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Margaret A. Hamburg, M.D., Commissioner of Food and Drugs - Remarks at Yale School of Public Health Commencement
Remarks as Delivered of Margaret A. Hamburg, M.D.
Commissioner of Food and Drugs
Yale School of Public Health Commencement
May 24, 2010
Dean Cleary, distinguished faculty, proud parents and grandparents, siblings and spouses, family and friends — and, above all, the class of 2010.
We gather here today in this historic chapel to celebrate the transition state, to borrow a science term, that is Commencement. Today is your victory dance between the end of one journey and the beginning of the next. And I am honored to be here to share it with you.
This is actually the second time that I have been invited to give the commencement address at the Yale School of Public Health. Only the first time I never made it. Because of inclement weather I sat in the airport waiting. Commencement managed to go on without me, but no one was happy. So I was delighted, albeit a little surprised, to be given another chance … and this time I took the train.
Unfortunately, I have never experienced this campus as a student. I earned my degrees at Harvard before moving to New York for my medical training … I hope you’ll excuse my mistakes — we all make a few in our lives …
But, in all seriousness, I’ve always felt a close bond with this university. In fact, my mother, Beatrix, was the first African-American woman to graduate from Yale Medical School. Which means I have heard about, and have deeply admired, this institution ever since I was a child. And from everything I’ve heard about this dynamic and diverse class, I deeply admire all of you, too.
I have also long admired the world-class professors here at Yale who guide you and push you; who inform your opinions and refine your worldviews; and who have inspired you day after day.
Take Professor Schlessinger, who teaches the popular Health Policy and Health Systems course — and whose beard is the stuff of Facebook legend. Or Professor Desai, who was selected as 2009’s Teacher of the Year and who, Dean Cleary noted then, is even able to “make SAS [software] entertaining.” And so many others — the work you do everyday, in your research and in your teachings, will help to shape public health for generations to come. They may not be graduating today, but they definitely deserve our serious thanks.
Now, let me speak for a moment to those of you in the audience who raised the scholars earning degrees today — the parents, the grandparents, the uncles, the aunts. I know how proud you are — I have two children of my own — but I imagine many of you may also have a few questions about what exactly your children have been doing at this School of Public Health for the past year or two … I certainly received questions of that sort from my family when I began my career in public health almost 20 years ago.
I had always thought that I would pursue a career in academic medicine, but I soon found myself drawn to public health, which allowed me to work at the intersection of science and medicine with broader social, legal, economic and ethical issues. In 1991, I was given the opportunity to become New York City’s Health Commissioner.
My great-aunt Winnie, who was like a grandmother to me, was baffled … in fact truly upset. She complained to my father that she just couldn't understand why I would give up the opportunity — especially after all that training — to be a "real doctor."
My father tried to offer her some consolation. He told her that I would still be a real doctor, but that instead of having one patient at a time, I would have about eight million. And now, as Commissioner of the Food and Drug Administration, I guess I have more than 300 million.
Aunt Winnie didn’t buy it — but I did. I embraced the idea of being a public health professional back then, and I have continued to throughout my career. Why? Because I see public health strategy and action as the key to achieving meaningful and enduring solutions to the serious problems that affect the health and well-being of our nation and our world.
The Institute of Medicine defines the mission of public health as “fulfilling society’s interest in assuring conditions in which people can be healthy” … which means the field of public health is uniquely positioned to address the complex interdisciplinary challenges of our world and to impact them in a substantial, sustainable way.
This mission has its roots in the earliest of civilizations. The Romans, for one, understood the connection between good health and proper disposal of human waste. The Chinese developed variolation to inoculate against smallpox and other diseases. The practice of quarantine was used in the Middle Ages to contain infectious disease.
And, as you graduates now well know, we’ve come a long way since the early pioneers of modern public health … since John Snow removed the handle from the Broad Street pump to stop a cholera epidemic and established the science of epidemiology; since Edward Jenner and Louis Pasteur developed the first vaccines for smallpox and anthrax; since Sara Josephine Baker led a team of nurses door to door in Manhattan’s Hell’s Kitchen to educate mothers, treat blindness, prevent sexually transmitted diseases, train midwives and provide pasteurized milk; and since the seminal bacteriologist and public health figure, Charles-Edward Amory Winslow, founded the Yale Department of Public Health within the School of Medicine back in 1915.
But it’s worth remembering that public health as a field of study has not always been the visible, highly regarded discipline it is today. In fact, even as I began my career in public health this was still the case. Clinical medicine and biomedical research were the fields that people understood and so respected…just like my Aunt Winnie.
But public health is something to be reckoned with. During the 20th century, the dramatic increase achieved in average lifespan is widely attributed to public accomplishments … thanks to such things as vaccination campaigns and sanitation, but also safety programs ranging from seat-belt use to occupational and environmental safety, to smoke free programs and nutrition education.
Public health has a way of inserting itself into almost every aspect of our lives and activities, and the benefits are truly felt. Finally, the public and policy-makers really do get it.
Over the past decade or so, I have watched an enormous shift take place, giving public health the importance and support it needs and deserves. As people have come to understand the most pressing threats to health today, the central role of public health approaches becomes clear.
In the words of a distinguished former Surgeon General, Dr Everett Koop, “Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.” So true, but not always appreciated.
I knew that public health was coming into its own when The New Yorker referenced it in one of its great cartoons — this one depicting a fashionable Manhattan cocktail party. In the foreground, one female guest is saying to the hostess: “And it was so typically brilliant of you to have invited an epidemiologist.”
An epidemiologist featured in The New Yorker, and as someone socially attractive, no less … need I say more?
I suppose some might say that we had finally arrived.
But it’s no secret, and it’s probably why many of you chose to study here, that despite the victories of public health — the eradication of smallpox, the control of polio, the dozens of successful campaigns against deadly diseases — we still have a very long way to go.
In developing countries, infectious diseases, malnutrition and poverty-related illnesses still kill millions every year and there is still more preventable disease and disability. Here in the United States, we too suffer needlessly from preventable illnesses. In fact, chronic diseases, like diabetes, heart disease and hypertension have grown into full-blown epidemics. Complex cancers and genetic diseases still elude treatment. And we find ourselves grappling with emerging disease threats, including new environmental health concerns, pandemic disease and the possibility of deliberate manipulation of biological agents to do harm in the form of bioterrorism.
I understand that President Clinton was here at Yale yesterday and spoke eloquently — and extemporaneously — about many of these issues … and that he issued a call to service and to action. He understands the importance of public health. And he is right.
You are the generation — you are the graduates — who must grapple with this transformed, and increasingly difficult, world. I know you may have been hoping for something simpler.
But if there was ever a generation poised to unravel the complexity of science and globalization, to confront the challenges of implementing healthcare reform, and, frankly, to address the future of all the arenas that impact public health: the financial climate, the national security climate, the political climate and, well, the climate climate — I can say without a doubt that it is yours.
Of course, as many of you are thinking right now, this is easier said than done. You’re right. But you’re also right where you need to be — sitting in Battell Chapel minutes from receiving your degree from the Yale Public Health School. All around you, there are pioneers with ideas powerful enough to solve the daunting problems before you.
Last month, for example, a team of top professors from Yale and Rwanda — including your own Professors Currie, Taylor and Bradley — wrote a paper for the journal International Health about a new prism through which to address the world’s greatest public health challenges. They call it, as some of you know, “grand strategy” — “the development and implementation of comprehensive plans of action to achieve large ends with limited means.”
This is a rich and interesting paper — but I want to touch on one idea in particular.
The paper tells us: Start with your ultimate goal — your end — firmly in mind. And then, while taking an ecological view of the world, carefully determine, almost like a great military tactician, what changing resources and approaches you will need to achieve your unchanging end.
In other words, dream big but think small. Not small in the sense of unimportant, but small in the sense of defining the realistic and discrete steps that will take you where you want to go.
This caught my eye because, at its core, it’s the way I’ve tried to approach public health problems in my capacities as NYC Health Commissioner, Asst. Secretary for Planning and Evaluation at the U.S. Department Health and Human Services, and, now, as FDA Commissioner. As you can imagine, I am overwhelmed every day by competing interests from industry, constituency groups, patient advocacy groups, Capitol Hill — the list goes on. And my job, often, is to juggle all their priorities while furthering the mission of our agency … to promote and protect the health of the American people.
But by keeping my end firmly in mind — to ensure the safety, effectiveness and quality of the food, drugs and other products we regulate for the American consumer and to use the best available science as a basis for decision-making — I can make everyday tactical decisions with a clearer mind and a more powerful compass. And in this way, I can hopefully make the right decisions.
In that spirit, I encourage every one of you — before too long — to find your “big thing” … the goal or idea that you want to spend at least the first stage of your public health career working toward. Find it, and hold it in your mind.
But as each of you proceeds forward, it is the other part of the equation…focusing on the little things — the execution details — that I believe holds the key to ushering in a new era of public health.
Many of you have already begun to do just that.
Molly Rosenberg traveled to Haiti to study the role of microfinance economic empowerment on HIV risk behavior in women.
Sara Bodner focused on the public health issues closer to home through her work with the grassroots start-up Farmers Market network, City Seed, in New York.
Javier Cepeda, the world traveler who won $12,500 on “Who Wants to be a Millionaire” last year, evaluated the relationship between HIV risk perception and trust among injection drug users in St. Petersburg, Russia.
Trang Thach worked this past summer measuring chloroform levels in local residences in Cluj, Romania and developed a questionnaire to measure exposure data from the study participants.
That’s what I’m talking about when I say “the little things” … little things that really matter.
We may not all be running our own foundations, agencies or empires but, in my experience at least, it’s the single-minded focus of caring and talented people like all of you to these little things that enables progress and heals people.
Consider the number of steps it took to eradicate smallpox — one of the grandest of public health goals and achievements. A vaccine was developed, surveillance and reporting practices were created, funding was secured, volunteers were recruited… and then community by community, village by village, people were vaccinated.
There’s no way that smallpox would or could have been eradicated without careful attention to the many, many steps that went into it.
I’ve seen this myself. As health commissioner in New York City, I made it my goal to defeat the epidemic of resurgent TB in the city. It was an enormous task fueled by poverty, homelessness, AIDS and the erosion of the public health infrastructure — it was formidable.
So we focused. We defined our goals, and set out to achieve them one step at a time: ensuring that patients took their medication, monitoring hospitals and homeless shelters and other areas where people congregated, adopting humane isolation procedures, building a state-of-the-art infectious disease control facility at the Rikers Island prison.
And in just five years, we managed to reduce the number of TB cases in the city by almost 46% and the number of drug-resistant cases by 86%.
Many had warned that we could not meaningfully combat TB without first addressing the poverty, homelessness and concurrent disease that fueled it. But taken in pieces, solving the problem became possible.
That’s why every day, beginning today, I would encourage each of you to ask not only whether you are being true to your big public health idea, but whether you are being truthful about the small steps it will take to achieve it. Immerse yourself in the details and you can always answer yes.
The good news is that despite the challenges of the world into which you’re graduating, you have the tools to determine your grand ends and execute your smaller means.
You are in a position to make a real difference when the country and the world need you most.
And there are plenty of domains for you to work in: government, academe, industry, civil society, policy, health care administration, global health, development … And you can.
You are not just public health professionals, but sociologists, nutritionists, epidemiologists, scientists, psychologists, anthropologists, physicians and more.
You are talented, you are tireless, you are innovative and you are committed. Who could ask for anything more?
So I want to leave you this afternoon with something that my former boss and yesterday’s Yale Class Day speaker, President Clinton, said in 2000 when he was addressing a gathering of Heads of States at the United Nations — for the final time as President. It was a rather different forum, but his words ring true today.
"The leaders here assembled can rewrite human history in the new millennium,” he said. “But we must believe the simple things — that everywhere in every land, people in every station matter. Everyone counts, everyone has a role to play, and we all do better when we help each other."
What sets you apart, graduates, is that you already know this … you believe it. You’ve internalized it. And, now, you’re ready to act on it.
You are armed with everything it will take to change public health forever — and for the better. You are exactly what our world needs.
Congratulations, Class of 2010, and good luck.