Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman  

In October, 2005 Mike LeFever hovered in a helicopter over the Himalayas of North Pakistan. It was less than 48 hours after a devastating 7.6 magnitude earthquake. He told us the mountains looked like they had been sliced open with a hot butter knife. Whole hillside. Villages were wiped out. Survivors were grabbing at the helicopter trying desperately to climb on board.

Mike LeFever  

When I landed in Pakistan, it was chaos. It was people from all over the world trying to figure out how to help and how to get there. Over 80,000 people died on a Saturday morning. Over 178,000 injured, and three half billion people homeless.

News Reporter  

The earthquake that hit India and Pakistan on October 8, 2005 was one of the most devastating in a century. 

Mike LeFever  

The devastation was nothing I had expected, nothing I had planned for. And so here I was an admiral sitting 700 miles from salt water up in the Himalayas, and my good friend and classmate, Jon Allen goes, we always need a good admiral in the Himalayas. 

Emily Silverman  

Mike had no plan, no protocols to fall back on just a simple directive from his superiors, provide humanitarian aid and improve us PAC relations. This is The Nocturnists, Uncertainty in Medicine. I'm Emily Silverman. Today we're joined by retired US Navy Admiral Mike LeFevre for our newest uncertainty profile, conversations with people who are skilled at navigating high uncertainty environments. In medicine, we make life or death decisions every day, but usually it's just one life at a time, one patient on the table, one diagnosis. In the military, those decisions play out on an entirely different scale. A single choice doesn't just affect one person, it can shape the lives of 1000s, even the trajectory of entire regions. Mike is a career officer who spent nearly four decades navigating uncertainty in high stakes environments from 2008 to 2011 he led all US armed forces in Pakistan during a time of immense geopolitical tension, and before that, in 2005 he found himself in an unexpected position, coordinating humanitarian aid in the aftermath of the earthquake In northern Pakistan. It was freezing cold in the Himalayas, resources were scarce, and Mike, a Navy admiral miles away from the nearest ocean, had no playbook.

Mike LeFever  

Here, I found myself in this very unique situation, in an embassy with all these organizations and egos, I was the elephant in a room, so to speak, in a country that really didn't want me there.

Emily Silverman  

Just days before the earthquake, Mike had been off the coast of Egypt commanding a US Navy Strike Group, 5500 people, six ships, a few submarines and an air wing. He'd been preparing for a six month deployment in the Middle East, but when the earthquake struck, he was diverted to Pakistan.

Mike LeFever  

I could have easily came into that room and said, Listen, nobody in the world operates at the scale and capability and capacity that we do. I have all the people, I have all the manpower. I have all the unique toys, and I could easily gone, okay, I'm in charge here, but we have a thing that talks about supporting relationships. And so in our environment, in this particular one, it was very clear that this was a mission about United States providing support to Pakistan. And so. So I made it a part for us to check our egos at the door and to be that supporting relationship that says, How do I use my assets, the wonderful men, women, the tools, the equipment and manpower, to be able to support the overall mission of how the US was going to help in Pakistan.

Emily Silverman  

Mike told us that in moments like this, he thinks about navigation. First, know where you are, then know where you're going. It may sound simple, but in a disaster zone, it becomes a survival strategy. So Mike started coordinating basic aid, food, water, medical care, and then turned his focus to something that's usually outside the purview of the military, rebuilding schools.

Mike LeFever  

Well, the schools were all devastated. A lot of the deaths, the 80,000 that were killed, were school children, because it was a Saturday morning, people in schools. So one of the key things in a disaster or thing is, let's try to get the normalcy as soon as possible. And so my CBS, the women and men of the construction battalion were building sea huts to provide classrooms.

Emily Silverman  

At the time, someone from headquarters in Washington, DC, raised concerns about the plan. They worried about staying within the usual boundaries of military involvement that rebuilding civilian schools was traditionally the host country's responsibility, but Mike saw an opportunity for collaboration. His teams could build the temporary schools while the Pakistani authorities provided the teachers and the books. If they could bend the rules together, they could help students get back to some sense of normalcy.

Mike LeFever  

How do you find those common grounds, and how do you get through those first couple of no's to find a way that is doable for everybody, and it takes everybody's consideration in mind, I think part of leading through uncertainty is to create that environment to allow people to be able to voice their concerns or have their problems, be able to talk them out and to really understand what's driving that reaction, and to see whether or not there is some common ground that we can move to to be able To solve the problem and work what's best for everybody. And so for the next seven months, we grew the force over 1500 people. We had two different hospitals, a mash hospital, Navy Marine Corps Hospital, in these very remote areas, providing level three care in environments that we're lucky to see any medical support whatsoever. It probably ended up being, personally and professionally, one of the most rewarding experiences that I had. Men and women that were in combat now repurposed to provide humanitarian assistance and aid, and so we were responsible, at the end of the day, probably, for saving 1000s of lives, which was quite impactful.

Emily Silverman  

During his seven months in Pakistan, Mike forged really strong relationships with local leaders and communities. And in 2007 Pakistan's president, President Musharraf honored Mike with an award called the crescent of great leader, one of Pakistan's highest civilian awards. Then in 2008 Mike returned to Pakistan for what was supposed to be a one year assignment. 

Mike LeFever  

I was sent back to Pakistan in 2008 thought it was a one year assignment in the combat zone that ended up for three years, all the way through the bin Laden raid. I tell people, it was probably the most uncertain, unpredictable environment I ever operated in. I almost preferred to go to Afghanistan or Iraq, because I knew we were at war and you had certain expectations of what that ensued. And Pakistan, it was in this quasi state, but yet very much inside the gray zone, I was fortunate enough to command at every level, ships and squadrons and strike groups and now Joint Task Forces in conflict, in combat and during the full spectrum of operations, my top three priorities were relationships. Relationships. Relationships. Could have them in any order, but those were the top three priorities for by command environment, to be able to conduct operations, to conduct diplomacy, to have difficult conversations with our friends in their time of need, but also in achieving the strategic end state that we needed as a country, to be able to take the fight to al Qaeda away from our shores, and not have them attack inside the United States. And so it was over three years developing that, and then at the same time, being able to brief and translate that back to the president in monthly calls about the statuses of what was going on in Afghanistan and Pakistan. Mike

Emily Silverman  

says that this emphasis on relationships became particularly important after the bin Laden raid in 2011.

Mike LeFever  

Obviously there was  operations along the border that I helped coordinate in control with Pakistan and Afghanistan and the ISAF forces, but they were very sensitive, a very proud nation, and of course, during the bin Laden raid, the idea that we basically invaded their country and took out the number one terrorist in an area that was basically a mile from where their version of their West Point was, as well as some of their weapons and nuclear storage facilities, was quite a shock to the system that we didn't give them any indication that we were going to be able to conduct that so as you could imagine, that relationship was really frayed quite a bit.

Emily Silverman  

Diplomatic ties were on the verge of collapse, but Mike had spent years in this country building trust, trust that doesn't vanish overnight. So while many American officials were shut out, Mike remained one of the few people the Pakistani leadership was still willing to talk to, learning to lead in hostile territory. Mike said, isn't just about showing up. It's about making hard decisions when everything is uncertain and the stakes couldn't be higher.

Mike LeFever  

I remember back as a as a midship, and you know, a famous quote by John Paul Jones of father the Navy, that basically says, He who will not risk cannot win. It's a great reminder. But in all these professions, when you think about this risk, it's acknowledging that, Boy, there's so much uncertainty. It's recognizing that even with that incomplete information that you did the best to your ability, that the information that you had, that this was the best way to do that. And, you know, sometimes it's it's not going to work out. You know, we all celebrate the wins, and everybody loves that. And then there's times that you don't. And in medical as well, in my world, sometimes it meant writing letters to loved ones about not having their loved one return to them, but at the time, it was in your best opinion that that decision was what's going to be able to be best for what you needed to accomplish. What I've realized through time and leadership and experience is that everyone is very different on how they respond to the stresses and also very different in how they incorporate that risk. I think in both fields, I call it the good news. Bad news. Good news is we compartmentalize very well. The bad news we compartmentalize very well. In

Emily Silverman  

medicine, just like in the military, there are hierarchies, chains of command, and while they can certainly be abused, they also serve a vital purpose, organizing chaos and clarifying responsibility. It's like when you walk onto a hospital ward, you want to know who's in charge here, who makes the decisions and when things go sideways, who's accountable. I told Mike that it takes a certain kind of stuff to lead in high stakes situations on the global stage. I wasn't sure that I could carry that weight, so I asked Mike where his courage comes from, self

Mike LeFever  

confidence and adaptability. The Self confidence is that you have prepared the best way you can. But adaptability, there was a quote by a special operator seal, Eric Olson, that I used in my book that said, when the terrain and the map differ, go with the terrain and it's like, oh, yeah, I had this mapped out this where I was going to go. Well, you know, you find out like, Oh, I'm in a different spot than what I thought I was going to be. You know, it stayed on this course, whether it's clearly not the right course, and to be able to be confident that the okay you can adapt and adjust the environment that's around you.

Emily Silverman  

And when you're leading a large team, so large that you can't possibly even know every person on your team, you still have to take responsibility, in Mike's case for every single sailor on his ship, I

Mike LeFever  

used to laugh sometimes when I'd be out on a Saturday morning, you know, whatever, with the kids or family running around in the soccer field, and I have a 17 year old sailor on the ship that's responsible for checking these remote spaces in the ship. Well, if that individual didn't do it, and the ship floods and it damages billions of dollars of equipment. Yeah, that poor sailor, you know, okay, didn't do a job, but at the end of the day, whether military or in a surgery room, there is one person that's ultimately responsible. You can't have two captains of the ship, or you can't have, you know, two Advils or two commanders of units or whatever.

Emily Silverman  

What Mike's not naming here, but seems to be core to his philosophy on leadership is humility. A leader is responsible for the outcome of a mission, no argument. But alongside that confidence, preparation and adaptability, there's an understanding that the leader cannot work alone. The whole idea of a leader implies that there are other people being led, and those people's. Perspectives are valuable. 

Mike LeFever  

I thought it was a Churchill, but it's actually General Patton that basically says, when two people are thinking alike, somebody's not thinking and to be it's such a great reminder that it's the diversity of thought and experiences that really contribute to the solution. One, it exposes you to different points of view. You know, we all have strengths and weaknesses, and so ensuring that those weaknesses are filled by other folks to make sure you get a complete picture is, I think, important as a leader. But again, this idea that everybody contributes, no matter how big or small, you know that Jana that's sweeping the floor or cleaning up that medical trash in the hallway or the restrooms or the restaurant before the team goes into the or the ER, those contributions are just as important as me providing, you know, 30 different helicopters and 1000s of pounds of airlift and sea lift. It's about, how do we work together to solve the issue?