Commencement address, delivered by Sherman James of Duke University, at the Tulane University School of Public Health and Tropical Medicine, New Orleans, LA; May 13, 2011.
Thank you very much, Dean Beukens, for such a generous introduction; however, it reminds me and it may remind the audience of some good advice offered by a famous politician[1] a few decades ago. He said: "Introductions of commencement speakers should be sniffed, but not inhaled."
But, seriously, I was very honored by the Dean's invitation to give the commencement address to this year's graduates of the oldest and certainly one of the best Schools of Public Health in the United States.
Graduates – this is your special day. Your talent and hard work, and the support you received from your professors, fellow students, friends and family have come together in just the right way to make this special day possible. Today, we celebrate your accomplishments and we rejoice with you. But, as we rejoice, let us also keep in our thoughts and prayers the many people – those who are distant and those who are close by - who are less fortunate than we. And, let us use this celebratory occasion to rededicate ourselves to doing all that we can to lighten their load.
"We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain inalienable rights; that among these are life, liberty, and the pursuit of happiness…"
These memorable words open the second paragraph of our nation's Declaration of Independence – a treasured document that was signed by the Founders on July 4th, 1776 – 235 years ago. Given the times in which the Founders lived, however, this document reserved the full benefits of these inalienable rights to men, and to white men at that. But, any objective reading of American history makes it clear that the central story of America is the inexorable, though often highly contentious, expansion of these inalienable rights to all of her citizens.
Rights, in contrast to privileges, impose duties on others for their satisfaction; hence, there is a broad consensus – at least in mature, western democracies – that governments have a key role to play in safeguarding what the Founders of this country called the inalienable rights to life and liberty.
It is not at all clear, however, that a similar, broad consensus exists about a key role for government in safeguarding the right to the pursuit of happiness. Safeguarding that right, to the degree that it is a right – skeptics would say - is the responsibility of the individual, not the government. Indeed, my own rugged individualist, 90 year old mother is fond of reminding me that "happiness results from being too busy to be miserable! "
However, I am inclined to believe that at least some of the contemporary difficulty with the notion that the pursuit of happiness is a basic human right is semantic. That is, the Founders of the American Republic may have used the word "happiness" in a way that we would use the word "wellbeing," today.
Here is how my Random House Dictionary of the English Language defines the word happiness: "pleasure, joy, delight, exhilaration, bliss …" (p.869) And, here is how it defines the word wellbeing: "a good or satisfactory state of existence; a state characterized by health, happiness, and prosperity…" (p. 2158)
Because the Founders were serious men – dealing with serious matters – I suspect that they were more concerned with the latter (i.e., the right of individuals to pursue a satisfactory state of existence), than with the former (pleasure, bliss and exhilaration), however much they – like all of us- welcome these positive emotions.
Thus, if what the Founders meant by the "pursuit of happiness" is best interpreted today as the pursuit of a "satisfactory state of existence" – wellbeing –then its inclusion as an inalienable right- along with life and liberty –is simply further evidence of their wisdom and far-sightedness.
But, what has all this got to do with public health, and specifically, with those of you who are about to begin your careers in public health? A great deal, I believe.
A now, largely forgotten 1988 Report by the Institute of Medicine entitled, The Future of Public Health, concluded that the mission of public health is to "assure the conditions where people can be healthy." With a nod in the direction of the Founders, I propose that we paraphrase that view of our mission to read: "Our mission in public health is to assure the conditions where people can pursue happiness - which is to say - a satisfactory state of existence."
Thus, when viewed historically, it is almost as if we, in public health, have been charged with the responsibility to safeguard the right of people to pursue happiness, i.e., wellbeing.
But, what is wellbeing? If national - indeed global - wellbeing is what we aim to safeguard, what – exactly- does wellbeing consist of? How do we know it when we see it? And, even more crucially, how do we know when a people's wellbeing has been seriously compromised, therefore requiring our immediate and concerted action?
In their superb 2006 book entitled, Social Justice: The Moral Foundations of Public Health and Health Policy, Madison Powers and Ruth Fader describe six core dimensions of human wellbeing. Each is a "core" dimension because each is morally significant in its right and none can be reduced to the others.
The first dimension is health.
- …not only physical and mental health, but the absence of hunger and malnutrition, and importantly, the absence of unnecessary and preventable pain, disease and death.
- Personal Security: people cannot have a decent life if they are living in constant fear of physical or psychological abuse.
- Reasoning: "wellbeing" not only requires basic intellectual skills to understand the world, but also the ability to take a critical, self-reflective stance toward one's own preferences and values.
- Respect – for others and self; the ability to see others, and oneself, as independent sources of moral worth and dignity.
- Attachment: the capacity for intimacy, emotional engagement, and sympathetic identification with others; and
- Self-determination: the ability to have a life that is shaped by one's own values…to live life, as it were, from the inside out.
Note that income, education, shelter, and medical care - what economists might call "primary goods," and what we in public health might call the "material conditions of life" - are not considered dimensions of human wellbeing. They are certainly important for the attainment of wellbeing, but they are not wellbeing, itself.
When certain segments of society suffer from a chronic insufficiency of these primary goods – something which is usually caused by inegalitarian public policies - major deficits in some, if not all, six dimensions of wellbeing will result. This leads to what Powers and Fader call a densely woven pattern of disadvantage, a set of circumstances which is extremely difficult to escape.
Hence, our mission as public health professionals, to safeguard the right of people to pursue a satisfactory state of existence requires that we actively monitor significant changes in the material conditions of peoples' lives along with any concomitant changes in their wellbeing. And we are obligated to sound the alarm when we detect the formation of densely woven patterns of disadvantage, for it is these that have the greatest moral urgency.
Densely woven patterns of disadvantage can be found in many parts of the world, today, and responding to them with a sense of urgency is the aim of Global Health training programs such as the one here at Tulane and many other universities.
There are also numerous examples –right here in the US - of densely woven patterns of disadvantage – morally urgent situations that were created by socially unjust public policies and which growing empirical evidence indicates can only be remedied by policies that are firmly grounded in social justice.
For examples of this, we need look no further back than to the mid 1960s, when passage of the civil rights act outlawed racial discrimination, and passage of Medicare and Medicaid increased access to health care for the elderly and the poor, combined synergistically to begin unraveling long standing, densely woven patterns of disadvantage.
The empirical evidence? Between 1965 and 1980, rapid and dramatic decreases in both infant and adult mortality – for all Americans, but especially for blacks in the South, were observed. This 15 year period marked the greatest narrowing on record of the gap in all cause mortality, and in life expectancy, between blacks and whites, and between rich and poor Americans.
That's the good news. The bad news is that, beginning in the early 1980s, the mortality and the life expectancy gap by race, and by household income, began to increase - a trend which continued largely unchecked into the 21st century. The current economic downturn will likely prolong, if not exacerbate, this trend.
In my view, these widening health disparities – a sign of newly forming, densely woven patterns of disadvantage – are the moral context within which we should evaluate the new health care reform law and its potential to advance national wellbeing. So far, the political debate about the law has centered on the constitutionality of the individual mandate regarding health insurance coverage, and whether expanded coverage for the poor and elderly can be paid for in a fiscally responsible way.
While these are clearly important issues, not nearly enough public discussion has focused on other provisions of the health care law that have major potential to reduce racial, ethnic and socioeconomic health disparities thereby advancing our national wellbeing.
For example, the law advances health care equity by prohibiting the denial of health insurance coverage due to pre-existing conditions - something which will greatly benefit racial and ethnic minorities. Other provisions call for increasing work force diversity among health care professionals – which would enhance cultural competency in the provision of medical care to an increasingly diverse American populace. And there are other provisions aimed at improving the material life conditions of residents in distressed communities through Community Transformation Grants – and this, as we know, would help reduce vulnerability to a whole range of preventable and unnecessary health problems.
In my view, then, It would not be too much of a stretch to see the new health care reform law as a bookend to the social justice oriented legislation of the mid 1960s, legislation that made it possible for many disadvantaged Americans to pursue a satisfactory state of existence without, literally, wearing themselves out in the process. In sum, the new health care reform law could do for our national wellbeing in the 21st century what the progressive social policies of the 1930s, and the mid 1960s, did in the 20th century. And that, needless to say, would make our public health mission, going forward, a lot easier.
I will close by reiterating my belief that the profession of public health – perhaps more than any other - is charged with the mission to safeguard the people's inalienable right to pursue happiness (wellbeing).
It has been my privilege to be a member of this profession for nearly 40 years; and while the current and future challenges we face are great, I can assure you that the rewards will be even greater. Chief among these rewards will be the dedicated professional colleagues and ordinary citizens you will meet along the way; the amazing students that you will be privileged to teach and learn from; and the satisfaction you will feel from knowing that your contributions will combine with those of others to make a healthier world. And, a healthier world will surely be a safer world.
Again, I congratulate you, and I wish you God speed!
