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From Dr. Paul Farmer, a six-pack and "Love, ID"

November-December 2003

Editor's note: Paul E. Farmer, M.D. '88, Ph.D. '90, is professor of medical anthropology in the department of social medicine. His title and departmental affiliation, unlike those of some of his Harvard Medical School colleagues, immediately suggest some of the work for which he has become world renowned. In 1985, he helped establish Clinique Bon Saveur, a charity hospital serving the desperately poor population around Cange, in Haiti's rural central plateau. Two years later, he cofounded Partners in Health, which has channeled support to the clinic and to programs in such difficult venues as the shantytowns around Lima, Peru, and prisons in Russia where Farmer and colleagues have pioneered programs to combat multiple-drug-resistant tuberculosis, AIDS, and other scourges that prey particularly hard on the poorest and most vulnerable of the poor. In each case, Farmer has maintained hands-on involvement as a doctor who is expert in treating infectious diseases, an advocate for needy populations, and a prolific author. His work has been recognized with a MacArthur Foundation fellowship, a Heinz Humanitarian Award, and many other honors.

Now his efforts have been recognized in a new way, in a characteristically nuanced book by Tracy Kidder '67, who met Farmer by chance in Haiti in 1994. Kidder, who has won a Pulitzer Prize and a National Book Award, has written about technology and manufacturing, about the building of a house, and about schooling, among other subjects. But he has never had a subject like Farmer, whom he accompanied around the globe for several years to prepare Mountains beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World. This excerpt, from chapter two, introduces a less-publicized but fundamental aspect of Farmer as bedside doctor, doing his rounds in a Harvard-affiliated teaching hospital, where the full weight and apparatus of modern tertiary-care medicine are brought to bear on the most vulnerable, needy, even "difficult" cases, mediated through a physician. [From Mountains beyond Mountains, by Tracy Kidder. Copyright ©2003 by Tracy Kidder. reprinted by arrangement with The Random House Publishing Group.]

 

Outside the Brigham and Women's Hospital in Boston, you're aware of a relative urban quiet. A Wall Street of medicine surrounds you: the campus of Harvard Medical School and the Countway Medical Library, Children's Hospital, Beth Israel Deaconess, Dana-Farber Cancer Institute, the Brigham. The buildings look imposing packed together, and even awesome when you let yourself imagine what's going on inside. Chest crackings, organ transplants, molecular imagings, genetic probes—gloved hands and machines routinely reaching into bodies and making diagnoses and corrections, so much of human frailty on the one hand and boldness on the other. One feels stilled in the presence of this enterprise. Even the Boston drivers, famously deranged, don't honk much when passing through the neighborhood.

House call: Dr. Paul Farmer visiting an AIDS patient, who has assistance from a care worker, in Boston's Dorchester neighborhood.
Photograph by Jim Harrison

The Brigham occupies one side of Francis Street and envelops, like a city around a Roman ruin, the renovated Victorian lobby of the old Peter Bent Brigham, a relic of the history of Boston medicine. The modern entrance, a towering atrium with marble floors, lies a quarter of a mile away, at the end of a shiny corridor called the Pike—short for turnpike—flanked by banks of elevators, clinical departments to the right and left, inpatient wards on floors above, operating rooms below (40, not counting the ones in obstetrics), dozens of laboratories in all directions, and mortal dramas everywhere. It's a medical mall, a teaching hospital and a full-service hospital and a tertiary-care facility, a hospital to which other hospitals forward their most difficult cases.

 

Crowds move up and down the Pike, in white uniforms and street clothes, carrying bouquets of flowers, trailing the sound of many mingled conversations.

Four floors down in radiology, Dr. Farmer and his team had staked out a quiet spot, an empty windowless room, and were discussing the last of their cases for the day. Farmer had recently turned 40. Perhaps his hair had receded slightly since I'd last seen him, five years ago. He looked a little thinner, too, and was much more formally attired. He wore wire-framed glasses with little round lenses, and a black suit, and a necktie, cinched up tight. He was still spending most of his time in Haiti, but he was also a big-shot Boston doctor now, a professor of both medicine and medical anthropology at Harvard Medical School, and an attending specialist on the Brigham's senior staff. Looking at him, sitting with two of his students, young doctors in white coats, I imagined a nineteenth-century daguerreotype—the austere, august professor of medicine in a stiff high collar and a waistcoat. That impression didn't last.

He and the young doctors discussed a patient who had recently been treated for a parasite in the brain. The man had become hydrocephalic, and the neurosurgeons had implanted a shunt to drain off the fluid. There was no evidence of further infection, but should the patient be treated for one, just to be safe? "What do you think?" Farmer asked his team, and they batted the question around, and Farmer mostly just listened, though it was clear he was in charge.

After a few minutes, the team agreed: they should treat the patient. Then the phone rang. Farmer picked it up and said, "HIV central. How can we help?"

The caller was a female parasitologist, an old close colleague of Farmer's, offering her view on the hydrocephalic patient. "Worm Lady!" Farmer exclaimed. "How are you, pumpkin? Oh, I'm fine. Listen, it's scandalous to say, but we don't agree. We want to treat his ass. ID says treat. Love, ID."

These last two lines were a saying of his. I'd heard him use it earlier in the day, and I'd worked it out for myself. ID stood for "Infectious Disease," his specialty. And the command was uttered as if in a letter, and generally meant that he wanted to treat a patient at once, rather than wait for further tests. Clearly, he liked the sound of the words. He seemed to be having a very good time, and from the reactions of his students, small smiles and shakes of the head, which they didn't try to hide from him, I figured that none of his sayings or his jokes or his general ebullience was new for today.

This day—a day in mid-December 1999—had so far been quite ordinary, at least by Brigham standards. Farmer and his team had dealt with six cases, each something of a puzzle, except for the next-to-last case of the day, which seemed rather simple. The resident on the team, a young woman, presented the facts to Farmer, reading from her notes: A 35-year-old man (I'll call him Joe). HIV-positive. Smoked a pack of cigarettes a day. Usually drank half a gallon of vodka. Also used cocaine, both intravenously and by inhalation. Recently overdosed on heroin. Had a chronic cough which five days ago increased, became productive—yellow-green sputum but no blood—and was accompanied by deep chest pain. He had lost 26 pounds over the last several months. The radiologists reported a possible right lower lobe infiltrate on his chest X ray—possible tuberculosis, they thought.

The tools for uncovering tuberculosis belong to an older era in medicine, and the diagnosis can be tricky, especially in someone with HIV. Certainly, Joe was a likely target for TB. Of all the infections that can come crowding into a person with HIV disease, TB was the most common worldwide. The disease was rare in Boston, indeed throughout the United States, except in the kinds of places where Joe lived—in homeless shelters and jails and on the streets and under bridges. But in spite of his HIV infection, Joe's immune system was still mostly intact. And he didn't have the classic symptoms of TB, which are fever, chills, and night sweats. "He has terrible teeth," said the resident. She added, "He's a nice guy."

Farmer said, "Let's go see the X ray, shall we?"

They went to another room and put Joe's chest X ray up on a lighted viewing screen, and Farmer stared, for less than a minute, at the spot where the radiologists thought they saw an infiltrate. Then he said, "That's it? It's rather underwhelming."

They headed upstairs, to visit Joe.

Farmer moved through the Brigham in a long-legged stride, making intermittent headway. He'd pause to receive a hug from a nurse's aide, then to exchange quips in Haitian Creole with a janitor. Then his beeper would go off. Answering the page, he'd greet the hospital operator—whichever of the dozen or so came on line—and quickly ask about her blood pressure, or her husband's heart condition, or her mother's diabetes. Then he'd have to stop at a nurses' station to answer an e-mail about a patient, then to answer a question from a cardiologist. Finally, stethoscope around his neck and singing in creative German, "We are the world. We are das Welt," Farmer led the infectious disease team to the patient's door. Then everything slowed down.

Joe lay on his covers, dressed in blue jeans and a T-shirt, a small man with scarred and wiry arms and prominent collarbones. He had an unkempt beard and unruly hair, and when he smiled nervously at the doctors trooping in, I saw he still had most of his teeth but probably wouldn't for long. Farmer introduced himself and the members of his team. Then he sat down at the head of Joe's bed, on a corner of the mattress, folding himself half around Joe in an agile way that made me think of a grasshopper. He leaned over Joe, gazing down at him, pale blue eyes behind little round lenses. For a moment, I thought Farmer might climb into bed with him. He placed a hand on Joe's shoulder instead and stroked it for a moment.

"Your X ray looks good. I think it's probably pneumonia. A little bit of pneumonia. Let me ask you, how's your stomach? Do you have any gastritis these days?"

"I'm eatin' everything in sight of me. Everything in front of me I eat."

Farmer smiled. "You need to gain some weight, my friend. You've lost some weight."

"I didn't eat much when I was outside. I didn't eat much at all. Messin' around, doin' this, doin' that."

"Talk to us a little bit. We're in infectious disease, and we don't think it's tuberculosis. Before I say that, though, any exposure to anybody with TB?"

Joe didn't think so, and Farmer said, "I think we should go ahead and make a recommendation that you not be isolated. We're ID, right? ID says hi. I think you don't need to have a negative airflow room and all that."

"Nah. A fella's in a boat by himself, y'know. People come in with masks on their heads and wash their hands all the time."

"Yeah," said Farmer, adding, "but washing the hands is good, though."

This day was the first on which I'd seen him at work, and it seemed to me just then that his part in the case was closed. Fancy specialist is called in to answer a question. For once, it is vanishingly simple, at least for the specialist. He answers it, makes some small talk with the patient, then departs. But Farmer was still sitting on Joe's bed, and he seemed to like it there.

They talked on and on. Judging from the resident's earlier report, she had asked many of the same questions as Farmer. But Joe was responding with greater candor now. He and Farmer talked about Joe's regular doctor, whom Joe liked, and about the fact that Joe had taken antiretroviral medicines for his HIV, but only erratically, Joe confessed, and Farmer explained that he might well have acquired resistance to some of those drugs and probably shouldn't risk taking others until he found himself in a position to take them faithfully. They talked about drugs and alcohol, Farmer warning him against heroin.

"But really the worst ones are alcohol and cocaine. We were saying downstairs during rounds, we were kinda joking around, saying, Well, we should tell him to smoke more marijuana, because that doesn't hurt as much."

"If I smoke marijuana, I'll create an international incident."

"Not in the hospital, Joe." The two men laughed, looking at each other.

They talked about his HIV. "Your immune system's...pretty...good, you know. Workin' pretty well. That's why I'm a little worried that you're losing weight, you know. Because you're not losing weight on account of HIV, I bet. You're losing weight because you're not eating. Right?"

"Yeah, that's right."

"Yeah," said Farmer softly. The way he stared at Joe's face just then seemed both intent—as if there were no one else in the world—and also focused elsewhere. I thought in his mind he might be watching Joe from a high window, as Joe went about what are known in social work as the activities of daily living, which in his case would mean scoring some narcotics on a corner, then heading off to his favorite bridge or underpass for camping.

In the midst of all this, another person entered the room, a medical student whom Farmer had invited to join him on rounds. Farmer introduced her. Joe had asked all the other doctors where they'd gone to school. Now he asked the newcomer in his Boston accent, "Are you a Hah-vahd graduate, too?"

"Am I?" she said. "Yes."

"Wow," said Joe. He turned back to Farmer. "I got some people from high places lookin' at me, huh?"

"She's a hotshot," Farmer said. And the conversation resumed. "So tell us now, Joe, how can we help? Because we know how the system works here. You come in here, you like us, we like you, you're very nice to us, we're very nice to you, and I think you feel like people here treat you right at home."

"I feel kinda lonesome in this room!" said Joe.

"That's true. And we're going to recommend that you get out of this," said Farmer. "So here's my heavy question for you. Heavy but good."

"What you can do for me."

"Yeah!"

"You ain't gonna believe what I'm gonna say. You ain't ready for this," said Joe.

"I've heard it all, my friend."

"I'd like to have an HIV home where I could go to..."

Farmer was gazing down at him again. " Yeah."

"Sleep and eat, watch television, watch games. I'd like somewhere I could go where I can drink a six-pack."

"I understand."

"I'd like to go somewhere where I wouldn't get in trouble, maybe have a couple too many beers, as long as I'm doin' what they tell me, and I'm home on time and I don't mess around, y'know."

"Sure."

"And I don't drive everybody crazy, runnin' out the doors and everything, y'know. Somewhere I could maybe even have a bottle of wine for dinner or something."

"Yeah," said Farmer. "I can see your point." He pursed his lips. "So I'll tell you what. I'll look around, and you're going to be here probably a couple of days, and you know I don't think it's that crazy an idea at all, what you said. Is it better to be out on the street using?"

"Freezing to death," added Joe.

"Freezing to death," said Farmer. "Or inside having a six-pack of beer or some wine with dinner? I know what I would want. The other thing is, if you have a place to stay, you could take medicines, if you want to take medicines."

"Yeah," said Joe, dubiously.

 

A few days later on the message board outside the door of the Brigham's social work department, a cryptic handwritten message appeared. It looked like this:

 

JOE

OUT
 IN
cold
warm
their drugs
our drugs
1/2 gal. vodka
6 pack Bud

Beneath this someone had scrawled: "Why do I know Paul Farmer wrote this?"

Friends of Farmer's had found a homeless shelter for Joe, but of course the social workers had reminded Farmer that shelters forbade drinking, and for good reason, too. He was still pleading Joe's case, just to keep his promise, I supposed, not expecting to win the argument.

Farmer was on service at the Brigham on Christmas. He spent part of the day visiting patients outside the hospital. He brought them all presents, including Joe—who got a six-pack of beer, disguised in wrapping paper.

Joe seemed glad to see him, as well as the present. As Farmer was leaving the shelter, he heard Joe say to another resident, just loudly enough to make Farmer wonder if Joe meant for him to overhear, "That guy's a fuckin' saint."

It wasn't the first time Farmer had heard himself called that. When I asked him his reaction, he said that he felt like the thief in Hawthorne's novel The Marble Faun, who steals something from a Catholic church and, before making his escape, dips his hand in holy water. "I don't care how often people say, 'You're a saint.' It's not that I mind it. It's that it's inaccurate."

This was seemly, I thought, resisting beatification. But then he told me, "People call me a saint and I think, I have to work harder. Because a saint would be a great thing to be."

I felt a small inner disturbance. It wasn't that the words seemed immodest. I felt I was in the presence of a different person from the one I'd been chatting with a moment ago, someone whose ambitions I hadn't yet begun to fathom.

 

Tracy Kidder '67 is the author of The Soul of a New Machine, House, Among Schoolchildren, Old Friends, and Hometown. He lives in western Massachusetts and Maine.