Measuring the Immeasurable

Phil Garrity, 25, joined the Partners In Health staff in Boston in 2011 after volunteering with Socios En Salud, PIH’s sister organization in Peru. As program coordinator on the Monitoring, Evaluation, and Quality (MEQ) team, he helps measure and evaluate PIH programs to improve quality of care and demonstrate the success of the PIH model.

In August 2012, Garrity was unexpectedly diagnosed with osteosarcoma, an aggressive and rare bone cancer, and began an eight-month treatment program that included surgery and chemotherapy. As he transformed from a servant of the sick to a patient himself, he learned to value an under-appreciated aspect of service, which he terms “non-doing.”

Garrity wrote the following reflection, which he read aloud to Partners In Health staff on May 15, 2013, the day his medical team declared him cancer-free, as a message of thanks for their accompaniment throughout his journey.

Over the past two years volunteering and working for PIH, I’ve been lucky enough to take part in a movement to integrate data-driven quality improvement into our operations. Much of my team’s work involves distilling an often nebulous web of people and activities down into a conceptual framework that reflects what is actually happening on the ground. We map out work protocols and data flows, we select process and outcome indicators, we create systems to collect, analyze, and visualize the information—all to gauge three simple but key aspects of our programs: What are we doing? How well are we doing it? How can we make it better?

But without drowning in the details, I’ll synthesize all this by saying that much of our work and my role here at PIH continues to place particular emphasis (as it rightly should) on an intrinsic part of serving the poor: the doing. My mind is often focused on what protocols our staff are implementing, how many home visits our community health workers have completed this month, how often our HIV patients have been seen in clinic. You may preoccupy yourself with such questions as how many letters have been sent, web pages designed, meetings scheduled, donors courted, supplies procured, services delivered, money raised. And, logically, we can’t know what’s being done unless we measure it. Because, as one MEQ site leader once remarked, “If it’s not documented, it didn’t happen.”

But this is where we reach a dilemma. To simply measure the value and quality of our work by the numbers, the performance levels, or the concrete investments of time, energy, and resources seems to neglect another invaluable, but often hidden, dimension of this work: the non-doing. This concept may baffle those of us more accustomed to the rational side of life, for so much of our culture values and rewards the practical and pragmatic, the logical and analytical. The idea of “non-doing” is easily equated to “not doing anything”—nothing more than a futile exercise and utter waste of time. But allow me to reflect on a few personal experiences that have transformed this irrational concept into a mysterious truth, one that I’ve come to find resonates less with my mind and perhaps more with my spirit.

I’m drawn back to my time volunteering with a local nonprofit in Cusco, Peru, in the months preceding my internship with Socios En Salud. A few days each week, I’d help out at a nursing home for the destitute run by an order of kind yet stern nuns who led by rigid example and hardly ever by word. Feigning competence, I’d be handed a pot and ladle and I would feed the ancianos; handed a bottle of ointment, I’d rub it on their itchy legs; handed a pair of clippers, I’d trim their overgrown toenails—all of this often done in total silence, even lathering and shaving the old men’s faces, eight of whom were blind. Their quiet gratitude for something so simple and seemingly trivial astounded me then and perhaps more so today as I look back and wonder what it all meant.

At the time, I was beginning to delve into questions that would serve me well in Lima and later in Boston: what were we really trying to achieve here? What were our goals and how close or far were we from reaching them? The long hours of just sitting with these old people, hearing their stories, tending to them in what small ways I could—it seemed nice enough, but was it doing anything of real value, at least as I understood it then? My mind would drift to hypotheticals somewhere beyond the confines of that small, quiet refuge. Shouldn’t I be saving children from starvation, protecting refugees from mortal danger, pulling this country out of poverty and into the 21st century? After all, I had come here to rescue people from their lot, to save helpless victims from suffering and injustice. This place seemed so stagnant, these people so quiet and inert. What was I doing here?

I felt that I had failed to be the protector, the helper, the healer—not for an entire country, but even for this one feeble man.

Early one morning, we found a frail old man had fallen and broken his hip in the middle of the night. His groans and whimpers suggested he had been without pain relief for hours, and he needed to get to the hospital. We placed him on a wooden board, loaded him into the church’s van, and were off. I rode alongside him, anxious yet keenly aware of my inability to do much of anything for the poor man. Once there, it pained me to see him relegated to a corner of a busy emergency room where he simply had to wait his turn to be seen. Hours went by and I sat near him, wallowing in the helplessness that I now shared with him. What could I do? I felt that I had failed to be the protector, the helper, the healer—not for an entire country, but even for this one feeble man.

Our driver, a seasoned caretaker from the nursing home, came in with some bread and juice for the man, who silently accepted the gift and began nibbling away, partly concealed underneath the sheets draped over his stretcher. I sat and watched him intently with a mixture of exhaustion and pity as he littered himself with crumbs and peered out at me, eyes gleaming. It was then that something miraculous happened: the old man broke his bread roll in half and stretched out his hand toward mine. An acute sense of surprise and embarrassment came over me, and at first I refused his offer, insisting that he eat it, for surely he needed it more than I. But my feeble attempts to decline the gift were wholeheartedly dismissed as he pushed the bread into my hand, motioning me to eat. And so I did, me looking bewildered and humbled, he looking quite pleased to share his meal with a near stranger.

Moments like these continue to deepen my understanding of what it means to embrace the non-doing. It’s come to mean being brave enough to disarm myself, to set aside my intellectual firepower and self-protective shields, and to enter into another’s chaos—not to do for them, but to simply be with them. It takes courage to sit in that silence, often empty-handed, and humbly accept the lesson that that feeble man so beautifully demonstrated that day: that I am as much the patient as he is the healer. That he is not a broken machine idly waiting to be fixed by the “non-broken,” the “privileged,” the “fortunate” among us. I believe that those we intend to serve have bread to offer us every day—humble reminders that we are co-creators in the promotion of life, gentle invitations to discard our pity and crawl down into the pit with another. In these precious moments, we’re able to see our shared vulnerability as humans and to simply open ourselves to it, perhaps without much of any real hope of fixing anything in that moment or hour or day.

Beyond all of the things we do to act in service for the poor—delivering medical supplies, building health systems, strengthening human capacity—I’ve come to believe that there is something far more powerful in simply being in service with those in need. We might consider this other dimension of our work a ministry of presence—one that underlies and encapsulates all of our tangible efforts to console, to palliate, to rebuild in the face of disease and distress. I would argue that this is our strategic advantage among those in the vast arena of development work: that we do not walk away when things appear impractical, unfeasible, or futile. We stay, to perhaps accept defeat again and again, if only to show the world that the people we serve are worth more than the steps they may gain or lose on their path to a more dignified life. That we ourselves are worth more than our successes or failures on our path to building a more just world.

Our collective attempts to concretize an abstract world—to understand the mechanics of material privation, to design interventions and harness resources that achieve a positive and quantifiable effect on the lives of the poor—can create the illusion that fixing is our only aim.

I see more clearly now how all my dissecting questions obscured the real meaning in those quiet gestures at the nursing home. Our collective attempts to concretize an abstract world—to understand the mechanics of material privation, to design interventions and harness resources that achieve a positive and quantifiable effect on the lives of the poor—can create the illusion that fixing is our only aim, that we must constantly be doing if we are to succeed. We can believe that if we can’t show progress, then none has been made. And so we easily fall into the trap of making systems and machines out of countries, communities, and individuals—broken devices that only we can fix. 

But real solidarity, true compassion, as I’ve come to discover through lived experience these past eight months, is grounded in something far deeper than our displays of technical prowess or standard notions of progress. It evades our attempts to capture its value with metrics and analytics, and perhaps for good reason. I believe it’s revealed through an earnest and humble kind of love, one that neither feigns strength nor fears weakness. It can simply sit with another in the silence, not feeling frantic to fill it with words or deeds. It has the courage to look into the darkness of our finitude—both of our bodies and of our ambitions—which we all face, not just the sick. It can trust in the value of non-doing, of simply being present.

And so I say all of this as a hopeful reminder for each of us to restore a balance between what we do and who we are, being careful to not forget the unconditional value of the latter. Because at our core we are radical love, we are goodness, we are justice—a core that cannot be marred or diluted by all the apathy, cynicism, and resistance the world might throw at it, a world of practicality that tries to convince us that our efforts to transform it will inevitably fall short, that our gestures of good will are in vain, that we have not done enough today. It is from this core of being that we are able to infuse what we do with the goodness that we are—to make possible real healing, both visible and invisible, that often can’t be measured.

I thank all of you for helping me to live out this truth and for being who you are, far beyond what you do.