CLASS DAY 2005 June 11, 2005 I am Stephen Spielberg, the dean of the Dartmouth Medical School, and I would like to welcome you all here today. Our students, MD, PhD, Masters of Science, MPH, their families, friends, and our faculty, all gather here today to celebrate the Class of 2005. I would also like to acknowledge the presence today of two Dartmouth College Trustees; Dr. Al Mulley and Michael Chu and introduce some members of our faculty and visitors on the platform. William Foege, who is going to be our Class Day speaker, I will introduce him in a moment. Dr. John Rassias, the William Keenan Chair of the Department of French and Italian and President of the Rassias Foundation who will do something very special and unique for our graduating Medical School class; Dr. Constance Brinckerhoff, the Nathan Smith Professor of Medicine and Biochemistry and Associate Dean for Science Education; Dr. David Nierenberg, Senior Associate Dean for Medical Education and Professor of Medicine and Pharmacology; Dr. Lori Alvord, Associate Dean for Student and Multicultural Affairs; and Dr. Gerry O’Connor, Director of Educational Programs in the Center for Evaluative Clinical Sciences. I would also like to acknowledge the presence today of some of graduates of the 2005 Brown/Dartmouth Program who received their MD’s from Brown University on May 30 and are joining us today. Welcome to you all. The first order of business is for me to introduce our Class Day speaker. Yesterday at our Awards Ceremony we began a theme for the upcoming several days related to the needs for improvements of health care, and the imperative for the improvement of health care for all those in need around the world. I cannot imagine a more appropriate speaker for our Class Day celebrations than Dr. William H. Foege. Dr. Foege received his MD from the University Of Washington School Of Medicine in 1961 and his MPH from Harvard in 1965. He became chief of the Center for Disease Control Smallpox Eradication Program and from 1977 to 1983 he was the director of the CDC. In 1984 he helped form a Task Force for Child Survival, a working group for the World Health Organization, UNICEF, The World Bank, the United Nations Development Program, and the Rockefeller Foundation with an aim in improving international childhood immunization and subsequently improving the quality of life for children around the world. In 1986, Dr. Foege joined the Carter Center as its Executive Director, and in 1999 became Senior Medical Advisor for the Bill and Melinda Gates Foundation. In 2001 he was honored with the Mary Woodward Lasker Award for Public Service in Support of Medical Research in Health Sciences. He was recognized for courageous leadership in improving world-wide public health and his pivotal role in eradicating Smallpox and preventing river blindness. It gives me great pleasure to introduce Dr. William Foege. Dartmouth Medical School Class Day Speaker Dr. William Foege, MD, MPH Thank you Dean Spielberg. Graduates and the many people here who invested in you, they invested time and talent and money, but especially they invested love. I congratulate you, I rejoice with you, I dream with you, and the fact is, I envy you. After Tim Russert received some bad publicity for recycling a Commencement address, let me start with a full disclosure. If I do this right, there should be significant recycling because some of these lessons I’ve learned over and over. But I want you to understand whatever I have used before was simply rehearsal for today. It was thirty-two years ago I arrived in India with my three children and my wife for Smallpox eradication, and the day after arriving, the five of us were in a small taxi going through a New Delhi street, and my seven year old son had his face right up to the window, watching a camel and then a water buffalo and a cow, and suddenly he turned and he said, “This is the second best day in my whole life!” And I asked him, “What was your first best day?” He said “Yesterday.” So we are here to celebrate one of the very best days in your entire life and it is better than the lottery. If you win the lottery you are still the same person the next day, but you just have money in the bank. But you are leaving today having won a lottery of high potential for a life of satisfaction and service. A bank account of knowledge and experience that will only grow and you are now one of the people with the highest capacity for making the world what we want it to be. Despite all of that preparation, the passion to teach far surpasses the passion to learn, so we are taking this opportunity to teach some more. And I would like to talk about some of the priority lessons I have learned in the past fifty years. By my count that list now is over three hundred and the good news, I am only going to mention twelve. Lesson #1: Bosses I was at my wife’s four year-old class, in a white coat, teaching them about stethoscopes and otoscopes and talking about how to stay healthy when a four year-old girl asked me a question that caused me to say to myself, “that can’t be accidental.” I would like to have followed her career. Her question was, “Do doctors have bosses?” Think of that. Well, I told her that the good ones do; their patients are their bosses. I used that story two weeks later at a UNICEF meeting asking who your bosses are. They said, all of the children of the world. But then as we talked about it, the real answer turns out to be all of the children of the world and every child who will ever be born in the future. You will all have bosses who do annual performance ratings, but in a very real sense, every person who will ever live in the future is your boss because you are preparing the world that they will live in. Abraham Lincoln has no biological DNA in our germ pool, and yet we are aware everyday of the importance of his living. Why? Because he left the social equivalent of DNA, and his DNA, his social DNA will go on forever. He helped prepare the future that we are living in, and the same is true for each one of you. Your social DNA will go on to influence the world for as long as there are people. Will Durant said “Immortality is not the survival of personality, but it is the absorption of the soul in deathless things. Lesson #2: This is a cause and effect world. You have been steeped in science in recent years and Stephen Hawkings said that the history of science is the gradual realization that things do not happen in an arbitrary fashion. This is a cause and effect world. You do histories and physicals and lab work because you can figure out what is happening, it is not a magical world. It is not a fatalistic world, and as bleak as things may look, Jonas Salk reminded us that evolution will be exactly what we want it to be because it is not a fatalistic world. You would not be here if you were fatalists. You got an education because you actually think you can change the future, and you can. So, avoid fatalistic thinking. At the same time, I have to say we are all fatalistic and non-fatalistic at times. I become most fatalistic when I get in a taxi cab and I loose control. One night in Philadelphia as I was going from the airport to the hotel, it is not a very long trip, and I realized I was smelling alcohol. I decided to engage the driver in conversation to see how high my risk was. I said to him you should know I am a high risk passenger. He said, “What does that mean?” Well, I have been in five taxi accidents in my life. He immediately responded, “That’s nothing, I’ve been in a lot more than that.” Lesson #3: The limitations and uses of science. Those outside of science are often overwhelmed by a sense of certainty that they think we have in science. But Richard Feynman, the great physicist, said that certainty is the Achilles heel of science and religion and medicine and politics. He said even physics facts are certain only within some margin of error, and that you are always trying to prove them wrong. So question and be humble and use certainty sparingly. The problem is just as bad with religion. Reinhold Niebuhr said, “Frantic orthodoxy is never rooted in faith, but in doubt.” It is when we are not sure that we are doubly sure. So, what should the use of your medical science be? Sir William Osler said “To wrest from nature the secrets which have perplexed philosophers in all ages; to track to their sources the causes of disease; to correlate the vast stores of knowledge so they may be quickly available for the prevention and cure of disease. These are our ambitions.” And Schweitzer reminded us to be aware of the destiny that we are preparing for another person. And he said “Stand in awe of the presence of life.” One problem in the use of science was elucidated 700 years ago by Roger Bacon when the Pope asked him for a summary of science. His summary showed absolute joy with science and the observation that science lacks a moral compass. This combination of science ecstasy and concern with its moral use comes back repeatedly by some of the best thinkers of history. Benjamin Franklin, for instance, wrote a letter to Joseph Priestly, and he said “The rapid progress true science now makes occasions my regretting, sometimes, that I was born so soon. It is impossible to imagine the height to which may be carried in a thousand years the power of man over matter. We may perhaps learn to deprive large masses of their gravity and give them absolutely levity for the sake of easy transport. Agriculture may diminish its labor and double its produce. Diseases may by sure means be prevented or cured and our lives lengthened at pleasure. Oh, that moral science was in as fair a way of improvement that human beings could at length learn what they now improperly call humanity.” And one more example: The great French physician, Rabelais, who was also by the way, an expert in law, theology, history, botany, astronomy, and cooking. Doesn’t that make you feel inadequate? He wrote the folk stories of Gargantua and has Gargantua in a letter to his son saying what Will Durant said are ten words to live by, “Science without conscience is but the ruin of the soul.” There is a Scottish proverb, “Don’t marry for money, you can borrow it cheaper.” Don’t use this great education you have received just for money. The great challenge to us is to use our science for the benefit of all, and we have yet to learn that lesson. And I say to students that they should love science, absolutely love it, but don’t worship it. There is something better than science, and that is science with a moral compass, science that contributes to social equity, science in the service of humanity. Lesson #4: Be a globalist. There is a bumper sticker that says think globally, act locally, and it is catchy but it is not totally adequate. What it should say, and then it wouldn’t make a good bumper sticker, is: think and act locally and globally. Einstein said nationalism is an infantile disease and he called it the Measles of mankind. Our Surgeon General fifty years ago was Leonard Scheele, and he said the world cannot be allowed to exist half healthy and half sick, so use your talents, both for your community and for the world. Lesson #5: Keep your balance. Try to be a generalist and a specialist simultaneously. Think big as a generalist. An astronomer from CAL Tech was asked, “How would you have made the universe if you had been God?” And his answer was, “I would have made it much larger.” So, think big, be endlessly curious, keep learning about the world, it will not only give you great joy, but it lets you know where your talent and where your understanding and your specialty fit in. Lesson #6: Friendships Samuel Johnson said we cannot tell the precise moment when friendship is formed. As in filling a vessel, drop by drop, there is at last a drop which makes it run over. So in a series of kindnesses, he says, there is that last one which makes the heart run over. Many of you found friendships here at school. Maintain those, because they are worth the trouble. Lesson #7: Do no harm. You have heard this from the first day of school, but let me repeat what I said when I was here a few years ago. You often heard it in terms of errors of commission. We hurt far more people by errors of omission, the things we don’t do. When I left for Africa forty years ago, my supervisor said to me as a throw away line as I was leaving, “Oh, by the way, he said, you will never forget the people you kill.” It took me a long time to understand of course we forget them because we don’t know them. We hurt and kill far more people by the things we don’t do, the vaccines not given, the science not shared, the orphans not cared for, the refugees ignored, the prevention not applied. Practitioners always say, but we don’t get paid for prevention, and I am telling you that is doing harm. Paul Frame has said an ounce of prevention is worth a pound of cure, but he also said an ounce of prevention is a ton of work and we have to do it. Lesson #8: Tenacity Tenacity won’t always bring success, but it is the only thing that will. Mae West once described a suitor as so tenacious, she said he was the kind of man a woman would have to marry to get rid of. Learn tenacity. Lesson #9: The measurement of civilization. Historians have tried different measurements, knowledge, technology, control of one’s environment. None of them work. Even happiness doesn’t work because Will Duran said if you use happiness as the criterion to measure civilization, you find that three year olds are more civilized than their parents. But there is a measure. The measure of civilization is finally how people treat each other. It measures a nation, a political party, a society, a university, a teacher, a graduate. How you treat people will be the measure of you as a person. The more education you get, the more money you make, the harder it is to connect with the poor and uneducated, and when they visit you for care, you may be the only genuine contact they have with a middle class person. If that divide is to be bridged in an authentic way, it will be because you make the effort, and again, it’s worth the trouble. Lesson #10: The need for optimism. The trouble with being an optimist, of course, is people think you don’t know what’s happening, but it is the way to live. I tell students there is a place for cynicism, there is a place for pessimism, and whenever they need it, contract out for it, but don’t get those people in your office, they just ruin your day. Lesson #11: Close the gap. Now that you are part of this blessed and educated group, close the gap so that everyone has the opportunities that you have had. Don’t think for a moment that you did this on your own. You’ve had an administration and faculty who have made this the objective of their lives. You are the product of an educational system that goes back to the beginning of time, but is well documented for the past ten centuries. That means 1,000 annual graduations. You are the product of governments that have funded education, the products of families that have let you know that this is important. Society and families invested in you and you can now leave here to use that investment for yourself or you can leave here so grateful, so thankful that you decide that everyone should have the same chance. You can promote the idea that the place of birth, the color of skin, and the finances of parents will no longer be the factor that determines whether a new born baby gets to have the same change that you have had. You can leave here so grateful that social justice becomes your song, your ambition, your identification. Gandhi reminded us that people often become what they believe themselves to be, and if you see yourself now as the person who lifts people out of both suffering and poverty, that is what you will become. And to paraphrase Teddy Roosevelt, this world is not a good place for any of us unless it is a good place for all of us. Lesson #12: We can never rest. It was at the Battle of Chancellorsville in May 1863 when Colonel Thomas Allen of the 5 th Wisconsin rallied the troops with words that the survivors remembered until the day they died, when he said, “When the signal forward is given, you will start at double click and you will not stop until you get the order to halt.” And then he added, “And you will never get the order to halt.” Improving the world for our future bosses, our neighbors, even though they won’t be born for hundreds of years, is worth your efforts. Learn the lessons well, for we will never get the order to halt. Mary Oliver, in her poem “When Death Comes” writes, “When it’s over, I don’t want to wonder if I 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.” So I wish you a good life, a life of participation, not just having visited the world. A life where you actually shape the world, where the future labels you a good ancestor. A life of kindness. Get up every morning knowing you are writing history, and get up every morning thanking your family, this faculty, and this school for teaching you how to do that. And thanks for letting me part of this moment.