Address to the alumni of Harvard T.H. Chan School of Public Health, October 25 2014

A Gift Unsolicited, Unrestricted and Unexpected

By Gerald Chan

The gift that my family just gave to the Harvard School of Public Health, notwithstanding it being the largest gift in the history of Harvard University, was unsolicited, unrestricted and unexpected – unsolicited by Harvard, unrestricted by the donor and unexpected by the public.

Harvard never came to me to solicit a gift. The best philanthropic giving comes from the heart, oftentimes a grateful heart. This gift is no exception. I am grateful to this university for the education that I received here. That education changed my life. I am also grateful to my late father who instilled in me the values by which I have lived my life. This gift is a way of memorializing my father and the values that he stood for.

A little story serves to illustrate the kind of person my father was. This is a story I only learned about last month after the gift was announced. When my father came to Boston to visit me in 1975, he learned that I had received a fellowship for my doctoral studies at the School of Public Health. On his way back to Hong Kong from Boston, he stopped in San Francisco to visit his old friend Mr S.P. Wong. For the few days that he stayed with Mr. Wong, he could not stop talking about my fellowship. On the one hand, he was proud that I had received a fellowship which in his mind was an honorific scholarship. On the other hand, he was profoundly disturbed that my taking the fellowship meant that I had displaced someone who, without the support of the fellowship, would not have the means to attend this school. He kept saying to his friend, “We have the means to pay tuition, why is Gerald taking the scholarship away from someone else?” That inner struggle between feeling proud of his son on the one hand and on the other hand feeling disturbed that social justice had been abrogated is a poignant portrait of my father.

I am so pleased that Dean Frenk has announced that part of this gift will be used for scholarships and student loan forgiveness programs designed to make it possible for graduates of this school to enter into public service careers. He talked about graduates of this school from developing countries who, rather than returning to their home country to work in public health, remain in this country to practice medicine which is financially far more lucrative. An op ed piece in the Wall Street Journal last week estimated that in Liberia where the Ebola epidemic is raging, there are one hundred twenty physicians serving a population of four million people. The database of the American Medical Association shows that there are fifty-six Liberia-trained physicians who have qualified and are practicing medicine in America. Using the estimate that about half of the foreign graduates who take the medical licensing examination in this country pass, the estimate is that there are about two-thirds as many Liberia-trained medical graduates in this country as there are working in their home country.

It is my hope that this gift to the School of Public Health will be a tool for stimulating the spirit of service amongst our graduates and a financial enablement for them to choose careers in public service.

This gift is also unrestricted. The full amount of the donation goes into the endowment of the school and the use of its proceeds is entirely at the discretion of the dean. The unrestricted nature of this gift is a statement of faith in the current leadership of this school and of this university. It is also a statement of faith in the institution of this university. The leadership of any organization will change over time; it is its governance which will ensure that the institution remains true to its mission. In talking about this gift in recent weeks, Dean Frenk often concluded his talk by quoting a verse from the Bible – the Gospel of Luke, chapter 21, verse 48, “From everyone who has been given much, much will be demanded; and from the one who has been entrusted with much, much more will be asked.” Dean Frenk speaks of this gift as resources entrusted to the school and that it is the solemn responsibility of the school’s leadership to put these resources to good use. It is in those who see themselves as being accountable that one can have faith.

While it is common for donors to specify use of the donation for something dear to their heart, and I celebrate this because, as I said earlier, the best philanthropy comes from the heart, in this instance, both the Harvard Corporation and I saw it fit that this gift should be unrestricted. Having been involved with many universities in various capacities, I worry that highly prescriptive donations can have the unintended consequence of balkanizing the university into a collection of special interests. I also worry that highly prescriptive donations will result in the university’s resource allocation becoming a reflection of the interests of the donor base. Many years ago, I attended a ceremony celebrating the establishment of chair professorships in a university in Hong Kong. Of the twenty some chairs established that year, most were established to support law, business and medicine. These are schools within the university which are more likely to produce graduates who are financially capable of donating to the university later in their lives after they have become professionally successful. In that ceremony, there were also two chairs established for Buddhist studies. The only chair that was established in the natural or life sciences was the Morningside Professorship in Chemical Biology which my family endowed. That distribution of disciplines receiving support was an expression of the interests and sensibilities of the Hong Kong moneyed crowd. I question whether that distribution of resources best served the interest of the university, its local community or humanity at large.

I was at a function here in the school last week. A gentleman was kind to come and congratulate me for the gift. He then proceeded to ask me what I plan to do to monitor the gift. I said, “Nothing.” He pressed me further and kept pressing me. “Surely you will monitor how the money will be spent.” My answers remained that it is the dean who runs the school, not me. Designated gifts can strengthen specific parts of the school; unrestricted gifts are designed to strengthen the school as a whole. My intention with this gift is the latter.

Finally, I want to talk about the unexpectedness of this gift. If the largest gift in the three hundred seventy-eight year history of Harvard University had been given to the business school or the medical school, it would not have been a surprise. But the School of Public Health? That was totally unexpected.

After the gift was announced, one response I got from some people was “What is public health?” as if it was the first time they heard of public health. Some others thought that the School of Public Health was the same as the medical school. Why is it that public health is so poorly understood and so scarcely recognized by the general public?

The first reason has to do with the different objects of the two disciplines of medicine and public health. The object of the practice of medicine is the individual, a patient. The object of the practice of public health is the public at large. If I may be facetious, medicine is about private health, public health is about health of the public.

We are all born as individuals, but we are also born into communities. One of the hallmarks of modernity is the recognition of the individual with his own identity and rights. A person is no longer defined only as in relation to a group. His thoughts, words and actions can be his and his alone. This possibility of individual personhood has unleashed so much of the human potential which was locked up for centuries.

But it is also true that as much as individuality has flourished in modernity, individuals have never been more interconnected and interdependent. Public concerns with privacy issues in recent years are but a minor expression of how this interconnectivity has eroded the autonomy of the individual. When it comes to health, it is no different. The Ebola epidemic today reminds us how interconnected humanity is. One country’s problem can quickly become another country’s problem. As to the air that we breathe, the water that we drink, the food that we eat, we are involuntarily impacted by the actions of so many people in different parts of the world. While modernity has allowed individuality to flourish, modernity has also subsumed the individual to the public. The hand that gives is the same hand that takes away. It is no longer feasible that human health be addressed only at the level of the individual. Our highly connected world today makes it imperative that human health also be addressed at the level of the population as a whole.

To be sure, the individual patient being the object of curative medicine means that the benefits of medicine can be perceived easily and tangibly. For a patient, these benefits can unfold over a short period of time and the results can be spectacular. A sick person becomes well again. Pathological metabolism is brought back in line, or lost physiological functions are regained. Something spectacular happens through the intervention of the physician. That is why grateful patients constitute a substantial donor base for hospitals.

In contrast, the ultimate success of public health work is not that something happened, but that nothing happened. One does not read in the newspaper that, on this day, no epidemic broke out. That would not be newsworthy. Our society is conditioned by the media to celebrate spectacular events, not the absence of events. The only time I know of that the media celebrated the absence of news was on April 18th 1930. At the 6:30 pm news program of the BBC, the news presenter announced that there was no news that day and piano music was played for the remainder of the program.

As impressive as our modern medical enterprise is, we in America are acutely aware that it is pushing up against formidable limits. Such limits impose diminishing marginal returns and in some cases, even negative marginal returns on incremental investments. I am sure you have seen the plot of life expectancy versus per capita healthcare expenditure of different countries in the world. The United States is by far an outlier. Our per capita healthcare expenditure is at least 50% greater than the next highest nation which is Switzerland, and yet our life expectancy is lower. Recent statistics show that life expectancy of the United States ranks twenty-sixth among the thirty-six members of the Organization for Economic Cooperation and Development (OECD) and is in fact below the OECD average. Our pushing healthcare expenditure is clearly not effective in pushing the limit for life expectancy.

Two books in my recent reading list have spoken to the limits of modern medicine. The first book is Medical Nemesis by the philosopher Ivan Illich published in 1976. Illich subtitled his book The Expropriation of Health. He coined the term “medicalization of life” as a critique of the invasiveness of medicine into culture and therefore how we live our lives, the infringement of the medical establishment into the autonomy of the individual, and the harm that medicine brings to society at the same time that it brings healing. This book is chock full of vintage 1970s radical left wing rhetoric which I find to be rather amusing.

The other book is Being Mortal published recently by our own Atul Gawande. This is a deeply moving book on old age and end of life. I highly recommend this book to you. This book speaks specifically to the limits of medicine at the end of life, the juncture where the most aggressive medicine is often practiced when in fact it is at its feeblest.

While the two writers come from vastly different backgrounds – one a philosopher who writes with incendiary rhetoric and the other a surgeon who writes in mellifluous prose – both writers speak to the limits of modern medicine. Accepting these limits has profound ramifications. For the medical practitioners, it will mean a new ethics, a new definition of harm when they take the Hippocratic oath to do no harm. For the individual, it will be a new morality by which he views the human life. For society, there will be ramifications of how the young and the old relate, a relationship that is fundamental to human existence. These are profound changes.

Recognizing the limits of modern medicine calls for a new world view by which we fashion our culture. When President Faust said in the gift ceremony that this is a public health moment, it must mean more than a call to having more public health initiatives. Public health must be a new world view which catalyzes a cultural shift from celebrating only the cure of diseases to celebrating the non-incidence of diseases and therefore the allocation of society’s resources to creating conditions which favor disease non-incidence. While we do celebrate the spectacular advances in medicine which bring us cures that would have seemed miraculous to earlier generations, the real miracle is that nothing happens and we keep on living to our full potential. This world view should be a voice in our policy-making in government, in the structure of our economy, the running of our businesses, the conduct of our scientific research, the content of our education, and indeed, how each citizen conducts his personal life and what he expects of society.

The research and teaching that goes on in the Harvard School of Public Health exemplifies the efforts we must fortified at this public health moment. In working with Harvard University’s administration to design how this gift should be communicated to the outside world, my family’s wish was to minimize the attention given to the donor and that the spotlight should be on the field of public health. We wanted to capitalize on the shock factor of the School of Public Health garnering the largest gift given to the university to send a message to the world that it is in public health that we should invest for a better future. I am gratified that the feedback from around the world confirms that this communication strategy has worked. Dean Frenk told us that he has received many phone calls from the deans of other schools of public health to say how much they appreciate this gift because it has elevated the standing of public health in the eyes of the public.

My hope is that public health moving to center stage in the public’s awareness will translate to a better funding environment for public health endeavors. I would also like to see public health capturing the imagination of more bright young people as they ponder their career choices. President Faust said in the gift ceremony that global health is now the most popular second concentration in Harvard College. In Harvard-speak, this means that global health is now the most popular minor. The wind has indeed shifted. Having social impact has overshadowed going to Wall Street as the preeminent aspiration of the Harvard undergraduates. It would be wonderful if many of them would follow in our footsteps and come to the Harvard T.H. Chan School of Public Health for their graduate studies.

Howard Stevenson, an emeritus professor at Harvard Business School and fund raiser extraordinaire for this university once told me what he said to a potential donor, “You are not giving to Harvard. You are giving to all of humanity through Harvard.” His words are certainly true of my family’s gift.

To you, my fellow alumni, I want this gift to be an encouragement as you continue your work in public health. We benefited from receiving a great education in this school. We will share this benefit with our fellow men by putting our education to use for the greater good.

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