Remarks by Paul Farmer
Complete text of speech to graduates, families and guests at Northwestern's 154th commencementJune 19, 2012
I’m so grateful to share this stage with Martha Minow and the other honorees whose talents collectively lead us from evil, keep airplanes in the sky, and teach us exactly how one thing is not like another. They, along with Morty, are reason enough to be glad to be in this stadium. But then there’s you: the new doctors, lawyers, engineers, teachers, journalists, and last but not least college graduates.
It’s a glorious day to be here with you. Now, enough of this fluff. It seems unfair to me that I have to make an impression on you on this of all days. As you graduate. Not unfair in the sense of the global lottery—who is born where—but in a much more crass sense. Why is it that I must upstage last year’s speaker, one Stephen Colbert? He who received hearty laughs by drawing on his well-known talent for humor, useful in such settings and about as fair if I were to perform, right now, a minor surgical procedure on Morty Schapiro. Colbert also drew on his arcane knowledge of Northwestern. For example: his reference to “the rock” not a professional wrestler from Samoa but as some sort of creepy hippie ritual, or his big build-up to a joke about “Dillo day.” Whatever that is. The crowd roared. Not fair, and also silly.
Levity aside, I know there’s not much I could say today that you’d remember tomorrow, much less a year or two from now. The Class of 2011 all recall that Colbert gave their commencement address, but do they remember what he said?
Let me lead with a message that I believe is of great importance for you graduates: with rare exceptions, all of your most important achievements on this planet will come from working with others—or, in a word, partnership.
The story I’ll tell today, about a hospital in central Haiti, is a case in point. It’s a story about partnerships—seen and unseen—and the power of those partnerships to bridge what seem like different worlds. Sometimes these links are often forgotten. Take the Haiti-Chicago connection: some of you will know that Chicago is said to have been “founded” by a Haitian. Jean Baptiste Pointe du Sable built a farm at the mouth of the Chicago River sometime in the late 18th century, making him the first non-native settler in the area now recognized as the city. Though the details of Point du Sable’s early life remain a subject of debate among historians—some claim he was born on a pirate ship—it seems likely that he hailed from Haiti, perhaps even from St-Marc, one of the towns in the Artibonite Department where we’ve worked for years.
But the connections between this city and Haiti run deeper still, as the rest of this story will reveal.
I first went to Haiti almost thirty years ago. Travel back with me to the early 1980s. A college class at Duke University got me interested in health disparities and also piqued my curiosity about Haiti, where I headed shortly after graduating. I ended up in a sleepy market town in central Haiti called Mirebalais, living in the rectory of an Episcopal Church and working in a hot, overcrowded clinic. Although not yet in medical school, it didn’t take an M.D. to see that excellent medical care was not likely to result from a five-minute exchange with a harried Haitian doctor with no lab or other diagnostics. And it didn’t require a degree in pharmacology to imagine that not many of the various potions poured into corncob-stoppered bottles there were likely to have more than a placebo effect, if that.
My job was to take vital signs, and to give moral support to the beleaguered young physician. We became good friends, and in time he confessed how tired he was of working in such a shabby facility. But he never did much to change it. The doctor, not yet thirty, had been schooled for scarcity and failure, even as I’d been schooled for plenty and for success. Even though he himself was not poor, working in that clinic had lowered his expectations about what was possible when it came to providing health care for those living in poverty.
And who could blame him? The same verdict was being drawn by most “experts” in international health at that time. As today, Haiti was the poorest country in the hemisphere and thus had one of the greatest burdens of disease; the magnitude of its challenges was difficult for me to comprehend. But the assumption that the only health care possible in rural Haiti was poor-quality health care—that was a failure of imagination.
I’ve since learned that the great majority of global public health experts and others who seek to attack poverty are hostages to similar failures of imagination. I’m one of the bunch too, of course, and am telling you this today, as you graduate, because it’s taken me a long time to understand how costly such failures are. Every day in clinic offered vivid reminders of the toll exacted by a lack of imagination. It wasn’t a failure to work long hours—we all did that—but rather a failure to imagine an alternative to kinds of programs that the public-health literature deemed “realistic,” “sustainable,” and “cost-effective”—three terms already in circulation by the late 1980s. Most of my Haitian colleagues were, like the doctor, unconvinced that excellence was possible. My experiences in Mirebalais that first brutal and instructive year inspired a life-long desire to see, in Haiti, a hospital worthy of its people.
Mirebalais, in 1983, was also where I met Ophelia Dahl, a 17-year-old British student on a “gap year” working in an ophthalmology clinic, and also Father Fritz and Yolande Lafontant, who took me in as a volunteer. (And it was in Mirebalais that my college pal Haun Saussy, now a Professor of Chinese Literature at the University of Chicago, paid me a surprise visit that same year.) All of us had figured out, with hope and angst and revulsion, that rural Haitians deserved better medical care, and a couple years later, this group founded Partners In Health along with a few others picked up along the way. Today our organization operates a dozen hospitals and clinics across Haiti.
That was the aim: to work with Haitian partners in building the kind of health care that country deserved. It’s not easy to admit, even today: we tried and mostly failed. Sometimes we succeeded: a child with acute malaria who received chloroquine; a teenager whose fractured bone was set with competence and compassion; a young woman with bacterial meningitis called back from the dead; an anemic woman in labor who was accompanied through the difficult hours of what should always be a joyous process. To be honest, when we look back at our first years of hard work and eighteen-hour days, we can’t claim to have done a good job delivering quality health services. We were delivering something as hard and fast as we could. But surely the quality of the deliverables matters more than the good intentions of the caregivers or the pace of their work. The doctors graduating today will know just what I mean.
Haunted by mediocrity, we keep returning to the task of raising the standard of care. But pile on as many idealistic docs and nurses as you like: good medical care can’t be readily delivered in poor-quality hospitals and clinics. It took years and an openness to partnership, never as easy as it sounds, to build a better hospital in a squatter community—an hour up the mountain road from Mirebalais. As we improved our services, however slowly, the quality of the country’s public facilities was declining. This was frustrating. As the number of mission groups and NGOs like ours grew, it didn’t do much for the Haitian health system. A suspicion took hold of us that our being outside of, and unaccountable to, the public sector—for all the convenience that entailed—was part of the problem. We weren’t adding up to the sum of our parts. We understood this more than a decade ago and resolved to expand our work in the public sector.
One of our greatest champions was none other than Evanston’s own congresswoman Jan Schakowsky, who not only pushed for more just American policies towards Haiti, but strengthened our connections with people living in her district—the very connections that would prove critical to the improvement of our infrastructure and our team. The decade preceding the earthquake were years of rapid growth for our partnership, which reached from Chicagoland to Haiti, and there, from the Dominican border to the western coast at St-Marc. But this wasn’t enough to keep up with the need.
None of us imagined that a greater affront to Haiti’s survival would occur on January 12, 2010 at 4:53 in the afternoon, when a massive earthquake laid waste to Port-au-Prince, killing perhaps a quarter of a million people and leaving another 1.3 million homeless. The quake forced us, for a time, into the role of a disaster relief organization in addition to that of a health care provider. It also made us completely rethink the project for the Mirebalais hospital. With Haiti’s national nursing school destroyed and its medical school damaged and closed, with most of Port-au-Prince’s hospitals down or in shambles, where would the next generation of Haitian health professionals train?
Partners In Health supporters had sent thousands of donations for rebuilding. But it wouldn’t be enough to rebuild something really bold and beautiful; we needed something bigger, many times bigger, like the one that Ann Lurie and other Chicagoans recently built not far from where we’re gathered today. The stars seemed aligned in other ways, too. One of my former students, David Walton, committed himself to a thorough overhaul and expansion of the project. His congresswoman, one Jan Schakowsky, connected us to her friend Marjorie Benton, one of the great gurus of partnership and now one of our most loyal supporters and mentors. The Chicago connection doesn’t stop there. Ann Clark, a classmate of mine from college, dragooned her small architecture firm and family into redesigning the hospital plans. Under Marjorie’s leadership, and that of her friend Sonny Garg, they all rallied donors and companies to the cause, building a powerful “community of concern” in Chicagoland. A former construction company owner from Boston, Jim Ansara, had been advising reconstruction efforts since the quake and was ready to pour time and resources and connections into making this one bigger and better. Together, this crew revised the plans more than a dozen times, enlarging their scope again and again, and making it, in the end, a 205,000-square foot, 320-bed medical center. That was three times the size of anything we’d ever attempted to build before. Let’s say that these plans were our response to the inveterate failure of imagination.
When I visited it last month, the Mirebalais hospital sprawled across a small dell like a temple, gleaming white and girdled by black Haitian ironwork. To see, in the largest city on the Central Plateau, an elegant hospital and medical campus taking shape across what was once a bit of broken terrain running from steep conical hills down to an unproductive rice paddy would be a stirring image for any visitor. But it is especially moving for anyone who remembers the modest and often discouraging beginnings at Partners In Health a few hundred yards down the road almost thirty years ago.
The Mirebalais hospital has also introduced new technologies into Haiti’s public sector: it’s very likely the largest solar-powered hospital in the developing world. It has created hundreds of jobs, many of them permanent. Although we can’t take direct credit, we’re proud of the efflorescence of hotels, small businesses, beauty shops, and other micro-enterprises around Partners In Health-affiliated hospitals. The people we serve don’t yet have jobs in the generative sector beyond agriculture. But release them from the burden of disease, as a first step, and they will.
To some, the hospital is just a building in progress, one project among many. But for me it’s emblematic of our respect for the Haitian people and their story and of our aspiration to make the fruits of science and the art of healing more readily available to Haitians. We now need to enlarge our community of concern to find the resources necessary to run it, and I hope there’s someone out there today who will help us make this happen.
How does this story relate to you graduates who will go off into the world today? Well, for those of you in global health or those developing technologies for places like rural Haiti, many of whom I was pleased to hang with yesterday, the answer is clear. I’d hope the newly minted doctors found it a compelling story, along with those of you from the business school and communication and journalism schools, too. But the lessons are, I believe, of relevance to all.
First, try to counter failures of imagination. A great many people, including public health experts and some of our own coworkers, shook their heads and advised against the more ambitious version of the Mirebalais Hospital. I’m not saying they were wrong. It will be a long time before we can declare this effort a success. Hospitals are the bedrock of every health system, but they are large, expensive, complex institutions to run. The complexity of hospital-based care is one of the reasons public health starts with the low-hanging fruit: vaccines, family planning, prenatal care, bednets, hand washing, and latrines.
But the more difficult health and development problems—from drug-resistant tuberculosis, mental illness, and cancer to lack of education, clean water, roads, and food security—cannot simply be left for a better day. What about the higher-hanging fruit? Do the models now dominant in global health and development permit us to care for people with more complex afflictions? Can we address more of the needs of those living in poverty?
The short answer: of course we can, with innovation and resolve and a bolder vision than has been registered over the several decades.
Second point: as you seek to imagine or reimagine solutions to the greatest problems of our time, harness the power of partnership.
Partnership has been the font of our work since it began in Mirebalais three decades ago. It’s why we refer to our collective as Partners In Health in a dozen languages. Sometimes, these are partnerships among service providers, teachers, and researchers. Always they are partnerships among people from very different backgrounds (within one country or across many). Sometimes the partnerships link different sorts of medical expertise (surgical, medical, psychiatric, and so on). Sometimes they bring together people who design and build hospitals with those who know how to power them with renewable energy or link them to the information grid. Sometimes they link talented students around the globe, as organizations like GlobeMed, founded right here by students at Northwestern, have taught us. Invariably they depend on a broad and durable set of supporters, like the many individuals and organizations hailing from this city who have made generous in-kind and cash donations to our efforts in Mirebalais. Above all, such partnerships link those who can serve with those who need services—and seek to bring the latter group into the former, by recruiting them to act as community health workers, for example. By moving people from “patient” to “provider” and from “needy” to “donor,” we can help break the cycle of poverty and disease. That’s our sustainability model.
But partnerships are not always easy to maintain. Often competition rules when collaboration should prevail. People working to fight poverty are too often socialized for scarcity and habituated to zero-sum games. Where joblessness is the status quo, building new hospitals and schools can bring disappointment to some: everyone wants to work there—and usually not because they want a better job, but because they want a job, period. Our colleagues are also socialized for scarcity—the assumption that if someone else gets a job, then they will not.
This sort of limited-good, zero-sum thinking is to be expected among those living in poverty, who know from firsthand experience that good things usually are in short supply. But such thinking is less acceptable among goodwill groups (foreign or home-grown) and among development experts seeking to attack poverty. Poverty will not surrender to a zero-sum strategy. And neither will the other great challenges before us, from global warming to sustainable and equitable growth of the world’s economy.
Remember, graduates, that your own success will not come without real partnership. You should never think of it as coming at the cost of someone else’s success. As new challenges arise to the survival of all dwellers on this planet, remember that your generation, more than any other, will need to embrace partnerships. So when you go out and paint that rock, do it together.
President Schapiro, friends and family, Chicagoland community of concern, and especially you class of 2012, thank you for having me back to Northwestern.