Paul Farmer's speech from the 2011 Skoll World Forum on Social Entrepreneurship
PIH co-founder Paul Farmer on "deep leadership"
Posted on Apr 1, 2011
By Paul Farmer, PIH co-founder
Dr. Farmer presented this speech at the 2011 Skoll World Forum On Social Entrepreneurship.
When Mabel and Sally asked me to participate on this panel, I said yes—I am fundamentally obedient when they are concerned—but with anxiety. It wasn’t the large-scale change part that worried me. That’s why we’re here at Skoll. But “interior dimensions” often leads to dismissive comments about singing Kumbaya. This year is different for many reasons. One stems from having worked in the “quake zone” in Haiti this past year. Another is the presence of “the Arch”—Desmond Tutu—who is no stranger to struggles for large-scale change, or for understanding its interior dimensions. My admiration for the Archbishop comes not so much from his Nobel Prize or other honors, but from his decades of humble service to the poor.
What is there to say about “deep leadership and the interior dimensions of large-scale change” when we’re talking about disasters natural and unnatural—from the Haiti earthquake to apartheid? One thing we can do here, in the city of dreaming spires, is to bear witness to difficult times—and the quake was the most difficult time I’ve been through. Another task, to paraphrase Haiti’s former President, who himself found shelter in South Africa for years, is to “echo and amplify” the voices of the poor majority and those who support them in their struggle for survival and for dignity. After the quake, this diverse group included local women’s groups, international teams of trauma surgeons, Cuban caregivers, and community health workers in the country’s rural reaches. It included so many of you gathered again at the Skoll Forum. Together, we can try to honor the voices silenced on that night fifteen months ago. This is, I believe, the most important kind of “deep leadership”—witnessing, building partnerships, and promoting collaboration rather than competition.
Alas, this has not been easy. Deep leadership will require social entrepreneurs to rethink siloed approaches to “branding,” innovation that is deemed proprietary, as if worthy of patent. It requires not that we reject these notions, but rather that we interrogate them whenever our humanity and dignity are under fire.
Let me describe the events of a single night at the General Hospital, Port-au-Prince’s largest. It was just after the quake. Although there were, in those days, never enough supplies or staff or space for the patients streaming in, expert mercy was not in short supply. Trauma teams from all over had set up tents throughout the damaged hospital. (There were even Scientologists in bright yellow t-shirts, though I didn’t know how to explain to my Haitian colleagues what they were doing, because I hadn’t a clue.)
In one tent, I spied a Haitian doctor standing anxiously over a thirty-four-year-old man who thought he’d escaped serious injury when his parents’ house collapsed around him but now presented in respiratory distress. He looked whole but was gasping for breath. I gave him morphine. His story came tumbling out in shreds: part of a wall had fallen on his legs; it took him an hour to free himself, but he was soon up and helping others in the neighborhood. A physical exam revealed a high fever, but only minor abrasions on his legs. He’d been treated with antibiotics in another facility (the General Hospital was the third one in which he’d sought care), but an X-ray suggested severe pneumonia. We gave him a broad-spectrum antibiotic, and tried to treat him for blood clots that might have traveled from the large veins in his legs to his lungs, but we didn’t have the right formulation of blood thinner on hand.
In a few minutes the morphine kicked in and he was feeling well enough to ask, in one of his first complete sentences, for something to eat. We knew the morphine was responsible for his improvement, but morphine doesn’t last long, nor does it treat problems at their root. Fearing that he wouldn’t survive the night without mechanical ventilation, we tried to transfer him to the USNS Comfort—a navy-ship-turned-hospital steaming, that day, toward Port-au-Prince.
We had many other patients to see that night. A slight elderly woman at the other end of the tent was wracked by the spasms of tetanus—the first of many cases we would see that week and the next. White-haired and weighing about ninety pounds, she had tears rolling down her cheeks. Every few minutes she would go rigid with potentially bone-breaking and suffocating spasms. The slightest stimulus triggered them; she needed to be in a dark, quiet room—but that would move her far away from medical care because, with frequent aftershocks shaking the foundations of the hospital, no one wanted to work inside.
With all this suffering hemming us in from every side, what was there to be said about our own “interior suffering”?
At one point, I ducked outside for a breath of fresh air, and saw a young woman, perhaps twenty-five, lying on a stretcher outside, all alone in the pitch dark. Had she died? No, she was breathing and warm to the touch. I said hello and asked her how she was; she raised her hand and said, simply, “I think my legs are broken.” I looked at an X-ray that had been tucked under her feet: both of her femurs were fractured high up, near the pelvis. I asked if she’d received anything for her pain; she had not. She had no family present; that was clear. She feared that her parents and infant daughter had perished. “The roof fell on us,” she said and began to weep quietly. The best feeling I had during that wretched evening was bringing her pain medications, which soon led her to what might have been her first sleep in days.
As with every night those days, there was no shortage of work and no reason to leave, except that we would be exhausted and useless the next day if we stayed. I tried to corral my coworkers into rest—it was almost midnight, and we’d made some progress: we’d secured for the young man in respiratory distress the promise of a transfer to the floating hospital by helicopter at daybreak; the old woman with tetanus had received antibiotics and heavy doses of diazepam; a number of patients with major trauma were now, like the young woman alone in the dark, resting thanks to pain meds.
We finally left the hospital for houses up the hill, away from the worst damage. We were spent. As our car climbed through a wrecked and darkened neighborhood, a dog darted in front of us and we heard a thud. No one said a word. I got to sleep in the wooden (and thus safer) house of some close friends, far above the heat and stench of the vast, blacked-out city below. There was a bottle of water by my bed and blessed silence.
But I couldn’t sleep. In the dim reaches of misery, insomnia is a constant companion, especially wherever twenty-first-century people die of nineteenth-century afflictions—minor injuries and simple fractures as well as pneumonia, tuberculosis, and other infections, such as tetanus, that are preventable with a vaccine available for pennies. Archbishop Tutu knows exactly what I’m talking about. I was pursued by the sights and smells and sounds of the day: the unrelieved pain; patients and doctors sprinting outside during an aftershock; phone calls from people trapped under rubble; the charnel-house odor from the morgue and from under the rubble. Counting sheep kept turning into the grim process of counting the dead. I even thought of the hapless dog. Was I praying, or fretting, or what? The image of the man who couldn’t breathe was still with me as dawn approached—had he survived the night? Surely the floating hospital could save him.
Hanging on to this hope, I fell into a deep sleep. But after an hour or so, I was shaken alert by a large aftershock. The wood of the house strained and creaked; the paintings in the room tilted; the plastic water bottle at my bedside started to tremble. My host yelled for us to “get out of the house right now!” The sun was coming up, and I watched impassively as the water bottle fell to the floor. I heard people in the house scrambling to get out, and saw, in my mind’s eye, the crushed limbs of people trapped in countless other houses during the quake. I knew I should move and thought of my children, who had spent the recent holidays in Haiti but, by the grace of God, had been spared the fate of so many a few days after they left. It would’ve been prudent to bolt down the stairs and into the street. But I didn’t move a leaden muscle and did not wake again until the sun was high in the sky.
Dr. Paul Farmer is a co-founder of Partners In Health; Kolokotrones University Professor, Harvard University; Chief of the Division of Global Health Equity at Brigham and Women’s Hospital; and UN Deputy Special Envoy for Haiti.
