https://en.wikipedia.org/wiki/With_great_power_comes_great_responsibility
Ten Great Public Health Achievements — United States, 1900-1999 (MMWR)
Ten Great Public Health Achievements – United States, 1900-1999 (pdfs)
Achievements in Public Health, 1900-1999: Healthier Mothers and Babies
Hamming’s “You and Your Research”
Pearl Kendrick, Grace Eldering, and the Pertussis Vaccine
The Role of the WI-38 Cell Strain in Saving Lives and Reducing Morbidity
Malaria: a problem to be solved and a time to be bold
“indistinguishable from magic“
Thank you Manish
Thank you Dean Compton, Director Barnato, Exec. Director Westling,
and Directors Theroux, and Passow.
And most of all thank you, TDI class of 2022,
for the privilege of sharing this moment with you and your loved ones.
I believe I was asked to speak to you today for essentially one reason.
Approximately 80,000 hours ago, a number whose significance we’ll return to shortly,
I was sitting there, where you are now.
Standing here now, after a meandering professional journey,
I am employed by the Executive Office of the President.
I believe this fact says more about you, than it does about me.
It is a useful existence proof, demonstrating that once you exit the stage with your TDI diploma.
you can keep walking, as far as you want in any direction and you will be taken seriously
(unless you are still dressed like this after today, in which case your credibility will be seriously questioned– Dartmouth degree or not…) [even over Zoom]
What I mean is, that it is now fully within your ability to further climb the ivory tower, or
descend to fight on the front-lines and trenches of patient or population health care,
to wander the market bazaar of industry and technology,
or enter the halls of policy and governance, if you so choose.
Said another way:
You now have the professional capacity to access essentially anywhere– which is an interesting fact.
But not nearly as interesting as the question it invites,
perhaps the most consequential question of your professional lives,
what will you do with this access?
over the next 8 hours a day, 5 days a week, 50 weeks a year, times 40 years
–or approximately 80,000 working hours— of your career?
That is a heavy question.
Before hefting it together, let’s take just a moment for something lighter
I am far from the first or last person, to congratulate you today
But it has been my experience (and others can back me up here),
that no one will ever take the trouble of addressing you by your now proper title
So let me be probably the first and the last to say, congratulations, masters…
Of Science, and Of public health (both residential and hybrid)
One definition of mastery is: “the ability to control outcomes”
and after reviewing your remarkable ILE presentations
where you tackle problems ranging from maternal telehealth to the repercussions of tackling itself–.
you’ve clearly acquired the knowledge necessary to effect truly consequential outcomes.
So let me also be probably the first and the last today to say, condolences, masters
Why condolences? Because of the debt that you’ve incurred by being here– don’t worry, that isn’t a student loan joke.
We all know there is nothing funny about those things…[hundreds of thousands of reasons not to laugh]
No, I’m merely reminding you of your obligations under the Bacon-Parker Principle. For those who are rusty, Francis Bacon, in his 1597 Meditations, wrote that “knowledge itself is power”
his collaborator Stan Lee, in the 1962 comic book sequel to Meditations— Amazing Fantasy #15, added: “with great power there must also come — great responsibility”
Therefore, the masterful knowledge you now possess, also entails responsibility.
And I’m afraid this obligation is of a special kind for TDI graduates.
Let me demonstrate. By show of hands, when applying to Dartmouth,
how many of you said you wanted to come here because you wanted to help people? Or even to save lives? [me too]
You see, whereas folks at the college or Thayer or Tuck merely have the obligation to refrain from abusing their learning, and at Geisel Med we swear an oath to help one patient a time,
you’ve signed up for the knowledge to help people at the greatest possible scale…
You’ve asked for, and now received, a super power. This is indeed a great responsibility…
But don’t worry. We are in the Same Boat, obligation-wise at least.
I am clearly not a superhero– I am a bureaucrat. [Russell Wilson however, is a super hero!]
But not only did I also sign up for the same thing as you 9 years ago,
I now serve an Office whose mission is:
“to maximize the benefits of science and technology
to advance health, prosperity, security, environmental quality, and justice for all Americans.”
Which is just a fancy way of saying we too are on the hook to help as many people as possible, using the powerful knowledge of science and technology.
Now my usual approach to this Mission is to try and make biosecurity and pandemics boring again, through the medium of extensive paperwork.
But today instead, I am speaking to you. This is not coincidence or mere ceremony;
I fully believe that by doing so, I am both fulfilling my mission and buying down a portion of my debt
by hopefully helping you to think for a moment about paying off your own.
But that is fairly selfish—it mostly helps me, and it doesn’t answer the fundamental question before us.
You’re sitting there holding this new super power.
What could or should or will you do with it?
Unfortunately, I have no idea.
Since leaving Hanover, I’ve learned that I am terrible at predictions.
Had you asked at any step of my career to anticipate the next, I’d have failed confidently and spectacularly. So I am disqualified from offering you foresight.
But I did not show up empty-handed today.
I brought you a gift, in the form of a thought experiment. Along with a few tools that others were kind enough to lend to me for my own journey.
First, the Thought Experiment
Are you ready? Close your eyes.
Open them. Look around. It’s now 1922– the second year of the Harding Administration
Here we sit, in a field. Baker-Berry Library won’t be built for another 6 years.
Just behind you, in time, lies the recent end of years of expeditionary war, the great financial crisis of 07-08, the worst pandemic in living memory starting in 1918, and an ongoing conflict involving Russia and its neighbors…
In other words, it was a different time, but one not entirely dissimilar to our own, unfortunately.
You couldn’t have known it then, in 1922.
but ahead of you lies financial depression, World War, famine, genocide, the weaponization of atomic energy, decades of existential standoff, and innumerable injustices at home and abroad whose consequences will echo well into the following century.
You couldn’t have known it then,
but ahead of you also lies the flourishing of rights movements, opposing those iniquities just enough to reveal “the long arc of the moral universe and its bend toward justice.”
Ahead of you also lies advanced technology, “indistinguishable from magic”, bringing unexpected insight, and plenty; lifting billions out of poverty. And propelling humanity’s feet to the moon, even while the hands wielding those most terrible weapons in stalemate, would remain unexpectedly stilled…
But you would know none of this, on a cool June afternoon in 1922.
So how might you have chosen where to apply your new powers, to help as many people as possible—knowing that you are blind to even the most epic contours of the century before you?
This is where the retrospectoscope comes in handy.
As you know from your long educations, the answers are always at the back of the book.
In 1999, my CDC colleagues conducted a wonderful retrospective of the 10 greatest public health achievements of the 20th century.
What they found was striking:
the 1922 versions of yourselves achieved greater than 90% reductions across
many of the greatest health problems we then faced
– resulting in a miraculous 30-year gain in life expectancy at birth by century end.
They also found something else unexpected and instructive,
that even among these biggest wins, the impacts in terms of lives saved, varied by orders of magnitude…
For example, in my own field of occupational medicine, heroes like Dr. Alice Hamilton were able to reduce the rate of workplace fatalities from 1 in every 2500 workers per year in the 1930s to under 1 in every 25,000 by century’s end.
This was a phenomenal achievement, CDC calculating that this was the equivalent of averting 40,000 deaths per year when they ran the numbers on 1997 data. A truly massive impact.
Yet if we look just next door on the list, we see something astonishing:
US infant mortality, in 1922 was a staggering 85 in every 1000 live births (today it is about 6)
had the early 20th century’s death rates carried into the 1990s, it would be the equivalent of an extra 500,000 infant deaths, each year.
A steeper risk, affecting a larger portion of the population, yielded a greater than factor of 10 difference, in the size of opportunity to save lives.
Of course, I don’t mean to suggest that everyone should be crowding around to work on the same problem, neglecting crucial others.
I do mean to suggest however, that if you aren’t working on a problem causing massive harm, that you’ve deeply examined the reasons why, given you now have a superpower that applies to health problems at any scale.
Of course, tractability also matters– it is probably better to solve a smaller significant problem, than to founder against a larger one. So if you are the Alice Hamilton in the audience, please go find and solve the 21st century equivalent of occupational medicine. But if you’re unsure where your comparative advantage lies, as most of us are, why not go big?
At the very least, this will protect you against the dreaded Hamming questions– which were posed to me on my first week of the job at the White House.
Richard Hamming was a renowned mathematician at the legendary Bell Labs, who used to drift amongst the various groups of researchers in the cafeteria at lunch and ask three simple questions:
- “What are the most important problems of your field?”
And after a week or so of listening, he’d ask:
- “What problems are you working on now?”
he’d listen intently for some days, before finally:
- If what you are doing is not important, and if you don’t think it is going to lead to something important, then why are you at Bell Labs working on it?’
He eventually ran out of folks to eat lunch with,
but his legacy has been a useful goad to impact-minded folks ever since.
// So let’s say you decided to walk off the stage in 1922 and attack the infectious diseases of childhood.
And we know now that you could have succeeded beyond your wildest hopes.
Pulling the threats of how this actually happened reveals two useful and fundamental approaches to keep in your 21st century toolkit.
In 1922, pertussis (or whooping cough) was killing about 6000 US children each year–comparable to nearly 20 thousand per year today.
The chain of discovery to solve a problem like this with vaccine development has about 7 steps.
In 1922, only step one was solved. We knew the bug– Bordetella Pertussis. But it was hard to grow, and no effective therapy had been demonstrated, let alone distributed at scale.
In the 30’s, public health researchers Drs. Pearl Kendrick and Grace Eldering sequentially and successfully attacked every remaining link in the chain needed to solve this problem.
They improved the growth medium, figured out how to isolate and attenuate the pathogen, conducted sterility and safety tests by injecting their own arms….
They designed, funded, and ran some of the first wide-scale vaccine trials to demonstrate efficacy (well before big trials and national science funding were the norm),
they worked with industry to standardize production at scale, and with NGOs to scale up distribution.
By 1940 their vaccine was distributed nationally, and soon after globally by the newly formed World Health Organization. By century end, fewer than 10 US children per year would succumb to whooping cough. Still too many, but the world was 19,000 tragedies lighter each year than it might have been otherwise.
At her passing in 1981, Pearl Kendrick’s contribution alone was estimated to have saved hundreds of thousands of lives– an impact undoubtedly in the millions today and still accruing interest.
A second anecdote, suggests a parallel approach:
Recall the 7 steps in the chain of vaccine discovery just mentioned. For decades there was a profound bottleneck at step 2 (growing pathogens) especially for viruses. This is because the cell cultures then in use were both finicky, and dangerously contaminated, hampering vaccine development.
In 1962, researcher Dr. Leonard Hayflick successfully isolated the first uncontaminated human cell strain, capable of both serial culture, and resurrection from frozen storage– relaxing the bottleneck.
WI-38 would eventually be used to develop or produce the majority of the 20th century’s human virus vaccines, (such as measles, mumps, rubella, zoster, and rabies) which collectively would save many tens of millions of lives globally through the remainder of the century.
A conservative accounting of the impact of this single innovation, even just over the 5 years between it and the development of other cell strains, runs easily into the hundreds of thousands to millions of lives.
//These two approaches have enduring utility, and are worth recycling for your own 21st century toolkit.
- going deep into one problem and working backwards from its solution
- or attacking a bottleneck, unblocking the solutions to many problems at once.
Now, the contrarians among you, – and I would have been one of them – may be thinking, well if people are working on every problem, someone is bound to get lucky, and in retrospect look like a hero just from random chance.
You’d have a point, that chance plays a role. But I’d like to submit that it is easy to underestimate just how scarce a resource people like yourselves are. There are not enough super heroes to go around.
And to the extent that their efforts are not optimally allocated,
there really are opportunities to help people at massive scale, just lying around
–but for the right people to become obsessed with solving them.
The Market for saving lives is far from efficient.
This is as true in 2022 as it was in 1922 and 1962. The well of opportunities to help people or to save lives at scale, certainly hasn’t dried up.
Just since my own graduation in 2013, approximately one million malaria deaths have been averted, through efforts such as scaling up distribution of insecticide-treated bed nets.
And in our current pandemic, the unbelievably rapid development of mRNA vaccines by folks like my OSTP colleague Dr. Matt Hepburn, helped to save millions of lives globally over the past 2 years.
An individual with knowledge like yours can still have a disproportionately positive impact on the world.
And while this is far from certain, it is also far from random.
Luck can be courted, or even, reverse-engineered.
If you combine the skills you now have with the aspirations you began with, you can take more and higher-quality shots on goal, against the biggest problems we collectively face, for the rest of your career.
There are quite literally billions of lives waiting to be impacted by the decisions you make after today.
You will have that impact, if you are as intentional and rigorous about the choice of problems that you attempt to solve, as the methods by which you’ve now been trained to solve them.
This, I submit, is what it means to wield your super power wisely.
In Closing It is important to add that you can’t, and shouldn’t try, to do this alone
And you won’t have to.
The real secret of access is that the world has a way of opening its arms,
and extending its hands, when it discovers that you are credibly attempting to better it.
You have the folks who got you this far– hang onto them!
And you have now joined a community of alumni, standing by in support,
along with a wider network of fellow travelers stretching to the White House and well-beyond.
Finally, if I can serve as an existence proof of a final possibility,
it is that you’ll be back, and up here, if you so choose.
What stories will you tell then, about how you chose to use your superpower, starting today?
I, everyone here, and even everyone not here– cannot wait to find out.
Our future quite literally depends on your answers…
And so we collectively wish you, “way more than luck.”
Thank you.
make myself 