CANGE, Haiti - Dr. Paul Farmer drove to Boucan Carre, in Haiti's central plateau, to check on the construction of a hospital and a public well. While he was there, as often happens, he acquired a patient.
A 33-year-old woman, Rosemonde Jeanty, had been diagnosed with typhoid. But doctors at the partly built hospital were unsure whether the infection had spread through the wall of her intestine, which would require emergency surgery.
Jeanty lay on a stretcher in a blue dress that looked like her Sunday best. Farmer placed his hands on her swollen abdomen, watched her grimace and asked her a few questions.
Yes, she needed the operation, he decided. He then offered the most reassuring words a sick person can hear on the central plateau - or maybe in all of Haiti:
"You're going to Cange."
A moral force
Cange (pronounced "Cahnj"), a tiny village 35 miles north of Port-au-Prince, is a refuge in a country wasted by poverty and political strife that is now degenerating into civil war.
Most of Haiti has been stripped of its tropical forests. Cange is shaded by tall ficus and mango trees. In most of Haiti, water is either scarce or contaminated. In Cange, it is pure and plentiful. Most adults in Haiti cannot read or write, and much of the country lacks schools of any kind. In Cange, children run to and from classes in pressed uniforms.
Public medical care is primitive and so expensive that many Haitians - who earn, on average, a dollar a day and die at age 49 - do without.
At the hospital in Cange, the care is free and first-rate, with an operating room, a blood bank and a well-stocked pharmacy; it has not lost a patient to tuberculosis - a terminal illness in some parts of Haiti - since 1988.
And Cange, as it is now, is largely the creation of Paul Farmer.
He moved to an isolated Episcopal mission here 21 years ago and has stayed ever since, even while commuting to Harvard to earn a doctorate in anthropology and a medical degree.
He planted the trees. The organization he co-founded in 1987, Partners in Health, helped the church build the water system and school and transformed a ragged clinic into a modern hospital.
This work, performed in isolation, has been recognized and copied around the world.
Farmer, who grew up in Hernando County, won a MacArthur "genius" Fellowship in 1993 and last year was the subject of a bestselling book, Mountains Beyond Mountains, by Pulitzer Prize-winning author Tracy Kidder.
Partners in Health has established global models for treating AIDS and drug-resistant tuberculosis, mostly because Farmer and his colleagues insisted on treating poor patients with the same medications available to the rich.
That is the least we should do, said Farmer, 44, who believes that poor public health is caused by poverty, and that poverty is caused by the exploitation of weak countries by powerful ones.
To visit him in Haiti is to see what a huge job it is to push back this tide of deprivation - and to feel that Partners in Health, remarkably, just might be starting to get it done.
"There are certain days I think this is a drop in the bucket," Farmer said one morning in mid January.
"And there are certain days I think we've started a virtuous social cycle that can't be stopped."
The road to Cange
The increasing violence will almost certainly make things worse for the average Haitian. Judging from the scenes Farmer passed as he drove Jeanty over the rutted road to Cange last month, that is hard to imagine.
Most of the other travelers walked or rode donkeys. The lucky few clung to precariously stacked bags of charcoal - still the country's main source of fuel - in the back of pickup trucks.
Cultivation was limited to patches of banana and millet and living fences of cactuslike candelabra trees. Many of the houses were stick huts with roofs made of palm bark and patched with wadded rags. Naked or partly clothed children, their skin tinted by road dust, wandered alone and drank from clouded creeks.
Jeanty's typhoid was probably caused by drinking such foul water, Farmer said. Other preventable diseases that commonly kill people in Haiti - malaria, tetanus, malnutrition and tuberculosis - are likewise, he said, "the outcome and cause of social misery."
With Jeanty groaning in pain, Farmer drove as quickly as possible but was forced to stop repeatedly, including, near Cange, for a common sight in rural Haiti: a crowd of mourners, jogging and clapping while ferrying a shrouded corpse on a straw stretcher.
"It gets old, I'll tell you," Farmer said.
An average day
The Partners in Health compound in Cange, a cluster of flat-roofed stone buildings, is surrounded by a high concrete wall that looks both imposing and welcoming.
The organization's logo, four outstretched hands, is posted outside, along with the name of its Haitian affiliate, Zanmi Lasante, Creole for "Partners in Health."
The sliding metal door opens to a shaded alley that serves as a 24-hour waiting room. Each day the 104-bed hospital treats about 1,000 patients, dozens of whom sleep here every night.
Jeanty was carried on a stretcher through a crowd still waiting at midday. Farmer and Pedro Ung, a Cuban surgeon paid by his government to work in Haiti, examined her on the tile floor of the surgical ward.
Ung agreed to operate immediately. The incision released a smell that confirmed the infection had spread to the abdominal cavity. Before he could proceed, the operating room went black and the doctors and nurses stood calmly for a full minute before a generator revved up and light returned.
"What a day," Farmer said. "Pretty typical for Haiti, actually."
Farmer says Kidder's laudatory book - subtitled A Man Who Would Cure the World - slighted the other Zanmi Lasante doctors, most of whom are Haitian and all of whom put in the same dawn-to-midnight workdays that he does.
He is embarrassed by the book's focus on his personal life and is dismissive of the speculation it has generated, that he may be in line for a Nobel Peace Prize.
"Didn't Henry Kissinger win a Nobel Prize?"
But talk of such an honor does not seem far-fetched once you spend time with Farmer and consider his accomplishments and sacrifices.
Partners in Health operates programs in Siberia, Boston and Peru, all of which Farmer visits regularly. He has published five books and teaches part of every year at Harvard Medical School, where he is a professor of medicine and medical anthropology.
Tall and delicate-looking, wearing rimless glasses and freshly laundered dress shirts, he appears more bound to Cambridge, Mass., than Cange. In fact, the reverse is true.
He works eight months a year in Haiti, where he answers hundreds of e-mails daily and runs the hospital, down to such details as planting, outside the pediatric wing, a garden with a fish pond and a large Fisher-Price playhouse.
Though he sees vast numbers of patients, his manner with them is warm and unhurried. He examines them without reticence, hands on flesh. He hugs them and jokes with them. He has suffered some of their ailments, including hepatitis, several bouts of malaria and, in August, a severely broken leg when he slipped while walking on the steep trail that leads to his cottage.
His home is surrounded by trees and filled with family photos and his unusual collection of books: Rwanda: Death, Despair and Defiance is just down the shelf from a Spanish-language version of Harry Potter and the Chamber of Secrets.
It is not austere, but it is tiny - with rooms the size of office cubicles - and almost always empty.
His wife, Didi, who is from Cange, is studying in Paris. Farmer celebrated his daughter's sixth birthday on Jan. 13 with a phone call.
"Do I wish I was in Paris? I wish she was in Haiti," he said. "My work is in Haiti."
His patients and co-workers return this devotion by greeting him with a phrase usually reserved for other Haitians: "neg pa," which translates generally as "my man" and literally as "my black man."
Members of the family
The morning after Ung operated on Jeanty, Farmer faced a new but hardly surprising emergency.
"The hospital is bulging. Bursting," he said.
To free up beds, doctors met before breakfast to select a few patients to release, a wrenching job because of Farmer's philosophy of solidarity.
Health care for the poor has traditionally taken what Farmer calls "the nihilistic approach," meaning that agencies base treatment on the amount of money available. Partners in Health's stated mission, on the other hand, is to "do whatever it takes to make (the patients) well, just as we would do if a member of our own families - or we ourselves - were ill."
"That means you side with the poor, period," Farmer said.
A 13-year-old boy's face was seared into a mask of scar tissue after he lurched into a cooking fire during an epileptic seizure.
"Those kind of burns are very common in developing countries, and usually fatal because of infection," said Dr. Joia Mukherjee, the Partners in Health medical director.
The boy had been saved but not healed, she said; he would stay at the hospital until he received reconstructive surgery for his nose and lips.
Jonathan Antoine, 10, was less fortunate. The swelling of his face, which had reduced his eyes to slits, indicated that his kidneys were no longer producing urine.
Partners in Health had flown Jonathan to a hospital in Miami for dialysis and to try, unsuccessfully it turned out, to place him in line for a kidney transplant.
"A kidney for a kid from Haiti? It doesn't happen," Farmer said, betraying a distrust for the U.S. medical establishment.
"There are just tons of kidneys that come from poor countries, but not the other way around."
Jonathan, who had recently returned from Miami, would now be discharged from the hospital in Cange.
"It's too bad, but there's nothing more we can do for him," Farmer said. "He's dying."
After breakfast, Farmer settled into his office with a pot of coffee and began a session of examining AIDS patients that would last until the Haitian lunch hour of 3 p.m.
From this small room, its white walls decorated with his patients' colorful art, Farmer has revolutionized the global fight against AIDS.
The expensive drugs that can all but eliminate symptoms of the disease were long out of reach for countries like Haiti, which, besides being poor, has an HIV infection rate of 5 percent.
In 1998, Farmer began prescribing the medications regardless of cost and then scrambling to pay for them, hitting up donors who had supported his mission from the start, especially Boston developer Tom White, and selling the Partners in Health headquarters in Cambridge.
Partners in Health also began negotiating with pharmaceutical companies to bring down the cost of the medication, enlisting other international health care agencies to help apply pressure.
Because of this - and because Partners in Health and some of these other organizations now buy large quantities of AIDS drugs - the cost of a year's supply for one patient has dropped from $2,000 in 1999 to $300.
One overwhelming obstacle remained: ensuring that patients take the medication. Partners in Health's solution, first developed for its tuberculosis patients, was to enlist and train villagers as community health care workers, paying them $40 per month to deliver the pills and watch as each one is swallowed.
"Partners in Health has been visionary in delivering HIV care in poor countries," said Anil Soni of the Global Fund to Fight AIDS, Tuberculosis and Malaria; this organization, which is backed by the United Nations, distributes money to groups with a proven ability to fight these diseases. In 2002, Partners in Health received its first grant: $13.5-million over five years, most of which is used to pay community health care workers and for drugs.
"It's a small organization with a model that has been adopted by the World Health Organization. That's saying something," Soni said.
The results can be seen in Farmer's patients, who are visibly healthy. They complain not about fatigue and opportunistic infections, but about the everyday Haitian deficiencies of money, housing and food.
One of the morning's first patients, Thelemaque Innocent, tells Farmer he feels well enough to work but cannot because his illness cost him his teaching job. Farmer fires off an e-mail to see if Partners in Health has a place for him.
"Thank you, Polo," Innocent says, using the Creole nickname for Paul.
"You are my friend. If I can get a job, it will be good for my dignity."
A Florida childhood
The contrast between these daily dramas in Haiti and the quiet of his old hometown still amazes Farmer.
"It's a long way from Brooksville, isn't it?" he said.
It is, but, considering Farmer's boyhood, not as far as it could be.
Farmer's parents, originally from Massachusetts, moved with their six children to Brooksville in 1970, when Paul was 10. They lived in a converted school bus north of Brooksville and on a boat docked near the gulf on Jenkins Creek.
His sweet-natured mother - a clerk at Winn-Dixie - put up with these arrangements, Farmer said; his gruff and massive father insisted on them.
"He had the reputation among the kids as a very mean man," Mary Ann Hogan, whose daughter graduated with Farmer, said of his father. "I don't know if was deserved or not."
"Bad-tempered, maybe, but not mean. Definitely not mean," said Farmer.
His father, who worked as a schoolteacher and with retarded adults, was determined to give the family a life of romance and adventure, Farmer said; the boat, which many of Farmer's friends regarded as shockingly primitive, was a way of doing this on a budget.
Jenkins Creek, now a county park, was wilderness then. In the evenings, the family sat outside and watched ospreys and river otters. Farmer planted flowering bushes and built a concrete fish pond.
All this may have put his life on its current path, he said, or maybe that interpretation is "too neat."
"I grew up without running water. Is that relevant or not relevant? Was it relevant that my dad was a service-oriented guy? I think that may be why (serving the poor) meant so much to me, but I'm not sure."
His friends agree on other impressions of the family. The parents were intelligent and devoted, the kids polite and good students. And though no one could have predicted how it would happen, many of them said they expected Farmer to be famous.
"Now you have brought up my favorite subject," said his choral teacher, Barbara Manuel, who remembers having uncannily adult conversations with Farmer when he was in middle school.
"He was just blessed with an extremely high degree of intelligence."
At Hernando High School, he organized food fights, drove wildly in a battered station wagon and spoke with his closest friends in their own, invented language. He worked on the yearbook, starred on the High Q television quiz show team, joined community service clubs and held several part-time jobs.
"He made straight A's with very little studying," family friend Sam Griffin said. "He was always doing more: school activities, working at Scotty's, visiting people. He had to have things to fill his time, and he never seemed overloaded. Sure wore his friends out, though."
Farmer studied medical anthropology at Duke University, and, after graduation, worked and traveled throughout Haiti. Once he had seen the suffering and injustice there, he began to feel, as he has ever since, that to turn his back on it would be moral cowardice.
"What I always say is, "The only thing worse than doing something about it is not doing something,' " Farmer said. "I mean, you can leave, but unless you have some pretty good drugs, you're not going to forget."
The politics of loyalty
A few years after moving to Cange, he befriended another advocate for Haiti's poor, a fragile-looking priest named Jean-Bertrand Aristide, who in 1990 became the country's first democratically elected president.
Much of Aristide's support has since slipped away, especially among educated professionals. In the past few months, opposition groups have staged almost daily protests, many of which government supporters put down with gunfire. In recent weeks, anti-Aristide forces have occupied several towns, including, most ominously for Farmer, Hinche, the capital of the central plateau.
Zanmi Lasante had planned to assume operation of the regional hospital there; the paramilitary group that seized it last week once backed the coup that forced Aristide, and later Farmer, from the country in the early 1990s.
Though less vocal in his support than he once was, Farmer has remained loyal to Aristide; in doing so, opposition leaders say, he is lending legitimacy to a corrupt and violent ruler.
"Paul Farmer has linked his own project very closely to the regime," said Leannec Hurbon, a prominent Haitian anthropologist and Aristide critic.
"Farmer must explain why Aristide must govern with armed gangs," Hurbon said.
"Farmer must explain the murders."
Even a month ago the political pressure was building, and Farmer had begun to discuss stockpiling medications in the event of Aristide's fall.
"Solidarity with the Haitian poor is going to get you in trouble," Farmer said. "It's going to put you in harm's way."
If he was worried, though, he didn't show it.
After his day in the AIDS clinic, he scheduled a tour of current and future Zanmi Lasante projects north of Cange. Though the itinerary included several stops, it was light enough by his standard to classify, he said, as a "MIPS - mental illness prevention strategy."
It allowed for a rare treat in Haiti, a restaurant lunch with a couple of beers, as well as time - sitting on a wooden bench in the back of a pickup truck - to comment about the politics of Haiti.
Through their country's history of slavery and oppressive rulers, Haitians have never had a chance to govern themselves, Farmer said. They still cannot, he said, because the United States and other nations have withheld millions of dollars in aid to Aristide since the contested parliamentary elections of 2000.
This has effectively overruled the millions of Haitians who elected Aristide and continue to support him, Farmer said.
"Is that fair? I don't think so. Call me an old-fashioned American, but I believe in one person, one vote."
Denying aid to the government has also gutted its health care programs, which has strained all of Zanmi Lasante's projects, he said, including its clinic in the town of Thomonde.
The clinic was opened two years earlier in the hope that it might take some of the pressure off the hospital in Cange. Instead, it tapped into a population that previously had no access to health care, said Patrick Almazor, the clinic's director of AIDS and tuberculosis programs. The clinic now sees 250 patients a day.
"People used to say, "Look how many people die in Thomonde. It must be the sorcery,' " Almazor said.
"Now they say, "Where is the sorcery?' "
Farmer was delighted with what he saw a few blocks away: an abandoned agricultural depot where Zanmi Lasante plans to build a public hospital. To help with this and other new projects, the organization has enlisted several partners, including the University of Miami.
The low block buildings, easily the most substantial in town, were shaded by two giant hardwoods, an extreme rarity in Haiti.
"This is what I call a campus," Farmer said, starting to sketch the layout on a legal pad.
The aid that once went to the Haitian government now goes to various relief organizations, Farmer said, most of which refuse to work with the Aristide government.
Zanmi Lasante does, he said, partly because it is the best way to coordinate social and economic projects like this hospital and school, which, together, will employ 500 Haitians.
"It's kind of a New Deal idea," Farmer said. "Or we could call it a Marshall Plan, because this place looks like it's been razed by war, which it has in a way. A class war."
Farmer's last stop was the public hospital in Hinche.
It was nearly deserted because it cannot afford basics such as a generator or an anesthesia machine. Patients must provide their own food, medicine and medical supplies.
"If we just had $100,000 a month," said regional health minister Raoul Raphael, "we could do so much more."
That amount is the equivalent of some doctors' earnings in the United States. This is just one example, Farmer said, of the economic disparity between Haiti and its close neighbor.
There are countless others:
The Harvard-affiliated hospital where he teaches has an annual budget of $1-billion. That compares with the $15-million - or less than $2 per resident - for Haiti's Ministry of Health.
Zanmi Lasante has built, from the shells of abandoned buildings, two well-equipped hospitals at a cost of about $140,000 each, the price of a starter home in some parts of the Tampa Bay area.
The weatherproof houses the group constructs for patients cost less than $1,500, or about the same as a good bicycle in America.
Even as Zanmi Lasante expands into a social and health care network that will serve all the 570,000 residents of the central plateau - and draw patients from throughout Haiti - it is spending only about $6-million a year.
So, providing health care in poor countries, often portrayed as overwhelmingly expensive, is actually absurdly cheap by American standards.
"It's nuts," Farmer said.
Especially when you consider the benefits.
The antibiotics Rosemonde Jeanty received to control her typhoid before the surgery, and the ride she got from Boucan Carre to Cange, probably saved her life, Farmer said.
When he visited her two days after the operation, she agreed.
"I was too sick to ride a donkey (to Cange). . . . I would be dead," said Jeanty, who added that her four children would have been left motherless.
Jeanty said she felt fine other than the annoyance of the oxygen tube taped to one nostril. She was expected to make a full recovery, she told Farmer, and for that she was extremely grateful.