Harvard School of Public Health commencement speech, May 24 2012

The Idea of Public Health

By Gerald Chan

Commencement is a rite of passage whereby the new graduates are inducted into the company of the learned. In your honoring me by inviting me to be with you today, I suppose I am expected to offer some words of wisdom as part of this rite of passage. Being one who had studied in this school and then gone on to do different things, I also sense there is an expectation that I would draw on my diverse life experiences in formulating my comments. I will attempt to do so by gathering my thoughts around three themes – idea, public and health – which, as a play on words, became the title of my speech today.

First, let me talk about idea. In times past when the discovery of new knowledge was slow and the dissemination of knowledge constricted, a learned person was one who had acquired and possessed knowledge. A gentleman in China once brought me to the library of his late father who was a professor there in the first half of the twentieth century. Examining the books in the library, I couldn’t help but notice that the university-level books of that era were written strictly for the conveyance of knowledge. It was a time when knowledge was precious and few had possession of it. Times have changed. New knowledge is now being produced at a breakneck speed and is readily accessible to anyone with connection to the internet. A learned person can no longer be defined merely as one who is in possession of knowledge, or perhaps more accurately, and somewhat derogatorily, one who is in possession of information. Today, whether a person can be considered a learned person hinges on what he does with the knowledge he has. A beautiful mind is not beautiful by virtue of its storage capacity, nor even what has been stored in it.  A beautiful mind is a mind with beautiful ideas.

By an idea, I do not mean a thought which unexpectedly pops into your consciousness like the four year old in a play group who exclaims, “Hey guys, I have an idea!” By an idea, I mean the conceptualization of a matter which results from a conscious examination of it. Let me use a specific case to illustrate what I mean. I refer to the book The Idea of a University by John Henry Newman. Universities have been in existence since the eleventh century, but it was not until the publication of this book in 1852 that there was a conscious examination of the aims of a university, what should be taught, how knowledge should be handled, and what should be the university’s relationship to the students, professors and to other institutions, religious or secular. An idea is therefore both an abstraction and a generalization concerning a matter, a mental structure which brings into view the whole as well as into focus the parts.

Let me elaborate further by resorting to history. The actors on the stage of history come and go. The effects of their actions decay rapidly, albeit with differing half-lives, except in so far as those actions express ideas. It is the effects of these ideas that persist and move history forward in the long run. The founding fathers of America are long gone, yet their ideas, embodied in the Declaration of Independence, the Constitution, the Federalist Papers and the Bill of Rights, continue to inform how society should be organized in this country; they still set the course of this nation’s journey. From the other end of the political spectrum, one can point to Karl Marx. Long after he died in obscurity, his ideas continued to sustain utopian imaginations and animated social and political struggles all over the globe. The historian R. G. Collingwood went so far as to say that “…the historian is not concerned with events as such at all. He is only concerned with those events which are the outward expression of thoughts, and is only concerned with these in so far as they express thoughts,” this coming from his final work, a book entitled The Idea of History.

I talk about ideas because I see in the communications of today’s society, be they among individuals or the masses, an impoverishment of ideas. Politicians are known by their sound bites. Messages with 140 characters or less encourage the communication of the trivial. Tweets are great for knowing where your friends are having dinner tonight, but they are not conducive to the generation nor the communication of ideas. If modern communication technology has dumbed down society, it is in its proliferating communications which have no relevance to enriching the pool of ideas found in society. Being flooded with minutiae of everyday life subverts our intellectual life by luring us into, and holding us captive in the present, in what is, such that we have no time and no energy left to consider what might be, or what can be, or what should be. The peril we face in today’s society is that we unwittingly become mere pragmatists, and soon, exhausted realists.

I may be condemned here for being idealistic. Rightly so. History shows us that ideas are indeed aspirational. In the idea that all men are created equal is the aspiration that all men may be able to live as equals. It is in this gap between what should be and what is that there is a potential energy which, when harnessed, can be converted into kinetic energy to power action. In other words, ideas empower action. A person devoid of ideas will have neither ideals to work towards nor the energy to do so.

My first advice to you, graduates, is to enrich your lives with ideas, even big ideas. Read, reflect, and ruminate (the new three Rs). Observe and deduce, postulate and verify, look for connections. Be curious, be open-minded, reframe problems rather than just looking for answers, have the courage to differ from conventional wisdom, do not dismiss your intuition. Discuss, debate and discourse with others. Look into history, watch current affairs; study the sacred texts, observe humanity. These are the mental habits conducive to the spontaneous generation of ideas.  A life is rich when it is rich with ideas.

I shall turn now to address my second point: public. When I taught a course in the school this past January, I was struck by how purposeful and how public spirited the students were. They were troubled by certain unmet needs in society, so they came to the School of Public Health to broaden their skills in order to do something about those needs. One student from Africa was bothered by the long waiting time that patients had to endure before being seen by a physician while the physician’s time was being used inefficiently. Another student from Asia was bothered by the stigma associated with, and therefore the scarcity of healthcare resources devoted to mental health in his country. An American student was concerned about binge drinking among female college students. One student wanted to address the lack of availability of healthy food in poor neighborhoods. Yet another student wanted to quantify the attributable disease burden among people who live downwind from power plants. These are young people whose consuming passion is not their private interest, but that of the public’s. I truly applaud them.

When Senator Olympia Snowe of Maine announced her decision not to seek re-election a few months ago, she cited as the reason her frustration with the corrosive climate of the public sphere of this nation. Her words conjured up the same frustration cited by earlier senators who retired from public life: distinguished senators such as Bill Bradley, William Cohen, Claiborne Pell, and Paul Simon. It is ironic that in these times when there is so much cynicism about government that our young people are in fact so public spirited. The result of this discordance is that the public spiritedness of today’s young people no longer resorts to traditional channels to find expression. They take things into their own hands. This is why social enterprises are flourishing. Technology has enabled the surmounting of many obstacles which had previously impeded ideas from being translated into actions, even actions at a large scale.

What this means for our graduates is that many entrepreneurial career paths are now open to them. Serving the public no longer means only to work for government agencies or running for public office. If the students in my class were any indication, many of our graduates will work for the public good in organizations which are private sector in their organization and operation, at once making profits and doing works which were previously consigned to the charitable or the public sector. For them, the goals of making a profit and doing good works are not mutually exclusive. They will raise money not from donors or benefactors, but from investors whose expectations are as commercial as they are benevolent. They will run their enterprises for financial sustainability while being true to their mission of delivering benefits to society.

Conventional wisdom has it that private interests and public interests are adversarial. People who want both to attend to their private interests and to devote themselves to working for the public good tend to do so sequentially. Society as a whole also tends to oscillate between preoccupation with public interests and private concerns. Post-WWII America is replete with examples of this oscillation ranging from as short as a mid-term election cycle to as long as generational transitions from the Baby Boomers to Generation X to Generation Y. Perhaps in social enterprises, our young people will find a way of melding together public and private interests and in so doing, will define a sustainable equilibrium both in their own personal lives as well as for society at large. In idiosyncratic ways, societies all over the world are struggling to find that balance.

Lest my words today, together with my words at the school last year be construed as my being partisan to the private sector as the locus for effecting public good, I would be remiss not to say that the public sector in this country is ripe for renewal. Historically, the Harvard School of Public Health has produced many graduates who went on to exemplary careers in governments around the world. Among our fellow alumni are a prime minister, many ministers of health, including our current dean, and innumerable public health officers, physicians and scientists. My sincere hope is that this fine tradition of service in the public sector will continue in the years to come. It is only when fine young people such as our graduates go into government service that the public sector can be reinvigorated, and with that, public service once again ennobled.

Finally let me talk about health. Health can be had by averting diseases or by diseases, once had, being cured or brought under control. Sickness is an integral part of the human program that can best be described in the words of an English poet, “Every man who lives is born to die.” Exogenous pathogens used to play a big part in accelerating the execution of this program, thus cutting short many human lives.

One of the most brilliant chapters in the history of medicine was the discovery of antibiotics for treating infectious diseases. When the sulfur drugs and penicillin showed their efficacy in curing infections in the 1930s, it was treated with flat disbelief. Drugs which worked so predictably in curing such prevalent diseases were hitherto unknown to man. What followed was an era of exuberant optimism and unquestioned faith in the power of modern medicine.

The experience of the last half a century, a period of astonishing scientific progress, has nevertheless taught us that we must use wisely the tools modern science and medicine have given us, with the understanding and due respect that there are limits to what they can do. Let me illustrate.

In the case of AIDS, progress in our understanding of the disease and developing remedies to treat the disease was nothing less than spectacular. In less than three decades after AIDS was first diagnosed, the causative virus was identified and characterized and more than twenty drugs were approved by the FDA for treating the disease. What was formerly a sure death sentence upon diagnosis of infection can now be managed for survival measured in decades. Vertical transmission from mother to child can now be stopped. As impressive as these achievements are, the global disease burden of HIV infection has continued to rise. In several African countries, the percentage of the adult population that is HIV positive is now in the double digits. A dichotomy has emerged between our ability to control the progression of the disease in a patient and our inability to control the proliferation of the disease in a population.

The same dichotomy is evident if we are to turn from infectious diseases to chronic diseases. Consider obesity and diabetes, probably the most urgent epidemic afflicting developed countries today, and the developing countries are following not far behind. We know how to manage a diabetic patient with medication, but we are powerless in controlling the runaway increase in the incidence of obesity. Projections presented at the Center for Disease Control conference two weeks ago suggest that by 2030, 42% of American adults will be obese. In the United Kingdom, the projection is that in thirty years, 50% of the adults will be obese. Unlike infectious diseases, there is not an exogenous pathogenic agent that we can eradicate with medicine, nor is there a vaccine that can be used as prophylaxis. How do we deal with a disease burden whose biggest risk factor is lifestyle – what we eat, how much we eat, how active or sedentary we are, or in short, how we live? Eating is so very pleasurable; this is undoubtedly hard-wired into human nature. How do we curtail pleasure in order to promote health? This is no longer a medical issue; it is a cultural issue and a behavioral issue. The crisis of obesity is a crisis of culture, culture in so far as it shapes human behavior.

To pop a pill every day is easy, but to repeatedly refrain from consuming food that is delicious and sumptuous is difficult, all the more now that food is more abundant and the culinary arts more refined than ever before in human history.  We who have children know to say no to the little ones, but we do not know to say no to ourselves. It is exceedingly hard to say no when what is at issue are T bone steaks, eggs with bacon, chocolate donuts, Boston cream pies, fudge brownies and ice cream. Who doesn’t struggle with the tradeoff between future benefits, ever so remote and contingent, and present gratification that is ever so immediate and real? The Pogo comic strip said it well, “We have met the enemy and he is us.” I once drove past a Depression Era municipal building in Sioux City, Iowa. On top of the façade of the building were inscribed these words, “There is no greater conquest than that of self.”  And so it is whether we are talking about our bodily health, or we as a nation, its fiscal health.

Experience with both HIV and diabetes showed that although the tools used to control the disease in a patient are medical, the most effective means for controlling the proliferation of these diseases is by effecting behavioral change. For our graduates who will go into public health work, tools of science and medicine alone will no longer suffice. For the effectiveness of their work, they will have to look to education, community building, mass media, social media, legislation and civic leadership. In keeping with the basic tenets of a free society, they will have to find ways to change human behavior for the good. This task is daunting indeed. How can we be blind to history that the Enlightenment’s lofty idea of the perfectibility of man has left behind a long string of broken dreams?

Few are the examples of human behavior changed in large scale for a favorable public health outcome. The poster child here that gives us hope has got to be the public campaign against cigarette smoking in America.  In 1965, 42% of adults in America were smokers. A cigarette dangling in one’s mouth was a symbol for being cool, sophisticated, in control. From Humphrey Bogart to James Dean, from Ava Gardner to Lauren Bacall, from FDR to LBJ, cigarette smoking was integral to the social and cultural life of America. The idea that such a pervasive and ingrained habit in American life could be changed was hitherto unthinkable, worse yet when that change was opposed by an entrenched industry with a powerful lobbying machine. From the early 1970s, mass media campaigns, education and aggressive government actions such as imposing label warning, taxation, cigarette advertising ban, and prohibition of smoking in public spaces succeeded in producing a cultural shift in American society. Smoking became a cultural taboo. By 2002, the percentage of Americans that smoked had been halved and the number of ex-smokers exceeded the number of current smokers. One would like to see this kind of public health triumph for other diseases which are preventable by the reduction of risky behavior.

If the track record of perfecting the human race to the elimination of war, crime, hatred and avarice is less than stellar, perhaps we can do better in the improvement of health.

And so I say to the graduates – we look to you for fresh ideas, we look to you for public engagement, we look to you to bring better health to mankind. Many are the public health challenges of the world today; the solution to some of them will be the laurels awaiting you tomorrow.

I offer you my congratulations on this day of your graduation and I send you all of my very best wishes.