This chapter is essentially about a boy named John who like a few previous patients at Zanmi Lasante is in need of care that even Farmer's clinic cannot provide. He has swellings in his neck that Farmer determines are cancerous. However, the diagnosis needs to be confirmed in Boston. Serena Keonig, a Brigham doctor, finds an oncologist at Massachusetts General who will make the diagnosis for free. Of course, he needs a sample of John's tissue and blood, and so Farmer sends a Haitian surgeon that he knows to be competent to do the biopsy for $1000. The trip takes the surgeon twelve hours, because it's raining, creating mud and swollen streams. The biopsy itself lasts until dawn. Farmer flies the samples himself to Boston, and Serena takes them to Mass General. The news is bad: John has nasopharyngeal carcinoma, a very rare cancer. It is often fatal, but if caught in its early stages, 60 to 70 percent have been cured.
The plan is to treat John in Haiti, but Serena is told by an oncologist that it will kill the child to do it there. So Serena and Farmer agree that they'll try to bring the boy to Boston. Serena begs and cajoles the administration in Boston until they agree to do all the treatment for free. The next hurdle becomes the documents needed to get him out of Haiti and into America. He has no birth certificate, so Serena makes up names for his parents and even finds him a Creole-speaking resident in pediatrics from Mass General to accompany him on the flight.
Serena brings two suitcases with her to Haiti - one filled with stuffed animals and toys for the pediatric ward in Cange and one filled with medicines she thinks they might need to get John to the United States. She also carries a plastic bag filled with water and two goldfish for Farmer's fish pond in Cange. Farmer wouldn't be there when they arrive, but he has full confidence in Serena and the other caregivers. The plan is to get John a visa when they arrive in Port-au-Prince, drive to Cange, and bring him back on a first class commercial flight the next day. The first part of the plan unwinds smoothly thanks to Ti Fifi Farmer's, best and oldest Haitian friend. She has already managed to get John a Haitian passport, and the American consulate grants the visa at once. The road on the way to Cange is worse than ever, and when the finally arrive, Kidder feels like the hospital isn't quite as clean, the air is hotter, and the flies are heavier. He then realizes that it just doesn't seem the same, because Farmer isn't there.
The next part of the plan becomes a nightmare. It is no longer possible to fly John commercially because of how much sicker he has become. He has to be constantly suctioned or the tumors in his neck and nose will suffocate him. Furthermore, he is emaciated even though Farmer has him on a feeding tube. Nonetheless, they all think he deserves his fighting chance. They wonder if they can hire a helicopter to fly him out, but it will cost $20,000. So, Serena and Ti Fifi head back to Port-au-Prince the next morning. They are in and out of traffic jams all day going back and forth from the airport to Ti Fif's home, to the office of a friend, and more. The medevac flight from Port-au-Prince to Boston is easy to arrange, but it costs $18, 540, so Serena wants to clear it with Farmer. In their e-mails, Farmer seems worried about the expense and the precedent it might set. Serena wants to just go ahead and say she paid for everything, but Ti Fifi won't allow anything to proceed without Paul's approval. Finally, Paul okays the expense, and now the difficulty of getting the boy down Highway 3 is the next problem. He will die on the road without suction, and the only machines they have are electric. The thought then is to hire an ambulance which has its own suction equipment on board. This search takes them to a private ambulance company run by a man named Ralph who is willing to try the road to Cange. The ambulance breaks down twice even with Ralph and his friends doing everything they can to keep it going. It's then decided to borrow Ralph's suction equipment and take the boy down the mountain by truck. Ralph is agreeable to drive, and they hook the ambulance's suction equipment to the cigarette lighter of the truck. Three of those going along with the truck agree to ride in the back in the rainstorm at night, including Kidder and Serena.
Even though Ralph drives very slowly over the bad road, it is excruciatingly painful for John, but finally they arrive in Port-au-Prince where a Learjet awaits them. When they arrive in Boston, Kidder is amazed when their driver tells them it will be rough driving, because there are bad roads between the airport and Mass General. If that driver could only know Haiti, he would never have said that. The pediatric team is swift and deft and gets John into a bed. One of the interns lectures Serena about John's state, wondering if they haven't been feeding him. Serena begins to try to explain, but fortunately is saved by the entrance of Dr. Alan Ezekowitz, the head of pediatrics, who has heard the intern's comments and tells her, Well, this boy is a challenge. But I've cured sicker kids . . . We can always do better can't we? This subtle rebuke quiets the intern.
The next afternoon, Serena calls Kidder and says that a formidable group of physicians have examined John and discovered that he has one solid tumor growing back into his spinal column and the roof of his mouth. He's going to die, and now she questions why she brought him to Boston. She can quickly answer her own question: Isn't it better that he can have a private room without flies on his face to die? Isn't it better that he is treated by people who are trained to help him die comfortably and that his mother has a private place to grieve? And so John receives first rate care and is never again in apparent pain. All the PIHers take turns staying in his room with him to help with his care. His mother finally arrives, and he is satisfied. Serena sets up her apartment as hospice care and a couple of days after John is moved there, he simply doesn't wake up. They are all glad he didn't have to die in Haiti, but displeased that his extraction from Haiti took so long that it actually contributed to his death. Other consequences are surprising: Serena feared there wouldn't be offers of free care from Boston after that, but just the opposite occurred when Paul convinces Dr. Ezekowitz to take a few of their patients each year; also there isn't a precedent set for the people of Haiti who don't demand the same care for their own children. They are just happy someone cares about them. As for Kidder, he wonders if the whole thing isn't an object lesson in the futility of Farmer's enterprise.
This entire chapter is a metaphor for the disaster named Haiti and Kidder is right to wonder if all of Paul Farmer's attempts to change the medical care for poor people are nothing more than an exercise in futility.