Cameron Nutt: "On Serotiny: Lessons from Paul"

Cameron Nutt, infectious disease fellow at Massachusetts General Hospital and Brigham and Women's Hospital and Paul's former research assistant, wrote a tribute to his mentor:

"In the impossible months following the sudden passing of Dr. Paul Farmer in Butaro, Rwanda, many of his friends, colleagues, and mentees have found ourselves thinking about roots and about seeds.

Paul famously subjected those blessed to spend a day with him outdoors to enthusiastic lectures on the local flora, from the bald cypress of the western Florida shores where he grew up to the staghorn ferns of southeastern Liberia, where he launched one of Partners In Health’s newest sister organizations.

This, as Paul delighted in calling it, was “hortitorture.”

A student of his once quipped after class, referring to his frequent arrivals to Harvard classrooms straight from wards of patients with multidrug-resistant tuberculosis: “When Paul Farmer speaks, people listen… when Paul Farmer coughs, people run!” Some trainees (and even patients) would learn to do the latter when he began speaking about plants.

Those who stuck around, though, often learned remarkable things. More than simple facts about verdure, his lessons included metaphors for our own lives and shared work. Paul’s beloved giant sequoia, for instance, slowly grows its seeds in clusters of resin-covered cones high above the forest floor and holds fast to them for years. Through a property called serotiny, the tree releases these seeds, suddenly and all at once, only after exposure to fire.

But among Paul’s greatest joys—and his hortitorture method with the greatest staying power—were the gardens he invited others to help take root in the courtyards of the hospitals and health centers built by Partners In Health in settings from the rural reaches of central Haiti to the mountains of Lesotho.

The saplings Paul gently placed into the soil of the places he loved will continue to take deep root, to flower and to grow and to shade for generations to come. Although he may no longer listen through his stethoscope, Paul’s trees will ensure he continues to help each of us—the whole earth as his patient—to breathe.

***

On the eve of the opening of Butaro District Hospital on the mountaintop site of an abandoned military base in northern Rwanda in early 2011, Paul and a large team of Partners In Health colleagues and local residents stayed late readying the wards for patient care. Long after dusk, he’d then asked for volunteers to stay and help put the finishing touches on the hospital’s new gardens—and of course its fish ponds—before sunrise. As the last group retired and walked down the road a few hours before dawn, Paul turned to his friend Emmanuel Kamanzi.

“Thank you for staying so late just to tend to some flowers! Every one of us has been working like a dog the whole week,” Paul said. “This final push to make sure this place isn’t just ready to provide excellent care tomorrow, but that it looks beautiful for our first patients… it means so much. In fact, it's what this is all about.”

As Paul later recalled, Kamanzi shared that his turn of phrase didn’t have much cultural resonance. “We don’t have that saying here in Rwanda, ‘to work like a dog.’ I mean, dogs don’t really work—their lives are pretty easy!” He paused and everyone laughed into the night. “But I think I know what you mean. In Kinyarwanda, we say: ‘gukora nk’ umutima,’ to ‘work like the heart.’”

Not only because the heart is the strongest muscle in the body, as children learn the world over, but because it works hardest when times are most difficult, when hope seems to fade.

The tiger lilies Paul planted that night flourish today, more than a decade later. They have greeted countless patients on their way into Butaro District Hospital, an improbable cathedral of human dignity and a place Paul had long said he hoped to teach medical students during an imagined retirement.

***

On Paul’s final morning in Butaro, as he went back to rest in his apartment at the University of Global Health Equity following a month of teaching the school’s inaugural class of Rwandan medical students on their first clerkship, he passed a skinny tree he’d helped tend on his visits over recent years.

Paul’s dear friend Agnes Binagwaho, who had first invited him and Partners In Health to Rwanda two decades prior, had brought the tree back from San Francisco as a tiny sapling. They cared for it together, first collaborating via WhatsApp photos and texts as Paul worked in Haiti and West Africa, then later in person during a joyful reunion at the school they had built next to Butaro District Hospital. The tree was only four years old by February 2022, but it was already twenty feet tall.

For one of the last plants that Paul helped to care for was a coast redwood, or sequoia sempervirens (“everlasting” in Latin), cousin of the giant sequoia and the largest species of living thing in the history of our world. These tallest of trees can flourish only with the perfect combination of fertile volcanic soil at the right altitude and frequent dense fogs of the sort that occur along California’s northern coastline—and, it turns out, the montane valleys of northern Rwanda.

When the largest of these giants, which can exceed thirty-five stories in height and live two millennia, sense an approaching wildfire, they do something extraordinary. The roots of the everlasting redwood send out new shoots underground in all directions that then rush towards the surface after the flames burn out. A dozen new trees result, rising in a perfect circle from shared underground ties.

The next generation grows rapidly, nourished and stabilized and held aloft by the well-laid roots of the giant, and all at the same height, as one movement, up towards the light. The trunk of the fallen sempervirens turns to soil, leaving a tremendous void at the center of the community.

In the darkest days of the COVID-19 pandemic two years ago, Paul spoke to graduating medical students back at Harvard as they prepared to join the front lines. One of his beloved mentees, Kirstin Woody Scott, asked him to share guidance on weathering the sorts of deep losses that accompany working alongside the poor and the sick, and on cultivating resilience in uncertain times.

“I don’t know that resilience is really the word I would use,” Paul replied. “I’ve been broken by some of these losses… resilience implies that we spring back to the same shape. If you’re broken, you can be mended—but you’ll be different.” For Paul, healing often required transformation, and an openness to grief as love persisting.

“Working alongside people like you,” he continued, “I’ve rarely been in a place for long where I don’t see some reason for optimism, for humor, for hope. And I’m feeling that now.”

Arborists call the ringed formations of everlasting redwoods that rise after loss “cathedral trees,” invoking the sense one gets of the infinite when looking up from the middle of what feels to be a holy space.

Nothing will ever fill that space at the center where a giant once stood, or repay the gift of those deeply-laid roots. But perhaps it’s this knowledge—an understanding of serotiny—that makes standing beside one both sacred and, even in our brokenness, full of hope."