Graduation Address - Rollins
School of Public Health
Emory University
May 15, 2000
Thank
you for that kind introduction. It is wonderful to be back on the Emory
University campus and to visit with so many good friends and colleagues.
It is difficult to believe that it is five years to the day since I
left the Rollins School of Public Health. The intervening years have
passed quickly, and much has happened in the interim. I return to find
the School today larger and stronger than it was when I left. Dean Curran
and the faculty, staff and students are to be congratulated on the growing
reputation of the Rollins School of Public Health.
Speaking
as one who knew the School from its earliest days, it is overwhelming
to see our wildest dreams and expectations exceeded. A decade ago, we
operated out of rented office space, with a small faculty and student
body, and big gaps in our academic program. We were not accredited as
a School of Public Health and we had no endowment. I vividly recall
my first meeting as a dean - it was for the newly launched fund-raising
campaign for Emory. After several hours of presentation to the deans,
we were each asked to turn to a particular tab in the large spiral binders
in front of us. At that tab was a list of prospective donors for our
fund-raising efforts. When I turned to that section in my notebook,
all that was there was a blank page.
In
many ways, that blank page was a perfect metaphor for the young School.
Although there was a Master of Public Health program that had been operating
for 15 years, there was essentially no infrastructure in place for a
school. Through the collective efforts of an energetic faculty and staff,
we began filling that blank page up quickly.
Our
task was made easier by the rich resources around us. Our neighbors
included some of the leading public health organizations in the country
- the Centers for Disease Control and Prevention, the Carter Center,
and the American Cancer Society. With such extraordinary partners, the
School was poised for success. That destiny was assured when the Rollins
family came forward with their generous support. It was no surprise,
therefore, when national surveys ranked the Rollins School as a leader
in academic public health within just a few years of its creation.
I could
go on at great length reminiscing about the early days of the Rollins
School of Public Health. Although that may be of some interest to those
of you who were here at the time, I suspect that most of you view that
as ancient history. Accordingly, I will spare you a trip down memory
lane.
Instead,
I would like to direct my remarks to the graduates and talk about the
state of public health as you enter the profession. I do so, recognizing
that this is a very broad topic, and there is nothing worse than a long-winded
commencement address. In that spirit, I will keep my remarks brief by
avoiding any pretense of thoroughness. My approach will be to focus
on two current circumstances as emblems of the opportunities and challenges
that will face public health in the years ahead.
First,
I would like to touch on the extraordinary progress being made in the
sequencing of the human genome. As most of you are aware, there are
predictions that the entire human genome will be sequenced before this
calendar year is over. Some enterprising souls predict an even faster
completion. Whenever it is accomplished, and it will be soon, the completion
of this task will be a landmark event in the history of science. In
my opinion, it will represent a scientific achievement as profound as
the advances of mathematics in the 17th century, or chemistry
in the 18th century, or biology in the 19th century,
or physics in the 20th century.
Of
course, sequencing the genome is only the first step toward understanding
the role of genes in health and disease. Complex associations between
certain genetic profiles and the risks of various conditions will require
years to elucidate. These studies will be complicated in several respects.
First, in most instances we will be talking about probabilities, not
certainties, of disease occurrence. It is one thing to say that a person
is at increased risk for developing a disease, it is quite another to
say that he or she will definitely develop it. Second, there are likely
to be multiple genes, or more properly multiple gene products, involved
in any particular pathway toward increased susceptibility to disease.
Finally, there are likely to be a variety of different pathways to increased
risk of many of these conditions.
Despite
these challenges, there is every reason to believe that the complex
patterns of inherited susceptibility to many common diseases will be
identified soon. When that occurs, we will have powerful new tools to
help inform individuals about the risks of disease. For instance, we
will be able to target screening for early detection of disease to high-risk
populations. We also will be able to focus preventive measures for greatest
benefit. We can also anticipate more effective treatment, including
the possibility of gene therapies to address underlying inherited susceptibilities.
Collectively, these advances will offer extraordinary benefits in terms
of reduced human suffering.
Of
course, there is a potential dark side to this genetic revolution as
well. Who will have access to this information? Will life and health
insurers be able to obtain it and use it to rate prospective clients?
Will employers have access to it, allowing them to pick and choose potential
employees in terms of potential disability and longevity of employment?
Will those contemplating marriage have access to such information in
selecting a potential spouse?
One
of the on-going great debates is whether companies involved in obtaining
these genetic sequences should be permitted to patent them. If companies
are allowed to patent this information, the price of obtaining a genetic
profile is likely to rise accordingly. It is not inconceivable that
cost will become a barrier to access to this information. If that occurs,
we can anticipate an even greater widening of the disparities in health
status between the "haves" and the "have nots."
In
the interests of time, I will not elaborate further on the opportunities
and challenges that will derive from the sequencing of the human genome.
For our present purposes, it is sufficient to recognize that we are
on the verge of one of the greatest achievements in the history of science.
As with any fundamental advance in knowledge, it will bring the potential
for great benefit as well as the risk of some harm. Nevertheless, it
represents for me a symbol of how far we have come in understanding
the human condition.
Let
me turn now to another topic, which is emblematic to me of how far we
have yet to go. I am speaking about the issue of the medically uninsured.
In the United States today, we have reached an all-time high in the
number of persons who lack health insurance. Shamefully, it is not for
lack of societal resources. We are after all, experiencing the longest
sustained period of economic growth in the richest country in the history
of the world. Unemployment rates are among the lowest in any peacetime
economy. Yet many of the jobs that have been created in this booming
economy pay low wages and offer few benefits such as health insurance.
As a society, we tolerate this situation while we watch the creation
of instant millionaires through initial public offerings of stock in
companies with no actual sales.
If
surveys are correct, most Americans would be willing to pay more taxes
to assure that all of their fellow citizens have basic health coverage.
Yet, this willingness on the part of the electorate has not been realized
in the form of public policy. What has happened legislatively is that
the Balanced Budget Act of 1997 reduced federal appropriations to the
Medicaid program. Among the budget slashing casualties was the disproportionate
share program, through which hospitals with large numbers of uninsured
patients receive compensation for this care. Thus, we have the disastrous
combination of a rising number of uninsured persons with a weakening
of the safety net to take care of them.
It
seems obvious to me, although perhaps not to our elected officials,
that this is a recipe for disaster. I will confess that my own sense
of the impending crisis probably is influenced by the situation at Charleston
Memorial Hospital. That facility is the equivalent in our community
of Grady Hospital in Atlanta. Charleston Memorial Hospital lost $10
million in federal appropriations last year, or 40% of its operating
budget. Along with others, I now face the decision about whether this
hospital can remain viable under the present financial circumstances.
Well,
let’s not detour into my current problems. What is this message
here? Those of you graduating today are entering the field of public
health at an extraordinary moment in time. On the positive side of the
ledger, you will witness, and perhaps participate in, advances in biomedical
science that border on the miraculous. Progress will occur at breathtaking
speed, as publicly and privately financed teams throughout the world
race to sequence the human genome and relate that information to human
health and disease.
All
of this scientific advance will occur against a backdrop of a society
that still has not accepted a commitment to assuring access to basic
health care for all of its citizens. As always, the pace of scientific
discovery will be far faster than the pace of public policy. Accordingly,
we will confront a growing gap between what we know to be possible and
the translation of that knowledge for the greatest societal benefit.
In
another context, almost 40 years ago, Martin Luther King, Jr. wrote
the following: "The means by which we live have outdistanced the
ends for which we live. Our scientific power has outrun our spiritual
power. We have guided missiles and misguided men."
In
many respects, the role of public health is to help bring the ends for
which we live back into compatibility with the means by which we live.
One such end is to preserve and optimize human life. The means to that
end undeniably involves many features, such as educational and employment
opportunity. None is more important, however, than good health and access
to basic health care. The end of preserving and optimizing human life,
therefore, is incompatible with the fact that a child born into poverty
in rural South Carolina, or inner city Atlanta, or sub-Saharan Africa,
has limited access to health care. As public health professionals, we
must strive to bring the end and the means into balance.
It
is easy enough to say that this is someone else's responsibility. We
are, after all, speaking of a societal concern. Should the solution,
therefore, not involve all members of society? If we cannot engage the
public-at-large, should we not then expect the elected representatives
of the people to address the issue?
No
doubt, resolution will come only when the public is willing to accept
this responsibility. In the meantime, however, we in public health have
continuing obligations in this matter. We must collect the information
that demonstrates the relationship between access to care and health
outcomes. We must document the existing inequities in access to care.
We must communicate this information to the decision-makers, as well
as to the public-at-large. We must develop model programs to show that
improving access does produce the desired results, and can do so cost-effectively.
These are our responsibilities, and I trust that members of this graduating
class will be at the forefront in meeting them.
As
you begin your careers in public health, may you find guidance in the
values that you were taught here. May you see yourself as an instrument
for promoting the health and well being of the public you serve. May
you find fulfillment in your work and become an inspiration for others.
I extend
to you my heartiest congratulations and offer you best wishes for your
future success.
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