Mountains Beyond Mountains

Treating the Ills of Poverty in Haiti

by Tracy Kidder

Amnesty Now, Amnesty International, Spring 2004

[In the dirt-poor, politically roiling Haiti, Dr. Paul Farmer treats the rural poor and confounds the public health establishment. His prescription includes expensive medicine, new schools, communal water systems, and long-trek house calls.]

From the moment I saw the Zanmi Lasante Hospital, out there in the little village of Cange, in what seemed to me like the end of the earth, in what was in fact one of the poorest parts of the poorest country in the Western Hemisphere, I felt I'd encountered a miracle.

In Haiti, I knew, per capita incomes came to a little more than one American dollar a day, less than that in the central plateau. The country had lost most of its forests and a great deal of its soil. It had the worst health statistics in the Western world. And here, in one of the most impoverished, diseased, eroded, and famished regions of Haiti, there was this lovely walled citadel, Zanmi Lasante. I wouldn't have thought it much less improbable if I'd been told it had been brought by spaceship. In fact it had been "brought" by Paul Farmer, a Harvard-trained American doctor who

My first week in Cange I met a peasant farmer who had brought a sick child to the hospital-by donkey, on a trek of 12 miles along Highway 3. I asked him if he'd felt relieved when he got to Cange and the medical complex. I needn't have bothered. He looked surprised at the question and simply said, "Wi. " There were a handful of other clinics and hospitals in the region, but none were well-equipped and some were downright unsanitary, and everywhere patients had to pay for medicines, and even the gloves that would be used to examine them, and very few people in the central plateau could pay much of anything. At Zanmi Lasante, too, patients were supposed to pay user fees, the equivalent of about 80 American cents for a visit. Haitian colleagues of Farmer's had insisted on this. Farmer was the medical director, but he hadn't argued. Instead-this was often his way, I would learn- he had simply subverted the policy. Every patient had to pay the 80 cents, except for women and children, the destitute, and anyone who was seriously ill. Everyone had to pay, that is, except for almost everyone. And no one-Farmer's rule-could be turned away.

Perhaps a million peasant farmers relied on Zanmi Lasante. At the moment, about 100,000 lived in its catchment area, the area served by its community health workers, 7o in all. Some patients came great distances, as distance is measured in a country of ruined roads and villages served only by footpaths-from Port-au-Prince and Haiti's southern peninsula, and from towns along the border with the Dominican Republic, speaking Spanish. Most came from the central plateau, on the battered, overloaded passenger trucks that navigated Highway 3. Many came on foot and by donkey. Now and then out on the road, a bed moved slowly toward the front gate, a bearer at each corner, a patient on the mattress.

Sometimes Zanmi Lasante's pharmacy muddled a prescription or ran out of a drug. Now and then the lab technicians lost a specimen. Seven doctors worked at the complex, not all of them fully competent-the staff was entirely Haitian, and Haitian medical training is mediocre at best. But Zanmi Lasante had built schools and houses and communal sanitation and water systems throughout its catchment area. It had vaccinated all the children, and had greatly reduced both local malnutrition and infant mortality. It had launched programs for women's literacy and for the prevention of AIDS, and in its catchment area had reduced the rate of HIV transmission from mothers to babies to 4 percent-about half the current rate in the United States. A few years back, when Haiti had suffered an outbreak of typhoid resistant to the drugs usually used to treat it, Zanmi Lasante had imported an effective but expensive antibiotic, cleaned up the local water supplies, and stopped the outbreak throughout the central plateau. In Haiti, tuberculosis still killed more adults than any other disease, but no one in Zanmi Lasante's catchment area had died from it since 1988.

A crowd of perhaps 30 or 40 waits in the hall, some sitting on benches, some milling around.

A man whom Farmer refers to as Lazarus, who arrived some months ago on a bed frame carried by relatives, wasted by AIDS and TB to about go pounds, now weighing in at about 150, cured of TB and his AIDS arrested thanks to medications.

A healthy-looking young woman whose father, only a month ago, was saving up for her coffin.

A lovely-looking young woman being treated for drug-resistant TB, now in the midst of a sickle-cell crisis and moaning in pain. "Okay, doudou. Okay, cherie," Farmer coos. He orders morphine.

A man with gastritis in late middle age. In Haiti, Farmer told me, that could mean 30 years old, since 25 percent of Haitians die before they reach 40. "It's because there's a near famine here," Farmer says while examining him.

A 16-year-old boy too weak to walk, who weighs only 6 0 pounds. Farmer diagnoses an ulcer. "His body's gotten used to starvation. We're gonna buff him up. " Farmer hefts a can of the dietary supplement Ensure. "This is good stuff So we'll give him a couple hundred dollars of Ensure, and I'll take great pleasure in violating the principle of cost-efficacy."

Through the louvered windows high on the wall behind his desk, I see stars shivering in the warm night. A sad-faced young man takes his seat beside Farmer and stares down at his own feet, shod in ragged running shoes, splitting at the heels. His name is Ti Of a. He has AIDS.

No one else, not at this time, is treating impoverished Haitians with the new antiretroviral drugs. Indeed, before Farmer, almost no one in any poor country is treating poor people who have the disease. Even some of Farmer's friends in the Haitian medical establishment have told him he's crazy to take on AIDS this way in Cange, and certainly many experts in international health would agree. Leaving aside all other objections, the new AIDS drugs could cost Zanmi Lasante about $5,000 a year per patient. Nonetheless, Farmer had started some patients on triple therapy.

Even more controversial was Farmer's commitment to treat not only the diseases that racked his patients' bodies, but also those that devastated their communities: the socioeconomic ills or "structural violence" as he called it. One health worker at Cange recited a Haitian saying: "Giving people medicine for TB and not giving them food is like washing your hands and drying them in the dirt."

Thus, all TB patients in the catchment area received the full package of services. Each continued to get what is called directly observed therapy, a community health worker on hand to be sure the patient took the medicines on schedule, and each got the monthly cash stipend- the equivalent of about five American dollars- to pay for extra food, child care, and transportation to a monthly doctor's appointment at Zanmi Lasante. The program had worked well, indeed, couldn't have worked better. They hadn't lost a single patient to TB in 12 years.

Just recently, a TB patient from a village called Morne Michel hadn't shown up for his monthly doctor's appointment. So-this was one of the rules-someone had to go and find him. The annals of international health contain many stories of adequately financed projects that failed because "noncompliant" patients didn't take all their medicines. Farmer said, "The only noncompliant people are physicians. If the patient doesn't get better, it's your own fault. Fix it." A favorite Dokte Paul story in the village of Kay Epin was of the time, many years back, when Farmer had chased a man into a field of cane, calling to him plaintively to come out and let him treat him. He still went after patients occasionally. To inspire the staff, he said, and to give him a break from his office. So he was going to Morne Michel himself, and was taking me with him.

Beyond mountains there are mountains." The proverb appeared to describe the location of Morne Michel, the most distant of all the settlements in Zanmi Lasante's catchment area.

Farmer drove the first leg in the pickup truck, south down National Highway 3, past two-roomed huts with metal roofs and little granaries on stilts-built, he explained, to keep food safe from animals, but rats still ate about a third of harvests-and stunted-looking pigs and goats and scrawny yellow dogs. Smiling for a moment, he said that Haitian peasants had a lot of sayings: that they're the only farmers with land so steep they break their legs in their cornfields, that their dogs are so skinny they have to lean against trees in order to bark. Soon a reservoir came into view, a mountain lake far below the road. The scene looked beautiful, blue waters set among steep, arid mountainsides. And, if you saw with peasant eyes, Farmer said, the scene looked violent and ugly, a lake that had buried the good farmland and ravaged the highlands. He parked beside the ruin of a small cement factory. Plants were growing helter-skelter high up on the rusted structure. A hundred yards away stood a concrete buttress dam.

These days, when he wasn't in Haiti, he gave a lot of speeches, sometimes several in one day, and in every one I heard, he talked about the dam. It appeared in all the books he had published by 2000 and in the books that he had helped to write and edit, and also in many of his journal articles-42 of those by then. As a scholar and writer, Farmer had taken his greatest pains to assert the interconnectedness of the rich and poor parts of the world, and the dam was his favorite case study.

It stops up Haiti's largest river, the Artibonite. It's called the Peligre Dam, and the impounded waters behind it, the Lac de Peligre. The U.S. Army Corps of Engineers had planned it. Brown & Root of Texas, among others, built the structure in the mid-1950s during the reign of one of Haiti's American-supported dictators, with money from the U.S. Export-Import Bank. It was advertised as "a development project," and no doubt some of the people behind its creation believed it a gift to Haiti. But no one seems to have given much thought to the peasant farmers who lived in the valley upstream.

The project was intended to improve irrigation and to generate power. It wasn't as though the peasants of the central plateau didn't need and want modern technology, Farmer said. But, as they themselves often remarked, they didn't even get electricity or water for their land. Most didn't get money either. In fact, the dam was meant to benefit agribusinesses downstream, mostly American-owned back then, and also to supply electricity to Port-au-Prince, especially to the homes of the numerically tiny, wealthy Haitian elite and to foreign-owned assembly plants.

Since the flooding of the valley, many peasant girls and boys from Cange, children of what Farmer called `'the water refugees," had left home looking for work in the capital, where they cooked and cleaned and stitched Mickey Mouse dolls and baseballs, more than a few of them nowadays returning home with AIDS.

When Farmer first saw this piece of Haiti and began to ferret out its history, old-timers talked longingly to him about the days before the water rose, when families lived on farms beside the river and everyone had enough to eat and something left over to sell. Some remembered being warned that their land was going to be submerged. But the river had always flowed by, and they'd examined the dam in progress, and they couldn't believe that a mere wall of concrete could hold back their river. One of the old people of Cange remembered seeing the water rising and suddenly realizing that his house and goats would be underwater in a matter of hours. " So I picked up a child and a goat and started up the hillside."

Families had hurried away, carrying whatever they could save of their former lives, turning back now and then to watch the water drown their gardens and rise up the trunks of their mango trees. For most, there was nothing to do but settle in the steep surrounding hills, where farming meant erosion and widespread malnutrition, tending nearer every year toward famine. And for years there were wailings and curses and loud arguments among old neighbors, fighting over titles to the land that was left.

Things got worse. Even after the dam, most peasants still had their black, low-slung Creole pigs, which they kept like bank accounts, to pay for things such as school tuition. But in the earIy 1980S, they lost those as well. Alarmed about an outbreak of African swine fever in the Dominican Republic, afraid that it might threaten the American pork industry, the United States led an effort to destroy all the Creole pigs in Haiti. The plan was to replace them with pigs purchased from lowa farmers. But these were much more delicate, much more expensive to house and feed, and they didn't thrive. Many peasants ended up with no pigs at all. When school started the year after the slaughter, enrollments had declined dramatically, throughout the country and around Cange.

We walked across the top of the dam. The railings were rusted, the concrete flaking. To our right the roiled waters of the Artibonite rushed away, and to our left a few small canoe-like vessels plied blue, placid waters. It looked almost like a tropical resort. Farmer walked briskly along. A small juvenile escort followed him for a time. Local people heading the other way smiled when they saw him and said, "Bonjou, Doc mwen." (Good morning, my Doc.) There were clouds then sun then clouds again, and a gentle breeze. I felt vigorous and cheered by borrowed popularity.

On the other side of the dam, a footpath- loose dirt and stones-went straight up. Farmer had a slipped disk from 18 years of traveling Highway 3. His left leg had been surgically repaired after he'd been hit by a car back in 1988, and it turned out at a slight angle-like a kickstand, one of his brothers said. He had congenital high blood pressure and mild asthma, which developed after he'd recovered from a possible case of tuberculosis. But when I got to the top of that first hill, sweating and panting, he was sitting on a rock, writing a letter to an old friend, a contributor to Partners In Health whose spouse had recently died. It was the first of many hills.

We passed smiling children climbing steep rocky paths that I had to clamber up on all fours. They were carrying water, in pails and plastic jugs that once held things like paint, oil, and antifreeze. The full containers must have weighed half as much as the children did. We passed many patches of millet, the national staple, which seemed to grow out of rocks, not soil, and small stands of banana trees and, now and then, other tropical species, Farmer pausing to apply the Latin and familiar names-papaw, soursop, mango-a gloomy litany because there were so many fewer of each variety than there should have been.

Many aid experts from prosperous places gladly expressed hopelessness on the Haitians' behalf, Farmer would say. By this point on our hike, I too was guilty. The houses we passed in the mountains were much worse than most of the ones around Cange.

They had dirt floors and roofs made of banana fronds, which, Farmer pointed out, leaked in the rainy season, turning the floors to mud. We passed a group of women washing clothes in the rivulet of a gully. "lt's Saturday," said Farmer. "Washing day. I guess the Maytag repairman didn't come." Haitians, he said, are a fastidious people. "I know. I've been in all their nooks and crannies. But they blow their noses into dresses because they don't have tissues, wipe their asses with leaves, and have to apologize to their children for not having enough to eat."

"Misery," I said. But this would not suffice. He was on a roll.

"And don't think they don't know it," he said, and referring to white liberals added, "There's a WL line-'They're poor but they're happy' line. They do have nice smiles and good senses of humor, but that's entirely different." Like many of his remarks, this one gave me pause.

Just when you thought you had the hang of his worldview, he'd surprise you. He had problems with groups that on the surface would have seemed like allies, that often were allies in fact, with, for example WL's, some of whose most influential spokespeople were black and prosperous. "l love WL's, love'em to death. They're on our side," he had told me some days ago, defining the term. "But WL's think all the world's problems can be fixed without any cost to themselves. We don't believe that. There's a lot to be said for sacrifice, remorse, even pity. It's what separates us from roaches."

We went on, deeper and deeper into the mountains, Farmer leading the way. We chatted front to back. I was drenched in sweat. I couldn't see even signs of perspiration on his neck-his pencil neck as friends of his called it. Many people waved to him-the lifted hand motionless, the fingers fluctuant, like the legs of insects on their backs.

"Do you see how Haitians wave? Don't you love it? You dig?" he said to me, waving back with his fingers. The trail wound across barren, steeply folded mountainsides. I had thought that I was fairly fit, but at the top of every hill, Farmer would be waiting for me, smiling and making excuses for me when I apologized-I was 14 years older; I wasn't used to the climate.

The one-way trip to Morne Michel usually took him two hours. About three hours after we'd set out, we arrived at the hut of the noncompliant patient, another shack made of rough-sawn palm wood with a roof of banana fronds and a cooking fire of the kind Haitians call "three rocks."

Farmer asked the patient, a young man, if he disliked his TB medicines. "Are you kidding?" he replied. "I wouldn't be here without them." It turned out that he'd been given confusing instructions the last time he was in Cange, and he hadn't received the standard cash stipend. He hadn't missed any doses of his TB drugs, however. Good news for Farmer. Mission accomplished. He'd made sure that the patient's cure wasn't being interrupted.

We started back. I slipped and slid down the paths behind Farmer. " Some people would argue this wasn't worth a five-hour walk," he said over his shoulder. "But you can never invest too much in making sure this stuff works."

"Sure," I said. "But some would ask, 'How can you expect others to replicate what you're doing? 'What would be your answer to that?"

He turned back and, smiling sweetly, said, "F* *k you." Then, in a stentorian voice, he corrected himself: "No. I would say, 'The objective

is to inculcate in the doctors and nurses the spirit to dedicate themselves to the patients, and especially to having an outcome-oriented view of TB.'" He was grinning, his face alight. He looked very young just then. "In other words, 'F* *k you."'

We started on again, Farmer saying over his shoulder, "And if it takes five-hour treks or giving patients milk or nail clippers or raisins, radios, watches, then do it. We can spend $68,000 per TB patient in New York City, but if you start giving watches or radios to patients here, suddenly the international health community jumps on you for creating nonsustainable projects. If a patient says, I really need a Bible or nail clippers, well, for God's sake!"

The rest of the way back was mostly a descent, but there were still some slopes to climb. I straggled up out of another ravine and as usual found Farmer waiting for me. He stood at the edge of a cliff, gazing out. I walked over to him. The view from where he stood was immense.

Scrims of rain and clouds and swaths of sunlight swept across the yellow mountains in front of us and the yellow mountains beyond those mountains and over the Lac de Peligre. The scene, I realized, would have looked picturesque to me before today. So maybe I'd learned something. Not enough to suit Farmer, I suspected. Education wasn't what he wanted to perform on the world, me included. He was after transformation.

I offered him a slightly moist candy, a Life Saver from my pocket. He took it, said, "Pineapple, which, as you know, is my favorite," and then went back to gazing.

He was staring at the impounded waters of the Artibonite. They stretched off to the east and west and out of sight among the mountains.

From here the amount of land the dam had drowned seemed vast. Still gazing, Farmer said, "To understand Russia, to understand Cuba, the Dominican Republic, Boston, identity politics, Sri Lanka, and Life Savers, you have to be on top of this hill."

The list was clearly jocular. So was his tone of voice. But I had the feeling he had said something important. I thought I got it, generally. This view of drowned farmland, the result of a dam that had made his patients some of the poorest of the poor, was a lens on the world. His lens. Look through it and you'd begin to see all the world's impoverished in their billions and the many linked causes of their misery. In any case, he seemed to think I knew exactly what he meant, and I realized, with some irritation, that I didn't dare say anything just then, for fear of disappointing him.

For more on Partners in Health: www.pih.org

Tracy Kidder is author of The Soul of a New Machine, House, Among Schoolchildren, Old Friends, Home Town, and most recently, Mountains Beyond Mountains, Healing the World: The Quest of Dr. Paul Farmer, 2003, from which this article is adapted. He won the Pulitzer Prize and National Book Award, among other literary prizes. was challenging standard preconceptions of public health for the world's poor.

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