As the airplane touched down in Addis Ababa Bole International airport, I felt a surge of excitement, enthusiasm and energy. Though this was my first visit to Ethiopia, I was strongly drawn to this country. I had started fantasizing that this will be the third country and culture that I will adopt as my own, after being born and raised in India and spending my early career life in the US. Even in the US, I had been cooking or eating Ethiopian food regularly, listening to Ethiopian music and reading translated literary works.
I had realized after my stay in the US that to become a part of any country and its culture, there is no alternative, but to submerge myself in work and life there. Thanks to the internet, I researched Ethiopia from Boulder, Colorado, and found that this country of 90 million people had no cardiac care to speak of. Well, that could be something I can work on, I told myself; after all I was a trained cardiologist. I could do something in my field – help people there and help myself become a part of it. I contacted Universities, built a network, and offered training to Ethiopian physicians. However, doing it from the US seemed like trying to steer a boat in the middle of the lake while sitting on the shore. Finally, I had decided to take a plunge and go there.
As my flight taxied on the runway, I wondered: Why has specialty health care training not evolved here (in Ethiopia)? Of course, any investigation regarding lack of anything in Africa always leads to the one usual suspect called ‘poverty.’ In this case it was not.
Addis Ababa, the capital, was like a smaller version of Mumbai, streets congested and socially cut-off, with its wealthy living comfortably oblivious to the poverty all around them. I spent a couple of days at the Cardiac Care center in Addis Ababa. The center had good equipment and staff, and a couple of partially trained and somewhat functional cardiologists. Across the street, at the Black Lion Hospital, there were 3 trained CT surgeons, and 3 trained cardiologists who had no access to any of the equipment available at the Cardiac Care center.
The two clinics or hospitals did not talk to one another. One, Black Lion, had the patients, surgeons, cardiologists but no equipment and the other, Cardia Care center, had equipment but not much else. The two centers could actually collaborate and together become one unique center of excellence around which specialty care in Ethiopia can be built. But each one wanted to take over completely and be “the only one”. It had been so for a while, and nobody seemed to have any interest in resolving the situation and creating a win-win solution that would actually provide good cardiac care to Ethiopians. Overall, in this 1 mile radius, Ethiopia had all its resources to provide good cardiac care, but still there was no cardiac care available since the different players did not want to collaborate.
My next destination was Jimma University, 355 km southwest of Addis. Here I met the higher-ups within the system, and soon realized that the administrators were willing to spend the money to bring cardiac care to the community. A surgeon had just returned from a 1-year training stint in India. Now, she is capable of performing cardiac surgery but there was no cardiac anesthesiologist, and no operating room to support her. The physicians did not invite her for any meetings. The physicians wanted to build a cardiac program without a surgeon, which was like saying: We would like to build a three-storied building without the second floor. Interestingly, the trained cardiac surgeon also wanted to be left alone by the physicians without considering where the patients would come from. It seemed like they all wanted to excel in their field without recognizing that their success is intricately intermingled with the success of the others. They all wanted to be the big fish in a pond – a pond too small for any big fish to survive – and no one wanted to help the pond grow. Each big fish was smothering because they had not worked to make the pond bigger.
As I sat in my hotel room in Addis Ababa, I wondered about this situation. Each of the players I had met over the course of my stay was working from their self interest. And we believe, all of us who live and survive in this contemporary world of ours, that it is self-interest that makes enterprise and societies grow. We consider self-interest to be the engine that drives and propels our so-called successful system. The Randian world view has us convinced that self interest is good, selfishness is a virtue. The society has acquiesced that such selfishness guided by the invisible hand of the markets will lead to individual prosperity which in turn will beget human progress.
But here I was staring at the failure of self-interest in allowing cardiac care to grow as an enterprise in Ethiopia? Should they not have succeeded immensely over the years? Was it something about the weather in Addis Ababa or the culture in Ethiopia that did not allow the seed of self-interest to blossom? Or do we need to tweak our understanding of how self interest works?
While thinking about self-interest and the detrimental effects of narrow, narcissistic self-interest, the first image that came to mind was that of a very happily married friend of mine. Chuck was not only married, he was THE great defender of the institution of marriage. And because of that I would take plenty of below-the-belt potshots at the institution. Eventually, I asked directly about the virtues of marriage in this post-feminist era. As if he had been waiting for this opportunity to bestow some wisdom upon me, he said, “..the advantage is that we are there for each other when we need. Over the 20 years of marriage, there have been times when I was providing more support than receiving and I thought that this was becoming a relationship of me giving and her receiving and I thought of leaving. If it was easy to leave, I would have. But am I glad it wasn’t and I did not. It was only a matter of year or two, where the roles were reversed and I was happy she was there to support me when I needed it to survive. A chill runs down my spine every time I think of what would have happened if I had acted selfishly just a year or two back. Mind you, the roles reversed once again in sometime, and then it was my broader self interest that kept me in the relationship. I can’t think of any better reason for marriage than that of self interest”. For the first time, I could not come up with argument against a potential benefit of marriage. The rules applied to marriage by Chuck can also be applied to friendships and relationships. We understand this intuitively and are there for our loved ones knowing that they will be there when we need them. We do not even consider the selfish act of abandoning our loved ones in their times of need. Even the most fervent Rand disciple will not argue against this social norm of enlightened self interest.
The same principle was subtly evoked by Pastor Martin Niemoller. In his provocative poem against those who remained quiet and did not act socially against the victimization and purging of various social groups during the Nazi rise to power in pre-World War II Germany:
First they came for the Socialists, and I did not speak out—
Because I was not a Socialist.
Then they came for the Trade Unionists, and I did not speak out—
Because I was not a Trade Unionist.
Then they came for the Jews, and I did not speak out—
Because I was not a Jew.
Then they came for me—and there was no one left to speak for me.
Isn’t this a great example of self-interest as applied to groups? If you help me survive, I will be there for you when you are fighting for your own survival.
There is an interesting example of how this works between humans and their pets. Bill Thomas, physician and medical director of Chase Memorial Nursing home, realized that the plagues of the human spirit were: Loneliness, Boredom and Helplessness. He transformed this nursing home from a “total institution” to a Garden of Eden by introducing children, plants, animals and birds as integral part of this environment. This newer environment led to increased longevity, decreased medication use, decreased infection and other statistical benefits. At the individual level, there were examples of severely depressed patients, after having failed to respond to latest medications and cutting-edge therapy, who were now taking care of parakeets, walking the dogs and eventually improving their own mental state to start independent lives outside of the nursing home. Letting go of narrow self-interest and becoming part of an ecosystem saved lives. Knowing what we know from these data, can we not consider that becoming part of something larger than who we are and caring for others, whether human, animal or plant, is an act of enlightened self interest?
Carrying this notion further, American philosopher Josiah Royce argued that a person is defined by his or her pursuits but for these pursuits to have stability, they must go beyond individual desire. Stability of standards and a stable sense of personal worth come when a person loyally pursues some cohesive group activity. Thus, according to Royce, a person is defined by things he pursues for his group and in bearing loyalty to his group. Thus narrow self-interest was clearly vetoed by Royce in favor of team work as defining of an individual. Even the narrow definition of individualism is abandoned and others are included in it.
But it appears that we are simple beings buying into fallacious theory because they seem so simple. A classic example in this regard seems to be Maslow’s hierarchy of needs, wherein he explains the various needs: physiological, safety, love, Esteem and Self actualization. He specifically claimed that one cannot get to the next step before mastering the previous. It is a theory that is understood easily and is widely accepted and taught but has not withstood the test of studies. Studies have shown that the priority of needs changes according to age, cultural norms, and circumstances. For example, self-actualization, where we are willing to do something beyond us and larger than us or our physiological needs, may be very important for an artist, or actors looking for jobs in Hollywood and anyone who is passionate about her work or craft. For most young adults, self-actualization may be the most important need even when their need for safety and love has not been met or mastered. However, society imposes upon us this questionable hierarchy of needs, deems this hierarchical arrangement of needs to be the truth, and convinces us to pursue our narrow self-interest prior to self-actualization. Unfortunately, we buy into society’s idea of the truth, despite what our hearts tell us, and pursue our narrow individualist self-interest. In a few years we find our lives vacant and unfulfilled. We have the house and the car but we feel something is lacking – and ask ourselves: what was it that I really wanted to become? Isn’t this pursuit of narrow self-interest then to our own detriment and to the detriment of our group? After all if every member of society is feeling unfulfilled, then how can they even contribute to making that society better?
The bell rings. I open the door of the hotel room in Addis Ababa. My dinner has arrived. The waiter who has brought the food explains how to use the “injera” as a spoon to eat the rest of the food. The injera is a large sourdough flatbread. I indulge the waiter, and do not tell him of my Ethiopian food habits in the US, because he is genuinely interested in teaching me the intricacies of Ethiopian food. After he leaves the room, I dip my injera spoon into the bowl of “atkilt wat,” sometimes used to refer to all vegetable dishes, and enjoy a delicious Ethiopian meal cooked in Ethiopia. Food always touches my heart and my mind returns to the question of cardiac care in the country.
I wonder if a better way to understand the situation I faced with respect to an Ethiopian cardiac care program is to appeal to the enlightened self-interest of the individuals. If the individuals can work in the self-interest of their future, more accomplished selves, they will do what may be right for themselves, for the group and for their patients. How can a physician become a better cardiologist? By thinking of what the future chief of cardiology would want? He would want a stronger division with smart colleagues, knowledgeable ancillary staff to help them handle complex cases and accomplished cardiac surgeon who can save patients with severe complications. So, why not start training these various groups now, so that when you are ready to become chief of cardiology, the ground work would have been laid.
What is the alternative? The alternative is what already exists: the cardiologist trains in some foreign country, comes back home with no trained support staff, no buy-in from other physicians, and no cardiac surgeon to help with complicated cases. By helping the surroundings to evolve and grow systematically, to pursue goals for the group will define the cardiologist and in turn help the group. The enlightened cardiologist will have a better chance of being a bigger fish in a bigger pond rather than a smothering fish in a small pond.
My mind raced back to an embarrassing time in my life, when I was given a lesson in enlightened self-interest. A few years ago I was working (as a physician) in a town where the healthcare was quite poor. The philosophy among physicians used to be: do the procedure first, ask about the symptoms later. Soon, my raucous distaste for the organization became well known and I was asked, “Well, where would you go if you were really sick in this town?” My answer to this question was, “The airport.” The answer got a lot of laughs. Even I liked my answer so much that I repeated this answer every opportunity I got. Once at a party, I mentioned this to a group of senior retirees. After I had made my standard airport comment, one of the seniors took me aside and said, “Son, I used to think similarly about the city I grew up in. I was always bothered by the lack of civic sense, organization, public services….but at some point in time, I decided that I am going to spend the rest of my life here since everyone I knew and loved was in that town. And I asked myself, what would the 65-year old me want the 35-year old me to do? I realized, he would ask my energetic 35-year old to strive to improve the city for the 65-year old me. It wasn’t easy, it took years, lots of trips to the government offices, lots of public speeches, emails to other concerned citizens……………I gathered a group of enlightened citizens, we improved as many aspects of the city as we could. Slowly but surely, and together, we created a city we were proud of. I was happy to be a citizen of the city and eventually retired there. Today, my 65-year old self is proud of what my younger 35-year old self did. I hear you are a very good doctor. Son, it may be in your self-interest to go beyond your own skills, improve the hospitals in this town so that when you fall sick, it will be there for you. Do it for your future self.”
I guess all of us can do something for our future self. If I want to be a leader of a robust team, I need to evolve and grow the team. By helping others grow, I care for my future self. It is self-interest but not narrowly confined to today – to instant gratification, immediate success or money-making. It is self-interest but enlightened enough to include others and most importantly include the future in it. What if we no longer think of self-interest as the engine that drives our society, but rather create a today that is based on the interests of the future self?
“The choice to be a leader is a lifestyle decision; it means you are willing to take care of others. The true cost of the leadership privilege comes at the expense of self-interest. Leadership is not about the next election, it’s about the next generation.”
Author, Leaders Eat Last
© Jignesh Shah, 2015