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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.