Dr. Paul Farmer on Medicine and the Boston Marathon Bombing

Dr. Paul Farmer, co-founder of Partners In Health, delivered this address at the Celebration of Partnership event on April 28, 2013, at Hôpital Universitaire de Mirebalais (HUM) in Haiti. We’re publishing it for the first time, in gratitude to all who helped make possible University Hospital’s first year of services, and in remembrance of the victims of the Boston marathon bombing one year ago.

Many of you here today are from—or are somehow connected to—Boston, where Partners In Health is headquartered. But all of you, whether from Mirebalais or Cange or Washington or Miami or Chicago, have been thinking about the aching city of Boston, of those lost or injured at the home stretch of its annual marathon. A tranquil day, at least for such a massive sporting event, until suddenly there were hundreds of injuries, many severe.

And they all happened at once, as is ever the case with bomb blasts and most disasters, natural and unnatural.

Not a single patient who made it to a hospital died.

You have imagined or contemplated the scene. Now imagine it as a patient or a doctor or other provider of medical care. George Packer described the bombing’s aftermath in this week’s New Yorker:

In the minutes, hours, and days after the blast, everything seemed to work. People knelt on the pavement and used belts or scraps of clothing to tie off tourniquets and prevent the maimed from bleeding to death. A pediatric resident who had almost finished the race jumped over the barricades and evaded the police to tend to victims. Volunteers instantly transformed the medical tent behind the finish line into a triage station. A man who had just lost his own son in the Iraq War rushed a young man whose lower legs had been blown off to the tent, and so kept another father from losing his son. . . . Ambulances made their way through the chaotic streets in minutes. Staff at Boston’s hospitals quickly and methodically prepared to receive mass casualties and began operating on the injured within half an hour of the blasts, preventing any more deaths after the first, tragic three.

Boston law enforcement functioned well, too, but my point today is that our teaching hospitals did a splendid job that day and in the days that followed. Not a single patient who made it to a hospital died. “Since we live in a period when many things in America don’t work,” Packer continues, “it’s almost strange to find so many institutions and individuals meeting our highest standards.”

In other words, there was, in addition to heroism and compassion, a system in place in Boston hospitals. It worked. A few days ago, I was consulting with George Dyer, a Brigham orthopedist, about a patient with a possible bone infection due to an injury unrelated to the bombings. But I asked him how he and his team were doing in their wake. I knew they’d been working long hours, from April 15th on, to respond to the spike in demand for trauma care, and was grateful for the attention he turned to every case, including the patient we were discussing. I’d come to expect such attention, at the Brigham as here in Haiti, where Dr. Dyer has often volunteered since the earthquake.

“We had the largest number of serious injuries, as it turned out,” he responded. “I was proud of how well the Brigham managed the patients and most are doing well, at least physically.” Knowing I was headed back to central Haiti, Dr. Dyer added the following: “This was a small disaster, in the scheme of things. It made me think again how important it is to have clear plans in place for Haiti’s next big disaster and the role HUM will play in it.”

The H stands for hospital and the M stands for Mirebalais, the town in which we gather and the one where Father Lafontant and Ophelia and I and several others here today met over 30 years ago. More on the U in a second.

I love practicing medicine at the Brigham. And I want Haiti to have something like it, too.

The need for a better system of care was evident from the start of our collective efforts here, humble as they were; it’s why we founded Partners In Health. In our first few years of a health survey in Cange, we lost three of our close friends and co-workers. That was almost half our team. All of them were more or less my age and as enthusiastic about introducing health services to this region. Not one lived to see 30. I sometimes get the order of their deaths confused, not because it was such a long time ago but rather because they’re still so painful to think about. Acephie died of cerebral malaria, misdiagnosed as a psychotic break. She died sitting in a psychiatrist’s waiting room. Another, Michelet, was felled by typhoid fever, complicated by an ileal perforation: microbes ate through his small intestine.

He was taken too late to the operating room, and died in a busy referral hospital, writhing in pain and fear, well-founded fear, while waiting for surgery. The first to go was named Marie-Therese but everyone called her “Ti Tap.” She died of puerperal sepsis days after delivering a baby boy, who is here with us today. The disease has been rare in places like Boston since doctors and midwives learned to wash their hands properly before and after each delivery, and almost never registered in such settings after the advent of modern infection control and antibiotics. In every sense, these were three pre-modern premature deaths.

Each of these young people, our friends, lived in the town of Mirebalais, which did not figure, until today, on the map of modernity. As you can see, HUM is the acronym for Mirebalais University Hospital. There’s not really a university in this town. Not yet. But University Hospital was built to be a teaching hospital because the hypothesis, here, is that the quality of medical care will be improved whenever training and research—the “feedback loops” that allow us to learn—occur in tandem with compassionate care.

I love working at a great Boston teaching hospital, as do Dr. Dyer and several of the physicians who lead them, here today. I love being able to train the next generation of physicians and nurses. I love that the Brigham has large teams able to respond to complex emergencies, which in many parts of the world are unattended and result in death, up to half of them that would have been averted with proper medical care. I love the collegiality between and within teams of caregivers who know, even when they protest to the contrary, that they have adequate time and resources for the sickest patients, the toughest cases. I love not having power-outages or stock-outs or strikes or anything that might interrupt patient care. I love that there are back-ups and redundant and hidden systems that work and even the ability, when overwhelmed, to bring in more resources—which is difficult to imagine when one sees how well-staffed and supplied the Brigham is.

I love practicing medicine at the Brigham. And I want Haiti to have something like it, too.

In recent decades, such aspirations have sometimes been derided in public health, especially by those tasked, by self or other, with serving the poor. Teaching hospitals are not “cost-effective,” nor “sustainable,” nor a wise use of “scarce resources.” They’re a “black hole,” doomed to fail in settings of poverty and privation.

So why are we standing here today at University Hospital, now up and running? Because those gathered here, like all those who’ve joined Partners In Health, have rejected low-ball aspirations. You have rejected cynicism, defeat, paralyzing anxiety, and a host of other common, indeed universally felt emotions. You’ve interrogated analyses that place risk to ourselves and our home institutions far above risk to unknown others. We stand inside this monument to expert mercy and human solidarity because you have accepted responsibility for the well-being of your fellow man, woman, and child—and not because you know them, as I did Acephie and Michelet and Ti Tap, but although you do not. You’ve all said, in other words, We can do this right here because it is the right thing to do.

And so you have. Today we celebrate what is already done and the partnerships that gave flesh to our dreams, that we may provide expert care for those known and unknown. We give thanks for all “staff and stuff,” of course, but in our division of labor, I’ve been accorded the chance to thank those who helped to build University Hospital by donating time and skills in the building trades to erect here a hospital worthy of the Haitian people. Most of all I’d like to thank the hundreds who’ve sweated on this campus from the time it was mostly a swampy rice field to now, so I’ll add a word in Creole. Mwen ta remen di mesi, chapo ba, pou tout moun ki te kraze ko yo, anba gwo soley, pou leve lopital sa a. Se nou ki bati kokenshenn lopital sa a.

But today we’re giving thanks for the transnational accompaniment that after the earthquake brought new skills, in design and engineering and construction, to central Haiti. People like my college classmate Ann Clark, who kept a 20-year-old promise by laboring over the plans, revising them more than a dozen times when, after the earthquake, we kept saying, No, bigger. People like Mark and Teresa Richey who helped provide the lovingly finished mill work. The members of the electricians’ union, IBEW 103, the carpenters’ union, and the painters’ union, who made apprentices, then skilled tradesmen and tradeswomen, out of the young Haitians on the job. We thank folks like John Cannistraro, who designed the medical gas and mechanical systems that constitute the hidden guts of the hospital, and Maria Concha Hein who spent months writing up the equally invisible contracts for companies, and Andy Leonard, who led the site work and shaped the very earth you’re standing on, and Beth Floor who connected us to GE. We thank Bill Horan who helped build the potable water system. We thank Laurel True and her band of newly minted mosaic artists, who made the pediatrics ward a place of beauty rather than a site of suffering and fear.

Most of all I’d like to thank two people even though they know as well as anyone that it takes a legion to build a medical center. You know who they are, and what they did to build HUM. Jim Ansara, more than 30 years after joining a carpenters’ union, as most Amherst College drop-outs do, years after slowly growing a successful construction company in his hometown by investing in the best skilled labor, did something else that not every builder-turned-CEO does. He kept and maintained his friendships with all those who build hospitals like the ones that functioned so well in Boston over the past two weeks. Jim’s web of connections gave us builders who came here from across the United States, the Dominican Republic, Mexico, Ireland and South Africa and sweated side by side with the Haitians. Together they built this, the hospital we needed here during the long years we lost too many Acephies and Michelets and Ti Taps because of poor infrastructure, a lack of emergency and intensive and surgical care, and because, frankly, of an impoverishment of aspirations.

These professionals—engineers and carpenters and electricians and people from all the building trades—came to Haiti not just to build this facility but also to train their Haitian co-workers and apprentices how to build better. They also came to learn. So you see, thanks to Jim and the spirit of this web, HUM became a teaching hospital long before the first patient entered its doors. The highest praise I can give you, Jim, is that you remind me of Tom White.

We have a long way to go just to make this one institution function, as the Boston hospitals functioned after the bombings.

Last but not least, I thank Dr. David Walton. He’s shed blood, tears, and sweat since his first year at Harvard Medical School, when he, also at 23 years of age, came to Haiti: no one sweats more than David. Like most physicians in training, David was always interested in making broken things work again. Unlike most medical students, David was always interested in design and building, in infection control and how patients flowed, or did not, through clinics and hospitals. And he had the good sense to understand that real leadership requires recognizing expertise one doesn’t have, hence his fruitful partnership with Jim. He understood that translating our shared dream into reality requires stirring enthusiasm in others. He has brought many into this project, Haitians and Americans and others, who have learned and taught about making a complex institution rise from the mud and work. To his mother and brothers and Heather, to all those who have seen little of David since the quake, now you see why.

My own faith in David’s and Jim’s capacity, and in the good will of all those who gave the staff and stuff and funds to build this hospital, has been richly rewarded. It takes years to turn the nightmare of countless Acephies and Ti Taps and Michelets into a clear vision, not yet realized, but getting ever closer.

I am at once the least surprised and the most joyful man here.

Let me close by citing Jon Sobrino, a Jesuit theologian from El Salvador, in a book subtitled “Earthquake, Terrorism, Barbarity, and Hope.” Not long after two earthquakes in El Salvador, and three decades after suffering the loss there of his closest friends and many he did not know, Father Sobrino has this to say: “Compassion is central to being human. The suffering of victims can de-center human beings and place love at the center. Who fulfills all the commandments? That is, who is truly human? The Samaritan. When he saw the victim, he was moved by pity and bandaged his wounds. Here is the fully realized human being, not because he is ‘religious,’ or ‘democratic,’ or ‘the best,’ but because he is moved to compassion.”

Standing here at University Hospital and in solidarity with Haiti’s public-health authorities, we know we have a lot of work to do to build a national system of health care, including a social safety net able to do a lot more than bandage wounds. This will require thousands of partners, and good leadership, and long years. We have a long way to go just to make this one institution function, as the Boston hospitals functioned after the bombings, and to make University Hospital part of a public system rather than an island of expertise and new equipment surrounded by a deep moat designed to keep people out. Keep accompanying us on this path forward.

Thank you builders, and thank you all who helped them build.