If you haven’t read Tracy Kidder’s biography of Paul Farmer, here is the synopsis to the best of my memory. I’m guessing most of what I’m saying is chronologically inaccurate to his life, but these events transpired. Paul Farmer, prior to beginning medical school goes to Haiti as a volunteer and falls in love with the country and people. He then goes off to Harvard Medical School, during which time, he spends a substantial amount of his time seeing and treating patients in Haiti. Later as a resident, now at Brigham Women’s hospital, Farmer starts a clinic called Partners in Health, a groundbreaking, third world clinic that aspires to treat the world’s poorest with same ethos we treat the world’s richest. Farmer eventually takes on the quest to spread this philosophy to other countries and today is regarded as the man who popularized the notion that we should treat poor people for diseases like HIV and TB aggressively, despite the fact that the treatments are expensive and often labor intensive. He’s written a number of books on this matter and I own and have sort of read one. As a result of all of this, Paul Farmer is probably the most famous real doctor in America.
Kidder’s book arguably deifies Farmer a little too much in the sense that we don’t get a great sense of his weaknesses other than his weakness for helping people. Farmer is described as your classic work-addict, the kind of man who leaves work at Harvard, hops directly on flight to Port-au-Prince, works on the entire plane ride and upon landing immediately gets to work personally seeing patients. He’s tireless (another example of what you could do if you weren’t handcuffed to eight hours of sleep), passionate (I’ve seen him speak in person and the man is not short of passion), dedicated (near the end of the book as Farmer’s mission becomes embraced globally, it becomes obvious that he’s now more valuable working administratively with governments in formulating policy and to scale back his clinic responsibilities; but Farmer’s solution is to basically just work more so he can still see patients in Haiti), intelligent (part of the problem with Farmer’s writing as I saw it when I sort of read his book is that its so dense and complex — the ideas are too difficult for a greater audience to extract), compassionate (much of the book consists of stories where Kidder recounts Farmer trekking three hours to personally track down a patient and treat them) and uncompromising (the book does allude to the fact that he may or may not be moderately estranged from his Haitian wife and daughter because of his unrelenting commitment to treating and advocating for his patients). Kidder’s portrayal of Farmer as a superhuman being is the essence of why this book is so compelling (Kidder won the Pulitzer for this book). And while it doesn’t necessarily ask anything of its audience, it certainly implores the reader to examine themselves relative to Farmer.
In M. Night’s Shamalayan’s movie Unbreakable, Samual L. Jackson’s character Mr. Glass predicts (correctly) the existence of Bruce Willis’ character based on the premise that if someone as fragile as him exists in the world, then someone else must exist on the other side of the spectrum, equally far from the center of the bell curve — someone unfragile and unbreakable. Jackson’s supposition is based on a lifetime of reading comic books. Reading them, he notices that there is a balance between the powers of good and evil, that their powers often have a dichotomous, balancing relationship. He becomes obsessed with finding Willis, because finding Willis gives his horrible disease meaning and in way it gives his frail, flawed existence purpose. I think ultimately our (my) fascination with Farmer’s story is similar. Maybe men like Paul Farmer are owed to us by the universe for all the mass-murdering dictators and anyone involved in the crime of inventing electronica music, but I think we’re obsessed with Farmer’s story because at its core it is inspiring and it gives our flawed existence purpose. I think all of us would like to believe that there is the potential to be extraordinary in our lives. And as life jades us and tempers our aspirations, Farmer serves to remind us that extraordinary beings without superpowers do exist and that even though we’re not the person we think we can be, that person is still worth searching for.
I felt like one of the opportunities of coming to Mulago was that I had a chance to see how much Paul Farmer there was in me. Mulago on paper has all the qualifications necessary for a resource-rich, trained provider to aid a resource-poor trained system. It’s understaffed, under-resourced, and over-taxed with patients. Coming to Mulago meant that I had an opportunity to put inspiration in action. But during my time in Mulago I never felt like doing anything Farmeresque and I think a lot of it has to do with how inspiration works.
As far as I can gather, there are only two prerequisites for “inspirating” (the act of being inspired): empathy and imagination. The relationship with empathy is fairly straightforward. I don’t find how fast a cheetah runs particularly inspiring because I can’t imagine incorporating “being a cheetah” into my self-perceived identity. By the same token I don’t find Roger Federer’s tennis game all that inspiring despite the fact that he is my all-time favorite tennis player to watch. Federer is just a man of superhuman talent, and I can’t relate to that. I do however find athletes that puke their guts out and then go back in the game to be inspiring nearly 100% of the time, no matter who they are. This is because I can relate to enduring some physical torture in order to achieve something personally satisfying. Moreover, I find puking and playing sports inspiring because I’ve never done it (unless you feel like beating a Chinese buffet is a competitive enterprise) and this requires imagination. To me imagination serves to augment the relationship between empathy and inspiration in the following way: the more imagining you have to do in order to empathize with something, the more inspirating you can do. I’m more inspired by someone running across the Sahara dessert than running an equal distance across Pennsylvania. I’m more inspired if that person is handicapped, if that person has malaria and if that person is 70 years old because I am none of those things and I don’t really understand them. Thus to me, inspiration is like seeing a potentially attractive girl from afar. From a distance, we can only make out a figure, maybe a hair color and vague sense that the facial features are correct. From a distance she can look like anyone and so she might as well be perfect. As we get closer she might prove to meet her potential, but more than likely the details you gain will reveal flaws, and so to a certain extent you’re better off never really getting closer. As far as inspiration goes, from a distance, you can do anything, be anyone.
I think you know where I’m going here, so let’s go there first and then cover the details. Working in Mulago hospital brought me a lot closer to Paul Farmer and as a result I got a lot less inspired. As I’m typing this right now, I’m sitting at a table outside with another medical student under a palm tree. It’s Thursday mid-morning and in a little while, I’m going to order African tea to compliment the comfort of an overcast summer day. I have no plans to go to the hospital today. Despite this, on the spectrum of foreign medical students here at Mulago, I’m probably somewhere toward the “more committed” end on the wide range of “commitment” to working at the hospital. Some medical students (Australians, Dutch and Iowans) found Mulago too overwhelming and haven’t seen the hospital in weeks. Some (Northwesterners, Israelis, Brits) go in the majority of weekdays and put in 5-7 earnest hours before they head home. There is no accountability from a hospital standpoint of whether or not we are there so going to the hospital each morning becomes an extremely revealing test of what we are made out of not only because it questions how often we go, but also WHY we go.
Here is my best attempt to honestly list all the reasons I go to Mulago (in order from strongest impetus to weakest)
1. Because I want to see how the developing world does medicine. I suppose you could call this medical tourism, but I think the people who paid to send me to Kampala would list this highly on the reasons why they paid.
2. Because I want to learn. I should feel better about listing this reason so highly but I don’t think the medicine I’m learning is actually that valuable. Resource discrepancies mean that medicine here is practiced so differently, there’s barely any chance I’ll ever use a lot of these skills/knowledge again in life. For example, on the infectious disease wards, much of what I see is HIV and TB and the sequalae of untreated illness. This would be a pretty high yield topic if it weren’t for the fact that I’m going to be an Ob-Gyn. In the US, if I were to come across a patient with say, disseminated tuberculosis causing abdominal ascites, I would be speed-dialing the infectious disease experts before you got the B in ‘TB’ out of your mouth. Likewise, I’ll probably never do a lumbar puncture as an OB despite the fact that I got mildly comfortable doing them here. American medicine has evolved to the point of extreme precision and specialization so there is just no point to knowing how to “sort of do something” or “kind of know what that’s about.”
3. Because all my friends go. I don’t want to overstate or unfairly understate this effect because I can’t totally quantify it, but I don’t think it’s a coincidence that all of the Northwesterners have an approximately equal commitment and the other foreign students that stopped going all seem to hang out at the opposite end of the bar on Friday nights.
4. Because I believe I am a resource in a resource deficient country (because I am helping people). There are a lot of ways reality intervened and prevented this from being number one on my list as I, prior to coming, believed it should be. One reason is that I’m not skilled/knowledgeable enough to be as helpful as I want to be. Unattended vaginal births in the labor wards occurs rampantly, but even though I’m going into Ob, I’ve only caught a handful of babies during my medical school rotations and those were heavily supervised. If something were to happen, like a cord around the neck, or a shoulder dystocia, I would have no more experience with those emergencies than any random person off the street. Another reason has to do with a general feeling of futility in the hospital. I know a lot of this feeling comes from shock and unfamiliarity, but it’s still deflating and de-motivating. The infectious disease wards — like all wards in Mulago — are divided into a men’s and women’s side. When I was on the service, I worked on the men’s side where there were attendings, a chief resident, an intern and a hoard of Ugandan and international medical students. On the women’s side, it’s unclear if there was a single doctor that week. This kind of “are you kidding me” quality is pervasive in almost every aspect of the hospital, and that hopelessness makes your own work feel futile. The last and most prominent reason is that Mulago, despite the fact that it feels chaotic, actually has organizational schemes in place dictating how care is conducted and how care is doled out. It might seem like attendings come when they feel like it, but they actually come Mondays, Wednesdays, and sometimes Friday. It might seem like the laboring woman who wails the loudest gets to move from the floor to the bed, but the midwives have a sixth sense for sensing who’s closest to actually delivering. And it may seem like there are no sterile gloves on the ID ward, but if you ask the right nurse, she’ll show you the drawer where they are kept. It’s amidst this chaos that we are trying to learn the infrastructure, processes and rules in order to be a part of the care. Sometimes you forget why you were doing something as you try to sort out how to do it.
Trying to guess what Farmer’s list would look like feels like trying to imagine what it’s like to be a cheetah. I tend to view extraordinary people like Farmer the same way I view serial killers, porn stars and self-made billionaire oil tycoons. I assume that in their “formative years,” they had experiences that were so far outside of the experiences of an average person (physical violence in killers, rape in porn stars, poverty in Rockefeller’s case and who knows what with Farmer), that these experiences rocked them and as a result they matured with a powerful, but deeply buried sense of obligation (to kill people, to be exploited by men, to make money, to save forgotten human life). For those reasons I doubt Farmer’s list would be a simple rearrangement of my own. His list would not be fraught with such lack of conviction and insecurity.
But I don’t need Farmer’s list of motivations to know that reading my own list doesn’t make me feel all that good about myself. As a medical student at Northwestern, I got good grades, but I accomplished it with an “I’m not wasting my time if I can help it” attitude. My data shows that 90% of the time as a US medical student you’re either standing watching someone else work, or doing work that will be done over again by someone else. Since a lot of that fell under my definition of “wasting time,” I pretty much spent my time at the hospital trying to figure out how to get the hell out of there. Despite the fact that I may have gone through my clerkships “efficiently,” I think this was a terrible attitude to harbor because I was rarely earnest as a medical student and so I rarely felt any kind of enjoyment in being a medical student. In Mulago, I’m not held to any real standard, evaluated in any critical way and supervised by any judging eyes so this is the purest “context” I’ve ever been plugged into. But even though I came here to practice medicine liberated of the confounding personal gain, I don’t think I’ve proven that I am a better caregiver under these circumstances. Knowing that Paul Farmer is alive certainly doesn’t make me feel any better.
I’ve constructed an argument in my head as a response for anytime someone makes the remark that we (I) should be proud of ourselves for choosing to become doctors. Aside from the fact that my observations at Northwestern have led me to believe that physicians aren’t particularly more compassionate on average than those people outside the profession, I always like to point out that doctors in America are a fungible commodity. Except for a few rural places that no one wants to go to anyway and a few obscure circumstances where a certain doctor might be the only expert in the field, there is no shortage of physicians where you are and where I am. So if you’re a pediatric oncologist, curing ALL in a 10-year-old might make you feel pretty good, especially when the parents gush over you with appreciation, but if you didn’t do it, someone else almost certainly would have. That protocol you ran for diabetic ketoacidosis in the ER might have saved that woman’s life, but if that woman had come to the hospital 24 hours earlier or 24 hours later, another doctor would likely have ran the exact same protocol and similarly saved her life. I always argue that doctors should only feel good about themselves if they believe the work they do is better than that of the average doctor in their field which is a problematic statement on so many levels, not only because there is no real way of measuring the validity of this belief, but also because I would bet more than 50% of doctors (and probably close to 100%) would answer that question affirmatively.
By similar logic, I’ve always thought that running off to doctor in developing nations was just a way to circumvent this problem of proving value-added in a relatively value-rich society. By going to a place where there is shortage so that by virtue of your existence, you’re adding something to the community, anything you do, even if kind of shoddy by US standards, justifies that rewarding feeling you may get from being a doctor. But my time in Mulago has changed the way I feel about this. I think that in reality, when you go to a developing country, it’s much more difficult to feel the rewards of being a doctor. Because expectations of those you serve are probably far below your norm, your standards are instead set by your own moral conscience. And you can’t cheat your moral conscience if you know that men like Paul Farmer exist. You can’t fully satisfy it either. You can’t just look at the doctors around you and decide that you’re more efficient, more up on the journals, more personable and sometimes more dedicated. When your patient dies, there is no courtroom to think about — there’s no one but you to judge if you did all you could. There’s no neatly-set ending to your day’s tasks so you can then go above and beyond them. With not enough, there is no end and so there is no above and there is no beyond. There is only what you can do and what you can’t. And that, to me, is haunting.