February 20, 2024

Thank you so much for this kind invitation to address the medical students at the University of Global Health Equity and their families on this momentous and joyous occasion. Students, I have seen you in class and I have watched the development of your curriculum and various projects—and from my perspective of thirty years teaching medical and public health students, I must say you are among the most inspiring with whom I have worked. I have witnessed your courage to learn new material, your commitment to help each other succeed in class, and your devotion to a career to help people who face enormous adversity.

The UGHE model is unique in the globe. It was developed to fit its circumstances here in Africa, but honestly, the approach is enormously applicable not only in Rwanda and on the African continent but also in higher-income settings, which sadly have in many parts of the world developed around concepts of competition and economic efficiency rather than on the bedrock principles of UGHE: collaboration and social equity.

I want to begin with a true story, from 2012:

Joe is a 28-year-old man with Type I diabetes living in the United States. He lacks permanent housing and has been living in a friend’s condemned, boarded up house. To avoid being seen there, Joe enters through the swampy area behind the house. His shoes are full of holes, but he cannot afford to replace them. Joe’s diet similarly suffers from lack of income; he sometimes goes several days without fresh food. As a result of his poor diet, he struggles to control his diabetes; and after a lifetime of poor insulin control, he is starting to lose circulation in his feet. Last year, Joe had two toes removed on his right foot to save his life (hospital cost about $10,000). Still, neuropathy continues to cause him decreased sensitivity in and increased risk of trauma to his feet. The doctor he last saw emphasized the importance of keeping his feet dry, getting proper nutrition, and taking his costly insulin as prescribed, all of which Joe is eager to do. Since that appointment, Joe has been diligent in taking his insulin, but dry feet and proper nutrition remain difficult to achieve based on his living conditions and lack of employment. His doctor has already raised the issue of having to have more toes removed on his left foot (cost about $20,000), and without immediate changes, Joe will need to have a below-the-knee amputation in the years ahead (cost $25,000 or more) and will need a wheelchair (cost about $1,500). The estimated cost of his medical expenses will top $50,000, paid by a state medical assistance program funded by taxpayers. Amid a system marked by the most advanced medical treatment in the world, Joe is dying a slow, painful, and expensive death. A decent pair of shoes costs $50.

It goes without saying that Joe needs more than a good pair of shoes to improve his health; he also needs accessible shelter and nutritious food. But the cost of these interventions is modest compared with $50,000 in medical treatment he is currently on track to accrue. Furthermore, shelter, food, and shoes might enable him to return to work rather than suffer a lifetime dependent on a wheelchair. Joe’s story illustrates how inadequate attention to social services and support can lead to exorbitant medical expenses and poor health outcomes.

I wish this were an isolated case; it is not. Health, as you know because you have been educated for social medicine, is determined by far more than medical care. In fact, only about 10-20% of premature deaths averted are due to medical care. The lion’s share of premature deaths averted are due to social and environmental factors—most prominently food, shelter, and early childhood nutrition and education.

Don’t get me wrong. In individual circumstances, with a patient with a medical problem in front of you, they need medical care—surgery, chemotherapy, antibiotics, and other life-saving medical interventions. And you have spent two years learning foundations that, coupled with your clinical training, will equip you to effectively diagnose and treat patients who will expect medical care from you, their physician or surgeon.

But if we broaden our perspective to human health on a global scale, we find far more than medicine that is crucial for improving human health worldwide, and in fact, for individual patients as well to achieve health.

And there is so much work to do! Every year, more than 250,000 women die in childbirth from preventable causes; more than half a million die from malaria, which can be treated, and 1.5 million die from TB—a curable illness.

Many of these deaths occur in low-income countries, but even in high- and middle-income countries, preventable deaths are common—for instance, as related to homelessness, drug use, inaccessible medical care, and despair.

Importantly, the health care systems and thus population health outcomes are very much a product of the underlying values of the country or larger society in which care is given. And as you are training to work globally, it is important to recognize this larger political and cultural influence on health. The dream of your faculty and of all of us is that you will not shy away from these larger dimensions of health but rather be an active influencer of the political and cultural norms that shape health and health care for us all.

What a country values matters. For instance, asked what the most important roles for government in Scandinavia, common answers are: 1) address income inequality, 2) foster education, and 3) support health of the population. They have a strong safety net and social welfare programs, which address medical care and social determinants of health as well. In the US, this question gets the common response of 1) protect us from criminals, 2) protect us from international wars, and 3) foster a strong economy. And the US has large police and military investments and a robust economy, but a fragile social welfare state—and we see the difference. American health outcomes lag those in Scandinavia, even as the United States spends far more on medical care.

Rwanda is a diverse country, but its cultural values are clear—unity and social cohesion are central, as is the concept of inclusion. Perhaps due to its small size and its complex history, Rwanda has a strong vision of inclusion…social and economic inclusion. One can see this value of collaboration and inclusion in the tradition of umuganda, how communities are organized and governed, and even in this path-breaking model of medical training, which you are all bringing to life.

I wonder, as you look out to your future selves, if you ever feel overwhelmed? Medicine and public health—especially social medicine—is a profound calling. It brings us face to face with life and death but also with human suffering and joy all kinds. The profession you have picked is far more than a job; it is a way of life. You will be at the bedside of the patient, at the home of the family, and on the roads, in the fields, and at the center of the community. The commitment you have made—to yourself, your families, your country, and this global community—is daunting.

You will accomplish amazing feats; you will save lives, and you will comfort those whose lives you cannot save—but you may also have moments in which you want to buckle under the weight, the responsibility, of your chosen profession. Anticipating those moments, and we have all had them and will have them, I wanted to recount another story:

Once upon a time, two friends who had not seen each other for a long time were walking on a long, beautiful beach several days after a large ocean storm. The storm, which had whipped up the ocean waves for days, had washed thousands of clamshells on to the beach. The sun was baking hot now, and the clams—many with shells broken or dangerously half-open, were becoming dehydrated and dying a slow death on the scorching beach. As the friends walked, they were chatting about their families and jobs, hardly registering the impending clam deaths under their feet, when one of the friends instinctively reached down, picked up one of the clamshells, and threw it back into the water. The other friend looked perplexed and with some cynicism said “What good does that do? There are a thousand other clams on this beach and we cannot save them all.” The first friend looked back to the ocean where she had returned the clam to its natural habitat and said, “Maybe not, but that one clam sure feels better now.”

I have remembered this story often in my decades of work in global health. We cannot know the outcome of our work always; we cannot even imagine all the many needs that we wish we could satisfy, and sometimes the process is messy—you make three steps forward, two back, one forward, one back, two forward…and over time, with focus on living our values, progress is made. Often not as we had planned exactly, but still progress—for someone, somewhere, and the world is better because of what we have done, even if problems persist as well.

I have tried to focus my remarks on the importance of a broad perspective on health (with the story of Joe and his diabetes) and on UGHE’s unique model of equipping students with what is needed to understand and address the broadest determinants of human health globally. I have also addressed (with the clam story) how we can sustain our energy and hope even in the wake of various “ocean storms” that may challenge our dreams for a healthier world.

And now, I would like to end with one last story, a story of Paul Farmer and Vassar. I met Paul decades ago as we both worked in global health, and like so many of us, I was inspired and energized by his way of thinking and his commitment to challenging the status quo in order to promote greater health equity. When I left Yale after twenty years and became the President of Vassar, Paul came to see me and one of our faculty members who he had met in Sierra Leone the previous summer. Paul met our students and came to dinner at the President’s House, and after dinner, he said “Come on, you have to come to Rwanda and help me with UGHE.” I remember thinking: “He’s crazy; how could I ever do that? What could I offer? I am a college president now, and have another job.” But Paul would hear none of it. He instead made everyone at that dinner feel like their work—whatever it was—was important to the mission, and that we need everyone to work together on human health globally. I have thought often of that dinner and that visit—particularly now that Paul is gone from this earth. He was all about partnership—partnerships between patients and their physicians, between different caregivers on the health care team, and among institutions dedicated to global health. I have carried his magic with me, remembering his unyielding commitment to health equity, his clear-eyed perspective on the challenges we face coupled with an uncanny hopefulness that we, in partnership, could make a difference.

And here we are—such unlikely partners—a medical school in Butaro, Rwanda and a liberal arts college in Poughkeepsie, New York—learning from each other and aligned toward the noble work of transforming medical education to better advance health equity globally. We do this through partnership, and I will end with a quote from Paul Farmer who said:

With rare exceptions, all of your most important achievements on this planet will come from working with others—or, in a word, partnership.

Congratulations to you all, as well as your families, teachers, and mentors who have brought you to this place. May you continue your careers and lives with clear vision, quenchless hope, and strengthened by transformational partnerships.