11/14/23

Paul in Haiti, Haiti in Paul

I first met Paul at Duke in 1979. We were both undergrads of a somewhat nerdy cast, and therefore odd ducks in a school where sports and fraternities set the tone. I was fresh from a high school year abroad in France and had been reading all the structuralist anthropology and linguistics I could get my hands on—Lévi-Strauss, Benveniste, Jakobson, Barthes, Kristeva, and also Foucault, Althusser, Deleuze, and Derrida. Paul knew this stuff too, but he wasn’t as impressed by the elegant ballet of signifiers as I was. 

Our teacher Weston LaBarre was an eclectic structuralist, adept at handling networks of meaning and also warmly curious about the lives of the people he studied. Through Weston, Paul got to know the ethno-psychiatrist Georges Devereux, a builder of theories with an astonishing range of on-the-ground experience, having lived and worked as a therapist among Native Americans and mountain peoples of Southeast Asia, as well as practicing and teaching in US hospitals. Devereux’s work made a deep impression on us because of its respect for the dynamic of transference and counter-transference—in other words, the ways that the person being observed influences the observer, and the observer influences the observed. 

At that moment in his life I think Paul was expecting to train as a psychiatrist and work with indigenous populations somewhere in the world. But Devereux was too ill and frail to take Paul on as a student. That turned out to be a providential dead end. For another part of Paul’s omnivorous reading in French anthropology had led him to Haiti. In ethnopsychiatry there was the great book on Haitian vaudou by Alfred Métraux. Métraux had been close to Parisian surrealists I was reading: André Breton, Michel Leiris, Léopold Sédar Senghor. And from that group it was a short step for me, under Paul’s tutelage, to begin reading Haitian authors like Jean Price-Mars, Jacques Roumain, Jacques-Stéphen Alexis, René Depestre, Jean Métellus, René Bélance, just to cite those who wrote in French. He met Depestre, Bélance, and Métellus and interviewed them for a book we were going to write together, Three Haitian Poets, Selected Translations and an Introduction. That book never happened as such, for reasons having to do with the timidity of American publishers and our being total unknowns, but parts of it eventually leaked into print.

Paul went to Haiti after graduating from college. The year was 1982-1983, coincidentally the year that a mysterious and fatal auto-immune syndrome began to be reported among gay men, blood transfusion recipients, and Haitians (a collection of categories that was random but somehow not random, if you thought less about causality than about stigma). There he came straight up against the limits of what was known (charitably) as charitable healthcare in a profoundly impoverished country: patients were turned away from the hospital’s door for no reason but lack of funds, and other patients were given useless diagnoses—prescribed treatments they could never access. Tracy Kidder has written memorably about one night of desperate frustration in a hospital that was poorly set up to do its job. So Haiti announced to Paul, in the starkest possible terms, what the problem was. It was what he would later call “medical nihilism.”

And Haiti also brought Paul the vision of a solution. When I went to visit Paul in the spring of 1983, he had just moved from a room in Port-au-Prince to the town of Mirebalais, where he was living with the Lafontant family. Father Fritz Lafontant incarnated the “preferential option for the poor.” Père Fritz and his wife, Yolande, whom we called Mamito, chose to live among the squatters in the mountain village of Cange, people who were badly-off even by Haitian standards. He leveraged ecclesiastical connections with the Episcopal Diocese of South Carolina to bring doctors and dentists in for short clinical visits. Built like a football tackle, a theologian of great insight, Father Fritz saw no reason central Haiti should not have its own well-equipped, well-staffed, and free hospital, ringed round with outreach services and social benefits. Nobody in Cange or Mirebalais disagreed or called him unrealistic, at least not in my hearing. His utter conviction inspired and guided Zanmi Lasante, the original core of Partners In Health. HIV, hurricanes, earthquakes, coups, murders, kidnappings, and other heartbreaks—nothing could divert the ékip solid of Zanmi Lasante from their path.             

The successive challenges and, let’s put aside modesty, victories of PIH, which I trust will go on until there is no more need for them, all grew out of that encounter. Paul’s passion for Haiti was infectious and his engagement was total. I don’t know what would have happened if Paul had gone somewhere else after college. By now it is impossible to imagine Paul without Haiti or, I think, Haiti without Paul.

(Read at the 2023 Paul Farmer Symposium on Global Health, Harvard Medical School.)

10/2/22

Paul Before Paul

(pronounced at the conference “The Moral and Intellectual Legacy of Paul Farmer,” Harvard Medical School, October 1, 2022)

“It is incomprehensible, the fact that someone can become something so quickly. I’ll never forget the moment when what used to be my father arrived in an urn of fake marble.” That is Paul Farmer speaking, in 1985, from a letter I’ve been keeping, like all of his letters, through countless moves and life changes. Like all of you, I can’t bear to see Paul turn into a thing, and one way of forestalling that is to make his words resound again.


            I had the astonishing good fortune to befriend Paul in 1978 or 79 and to keep up with him ever after. We exchanged a lot of letters (for the younger ones in the audience, a “letter” is a document often written by hand on paper and sent through an agency called the “post office”). Whether in person or by letter, conversation with Paul was a constant laser-tag stream of jokes, questions, gossip, reflections, and grandiose plans. I don’t want to claim excessive privilege from this long acquaintance, which I’m certainly not alone in having, but today it allows me to let Paul speak for himself from the time before he was Paul, so to speak.

We’re talking today about Paul’s moral and intellectual legacy, Paul as a world-historical figure, as Arthur Kleinman said this morning. Yes, we must. I think Paul really came into his own when PIH demonstrated, first, that MDRTB was infectious and could be cured, even in the poorest communities; and second, that HIV could be controlled, also in the poorest and least-equipped communities, if only the necessary drugs were made available. These two victories (owed to many, but many who were inspired or led by Paul) solidified his position in global health and made his so-called idealism look like practical common sense. But I want to take you back to a time when Paul was just a guy named Paul, so to speak, when nobody knew about him and he had little but his own stubborn energy and commitment to go on.   

            One of the characteristics that made him so endearing was his ability to focus on the particular person in front of him, not caring at all about whether that person was important or influential—since every person is important to him or herself, and he could adopt that perspective. An example. 1983, and Paul was back home from Brooksville after a stint in Haiti—recovering from malaria, as I learned later. But he found time to write me a succession of missives chronicling his erotic pursuit through the swamps of an elusive blue heron named Great Blue—a sort of comic allegory of one of our frequent topics of discussion, our ongoing late-adolescent girlfriend problems. My problems were not serious in any sense, but he cared enough to give me therapy through parody. He wrote from Haiti after a brief visit to Boston that he was “relieved to be free of Jack Frost and his foliage-hating henchmen.” A month or so later, from Boston: “I am going to Haiti in 19 days (Ba-m nouvel zanmi ou!) for a site visit, as they say in development set jargon, and I wish it were for 19 years.” I got to travel around Haiti with him, got to know and admire the great Father Fritz Lafontant who was Paul’s strongest local supporter, and saw for myself how completely dedicated he was to the place and to all Haitians (the zanmi, “friends,” he mentioned were some Haitian neighbors of mine in New Haven whose lives and extended family he never failed to enquire about). Some of the pictures you’ve seen this morning were taken by me in 1983, starring a gangly, grinning, excited Paul, in his real country and in his element. I only wish I had taken more. In 1983 Haiti was still in the grip of the Duvalier kleptocracy, and we had to be careful what we said and to whom, because Baby Doc’s informers and enforcers were everywhere. That changed in 1986 with the déchoukaj or eradication of the Duvaliers. Paul wrote me: “Still celebrating about Haiti. Touch and go for a bit, as Père was ‘missing’ for 10 days (‘Li kache nèt!’). He resurfaced, quit the maquis, the day after the Baby left.” As you know, the ebullience didn’t last. A junta took control and declared Paul persona non grata for several years, forcing him to remain, unhappily, the prisoner of Jack Frost and Harvard. Those were hard years for the clinic in Cange: years of intimidation and scarcity. Then came, in 1994, the chance to go back. Paul’s first act was to give the clinical staff time off: “On Friday, it was my great pleasure to send the bulk of the medical staff—two doctors and two nurses—home. No problem, I said—I can cover both the general and the women’s clinic. The first couple of hours was fun, straightforward (malaria, bronchitis, one case each of typhoid and TB, diarrheal disease, some dermatoses, impetigo, etc.). But then came a tibial fracture. As you know, the X-ray machine is down, so I had to set it manually and cast it (thanking all the while my ortho tutor)… Less than an hour ago I delivered my first post-Titid baby.” “I arrived to find no asthma meds (mine are gone now too…), no metronidazole, no cipro, kanamycin, no sterile saline solution, no catheters, and no morphine. Ringer’s lactate is the only IV solution available. The women’s health clinic is poorly stocked…” “The health crisis is unprecedented… Cange has the only functional medical care in the entire central plateau. Three years ago, it was one of 7 comparable institutions.” 

            The harm done by those harsh years took time to repair. Merely repairing was never on Paul’s agenda, though: “There are enough new cases of AIDS in the central plateau, and enough horror stories, to warrant the building of a small hospice. This is something Fritz and I had discussed last year, and it seems, more than ever, a noble idea….” That noble idea led to the provision of advanced therapies that brought HIV patients in the Cange clinic back to life and health and proved the naysayers wrong. 

            You know the story from then on. We are all grateful to Paul. Even if we were not his patients, he did cure us, many of us at least, of our depressions and hopelessness, of the feelings and thoughts of futility and resignation that disarmed us before the injustices he wouldn’t accept. It seems to me that he knew from the start, from his gangly, giggly start, what he needed to do. I was fortunate to have him for 43 years as my reality check, my moral compass, the person I could count on to read my messy drafts, the friend I could tell anything to. Every one of you, I know, can say something similar. 

            Paul sometimes reminded me of his namesake, the apostle Paul. You remember, the one who said that the wisdom of the world is folly in the eyes of God and the folly of the inspired is the true wisdom. Surely it took more than a grain of folly, or wisdom, to fail to understand why people in Haitian villages should not expect the same quality of healthcare that the well-heeled citizens of Cambridge, Mass., expect. As Confucius said: “I need two kinds of people, crazy ones and careful ones. Crazy ones to forge ahead; careful ones to avoid making mistakes.” (必也狂狷乎, 狂者進取, 狷者有所不為; Analects 13) Paul could be as careful as anyone, but his soul, if I may speak in such terms, was with the craziness. He loved defying passive acquiescence. Some of his more stinging phrases hang for me as brightly as warning comets in the sky: “managing inequality,” “socialized for scarcity,” “medical nihilism.” And on the bright side: “the hermeneutic of generosity,” “the preferential option for the poor,” “expert mercy.” Paul’s priorities were: prisoners first, then patients, then students. You can analogize to fit your own sphere of action. I always try to do so.

04/15/22

From a talk about Paul Farmer

I went to Johns Hopkins the other day to give a talk about what I chose to call “Medical Humanity” (the singular was intentional). One paragraph from the talk, I think, gets the point across:

Taking a phrase from his Haitian interlocutors, Paul often spoke of “stupid deaths”— deaths brought about by human negligence, fecklessness, miserliness, obstinacy, and the like. Death comes to us all, of course, but the point is to forestall the avoidable deaths. Medicine in the immediate sense and in the larger sense of social medicine tries to do that. But are any deaths not stupid? Attempting to fix a meaning on a death is a task that should be approached with the utmost forbearance and caution. But from Gilgamesh on, the job of the humanities has been to surround death with auras of potential meaning. If we who deal in words and images and ideas are unable to hold off stupid deaths, we can at least avert the stupidity of those deaths. Pluck the flowers from the chains, my fellow humanists! Our assumption should rather be that all deaths are stupid, consummately stupid, until proven otherwise. 

43 years of friendship have at least taught me that much.

“Why should a dog, a horse, a rat, have life, / And thou no breath at all?”

09/13/18

There’s an App for You

For the last few months I’ve been plagued by a high-pitched whine, like the sound made by an older refrigerator, in both ears. It’s louder sometimes, fainter sometimes, but never really switches off. I finally went in search of a specialist who could help do something about it. The first was an old-school psychoanalyst, a very kind fellow whose German was so classic I had no trouble understanding it. (I learned German to read the writers of 1770-1830, so my vocabulary tends toward the elevated and philosophical.) But I don’t have time just now to commute an hour each way for analysis terminable or interminable; it seemed a bit wide of the mark. He additionally recommended I look into chewing gum, yoga, massage, and iPod apps that mask, reduce or (unverified claim) reprogram the subjective noise.

I got one of those apps last night. It pipes white noise into your ears as a distraction; you can give the white noise a “brown” or “pink” tinge. You can also set it to play an indefinite loop of relaxation sounds, and mix different sounds until you find the thing that relaxes you best.

After half an hour of tweaking, I settled on a combination: Underwater + Bubbles + Monks + Wind. So now you know: the guy whose idea of relaxation is to hear monks chanting underwater, while haschischins tug on their hookahs and a four-knot gale blows, that’s me. In fact, that may be all you need to know about me.

04/1/16

Longer Views

There is (this will be no news to anyone who’s been awake for the last forty years) a debate about whether state-provided social services are too expensive to be continued, whether they’re actually beneficial to their recipients or reduce them to the status of helpless dependents, whether they’re more or less efficient than some hypothetical market mechanism– in sum, whether they should exist at all. At least as presented in the relatively highbrow newspapers and magazines that cross my threshold, the matter of cost is always framed in relation to current expenditures: health and education as a fraction of GDP, or as compared to defense, etc.

That way of framing the math, however, renders invisible many dimensions of benefit and cost that become perceptible only when we look at matters in a longer view (say over a lifetime) and dice more finely the categories of payers and recipients. It turns out that for the overwhelming majority of British rate-payers, and by overwhelming I mean 93%, the amount paid in over a lifetime exceeds the amount received in benefits. So you can forget about the welfare queens, the “culture of dependency,” and all that stuff. Who knew, you may ask, that the public was always stepping up to the plate and giving a little more than necessary to help the less fortunate?

In another way, social services such as education, healthcare, and unemployment insurance act as a collective savings account to get people through the hard times. The number of people who will at one point or another need to call on these collective savings is large. Only a few people never experience need over their lifetimes. The few lucky standouts shouldn’t begrudge the majority whom social investments kept from going broke at one point or another: if the unlucky folks really had to eat garbage or steal on a regular basis in order to survive, surely the lucky ones would be sleeping less well at night. And need is not a lifetime thing; it happens in moments or cycles and, once again, the impact can be cushioned by the whole society’s willingness to think and pay ahead.

Admittedly, these results are from Great Britain, where some 70 years of Labour-inflected policy have created a long enough statistical run to give useful data. But surely in the US, even without a National Health Service and despite our patchwork of state governments, some more provident than others, the numbers exist to show what entitlements really do and don’t do, under a variety of conditions, over a lifetime. I’d be glad to read a factual comparative study. In the meantime, here’s the report on lifetime outcomes from the Nuffield Foundation’s Institute for Fiscal Studies:

 

11/25/14

Remedying

Another article about the failures of international aid, this time from the New Republic, and I fear the overall effect of such think-pieces will be to validate the indifference of people who were looking for a reason not to help others anyway. It’s true that celebrity jaunts to Africa, etc., have little lasting effect except perhaps on the celebrity’s public image. That’s a problem with the culture of celebrity, not of aid. It’s also true that sudden infusions of money into an economy are apt to destabilize and to have perverse effects. That’s a problem of bad planning. White Land Rovers? I would recommend steering clear of any project that involves the purchase of many white Land Rovers.

The article suggests that low overhead is not in and of itself a good marker of charitable effectiveness, that spending money on fund-raising is often a precondition for having an effect: well, here I think you must use your judgment about what is the tail and what is the dog. A low tail-to-dog ratio matters when deciding where to put one’s donations, but it’s best to concentrate on questions such as these (also legible between the lines of the article): have the intended beneficiaries themselves expressed a desire for the planned interventions? Is there a concrete plan for engagement on the part of the beneficiary population, rather than a scheme in the heads of well-intentioned First Worlders to build something, feel good about it, and abandon it? “First, do no harm” is a rule worth following even if you’re not a medical worker.

Most important is to have an accurate sense of the economic flows among which a development-assistance plan will exist. How much of the money flowing in and out of a given country is dedicated to arms procurement, to food assistance, to financial whizzbangery (including corruption)? How much does the local economy rely on expatriates remitting their paychecks? What’s up for sale, in terms of natural resources or the vital interests of the residents, and what is protected (and how well) from rent-seeking investors? The perplexed, such as yours truly, appreciate a sense of proportion about all these things.

06/6/14

Do Feed the Public Intellectual

(Introducing Paul Farmer, Human Rights Program Kirschner Memorial Lecture, June 5, 2014)

Good evening and welcome to tonight’s Kirschner Memorial Lecture. I’m delighted to see so many of you here tonight, a direct acknowledgment of the significance of our Human Rights Program and a hint that our benefactors’ generosity has not been totally misplaced. The questions examined in the Human Rights Program are among the most serious questions raised in a university, and I would say that for us, specifically, in this country, with our history and assumptions, the area of health and human rights has the greatest power to change the way we see ourselves and others.

For many of us in Paul’s and my generation in the United States, the first time we heard about human rights as a field of activism, it was in connection with the denial of people’s rights to free speech and assembly, their right to emigrate, their right to seek redress, their implicit right to representative government. And we learned about this in the context of the Cold War, when it seemed self-evident that people in some part of the world benefited from the recognition of those rights, while people lacked them in many other parts of the world—not only the Soviet bloc and China, but also Latin America, Asia and Africa, where the client states of the great powers all seemed to repress their dissidents with the greatest indifference. Of course, it didn’t stop there. The response to human rights activism by official representatives of the socialist countries and by some of our own home-grown leftists was to point out how inequitably the market system distributed such basic goods as food, housing, education and medical care, goods which, it was implied, were a fair trade for civil and legal rights. The funny thing about this answer is that it was taken just as a rebuke of the West’s hypocrisy. Despite some laudable exceptions, we did not experience, even in the Carter era which made such a noise about making human rights the driving force of our foreign policy, a large-scale effort to wrap social and economic rights around the uncontestable but rather abstract goods of free speech and fair elections at home. The struggle for civil rights and equality within the US, which had concluded in the courts with a handful of imperfect measures for instituting fairness in civil life, did not carry over into an effective War on Poverty. The Great Society spent most of its surplus on weaponry, with a small percentage allocated to nagging our rivals about their bad human-rights record.

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