Donna Shalala

"Expect the Unexpected" - Harvard T.H. Chan School of Public Health Commencement Address - May 26, 2016

Donna Shalala
May 26, 2016— Harvard University, Boston, Massachusetts
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Thank you so much, Dean Hunter. And thank you for your leadership. Let’s give Dean Hunter a big hand. It’s not easy to be an acting anything.

Before I begin, I’d like to give a shout out to the Green Team. I had a chance to meet them when I first arrived, and all of you have done a remarkable job, not just in recycling but in thinking about how we improve the environment. So let’s give a bug hand to the Eco-Opportunity group.

Dean Hunter, let me also congratulate Michelle Williams, your new dean, who will be leading this remarkable school.

I also want to acknowledge Yu Na, you student speaker, because she’s already learned one of the most important things about public health—it’s not the big policy making, but it’s the individual life that you can affect, and I think her message was the most important message that anyone in public health can transmit to all of you. Look around you and give a helping hand to individuals, and you will only learn how to do that if you learn to listen and if you’re present in this world to help as many individuals as you do big policy decisions.

I remember my own commencement. I was very anxious, very stressed out, wondering whether the speaker would ever finish. Actually, it’s been said that commencement speakers should be like a body at an Irish wake—they need you for the party but they don’t expect you to say very much.

Twenty years ago at a conference hosted by former President Gerry Ford, I actually got into a debate with the then-U.S. Ambassador to the United Nations, Jeane Kirkpatrick, on the issue of health as a national security issue. Ambassador Kirkpatrick argued very strongly that health was a kind of soft social issue and didn’t belong in any high-powered security discussion. I actually used AIDS as an example, noting that it was devastating the next generation of leaders—particularly in Africa—and that militaries around the world were confronted not only with conventional conflicts, but what was, at that time, a deadly untreatable disease. During the second term of the Clinton administration I even detailed a senior Public Health Service officer to the National Security Council to make the point that health was indeed a national security issue.

It seems quaint to say that today, because not only has that case been made, but indeed increasingly, almost everyone believes that the progress of nations depends on the quality of the health and education of all of our citizens.

This week at the G7 Summit in Japan, health issues will be a key item on the agenda, in part I think because Japan has consciously focused in recent years on the promotion of health security and sustainable development as national priorities. At the core of both of those concepts is the issue of health.

When the international community adopted the Millennium Development Goals in 2000, only three were health goals and all were focused on low-income nations. And we made substantial progress on all of these goals—cutting maternal mortality nearly in half, reducing child mortality by the same amount, and reaching more people with treatment for HIV/AIDS than ever before. It was proof that even in the poorest places on this earth we could dramatically improve public health.

While the new Sustainable Development Goals adopted last September are broader and cover developed countries as well as growing countries, they too are measurable. And all of us are hopeful that with the same kind of effort by the global community, they will continue to improve the health and well-being of the world’s population.

I tell you all this to remind you that not only has public health evolved around the world from improvements in sanitation, vaccination, clean air and water, and building codes. But, for the first time, it has the attention of the world’s leaders because they know it impacts their economies, their security, and their reputations.

You have learned a lot of this in the classroom—along with superb analytic and technical skills.

But the test of your professionalism and the test of your effectiveness will be how well you understand people and their lives, and, more importantly, how well you handle the unexpected.

The new challenges for all of you are almost obvious.

When you leave here today, you will be expected to:

  • Research, understand, and manage the next generation of infectious disease and environmental crises.
  • You’ll be expected to find a way to improve the health and science infrastructure of every place on earth.
  • You’ll be expected to advocate for wealthier nations not to abandon their financial commitment to poorer nations.
  • And you’ll be expected to convince health policy leaders—the heads of state of the world—to use rigorous scientific evidence to make decisions.

These aren’t small tasks.

In case you haven’t noticed there is an election going on this country. And so I thought as your last assignment I would urge you to write a memo to the next President of the United States—and if you’re not an American, you can write it to your own head of state. Hopefully you have learned enough to write that memo. But that memo must be a memo to improve lives. The letter should be short and to the point. The new President will be overwhelmed with advice. More importantly he or she will have made promises during the course of the campaign that he or she will be expected to keep.

In fact, to put this into context, at this moment there’s a college dropout somewhere following each presidential candidate and writing down on their iPad all the promises made by the candidate to the American people.

And here’s what happens in January of next year: On their first day in office the new President will call in their new cabinet members one by one and give them a list of commitments already made in their area. Most likely, the new cabinet member will have my reaction—“You didn’t say that, did you?!”

As the health secretary, on the top of the list I was given was getting all the children in the United States immunized on time—that means before they were three years old. To put the scope of the challenge in perspective, in the early nineties the United States ranked just above Haiti in our region on early immunizations. Less than half of our children were being immunized on time.

So, like a well-trained enthusiastic new government leader, I called together the public health leaders of my new department—the Food and Drug Administration, the Centers for Disease Control, the National Institutes of Health, the Surgeon General. One by one they patiently explained to the new secretary that without universal health care, we could not get the job done. Second, they assured me that the cost of immunizations was simply too much for young families to bear and then they urged me to tell the President that the kids will get their shots by the time they started school, and that there was no reason to be anxious about getting their shots early, even though the science had been very clear.

However, not wanting to return to the new President with an early failure, I reached into my purse and pulled out a postcard. It was written to my dog—a wonderful golden retriever named Bucky.

This is what it said, “Dear Bucky, Time to come in for your next shot,” and it was signed by Bucky’s veterinarian.

“A-ha,” I said to the assembled group of these powerful public health people, “If the veterinarians in this country can put a system in place to get all the dogs, the cats, the sheep, the goats and the cows vaccinated on time, we can do it for the children of the United States.” Well, we did it! We built an ad hoc system that continues to this day.

The issues that you’re going to face are far more complex and daunting.

And so my message to you today is to expect the unexpected.

The history of public health is the story of surprises. We now expect the unexpected. During your time here, the world has dealt with H1N1, MERS, Ebola, and now Zika—and possibly next year Yellow Fever.

Unless the world leaders confront the fact that our international public health infrastructure is too weak to manage outbreaks and emergencies, many of you will spend your careers simply being reactive to the latest public health crisis.

Numerous panels have analyzed the world’s response to Ebola and have told us what to do—including one of the panels led by this School, which included two members of my board, Chelsea Clinton and Eric Goosby.

One of the panels, the Advisory Group on the Reform of WHO’s work in Outbreaks and Emergencies, made this point very clear. As the lead international health organization, the WHO, they wrote, “must be prepared to undertake a profound organizational transformation rather than piecemeal reform.” It’s not easy—there aren’t a lot of governments or organizations that can undertake a profound organizational transformation. Words like “profound organizational transformation” rarely happen.

In our frustration with the WHO, we have allowed a fragmented group of international health agencies and initiatives to develop, each of whom have their own separate funding streams. This has delayed the major reforms at WHO and jeopardized not only the effective management of global health crises, but our citizens’ confidence in their governments’ ability to respond to unexpected and daunting public health challenges.

But no matter how strong any organization’s ability to respond to these challenges, all the complex situations require the expertise and input of many people—of NGOs, of governments, of the private sector working together to find the best solutions. In our experience at the Clinton Foundation, we’ve found that bringing together partners with diverse skill sets and points of view—each of whom knows something that the other doesn’t—produces solutions that are better and faster and less expensive than any single organization could produce on its own. And it’s the approach to partnership and problem solving that we take at the Foundation.

To give you an example, during the Ebola outbreak in West Africa, 24 Clinton Global Initiative members from the public, the private and the nonprofit sectors came together at our 2014 Annual Meeting to figure out how they could support the governments of Liberia, Sierra Leone and Guinea in their efforts to stop the outbreak.

If you remember, at the time, no one was sure exactly how quickly Ebola would spread. Or how far. But with the number of new cases doubling every week there was an urgent need for critical medicine, personal protective equipment, and medical supplies in each of those three countries. Not to mention more healthcare workers who could identify new cases, care for the sick, and continue to provide routine medical care for the well.

Together these 24 CGI members mounted a truly staggering response to deliver, as Paul Farmer likes to say, “the staff, the stuff, the space, and the systems” that heroic workers on the front line needed to help contain the epidemic. They included corporations working in the region to provide support to their employees and to keep operations running. And nonprofits who provided and coordinated the delivery of hundreds of tons of urgently needed medical supplies—all in cooperation with the ministries of health in each of the affected countries and with the support of many partners in the United States and overseas. It was a monumental effort and, I think, an example of public-private partnership at its finest.

But even beyond the global epidemics like Ebola, which require an outsized response and extraordinary systems, we have to confront the lack of investment in public health infrastructure in our daily lives and home countries if we want to improve the health and well-being of our citizens—including in the United States. My own experience in politics is that politicians’ eyes glaze over when you talk about the need for such investments.

Only the linking of emergencies and national security has moved them, and not often or quickly enough.

However, we must repeat over and over again. There is no substitute, as Larry Brilliant has pointed out, for “early detection, and early response” and, I’m sure he would add, for an effective decision making process and strong health infrastructures.

Finally, we need to make our case to our citizens much more clearly on why a strong health infrastructure, including the preparation of the next generation of health workers, is so important.

It would help if we learned to communicate when there is a crisis—and an outbreak—more clearly and consistently about the scientific facts of the outbreak and the standard treatment protocols.

I used to have a rule at HHS that no one without a white coat or a uniform for the Public Health Service, or without the proper scientific public health credentials, could speak about a health emergency. The trust that we have in public health, science and medicine erodes quickly when we politicize it, or allow non-health experts to explain the crisis and reassure the public.

You will spend your careers struggling with these issues.

The big issues of infrastructure and preparation for emergencies will determine the fate of millions of people.

It will be a great life adventure for each one of you.

Each one of you will get the opportunity to save lives—and enrich them because you have chosen to embark on this great adventure called public health.

And so I wish you well in the years ahead as you expect the unexpected.

Thank you.

Speech from https://www.hsph.harvard.edu/news/features/commencement-2016-clinton-foundation-president-donna-shalala-address.