Nonprofit Leadership Lessons From Dr. Paul Farmer

(Photo by iStock/La_Corivo)

When the legendary physician and advocate Paul Farmer unexpectedly passed away at the age of 62 in February, he was called a hero, a visionary, and a global health giant. His ideas changed paradigms of public health and human rights, and he demonstrated that it’s possible to deliver world-class medical care to people in the most resource-poor settings imaginable.

Yet Paul Farmer was also a brilliant, original, and often iconoclastic thinker when it came to nonprofit leadership. Paul brought an uncommon degree of attention to matters of economic, racial, and health justice in virtually every big decision he made, and as a key leader of Partners In Health (PIH)—a complex and phenomenally effective organization spanning over 10 countries and comprising more than 18,000 affiliated staff members—he brought an extraordinarily long-term perspective and a penchant for bridging radically different disciplines.

Here are three lessons that were key to his approach to leadership:

1. Practice the “hermeneutic of generosity.”

In 2018, Paul emphasized to me that despite the importance of systematically analyzing structural injustice, “We can’t forget that partnership, solidarity are out there. That’s why I think a hermeneutic of generosity is important and undervalued.”

Paul was fond of this phrase—“hermeneutic of generosity”—which has deep roots in theology but that we rarely hear in management literature or political discourse. For Paul, the “H of G,” as he called it, meant giving people the benefit of the doubt, always assuming that the individuals with whom we interact—especially partners in the workplace—are fundamentally good and want others to be happy (in contrast to a “Hermeneutic of Suspicion,” the assumption that we’re all out to get each another”). He saw this simple principle as an essential element of what made PIH function well, and a key element of how belonging could be purposefully built. “There's a natural tendency towards suspicion,” he explained, but he believed that a recognition of the inherent good in each person was a prerequisite not just for trust but also for operational effectiveness. When people assume good intentions, a team spends less time on drama and disagreement and more time getting important work done for those in need of help. Paul, therefore, encouraged us and his other colleagues—inside and outside Partners In Health—to strive to interpret the words and actions of others in a spirit of generosity.

In practice, the “H of G” might apply to everyday situations: being left off an email thread, receiving overly direct feedback, being passed over for a speaking opportunity. (As with everything in his life, Paul had a sense of humor about practicing the “H of G.” When such a slight might happen in the office, he would put things back in perspective by sheepishly murmuring one of his favorite catchphrases: “Umbrage – it will be taken.” He once joked that we should put this phrase on a shirt or bumper sticker since he said it so often.)

But Paul also applied the “H of G” in broader and deeper ways. He was legendary for fearlessly taking on the most powerful political leaders, medical institutions, and universities when they did not prioritize the interests of people in poverty. But he also spoke of “having a hermeneutic of generosity towards the individuals who find themselves in complicit structures,” including people working within government or financial institutions that were committing injustices. “The people who were doing the development project probably weren't out to make poor people suffer,” he said. So, Paul drew an important distinction between systems and individuals. “To apply a hermeneutic of suspicion to a structure that's unjust, I think that's a good thing to do. But I'd like to be the kind of person who applies a hermeneutic of generosity to individuals.”

This approach isn’t so common these days, and it’s always tempting to demonize people for doing wrong. Sometimes Paul found the “H of G” for those he disagreed with by imagining them as patients—humans in their most vulnerable state—since so much of his energy came from being a healer. In an age of cynicism and division, he demonstrated that a person can be extremely fierce in advocacy for justice and still deeply humane in leadership and interpersonal relations.

2. “Beware the iron cage of rationality.”

Speaking to an audience at Harvard’s Kennedy School, Paul once emphasized this phrase from the German philosopher Max Weber. The “iron cage” is the trap of focusing too much on operational efficiency and formal planning at the expense of deep listening and consideration of real lived experience.

Paul pointed to an example that was personal for him. In response to the devastating 2010 earthquake in Haiti, international aid organizations sought to build a major new settlement for displaced people at a location that, according to rigorous analysis, made the most financial and logistical sense. Yet Paul noted that these planners had never actually visited the area. If they had listened carefully to local impoverished people, they would have known that the site was in the middle of a dangerous floodplain. Paul believed that implementation failures happen most often when people want to help by applying expert knowledge, “but only from a controlled distance.” This, he said, “was the long, hard lesson of the earthquake. We all wanted to be saved by expertise, but we never were.” The right approach to problem-solving, he emphasized, “does not privilege technical expertise above solidarity or compassion or a willingness to tackle what may seem to be insuperable challenges.”

While Paul was a world-renown expert in both infectious disease and medical anthropology, he believed that technical expertise is often overrated. Why? Because even the most celebrated experts might lack knowledge of specific context, which requires the willingness to actively listen to people without formal education or official prestige. Effective problem-solving, “requires cooperation, openness, and teamwork … Much more can be accomplished looking forward with an open-source view of the world.”

This notion extends to many other fields of leadership in business, government, and the nonprofit sectors. For leaders of data-driven organizations, Paul’s position might seem revolutionary: more than sophisticated mathematical models or detailed case studies, what matters is the simple practice of paying attention to the people who stand to be most impacted by decisions. If the policymakers in the Haiti recovery project had simply spoken with local people rather than relying on their models, they could have avoided substantial unnecessary suffering and the waste of resources. A similar logic applies in everyday situations in workplaces and other professional settings: It’s often important for managers to look past the “iron cage” of formal strategic plans, financial models, or human resource dogmas to really listen to employees about what they’re experiencing and what they really need. When leaders fail to do so, they miss out on critical information.

3. Be whole-heartedly invested in outcomes.

The conventional wisdom in most fields is to do your best, but also to stay professionally objective and not to take failures personally. Paul Farmer rejected this approach. He treated his patients like family, taking on their struggles as though they were his own. This orientation was evident even in simple gestures, as when, while traveling between countries, he’d buy so many presents for patients in airports that he could hardly carry them all.

This approach was woven into the broader systems and structures he and his colleagues built. Using the term “accompaniment”—which he learned from liberation theologians—Paul envisioned and implemented a model of care at Partners In Health focusing on a long-term relationship of closeness and even interdependence between caregivers and patients. Instead of emphasizing doctors and nurses as service providers, the PIH approach elevates contributions from community health workers, local people who live among those they serve and who can be personally invested in their medical outcomes. Community health workers are a bridge between the community, where illness and healing happen first and foremost, and the health system, where many but not all solutions lie. When asked to define accompaniment, Paul once said: “It is an elastic term, but here it means sticking to a task until it is deemed completed by the person that you are accompanying.” While many business models, including in the health sector, focus on limiting liability and transferring risk to other actors, Paul and his partners demonstrated that it’s possible to succeed through an ethic of empowerment and mutuality.   

It’s because of the accompaniment model that PIH has been able to achieve more than 2.1 million home visits from community health workers and, in turn, vastly expanded health services in more than a dozen countries around the world. It’s been an essential part of the work of addressing long-ignored issues like multidrug-resistant tuberculosis and access to cancer care in low-income settings. Yet, perhaps most importantly, the vision has helped create a paradigm shift in healthcare: treating patients living in poverty as the real decision makers who ultimately determine when the work is complete.                

While Paul was a genuine hero and a once-in-a-generation innovator, he was also a human being who had to struggle through the everyday challenges of navigating bureaucracies, managing personalities, and maintaining energy and optimism. What made Paul especially unique as a leader is that he worked to bring his bold global vision—that every human being deserves care and respect—into his professional decision-making as well as his day-to-day actions. It was truly beautiful to watch him blend these many worlds with unifying wisdom and care.

Read more stories by Kim Samuel & Dan Palazuelos.