2012 Principal Address

By Paul Edward Farmer, founding director of Partners in Health

"The Story of the Inhaler"
May 25, 2012

Paul Edward Farmer

Thank you for inviting me back to Holy Cross. I was last here as a guest of Father McFarland's in 2005, and it's an honor to share this podium with him and with Lisa Cahill, and to be with you and your families today. A lot has changed for many of us: we've been through everything from retirements to commencements, from earthquakes to reconstruction, but Holy Cross looks exactly as it did eight years ago. And as you, class of 2012, head out into the world beyond, you'll find comfort in the constancy of Holy Cross and in its capacity to adjust to change, too. Change often bruises the heart but it's inevitable and necessary if you're to live up to the Ignatian ideal of "In this sign you shall conquer."

Wait — wrong motto. I meant "Men and women for others."
My experience as a medical professor has allowed me to meet several Holy Cross grads. One of them, Jon Niconchuk, class of 2009, addressed your class at convocation. He's as good an example as anyone of trying to live for others — especially those who've been left behind by poverty and illness, two scourges which will figure in my remarks today.

I promise to keep this short.  First, I'll tell a True Story, and then draw three lessons from that story.

This is the Story of the Inhaler.

In my pocket, underneath the Hogwarts get-up, is an inhaler. Even if you're not asthmatic yourself, you know someone who is. And you can imagine what it feels like to be unable to breathe, a universally distressing symptom. In this country alone, there are an estimated 25 million asthmatics, many of them children. Turns out that, among poorer kids in this country, especially in big cities, asthma remains a killer even though we have pretty good means of preventing and treating it. So although the Story of the Inhaler takes place in Haiti, the lessons I draw are relevant to this country and to the rest of the world. These lessons are not just for those of you heading to medical or nursing school: this is a story about unequal access to the fruits of modern science. This is everybody's problem, whether we contemplate pandemic disease or global warming. But it is, especially, your challenge: how we choose to build systems to deliver the fruits of science and technology is critical to our planet's flourishing in the coming decades, the very years in which you graduates become its stewards.

One day, about 25 years ago, I was in rural, central Haiti. I'd just finished my medical studies and a doctorate in anthropology. How I got to Haiti is part of the Story of the Inhaler. It was a college class at Duke University over three decades ago that got me interested in health disparities and in Haiti. During a research project in an emergency room, my professors helped me understand how race and class and gender (and other forces well beyond the So in the Duke emergency department I met a couple of Haitians. Migrant farmworkers in North Carolina. I don't recall what brought them to the ER in the wee hours of that night, but I did get a pretty good sense of what had brought them to the United States: poverty and political repression, which often go hand and hand. I learned, too, that they didn't have access to primary care. Neither in Haiti nor in eastern North Carolina, where they harvested tobacco, sweet potatoes, bell peppers, and other produce, were they in regular contact with modern medicine. That experience piqued my curiosity about Haiti, and I went there shortly after graduating.

Within a month, I got involved in a small project to introduce primary care to people who'd been displaced by the reservoir formed by Haiti's largest hydroelectric dam. My Haitian colleagues built a small clinic. It was the first modern clinic in the region, but most of all, thanks to the determination of its founders and supporters, the care was free. As barriers (geographic and financial) separating people from medical attention fell, we had more patients than we knew what to do with.

Although I'd been spared medical problems in my own childhood, I was diagnosed, in 1984, with asthma. It was easy for me, then a student at Harvard Medical School, to get the medication I needed. It wasn't a trivial problem, perhaps, but neither was it one of my top concerns while shuttling between Haiti and Harvard. Four years later, however, I had a more serious need of medical attention. Inattentive while crossing a busy street in Cambridge, I was struck by a car. (My advice to the graduates: look both ways before crossing the street.) Lying on the pavement, I could tell my left leg was broken. After being transferred from one Harvard hospital to another, I had surgery, including a bone graft. Again, being a Harvard medical student meant I was in luck despite my bad fortune. My surgeon was the same one who attended to the New England Patriots and I recovered promptly (although I never became a linebacker).

Since my college days, I'd tried to imagine what it would be like to be poor and sick or poor and injured. Every time I returned to rural Haiti, the reality was right in my face. In our crowded clinic, we attended to the sick and injured as best we could. We could see that much more preventive care was needed, and to this end we trained and salaried community health workers in dozens of villages. Part of my job back then was to visit them and their neighbors, and the Story of the Inhaler concerns one such visit made after I was able to walk again.

Though no linebacker, I loved walking, especially after my stretch of immobility. One day I walked eight miles, across the dam to a village on the far side of the reservoir. The community health workers in the settlement of Wóch Milat. had organized a town meeting in a thatch-roofed, dirt-floored church. They didn't have a lot of visitors down Wóch Milat way, so I got a proper welcome and was expected to say something in front of a couple hundred people. I'm pretty sure I talked about the importance of prenatal care, safe motherhood, and family planning.

After the talk, anxious to get back, I looked up at the gathering storm clouds. My leg was hurting by then.  It was afternoon, already, and getting back across the reservoir would mean a lot more walking even if we took a dug-out canoe halfway. One of Wóch Milat's community health workers asked me to see a patient. "He can't breathe," she said. I had an image, in my mind, of an older person, short of breath. I was pretty firm in my response: "No, the patient's home is not even in the same direction we're heading and it will soon be dark. If he's is having difficulty breathing, we need to get him to the hospital for a chest x-ray and lab tests." I added, perhaps guiltily, "I didn't even bring my stethoscope." I was also likely thinking how nice it would be to get home to a whopping dose of ibuprofen and a glass of ice water.

The health worker asked if I'd explain that to the sick man's wife and I said sure. A woman who looked about 20 years old began talking. "Yes," she replied, her husband was about her age. "He can't breathe. Please come and see him. He's been sick since yesterday." Frustrated, I acceded, complaining en route that whatever he had would be better treated in the hospital after a proper work-up.

It took 45 minutes to reach the house, half-way up a mountain and in the wrong direction. The sun was westering when we were ushered into a tiny shack. Three children, two of them toddlers, stood quietly. And there, leaning against a dirty pillow and a pile of clothes stacked on a mat on the floor, was the very young man who, as they said, could not breathe. His name was Joe and his every muscle looked corded and tensed; his lips were the color of bruises; he couldn't speak at all and looked to be well past panic. From across the room, even without a stethoscope, I could see that he was about to die of nothing other than an asthma attack. I'd seen status asthmaticus several times, but only in an emergency room, where the option of mechanical ventilation made it possible to get medications into even the stiffest airways. "Jesus!" I said, crossing the room. "How long has he been like this?"

Since yesterday, his wife responded. I couldn't imagine that anyone could really survive a full day of this struggle. Joe did not look like he was going to last much longer. The panic he should have been showing suddenly flared up in my own chest.

As regards medications, I thought I'd been telling the truth when I protested I had none on me. But I did have one. Just one. I had an inhaler full of albuterol: one of the few things that might save Joe's life in this out-of-the-way outpost of Wóch Milat. But how to get the medication in him? It's not as if he could exhale, take a deep breath, then hold it. I asked one of the community health workers to pinch Joe's nose shut — which alarmed everyone except the patient, by then too weak to struggle — while I pushed the canister into the blue plastic tube, triggering tiny doses of albuterol into the air around his mouth. I pushed again and again, trying to force some of the mist into his open mouth and down into seized-up airways. Would it work? Was it too late?

It worked. Within minutes, suspenseful, painful minutes, enough albuterol had gotten into his lungs to turn his shallow gasps into quiet wheezing. Indeed, Joe was soon sounding like a bellows — a big improvement. Joe seemed able to look at me for the first time; his rigid body went slightly slack. He was still fighting for every breath, but now could actually cooperate as we tried to get a proper dose of bronchodilator into him. Within half an hour he could even speak haltingly. "Thank. You. Doctor," he said, giving my hand a weak squeeze.

The man's wife and oldest child, a girl of about six or so, were in tears. "Thank you, thank you, thank you," they said.

A little crowd had gathered outside. Huge mounds of praise were heaped upon me. "I can't believe you were able to save him! You are a great doctor! You knew what to do immediately! You saved him!"

If I could've looked slyly at the community health workers, I might have. But my colleagues were as effusive as the patient's wife. And as Joe became slowly able to get out a few words, the young man joined right in. "You saved my life."

Technically, it was true. That is, the inhaler had saved his life. It was the only medication on my person and one used only for the treatment of acute asthma. There was no other illness I might have palliated on that afternoon and yet that was precisely his affliction — the very disease poised to snuff out his young life in slow motion, right in front of his family. Since I had the inhaler in my pocket and managed to get half a dose into his lungs, I guess I had, technically, saved him. In any case, it seemed, just then, a miraculously happy moment. "A real save," as we say in medicine.

It also seemed unnecessary to explain, right then and there, to mention that it was pure dumb luck that had caused me to show up with precisely the drug that might make him breathe, or that I'd originally been unwilling to even come to his house. I changed the subject to the prevention of another such attack, explaining that I'd leave The Inhaler with him and that we had other medicines at the clinic that would prevent attacks in the future. There was no point in explaining the gravity of the illness. No one on the planet understood that better than Joe.

I finally set off, in the company of my colleagues and with a trail of children and others who'd heard the story. After a ride in a small boat and then a jeep my co-workers sent for me, I was home in time for supper. A replacement inhaler was sent immediately. The ibuprofen worked its magic. I was feeling good.

And I was still feeling good the next day, when Joe came to see me. He looked completely fit and had, indeed, walked eight miles or so to see me. "I don't have words that can express how grateful I am, nor do I have worthy gifts. But I've brought you a rooster and some eggs." The praise was flowery: I had saved him; he was a second Lazarus; he would pray for me every day.

I'd heard this sort of thing many times in the preceding years, and was always grateful for it but embarrassed in this instance because of the random nature of this save, to use your generation's term. "It was an accident," I wanted to say, "not a miracle." But that too seemed to trivialize what had happened. And so I just said thank you and, after examining him and noting he was still wheezing, gave him a new set of inhalers and explained once more how to prevent future attacks or to cut them short if they recurred. "Which they will," I added. "Asthma is a chronic disease."

Less than a week later Joe was back in clinic, this time with clear lungs, a small goat, and another heaping of thanks and praise. My discomfort mounted. "It was only dumb luck," I said, coming clean at last. "Nonsense!" he replied. The half dozen or so people in earshot — in Haiti, there's always a peanut gallery — were clearly siding with Joe. So what if you have asthma, Dr. Paul, and were walking with the inhaler for your own use? So what, echoed the peanut gallery? It was meant to be: you were meant to be there to save Joe. It's clearly miraculous! Get a grip!

To this day, more than two decades later, Joe and his family and the community health workers probably feel more or less that same way — I'd lay money on it. But it's my job, here today, to underline what the inhaler story really means in a larger world riven by inequality but also connected in ways unanticipated even 20 or 30 years ago.

Here are my three points.

First, and most obviously: we inhabit a bizarrely unequal planet. This has long been true, of course. It was true in 1492, when Columbus crossed the ocean only to shipwreck off the coast of northern Haiti. It was true when Haiti became a French slave colony. It was true during the U.S. military occupation of Haiti, which lasted from 1915 to 1934. It was true more than 25 years ago when a recent Harvard Medical graduate was led unwillingly to Joe, dying on his mat. It was true when Jon Niconchuk, a Holy Cross student, traveled to El Salvador.

But it's even more true now, just a few years later, because global and local inequalities seem irreversibly to grow rather than shrink. Consider this country: thirty years ago, the much discussed "1%" owned 9% of all personal wealth; today they claim a quarter of it. Last year, 93% of all new wealth generated in the U.S. economy went to the 1%.(1) When you move to a global scale, the numbers are even more striking: 0.5% of the global population holds well over a third of the world's wealth.(2) Meanwhile, some 2 billion people live on less than $2 a day. With the exception of China and a handful of other nations, most "developing countries" were poor thirty years ago and remain poor today.

The steeper the slope of inequality, the greater our challenges. This was true, apparently, in ancient Greece, when Plutarch noted that "An imbalance between rich and poor is the oldest and most fatal ailment of all republics." Such imbalances are even less tolerable in modern times. What does it mean to die unattended of a severe asthma attack in the age of Facebook or LinkedIn? If we're really linked-in, what does that mean for the good stuff, such as albuterol?

Do we really lack mechanisms to deliver the benefits of modernity to all those who need them? John Maynard Keynes once argued that human society had achieved sufficient productive power to eliminate basic wants around the globe; it just lacked institutions to deliver services to those who needed them. That was in 1928. Today, global productivity dwarfs that of Keynes' day, but poverty persists, and in some places deepens. I hope all of you will keep tabs on our world's growing inequalities, and seek new ways, and old ones, of narrowing them.

Second, I've come to understand that there is something miraculous in the Story of the Inhaler. As much for me as for Joe. But I don't mean miraculous in some fatalistic sense. The miracle of human solidarity, when linked to both meaningful action and compassion, is something all of us, all of you, can foster in your lives and work and social networks. I say "social networks" not to sound hip, but in reference to something that predated the Internet: the need, occasionally, for the people around us to spin us around and yank us out of our stubborn ways. The insistence of the community health workers in Wóch Milat that I turn my "no" into a "yes" was a piece of social networking, and a miraculous gift to me.

In the largest sense, the social network is the social safety net. Being fortunate enough to exist in webs of friendship and shared purpose requires us to be responsive, to give and to get attention, to respond not just to events but to others' evaluation of those events. If I had been acting as an isolated particle, I might have said no, gone home, and cheated myself of a joyful occasion. But I was ashamed to cut loose from my social network. This meant rethinking my "no," changing it to a "yes," and climbing up the hill.

Third point, and hardest one to make: inequality and injustice can make fools of us all. Could I really take credit for saving Joe's life? Only a fool would mistake happenstance for destiny, or forget that only a privileged person is likely to recover from a limb-threatening injury to walk again for miles and miles. Only a person with means would end up at Harvard or Holy Cross, whether as student or speaker, even if we often forget that we're privileged, and that privilege comes with obligations to others and especially to the poor. Realize your good fortune, and share it with others by putting your gifts and training in the service of others who may not have had the same opportunities, but are certainly appreciative of your powers to do good.

Your school, a Jesuit institution, was founded on Catholic social teaching that reminds us of this obligation, unshirkable and imperious and beautiful. The way these obligations can be met is different from 30 years ago, when I listened to another commencement speaker drone on for longer than was necessary. But whether you "Slacktivists" work from Facebook or Twitter or YouTube, or engage in direct service, there's always room for Ignatius' reminder that we should live for others.

Let me close by quoting the talk that Jon Niconchuk delivered to your class as you began your time here. I asked him to send it to me. "I did not find myself by looking in a mirror," he wrote. "I began to find myself by looking out a window. Holy Cross gives you that window."

You stand at the window.
Outside, a world of peril and promise.
Throw open that window


(1) Nicholas Lemann. "Evening the odds: Is there a politics of inequality?" New Yorker, April 23, 2012.
(2) Credit Suisse Research Institute, Global Wealth Report, October 2010.