Commencement Address: James P. Grant School of Public Health of BRAC University
By Henry B. Perry
Greetings to each and every one of you — graduates, family members, faculty, and friends. I know all of us are feeling the pain of our social isolation from not being able to be physically present in the same space for this joyous moment. I join you from Durham, North Carolina, where I have recently moved from Baltimore as I transition into semi-retirement.
First of all, I want to extend my heartiest congratulations to each of you who are graduating from this extraordinary school of public health. You are standing at the threshold of a new stage in life during which you will have the privilege of translating the learnings of your MPH program into your day-to-day professional life — not only facts and tools but perspectives and passions that have arisen during your time of study. You have been very fortunate to be able to study at one of the world’s premier schools of public health that is immersed within the realities of Bangladesh and BRAC, which have made, as we all know, extraordinary progress in improving the health of its people.
Secondly, I want you to know how deeply honored I am to have this privilege of sharing a few words of provocation and inspiration.
Thirdly, I want to assure you that this will be brief. A few years ago at a commencement ceremony similar to this at Yale University, the commencement speaker focused his address around four points — one on the letter Y, one of the letter A, one on the letter L, and one on the letter E. After suffering through his overly long address, the chaplain finally gave the closing prayer and said, “Lord, we give you thanks that we are not at the Massachusetts Institute of Technology!” The implication in the joke is that the chaplain was so pleased that they were not at the Massachusetts Institute of Technology, because the commencement speaker, totally oblivious to how long and overly boring his speech was, would have likely spoken about each letter in the name and would have taken even far, far longer to complete his speech.
I am going to be brief and give you three pieces of advice that you can, I hope, at least ponder. But I know that speeches like these are not unlike classroom lectures — which someone defined as a series of words that pass from the tongue of the professor into the handwritten notes of the student without passing through the minds of either. If only a handful of you remember and take to heart one or two points from this, I will feel that my mission has been accomplished!
I am so grateful for the opportunity that I had to live and work in Bangladesh from 1995 to 1999 and to learn firsthand about BRAC and also about all the pioneering work in public health, community-based primary health, and social development that have made Bangladesh a “positive deviant” among low-income countries. It was during that time that I came to know many BRAC staff, most notably your first Dean and the Chair for our ceremony today, Dr. Mushtaque Chowdhury. In my view, Mushtaque has been one of the foremost public health champions of my generation because of his remarkable contributions to the development of BRAC as an organization, to the creation of high-quality programs at BRAC that serve the needs of poor people and empower women, and for the capacity that he has had to bring the best of science, public health, epidemiology, and monitoring and evaluation for the benefit of large-scale practical programs that have improved the lives of millions of people. After I left Bangladesh and moved to Haiti, I nominated BRAC for an award of $1 million that the Gates Foundation was giving each year to an outstanding organization working in the field of global health. Not surprisingly, BRAC won that award in 2004, beating out 50 other nominations. I was so proud to have played a small role in making that possible. Of importance for today, the funds from that award were used to help establish this school of public health. So, I have always been very proud as well to have claimed, at least in my own mind, a small bit of ownership in the creation of this school.
The principles of BRAC and the James P. Grant School of Public Health
The principles upon which BRAC and this school have been built are so important to our world — not only for yesterday and today, but also for tomorrow as well. These include, but of course aren’t limited to, working in partnership with the poor, and especially with poor women, to build healthier lives for themselves, their children and their families through practical, effective sustainable programs to enable them to achieve healthier lives with dignity and purpose, using the best available knowledge, field experience and technical expertise. To soak in these values as a student in an MPH program that is immersed in the reality of the community and the rich community health programs that are Bangladesh’s has, I’m sure, been an enriching, ennobling and transforming experience.
Advice for the challenges of today and tomorrow
In thinking about the many challenges that you and all of us face both today and tomorrow, I want to focus today on three interrelated themes: i) ending deaths from readily preventable or treatable conditions, ii) engaging more effectively with communities as partners to help them improve their health, and iii) maintaining your moral compass.
Ending deaths from readily preventable or treatable conditions
The progress that the world has made, and that Bangladesh in particular has made, in improving the health and well-being of the world’s poorest countries has been one of the great advances of our world over the past 50 years. James P. Grant was one of the leaders who inspired and led this advance through his leadership for and promotion of what has been referred to as the first child survival revolution — the saving of millions of lives of children through highly effective vertical programs of immunization, prevention and treatment of childhood diarrhea (and promotion of home-made oral rehydration therapy), birth spacing, and other specific interventions. This was, as many have said, picking the low-hanging fruit off the tree. The fact remains that 5.3 million children are still dying each year,(1) almost all from readily preventable or treatable conditions.
Nicholas Kristof, the masterful op-ed contributor to the New York Times, wrote a column in July of this year that he entitled “The Mistakes That Will Haunt Our Legacy.”(2) He asked the question, “What will our great-grandchildren find bewildering and immoral about our own times?” This is a question highly relevant to us in the United States as we find our own history of slavery and racism so bewildering and immoral. His answer to that question contained the following:
“A second area [in addition to denialism about climate change and abuse of animals in factory farms] that … will leave future generations baffled at our heartlessness is our indifference to suffering in impoverished countries. More than five million young children will die this year around the world from diarrhea, malnutrition or other ailments; we let these children perish essentially because of our tribalism. They are not a priority for us.” (2)
Elsewhere, Kristof and his wife Sheryl WuDann, in their powerful book entitled Half the Sky: Turning Oppression into Opportunity for Women Worldwide,(3) argue that the defining challenge for the 21st century will be to overcome the oppression that women face throughout the world in the same way that overcoming totalitarianism was the defining challenge of the 20th century and overcoming slavery was the defining challenge of the 19th century. Ending preventable child and maternal deaths will require reducing the gender inequities that women throughout the world face.
The political scientist George Kent reminds us that “Health status is not determined primarily by health systems but by wealth and power. Widespread malnutrition and disease are due to poverty, but even more fundamentally to powerlessness…. Women and children are relatively powerless within the households. Small children in particular cannot fend for themselves, and are thoroughly at the mercy of others…. Empowerment means something more than people’s following instructions or answering questions. It means their full participation in the roots of their own problems, and it means their choosing action on the basis of their own analyses rather than on someone else’s…. To be empowered is to increase your capacity to define, analyze and act on your own problems. Who, when not deprived of the means, would not save their own children?”(4)
Given our knowledge, experience and expertise, these deaths are tragic and represent a failure of public health, of the global health community, national political leaders, and the world at large. All deaths from readily preventable or treatable causes represent failures of public health, of the global health community, of national political and governmental leaders, and of the world at large.
In addition to the 5.2 million deaths of liveborn children each year, there are 295,000 mothers dying each year from complications of childbirth(1), 2 million babies dying each year during the birth process,(5) 1.4 million people dying each year from tuberculosis(6), 690,000 people dying each year from HIV/AIDS, 445,000 dying each year from malaria(7), 1.5 million dying each year from lack of access to basic surgical care, 9.4 million people dying each year from hypertension(8) and 3.8 million dying each year from diabetes.(9) This totals to 25 million deaths each year — and the poorest billion of our world suffering disproportionately. These deaths represent one of the great moral and ethical challenges of our time.
An NGO called Muso, working in an impoverished peri-urban population of Bamako, Mali, has shown us that with frequent home visits, early detection of sick children with danger signs, and prompt treatment in the home or at a nearby clinic, under-5 mortality rates can be achieved that are the same as those enjoyed in developed countries.(10)
The United Nations estimates that one-half of the world’s population (3.8 million people) lacks access to essential health services.11 At the current pace, the goal of reaching the health-related Sustainable Development Goals established by the United Nations — Universal Health Coverage and ending preventable and child deaths — will not be achieved in 2030 by one-third of the world’s population and therefore a “measurable acceleration” is urgently needed.(11)
Advice number 1: Never forget your responsibility as a member of the human race and as a public health professional to support the elimination of deaths from readily preventable or treatable causes in your community, region, country and world. Accelerating the reduction in the number of these deaths is essential for reaching Health for All.
Engaging more effectively with communities as partners to help them improve their health
In spite of all the progress that has been made in global public health, one of the great failures in my view has been the lack of progress made in engaging communities as partners in improving their health. Even though the 1978 Declaration of Alma-Ata reminds us that “The people have the right and the duty to participate individually and collectively in the planning and implementation of their health care.”(12) The medical historian Randall Packard tells us that the history of global health has largely been a history of what he calls “interventions into the lives of other people”(13) — top-down initiatives in which the voices and concerns of the grassroots have been largely neglected.
When I was living in Bangladesh, I had the privilege of hearing the great Sir FH Abed, the founder of this great institution, give a lecture in which he said that after World War II when the United States was the unquestioned leader of the world, the rest of the world wanted to emulate what the United States had in terms of health care, and that meant specialized doctors, highly trained nurses, and well-equipped hospitals. Consequently, developing countries throughout the world sought to emulate the US health care system without first building a foundation of public health that had taken the United States decades to develop. And this foundation of public health was built at the local level, not at the national level, by local counties, communities, cities and states establishing their own health departments, promoting public health measures, registering vital events, and monitoring progress over time at the local level. As Sir Abed told us, the rest of the world failed to recognize that the good health that the US had achieved at that time was in reality built on a public health foundation of good nutrition, safe water and sanitation, adequate housing, and healthy household practices.
It was this over-reliance on Westernized, curative medicine that spawned the 1978 International Conference on Primary Health Care and the Declaration of Alma-Ata(12), which I like to refer to as the “sacred scripture” of global health. And James P. Grant as Executive Director of UNICEF, along with Halfdan Mahler, as Director General of the World Health Organization, convened this conference, which was the largest international governmental conference on health that had been held up to that time.
Unfortunately, still today, low-income countries are overly dependent on funding and initiatives from the national and global levels; empowered local communities, districts, cities and states with strong health departments that register vital events, determine their own health priorities with their local data, and monitor progress over time with their own data are a rarity. We have become too dependent on the “trickling down” of funding and technical assistance, leading to an overdependence on others rather than on what the community can do itself to improve the health of its members.
I am convinced that in all but the most impoverished settings, there is the potential for substantial local resource mobilization that can be used to strengthen local health services and improve the health of the local population. Even if the amounts are modest, these resources can play an important role in strengthening primary health care services and improving access to needed higher levels of care.(14)
I have been telling my students for the past decade now that our greatest resource in global health is the people in the community, not money or high-level health professionals or hospitals. That is not to say that these other resources are not important, but without empowered communities, we will never be able to complete the second child survival revolution of ending preventable child deaths or any of the other health priorities I just mentioned.
CEA Winslow, who founded the Yale University Department of Public Health in 2015, defined public health as:
“… the science and art of preventing disease, prolonging life, and promoting physical health and mental health and efficiency through organized community efforts toward a sanitary environment; the control of community infections; the education of the individual in the principles of personal hygiene; the organization of medical and nursing service for the early diagnosis and treatment of disease; and the development of the social machinery to ensure every individual in the community has a standard of living adequate for the maintenance of health.”
The key operative phrase here is “organized community efforts.”
One of my mentors, John Wyon, conceptualized public health as a three-legged stool. One leg he referred to as disease-oriented public health, the second leg as services-oriented public health, and the third leg as community-oriented public health. The goal of disease-oriented public health is the control of a disease of public health importance — and of course the efforts now underway to control the COVID-19 pandemic is now the most pressing public health emergency throughout the world. The goal of services-oriented public health is to get basic and essential health services to those who need them. This is often the responsibility of governments through their ministries of health or national health services, but as we all know NGOs and civil society make important contribution to services-oriented public health. The third leg of this stool, community-oriented public health, has as its goal to work with communities to help them improve their health. All three legs are vitally important, but as my mentor liked to say, this third leg has been the weak leg of global public health. Without a strong third leg, the stool itself is a weak and unstable one, unable to fully fulfill its purpose of optimally improving the health of the public.
In my view, community-oriented public health represents one of the great opportunities for the future in improving the health of the public. Learning how to work with communities to help them improve their health has been one of the great contributions that BRAC has made to Bangladesh and to the world, and the resources and skills that you have obtained in community-oriented public health will help you to be a leader in this still new frontier of public health. Without community engagement and partnerships with communities in which they themselves are motivated to take action in addressing their local health priorities, we will never be able to reach Health for All. This means giving communities the skills and tools to help them understand their own local epidemiological priorities and the capacity to determine if local health programs are addressing the local priorities and actually improving the health of their local communities.
Community health workers are one of the key resources we have at our disposal to promote community-oriented public health, to achieve Universal Health Coverage, and to end preventable child and maternal deaths. Bangladesh has been a global leader in the development of CHW programs at scale, but there is still more to do — especially as one considers the unmet challenge of expanding access to the prevention, screening, diagnosis and treatment of non-communicable diseases such as hypertension, diabetes and mental illness. And the role of CHWs in ending the HIV/AIDS epidemic and in controlling tuberculosis and malaria, is increasingly being seen as essential.
The COVID-19 pandemic is providing us with a lesson about the importance of community health workers and community engagement for promotion of preventive behaviors, surveillance, contact tracing. and immunization. The experts tell us that more pandemics are likely to occur, so building a stronger community platform for primary health care will be an investment in mitigating the effects of future pandemics. Even in developed countries, the role of CHWs and the number of CHWs are now expanding as evidence continues to accumulate of their effectiveness in improving access to services in marginalized and under-served populations.(15) A serious proposal has emerged for a national CHW cadre in the United Kingdom to bolster the response to the COVID-19 pandemic but also, once the pandemic has ended, to provide an ongoing source, through frequent routine home visitation, of support for those who continue to have unmet health needs.(16)
Without a massive expansion in community health worker programming throughout the world, it will not be able to achieve Universal Health Coverage or end preventable child and maternal deaths.(17)
Advice number 2: Do all that you can to engage communities in the process of improving their own health, helping them to have the skills and tools to understand their own health priorities and to engage in and monitor programs that address these priorities.
Maintaining your moral compass
William Foege, one of the great leaders of global public health of my era who was a leader in the smallpox eradication program in the 1970s and generally considered to be the greatest director ever of the US Centers for Disease Control and Prevention, posited the following four premises of public health:
i) The philosophy of public health is social justice.
ii) The primary goal of public health is to reduce or eliminate differences in mortality and morbidity between populations.
iii) The science on which public health decisions are based is epidemiology,… [and] the science of demography augments epidemiology in studying population problems.
iv) The most important medical ethical decision is how we allocate resources. This includes planning and administering public health programs to reduce major causes of mortality, morbidity, disability, and behavior which reduce the quality of life.(18)
Creating and maintaining one’s professional and personal moral compass is not easy, as we all are pushed and pulled in so many directions in a world that seems ever more confusing. I offer two suggestions to embolden your moral compass and to endeavor to follow its direction: i) identify persons who personify the ideals that you think are valuable and worthwhile and try your best, in whatever challenging circumstances you find yourself, to emulate them, and ii) identify colleagues with whom you can work who can support you as you try to follow the path to which your moral conscience is guiding you. Remember that public health is a team sport.
Here are a few words of wisdom that I have accumulated over my career that have helped me:
“Change is possible through human acts of compassion, courage and conviction. I have spent my life watching optimism triumph over despair when the light of self-belief is sparked in people. As a team, I want us to keep lighting these sparks.” – F. H. Abed
_____
“When you are in doubt, or when the self becomes too much in you, bring before your eyes the weakest, most wretched and miserable human being that you ever saw, and ask yourself that the step you contemplate, ‘Will it reduce his misery? Will it reduce his helplessness?’ You will get your answer.” – Mahatma Gandhi
“A true human is one who feels the pain of others, removes misery and is never arrogant.” — Mahatma Gandhi
_____
“Life is a voyage in which we choose neither vessel nor weather, but much can be done in the management of the sail and the guidance of the helm.” — Unknown
_____
“If you’re not failing, you’re not trying hard enough.” — Unknown
_____
“If you want to go fast, go alone. If you want to go far, go together.” — African proverb
_____
“There are five fundamental qualities that make every team great: commitment, trust, collective responsibility, caring and pride. I like to think of each as a separate finger on the fist. Any one individually is important. But all of them together are unbeatable.”
– Mike Krzyzewski (renowned Duke University basketball coach)
_____
“Far and away the best prize that life offers is the chance to work hard at work worth doing.” — Theodore Roosevelt
_____
“You don’t have to plan out your whole working life from beginning to end. Just start out doing your thing. Even if you don’t know where you’ll end up, you can have an exciting life. But never lose sight of your values. You should have a purpose, a passion that drives you.” — Edyth Schoenrich, Professor, Johns Hopkins School of Public Health
_____
When it’s over, I don’t want to wonder if I have made of my life something particular, and real. I don’t want to find myself sighing and frightened, or full of argument. I don’t want to end up simply having visited this world.
– Mary Oliver (poet)
_____
Do not get lost in a sea of despair. Be hopeful, be optimistic. Our struggle is not the struggle of a day, a week, a month, or a year, it is the struggle of a lifetime. Never, ever be afraid to make some noise and get in trouble, necessary trouble.”
– John Lewis (US congressman to died in 2020 and was a leader of the civil rights
movement)
_____
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane” — Martin Luther King, Jr.
_____
“The arc of the moral universe is long, but it bends toward justice.” — Martin Luther
King, Jr.
Advice number 3: Never lose your moral compass and your passion for serving others, for serving the public good, and for helping your colleagues in the pursuit of better health.
In closing
Remember always that you have now become a part of that treasured tradition of pioneering community-oriented public health. You are standing on the shoulders of giants who preceded you: James P. Grant and his father, John B. Grant, F.H. Abed, Mushtaque Chowdhury and many others.
In 1972 NRE Fendall wrote, “If I were asked to compose an epitaph on medicine through the 20th century, it would read: “Brilliant in its discoveries, superb in its technological breakthroughs, but woefully inept in its application to those most in need.” Will an epitaph on medicine (and public health) through the 21st century read “Health for All was attained”? The International Declaration of Health Rights(19) calls us to affirm that “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being. It is not a privilege reserved for those with power, money or social standing.”
Go forth with thanksgiving for what you have received, embrace the dignity of your calling, and commit yourself to do your part to achieve Health for All.
References
1. UNICEF. State of the World’s Children 2019: Children, Food and Nutrition — Growing Well in a Changing World. 2019. https://www.unicef.org/media/63016/file/SOWC-2019.pdf (accessed 18 January 2021).
2. Kristof N. The Mistakes That Will Haunt Our Legacy. 2020. https://www.nytimes.com/2020/07/11/opinion/sunday/animal-rights-cruelty.html (accessed 18 January 2021).
3. Kristof N, WuDunn S. Half the Sky: Turning Oppression into Opportunity for Women Worldwide. New York: Vintage Books; 2009.
4. Kent G. Who would not save thier own children? The impact of powerlessness on child survival. Development Forum 1988; 519.
5. UNICEF. Stillbirths. 2020. https://data.unicef.org/topic/child-survival/stillbirths/ (accessed 18 January 2020).
6. WHO. Tuberculosis. 2020. https://www.who.int/news-room/fact-sheets/detail/tuberculosis (accessed 18 January 2021).
7. WHO. World Malaria Report. 2017. https://apps.who.int/iris/bitstream/handle/10665/259492/9789241565523-eng.pdf;jsessionid=EABC4F0E444A9919D1CF0DDE5EF2D239?sequence=1 (accessed 18 January 2021).
8. Angell SY, De Cock KM, Frieden TR. A public health approach to global management of hypertension. Lancet 2015; 825–7.https://www.ncbi.nlm.nih.gov/pubmed/25752181.
9. WHO. Diabetes: Key Facts. 2020. https://www.who.int/news-room/fact-sheets/detail/diabetes#:~:text=In%202016%2C%20an%20estimated%201.6,the%20age%20of%2070%20years. (accessed 18 January 2021.
10. Johnson AD, Thiero O, Whidden C, et al. Proactive community case management and child survival in periurban Mali. BMJ Glob Health 2018; e000634.https://www.ncbi.nlm.nih.gov/pubmed/29607100.
11. UNGA. Resolution adopted by the General Assembly on 10 October 2019: Political declaration of the high-level meeting on universal health coverage. 2019. https://undocs.org/en/A/RES/74/2 (accessed 18 January 2021).
12. WHO, UNICEF. Declaration of Alma-Ata. 1978. http://www.who.int/publications/almaata_declaration_en.pdf (accessed 18 January 2021).
13. Packard R. A History of Global Health: Interventions into the Lives of Other People. Baltimore, MD: Johns Hopkins University Press; 2016.
14. Uddin M, Shams Z, Haque N, Jahan S, Perry H. Description and learnings from a pilot study to strengthen close-to-community primary health care services: the community-clinic-centered health service model in Barishal District, Bangladesh. Global Health: Science and Practice 2021.
15. Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annual review of public health 2014; 399–421.http://www.ncbi.nlm.nih.gov/pubmed/24387091.
16. Haines A, de Barros EF, Berlin A, Heymann DL, Harris MJ. National UK programme of community health workers for COVID-19 response. Lancet 2020; 1173–5.https://www.ncbi.nlm.nih.gov/pubmed/32220277.
17. Perry H, Hodgins S. Health for the People: Past, Current and Future Contributionss of National Community Health Worker Programs to Achieving Global Health Goals. Global Health: Science and Practice 2021.
18. Foege W. Morality, Ethics and Public Health: The Four Premises of Public Health, nd.
19. International Declaration of Health Rights. https://www.jhsph.edu/about/school-at-a-glance/international-declaration-of-health-rights/ (accessed 18 January 2021).
Henry B. Perry, MD, PhD, MPH is the Senior Associate of Health Systems Program at the Department of International Health, Johns Hopkins Bloomberg School of Public Health
