in your book that you actually got to know Farmer so well that
now and then he got on your nerves a little.

I think that's very important. I wrote this book in the first person. The
Soul of a New Machine was written in the first person, too, but it was a
pretty distant first person. I think of point of view as a choice among
tools—trying to find the best place to stand from which to tell your story.
In this case, from pretty early on I knew I'd have to write this in the
first person. A friend of mine said you could call this the problem of
goodness: How are you going to make a pretty improbable-sounding person
believable? That's one thing I thought a first-person narrator could do. A
first-person narrator could testify to the fact that this guy is for real
and could also acknowledge the kind of discomfort that almost anyone—anyone
a lot less virtuous than Farmer—would feel in the presence of someone so
passionate about his cause.

After my New Yorker profile of Farmer ran, some very nasty letters came in
saying, "Who does this guy think he is?" The one I remember in particular
was talking about Farmer's marriage. Farmer's work kept him apart from his
wife and daughter a lot more than he'd have liked. The separation was
rather painful for him—I thought that was clear. But the people who wrote
these letters thought they'd found a chink in his moral armor and seized on
it with gratitude and a certain ferocity. It was as though they decided
that this guy demeaned them somehow—that perhaps he was living out a life
that they had imagined they might live one day. I call this "moral envy" in
the book. That sort of thing is not Farmer's fault. What discomfort I felt
along those lines I wanted to acknowledge, and I wanted to acknowledge it
right around the time when I thought the reader might start feeling that
way too. I think it makes it much more palatable if the author has
acknowledged this. It's a question of tone. But I hope that I turned it
around, because for me, at a certain point, I began to realize that these
discomforts were pretty shallow. The fact is, if we're really being fair,
we judge a person according to their accomplishments. Judged that way, this
guy is spectacular and beyond reproach. I wanted people to come away
admiring him, because I admire him tremendously. I think he's something
special in the world—the sort of person we ought to pay attention to. They
don't come along all that often.

There's one point in the story where you allude to the fact that Farmer
tried to "reform" you several times. ("'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.") How did this tendency of his affect your work? Did
Farmer, in fact, "reform" you in any way?

To some extent that was written jocularly. Reform is part of Farmer's
mission on earth. It's interesting how well he's organized his life as an
instrument of reform. He's made himself into an extremely good doctor— it's
what he loves most. He's the doctor we all wish we had. He's ready to
doctor anybody at any time, even to the point where he has to borrow
patients when he goes somewhere where he doesn't have any! I think that's
utterly charming. He's also made himself into an epidemiologist—a person
who understands and can think about the problems of global health. And he's
made himself into an anthropologist as well, which is tremendously useful
in these settings because of the attitude that it breeds—"I'm here not to
try to impose myself on people, but to try to figure out who they are."
That makes all the difference in the world. If you're trying to do a
medical project in Haiti it's really important, for example, that you can
make a voodoo priest your ally instead of your enemy. He equipped himself
to do that sort of thing by learning the language, among other things. He's
also a teacher at Harvard Medical School, where one is apt to get very
interesting and very smart students. And he's a writer—to some degree a
polemicist. He writes highly technical papers, typically about why
multi-drug-resistant TB has to be treated and how it can be treated—very,
very technical papers. I have a friend who's in the business of
epidemiology who looked at his bibliography and said, "This is astonishing!
One person couldn't write all this!" But he does write all of this, and he
does the other stuff as well. It's daunting.

So, it seems to me that Farmer has developed himself simultaneously in
several different directions, and if you add them all up, you have this
person who has tailored himself to be a force to try to cure what he thinks
is wrong with the world. His message is that we have extraordinary tools
now in medicine and public health, but that they tend to be concentrated in
the places that need them the least. Which is not to say that those places
ought to be stripped of them, but that they ought to be better distributed.
I don't see who could argue with that.

On several of your hikes with Farmer, Haitians would approach him to talk.
Did any ever approach him for money? If so, how did Farmer respond? My
husband is working in Haiti right now, and this question was passed on to
me by some of the aid workers there. They're all curious to hear how Paul
Farmer deals with this, as it's a daily issue for them.

People don't approach him for money in Cange, and I didn't wander the
streets of Port au Prince with him. They do come to his office and ask him
for money, though—everybody knows who he is. What he does when that happens
is he quite judiciously gives money away. I had to cut this scene to keep
the book from becoming a doorstop, but I'll never forget the moment when
some students from a college in Texas had come to visit just for the day,
and Farmer had given them a talk. After his talk they got up a little
collection—maybe a few hundred bucks in gourdes. I went into his office
later that evening and this guy comes in whom we'd met on one of our
hikes—he had five kids and his wife had left him. He had no job and was in
a pretty bad way. Farmer just gave him all the money. He said to me
afterwards, "Today, we came into some money and, of course, a few hours
later someone came in and needed it. This is Haiti. But I prefer to be
mystical about it."

One thing you have to understand about Farmer is that he doesn't care about
money at all. The time that crystallized for me was when we were on an
airplane coming from Siberia and he said, "It's going to take resources to
stop the TB epidemic, and if people want to use money to stop it, that's
fine. I don't care what gets used—use cowrie shells." Unlike me, unlike
most of us, he realized that money is just a medium of exchange—it doesn't
have any inherent value. Which is not to say that he's profligate with it,
but he would gladly take a bunch of dirty old gourdes—pieces of paper—and
trade them for the chance to materially help some poor guy living in a
squalid place in the countryside who can't feed his five kids. It's really
simple for him. It's enviable in a way. So, sure—he gives money away. He
doesn't go around passing it out though—I think he would find that sort of
obnoxious. But he wouldn't condemn it.

I remember being in India and a lot of Westerners said you shouldn't hand
out money because it just encourages begging and it propagates the
situation; instead you should try to give the money to an organization that
will help deal with the root problems.

That may be true. But I'm pretty leery of that attitude. When Tom White,
the guy who's given millions and millions over the years to Partners in
Health, first came to Haiti, he started handing out money right and left to
Haitians. And I remember Farmer describing this to me and saying, "You
know, that can be annoying. But it said something about this guy pretty
quickly—that he was responding to something genuine inside himself, and
that was something I approve of. So, what's wrong with it? Who's suffering
from this transaction, really?"

One of my favorite stories in the book is of the TB study Farmer did. One
of the crucial things about the study is that they had two groups: one
group got $5 per month, the other didn't. In the group that got the $5 per
month, 100 percent get cured. The money wasn't the only reason, but it was
a pretty important part of it. Farmer will tell that story saying, "We
thought there were no barriers to these people getting care, but we
discovered that there were tons of them, and they were all related to the
person not having a donkey, or child care, or adequate food. So getting
medicine wasn't sufficient; they needed money. Some people in international
health circles would say that's almost the same as giving money to beggars
on the street—that's no way to run a program. But I don't think they can
argue with his results. And it's pretty inexpensive.

Of course, you experience the same questions here. When my daughter was
about five years old we'd be in a place like New York and she'd say, "Dad,
give that man $5." I think that's much better than walking right by
somebody. We get so inured to the homeless in a place like New York. To see
a homeless person and say, "It's not a good idea to give him money, it'll
just encourage him to be homeless," is the easy way out. But it would be
equally foolish to say, "I gave $5 to that homeless man, and therefore all
is right with the world."

It's never comfortable. If I were a religious person, I'd say those people
were being put in front of you by God. But now I'm making myself sound like
I'm as passionate about this as Farmer is, and I can't claim that. I can't
claim to have changed my life utterly for this. I have written a book,
which is what I love to do. I wouldn't know how to do anything else. I
don't want to make it sound like it's anything noble. I was out to find a
good story to tell. And I stumbled onto one that just happens to have this
other aspect to it. There's a great quote from Graham Greene: "I have never
minded being 'used' for a cause I believe in." If it's good enough for
Graham Greene, it's good enough for me.

I've also recently published a piece in The Nation which is a diatribe
about American policy towards Haiti, which I think is really evil. So I do
what I can. I'm not going to take a vow of poverty, but I hope to
contribute to the work of Partners in Health for the rest of my life.

With your writing?

I do have other things to write, but I don't intend to leave the subject of
Haiti or Partners in Health behind. Haiti burns itself into your brain. I
would not sleep well the rest of my life if Zanmi Lasante went under, for
instance, and I hadn't at least tried to do something. For me, it's writing
that's a mechanism for helping, but everybody has some
mechanism—particularly Americans. Farmer asks an enormous amount of his
colleagues and friends, but he doesn't ask more from people than they are
capable of giving. The first thing he asks Americans to do is not to hide
this stuff away and pretend it isn't there. Once you acknowledge that the
problem is there, you feel you ought to do something. There are lots of
people who want to go down to Haiti and work with Partners in Health. And
it's lovely that they do. But what Partners in Health has to say to them
more times than not is, "How's your Creole?—How can you really help?"
They're not running a training program. This is not just a project to give
you a better-looking résumé or to enhance your life. The point is to go
down there and save lives. That's the thing that I like about that
organization. They're so efficient and skillful. They don't settle for mere
good intentions—ever.

For me, it seems like a great luxury to have this organization which, if
you give them $200, it's not going to be used to make a payment on a
limousine for one of the bosses. It's going to be used to save someone from
dying a dreadful death from tuberculosis. That's about what it costs—$200.
Or you could give $350 a year to a peasant who lost his job, and that would
provide, not a decent life by our standards, but something like poverty
with dignity there. So we're very powerful in this country when it comes to
a place like Haiti. It's sheer economics.

After I'd written the book, I thought at first that it wasn't my place to
try to raise funds for Partners in Health, or to try to pitch their cause
to the world. And then I thought, Wait a minute—why isn't it my place? I
had gone out in the world and found something extraordinary. So why
shouldn't I say, "I'm not a great expert on philanthropy or NGOs, but I've
never seen one that is as effective as this." And that includes Doctors
Without Borders, whose work in Russia is highly suspect.

That's another book, though, right?

Yes—that's another story! You take those people on at your peril, but I
wouldn't mind taking them on if I had chapter and verse on them.

Can Farmer's success in Haiti be applied to other countries?

I know it can. Let me tell you how I know that: it's being reproduced in
Haiti by leaps and bounds by community health-care workers, who are largely
peasants—often former patients or continuing patients. Partners in Health
has about 700 of these community health-care workers now in Central Haiti,
and they've been expanding on the work of Zanmi Lasante by seeing about six
or seven patients a day, twice a day. This has all been happening beyond
the scope of my book, though I tried to signal it at the end. I just got
some recent figures from Farmer. They've expanded, reopened, or fixed up a
bunch of clinics and hospitals in the Central Plateau, covering about an
eighth of Haiti, and they're still going. They go out into the community
and do prevention and health training. Particularly with TB and AIDS, where
drug resistance is such an important issue, they do directly observed
therapy. In the morning they bring the AIDS medicines to the patients, and
they bring them again in the evening, and they make sure the patients take
them. Then they sit around and chat. They give the patients a sort of
social support. Partners in Health also sends the AIDS patients to school,
and gives them monthly cash stipends for extra nutrition and stuff like
that. It works awfully well.

There's an AIDS treatment program in Boston now—in Roxbury, right near
Brigham & Women's hospital—for people for whom AIDS treatments just haven't
been working. They've basically exported the program from Haiti and are
using it in Boston. It's working very well. And it's not expensive. It
doesn't require hospitalization, and so on and so forth. I don't see why it
wouldn't be a tremendously useful tool throughout this country and in many
other countries as well. If you can do it in Haiti, it pretty much stands
to reason that you can do it anywhere.

This year, about 400,000 patients will come through the doors of Zanmi
Lasante and these other clinics. So for clinical transactions, they're way
into the millions per year. And they're doing it all for about $7.5 million
($2.5 million of that is coming from the Global Fund). These are staggering
figures. You know, my local hospital spent over $60 million in 1999. I'm
sure they spend a lot more than that now. And they're not seeing anywhere
near as many patients. I'm not sure they're doing a better job, either.
They probably aren't, actually.

Having witnessed the plight of the Haitian people firsthand, what's your
sense of what needs to be done to raise their standard of living? What hope
do you see for the people of Haiti?

I think first of all, hope is an absolute categorical imperative. There has
to be hope. You're talking about at least eight million people, and to
declare hopelessness on their behalf is just simply wrong in every way.
It's wrong because I've seen what one very small group of people without a
hell of a lot of money can do in one of the worst parts of the country.

We need to have good NGOs working in Haiti. They're a mixed bag right now.
And they have to be working in concert with a duly elected
government—whatever government that is. Because the ultimate objective, of
course, is to have Haitians running their own country, doing all this for
themselves. But they're a long, long way from that. There are many, many
steps to getting there, because so many foreigners came in and screwed
things up systematically for so long. It's foreign interference that has
put Haiti in this bag as much as anything else. So aid has to flow to Haiti
in a sensible way. Of course, what is happening right now is the opposite.
The only aid that's flying to Haiti is going not through the government,
but through foreign-controlled NGOs. That simply won't work.

Anthony Lake recently wrote an article saying that, at the very least, we
ought to be including the Haitian Ministry of Health in all of our health
efforts there. Farmer believes that very strongly. He won't do anything
except in concert with the Ministry of Health. But USAID money—money from
the United States—is blocked from going to the Haitian government. We need
a completely different mindset about Haiti. We need to think of the place
and its inhabitants first of all—not of the politics. It doesn't matter
whether we happen to like a constitutionally elected president or not. If
the United States really earnestly wanted to improve Haiti, we could have
taken advantage of the fact that Haiti had a president who was tremendously
popular and was clearly someone we could work with. And we won't do
that—particularly now when the right wing is in power in the United States.
It's sort of hopeless.

We might look hard at some of the projects the Canadians have undertaken,
which seem to be better on the whole than ones that we do. People also
ought to take a look at books like Amy Wilentz's The Rainy Season to see
how disastrous some kinds of aid programs can be. Some of the reforestation
programs like the one she writes about have actually led to more deforestation.

But do you want to know what I really think? What I really think is that if
you wanted to fix Haiti, you'd give Paul Farmer about $10 billion and
complete authority over it, and he would do it. It might kill him, but he
would do it. Get the money to the Paul Farmers of this world, who care and
are brilliant at knowing how to spend that money really wisely. Haiti
cannot do it by itself.
----

Dana Rousmaniere was recently a new media intern at The Atlantic and is
currently a freelance writer living in the Boston area.

.