Assistant Administrator Atul Gawande Commencement Address “Trace”

Graduates, Faculty, Family and Friends, thank you for inviting me to speak. We are here to declare that as of today, the 22nd day of May in the year 2024, you know enough stuff to be declared a graduate of the Johns Hopkins Bloomberg School of Public Health. You are Doctors of Philosophy, Doctors of Public Health, Masters of Public Health, Masters of Health Science, and more. It’s been certified. Each of you is now an expert. Congratulations. 

So why – in your heart of hearts – does it not quite feel that way? 

The experience of a public health education is transformational. At first, it is a foreign country. You don’t understand the words, let alone the concepts or the customs. But then that changes. Half the words you routinely use, you barely knew existed before. You learn words like logistic regression, step-wedge study design, confounding effects. You learn about the patterns of threats to human health and what to do about them. You learn about the intricate workings of health systems and public health delivery. You learn about management and organizational behavior required to lead health programs effectively. How amazing is that? The impact of this field on people’s lives and well-being is extraordinary. 

Yet to take responsibility – to simply give advice – do you know enough? Can you know enough? You never stop being reminded of the gaps in what you know. 

Two weeks ago, for Mother’s Day, my 27-year-old daughter Hattie gave my wife, Kathleen, a facial cream made of purified snail excretions. 

“Snail slime,” I said? 

“Yep,” she said. 

Hattie had worked in public health for four years before becoming a police officer in North Carolina. When she first saw the product in her Instagram feed, she thought it was funny. But it’s become huge, she said. Friends of hers swore by it. One gave her a snail mucin face mask. She looked up the data and found solid studies behind it. And when she tried the mask, she became a convert. 

I turned to ChatGPT. It said that snail secretions have been widely studied and had proven benefits, increasing skin hydration, regeneration, healing, and also collagen production, which reduces wrinkles and fine lines. I went on PubMed and found 1,656 studies – more than I could read. I went down the rabbit hole for a day. It turns out Hippocrates mentioned using snail secretions to relieve inflamed skin. I read blinded studies of patients with facial burns, where it showed faster, better healing. It’s showing promise improving drug delivery through the skin. Ingestion of the stuff even healed gastric ulcers in lab rats. Snail secretions is becoming a billion-dollar industry. 

I have a medical degree, a public health degree, and more than three decades of experience. And I had never heard the first thing about this.

The great privilege of my life is that I’ve gotten to see and serve people’s health from so many vantage points – the operating room; a research and innovation center; a private sector start-up; nonprofit organizations; and now in my government role leading foreign assistance for global health at USAID, where I oversee teams working with more than 80 countries around the world to improve health and health systems. Everywhere you go, you will encounter a story that changes your understanding of what is possible in people’s lives. 

I was in Thailand this past winter, in a town of 34,000 people called Bueng Yitho. I was walking through one of its neighborhoods with Mrs. Poonsub Poomkaew, a supervisor of the town’s public health workforce. In Thailand, in every neighborhood, on every block, they have selected what they call a Village Health Volunteer -- a local outreach worker. It’s one for about every ten or twenty households. Their job is to visit every home at least once a month and check on how people are doing. Homes with poorer health they’ll visit more frequently. One of Mrs. Poomkaew’s outreach workers told me they spend about five hours a week making visits. 

They are not tremendously skilled or knowledgeable. They get only fifty hours of training and a small stipend. They can measure height and weight of children and the blood pressure and fingerstick glucose levels of adults. They have a short checklist of items they can run through with the people they encounter – such as whether they’ve had the immunizations they need; if they are pregnant, whether they have made their prenatal visits; if they have high blood pressure or TB or HIV, whether they have the medicines they need. 

But this is enough to give these health workers an invaluable expertise. They become experts on the gaps in their neighborhood. They see who is hungry, who is neglected, who is sick, who is missing their medicines. Some people don’t want to talk to them when they knock. They don’t want to have these women — and most of them are women -- snooping around on them. But when something is wrong, they open the door. They even seek them out. And when something is wrong, the village health volunteers call Mrs. Poomkaew. 

In Thailand, in 2002, the government adopted a universal health coverage law. They are not a rich country -- they spend only $300 per person per year on health. (The U.S. spends $12,000.) So Thailand had to pick what to prioritize. Most countries start with covering catastrophic hospital expenses. But Thailand is something unusual. They started with universal primary care. Primary care services and medicines are free. Even in a small town like Bueng Yitho, the local clinic staff includes a team of one family doctor, one dentist, a nursing team, and one pharmacist for every 8 to 10,000 people. Everyone has a default clinic they belong to. And in Bueng Yitho, Mrs. Poomkaew is the glue between that clinic and the households she’s responsible for.  When people miss their medicines or immunizations or blood pressure appointments, or when they just don’t seem right, she connects them to the clinic and does all she can to make sure they follow through. 

The result? In 2000, before the reforms, people in Thailand lived on average just 70 years. Thirty-five percent of deaths occurred in people under the age of fifty. Today, essential health indicators – such as child vaccination rates, HIV and TB treatment coverage, blood pressure control – have risen remarkably. Thailand’s life expectancy is now almost 80 years, exceeding US life expectancy – and on just $300 per year. As I said, everywhere you go, you will find a meaningful public health story. 

Expertise is in a precarious place right now – not least in public health. Confidence in public health guidance and those who provide it has sunk. And although the impact of what you provide – through your information, thinking, changes for the better – will continue to grow, so will the conflicts over it. Data is ubiquitous. Everyone has the chance to be their own health expert. Why not just ask ChatGPT? All of this raises a deeper, more fundamental question -- what is the value that you or any expert really has to offer? 

Think about Mrs. Poomkaew and her outreach workers. What is their expertise? They are experts in caring. They can see people in need and recognize their suffering. They can coax them to take the measures that will help them. And they connect them to clinics with the capacity to effectively reduce that suffering. They are experts in their neighbor’s reality, and they have just enough tools to use that knowledge to make a meaningful difference in those neighbor’s lives. 

Caring is at the heart of what you have to offer as public health professionals, and you offer it at the scale of communities, perhaps even nations. You have learned how to diagnose a community’s needs and effectively connect them to an ever-growing storehouse of knowledge and capabilities. There are many, many roles and places in which to do this difficult and necessary work. Your mission is now to find yours. 

One further point. Many people are attracted to public health for the seeming simplicity of its moral purpose. But the purpose of our caring isn’t simple. There are always trade offs to consider. People’s goals are never just about survival and health. People have priorities besides just living longer. We all want to matter, to have a purpose, to enjoy life. Caring requires listening for those priorities and helping people navigate the tradeoffs. This cannot be achieved simply through technology. And it cannot be hurried. 

Let me return for a moment to snails. The novelist Gunter Grass wrote a book called, “The Diary of a Snail,” which contains a line I love. “Progress,” he says, “often moves at a snail’s pace. But even a snail, slow as it is, leaves a trace behind.” And, I might add, that trace can work wonders.

May all of you leave your trace behind. Congratulations, graduates.