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.