His replies were so rapid that I found it difficult to keep pace, so I tried to get my whole concern out in one breath. “The CT has allowed us to diagnose patients with really complex brain tumors that look like they could be big saves if we got them to surgery in the US, but the surgeries are just too risky to do here, and it’s really challenging to get these patients to the US.”
“Ah, you think history began when you arrived?” Paul asked playfully and chuckled. “We’ve been dealing with these issues for the last thirty years!” He took his cell phone out of his pants pocket. “I am going to send you something,” he said. He fiddled briefly with his phone and then looked up from it with another birdlike jerk of his head, his blue eyes peering over his small circular spectacles. “Email address?” he asked.
I recited it and he typed it in. “Boom, sent!” he said giddily and put his phone away. “I just sent you the graduation speech I gave at USC last week.”
“Great, thanks!” I said with a mix of genuine enthusiasm (an email from Paul Farmer!) and irritated frustration (what did this have to do with our conversation?).
“The speech is about how we separated conjoined twins here at HUM,” he began. “Everyone said it couldn’t be done here. Shouldn’t be done here. Guess what? It’s done! We did it! Here! Read the speech.”
I could finally see where he was going with his argument. He thought we should be doing brain surgery at HUM. Paul wasn’t the first person to suggest to me that we send neurosurgeons to Haiti instead of struggling to bring patients to the US, since the latter was much more logistically challenging, time-consuming, and costly. Luckily, I had needed to counter this argument before, so I had a well-worn response to why I didn’t think this was a good idea.
“The surgery itself could technically be done here, but—” I began.
“In our beautiful modern operating rooms!” he interrupted exuberantly.
“But I’m afraid the patients would die postoperatively,” I continued. “What if they develop diabetes insipidus? How could we monitor and react to that?” Diabetes insipidus—distinct from diabetes mellitus (which is what most people refer to when they say “diabetes”)—is a condition in which miscommunication between the brain and kidneys causes the kidneys to spill massive amounts of sodium into the urine. It can occur after neurosurgery, requiring monitoring of blood and urine sodium levels as often as hourly to avoid fatal complications of fluid and electrolyte imbalances. There was no way to obtain labs and react to them that frequently at HUM. “I just think it would be safest for them to have surgery in the US,” I concluded, hoping I’d made my case.
Paul made a half smile, half grimace as I spoke. Then he smiled fully. “That’s what the new lab is for!” he said, pivoting back to the two emergency room doctors. “Like I was just telling my new friends here. Right guys?” He stood up. “Let’s have lunch!”
I stood up too. Lunch would mean a larger crowd, and I saw my chance to try to get his help on this slipping away. Suddenly I thought of a way of framing my argument that might just convince him.
“But, Paul,” I said, now standing just in front of him and looking up at him. “Don’t you think the preferential option for the poor when it comes to these patients is to have their surgeries done in the US where we know it will be safest and lowest risk?”
His eyes darted quickly to the right for a split second and he blinked. I got him, I thought. How could he argue against one of his own core principles, the very words highlighted in the opening line of PIH’s mission statement?
His eyes returned to mine. “Keep working on both fronts, then,” he said soberly. “Keep trying on both fronts.” He held my gaze with his for a brief moment longer. Then he nodded once and turned away to walk down the hall.
“Nou grangou. Kikote manje a?” he called out playfully. (“We’re hungry. Where’s the food?”) The hospital staff preparing the food erupted in laughter. Paul had phrased it like the question of a hungry kid coming home from school.
I sat among a group of about a dozen local and expat staff, a few donors, and some of Paul’s local friends around the conference room table where I’d had my feet up moments earlier. It had been converted into a dining table by the addition of a white tablecloth, place settings, and a buffet of rice and beans, goat stew, and pikliz (pickled cabbage, carrots, and peppers).
We listened to Paul with rapt attention as he held court on various topics. He talked about the new book he was working on, a critique of the global response to Ebola. “Umbrage will be taken,” he said as he passed around the manuscript, a huge stack of pages with double-spaced type covered in notes scrawled in red ink. “Umbrage will be taken,” he repeated.
He spoke of his three top goals for PIH in the coming year: completing the construction of the HUM clinical laboratory, building a new hospital in Liberia, and developing botanical gardens for the HUM grounds. The last one caught us all off guard, and he seemed to relish that. He paused for effect with a wry smile as we all looked at him, squinting, brows furrowed, confused at how creating a garden could be placed on the same level as the rebuilding of a health system in post-Ebola West Africa.
“I want HUM to be beautiful, not just functional,” he finally said. “Don’t our patients deserve that?”
I felt so privileged to be there, listening to the thoughts of this visionary hero who inspired a generation of health profession students—myself included—to pursue the goal of global health equity, to accompany the poor, to advocate for the marginalized. I caught myself smiling, remembering how blown away I had been when I read Mountains Beyond Mountains, the popular biography of Paul Farmer and his work with PIH. I couldn’t believe I was sitting across the table from one of my idols. Then I recalled our debate before lunch. Why had he responded so disappointingly to my advocacy for some of our patients in Haiti to get surgery in the US? It just didn’t make sense to me based on what I understood as his—and PIH’s—principles.
That night, I brought my phone under my mosquito net to read the graduation speech that Paul had sent me earlier in the day. I recognized the jokey, punchy style from speeches I’d heard him give. He mixed tragic tales of doctors dying of Ebola in West Africa with a comical story of when he returned to the US from West Africa during the Ebola epidemic, causing chaos at the airport when the crew and passengers realized where he’d traveled from: “They didn’t get Ebola, but they did miss their connections.”
Finally, I located the paragraph that I thought was why he had wanted me to read the speech. He discussed the debate over whether the Haitian conjoined twins should be surgically separated in Haiti or in the US:
Ah, dear doctors of 2016! Debates ensued. You will see this often in your training and practice, especially when bold or audacious plans are proposed. But not everyone agreed with me . . . that this course of action [doing the surgery in Haiti] was prudent or even possible . . . I’d asked [a US-based] surgeon if this procedure could be done in Haiti, since that’s the point of building a university hospital in the middle of the countryside: to provide care while training and learning. That transferring the babies to Los Angeles or Boston would have cost millions wasn’t the main point, although finding such resources, and visas and the like, would have been difficult. The primary point was the babies’ well-being. But it’s worth noting that the Haitian nurses and doctors who’d cared for [the mother] and her babies wanted to see things through. And that could only happen in Haiti. And it’s not like the United States is a medical paradise or our ICUs are free of highly drug-resistant pathogens. Research reported just last month ranked medical error as the third-largest cause of premature death. Right here in the US of A . . .