Trouble the Water

Thank you, Dean Daley, associate deans Hundert and Saldaña, and esteemed faculty.

Thank you to the Harvard custodial staff who set up and will clean this Quad, and to the many workers who support this event. Deepest thanks to all the families and friends that stood beside these brilliant young people. Congratulations to the Harvard Medical School Class of 2022.

Thank you for selecting me to deliver this address, the first in-person Class Day since the start of the COVID-19 pandemic. I am deeply honored to share this hopeful day with you. The practice of medicine is rooted in hope. Hope that your action, our collective action, can lead to healing and change.

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Yet, you are commencing your medical practice at a difficult time—one marked by despair and confusion. In the looming backdrop of a beautiful day are war, climate catastrophe, and COVID-19, a pandemic of pandemics, in the U.S. and around the world.

COVID-19 has worsened the pandemic of poverty, exposed the violence of racism, and demonstrated the epic failure of the market to deliver equitable health outcomes. Health care professionals—doctors, nurses, respiratory therapists, and the many staff that it takes to care for the sick, the dying, and the dead have been tested, exhausted, sickened, and have even succumbed to death.

And, as usual, those who have borne the brunt of this pandemic are the poor, the marginalized, the vulnerable—the sufferers of the pandemics, biological and social, that have long plagued humanity.

Dang, Joia, I thought you were talking about hope.

I offer this—hope is as important now as it ever has been.

Hope is an act of solidarity with those who are suffering.

Hope leads us not to a desire for normal, but toward action to achieve a better future. It powers a willingness to wade into messy waters of sickness and suffering, to analyze the milieu of social injustice, and to address the root causes of disparate suffering.

Hope with analysis and action is radical—it is a rejection of cynicism and pessimism.

It presents an alternative and brighter future.

Hope is an antidote to despair.

And to those more scholarly, less touchy-feely, folks, make no mistake, hope is evidence-based. It is rooted in an analysis that change, whether incremental or earth-shattering, is possible. Many of you will not only hope for a better test, a better treatment, a better outcome—you will work for change and you will bear witness to change as it occurs.

When we choose hope we side with children like Jessenia and her mother, Claudia. Jessenia was 12 years old when I met her decades ago in Peru. She took care of her younger siblings as her mother went off each day to sell newspapers. She had become, her mother Claudia told me, a skeleton of a child. Her raspy breath and sunken sad eyes broadcast her diagnosis, tuberculosis. Doctors blamed Claudia for a belief in witchcraft, and even blamed Jessenia herself for “cheeking the medicines” and spitting them out.

But Jessenia and her mom told a different story. Claudia took Jessenia to daily visits to the health center even as transportation to the clinic sunk the family into debt. Jessenia took her medicines regularly, despite the cost of care resulting in the family having little to eat. My proximity to Jessenia was possible thanks to a dedicated community health worker who walked with me up a steep road that wound into a barren hillside to Claudia’s tiny home. A small family picture wreathed by flowers suggested that Claudia’s husband had died. Tuberculosis had claimed his life, Claudia told me. He took every pill, for years. At that time there was no treatment for resistant strains of TB in Peru. Knowing that Jessenia had the same resistant strain that her father had, with no hope for cure, that might have been the end of the story.

Partners In Health had secured some drugs for resistant forms of TB but the ministry of health would not let us use them on children. We had to create a bit of trouble, generate a bit of evidence, and apply a bit of pressure. We had to create a team to analyze and mitigate the root causes of Jessenia’s illness—poverty, hunger, overcrowded housing, and a system that didn’t recognize the disease Jessenia had.

With Claudia and Francisco, a mason, we improved ventilation and expanded her home. Un abuelita, a grandmother in the community, made sangrecita—a highly nutritional blood pudding that she offered to supplement Jessenia’s nutrition. A nurse and militant fighter for the poor, Dalia, suggested an ally, a genteel pediatrician who had seen too many deaths from TB, as a shepherd for policy change.

A driver, Señor Valdez, dedicated every day to fighting traffic in Lima to shuttle Jessenia and her mom to the pediatric hospital. And Jessenia herself vowed to fight—when I asked her what might help her remain hopeful, she said, El Principito, The Little Prince, a book she had read in school before she got sick. “I like the asteroid B612 that the prince lives on. I would like to draw him on his planet. I am excited to think that another world is possible.” The next time I saw Jessenia, I arrived with a copy of El Principito, a pen, and a sketch book and the news that working with Jessenia herself, and this mighty team—doctors, nurses, community health workers, drivers, grandmothers, and mothers, we had received permission to treat her illness.

Our collective hope and action cured Jessenia, who is now a college graduate and a graphic designer. Our good trouble meant that Jessenia’s case and holistic treatment became evidence for change. Published as part of a small series, just 16 children, who were treated for drug-resistant TB in Peru, the article changed policy in that country, allowing the treatment of MDR-TB for hundreds of other children in the country. The collective work to save this lovely girl, along with the testimony from the Peruvian national TB program, Partners In Health and others changed World Health Organization policy and informed the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria’s TB treatment program. Measure that impact factor!