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The Quid Pro Quo

Paul Farmer Commencement Address: The Keck School of Medicine of the University of Southern California

May 14, 2016

It’s an honor to be back here, on this of all days. I’m not referring to Saturday, or even the weather, although today reminds me why people leave New England, or my torrid home state of Florida, for Southern California—and why most of you, once here, refuse to leave. I’m also not referring to Mother’s Day, although I think we owe a round of applause for all the moms here today, and indeed for those absent, since we wouldn’t be here without them. No, the day I’m referring to is your Commencement Day. Congratulations, doctors of the Class of 2016! May you long remember this day!

But alas you won’t.

I’ve learned that not many people remember the content of commencement speeches. I’ve been committed to higher education and its rites of passage long enough to meet people who say, “Hey, you gave my graduation speech.” Sometimes they’re residents or interns, which most of you will be in less than a month, but sometimes they’re fully grown doctors and nurses and folks from other walks of life. For a while I made the mistake of responding to such observations with, “Well, what did you think of my address?” After a few embarrassed shrugs and, occasionally, some wholly unwelcome candor, I knew that most had forgotten these sincere and carefully crafted speeches. Entirely.

The exceptions to such post-speech focal retrograde amnesia occurred when I relied on a single story, preferably concerning the soon-to-be alma mater of the graduates. When nothing extraneous to The Story (capital T, capital S) is added. Save all that extraneous detail, I learned, for the published version. This, as we know, is how surgical residents think of ID consults—useful largely for dictating discharge summaries. Or think of that big fat biography of Alexander Hamilton no one read until Hamilton: The Musical.

I have a doozy of a story for you, dear graduates. It unspooled over the past couple of years. Even the bare-bones version is dramatic. It is, in a way, Ebola: The Musical. And The Story definitely concerns the Keck School and affiliated hospitals. I’m here as the result of the most extraordinary quid pro quo in my medical career. I don’t hold with Latin in such speeches, although, believe it or not, a Latin oration is still given at Harvard’s commencement exercises. I had to look up quid pro quo yesterday, over Iowa or Kansas or Colorado or some such. “A favor or advantage granted or expected in return for something.”

This speech is part two of the extraordinary quid pro quo. I’m here as a favor to a Keck professor, who should have known, and probably did, that I’d have happily shown up just to cheer you graduates on as you rush to not leave California. No quid needed. You guys are extraordinary and just beginning an extraordinary profession, which holds enormous promise in spite of significant problems, plenty of them obvious right here in California. But it’s a wonderful profession. Don’t listen to the haters who say otherwise. The story of the extraordinary quid pro quo is one that reveals both the promise and peril of medicine today. Any life spent in medicine is extraordinary, since patients and colleagues, broadly defined, are extraordinary. But my life in medicine has surely been more varied than most. It’s taken me between Harvard and Haiti for well over three decades. By now, I hope you’re curious about the deal I made with a senior USC faculty member in order to get here. Who offered me the favor or advantage? In keeping with HIPAA regulations—already, we’ve lost the non-medical folk—he or she shall go unnamed. But I can mention, given the size of the crowd, that this person is sitting here today. Right up on this stage. And what exactly was the favor or advantage said faculty member gave in return? You should also be wondering, Really? You must have made a lot of bargains, some more Faustian than others, over the years. And the one that brought you here today —this is you thinking—was the most extraordinary one of your career? My career in medicine began, for me, before I started Harvard Medical School in the fall of 1984, which happens to be the year the USC faculty member graduated from that same medical school. Through great good fortune, which I won’t detail today—extraneous to The Story—I’d spent much of the previous year in Central Haiti. I learned a lot of tough lessons about what it meant, to practitioners but especially to patients, to lack the staff and stuff and space and systems required for the practice of medicine. Often, you need help—favors, advantages—with all four Ss, especially in settings of privation, which you can find anywhere. Here’s the other half of the QPQ: I asked said alumnus of Harvard to help us with a particularly complicated case.

Did I mention that this eminent personage, with tottering stacks of published papers, is a pediatric surgeon? Without that detail, the QPQ makes no sense. And the surgeon, who must remain anonymous, replied, “Whatever you want, Polo.” That’s my nickname in Haiti. I’m not saying that this person is Haitian, or related to Haiti in any way. I’m just saying that I was pretty sure he, or she, would help us out with whatever we needed in this particular case. But surgeons, as we all know, can be skittish. They have, as you say in California, serious commitment issues. Like emergency medicine docs. It was after extracting this open-hearted promise that I added that the patient was not one patient but two. The surgeon’s resting heart rate remained under 50, off beta blockers, and so I continued. Oh, and these kids don’t live in Los Angeles. Or California. Another pause. Still calm. Or even the United States.

I also dragged this out because my negotiating style differs substantially from that laid out in the number-one bestselling business book of all time, The Art of the Deal. I’m told this will soon be required reading in the United States, as we get ready to build The Wall, and cut a deal to get our neighbors to the south to pay for and erect it. But I digress. I wanted him or her—the surgeon, rather than The Donald—to agree to take care of these two patients just because I asked. That’s how I roll with many of the surgeons at the Brigham and Women’s Hospital. We trust one another. Why shouldn’t the eminent if unnamed surgeon, a Professor of Pediatric Surgery here at the Keck School, trust me? We’d met the better part of a decade ago and become close in the aftermath of a natural disaster in the country of his or her birth. Where I’d worked from some time. That time being measured in decades rather than months. So I thought he, or rather he or she, ought to trust me.

Then again, I hadn’t been completely forthright with this surgeon. It wasn’t one patient but two, as I said. As in twins. And they were conjoined. What were called, back in the days of deep political incorrectness, Siamese twins.

Non-extraneous backstory. In August, 2014—a couple of months prior to my request to the surgeon—one of my Haitian colleagues, a young obstetrician named Dr. Christophe Milien, called me about a patient. I’d just returned from my first trip to Sierra Leone, where an Ebola epidemic was moving east to west, from forest to coast, unimpeded. On July 29th, Ebola had taken the life of one of my colleagues, the only home-grown infectious disease expert in that part of West Africa. For a decade, my colleague had been toiling in a town called Kenema, famous for its blood diamonds but not for anything in the way of medical care. If fate had been kinder, he’d have spent the academic year doing research at Harvard. I was both saddened and angered by this loss, and so the call from Dr. Milien was welcome, since he’s always upbeat. He’d just met with a young woman named Manoushka, pregnant with triplets. This was rare enough, anywhere. But two of them, he said, were conjoined. What are the chances of that? I asked. “About one in a million,” he said.

Dr. Milien was and is the Director of Women’s Health at University Hospital, which didn’t exist in 2010, when an earthquake leveled the hospitals in which he’d trained. The triplets were, in a sense, the reason we’d built this hospital, which had been open for less than two years. Not in the sense of responding to rare one-in-a-million problems but rather common problems of grave illness and injury, which cannot be dealt with solely in clinics or by community health workers. Serious trauma. Cancer. Obstructed labor. Most surgical disease. And Ebola, as we were learning to our sorrow. Excellent supportive and critical care can, however, save even those with Ebola. A few days after my Sierra Leonean colleague died without receiving such care, two Americans were airlifted to Emory’s medical center. Both survived. So did the brave American infectious disease doctor who took my friend’s place in Kenema. But most of the equally brave nurses there did not survive. What we wouldn’t give for University Hospital in Sierra Leone, Liberia, or Guinea—all medical deserts even when compared with Haiti.

Fast forward to my anxious conversation with the surgeon. Could said surgeon, in due time, assemble a team to separate the twins? Not in Children’s Hospital Los Angeles, but in the hospital in which Dr. Milien and a huge team had delivered them? Needless to say, such a procedure or procedures had never been performed there.

I took a deep breath. My heart racing. I’m not violating patient confidentiality by observing that my Keck colleague’s systolic blood pressure had still not gone over 80. That could mean he or she is more likely of the she persuasion, leaving aside the social construction of gender identity, or that this surgeon was quite fit. Or just absurdly self-assured, a common affliction among surgeons. Or about to qualify or annul the promise to do whatever I, Polo, wanted.

This was probably in November of 2014, a tough time. Another Sierra Leonean colleague of mine, a young surgeon named Martin, had just fallen ill with Ebola, and I was heading back to join my colleagues from Partners In Health, who had just deployed to both Sierra Leone and Liberia. The Keck professor put a big paw on my shoulder. I’m not saying big paws mean he’s male; it could be acromegaly, after all. The response to this strange request came in a deep voice—some women have them—in two parts. First, and this is verbatim, “I got this one, Polo.” Second, “I will do it if you give the Keck commencement speech.” And so here I am. Quid pro quo. Since that deal was struck—in order to protect his or her confidentiality, I won’t mention in what country, but it is an island nation in the Caribbean—I’ve had the good fortune to be part of Partners In Health’s team in West Africa. I was in Sierra Leone on the day a large team led by Dr. Milien delivered the triplets, Tamar first. Then came Michelle and Marian. These two girls had already been diagnosed as omphalopagus twins, which means, a textbook told me, they shared a liver, a gastrointestinal tract, or genitals. Michelle and Marian shared a liver, but no major vasculature. They came out happy and mewling.

That was Monday, November 24. Things weren’t going well in Sierra Leone, which was far more medically impoverished than Haiti, if you can imagine. My friend Martin, the surgeon, had just died of Ebola, and there were hundreds of new cases each week in the western part of the country where the majority of the Partners In Health team worked bravely, if without the staff and stuff and safe space needed. It was a dark time, and the triplets’ birth reminded us—and here’s one of two take-home messages—that it’s important to aim for excellence and to build partnerships that might link, for example, rural Haiti to Harvard, and to this very school. The successful delivery of the triplets was, like Ebola’s spread and lethality in West Africa, a reminder that excellence cannot occur without long-term investments in the local health system. This had not occurred since the end of the wars in that part of Africa, and now thousands were paying the price for it.

By now, I guess it’s clear that the triplets were born in Haiti, but telling you that is not a HIPAA violation. Nor is noting that, as the West African Ebola epidemic began to shrink, the conjoined sisters failed to grow. The mystery surgeon and colleagues from CHLA and Miami and the Harvard hospitals joined their Haitian colleagues in evaluating the twins regularly and in preparing for the separation that needed to occur if Michelle and Marian were to survive.

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, or with the Keck professor, that this course of action was prudent or even possible. You will recall that I’d asked said 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 care for Manouchka 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 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, north of The Wall and west of the ocean that separates us from West Africa.

That’s where I was for a good part of the spring of 2015, which made travel to Haiti difficult. Even coming in and out of the United States, with its confusing and varied quarantine policies, was difficult and sometimes downright dispiriting. The politically-stoked hysteria of the previous fall had died down, since, of course, the United States did have the staff and stuff and space and systems to prevent a major Ebola outbreak, but one of my worst travel experiences last spring was on landing at LAX after traveling from West Africa to a medical conference in Thailand. I hadn’t been working inside an Ebola treatment unit on that trip. Needless to say, it’s a lot quicker to return from Asia via L.A., but let’s just say I did not endear myself to my fellow passengers from Tokyo when they were forced to sit on the plane for over two hours. I stood in the jetway during those two hours, alone with two nice folks from Homeland Security, but in earshot of the increasingly angry passengers and crew. They didn’t get Ebola, but they did miss their connections.

That’s not to say that none of our American co-workers fell ill. In March, as the unnamed surgeon was, along with colleague Jim Stein, was visiting his or her Partners In Health colleagues in Haiti and continuing to make plans for the twins’ separation in April or May, one of our American volunteers in Sierra Leone was diagnosed with Ebola and flown to Bethesda, Maryland, where colleagues and friends at the National Institutes of Health were waiting for him. I went to join them, and his worried family, and to watch what a great team with the necessary staff, stuff, space, and systems could do. They saved his life.

Lest all this seem overly exotic as you head out with your new degree, let me argue, in closing, that it’s not. You might never see, much less care for, conjoined twins or Ebola patients. But you will care for patients with equally complex problems, and you will do so not alone, but as part of teams. You will make errors. You will learn, with that team, to make fewer of them. You will face doubt and anxiety and churn. You will lose some patients who ought to have survived and didn’t because they were poor—maybe poor and poorly served right here in parts of Los Angeles or Chicago or Boston or some rural and underserved region of this country. You will encounter stigma and racism and xenophobia, which won’t often be directed at you but which concern us all. You will feel fear and see suffering. But most of all you will experience the joy that comes of the most rewarding profession I can imagine. And that’s true no matter where you end up practicing it or how.

So what about Michelle and Marian? On Thursday, May 21st, 2015, an enormous team, really several of them, ran through yet another simulation in University Hospital in Mirebalais, Central Haiti. The Chief of Nursing and the Chief Surgical Nurse, both Haitian-Americans, coordinated teams from CHLA, Partners In Health-Haiti, Harvard, and Port-au-Prince. In beautiful surgical suites that were only a dream when that country’s hospitals came tumbling down only five years previously, twin surgical teams went through a few last drills. Michelle’s team wore yellow bandanas; Marian’s wore red. In some senses, it looked like a typical first-world teaching hospital. Pediatricians hovered, as did the other attendings. Nurses and residents did all the work. Mom fretted and Dad filmed, although the girls seemed calm. Dr. Milien looked cheerful, as ever. If all these dozens of folks felt ready, the surgeries would take place the next day. On Friday, at 1:14 pm, the girls’ parents watched Haitian and American and Haitian-American nurses and doctors and OR techs make medical history. An hour later, Michelle and Marian, hidden under two scrums of red bandanas and yellow ones, began their lives together yet apart. The teams worked quietly, for they were far from done, but a cheer went up outside the giant glass panes of the ORs, and then, like a welcome breeze, through the hospital’s wards: NICU, pediatrics, internal medicine, surgery, outpatient wards, pharmacy, administration, security, housekeeping, transportation, maintenance. It was echoed by the crowd thronging the hospital’s courtyards and grounds, and, simultaneously, by colleagues and friends in Boston and Los Angeles and Port-au-Prince and Miami. Folks across Haiti’s towns cheered as reports came in on the radio and TV. So did friends in Havana and Lima, and in Rwanda and Mexico. We heard that cheer all the way over in Sierra Leone, where we dreamed, and still dream, of a quid pro quo that might have linked centuries of extraction to something resembling University Hospital. But we were happy for the family and their caregivers.

No one was happier than Haiti’s native son, Keck’s Vice Dean for Medical Education and Chief of Surgery of Children’s Hospital Los Angeles. Shortly after finishing the procedure, Henri Ford had this to say in his booming deep voice: “It takes more than a village. More like a city.”

This, dear class of 2016, is perhaps the most important message of all. A quid pro quo—“a favor or advantage granted or expected in return for something”—need not be some crass deal. If you’re to be effective physicians, it will be because you link your gifts and training to a notion that we owe our patients favors and advantages, including the favor of doing no harm. That takes more than a village. For the gift of being a part of yours, I thank you deeply. Congratulations and good luck.