Fieldwork before frameworks

If you don’t know the story of Dr. Paul Farmer, you should. He’s saving thousands of lives while changing how the world thinks about poverty, about disease, and about what’s possible.

As we try to change how companies work, we can learn a lot from his approach.

“Mountains beyond Mountains”

Paul Farmer grew up in an unconventional, poor family in various parts of the US. Always smart, he wound up graduating from Harvard Medical School and doctoring in two of the most different places on earth - Brigham and Women’s Hospital in Massachusetts and a hospital he built in Cange, Haiti.

In “Mountains Beyond Mountains”, Tracey Kidder chronicles how Paul Farmer could be in a crowded hut one day caring for a TB patient and in a posh conference hall the next day trying to change World Health Organization policy.

Besides making for fascinating reading, that contrast is instructive.

“Journeys to the sick”

On several occasions, Kidder accompanied Paul Farmer on long hikes to see patients in remote parts of Haiti. Farmer would speak to the family in Creole. He’d observe, listen, and touch - not as a doctor from Harvard with superior knowledge but as a human being who genuinely cares and wants to learn. What are their living conditions? How is the rest of the family? What else is going on in their lives?

By seeing the patients in their own environment, speaking to them in their own language, he can see more than the disease. He can see the entire environment around the disease.

“Every patient is a sign. Every patient is a test.”

But is it “appropriate”?

Not everyone agreed with Paul Farmer’s methods. Should a doctor who could affect worldwide medical policy be spending time seeing individual patients in remote huts? Kidder talked with him about it on the hike back after one of their visits:

“Some people would argue this wasn’t worth a five-hour walk,” he said over his shoulder. “But you can never invest too much in making sure this stuff works.”

“Sure,” I said. “But some people would ask, “How can you expect others to replicate what you’re doing here? What would be your answer to that?”

He turned back and, smiling sweetly, said, “Fuck you.”

It wasn’t that Paul Farmer did’t have better answers. It was that people were asking the wrong questions. You needed the fieldwork to make sure what you were doing was even worth replicating.

He faced similar questions about money, particularly about "appropriate technology." Could Haiti afford to treat AIDS and TB?

“We can spend sixty-eight thousand dollars per TB patient in New York City, but if you start giving watches or radios to patients here, suddenly the international community jumps on you for creating nonsustainable projects.

When “theory outruns practice”

This is the trap we fall into at work. We create strategies and frameworks and lists of “5 most effective ways to...” without enough testing of those ideas in the field. We talk about ROI and antiseptic approaches to the diseases (ineffective work practices) without seeing and touching and understanding the entire environment that’s making the diseases flourish.

“If you focus on individual patients, you can’t get sloppy....In public health projects in difficult locales, theory often outruns practice. Individual patients get forgotten, and what seems like a small problem gets ignored, until it grows large...

...a willingness to do ‘unglamorous work’ is the secret to successful projects.”

If you really want to change your company

Sure, we need frameworks and strategy to scale what we do. But they’re useless if people back in their cubes are working like it’s 1995.

I don’t want to just write about change from a safe distance. I want to actually change things.

And if a genius who’s saved thousands of lives and changed worldwide opinions about disease can spend time with individual patients, so can I. So can everyone who’s trying to change how companies work. Just as entrepreneurs keep testing their product with real customers in real conditions, we need to test our ideas about change in the field.

A close colleague observed that Paul Farmer's visits to patients “refresh his passion and authority, so that he can travel a quarter of a million miles a year and scheme and write about the health of populations. Doctoring is the ultimate source of his power, I think.”

To change how we work. that combination of fieldwork with longer-term, larger-scale thinking is exactly what we need.