Podcast Episode 152

with our guest Aaron Berkowitz

One by One by One: Making A Small Difference Amid a Billion Problems

Aaron Berkowitz [00:00:00] Have you ever been to Africa? I said, no. She said, do you know how much work it would be for people there to orient you, to make sure you’re comfortable, to make sure you understand what’s going on? You’re a student here, so why don’t you wait till you have a skill to offer and then you’re welcome to come and then many years later, I take her up on that.

Brilliant Miller [00:00:18] Hi, I’m Brilliant. Your host for this show. I know that I’m incredibly blessed. As the son of self-made billionaires, I’ve seen the high price some people pay for success. And I’ve learned that money really can’t buy happiness. But I’ve also had the good fortune to learn directly from many of the world’s leading teachers. If you are ready to be, do have and give more. This podcast is for you. If you’re interested in using your strengths, gifts and talents, bringing your life experience to bear to make a difference for others. In ways that you find enjoyable, I think you will enjoy my conversation today with Dr. Aaron Berkowitz. He’s a leading voice in neurology, global health and medical education. He’s also concerned with issues of social justice. He’s written a book called One by One by One: Making a Small Difference Amid a Billion Problems. It’s been praised by Dr. Sanjay Gupta of CNN as a heartfelt book that will inspire you to see the world differently and compel you to be a part of that positive change. Dr. Berkowitz is professor of neurology and director of global health at Kaiser Permanente School of Medicine after previously serving as director of global neurology at Brigham and Women’s Hospital and associate professor of neurology at Harvard Medical School in these roles. He’s worked tirelessly to improve access to neurology, care and education around the world, including Haiti. Malawi and not a whole nation in this conversation, we explore. Aaron’s experiences working in Haiti, the work he’s done with Partners in Health, I was interested to talk to Dr. Berkowitz because I know that every one of us wants to make a difference, but we don’t always know how. I found this book to be very humble and insightful, look at the challenges when we raise our hand, when we take a leadership role or we try to and how that doesn’t always work out well. But we can persist in the face of difficulty. And ultimately, every single one of us does have the ability to make a difference, to make a contribution you can learn more about. Dr. Berkowitz by following him on Twitter at Aaron Berkowitz. And you can visit Partners in Health Big to learn more about the incredible work the Partners in Health is doing to reduce poverty, provide a preferential treatment for the poor, and to improve the quality of life around the world. With that, I hope you enjoy this conversation with my new friend, Dr. Aaron Berkowitz Aaron. Welcome to the School for Good Living.

Aaron Berkowitz [00:02:51] Thank you so much for having me. Brilliant. I’m really excited to be here.

Brilliant Miller [00:02:55] I’m excited you’re here. Aaron, will you tell me, please, what’s life about?

Aaron Berkowitz [00:03:01] I don’t know. And I say that both because I don’t know and because I think that that mindset of not knowing that that’s so-called Zen beginner’s mind. Right. Of being open to to to not knowing and therefore being open to new experiences, new knowledge, new wisdom and the humility of saying, I don’t know. I think it’s sort of a guiding principle for me and in both my work and in medicine, neurology and and in life as well. So I’m going to give you an I don’t know, OK,

Brilliant Miller [00:03:34] an honest man. All right. I’m. Will you tell me who are you and what is your work?

Aaron Berkowitz [00:03:44] So I’m a neurologist, and I think if you had asked me 20 years ago and my future me had said I’m going to answer by saying my profession, my my young 20 something, he would have been disappointed in that in that answer to hear me identifying with a profession. But I really do identify with neurology and with being a neurologist. And I, I just feel so fortunate to have found this profession after life, as you know from from my book meandering to find my way there. It’s a profession that when I’m fortunate to to be practicing neurology, whether that’s at the bedside with a patient or teaching about neurology to a student or someone training in neurology, I just feel really in touch with what I’m of meant to be doing, thinking about the mind, thinking about the brain, solving challenging and complex problems to try to help others and to try to grow the awareness of this very important field in medicine and in science and hopefully inspire students to try to join us. There’s a great shortage of neurologists in the in the world. So so am I. I’m a neurologist and I embrace that that identity. And I feel very fortunate to have found that profession.

Brilliant Miller [00:04:55] So I’m going to have a few questions for you about neurology, because it’s something I myself am learning more about, what I’m interested in, what you said about the 20 year old self I’ve been disappointed in answering. Who are you with? Something about a profession. But two questions here. One is why? Why do you think the 20 year old might have been disappointed in that? And what else do you think the 20 year old might have might have answered or anticipated answering us?

Aaron Berkowitz [00:05:22] That’s a that’s a great question. I guess I’m thinking of being 20 and wanting to sort of find my way and not imagining that way would be such a circumscribed, quote unquote, traditional profession. At that time, I was about to start medical school and then left and decided I didn’t want to do that and wanted to live in Paris and try to become a musician and even coming back and starting medical school, very ambivalent about about take on that path. And in part because it just seems sort of so structured and and traditional. And and so I often tell students who are having similar experiences in medical school, I remember the sort of elders, as it were telling me, know it’s natural to feel that way. You’ll you’ll come to enjoy it. And I thought I really resisted that sort of conformity and feel I feel very fortunate that, as it turns out, as I tell people, I’m so pleasantly surprised that I really love being a neurologist and practicing medicine more than I could have ever imagined. So maybe that 20 year old would have liked to have heard that I’m still just living out of a backpack and traveling across the world. And I do spend some weekends or vacations living out of a backpack. But I probably would have been a short sighted view at that time. But as far as my elders told me, I had to learn that from it for myself, from my own experience.

Brilliant Miller [00:06:39] And, you know, that’s interesting to me to hear you at that. Maybe a crossroads as a as a 20 year old and looking at one path that’s maybe the arts and another that’s the sciences. And I think about a few years ago, I read Jung’s memories, dreams, reflections, and him being at a similar place of wanting to live this very creative life, but also wanting to live a life of of science and contribution. And, of course, we could make a contribution either way. It’s possible. But in your journey, I hear you say that. Well, first of all, I’m curious about the music. What when you say musician, what what are you talking about?

Aaron Berkowitz [00:07:21] So I was mostly a pianist, classical piano, and then got interested for a while in composing and then in travels through India, sort of fell in love with the sitar and was learning the sitar for a while with sitar guru. And so I was pretty, pretty broad interest in music. But at the time I left medicine before medical school and then during medical school, I actually left for for six years as well to try and was mostly focused around playing the piano and composing and and learning the sitar, trying to learn the sitar. It’s a lifelong process of music that

Brilliant Miller [00:07:58] I hear you say sitar guru.

Aaron Berkowitz [00:08:01] Yes, yeah,

Brilliant Miller [00:08:02] that’s pretty cool when I hear you say that you love neurology, so you chose this path, you followed it. What do you love about it?

Aaron Berkowitz [00:08:12] So many things. I mean, I think the mind and the brain are just so fascinating. All the organs of the body sort of miracle that our body does what it does are fascinating. But anything I sort of read before medical school or during medical school, I should have learned about all the different organ systems in the body. The brain just seemed to be the the real final frontier. I think we understand that so much less than other organs. And yet what we do understand is so fascinating. And where else do you find an organ that is trying to understand itself and is one of my mentors said this is the only field of medicine where the patient is trying to tell you what their concern is, what their issue they’re experiencing is with the organ that’s experiencing it with the brain. And so I think for someone drawn to the arts and philosophy and and different types of thinking about the mind and the brain is just such a such an extraordinary area intellectually. And then the practice of it, we’re able to through talking to a patient and examining them with very simple tools, a reflex hammer, a tuning fork and observe observation. A patient tells us what they’re experiencing, what symptoms they happen through, what I’ve learned hand the books you see on my shelf behind me and from amazing teachers and from our most important teachers, our patients. We can use that information to really figure out where the problem is. And the nervous system within centimeters, just sort of through the old fashioned kind of techniques of observation and medicine. So it’s it’s just endlessly fascinating and it’s just such a privilege to be part of patients lives. And we just learned so much from them and are so inspired by them and their families facing diseases that really affect who we are. They affect our ability to speak or to remember, to move with with fluidity, with dexterity. And so it’s I just learned so much from the resilience and and incredible families and friend networks that support our patients suffering from these diseases.

Brilliant Miller [00:10:13] Something I want to know more about is. You use the word ambivalence about this being at the point of entering medical school and so forth and embarking on this path is really a life’s work. And one thing I wonder is, was there a moment where you either closed the door, so to speak, or you made a commitment? Was there a single moment where you just resolved or you made a decision? And if so, what was it?

Aaron Berkowitz [00:10:42] I’m thinking I’m thinking about that because I’m not sure there was the epiphany that maybe the 20 year old self we talked about was hoping I would find somewhere, you know, growing up, I had sort of, you know, what do you want to be when you grow up? You’re always asked that, right? And I remember saying I want to be a fireman. And my mom said that would be too dangerous. I just started listing things, said I want to be a doctor, and that parents I oh, that would be great. Should become a doctor. What? Parents don’t want their child to become a doctor, and I’m not sure I have too much experience or reflection. And that process, I sort of went through it and I kind of liked science and high school. And in college I did the premed thing. Probably not that much reflection. And, you know, ambivalence was sort of, I think the cold feet of saying, wait, I’m really committing to a lifelong path and what do I even know about this? Except I’ve taken a few classes. So that’s when I I left for Paris looking for some insights and only became more confused that I really loved the music and the idea of sort of a shirt and tie kind of job one day didn’t didn’t didn’t feel right. But somewhere I knew I was drawn to medicine and came back to it. And then I found that medical school in some ways, as many do, just a lot of time in the classroom, a lot of memorization. I didn’t feel that looking back, medical school doesn’t give you a great impression, or at least it didn’t when I was going through 20 or so years ago, what it’s actually like to be a physician and and the incredible privilege and honor that that is and the joy and meaning it can bring. And so I sort of had moments in medical school. I said, well, this is this is be learning my whole life. I’m able to make such an impact. And others where I said, I don’t know if I want to live like this. It’s hard work. I can be a very unhealthy lifestyle, ironically, to be a physician, as you know. And I have a number of sort of moments, and then I would sort of waffle back and forth. I actually left for six years to sort of pursue music and learn languages and study yoga, learn to meditate, try to do all the things I wasn’t going to be doing as someone sort of going down this narrow path. And, you know, things just kept sort of drawing me back. I wrote a very powerful book called Mountains Beyond Mountains, which is a book about Partners in Health, the organization that I now work with. That was certainly an important moment, sort of drawing me back to medicine and realized that all the things I was working on, a music, trying to develop my creativity, trying to learn different languages and think about how the brain processes music and language that I could put all those to use and sort of one place in neurology. But even then, going back, I starting the very grueling training of medicine, a number of moments where I thought I was not going to be able to do it. It was just too physically and mentally difficult. And somehow people said it’ll get better, it’ll get better. Everyone feels like this. I no one wanting to do the thing they’ve always wanted to do and just suffering so much in the process. And I think somehow things just sort of, you know, I equilibrated to it and once I equilibrated the environment, I was able to sort of focus on what was just so compelling about urology and the practice of neurology. So I’m not sure there was one kind of epiphany moment as I was searching for maybe a number of small moments that kept pulling me back and then and somehow just committing to the longer journey of it, because it’s a very long process and there’s a lot of suffering along the way.

Brilliant Miller [00:14:11] You know, as I is, I hear you share your journey and, you know, making decisions and and getting clarity. I know that’s a process that we all go through in our own version. Of course, we don’t all end up as neurologists or whatever, but we’re all in that, I think on that same path and in that same sometimes it’s a struggle. So I am curious about what advice you would give to somebody who’s maybe at that younger self that does have a multitude of interests and opportunities, like what? What do you wish you had known or what would you say to somebody who’s who’s maybe very acutely in that same inquiry?

Aaron Berkowitz [00:14:49] I feel very fortunate that I made a few decisions that I was sort of advised against. I would say obviously deferring medical school. And after I have been accepted and then leaving for six years, as many people said, you know, you’re you’re wasting your time or medicine’s more stable than music. You know, you could love music, but it could be a very unstable life for you. And even though, as I said, looking forward and thinking I would one day be be saying how happy I am as a neurologist, I think that would have surprised my younger self. But I will say, just like anything, I think I need to learn from my own experience. So when I said, you know, I’m not sure I want to do medicine, I really want to pursue my music to the fullest. I don’t see putting those together. People would say, well, someday you’ll be a doctor. And if you can have some delayed gratification, right, to be able to afford a nice piano and be able to do all these nice things as a musician, you might not even be able to afford your own piano if you’re not good enough and you’re not famous and these things. So even if in the end I’m now I’m now a practicing physician, I play the piano much less than I my 20 year old self would have wished for myself. I’m not bothered by that. I’m not I found sort of what I was looking for ultimately in neurology, but I had to learn through my own experience that I needed to go and do my music thing and accept that I was shouldering the debt of medical school while going on the path of a musician. No one, despite many telling me, I think you should come back to medicine someday, you’ll probably come back to medicine. I sort of revolted against me and I did, but I don’t think I could have done it and could have given myself fully to that journey without my own exploration. So I think if people are sort of at a crossroads, I sort of felt it was important for me to people said you have to choose one or ultimately you can have both. I don’t think I could have known what that both would look like until I took one path, put it on pause, and then took the other one and then came back. And so I say I respect the wisdom of the elders, but perhaps you have to. It’s not your wisdom, it’s just intellectual knowledge. And so you have your own experience. And I when people say, how did you come back? I said, I don’t think I really could have given myself fully to what’s necessary to train in medicine, which is really a very full time mental, physical, emotional commitment. If I hadn’t had that period to explore music and other things in such depth that I felt comfortable that had been able to do that. And now is the time where I can do that lesson and feel perfectly, perfectly in equilibrium with that.

Brilliant Miller [00:17:23] I love that. You know, what I’m hearing in that is giving giving yourself the permission to explore deeply. I would say broadly in your case, it sounds like you traveled broadly and then you went deep into into some of these some of these subjects. But then that ultimately gave you a peace of mind and a clarity that allowed you to commit and to to do some what I think is really great work, in particular this book that I’m going to ask you about in a moment. Before I do, though, I just have one one more question related to this career path. That’s my personal curiosity. Why choose neurology as opposed to psychiatry, neuro surgery, maybe research in psychopharmacology or something else? Like why why did you zero in on this as opposed to some of the other places you could have landed?

Aaron Berkowitz [00:18:13] Well, you bring me back to many other points of ambivalence I experienced along the path. I got interested in, let’s say broadly the mind and brain sciences when I was when I was in high school or so, babysitting for a boy with autism and was just just very compelled and interested in his lived experience and that of his family. And I just started reading about it. And that sort of drew me initially to interests in the mind and brain. And I tried different ways of approaching that. In college, I did some work in research labs using brain imaging, some some studies of animals at that time as well. And in medical school, I sort of thought neurology is very interesting. I thought psychiatry was very interesting. I thought neurosurgery was very interesting at that time. When I was starting medical school, I still had this idea that I would be sort of a part time musician, part time doctor, and that sort of moved neurosurgery out of that, because if you’re going to be operating on people’s brains, that has to be your one thousand percent full time craft, just as you would want the pilot who flies the airplane for that not to be there a part time, you know, having a job if they’re operating on your brain. And yet when I went and sort of went on this musical journey and then came back and said, I’m ready to commit to medicine. And I thought, well. Maybe even more open, because I would have done this thing and I’m open to sort of committing myself and kind of had to rethink all this, am I going to go into neurology or psychiatry or neurosurgery, the research side? I think we have extraordinary researchers throughout the world looking at the brain and the mind. For me, I just felt that to succeed in research, often you have to have a very small niche and pursue it, sort of drill very deep. And I’m just sort of appreciated the breadth of clinical neurology. I can see maybe 10 or 15 patients in a day, each with their own story, each with their own condition. And just for me, I just felt sort of more resonated with me to be seeing individual patients. I remember a research mentor in college saying if you’re a doctor, maybe in your whole life you’ll help a couple of thousand patients. If you’re a researcher and you make a big discovery that you could be helping the entire world forever. And I had a rare moment of insight for that age myself. But I think I think I like the first one, and I think that’s what I feel I want to do. And I said, OK, well, if you know that, then and go ahead. I think we’re all in psychiatry. You know, they Freud was a neurologist. I believe they sort of came from the same origin. They’re studying the same organ. And yet they sort of diverged and then are hopefully coming back together where neurology is sort of more about the stuff of the brain, if you will, the kind of anatomy, physiology of the brain, the spinal cord, the nerves, the muscles. And psychiatry is more about the mind. And I’m again, great, great wisdom, great mentors. I remember when I was deciding between those when a mentor helped me see that no matter what field of medicine we practice, we’re going to be practicing some psychiatry because patients are going to be telling you their story and and you’re going to be helping them or helping them to figure out how they’re going to navigate life with illness. And if they said, if you do, psychiatry will be doing only that. But if you’re really, like, thinking also about the brain in the spinal cord, the nerves, muscles, ordering a CAT scan or something like that, and solving a diagnostic problem for someone like me who doesn’t like to choose between things like neurology, you’ll still get the psychiatry, but psychiatry might get less of the neurology. So that that’s sort of helped me. But I have difficulty between some of those fields and neurosurgery. I just realized I wanted to be someone sort of more with the patients when they were awake and talking with them, as opposed to when they were anesthetized and operating on them. And that’s how I eventually landed here.

Brilliant Miller [00:22:02] All right. Well, thank you for that.

Aaron Berkowitz [00:22:03] Yeah, thank you.

Brilliant Miller [00:22:05] You’re part of what I find interesting about about you in the work you do is that your work has a concern beyond the walls of a hospital in any given community or work, extends overseas deals with people who aren’t perhaps as fortunate as I mean, it’s not a perhaps people who aren’t as fortunate as us living in the United States or in the developed world. And so not only that, you have a broad view. I believe also you write about it and you share your experience, the experience of some of your patients in a very personal way. So you wrote a book, one by one by one, making a small difference amid a billion problems. Why did you write this book? Tell us a little bit about what is it, who did you write it for and why?

Aaron Berkowitz [00:22:57] Thank you. So. You know, I think when we hear about public health problems like inequities or access to health care, those problems are often framed in terms of these big, overwhelming numbers. We hear that four billion people in the world lack access to adequate health care. We hear about the millions of people who have contracted or died of coronavirus 19. We hear about the thousands of people who are affected by police violence in the United States. And we hear these numbers and they’re very overwhelming. And yet we don’t think in in numbers as human beings. We think in stories. And I think when we hear about these billions or millions or thousands, we lose track of the fact that they’re made up of individuals and they’re made up of individual people. And I think some of that gets lost in these arguments around numbers around crime or gun violence or public health. We forget that these are individuals being affected with with with individual stories. And when I think about some of the things that influenced me and the stories that I wanted to tell, I realized these sort of show us who are these billions? When people refer to the poor, that’s billions of people like you and me having lived experiences. And it’s one of my colleagues that, as I quote in the book, he said, you know, when we do this work, we give a face to a faceless problem. We give a voice to the voiceless people. So I’m very grateful for the people who can make the case to legislators or funders that this is a problem that measures in the billions and it should be funded or we should we should care about it. We should figure out a way to solve it. But it’s hard to solve a problem that measures in the billions. Right. And so on the on the flip side of trying to show the stories of ones behind the billions, it was important for me to also tell my story. And I was just being sort of one individual may be overwhelmed by a problem that measures and billions can take small individual actions toward solidarity that can try to reduce some of these problems like inequity that seem so abstract and so immense. But somehow we can each take actions and to try to help other individuals and that those individual ones can maybe add up to billions as well. That was sort of some of the motivation.

Brilliant Miller [00:25:17] Thanks for that. So in this, you you share about your experience working in Haiti. And I learned so much. I haven’t been to Haiti and I want to go. But I’m wondering what the point of it is exactly as someone who’s not devoting his life to serving others and in the same way you are, but as a reader of that, getting exposed to things I didn’t know, I didn’t know. I’m really curious to ask you, what is it that people now say, Americans? What is it that Americans don’t know about Haiti and probably should.

Aaron Berkowitz [00:25:58] Well, that we could spend hours talking, talking about that, so I’ll try to be concise, I mean, in one wonderful book about Haiti by the journalist Amy Wilentz, I forget which of her book she has several books about Haiti. It might be her book, Farewell Fred Voodoo. She says it is the most revolutionary place in history. So Haiti was the first, last and only successful slave revolt in history. Haiti had an indigenous population. That’s how they were discovered by Columbus on his fateful fourteen ninety two sailed the ocean blue voyage we all learned about and through the usual conquistador playbook of smallpox, slavery, slaughter, starvation. They were gone within two generations. Conquistadors moved on to what’s now Central and South America, and the French took over Haiti and populated it through an overzealous transatlantic slave trade route. Millions and millions and millions of individuals who were enslaved and brought to Haiti and this was in that time called the Pearl of the Antilles that the colony of Haiti was actually generating at its peak more revenue than the thirteen American colonies combined. And this backbreaking labor led to obviously revolts and ultimately revolution and the enslaved people living in what’s now Haiti defeated Napoleon’s navy. This is extraordinary history. Right. And so this is what they declared the first free black nation. And this was for 60 years before the US would abolish slavery. And so you can imagine the US reaction, the implications for their own enslaved people. They refuse to acknowledge Haiti. The French have just lost one of their most lucrative colonies. They refuse to acknowledge Haiti. And so he was born into a very hostile environment. And the forces of economics, politics, racism I’m talking about from hundreds of years ago still resonate today. Haiti was scapegoated for HIV AIDS. People used to say in the eighties when people were discovering AIDS, that there were four h.s and those h.s were. I’m blanking out as a doctor and neurologist for so long, blanking on the name of the hematologic disease, hemophilia. Sorry, it took me a moment there. I’m so much in the brain these days. Hemophilia, heroin, homosexuality and Asian people thought before places that AIDS came from obviously problematic on many levels. And Paul Farmer, one of the leaders of Partners in Health, his early work in Haiti, showed that actually the United States was bringing HIV AIDS to Haiti. But just an easy race, a scapegoat to say this is a poor country founded and run by self declared freed slaves, that this must be the source of this and all this sort of stigma, a stereotype that people were performing voodoo rituals and drinking each other’s blood, all totally false to scapegoat this population. So I think it’s and the one one one sense historically an extraordinary place. Imagine a group of enslaved individuals, an ocean from their homeland, defeating Napoleon’s navy. On the other hand, hearing that revolutionary and extraordinary history and understand it’s the poorest country in the Western Hemisphere just for being born there. Instead of an hour flight away in Miami, you would live most likely 16 years shorter. Your child would be eight times more likely to die in infancy. Your mother’s pregnant mothers would be twenty five times more likely to die in pregnancy. And when I mention these statistics, people shake their heads and say, oh, so unlucky to be born in Haiti. And I say, no, this is the history, the politics, the economics, the racism. This isn’t luck. This is the background. So I think it’s a country from whose history we can learn a lot and that continues to resonate very much in that and the present moment with the things that society’s reckoning with.

Brilliant Miller [00:29:57] Yeah, absolutely. And, you know, talking about Haiti, of course, there’s these specifics, these realities. And as you’ve pointed out, the lived experience like a real experience of human beings there. And at the same time, I think there’s something really valuable here to look at that’s this is beyond any specific country or person. Right, about this otherness. This foreignness this separation and even the name that Haiti calls the United States, the people in Haiti call the United States. I was really.

Aaron Berkowitz [00:30:31] Yeah, I’m glad that you mention that, because these these stories take place in Haiti, that’s where through serendipity they talk about I ended up finding myself working as a neurologist. And yet the story’s being told there are many people who’ve read the book, have written to me and said this sounds like a place where they’ve worked or a place where they’ve lived because this is can the lived experience of working in a place of dire poverty and what that means for individuals health and access to health care. And Haiti is one, unfortunately, among many places in the world that have billions. Haiti is an island of about 11 million people. There are billions of people in the world whose stories would be similar to the ones I told there. And so I’ve been very fortunate there. I’ve learned a lot of things. I’m working in Haiti, some of which I tried to transmit in this book. And when you’re mentioning are some of these phrases in Haitian Creole proverbs in Haitian Creole and many refer to United States as BOA, which just means the other side or the other side of the water. And maybe I read into it too much of is the other side, the water there and the in the Caribbean to to get from Haiti to to Florida. But it just seems so striking to me as someone who was going back and forth from from from Boston when I lived there, took to Port au Prince, that’s a four and a half hour flight. And so I mention that because I have done some work in Malawi, in East Africa, and to get from Boston to the place where I was working there, it was almost two days of travel, a flight to South Africa and then wait for the next flight to Malawi and then a long drive sort of to the village where Partners in Health has the health center or district. And when you get that far away from your home, it doesn’t maybe it’s still shocking, but maybe less surprising that you’re in an environment, as you said, that’s so other. That’s so far. And you see poverty beyond what you could have imagined. But when you get on a flight in the morning in Boston and by the afternoon you’re in Haiti and you see this dire poverty so close to where you live, of course, there is dire poverty in the United States. And then I mention that to colleagues in Haiti or places like it. They said, but you have water, right? And we don’t even have water. So so all all relative. So this idea of the other side, as someone who sort of went back and forth between these places, I found very interesting on a number of a number of levels.

Brilliant Miller [00:32:56] And you also talk in the book about stupid deaths, the term that Paul Farmer uses. What does that what does that mean and what does it look like? And what did you see personally? What are some of the examples of that in in your work?

Aaron Berkowitz [00:33:12] Yeah, so Paul Farmer, a prolific writer and extraordinary mind that has done an extraordinary amount of work to help some of the poorest people around the world and also really to build a movement or someone like me who was pretty soured to medical school and imagining what was possible as a doctor to realize there’s so much work. Realize there’s so much work. To pursue global health equity, he coined this term stupid deaths in an Article IV has this idea that it’s a person who dies for reasons they never would have died of if they were in a country that had adequate health care resources, either because they were never able to be screened for their high blood pressure, never knew that they had it, and then developed a fatal stroke or heart attack. I think the article he writes about a stupid death in a boy who accidentally had stepped on a residual landmine in the country where he was working. So Paul Farmer always teaches us he’s an anthropologist and a doctor to go back, know more proximal. Why was the boy playing with the landmine? Why was the landmine there in the first place? What was the history of why there was war in this region and who was responsible? And we saw this all the time and had patients who would come to the hospital either so late because they had had to come from so far away to find a hospital or so late because they couldn’t afford to leave their work supporting a large family with conditions that the United States or another wealthy country. We would have caught it early, treat it early, and the patient would have lived here. The patient shows up on death’s door or sometimes already dead from things where you thank goodness we would have been able to do so much for this patient one hour flight away. And that’s sort of as you know, it sort of gets me started in this book saying is this is are these some stupid deaths that we might be able to do something about? We have a little more time. This is not an acute emergency. And yet, as you know, I don’t know how much of a book you give away to potential listeners and readers, but certainly one several sort of stupid deaths in that case where in any place else and any wealthy country these patients would have survived and live a healthy, productive life. And I won’t say because of the luck of being born in Haiti, but because of the historical forces that led to Haiti being in the situation it’s in that the patient doesn’t have a fighting chance.

Brilliant Miller [00:35:32] Yeah, and something that. I found myself asking is, you know, and I and I think listeners to. What can I do, like what is what is my moral obligation? Is there one, you know, what can I do? What should I do? You know, this kind of thing. And as I as I thought on that, I thought of this this quotation attributed to E.B. White actually pulled it out in preparation for this. Right. This one about he says, if the world were merely seductive, that would be easy. If it were merely challenging, that would be no problem. But I arrived in the morning torn between a desire to improve or save the world and a desire to enjoy or savor the world. This makes it hard to plan the day, right. So this this thing where I in about trying to to enjoy life and trying to make a difference in the world and to balance those. And obviously that’s a very, very personal question that each one of us gets to answer for ourselves. But for people listening to this, what what do you say? Like what can we do? And I just want to interject one other thing. This idea of voluntarism. Right. Because does that matter? Does that make a difference? As we asked this question, what can I do if I go on a trip for a week or something? So anyway, let me let me try to ask that succinctly. What can we do?

Aaron Berkowitz [00:36:53] Yeah, it’s a great question. I like the the seven questions as well about voluntourism. And I think the important question is where do we balance finding what we can do for others? Right. And as you said from the quote, enjoying ourselves are finding ways to give us what renews us and gives us the the strength and the mental health and wellness. Right to be able to do this work as well as I’m going to start there because it reminded me of a story once I was in Haiti and from Boston, I had a full time job. There would often go for a week or two weeks at a time and think, I’ve been working there a couple of years and going a couple times a year at most. I think one year I went seven or eight times with my every few weeks. And one of my colleagues said, Have you been to this this beautiful beach in Haiti? I said. Each and he said. You’ve been working in Haiti for five years, you’ve never seen our beaches, and I said, well, you know, I come here at such a short time and only neurologist’s in the country, I feel like I should be working. And she said, you’re you’re working plenty. I’m taking you need a break. And so I think it’s sort of speaks to that question of, you know, yes, it’s important to work hard, but how can we work hard? And these ideas we might bring of saying, no, I’m here, I’m lucky I get to go back to United States, I’ll have clean running water and I’ll have water in the shower if I want to. Then I’ll have electricity all the time. And the things we take for granted here, I should really be doing everything I can. And she sort of looks at me like, that’s nice that you feel that way. We would like to show you the beautiful beaches we have in Haiti and you should enjoy it and relax. I think it sort of speaks to your quote on a practical level. So what what can we do? And this is something I wrestle with in the book as well, even as a neurologist even trained to, quote, do something right. This book is in part coming back to our first question is, I don’t know what what even I can do in these situations as a as a neurologist, as a doctor, someone trained with a very specific skill that can be helpful in some small ways. But is it something bigger problems or is that even the question we should be asking? So many people like myself, I read Mountains Beyond Mountains as a student. I said I want to do global work in medicine. I’m a medical student and I wrote to the only neurologist I could find who is doing global work at that time and said, Oh, I want to do this in my career. Can I come work with you? She was working and is Dr. Gretchen Berbick, one of the founders of global neurology. I said, Can I come work with you? She was working in Zambia. And she said, why don’t you call me in 10 years when you’re a neurologist and you can actually do something that was sort of very taken aback. And then I realized, oh, she’s teaching me a very important lesson here. So you could have you ever been to Africa? I said, no. She said, do you know how much work it would be for people there to orient you, to make sure you’re comfortable, to make sure you understand what’s going on? You’re a student, so why don’t you wait till you have the skill to offer and then you’re welcome to come and then many years later, I take her up on that. So on the one hand, what can we do? There’s so much right. People say, well, you’re a neurologist. We don’t think of neurologists, we think of surgeons or infectious disease specialist. But when I’m in Haiti, one of the one person I mention in the book, one of the people there does some of the most important work is the person who does all the plumbing for all the hospitals and the partners in health system in rural Haiti. Very complicated work, right? A plumber from outside of Boston comes down and spends months at a time figuring out the plumbing and how to get the oxygen into the hospitals. And so it’s not really all hands on deck. And then some people say, well, I don’t I’m I have skill X, let’s go. I’m not sure what I would do in Haiti. What if I came on a. And this is where we get into your your voluntourism question. I really mixed feelings about this. On the surface, you say what? As I talk about in the book, I would see these groups of people coming to Haiti on their spring break on the plane with matching t shirts and backpacks, you know, healing Haiti. And if you took all the money that went into their plane tickets to their matching shirts, to their matching backpacks, to their their cameras and all these pictures they’re going to take, you could probably build a school in Haiti and hire a teacher for you. And that’s just one week of people. And it’s actually the plumber. I mentioned the story I tell in the book or on the plane. I was sort of making light of this. And he said, you know, you doctors always think you’re the only ones who can do something here. Said those people may come on their spring break and never come back to Haiti. But just seeing Haiti, understanding what’s at stake here, it may be more likely to make a donation to an organization like Partners in Health. And they might think twice about things they read about or how they just live their lives and understand the privilege and power that they have just for being born in the United States or whatever wealthier country they’re coming from. So I think with anything and one thing I tried to convey in this book is every topic I mention is complex story that has multiple sides to it. So if someone says, hey, I’m going to do one of these trips where I go to Haiti for a week and play with some kids in an orphanage, say, well, OK, how much is it costing you and what is that orphanage and who runs it? And and does the does the money you’re spending on this trip go to help actually help the community? Or is it a non-governmental or nonprofit organization that’s actually taking the money and then hiring people away from sort of public services in Haiti who otherwise would have worked there? But so there’s all sorts of unintended ripple effects and these some negative and then some positive. Right. The person who goes and says, wow, I didn’t maybe accomplish much by bringing some toys to an orphanage, but I had no idea that that’s what poverty looks like. That’s what poverty feels like. And somehow that seed is planted and grows and compels them to take actions, whether that’s opening their wallets and making a donation to an organization they admire or saying, oh, actually, I do know someone who’s who is as a plumber or an electrician, an engineer who might be able to volunteer some some very useful skills. So that’s sort of my ambivalent answer, that one of our themes today may be ambivalence.

Brilliant Miller [00:42:59] In the book, you talk about a conversation you had with someone on a flight and about the same thing. Right, about how it can we can be critical of people who are doing that. But he said something to you that maybe give you a bit of a perspective shift, and it did for me just reading it. But would you be willing to share about that experience?

Aaron Berkowitz [00:43:20] Yeah. So I think this was Jack the Plumber who I worked with there and so bumped into on the plane. And as I was saying, I sort of sort of making light of all these people in their matching shirts, you know, what have they really done here? And he said, you know, maybe they’ve done a lot. What if, you know, an organization is building a hospital, they just need bodies to haul cement. Maybe they did that. And he said one of his best facilities, engineers from the states who helped him, many of his projects, that he went on one of these trips as a kid with his parents, because I was sort of saying there’s this whole families, like, what is this nine year old kid doing in Haiti? They can haul cement, can do anything. This is taking resources, right? This is not giving resources. And he said one of my best facilities, engineers from the states who help save one on one of these trips that just opened his eyes as a youth. And so, again, I think I think it’s sort of there’s always two sides, maybe many sides. And one of my colleagues at Partners in Health, when she read my book, I think one of the reasons I could tell she got it. She said, I hope people will read your book and understand a little more about complexity of the work is that we do. I think that was another example of nothing is all good about. Right. There’s complexity and of again, coming back to not knowing instead of judging that saying this is ridiculous, they should cancel this thing. Well, they may have some unintended negative consequences. Not every organization in Haiti is doing its good work or some are good intentions. And it doesn’t work out. Some are bad intentioned and and some are in between. But the unintended consequences aren’t always negative. There can be unintended consequences to things like this. So I think case by case basis would have to say, is that your organization doing good, doing well? Are the intentions matching the results? And if not, should we really be supporting that and encouraging people to participate in that type of work?

Brilliant Miller [00:45:17] And I might be misremembering this, but I thought that Jack said something like before. We criticize those who are coming. Consider those who aren’t.

Aaron Berkowitz [00:45:26] Thank you. Yeah, I’m remembering now the chapter closes. It’s been a while since I’ve looked that. Yeah, I think that’s a I’m glad that you highlighted that aspect before we criticize people who are coming. What about those who are right, those who don’t even know where Haiti is on the map or the history. So I think it was a very profound insight for me as well. Thank you for analyzing it.

Brilliant Miller [00:45:47] Yeah, and something else. That I’d love to get your view about, is this about the motive, right, because there’s this sense of I think some people try to fix others when they’re really trying to fix themselves or they’re they’re on a crusade or there’s a position where they’re coming from that I think they think they mean well. And you’ve talked about this mixed mixture of the positive and the negative and the consequences and so forth. But there’s a concept the partners in health is really important to partners in health, right, solidarity. And when I read that in your book, I’d love for you to talk a little bit about that. But it reminded me of a quotation that I’ve heard attributed to somebody named Lulla Watson where she says, if you’ve come here to help me, you’re wasting your time. But if you’ve come because your liberation is bound up with mine, then let us work together. And to me, there’s a bit of a maybe a metaphysical thing right there, right, because in some metaphysical way, any human suffering, any being suffering is my suffering. Right. And while I’m not a messiah, I’m not a savior. I do have an ability to respond, to act, so forth. And so this idea, we could go on a lot of directions with this. But I want to come back I want to come out of this thing about solidarity and about acting from a place not to fix or save anyone, but because in some way we are the same. What will you talk about that solidarity?

Aaron Berkowitz [00:47:21] Yeah. Thank you for mentioning that. There’s one there’s many Haitian Creole proverbs throughout the book, as you know, and one that is really, I think, a guiding principle is this probably wouldn’t say when every person is a person. And it sounds pretty simple on the surface, but as you said, it’s a very radical notion because if you again, if you hear of billions of people suffering from. Right, there’s no kind of connection there. But if you see in front of you an individual who could be you. Right. Who could be your brother, who could be your sister, your best friend, and you see that that they’re are suffering. Right. Then, as you said, that’s all of our suffering. Right. And you made this interesting point about there’s these ideas in global health that the practice of global health, is it actually helping to reduce inequity or is it just perpetuating colonial ideologies because they’re the rich people from the colonizing countries are going to the formerly colonized countries and doing work, as you said. Is it a sort of savior ism? Is it a sort of messiah ism that we’re going to go with our our wealth and our power and and fix this and partners in health really turn that its head? And again, not if there’s an intellectual framework there, as you said, but it really comes from Paul Farmer’s lived experience. He was a volunteer there as a student. And people said, you know, we don’t need a student here. We need a hospital and doctors and medicines. And and he talks about this in his his writing that he really learned in Haiti what is at stake from the Haitian people. He made the friends that he made there, not from going to a conference or reading a book or studying for his Ph.D. He did all of those things. But it was people in Haiti saying, this is our experience, and if you want to help us, quote unquote, help us, this is what we need. And so I think it gets into this aspect of solidarity. As you said, the Partners in Health mission statement has this incredible phrase, something like, our mission is based on solidarity rather than charity alone. And of course, we need charity. Right. The truth of the matter is, as you said, there are people with more resources and more power, whether that’s whatever the historical reasons behind that. And so the way I sort of tell this in sort of a parable for when people say, well, should you even be going to Haiti, aren’t you just instantiating these colonial power dynamics? I say I agree with that statement. Right. And yeah, I do have the resources to do it. And there are resources there, for example, in neurology that were absent. And so should I not provide them because of some intellectual hang up. And so the parable to say, what if I see an older individual who’s fallen on the street and I’m walking back, I should help them stand up. It looks like they can’t get up. I should get help. And then I say, well, that would be ageist of me to judge that that person would want the help of a younger individual rather than themselves being empowered despite their older age. To lift themselves up like this sounds the get go help the person. I think you can get hung up in these intellectual frameworks if we just come back to this idea of, as you said, a person to person and we ask and a lot of this book is about what I call global health to talk to is the global health one or one. We need to be aware of these colonial power dynamics, be aware of, even if I believe I’m not coming from a place of healing myself or savior ism or colonialism. As Paul Farmer says, history didn’t start when you arrived, right, so there’s 400 years of history that precede me on this relationship between the United States and Haiti. And the two of two is even if I’m sort of trying to be conscious of that, what a patient safety. I tell this story of asking this the general one of the main stories here of this young man needing brain surgery, but a very risky, high risk brain surgery. And should we do it in the United States and really being concerned with the language barrier and cultural barrier despite sort of intermediaries, are we really understanding here that this is not some magical self saving force from the United States? This is a very complicated, risky decision. And the United States, right. Would be going back and forth and who is empowered to make the decision? And my colleague said, these are your ethics right here. A patient, you don’t have to worry about being paternalistic, paternalistic. It’s good that you thought of that. This patient doesn’t know and they want the doctor to help them make the decision that you think balances the risk and benefit they don’t want it to be placed on. And that’s your thinking. So I think this humility of saying, what can you help me understand? What can I do? What should I not do? Because there’s no way I’ll understand if I lived my entire life in Haiti. So I think that principle of solidarity, every person is a person, if you and me are to live here to try to solve the same problem, even if we come from different backgrounds, can we sort of try to level the playing field to the extent that we can?

Brilliant Miller [00:52:11] Yeah. Thank you for for sharing that. You know, as I as I read your book and and followed the story of Genel, the person you just mentioned, that you made a pretty incredible effort and many other people to provide this lifesaving brain surgery for. One of the things that I was really struck by was this I think this fear or the paradox that we as human beings, I think we want to help and we want to make a difference. And yet that creates once we start, we then create a responsibility or for ourselves, our own expectation and others about what we’ll do. And I wonder if you would be willing to talk a little bit. I’m not going to ask you to recount the story here. People can read the book and it’s it’s really amazing. But we talk about how, you know, the way I read it, you didn’t use these words, but like, you started out very well intentioned. You saw an opportunity and then you got in really deep, really fast. Will you talk a little bit about what that was like and how you manage that?

Aaron Berkowitz [00:53:16] Yeah, well, you got it. That’s I’m glad that came through in the book. You know, I know you said we’ll talk a little bit later about the writing of the book, but I think this is a little bit related there. I really wanted to tell these stories for the reasons we talked about. I had never written a book like this before, and I was reading books and watching movies, trying to think what makes this a compelling story? Should it start from the beginning of this brain surgery where I recount the surgeon sort of opening the skull and then flashback to how we got there to begin with, sort of the ending and flashback I was really wrestling with what sort of order to tell the story and to make it compelling and having a journal, I would sort of journaling at the advice of a writer to just reflect on the writing process. And one of the major insights I had that helped me understand solve that problem and the problem of wanting knowing that the book was in part about me, but not wanting to make this a hero’s tale, because it’s really not that there’s a lot of fear and anxiety that comes to being in this position, but not wanting to sort of be out in front. And should I tell it in the third person or what order? I had this moment where I wrote my naiveté needs to be the main one. Needs to be the main one. Which is, as I said, I I read about Paul Farmer, I read about Partizan and solidarity rather than charity, and here’s my chance as a neurologist, I don’t have that many chances. We’re not surgeons to sort of swoop in and do some big save here. And I thought, this is it. I can live up to this mission statement now, very naively. Right. And well intentioned, as it said. And my colleagues encouraged me. This is what we do. We take care of each individual patient. We’re not waiting for the entire world to solve this problem when there’s someone right in front of us. So I went forward and quickly realized this is really complicated. Right, as I made all these have all these discussions and navigated and negotiated a way of getting him to United States over the phone and over email. And one of the first moments of point one on the on the curve here, realizing how naive I was, is I hadn’t even seen him even early in the book. I am in Haiti and I meet him for the first time. Just to give your listeners some background, I had heard that this is a twenty three year old student who was in school and then developed this brain tumor and was unable to talk, unable to walk and in my head with my biases. Imagine twenty three. He was a college student and my colleague said he can sort of walk but not really. And you know, we read into emails, we read into telephone calls and we read into this idea of I want to save this young person. And when I met him for the first time in the clinic, it’s this huge space of thousands of people in the waiting room waiting to come in. And someone yelled his name. And I’m waiting for this man who knows. I’ve been advocating for him thinking we’re going to have a big hug or a handshake and someone we’ll send this extraordinarily ill and debilitated young man in a wheelchair who can’t talk and his eyes are bulging out. And I have this moment of realizing, what have I gotten myself into? This is not someone who is in college. A few months ago, my colleague says, oh, what? I didn’t say he was in college. He was in third grade. I said, well, he was twenty three and happens here, you know, it’s very poor and he was clearly very intellectually disabled. I said, but how did he even go to school like this. And he asked his mother, I said, Oh I guess it’s been years since he’s been in school. And so I thought, how many lines of EMAP that I used to negotiate a philanthropist to donate a lot of money for this case, to get a hospital to agree to this very complicated situation. And if I had met him and seen him like this, would I have still thought this could be a big save? And is it now even riskier and more complicated? And yet here is a young man who in any many other places in the world would never be in this situation. Doesn’t he still deserve a shot? Even if that shot a very complicated brain surgery could kill him. And he understand with me coming from a very powerful, wealthy place, all the ambivalent ambiguity there or just me proposing, it would just seem, as we talked about earlier from the other side, right. Oh, there’s going to be a miracle medical miracle there. And so, again, complexity. And so, again, complexity. Many moments where I realized, you know, you have these principles you want to aspire to, and yet the real lived experience of walking the walk and falling down and deciding I’m going to get back up. Now, which direction do we go in is really something I wanted to show and sort of what we wrestle with in general as doctors, but particularly in these situations of steep gradients of inequity and power and wealth and trying to do the right thing, thinking we’re well intentioned, but knowing that we really don’t understand what we’ve gotten ourselves into and how do we kind of take steps here? Blind steps in the dark here toward them, toward the light.

Brilliant Miller [00:58:15] And. Some of this I thought was so remarkable, and of course, you did, too, as you tell it in the book about when you meet Janelle, who, if I understand it, was the biggest or one of the most unique brain tumors that you and other surgeons had ever seen. So, I mean, it’s already this unusual circumstance. But as you start emailing to seek care, basically free neurosurgery, the cost of him coming to the United States, someone to care for him that you wrote, as I understand it, to emails and got to big affirmative responses in basically forty eight hours.

Aaron Berkowitz [00:58:56] All right. Yeah. So the first sort of things that came back were were rejections, which is part of this. People said this isn’t cost effective, right, to get surgery for this young man in the United States, hundreds of thousands of those. You could build a whole new hospital in Haiti. You could vaccinate a whole country probably with a vaccine that they might need. This was well before covid other vaccines, even simpler ones we take for granted. That’s not cost effective. And they said that that’s not sustainable. You might let’s say a donor supports this. You bring him to the United States. What about the next patient that comes? You won’t be able to focus on the low hanging fruit. You’re a neurologist. You could treat migraine, stroke, epilepsy, Parkinson’s. These are very rare, very complicated things. And Paul Farmer likes to say, you know, when you hear it, cost effectiveness and sustainability maybe make sense to policymakers. Right. But you never hear a person in a poor country or poor region, even in the United States, say it’s care, cost effective. Is my life sustainable like that? People just want the care. And he says, you know, you can’t wait to solve all these lower hanging fruit problems to address the big ones. Maybe you solved, you know, childhood vaccinations and nutrition. And then a woman comes with breast cancer. You can’t say, well, we don’t we don’t do that yet. And so those were the initial emails. And then I sent this to an extraordinary brain surgeon who I talk about in this book, Dr. Ian Dunn, who was then in Boston and is now in Oklahoma, a real virtuoso wizard. I can’t think of enough amazing things to say about this person who operates. Mm. In people’s brains and has extraordinary results. He said we should do this case and if you can figure out logistics, let’s do it. And the hospital said there is a donor who sometimes funds these cases, the Retie Medical Aid Foundation. Another extraordinary story maybe we could talk about. And I wrote to them and they said, this is what we do. We fund care for people who who can’t otherwise get it. When can you come? And it was just sort of this extraordinary, you know, you sort of put this intention of doing the right thing. And if you are in the right place and the right time and know the right people and these these things that sort of hopefully give you a signal that other people want to help. And, you know, once you start with this intention of trying to do what you think is the right thing, it was just amazing to us there early on. And then as Janelle’s care became more complicated, how many people really rallied to support him in terms of advocacy, in terms of a home for him in Boston while he was there getting him to appointments, navigating a very challenging medical and sort of sociocultural situation of this person who never left Haiti and is now in a tertiary hospital skyscraper in Boston and an intensive care unit. So as you mentioned and I’ll underscore, this is work that no single person could do alone. This was really extraordinary team of people in Haiti and Boston and between the two to care for this young man and again, to try to live this principle that every person as a person, every person deserves the best possible medical care we can we can provide and somehow we can make it happen.

Brilliant Miller [01:02:07] Yeah, and that was that was something I was really touched by, just about how there’s red lights and green lights and you get some big green lights and then you run into a wall, there’s a roadblock. And and you talk about this, whether it’s with the passport or whether it’s with the the air transportation or the care once you’re there or the additional surgeries and like all this and I love the way that you kind of maybe some this up near the end of the book where you said I was beginning to realize that maybe this was just how it feels to do this work, proceed on principle, struggle to a solution, address obstacles as they arise. And again, how that I think is a pretty universal experience, the fear or the doubt that we all have. And we we take action, we get some affirmation and hopefully right then there’s going to be an impediment and then we just keep taking one step after another.

Aaron Berkowitz [01:03:00] Yeah, absolutely. I’m glad you highlighted that phrase. Yeah. That’s sort of one of the other many meanings of the title of one by one by one. Right. These individual patients, among the billions, these individual actions that we can each take and then one step at a time. Right. I remember when I first heard about Chanel, one of the heroes of this book, Dr. Michelle Morris, who’s one of my mentors and close friends in this work, just became the chief medical officer for the New York City Department of Public Health, extraordinary leader and advocate in medicine and in health equity. And I sort of said I you know, I think we should do this right from the medical, from the logical perspective, but how do we do it? So we said, well, here’s the first step. Right. And so much of this was, OK, we took one step and something happened. And we can react or we can act. Right, and act meaning sort of with intent. Right. We can react to this. And a lot of people are saying this is not going well. Let’s stop. This is not I said, OK, what’s the reaction? Let’s take a breath. Right. And. Let’s zoom out, right? This is where we started. This is where we are. This is where we’re trying to get what are some of the next small steps we can take. And as you said, you hit an unexpected roadblock. And as I said, also, this book really had to, I realized, had to begin with my same well-intentioned but very naive, intentioned approach so that the reader could feel with me, oh, my goodness, now this happened. What should they stop and I’m wrestling with? Should we should we stop people telling us to stop? Should we keep going? What does that mean for this patient? What does that mean for the hospital? What does that mean for his family in Haiti? So one step, one step by step is to take a step, look around, what are the directions we can go and have to proceed on principle, struggle to a solution and take a step and and see where to go from there.

Brilliant Miller [01:04:50] Awesome formula. You know, in life there are I think there really are no algorithms for living. Right. But there’s there’s some value. And in considering that what you’ve just proposed for sure. So thank you for that. Well, the last of the last things I want to ask you here about about in this part of the interview, one is I do want to ask you your take on an understanding of what Paul Farmer meant when he talked about, if I understand. Right, that there are no failures. There are only failures of imagination. What’s that mean, and did I have that right?

Aaron Berkowitz [01:05:24] Yeah, what a powerful quote. Right. And Paul Farmer is such a inspirational figure, someone I feel so fortunate to have read this book about him and sort of said, that’s it, I’m gonna do that and find myself. Years later, I’m being able to work for his organization and learn from him. No failures, only failures of imagination. And I think that’s sort of a guiding principle for this organization. But as you said, a very powerful statement for life where in some ways constrained by our own minds. Right. And so if we think small. Right, then we can achieve small. And if you say I think big, I’m thinking as big as I can within the constraints that I have. Well, that’s thinking. What about imagining? And to think that, for example, this area of the hospital where we met Shanelle in Mirebalais, a very destitute, very poor rural region of Haiti in the central plateau where Paul Farmer had had first sort of worked in Haiti many years ago, they were building a very small plan to build a new hospital there when this large earthquake happened in 2010. And there was this idea to build back better. A lot of philanthropy was flowing into Haiti and they said we should go big, right. We should build a big hospital here. And I wasn’t part of those discussions. But I can only imagine how complicated it would be to buy the land and to decide how you’re going to figure out how to how to do this. And the earthquake was in twenty ten. I don’t know how, but in twenty thirteen, Partners in Health opened the largest solar powered hospital in a poor country and and in a low income country. This place has modern operating rooms, a CAT scanner, endoscopy suites, treats, oncology patients. And I thought, how would you even imagine that you could do that if you were there? What was there before and was still there? Around there? There’s cows grazing and chickens. And how would you think? We should build a solar power, 200 bed modern tertiary academic center in the middle of one of the poorest countries in the world, even if you imagine it, then say, OK, let’s take one step toward doing that. Let’s see what it would look like. How would we do this? So this idea of doing things that he was told was impossible. He was told, don’t try to treat HIV or a drug resistant tuberculosis in these poor countries. It won’t work. You’ll just make things worse. You create resistance. And he said, I don’t believe you. I think it can be done and no one wants to support me. I’m just going to do it. And so he’s proved that things that were thought to be impossible by the medical community or with the global health community are impossible. He’s shown that because he was so compelled by the individuals suffering from these conditions that we should be able to do this. If we can do it in the United States, we can do it in Haiti and and we should be able to do it. So it’s sort of this dream big sort of idea. But when we’re stuck, maybe we’re just failing to imagine big enough what is possible in the world and for ourselves. I think it’s a very powerful, powerful quote.

Brilliant Miller [01:08:24] Yeah, yeah. That’s really beautiful. I love that distinction. I’d never, never encountered that. The distinction between thinking and imagining. That’s really cool. And I’m a huge fan of possibility, so I love it on that basis. And it also reminds me of that Mandela quote, It’s always impossible until it’s done

Aaron Berkowitz [01:08:44] exactly the same idea. Exactly.

Brilliant Miller [01:08:48] All right. What happened? So before we transition to the next part of the interview, what, if anything, and then we’ve talked for just over an hour already, why haven’t we talked about that the listener might find value in or just that you want to talk about?

Aaron Berkowitz [01:09:03] Oh, thank you. Well, you mean with respect to the book or yeah,

Brilliant Miller [01:09:08] the book or your work or your view of the world, anything related to that will go to the lightning round and then we’ll do the writing and creativity portion so that that part will get to.

Aaron Berkowitz [01:09:18] Perfect. Well, again, I appreciate you having me here and highlighting the book. As I said, I really wanted to tell some of the stories from the front lines of humanitarian work. I think most people know about Doctors Without Borders or Partners in Health, maybe some of your listeners or even supporters of those organizations. But I really wanted to tell these stories from the front lines. What are our patients lives like there? What’s really at stake? Trying to live a life as we’re all trying to live under the most challenging of circumstances, not just the poverty, the inequity, but now superimposed on that, the patients. I see those with neurologic disease and the associated disabilities. Associated disabilities. And privilege reckoning with as many of the things we’ve talked about, how do we try to help in ways that we can help that are supportive of growth in the system and and not give recapitulating colonial ideologies and savior type ideologies? So if you’re interested in the stories of what it looks like to try to do this work from the front lines and brilliants, as you alluded to, sort of my internal world doing that, wrestling with and reckoning with the ambiguities, the complexities, the ambivalence, the worry, the fear of what I call the triumphs, the tragedies and the confusing spaces in between, which is most of it, then I hope that that could be of interest to some of your listeners. I’m curious to hear some of your additional reflections on the book as well.

Brilliant Miller [01:10:45] Yeah, I love the way you framed that triumphs and tragedies that confusing places in between because, you know, that’s that’s life and some of us self-destruct or check out and so forth. And I think we all do that sometimes in our own ways. But I’m really just amazed as I live and the challenges that we all face and about how pain is inevitable. And I do think it’s a cliche in personal growth work to say, right, pain is inevitable, suffering is optional. But I think that’s true. And I love how you did put a face to the suffering or the unnecessary needless suffering and gave a really powerful example of how one person really can make a difference in a billion is made of ones. And I’m reminded of that saying, too, about right. No one can do everything, but everyone can do something. And and I’m just so fascinated by what motivates us and what we think motivates us isn’t, I think even necessarily what motivates us and how your book really honestly tells that. I mean, it’s it’s it’s really remarkable insight, not only to a different part of the world and a field that I don’t have deep exposure to medicine and so forth, but then also your own interior life. So I can just imagine that people, especially those who have aspirations to to do international work, those who want to work in in global health, could find a lot of value. And just how honestly, you know, you write about this and not have to, you know, have all of the same lessons through their own experience where we’re all going to have our own experience and our own lessons, hopefully. But that was where I thought, you know, this really is really a gift. It was really a privilege to to read. And I felt like I was right there with you through through some really challenging times and some triumphs, as you said.

Aaron Berkowitz [01:12:40] Well, thank you for those reflections. I’m so glad that came through, that was really the ultimate goal was to to bring the reader with me into my mind, seeing through my eyes what it’s like to to land in Haiti, everything from the flight to the landing to really being in the trenches on the front lines here, trying to do the best that we can and coming up against our own constraints and systemic constraints and trying to imagine beyond them.

Brilliant Miller [01:13:06] Yeah, awesome. OK, well, with your permission, let’s go ahead and transition to the next round of the interview. Next part. How are you doing, by the way?

Aaron Berkowitz [01:13:16] I’m doing great. I’m loving our conversation. Thanks for your fantastic questions.

Brilliant Miller [01:13:21] Me too me, too. All right. So, again, the enlightening lightning round is a variety of questions. My aim for the most part is to ask the question and stand aside. You’re welcome to answer. As long as you want. I might ask you to elaborate here and there, but for the most part, we’ll keep moving through this. OK, question number one, please complete the following. I’m going to start again, so please complete the following sentence with something other than a box of chocolates. Life is like a…

Aaron Berkowitz [01:13:54] That’s a hard one. An adventure, I don’t know, that wasn’t a very inventive answer, but that’s all I’ll try to be more spontaneous. That’s great. You blocked me with box of chocolates because the phrase is filled in. So coming like that’s not what I would say. But then I it’s hard to come up with something. Sure. For sure. Try to do better on the next one.

Brilliant Miller [01:14:22] Number two. Here I’m borrowing the technologist’s and advanced investor Peter Thiel’s famous question. What important truth do very few people agree with you on?

Aaron Berkowitz [01:14:34] Wow, lightning round, but these are these are hard questions, one important truth, do I believe that few people agree with me on I guess I’ll I’ll stick with the book there and say tossing out this cost effective, sustainable and replacing that with 220 million with every person is a person. People say, oh, no, that’s you have to think of the big picture, right. The billions. How do you make that the largest, quote, impact but that impact us through individual? So I guess I’ll I’ll stick with what I care for my for my book.

Brilliant Miller [01:15:09] They’re awesome. I just I’m going to divert from the Enlightening Lightning Round again for a moment to say I love what you point out in the book when people challenge this, saying it’s not sustainable and you point out neither’s the alternative, right?

Aaron Berkowitz [01:15:24] Exactly. Exactly.

Brilliant Miller [01:15:26] So, OK, question number three, if you were required every day for the rest of your life to wear a T-shirt with a phrase on it or saying or a quote or a quip, what would the shirt say?

Aaron Berkowitz [01:15:37] I would probably just put a peace sign on there.

Brilliant Miller [01:15:40] OK, awesome. Question number four, what book other than your own, have you gifted or recommended most often?

Aaron Berkowitz [01:15:48] Just Mercy by Bryan Stevenson. I can say more or you may know what I do.

Brilliant Miller [01:15:54] One of my guests, his story is featured in that book in Ian Manuel. He’s been on the show before. And I know that’s a very powerful book. Why is that the book that you’ve recommended most often?

Aaron Berkowitz [01:16:08] So I have a number of reasons, and it was a book that was sort of a guiding light for me in writing this book. I think the stories there about the justice system in the United States and the history that’s led to mass incarceration, disproportionately affecting the lives of minorities, individuals, particularly those who have black or brown skin compared to those with white skin. Again, it was something I maybe knew in principle, but I feel like that book I really wanted to model my book after that in the sense that that he really tells the stories. One is the sort of main story he carries through the book that became the movie. But all of these other stories in the intervening chapters, in the stories are all meant to illustrate a larger point about the way society functions, the way the criminal justice system functions, but is through this very human lens. So I think it’s what is to be learned from that book about how broken and how tragic the system is as important. The way of his teaching that through these incredible human stories, so powerful of people sitting on death row, innocent, wrongly accused, and again, what you might imagine in your mind and again, sort of trying to think similarly in Haiti, what people imagine when they think the poor or the people without education here at the incarcerated just really bringing that human lens. You know, these people that he learned so much from that inspired him so much. And then the third level of sort of craft, you know, and I wanted to write my book. I really wanted to tell these stories. And I really, as I said, did not want this to be a hero’s tale. A person from a rich country who goes to poor countries saves lives. That’s not what this book is about. And yet there’s the risk of it coming off that way, if not done properly. And I wanted to understand in his book, I mean, I presume he will win the Nobel Prize. Right. And he’s doing this extraordinary work in that book, getting people off death row, changing legislation related to the death penalty. And yet you never get the sense that he’s out in front. And yet he’s very present, sort of telling you what he’s experiencing, what he’s feeling, what he’s learning, what he’s reacting. So I went back to that book a number of times for Kraft. How did he manage to tell the stories, the in the stories, but never sort of be sort of out and out in front, and yet you’re there with him on the front lines meeting these people and you’re right there with him as you kind step up my book. So I recommend it to everyone to read and then people who tell me I’m thinking of writing a book and usually those are other doctors and say, but I don’t want to be kind of your book is really a study in humility. And I say this book, read this book and then read it again for for kind of the craft. What is the kind of humble servant leader tell their story and other stories, but not one that looks like they are accepting their Nobel Prize and every page powerful.

Brilliant Miller [01:19:03] OK, thank you. Question number five, you travel a lot. What’s one travel hack? Meaning something you do or something you take with you and you travel to make that travel less painful or more enjoyable?

Aaron Berkowitz [01:19:17] Goodness. It’s been so long since I’ve gotten on an airplane with that with covid-19. But someone told me when I was doing all this work in Haiti and said, do you have the global entry? And at that time I did not. And I said, oh, no, no, you have to go for the appointment. And there’s a wait list. And they said it’ll change your life. And for someone who for many years and probably will be for many years, again, traveled a lot and changing flights, flights canceled, going through customs, that global entry, when you get into LaGuardia, into JFK Airport in New York, coming from anywhere internationally, you see that line snaking around the global entry line. You just walk right through, put your hand up like that. I will definitely thank the friends who told me it’s worth the money. It’s worth the time. It’s worth the effort to keep refreshing that page until you get your appointment. Global entry is definitely worth it. Yeah.

Brilliant Miller [01:20:08] Awesome. Thank you. Question number six, what is something you’ve started or stopped doing in order to live or age well?

Aaron Berkowitz [01:20:18] So two things one is going to stop doing as I grew up eating sort of anything, everything, and the more I studied yoga and meditation and sort of move towards vegetarianism, veganism, again, I think the science is challenging because nutrition is so hard to study, because it’s so complicated. But at least to me personally, I feel so much healthier. I’m on a plant based vegan diet. I’m not sure if it’s healthier than other diets, but for me it has worked well and then started when I used to do for my exercise essentially only yoga and have recently with our moved to Los Angeles from Boston, where there’s a much longer outdoor season. I’m just eager to spend a lot more time outside in the beautiful weather and nature here. So I’ve started doing a lot more outdoor exercise, running, hiking, backpacking, those sorts of things. So those are those are two things that I’m hopeful will I enjoy and I’m hopeful and they make me feel good and hopefully be good for my health as well. Awesome.

Brilliant Miller [01:21:24] OK, question number seven. What’s one thing you wish every American knew?

Aaron Berkowitz [01:21:31] Wow. I think coming back to what we discussed before, what’s happening both within our country, beyond a small place where one might live and what’s happening in the world, keep it keep this one short.

Brilliant Miller [01:21:46] OK, question number eight, what’s the most important or useful thing you’ve ever learned about making relationships work?

Aaron Berkowitz [01:21:57] Humility, probably to keep it short and takes a little bit earlier about neurology as a specialty, and I sort of said I am a neurologist and asked, who am I? And I I sort of feel like in medicine and neurology in particular, it has a lot of life lessons within it, many ways. But in neurology, the first question we ask when we see a patient is where is the lesion? We say where is the problem is it could be anywhere from the brain, through the spine, through the nerves. And I realized at a certain point that was very powerful to start asking where the problem is before I ask what the problem is. And so I think in relationships, people often there’s a blame on it’s you or it’s me or it’s this. And to just instead of asking what the problem is, ask where the problem is. I haven’t explored this one, but something I want to write about and say is let’s take it out of what the problem is. Is it a problem of communication? Is it a problem of circumstance? So for me, swapping out that, what’s the problem? Who’s the problem for where is the problem coming from? Neurology. I’m still sort of teasing apart what that means, but somehow I found that helps to sort of pause and again, act rather than react.

Brilliant Miller [01:23:05] And I’m curious to know, what does humility mean to you?

Aaron Berkowitz [01:23:11] I think it comes back to your first question, right? Just I don’t know. Right. And close colleague and friend of mine who’s position who maybe want to have he has a book coming out soon on his journey in medicine. Dr. Simonet might be interested to have on your show once he his book comes out in the next few months. We were talking about how early on in medicine you see these amazing professors who seem to know everything. Anyone ask them a question, they know the answer. Patient comes in, they know the diagnosis, and you really admire that. And you want to be that when you grow up. And we’re talking about how. Later, as you evolve, you come to admire that people who say, I don’t know the most because it shows their humility and the more, you know, has he tried to say, the more you know, the more you realize you don’t know. And there’s no nowhere that’s or it’s so true in medicine, as in many areas where just when you think you’ve come to understand something, the next patient will show you that. As we say, the patient didn’t read the textbook. Right. It didn’t fall into the right pattern. And you learn something and realize I made too quick of a judgment there. I, I missed something. I was. Now, people say experts. Right. They think quickly because they recognize patterns. But you have to also be able to pull back and say, I don’t want to I don’t want to commit to that pattern recognition yet because I might miss something. Thinking fast and slow so that I don’t know is to me that humility to both acknowledge and realize that one doesn’t know and then express with with confidence. Right. Not knowing where it’s actually I don’t know I don’t know what’s going on here or I don’t know. We should ask this this person. So that’s

Brilliant Miller [01:24:50] all right. Thank you. OK, question number nine. Aside from the compound interest, what’s the most important or useful thing you’ve ever learned about money?

Aaron Berkowitz [01:25:05] So I was taught from a very early age to save it. And so I sort of give you two sides of the coin. I’ll never forget my grandmother. My father’s mother wrote me a check for my birthday, and I must have been very young, probably eight dollars for my eighth birthday. And she wrote in the memo on the check directly to the bank, I said, what? I want to buy a toy or a Star Wars toy, whatever. And if you put it in the bank next year, you’ll be able to buy more. I guess that’s compound interest. That’s cheating. And I’ll say on the flip side, unfortunately, my father passed away relatively young to, you know, in the last two years. I’m in his mid 60s and I remember him saying he was reflecting, you know, you can’t take it with you. Right. So suspend your money and enjoy it. And so two sides of that coin save your money. And if you’ve been saving it, you never know what, unfortunately, life might put in your put in your path. And so enjoy it. You can’t you can’t take it with you. So I’m going to do opposite answers to that question. Save it. And then if you have saved it, spend it.

Brilliant Miller [01:26:12] OK, thank you for that. Sorry to hear about your dad. I lost my dad in his mid 60s.

Aaron Berkowitz [01:26:17] I’m sorry to hear that.

Brilliant Miller [01:26:21] OK, so the final question in the Enlightening Lightning Round is that if people want to learn more from you or they want to connect with you, what would you have them do?

Aaron Berkowitz [01:26:31] They can contact me, I’m I’m on Twitter. That’s the way people usually find me and I’m always happy to correspond with people. And I think one saw this silver lining of the pandemic, but there’s not too much good to say about it. As people have. People have felt more comfortable reaching out to people maybe they don’t know. And I’ve been so fortunate things I’ve been getting involved that I mentioned my friend and colleague, Dr. Rasim Manesh, and has a very powerful program called the Clinical Problem Solvers, that their goal is to democratize medical education. And they have a podcast and they have sort of a virtual case discussion. And I was fortunate to be sort of the neurologist discussant there. And we have people from all over the world. And so it’s you know, usually I teach and mentor students sort of in my the school I work in or locally. And this is an amazing opportunity where now I’m working with students from Guatemala and Peru and India. And so just and I think, again, a few silver linings to the pandemic. But being there and being trying to have an Internet sort of place where people can find me has led me to meet extraordinary people and new friends who I’ve never seen in person, but hopefully will someday.

Brilliant Miller [01:27:41] And a few things that I want to let you know before we go to the writing portion of our interview is that, as you mentioned, I think before we began recording as a as an expression of gratitude to you for making time to share so generously of your knowledge, your experience with me and everyone listening. I’ve made one hundred dollar donation to Partners in Health. I made a hundred dollar donation to Doctors Without Borders. And then I also went to kiva.org and I made a microloan to a woman. Entrepreneur in Haiti named Marie Rose is going to a place. I’m saying this right, bon bon repoll. Use this money to to buy pills and multivitamins. I guess she runs a pharmacy. So just a few few small gestures to say thank you.

Aaron Berkowitz [01:28:29] Well thank you. That’s very meaningful and impactful that you’re supporting these organizations and it means so much that you did that so thoughtfully. And I’m sure the organizations and the people that work for them will be very grateful for your contributions. And those are extraordinary organizations you’ve you’ve chosen. And I know they’ll every penny of that will be put to good work. So. So thank you.

Brilliant Miller [01:28:52] Awesome. My pleasure. OK, the last part here about writing and creativity. So just a few questions. I think I’ll start I think I’ll start with this one. When did you first know yourself to be a writer?

Aaron Berkowitz [01:29:15] Wow, you know, you asked me earlier, was I going to go into sort of science or research, science or medicine, and I remember in high school just really not liking writing in college, trying to pick the science classes, that there was a lab and no paper and medical school. You don’t really have to write many papers. This is a place where I can you know, I won’t have to write anything. I really was averse to writing. When I left medicine to do music, I was doing graduate work and the anthropology of music and ethnomusicology and from the first weeks were supposed to be writing papers, right? This is the humanities. And I thought, oh, my goodness, I wanted to be doing music, not writing papers. That people said, you’re writing is terrible. Your typical doctor. You don’t know how to write anything. You’re really going to work on your writing. I sort of resisted it. And there’s two things that sort of happened during that period that allowed me to really start taking writing seriously and eventually find joy in one, as I had felt that it was very challenging to medicine, unnecessarily complicated to learn things that are complicated but not as complicated as they seemed if they would be only taught more simply. And a lot of medical students went to these books in a series called Made Ridiculously Simple. It was cartoons and very clear explanations. I we learned this way makes so much more sense. And when I was sort of getting my notes together to sort of remember medicine and go back to medicine, I found ways of teaching myself and I thought it could be helpful to others. And I wanted to sort of write a book in that series. And I wrote to the editor who was a retired physician, and he said, I relate to you because he said he thought 30 years earlier that it was too complicated. He wrote his first book, All the Publishers Rejected. So this is silly. Medicine is serious and that he sells millions of copies of this book. Clinical neuroanatomy made ridiculously simple. And he said, I can tell from what you put together that you’re a good teacher and I want to help you. But your writing is terrible and you don’t know the difference between which and that. And he simply Strunk and White and Red pen all over everything. And I didn’t really get it until I was probably a little hard headed. But as we he very patiently went through these drafts with me, I saw the comment that I had gotten in my writing classes where they’d say, I see what you mean, but you didn’t really say it. I thought, whatever, if you saw what I meant. And he kept saying, you can see what you mean, but you didn’t say it. What if you said it this way? And I thought, oh, that’s so much better. And then it became sort of a fun puzzle to kind of figure out how can I make this the most clear, most concise, repetitive enough to get the teaching point home, but not redundant. And that was happening at the same time as as a graduate student, I was a teaching assistant having to read a lot of student writing and I found myself writing. I see what you meant. But you didn’t say, oh, this is actually kind of cool. This is from the neurologist. Right? It’s a psychological perspective. We have an idea. The translation of that idea into language is already imperfect and then that language into writing is imperfect. You may know this paper, the conduit metaphor probably from the 70s, or the psychologist writes about this idea that you have a thought and we’re under the illusion that we take that thought and we sort of print it out in language and we put it in an envelope and we send it to someone else and they open the envelope and they read it and they’re getting the exact same original thought. And every stage of that is fluorite. The thought to language is imperfect, the transmission is imperfect, and the understanding is based on the person’s own buys. What they thought you were going to say, what their experiences. So I thought it was sort of a powerful study. And that got me really into how can I make this writing really complex? But I started actually a very technical writing. And then gradually I found myself having to write this book. But after really some very tough love from some editors helping me see that, I wasn’t saying when I thought I was saying

Brilliant Miller [01:33:02] part of what I love about what you’re sharing is, you know, that you’re getting this feedback like you’re writing is terrible. But you persisted and you wrote a book that is actually, I think, pretty good. My favorite some of my favorite guests on this show have been the ones who said I never intended to write a book. Right. But they just had something to share that was they felt was so important or they knew would help other people and and they did. So obviously, writing a book is despite having word processors and access to the Internet and, you know, more books published now than ever before. So great content and all this kind of stuff. Still an extraordinarily challenging endeavor. What was if you were to sketch this out, kind of beginning to end, how did you get it done? What was the process you followed?

Aaron Berkowitz [01:33:50] Yeah, so I was very fortunate to have people giving me advice. And I will pass along that advice because I find it very helpful. The first thing a couple of first things. One was to really ask myself what the book is about, because I answered I was having lunch with a friend and she sort of asked me, what’s your next big project? I said I was thinking of writing a book about this. And there’s this case and this patient in Haiti. And this happened and this and she said that would be an amazing book. You should write that book. And but but what is it really about? And I don’t think I really knew at that stage the way I could answer you today. So I didn’t know what it was about. But I was so inspired by that question that on the way home, I just started writing down. And one thing I wrote was the review I would hope this book would get if this book was reviewed in The New York Times or whatever, what what what words would be in there. And I remember writing. Humility, humanity and humor and sort of these sort of things became kind of like a guiding principle that I was to have there and say, oh, are you writing with humility, humanity, humor? So that gets it to the next thing. This this person told me, get yourself to notebook’s. I’m old fashioned. I like to write long that I think there is value to writing longhand. Different things come out. And when we type two journalists to write in, one is a journal where you just reflect on the writing process. Things like I said, the review you would want to get where you would write just what happens in your writing. As I told you before, trying to struggle with the order, I was just sort of free hand writing free association came to this idea. My naiveté should be the structure and principle of this book. So that’s one journal to have and the other journal she said, get this journal. And as you you have to read a lot of books because you’re going to have to figure out, you know, these famous doctor writers, Oliver Sacks and Neurology or Tulga, one day medicine. What voice are you looking for? What’s your voice going to be? And you’ll read things and you say, definitely doesn’t want to be like that. And then you have to ask yourself why, where you read something, say, that’s it for me. That was just Mercy was how is he doing? How is he managing to do all the things that I have mentioned earlier said in that notebook you just as you read, you maybe write out a whole paragraph from another book. Do you think that was a beautiful setting of a scene? What what’s there? Oh, it has a sight, a sound and a smell. And then I read a couple of books on the craft of writing. Some were better than others. But you start to see the principles in this work. You say that scene was so powerful, I felt like I was there. Why? Actually, there was very little detail. It was just dialog. And what made that dialog so good? Why is it not? He said. And then I said and then she said that I said. And so being really attuned to reading and picking up on things that you say, I want to do something like that. And it’s not plagiarism or copying. It’s like people say that classical composers write. They would hear a piece from a composer in Italy and say, that’s really cool, I’m going to do that in my music, and this happens in art and I’m writing. And so those two notebooks were really helpful. And there were times in the first notebook I was just writing. I think I have a good story here, but the writing is terrible. It’s just this happened and then this happened and this happened. How do I get from the story and its meaning and its power to from the events sort of to conveying that the story and the meaning and its power. And I would say, I don’t know. Let me just Mersea really did that in that particular scene was so what was it. Oh it was all dialog. What if I cut out this whole thing and it’s just me and dialog with this person? Maybe that would really bring it to life. So it’s a lot of trial and error. It’s a lot of drafting and revision. And there is a lot of what I call no backspace writing where you have to just get there. You can reflect in your journal and you can read and say, I want to be like this. I don’t want to. There’s other times I have to say I’m putting everything away, no alerts on my phone, and I’m just going to write. And it might be good. It might be bad. You might write all morning and you come up with that phrase you read earlier. You proceed on principle, struggle to a solution, address obstacles as they arise. Well, that’s that’s a good one. That’s a keeper. The rest might be junk or you go back to it later and say, I need to tell this story and I just needed to get it out. And for me, as someone who’s working, as many of your listeners probably are most committed to this project. But there were times where I could work out at all times. Right. So I kind of have Monday morning, but there’s all this Monday afternoon. I really focus on writing. I look and say what’s a discrete thing? And I would make these maps for myself. You need to tell optional story. There are other patients stories that you need to at some point a little bit on the history of Haiti just for context. So you have four hours this morning. What if you try to hash out, like the scene? You know, that scene is going to be in the book. Just give it a shot and then write in my notebook. This one I tried and then I only have two hours. I don’t have time to really write. But let me pull this one out. It was something I worked on a few weeks ago and chisel out a little bit and try to make it better. So those are sort of how I how I worked or at least to start I was happy to elaborate or answer other aspects of that.

Brilliant Miller [01:38:53] Something something there that I would definitely want to know more about is the time, because there’s never a good time to write a book. In fact, there’s lots of reasons why. There’s lots of valid reasons why it’s always a bad time. But how did you think about time? How did you structure your time both in a like an overall schedule for the project, but then in a in a habit and routine if you had one?

Aaron Berkowitz [01:39:18] Great question. You know, a lot of the writing I did was in Haiti, actually, because there was a lot of downtime, I would take a connecting flight, a flight would be canceled. I’d be in the airport. And, you know, there were sort of fewer distractions than when I’m at home and at work and work, phone, personal and all these things sort of going on. And I feel like I can’t really put everything aside. But these two weeks, there’s someone covering my patients in Boston. There is you know, the bills are paid because I’m going to be away and whatever these things may be. And here I’m here to do my work in Haiti. But right now, I’m just on a flight for four hours and there’s not really any good movies playing that. Sometimes I just lay back and I’m going to watch a movie. I had to read a book. And then in Haiti, we would work during the day into the evening, but then we would go back to the place where I stayed. When I was there, there was no Internet off and there was no electricity at night. And so there were some trips where I said, I’m just going to relax, I’m not going to work. I’m just going to read a book or just just sit around and others where I thought, here, it’s seven o’clock. I’m going to be awake for another three or four hours at home. I would have ended up, you know, doing something on the Internet, catching up on email. But here I am. There’s I’ve eaten nothing else to do. And I had this really sort of pure writing space. And I was I’m going to Haiti two weeks or one week or two weeks every every couple of months. So I feel like I got a lot of writing done in transit and sort of in there and just different type of downtime that we have here because there’s less things to distract you. And then, yeah, there were some weeks, obviously, working full time in the hospital where there was no possibility of doing any writing and some weeks. Right. So I have clinics, you know, on these days and I’m teaching on this day. So I’m going to write this week. It’s going to be Thursday. Can I protect that day? And that I really fully protected most of the time? Probably not. But there were definitely some days where I said it’s a writing day and I think I can check my email in the morning or not and get right into writing or I’m going to do some email at lunch and email the evening, keep things moving and and really try to protect this time to to write. So, yeah, I’ve admired Asturiana, heard people say, oh, they went in their cabin for a month and just did this whole book. I wonder what it would be like to work like that and if I would get a lot done or I’d sort of spend a lot of time thinking. I think there was a certain stage where I sort of had the momentum and things were kind of all in rough form and just needed to be chiseled where I could be in Haiti and then for a whole evening feel like, wow, a chapters is getting there. I was really in the zone, but it’s it’s rare to be able to set yourself up to get into that zone. I’m not sure I have a good answer, but that’s how I sort of juggle it. And again, I think I was really lucky to to be doing this work in Haiti. And I’m there sort of by myself and obviously working hard during the day. But in the evening, very few distractions with no internet, no electricity. And that’s the perfect thing we need for focusing on writing is no distractions.

Brilliant Miller [01:42:12] Yeah, for sure. What was the best money you’ve ever spent as a writer? What’s the best investment you ever made?

Aaron Berkowitz [01:42:21] Investment as a writer, I mean, I would say those two blank notebooks, I mean, I’m sure that was four dollars in tax, but I feel like the a lot of the real work happened in those happened in those notebooks. I can’t think of a financial investment. And I bought a lot of books and bought a lot of books and read them. And I think I was advised that you’ll learn a lot about how you’re going to do this by reading and reacting to other writings. So I think pretty simple stuff to blank notebooks, some pens. And of course, I used my laptop as I use it for other things to actually do that. The typing. But but. Yeah, and reading and I guess depending on whether you consider this investment, as you know, to even find your way to a publisher as someone who’s not written a book like this before, it doesn’t have a name. One needs an agent. And obviously that is an investment that has a percent of your advance in royalties and all of those things. So that was a fantastic investment for many reasons when there’s no way to publish a book from my position about that, too, because as a former editor, this agent, I’ll never forget our for our breakfast. We had said I read your manuscript. There’s a few problems you need to solve. And they were the exact problems that I knew were not fully solved. And she didn’t tell me how to solve them. But she by the question she asked by the end of that breakfast, I was sort of teed up and then got home and she knew what I needed to do to solve some of those problems. So I guess I didn’t think of that as investments. I didn’t pay for it up front. But obviously, some of the the smaller things from the book go to that agency. And and she is her name, Neriman Williams. And in Boston, extraordinary, extraordinary advice and insights into how to take this from what I wanted. It was hoping it could be and trying to get through to really getting it to the where an editor would be excited about it.

Brilliant Miller [01:44:17] I know today there’s more options to publish than ever before. And self publishing is is a possibility, of course, that it wasn’t available like it is today, even a few years ago. But you chose to follow this what would now be called this traditional publishing path. Just talked about an agent. I’m sure there was a book proposal in there somewhere. But tell me, if you will, the story behind that connection. Right. Because I know there’s a common question for especially aspiring writers. When when is it time to find an agent? Do I really need a book proposal? You know, should I self publish or or try to find one of the New York publishers, this kind of thing? You talk about your thoughts and your experience related to that and anything else that might be relevant?

Aaron Berkowitz [01:45:00] Yeah, so I didn’t really think about self publishing this book. I have written in the past a neurology textbook that the first publisher I sent it to rejected it. And I thought about self publishing and looked into it and thought it was sort of a very compelling and interesting way of approaching things, sort of, again, democratized, you know, if you can be on Amazon, you can compete with others. But your colleagues said, look, if you find a good textbook publisher, it’s just going to be a higher quality product. They have platforms that can you know, your goal in writing a book is as many people as possible will read it. That’s why you wrote it. Right. And self publishing you might. But the publishers really have ways of doing that. So I have thought about that before this book. I really hadn’t really thought of self publishing it. And again, it’s finding an agent. I sort of looked around a little bit on the Internet and realized it’s going to be very hard. I don’t have really a platform on which to stand where people would recognize my name or want to publish something by me. And I’ll just tell you that the funny story, because it shows, I think, how just how challenging this is and how lucky I was to Ophelia Dahl is the executive director of Partners in Health, one of the founders approach to learning more about our beautiful interview with her several years ago in The New Yorker. So I wrote to her and said, you know, I’ve written this book and I want to see if I have partners in health blessing, of course, to to write about Partners in health. And, you know, I presumed her from her position, probably knew some some important people in the literary world as as well and might be able to connect to me. And she said, well, we do know a very good agent, this agent, Jill Nerem, what I mentioned and she said I could introduce you and I said, that would be wonderful. I’m grateful to introduce me. And she wanted to read a little first, as you can understand, the city of Sloots. I think this will be great. Let’s introduce you. I didn’t really get a response and I tried a few times. I didn’t really get a response and, you know, sort of gently, gently pestered. And I was in Haiti actually and waiting for this person to respond. And would they like my book or would they be willing to help me? And she wrote, I’m loving your book and I never say that. And I’m very surprised. Let’s talk. I thought, what does that mean? And she said, I was really dragging my feet reading your book because doctors think they can do anything right. They can run for office, they can write a book. And most of the time, I mean, it’s terrible. And she said, we get thirty I get thirty proposals that I can’t read all of them. And you’re very lucky that you, Ophelia, because she’s someone we all admire and she’s a good friend. And I knew as a favor to her, I had to look at this, but I really expected very little. And it’s such an amazing story. And how did you pull yourself up by your bootstraps to learn how to write? Because most people can’t say it was. I say that both because it was serendipitous and because it’s so challenging to think that without that connection to Ophelia that she would have just this would have been deleted without being looked at. And so. Talking to other writers before I found her position, writers are sort of coming from this as I’m learning, sort of a bias that we think we can do more than we actually can. But very skilled writers who have published books, some of them said, well, they were very active on social media and had written for publications like The New Yorker, The New York Times. And so agents actually found them and said, we like what you’re doing and we like your blog. Would you write a book? I had no Twitter account. Zero. All right. I was coming from a challenging place, and it took someone who believed in the book and saw the idea that either you could compress the call into a diamond or a diamond in the rough, whatever metaphor you want to use to try to get it to the right place. So I found it a very valuable learning experience also because she had such experience. And I’ll never forget in this conversation, I had had an undergraduate who was helping me with my work in Haiti, sort of a research assistant. And I said, I’m working on this book if you’d like to read it, and because you would sort of be the target audience, right? A student interested in global health and neurology. And she read it and she liked it. And I mentioned that because I was talking to this agent and she was telling about these problems that I need to solve. And I said, well, you know, I had sort of someone from the target audience, a future medical student, read it and she thought it was pretty good. And so I think hopefully other medical students, she said, that’s great if a couple hundred med students buy your book. But I want everyone in this cafe to want to read your book, and we have to figure out how it’s going to really appeal to people beyond the small circle. So I was very fortunate to learn a ton from her. My colleague, who I mentioned earlier, is self publishing a book. And I was sort of trying to say, oh, I think I learned so much from an agent who is also a very good editor and from the editor who helped me really see what was needed to get this from where I where it was to where we aspired for it to be. And so I was sort of reflecting on that recently with that process. Another sort of feel like, you know, there’s too much kind of too many steps, too many levels, too much complexity. And I can go straight to market with what I what I have. But for me, I felt like I learned a ton in that process and that made the book so much better. But I don’t know any tricks except knowing people who know Cajun’s because I was told about this personal connection that would have been deleted.

Brilliant Miller [01:50:14] It is amazing the difference. And of course, your book, you talk about that as well, right? People getting passports because they know somebody and you know how much of life is is who, you know. But but not all of it. For sure. For sure. OK, so my last few questions for you, one is I want to be sure to ask you about you, about the compass as you talk about keeping you had the compass on your desk during the act of writing. So will you tell us about the compass and its significance to you?

Aaron Berkowitz [01:50:46] Thank you. So the compass, as you can see up there on the top of my bookshelf, was a gift from my parents when I graduated from high school. And as a 17, 18 year old, I was I was probably like most 17 year olds, eager to get out of the house and go to college. And my parents said, well, we have a gift for you. And I thought a car, something I can use. And I open this thing. I thought, what is this? It’s a nautical compass. And my dad had written a beautiful letter with it saying, you’re going out into life. And this is really more of a symbolic gift and sort of to help, you know, just remember that sometimes you need something to help you find your way. And that arrow can always point back home in retrospect, extremely moving. As a 17 year old, I sort of thought, what am I going to do with this? I need a computer. I need a car. And the other things that I’m going to be a college student. But, you know, as I mentioned earlier in our discussion, right, sometimes the wisdom of our elders, we have to learn from our from our own experience. And I have you don’t see it there. But the letter from my father under obviously takes on more meaning with his passing seeing despite me being sort of a nasty, ungrateful teenager, the love you is trying to give to me and the path he was trying to show me and the philosophy he was trying to teach. And so it was sort of more symbolic. But in the past year, as I mentioned earlier, I’ve gotten very connected to the outdoors, hiking and backpacking and learning how to actually use a compass that would be a little heavy for out on the trail. But the power of these simple tools to help us find where we are, where we were, where we’re going, I think it’s a rich symbol. And then also just a connection to my to my father, as I mentioned, unfortunately, passed away in the last few years. And a reminder of his sort of philosophy to have some symbol of your family and where you’re going and where you come from and where you can head back to. So thanks for for asking about that.

Brilliant Miller [01:52:42] Thank you for sharing. And speaking of guidance, what advice or encouragement would you leave people listening with, especially those who are either in the middle of their own book project or it’s like a dream or an intention they’ve been harboring for a long time? What do you what do you say to them?

Aaron Berkowitz [01:53:02] Now, the same advice, my sort of this book, sort of spiritual godmother, I call her Rosanne Gold, who’s a chef in New York. She’s written many cookbooks again, fortunate that she was a friend of my mother’s growing up, became a friend of our family. A friend of mine. Was the lunch I was mentioning with her, said, you really should write this. And here are some ideas on how you might get started. And the advice was really just you should do this. And that’s what I would tell anyone who sort of had this idea, because this just a very vague, ill formed idea and just her gently nudging you. You really should do this. Now, that’s a bit abstract. And I’ll say on a practical level, so many times I was writing in this writing journal I mentioned this isn’t coming out well. The story, I think is worth telling, but I’m not telling it. Well, I don’t think I don’t think I’m able to do this. I wrote a medical textbook. That’s one thing I don’t think I can write a book for a large audience that that brings them into this world. And then I would pause and I would write that’s keep going. This is just what the work feels like at this point. And that’s something I learned from a piano teacher of mine. I have a lot of risk problems and injuries and other things from repetitive practicing in these things. And I met a very skilled teacher, a very particular technique, and he sort of said, we need to start all over with your finger touches the key and sort of like erase the hard drive years and years of playing the piano the wrong way and sort of put in place a new way of doing things. And it was very, very difficult. There was a point where I couldn’t really do the new technique he was teaching me and I couldn’t really play anymore the old way because I had done the work to kind of get rid of it. And I was pretty young and it was just very frustrating. I really want to be able to play it. I had left medicine to try to become a musician as I couldn’t play two notes together the old way or the new way. And I was really upset and I just thought, is this even going to work? I just remember this was a piano teacher named Bob D’Urso. He’s in Philadelphia, a wonderful person who really put up with me being a difficult student, looked at me and he said, Aaron, this is just what the work looks like at this stage of the work. And it was just said with such confidence and generosity that I’ve seen this before. And at this stage, it’s very hard. It’s very upsetting. And you don’t have the pass and you don’t have the future yet. But you’re in a present that I’ve seen and there are steps of the future. And it just stopped me in my tracks. I haven’t thought of anything about meditation or sort of philosophy that I thought and I always come back. That’s just what the work looks like at this stage. And the writing process is can be so difficult just to get started on their points where you want to give up. And I just would write to myself his his is a phrase from that moment. This is just what the work looks like at this stage that is very raw, doesn’t feel good. It’s not fun to be writing their stages that are a lot of fun. You have flow, you feel like you’re in the zone. You just come up with a turn of phrase or you feel like I’m really painted this portrait of someone. It really looks like them on the page and others where you say, this is terrible. I know it’s going to read this. And just this is what the world looks like at this stage. There are stages ahead of that that you haven’t gotten to yet. So that was powerful advice from my is that the important life life lesson, especially to something as complicated and challenging as writing a book.

Brilliant Miller [01:56:14] What a gift to have a teacher or a mentor who has that that perspective. It reminds me when I studied Japanese and I learned that the the literal translation of Sensei is one with experience, and he was able to give you that reassurance if this is just what the work looks like at this stage.

Aaron Berkowitz [01:56:32] Yeah, exactly. Yeah, that’s great.

Brilliant Miller [01:56:35] OK, well, the final thing then is just, you know, we’ve covered so much and. About life, about writing, about the world, about the journey that we’re on, this kind of thing, if there was a final thought or a suggestion or request or a question or anything, that you would leave people listening with what what is.

Aaron Berkowitz [01:57:00] Well, I think I’ve learned a lot of lessons in doing this work and in writing this book, and I I think the main one we began with, I don’t know. And that humility, whether it’s cultural humility in another place or just realizing what we don’t know and seeking to learn it. Right. And I think that brings us into some of the solidarity aspects that you brought up earlier. Right. Because when we come from a place of thinking, we know something or I know that or I know what that is or I know what that’s like. The reality is we probably don’t write and probably barely know it for ourselves, let alone someone else. But we come from that place of humility. And I don’t know that so-called beginner’s mind. Right? Oh, I know what that’s like. I’ve been through that when you haven’t been through it as that person. Right. And you don’t know what they’re like experiencing that moment. This is a lesson we’re privileged to learn in medicine over and over again because we’re seeing a patient in a short window maybe of their life. But they bring to that so much that is below the surface. Right. And everything has so much below the surface. As I said, Ophelia does this phrase for me, which I carry with me, which I hope people read your book and learn a little bit more about complexity, understand a little bit more about complexity. Everything is so complicated and that need not make us sort of give up on things, but just acknowledging that complexity and then, you know, finding that the simple piece that we can work on in ourselves or in the world. So I’m sure that’s a concise sort of ending statement for you. But those are some of the lessons I learned in this work and in trying to bring it into a book form.

Brilliant Miller [01:58:40] Awesome. OK, fantastic. Thank you. It’s perfect. All right. Again, Dr. Aaron Berkowitz, his book, one by one, making a small difference amid a billion problems. I hope you pick it up and I hope you enjoy it as much as I did. Thanks again for being on the show.

Aaron Berkowitz [01:58:58] Really. Thanks so much for having me. For your thoughtful questions and our our wide ranging discussion and for your generosity and donating to Partners in Health and Doctors Without Borders and to microlensing in Haiti. Very grateful for that and grateful for the work that you do.

Brilliant Miller [01:59:13] It’s my pleasure. Hey, thanks so much for listening to this episode of the School for Good Living podcast. Before you take off, just want to extend an invitation to you. Despite living in an age where we have more comforts and conveniences than ever before, life still isn’t working for many people, whether it’s here in the developed world where we deal with depression, anxiety and loneliness, addiction, divorce, unfulfilling jobs or relationships that don’t work, or in the developing world where so many people still don’t have access to basic things like clean water or sanitation or health care or education, or they live in conflict zones. There are a lot of people on this planet that life isn’t working very well for. If you’re one of those people or even if your life is working, but you have the sense that it could work better. Consider signing up for the School for Good Livings Transformational Coaching Program. It’s something I’ve designed to help you navigate the transitions that we all go through, whether you’ve just graduated or you’ve gone through a divorce or you’ve gotten married, headed into retirement, starting a business, been married for a long time, whatever. No matter where you are in life, this nine month program will give you the opportunity to go deep in every area of your life to explore life’s big questions, to create answers for yourself in a community of other growth minded individuals. And it can help you get clarity and be accountable. To realize more of your unrealized potential can also help you find and maintain motivation. In short, is designed to help you live with greater health, happiness and meaning so that you can be, do, have and give more visit good living dotcom to learn more or to sign up today.