May 29, 2014
Welcome and thank you to graduates, families, faculty, Dean Frenk, friends and guests. Congratulations. Your being here today is a tribute to your hard work, and to your personal and academic growth and learning. And as you finish, make sure not to forget to thank your parents—especially if you might need to move back in with them.
Congratulations also for being part of the Centennial class. One hundred years ago public health was struggling with two essential issues. First was widespread preventable illness and the second was widespread health disparities. I wish these were things of the past, but they’re not. Addressing these two problems remain the cardinal imperatives of our field. Let’s hope that a graduation speaker 100 years from now doesn’t say the same thing. And I’m confident that you can be an important part of changing that reality—of making prevention happen and making it happen for everyone. And I’ll share with you a few thoughts on how you might be most effective in doing that.
But I also remember that I’m one of the few things standing between you and your diploma, and good advice given to a commencement speaker to think of himself as the body at an Irish wake. They need you in order to have the party, but no one expects you to say very much.
One thing you all have in common is a desire to help others—a commitment to helping others. Public health is a profession where it’s natural to feel good about what we do. But actually, that’s one of the greatest risks of our work. It’s all too easy to fall into a trap of self-righteousness when we know our motives are pure.
It has been said that ‘the road to hell is paved with good intentions.’ And just a few miles from here, Henry David Thoreau wrote that ‘there are a thousand hacking at the branches of evil to one hacking at the root.’ So the challenge, really, is to go beyond feeling good about what we do to doing good.
I’ll give you three words of advice on how to cross that road—how to be sure you’re not just feeling but actually doing good: Ask hard questions.
The first time I worked in global health I worked in a small country in Latin America, and I was helping, among other things, to improve the data available to the Ministry of Health. It was early in the personal computer era and there were, if you can imagine this, things called floppy disks, and there were floppy drives, and you took your floppy disk and you put it in the floppy drive, and you typed ‘format/a/colon/forward slash/enter,’ and that formatted the floppy drive so you could put data on it.
So I was helping out, improving the ability of the Ministry to track trends and to respond, and I needed another floppy disk, and I put it in the floppy drive, and I typed ‘format/space/enter.’ What that does is erase the entire hard disk. It was a very painful moment. It still is a searing memory. And we were able to recover some though not all of the data.
But the most dangerous time is not when you know you’ve made a mistake. The most dangerous time is when you don’t have the information systems in place to know whether or not you’re hitting the mark.
Overconfidence can kill. And it’s so important that we recognize the limitations of our knowledge and recognize that whatever we accomplish is accomplished because of the work that we do with others. Humility is a critically important attribute—not only because it’s a nice thing to have but because it’s important to be effective. And I hope you don’t mind my saying so, but as you become Harvard graduates, a lack of humility might be an occupational risk. So don’t be afraid to ask those hard questions about your own work as well.
My first big job in public health was running the tuberculosis control program in New York City. It was in the midst of a large outbreak of multidrug-resistant tuberculosis. Patients were becoming infected. Health care workers were becoming infected. Drug resistance was spreading. And I worked hard to try to reverse it. I went to the hospitals, I conducted rounds on the patients, I got new resources for the program, and we improved laboratory and treatment and follow-up.
And then a man named Karel Styblo came to visit. And he asked me a single question—a hard question—that changed my life. He looked at our information summary, which I had written, and he said, ‘Dr. Frieden, this information summary gives me lots of good information, but there’s one really important piece of information it doesn’t tell me.’ I said, ‘What’s that?’ ‘Well, last year, you diagnosed 3,811 patients.’ I said, ‘Yes?’ ‘Well, how many of them did you cure?’
And I didn’t know. And I was terribly ashamed. And the next day I began implementing a program to track the outcomes of every single patient diagnosed in New York City. It was a hard question that changed my life.
When I became health commissioner in New York City, we implemented the tobacco tax, increasing the cost of cigarettes. We made virtually all workplaces smoke-free so no worker would have to choose between their work and their health. And we saw smoking rates go down steadily for the first time in a decade; I thought our work was done. But we had put into place an information system, and that information system showed that, in the next year, smoking rates didn’t go down; in fact, they went up a bit. Because we had that feedback loop and were willing to ask the hard question of whether our program was working, we then began new programs with hard-hitting ads—some of them made here in Massachusetts—that re-started that downward trend.
It’s important not to be afraid of asking the hard questions, even or especially if you’re afraid of what the answer might be. To answer those questions, it’s so important to find mentors: people you can look up to, get advice from, maybe people who aren’t flashy or in the news, but people who are working hard and who are the kind of person you’d like to be. Karel Styblo was not widely known. But his way of treating tuberculosis has saved millions of lives around the world.
Now some people think that epidemiology is kind of like the weather. You can describe it, complain about it, maybe predict it, but certainly not change it. In fact, by making prevention happen, and by making it happen for everyone, we can change the epidemiology of communities and of countries and of the world. After Styblo asked me that question in New York City, we made the patient the VIP of the program; we made the frontline outreach worker who helped patients get cured the most lauded person in the program because they were making the difference on the front lines; and we were able to cure virtually all patients in the city. Multidrug-resistant tuberculosis declined by more than 90%. And it became a model that I was then able to help India begin to implement, and other parts of the world as well.
When we saw that stall of smoking rates in New York City and we implemented new programs, we were able to prevent more than 100,000 deaths from smoking in New York City. And when Mike Bloomberg, who’s now in another part of this campus giving the Commencement address, generalized that program and began working in dozens of countries around the world, he was able to foster change that, in just five years, has established programs that will prevent 10 million deaths. It is possible to change the world through public health.
From my time in India, the one key concept that I learned was that irrational optimism is a prerequisite for success. You have to be willing to think big.
Now, it’s not just about what we do. It’s also about how we communicate it that we need to ask the hard questions. You need to know whether you’re reaching people and whether they understand what you’re saying. Communication is never as good as you think it is. My first job in this country was in a rural health clinic, helping that clinic trying to increase its utilization. It was underutilized despite being in a very poor Mississippi Delta area, with an underserved population. Not many people were coming into the clinic.
So we did a community survey. We went to 500 houses and we asked people a whole host of questions. This is a small town where we assume everyone knows everyone. Only 10,000 people lived in the catchment area. But actually, 50% of the population did not know the health center existed. Eighty percent didn’t know that it had a sliding fee scale. And those who knew were much less likely to need the clinic than those who didn’t know.
So communication can always be better. It’s important to state things plainly and clearly as well. Mark Twain said, ‘Never use a five-dollar word when a fifty-cent word will do.’ Respect your audience but don’t make things unnecessarily complex. Big words often hide either fuzzy thinking or uncomfortable facts.
In health care we have some really wonderful big words, words like “iatrogenic”—which means not something that you think is bad, but it is. It means, ‘We made this person sick.’ But we don’t say that; we say, ‘Oh, his illness is iatrogenic.’ We say, ‘He has a nosocomial infection’ instead of ‘We gave this person a terrible infection.’ And of course there’s that wonderful word ‘idiopathic’—‘We know the cause of his illness is idiopathic,’ which means, ‘We don’t know what causes it.’ Another definition of idiopathic is: ‘The patient is sick and the doctor is an idiot.’
But in fairness to doctors, there’s a lot we don’t know. And approaching clinical medicine as we should approach public health—with an attitude of humility, of the importance of asking hard questions and not being afraid of where those answers will take us—is so important.
One of the major areas in the coming years for public health will be the intersection of public health and clinical care. It’s going to be a major growth area. And we have a lot to offer the clinical care system.
Another word that you’ll hear in the clinical care system is ‘unwarranted clinical variability.’ It’s a wonderful term. We used to call it ‘malpractice.’ And we know how to reduce it from our work in public health. Team-based care, evidence-based protocols, task sharing—all of these things can make a huge difference improving health care delivery and achieving public health goals.
One of the things that we can bring to the health care field is the ability to ask hard questions about denominators. An epidemiologist is someone who loses sleep over denominators. So if you’re a clinical provider and you think you’ve treated all your patients who smoke or have high blood pressure, but you haven’t cross-referenced or triangulated the numbers of your patients against what the prevalence of those conditions should be, you may well be deluding yourself and thinking you’re doing a good job when you’re not. Asking the hard question about how many patients really need care, rather than how many happen to be diagnosed by you and remain in-care, can improve outcomes and save lives.
Well, now that I’m talking about triangulation and denominators, I think that, like the guest of honor at an Irish wake, my time is up.
When you go out into the world and tell people that you went to Harvard, they’ll think of the Square and the ivy and the Yard, and it’s probably best not to tell them that you were stuck near Brigham Circle the whole time. Let everyone think that you had those memories, and 20 years from now, you’ll begin to believe that you did.
Thank you all very much and congratulations to the Class of 2014.