Paul Farmer told me in January of 2004 that he sometimes allowed himself to think "we've started a virtuous social cycle that can't be stopped."
It didn't seem likely.
This was just weeks before the ouster of former President Jean-Bertrand Aristide. Armed gangs cruised the streets of Port-au-Prince. Times photographer Daniel Wallace and I could hear gunfire from our hotel room. Like most first-time visitors to Haiti, we were horrified by the poverty — the bone-thin children and desperate-looking mothers.
We returned to Haiti in September, eight months after the earthquake that killed an estimated 230,000 people in and near Port-au-Prince. We went to report on the recovery work of Partners in Health — co-founded by Farmer, a Hernando High graduate — and to see how the organization and country had fared since our last visit.
In Port-au-Prince, we found less violence but more misery.
Watching heavy rain fall on a vast, muddy settlement camp, we knew that this was just a small sample of the suffering; 1.3 million earthquake survivors in Port-au-Prince — more people than in all of Hillsborough County — still live under tarps or in tents, still struggle to stay dry every time it rains.
But the next day, at another camp, we visited one of four clinics in Port-au-Prince run by PIH.
Here, we found order.
One large tent offered psychological counseling. Women needing prenatal care or gynecological exams were seen at another tent. At yet another, nurses dispensed jars of the new wonder treatment for malnourished babies, fortified peanut butter. If any of these patients required a prescription drug or a blood test, there were tents for that, too.
On to the Central Plateau, the focus of PIH's work in Haiti for more than 20 years.
With a grant from the European Union, the old lime rock highway and its truck-swallowing potholes had been replaced with smooth pavement. The driving time from Port-au-Prince to Mirebalais had been reduced from three hours to one.
It wasn't PIH's doing, but it's a lesson to anyone who doubts that foreign aid can make a difference in Haiti.
A decent road leading to big markets means it's finally possible to think about large-scale commercial agriculture in central Haiti, said Cate Oswald, a PIH program director. We saw oncoming trucks stacked high with bags of charcoal, the crop that stripped these mountains of their trees. But we also saw loads of avocados, which, along with mangoes and coffee, might once again make these hills green and productive. And though many families still live in homes made of sticks and palm bark, Oswald said it's not unusual to see roadside signs announcing future development.
One of these signs was for a project that definitely is PIH's doing — the hospital in Mirebalais (MEER-ba-lay). The government will own the building as soon as it is finished. The hope is that the Ministry of Health will also eventually pay and supervise its staff.
But in the near future, the doctors there will work for PIH, just as they do at the other clinics and hospitals the organization has established in the Central Plateau. And these doctors are one answer to an early criticism of PIH — that Farmer was a unique visionary, that when his brilliance and devotion started to fade, so would his organization.
Not that Farmer is running out of steam. It's just that he's far from the only devoted doctor associated with PIH.
At the cornerstone-laying event for the new hospital, he was joined by a large contingent from the school of public health at the Harvard-affiliated Brigham and Women's Hospital. It's one of the most selective medical programs in the country and turns out young doctors who want to do exactly Farmer's kind of work.
So do Haitian doctors such as Martineau Louine, who at age 29 supervises HIV and tuberculosis treatment at the PIH hospital in Lacolline.
Dr. Corrado Cancedda, PIH's director of medical education in Rwanda, said PIH doctors in foreign countries must stay long enough to learn the culture and the needs of the people. Like Farmer did, he said, they learn to accept that "there are no boundaries between life and work."
Dr. Anany Gretchko Prosper, head of PIH medical operations in Port-au-Prince, didn't mention Farmer. He said the group responds to the people it serves, not its donors. It's not that way with some aid organizations, certainly not the other ones for which he's worked.
PIH is probably best known for fighting AIDS. Even so, the success of the treatment models it helped establish seems under-reported. Haiti was long stigmatized as a major breeding ground for the disease. But the HIV infection rate here is now 2.2 percent, or about 1 percent lower than in the District of Columbia.
Why has PIH been so effective? Why is it able to build a modern teaching hospital for $15 million while other organizations with far more money struggle to move beyond the handout phase of aid delivery?
Farmer is our hometown hero, so many of us would like to think it's all because of him. True, he set PIH's high standards for care. His star power has helped draw students to Brigham and Women's and inspired PIH's celebrity supporters, such as George Clooney and Matt Damon.
But besides his role with PIH, Farmer works for the United Nations. His home is Rwanda. He's not the constant presence in Haiti he once was.
And PIH is proving it can carry on without him. It might be called a social cycle, and from what I saw, it's clearly virtuous. Of course, nobody knows whether it can be stopped. But for now it's spreading and thriving.