Adonis Diaries

Posts Tagged ‘Commencement Address

Commencement Address 2016 at American University in Beirut

By Nassim Nicholas Taleb

Dear graduating students,

This is the first commencement I have ever attended (I did not attend my own graduation). Further, I have to figure out how lecture you on success when I do not feel successful yet –and it is not false modesty.

Success as a Fragile Construction

For I have a single definition of success: you look in the mirror every evening, and wonder if you disappoint the person you were at 18, right before the age when people start getting corrupted by life.

Let him or her be the only judge; not your reputation, not your wealth, not your standing in the community, not the decorations on your lapel.

If you do not feel ashamed, you are successful. All other definitions of success are modern constructions; fragile modern constructions.

The Ancient Greeks’ main definition of success was to have had a heroic death. But as we live in a less martial world, even in Lebanon, we can adapt our definition of

success as having taken a heroic route for the benefits of the collective, as narrowly or broadly defined collective as you wish.

So long as all you do is not all for you, secret societies used to have a rule for uomo d’onore: do something for yourself and something for other members.

And virtue is inseparable from courage. Like the courage to do something unpopular.

Take risks for the benefit of others; it doesn’t have to be humanity, it can be helping say Beirut Madinati or the local municipality.

The more micro, the less abstract, the better.

Success requires absence of fragility. I’ve seen billionaires terrified of journalists, wealthy people who felt crushed because their brother in law got very rich, academics with Nobel who were scared of comments on the web.

The higher you go, the worse the fall. For almost all people I’ve met, external success came with increased fragility and a heightened state of insecurity.

The worst are those “former something” types with 4 page CVs who, after leaving office, and addicted to the attention of servile bureaucrats, find themselves discarded:

as if you went home one evening to discover that someone suddenly emptied your house of all its furniture.

But self-respect is robust –that’s the approach of the Stoic school, which incidentally was a Phoenician movement.

(If someone wonders who are the Stoics I’d say Buddhists with an attitude problem, imagine someone both very Lebanese and Buddhist).

I’ve seen robust people in my village Amioun who were proud of being local citizens involved in their tribe; they go to bed proud and wake up happy.

Or Russian mathematicians who, during the difficult post-Soviet transition period, were proud of making $200 a month and do work that is appreciated by twenty people –and considered that showing one’s decorations –or accepting awards–were a sign of weakness and lack of confidence in one’s contributions.

And, believe it or not, some wealthy people are robust –but you just don’t hear about them because they are not socialites, live next door, and drink Arak baladi not Veuve Cliquot.

Personal History

Now a bit of my own history. Don’t tell anyone, but all the stuff you think comes from deep philosophical reflection gambling instinct –just imagine a compulsive gambler

playing high priest.

People don’t like to believe it: my education came from trading and risk taking with some help from school.

I was lucky to have a background closer to that of a classical Mediterranean or a Medieval European than a modern citizen.

For I was born in a library –my parents had an account at Librarie Antoine in Bab Ed Driss and a big library.

They bought more books than they could read so they were happy someone was reading the books for them.

Also my father knew every erudite person in Lebanon, particularly historians.

So we often had Jesuit priests at dinner and because of their multidisciplinary erudition they were the only role models for me: my idea of education is to have professors just to eat with them and ask them questions.

So I valued erudition over intelligence –and still do.

I initially wanted to be a writer and philosopher; one needs to read tons of books for that –you had no edge if your knowledge was limited to the Lebanese Baccalaureat program.

So I skipped school most days and, starting at age 14, started reading voraciously.

Later I discovered an inability to concentrate on subjects others imposed on me.

I separated school for credentials and reading for one’s edification.

First Break

I drifted a bit with no focus, and remained on page 8 of the Great Lebanese Novel until the age of 23 (my novel was advancing one page per year).

Then I got a break on the day when at Wharton I accidentally discovered probability theory and became obsessed with it.

But, as I said it did not come from lofty philosophizing and scientific hunger, only from the thrills and hormonal flush one gets while taking risks in the markets.

A friend had told me about complex financial derivatives and I decided to make a career in them.

It was a combination of trading and complex mathematics.

The field was new and uncharted. But they were very difficult mathematically.

Greed and fear are teachers. I was like people with addictions who have a below average intelligence but were capable of the most ingenious tricks to procure their drugs.

When there was risk on the line, suddenly a second brain in me manifested itself and these theorems became interesting.

When there is fire, you will run faster than in any competition. Then I became dumb again when there was no real action.

Furthermore, as a trader the mathematics we used was adapted to our problem, like a glove, unlike academics with a theory looking for some application.

Applying math to practical problems was another business altogether; it meant a deep understanding of the problem before putting the equations on it.

So I found getting a doctorate after 12 years in quantitative finance much easier than getting simpler degrees.

I discovered along the way that the economists and social scientists were almost always applying the wrong math to the problems, what became later the theme of The Black Swan. Their statistical tools were not just wrong, they were outrageously wrong –they still are.

Their methods underestimated “tail events“, those rare but consequential jumps. They were too arrogant to accept it.

This discovery allowed me to achieve financial independence in my twenties, after the crash of 1987.

So I felt I had something to say in the way we used probability, and how we think about, and manage uncertainty.

Probability is the logic of science and philosophy; it touches on many subjects: theology, philosophy, psychology, science, and the more mundane risk engineering–incidentally probability was born in the Levant in the 8th Century as 3elm el musadafat, Science of hazard) used to decrypt messages.

So the past thirty years for me have been flaneuring across subjects, bothering people along the way, pulling pranks on people who take themselves seriously.

You take a medical paper and ask some scientist full of himself how he interprets the “p-value”; the author will be terrorized.

The International Association of Name Droppers

The second break came to me when the crisis of 2008 happened and felt vindicated and made another bundle putting my neck on the line.

But fame came with the crisis and I discovered that I hated fame, famous people, caviar, champagne, complicated food, expensive wine and, mostly wine commentators.

I like mezze with local Arak baladi, including squid in its ink (sabbidej), no less no more, and wealthy people tend to have their preferences dictated by a system meant to milk them.

My own preferences became obvious to me when after a dinner in a Michelin 3 stars with stuffy and boring rich people, I stopped by Nick’s pizza for a $6.95 dish and I haven’t had a Michelin meal since, or anything with complex names.

I am particularly allergic to people who like themselves to be surrounded by famous people, the IAND (International Association of Name Droppers).

So, after about a year in the limelight I went back to the seclusion of my library (in Amioun or near NY), and started a new career as a researcher doing technical

work.

When I read my bio I always feel it is that of another person: it describes what I did, Not what I am doing and would like to do.

On Advice and Skin in the Game

I am just describing my life.

I hesitate to give advice because every major single piece of advice I was given turned out to be wrong and I am glad I didn’t follow them.

I was told to focus and I never did.

I was told to never procrastinate and I waited 20 years for The Black Swan and it sold 3 million copies.

I was told to avoid putting fictional characters in my books and I did put in Nero Tulip and Fat Tony because I got bored otherwise.

I was told to Not insult the New York Times and the Wall Street Journal; the more I insulted them the nicer they were to me and the more they solicited Op-Eds.

I was told to avoid lifting weights for a back pain and became a weightlifter: never had a back problem since.

If I had to relive my life I would be even more stubborn and uncompromising than I have been.

One should never do anything without skin in the game.

If you give advice, you need to be exposed to losses from it. It is an extension to the silver rule.

So I will tell you what tricks I employ.

Do not read the newspapers, or follow the news in any way or form. To be convinced, try reading last years’ newspaper.

It doesn’t mean ignore the news; it means that you go from the events to the news, not the other way around.

If something is nonsense, you say it and say it loud. You will be harmed a little but will be antifragile – in the long run people who need to trust you will trust you.

When I was still an obscure author, I walked out of a studio Bloomberg Radio during an interview because the interviewer was saying nonsense.

Three years later Bloomberg Magazine did a cover story on me.

Every economist on the planet hates me (except of course those of AUB).

I’ve suffered two smear campaigns, and encouraged by the most courageous Lebanese ever since Hannibal, Ralph Nader, I took reputational risks by exposing large evil corporations  such as Monsanto, and suffered a smear campaign for it.

Treat the doorman with a bit more respect than the big boss.

If something is boring, avoid it –save taxes and visits to the mother in law. Why?

Because your biology is the best nonsense detector; use it to navigate your life.

The No-Nos

There are a lot of such rules in my books, so for now let me finish with a maxim. The following are no-nos:

Muscles without strength, friendship without trust, opinion without risk, change without aesthetics, age without values, food without nourishment, power without fairness,

facts without rigor, degrees without erudition, militarism without fortitude, progress without civilization, complication without depth, fluency without content,

and, most of all, religion without tolerance.

 

“Don’t work. Don’t tell the truth. Be hated…”: Commencement address by Adrian Tan. Part 2

Guest-of-honour at NTU convocation ceremony, Adrian Tan, author of The Teenage Textbook (1988), delivered this speech to the graduating class of 2008. I split the speech into two posts, the first part expands on “Don’t work”, “life is a mess” and “Don’t tell the truth”.

If you missed part 1: https://adonis49.wordpress.com/2012/04/19/part-1-dont-work-dont-tell-the-truth-be-hated-commencement-address-by-adrian-tan/

Be hated
I have told you that your life is over, that you should not work, and that you should avoid telling the truth. I now say this to you: be hated.

It’s not as easy as it sounds. Do you know anyone who hates you? Yet every great figure who has contributed to the human race has been hated, not just by one person, but often by a great many. That hatred is so strong it has caused those great figures to be shunned, abused, murdered and in one famous instance, nailed to a cross.

You don’t have to be evil to be hated.

In fact, it’s often the case that you are hated precisely because you are trying to do right by your own convictions.

It is far too easy to be liked, one merely has to be accommodating and hold no strong convictions. Then one will gravitate towards the center and settle into the average. That cannot be your role.

There are a great many bad people in the world, and if you are not offending them, you must be bad yourself. Popularity is a sure sign that you are doing something wrong.

Fall in love with someone

The other side of the coin is this: fall in love.

I didn’t say “be loved”. That requires too much compromise. If one changes one’s looks, personality and values, one can be loved by anyone.

Rather, I exhort you to love another human being. It may seem odd for me to tell you this. You may expect it to happen naturally, without deliberation. That is false.

Modern society is anti-love.

We’ve taken a microscope to everyone to bring out their flaws and shortcomings. It is far easier to find a reason not to love someone, than otherwise. Rejection requires only one reason. Love requires complete acceptance. It is hard work – the only kind of work that I find palatable.

Loving someone has great benefits. There is admiration, learning, attraction and something which, for the want of a better word, we call happiness. In loving someone, we become inspired to better ourselves in every way. We learn the truth worthlessness of material things. We celebrate being human. Loving is good for the soul.

Loving someone is therefore very important, and it is also important to choose the right person. Despite popular culture, love doesn’t happen by chance, at first sight, across a crowded dance floor.

Love grows slowly, sinking roots first before branching and blossoming. It is not a silly weed, but a mighty tree that weathers every storm.

You will find that, when you have someone to love, that the face is less important than the brain, and the body is less important than the heart. (Provided that face and body are about normal?)

You will find that it is no great tragedy if your love is not reciprocated. You are not doing it to be loved back. Its value is to inspire you.

Finally, you will find that there is no half-measure when it comes to loving someone. You either don’t, or you do with every cell in your body, completely and utterly, without reservation or apology. It consumes you, and you are reborn, all the better for it.

Don’t work. Avoid telling the truth. Be hated. Love someone.

Don’t work. Be hated. Love someone

Commencement Address to graduating Harvard architects, May 30, 2011

I do disseminate articles that are worth re-publishing, as well as translating what I think people need to read. I edited out redundant sentences and shortened the speech.

“By getting this far, the Harvard Graduate School of Design class of 2011, have proved that you possess a certain, incredible talent. It’s a talent that is unique to our species. And if you were to rank this talent among members of our species in general, I have no doubt you would all be in the top 1% of 1%.

I’m not talking about intelligence, fine breeding, good looks, dress sense, or compelling social skills.   I am talking about the talent which some would call…   imagination or invention or innovation. It is the remarkable ability first of all to model some aspect of the external world inside our heads… and secondly to play with that mental model until suddenly… bingo… you find a a way to rearrange it so that it’s actually better.  This is the amazing engine that underpins both technology the T of TED, and Design the D of TED.  It is this skill that has made possible human progress of the last 50,000 years.

For almost the entire period of life on earth, the appearance of design has been driven differently. It was mostly done by random trial and error; like a drunkard lumbering through a dark maze of passages, and life has lurched its way forward. For every evolutionary step forward, there have been countless dead ends.
In a single lifetime, change was not detectable. It happened slowly, painfully over millions of years. Somehow, in our species the light came on. We actually found a way to model the future before lumbering into it. That… changed… everything.
Viewed from a different perspective, you could say our brains became the ecosystems for a new kind of life, a life that replicated and transformed itself at a rate hitherto unknown in our corner of the universe. The thrilling life of the world of ideas. TED is devoted to nurturing this life form.
You’re about to devote the rest of your life to that same mission. But whereas we, at TED, nurture ideas by putting free talks up on the Internet, you will be not just dreaming them, but turning them into reality so that thousands or millions of other people will be impacted by them.

Espoused in a mind over here, I think I can just about make out… a gorgeous building, full of natural light whose bio-inspired curves evoke wonder and delight in everyone who sees it.  Over there, I can see a once barren industrial wasteland converted into a glorious city park where people gather, mill, walk, play and dream.  Here is a spectacular city of the future, one in which cars are replaced by intelligent, next-generation  transport systems, and human-scale meeting places where people naturally mingle and connect.  A city which breathes and adjusts and interacts with its citizens like a living system.

When you sum up all the visions contained in this room right now I have to tell you, the future looks pretty enticing.  And the most thrilling part? A significant proportion of those dreams will, within the next decade or two, become real. Why? because you will make it so. You are the 2011 graduate class of the GSD.  Like few other people on earth, you have the skills and the  resources to truly change the world.
But here’s the rub. What will determine which of the dreams today see the light of day, and which will languish unfunded, forgotten, ignored?
Well, usually a single person can’t make a big idea come true (unless they have extremely rich parents).  In almost every case, an idea need multiple backers. So it must first spread from one brain to many, spreading excitement as it goes. So what makes THAT happen?
It certainly helps if the idea itself is powerful, with some combination of beautiful, ingenious, and… affordable.  But there’s something else. It needs to be communicated with power.
One of the most tragic things in the world is a powerful idea stuck inside the head of someone who can’t actually explain it to anyone else. At TED over the years, we’ve had a lot of architects come and share their visions with us, and a good number of them have been absolutely… awful.  How can that be?  They have the most compelling subject matter imaginable. Giant designs at a scale that impacts thousands or millions of people… Yet when it come to articulating them, they descend into gibberish – the abstract, over-intellectual language of architectural criticism that makes an audience’s eyes glaze over and their brains numb.  This is an utter tragedy!
Whatever else you do in the coming years of your life, I beg you, I truly beg you to find a way of sharing your dreams in a way that truly reveals the excitement and passion and possibility behind them.  The good news here is that you’re entering the profession at a wonderful moment.
I speak as an outsider, but it seems to me that three giant trends are combining to transform both the role of architecture – and  how it can be talked about. First of all, in recent years, a mode of thought that has dominated intellectual life for much of the past century is gradually being laid to rest.  I’m referring to the toxic belief that human nature and aesthetic values are infinitely malleable, and determined purely by cultural norms. For a while, this gave a generation of architects exhilarating freedom to abandon all traditional architectural rules, and impose their own vision on society. But like similar experiments in music, art, drama, and literature, they didn’t always win the world’s love.

Today there’s a growing consensus that we should think of humans differently. That far from living in separate cultural bubbles, we actually share millions of years of evolutionary history. That there are far more ways that we are the same than that we’re different. The anthropologist Donald Brown has documented more than 200 human universals present in every culture on earth. They ranged from things like body adornment, feasting, dancing to common facial expressions and, yes, shared aesthetic values. This latter question has been the subject of countless experiments around the world in the past couple decades, and they’ve mostly revealed an amazing degree of resonance among vastly different people on what they find…  beautiful.

This shift is surely allowing us to change the language in which architecture is discussed. In a world of pure cultural relativism, there are no absolutes to appeal to. To succeed you had to learn the opaque language of a tight-knit clique of critics and opinion formers. It didn’t matter if the rest of the world was left scratching its head.

Today, slowly, gingerly, it’s become possible once again to use language the rest of us can understand. I think it’s even OK to use that B word again: Beauty. Not as a proxy for arrogant artistic self-expression, but as a quest to tap into something that can resonate deeply in millions of souls around the world.  I’m happy to report that in the last couple years at TED,  we’ve been wowed by a new generation of architects like  Joshua Prince-Ramus,  Bjarke Ingels, Liz Diller, Thomas Heatherwick and others, as they’ve shared with us – in plain English –  their passion, their dreams, and yes, the beauty of what they’re created.

When Thomas Heatherwick shared his vision for a stunning, new residential complex in Kuala Lumpur, curved out from narrow bases like a bed of tulips, I had just one thought.  I wish I had been born in the future.

I suppose an architect might have dreamed of such a development 30 years ago… but it could never have been built. And that brings us to the second trend. Technology is changing the rules of what’s possible. The astounding power of computer-assisted design and new construction techniques are giving us the ability to actually build what before could only have been a whimsical doodle on a sketch-pad.. .

Suddenly, the fractals and curves of Mother Nature, are a legitimate part of the architectural lexicon. And around the world, as people watch these new buildings arise, instead of muttering “monstrosity”, their jaws are dropping, their eyes moistening.

And finally, perhaps most important of all, we’re at a moment in history where the world is paying attention to you like never before. As leading designers of scale, you, more than anyone else, hold in your hands the answers to the most important question we all face. Namely this. Can the coming world of 10 billion people survive and flourish without consuming itself in the process.

The answers if they are to be found, – and I think they will – will come from… design. Better ways to pattern our lives. There is nothing written into our nature that says that the only path to a wonderful, rich, meaningful life is to own two cars and a McMansion in the suburbs.

But it’s becoming urgent for the world to start to see a compelling alternative vision. Probably it’s going to come down to re-imagining what a city can be, and making it so wonderful, that few people would want to live anywhere else. If there are to be 10 billion of us, we will have to live close to each other — if only to give the rest of nature a chance.

Indeed, more than half the world already lives in cities and the best of them offer so much to the world : richer culture, a greater sense of community, a far lower carbon footprint per person – and  the collision of ideas that nurtures innovation.  And the future cities you will help create need not feel claustrophobic or soulless.

By sculpting beautiful new forms into the city’s structures and landscapes; by incorporating light, plants, trees, water; by imagining new ways to connect with each other and work with each other, you will allow the coming crowd to live more richly, more meaningfully, than has ever been possible in history – and to do so without sacrificing your grandchildren.

Let me offer a few personal advices to you as you embark on your career. Everything from “one word: plastics”.  to… “follow your dream, pursue your passion”.  Indeed the mantra of romantically pursuing passion is hammered into us by countless movies, novels and pulp TV. I’m not convinced it is very good advice. Apart from the fact that many people aren’t sure what their passion is, even if they were, there are lots of wonderful things in life that absolutely should not be pursued directly. Take love.  We all want it. But there’s a word for people who pursue love a little too directly.  Stalker.

Or take happiness. Go after that wholeheartedly and most likely you’ll end up a hedonist, a narcissist, an addict.  A great musician who wants to pursue the absolute in artistic creativity doesn’t get there by being creative. She gets there by being disciplined. By learning, listening and by practicing for hours… until one day the creativity just flows of its own accord.

The architect Moshe Safdie ended his TED talk a few years with this poem.
    He who seeks truth shall find beauty. He who seeks beauty shall find vanity. 
    He who seeks order, shall find gratification. He who seeks gratification, shall be disappointed. 
    He who considers himself the servant of his fellow beings shall find the joy of self-expression. He who seeks self-expression, shall fall into the pit of arrogance. 
    Arrogance is incompatible with nature. Through nature, the nature of the universe and the nature of man, we shall seek truth.  
    If we seek truth, we shall find beauty.
So I guess my advice would be… Don’t pursue your passion directly. At least not yet. Instead, pursue the things that will empower you. Pursue knowledge. Be relentlessly curious. Listen, learn. You’re leaving Harvard this week, but your learning cannot ever, ever be allowed to stop.
Pursue discipline. It’s an old-fashioned word, but it’s never been more important. Today’s world is full of an impossible number of distractions. The world-changers are those who find a way of ignoring most of them.
And above all. Pursue generosity. Not just because it will add meaning to your life — though it will do that — but because your future is going to be built on great ideas and in the future you are entering, great ideas HAVE to be given away. They do. The world is more interconnected than ever. The rules of what you give and what you hold on to have changed forever.
If you hold on to your best ideas, maybe you can for a moment grab some short-term personal commercial gain. But if you let them roam free, they can spread like wildfire, earning you a global reputation. They can be reshaped and improved by others. They can achieve impact and influence in the world far greater than if you were to champion them alone. I
f we’ve discovered anything at TED these past few years, it’s that radical openness pays. We gave away our talks on the web, and far from killing demand for the conference, it massively increased it, turning TED from something which reached 800 people once a year, to something which reached half a million people every day. We gave away our brand in the form of TEDx, and far from diluting TED, it democratized it, and multiplied its footprint a thousand fold.

Knowledge, discipline, generosity. If you pursue those with all the determination you possess, one day before too long, without you even knowing it, the chance to realize your most spectacular dreams will come gently tap you on the shoulder and whisper… let’s go.  And you’ll be ready”. (end of quote)

Architects and engineering designers are not necessarily better than others in retaining any model fresh in the mind for any length of time.  They are trained to transcribe their models on paper, or on any other medium, with details in two dimensions of various sections.  The transcribed sections can be read to reconstitute the entire model at will. 

Designing is a long process that involve studying and analysing people behaviors so that the end-product is useful, safe, and acceptable by the users.  It is a shame if designers are not exposed to the human capabilities, limitations, and behaviors.  It is a greater shame if any design is done for “art sake”, not taking into account the end users acceptance, even if the designer is rich enough not to design for monetary remuneration. 

Chicago: Short history of public health

Part of Commencement Address given by Dr. Bechara Choucair to Feinberg PPH, May 4, 2011

“Today is about you. You decided to invest in your education. You decided to focus on public health. You worked hard. You read many articles.

I am sure you wrote many papers. You participated in many work-groups. You sat for many exams. You gave many presentations. It is all paying off today.

Brief description of the history of public health in Chicago.

The population-based approach of public health has had a tremendous impact on the health of our communities for almost two hundred years.  In Chicago, the formal establishment of public health took place in 1834, when the Board of Health was established to fight the threat of cholera.

During this Early Sanitation era, sanitation and quarantine were our best tools for fighting disease. The first sanitation regulations were passed and required all men over 21 years old to help clean the city’s streets and alleys.

We conducted home visits to persons with infectious diseases and boarded ships in Chicago’s harbor to check on the health of crewmen.   Our deepest public health roots can be traced to disease control.

The earliest public information efforts starting in the 1850’s. 

The efforts in the era of sanitary reform, focused heavily on sewers, water and food and dairy. During this period, the Health Department issued regulations governing the drainage and plumbing of new buildings (1889); we initiated meat inspections at Chicago’s Union Stock Yards (1869), and full milk inspection activities began (1892).

We saw some of our highest death rates during this era due to diphtheria, typhoid and scarlet fevers, measles and whooping cough. Using his regulatory authority, the health commissioner at the time, Dr Oscar Coleman De Wolf, required the reporting of contagious diseases by physicians in 1877.

By 1887, our advancements in medical understanding helped us see that typhoid would continue to kill, unless we stopped the flow of contaminated water into Lake Michigan–the source of the water we drank, the water we cooked with, and the water in which we bathed.  Building the 28-mile Sanitary and Ship Canal, which reversed the flow of the Chicago River by 1900, was a major medical/public health intervention.

With the advent of the Hygiene Movement (1880’s-1950’s), and the continued advances in understanding disease and medical practice, the focus of public health shifted to individual hygiene and medical care, particularly children’s health.

In 1890, a Chicago child had only a 50% chance of reaching 5 years of age. By 1900, the odds of surviving to age 5 had increased to 75%.

In 1899, with the support of 73 physician volunteers, the City initiated its first campaign against infant mortality.

Service delivery focused on the provision of dental services in schools in 1915, public health nurse home visits to infants in 1925 and educational campaigns against venereal disease in 1922.   These remain among our priorities today.

The early public health nurses at work.

The nurses “finders of sick infants” would seek out sick babies and refer them and their mothers to Tent Camps, where they would receive medical treatment and hygiene education.

In 1956,  516 persons were stricken with polio. Public health authorities assigned 90% of the city’s health workers to reach a goal of one million inoculations in 2 weeks. One year later, Chicago had only 28 cases, and in 1959 when the U.S. went through a record- breaking year for polio, Chicago had only one case.

The 1950’s saw the beginning of dramatic growth in medical interventions which prompted the era of health care services. During this time, the delivery of personal health care services, primarily to low-income populations, was becoming the primary public identity of public health in Chicago.

In 1959, the Health Department opened the Mid-South Mental Health Center, the first of what would become a network of community mental health centers by the early 1970’s.

The first half of the 1970’s  saw the development of several Department neighborhood health centers, under the federal Model Cities Program.

The first of our centers, in the Uptown community, was established in 1970. On this slide, you can see our clinics in Lakeview, and the 1987 groundbreaking for the expansion of our West Town clinic.

The 1960’s and 1970’s brought significant changes at the federal level as well. The passage of Medicare and Medicaid in 1965 greatly expanded access to care for some of our most vulnerable populations.

Since that time, CDPH has greatly expanded its capacity in Epidemiology, Policy, Planning, Resource Development, and more recently, Information Technology, while maintaining its efforts in critical public health functions such as disease prevention and control, and in the last decade, emergency preparedness.

Note:  This article is part of the Commencement Address at Feinberg School of Medicine at Northwestern University, delivered by Dr. Bechara Choucair, Commissioner of public health of the city of Chicago.  This speech covered all the grounds and it is impressive.

Feinberg PPH: Commencement Address given by Bechara Choucair, May 4, 2011

Dr. Bechara Choucair is Commissioner of public health of the city of Chicago.  I liked his Commencement Address at Feinberg School of Medicine at Northwestern University and decided to publish it on wordpress.com.  This speech covered all the grounds and it is impressive.  I found it acceptable to edit out sentences that are not closely related to the subject matter in order to shorten the message.

“Today is about you. You decided to invest in your education. You decided to focus on public health. You worked hard. You read many articles. I am sure you wrote many papers. You participated in many work-groups. You sat for many exams. You gave many presentations. It is all paying off today. Congratulations.

My mom, dad, my sisters and my grandfather came along to my college graduation. I was so excited to have made it through College. At that time, I was accepted into Medical School at the American University of Beirut. I was really happy with the progress I made. My grandfather, who graduated from the same school 60 years earlier, gave me a big hug and said: “I could not be any more proud!” To this day, these are the words that come to mind anytime I think of him. He passed away a few years later. I am so glad I made him proud.

I have no doubt that many of your loved ones could not be any more proud today. To your loved ones: Thank You. Thank you for your support. Thank you for your love. And most importantly, thank you for being there.

As I reflect back on how my career has evolved, I can’t help but wonder if I would be here today if I did not work with Dr Hamadeh as my community medicine project mentor in my second year of medical school. Dr Hamadeh is a Family Physician with a Masters in Public Health. I worked closely with him and I realized that there is a lot more to Medicine than seeing patients. I saw the potential power that public health has, to truly make our population healthy. Every time I go back to Lebanon to visit with family, I make sure to stop by his office. I hope he knows how critical his role was, in shaping my career.

Today, I wanted to do 3 things:

  1. I will briefly describe the history of public health in Chicago
  2. I will talk about the intersection between public health and medicine
  3. I will tell you about the future of public health in Chicago

The population-based approach of public health has had a tremendous impact on the health of our communities for almost two hundred years.  In Chicago, the formal establishment of public health took place in 1834, when the Board of Health was established to fight the threat of cholera.

During this Early Sanitation era, sanitation and quarantine were our best tools for fighting disease. The first sanitation regulations were passed and required all men over 21 years old to help clean the city’s streets and alleys. We conducted home visits to persons with infectious diseases and boarded ships in Chicago’s harbor to check on the health of crewmen.   Our deepest public health roots can be traced to disease control.

[Slide 1]   Earliest public information efforts.

Starting in the 1850’s,efforts in the era of sanitary reform, focused heavily on sewers, water and food and dairy. During this period, the Health Department issued regulations governing the drainage and plumbing of new buildings (1889); we initiated meat inspections at Chicago’s Union Stock Yards (1869), and; full milk inspection activities began (1892).

We saw some of our highest death rates during this era due to diphtheria, typhoid and scarlet fevers, measles and whooping-cough. Using his regulatory authority, the health commissioner at the time, Dr Oscar Coleman De Wolf required the reporting of contagious diseases by physicians in 1877.

[Slide 2]   By 1887, our advancements in medical understanding helped us see that typhoid would continue to kill unless we stopped the flow of contaminated water into Lake Michigan–the source of the water we drank, the water we cooked with, and the water in which we bathed.  Building the 28-mile Sanitary and Ship Canal, which reversed the flow of the Chicago River by 1900, was a major medical/public health intervention.

With the advent of the Hygiene Movement (1880’s-1950’s), and continued advances in understanding disease and medical practice, the focus of public health shifted to individual hygiene and medical care, particularly children’s health.

In 1890, a Chicago child had only a 50% chance of reaching 5 years of age. By 1900, the odds of surviving to age 5 had increased to 75%.   In 1899, with the support of 73 physician volunteers, the City initiated its first campaign against infant mortality.

Service delivery focused on the provision of dental services in schools in 1915, public health nurse home visits to infants in 1925 and educational campaigns against venereal disease in 1922.   These remain among our priorities today.

[Slide 3]  Early public health nurses at work.

On the bottom is one of a group of nurses known as “finders of sick infants.” These nurses would seek out sick babies and refer them and their mothers to Tent Camps where they would receive medical treatment and hygiene education.

[Slide 4]These pictures are from 1956 when 516 persons were stricken with polio. Public health authorities assigned 90% of the city’s health workers to reach a goal of one million inoculations in 2 weeks. One year later, Chicago had only 28 cases, and in 1959 when the U.S. went through a record breaking year for polio, Chicago had only one case.

The 1950’s saw the beginning of dramatic growth in medical interventions which prompted the era of health care services. During this time, the delivery of personal health care services, primarily to low-income populations, was becoming the primary public identity of public health in Chicago.

In 1959, the Health Department opened the Mid-South Mental Health Center, the first of what would become a network of community mental health centers by the early 1970’s.

[Slide 5]The first half of the 1970’s also saw the development of several Department neighborhood health centers under the federal Model Cities Program. The first of our centers, in the Uptown community, was established in 1970. Here you can see our clinics in Lakeview and the 1987 groundbreaking for the expansion of our West Town clinic.

The 1960’s and 1970’s brought significant changes at the federal level as well. The passage of Medicare and Medicaid in 1965 greatly expanded access to care for some of our most vulnerable populations.

Since that time, CDPH has greatly expanded its capacity in Epidemiology, Policy, Planning, Resource Development, and more recently, Information Technology, while maintaining its efforts in critical public health functions such as disease prevention and control, and in the last decade, emergency preparedness.

We have a public health history to be proud of. From the early days of the sanitary reform era to running medical care facilities, I can’t be any prouder of our history as a City. We always invested in building a healthier and a safer Chicago.

The intersection between clinical medicine and public health. These two worlds are often seen separate. We often see them as different disciplinary silos in which many of us spend entire careers. Ted Schettler, the Science Director of the Science and Environmental Health Network, frames both disciplines with respect to focus, scale, ethics, education and the nature of the science.

Clinical medicine focuses primarily on the individual while public health focuses on the community. Relevant time frames in Clinical Medicine are usually single lifetimes, while public health thinks in terms of generations.

From an ethics perspective, clinicians advocate for individual people. Public health practitioners advocate for the community, for a group of people. In clinical medicine we focus on individual patient rights. In public health, we think about human rights, social justice, and environmental justice.

From an education perspective, in clinical medicine we focus on the biomedical model with more emphasis on cure than prevention (although this is shifting now). In public health, we learn more about sociology, epidemiology, cultural anthropology, economics and more.

Think for a moment about the evidence of the science. In clinical medicine we love to talk about controlled, double-blind clinical trials. We don’t find that type of approach often in public health.

Have you ever asked yourself where do you fit better? Have you ever seen yourself in one of the two worlds?

Clearly, there are differences: differences in focus, differences in scale, differences in ethics, differences in education and differences in the nature of science.

But the reality is that the health of the individual and the health of the community are inter-related and inter-dependent. Maintaining two disciplinary silos is NOT the answer. Bridging the gap is critical if we are serious about improving the quality of life of our residents.

Bridging the gap starts right here. It starts with education. We have to enhance the understanding of public health principles among our students in the clinical field and we have to enhance the understanding of clinical medicine principles among our public health students.

Bridging the gap happens in research. We have to expand our research portfolio to focus on health disparities and other population level research.

Bridging the gap will not be successful unless we translate what we learn in research all the way into public policy.

And finally, it is people like you, like the faculty here and like me, who will take the lead in bridging this gap. The good news is that here in Chicago, there are great people who have done great work in bridging this gap. I am forever grateful for their contributions.

At the Chicago Department of Public Health, we are exploring how to fully exploit the intersection of public health and medicine. We are excited about having the opportunity to use, as the foundation of such efforts, the proliferation of HIT initiatives, particularly in under served communities. A major federally-funded initiative to help us achieve this goal is CHITREC, housed here at Feinberg and funded through stimulus funds (American Recovery & Reinvestment Act).

CHITREC (Chicago Health Information Technology Regional Extension Center) provides technical assistance to primary care providers serving predominantly uninsured, under insured, and medically under served populations in developing an Electronic Health Records system that will improve health outcomes. CHITREC is collaboration between Northwestern University and the Alliance of Chicago Health Center Services, a health center-controlled network. It builds upon extensive collective Electronic Health Records implementation and clinical informatics experience.

We anticipate that as the participating providers come on-line, there will be wonderful opportunities to use the wealth of data available through an Electronic Health Record to measure population health and be able to pinpoint where particular interventions are needed to improve outcomes.

Other federal funding, including the 2010 Patient Protection and Affordable Care Act, has provided additional opportunities for investments in the electronic data infrastructure supporting population health. Your Chicago Department of Public Health (CDPH) is positioned to become a leader in the public health applications of Health Information Technology. Current CDPH activities include:

  •  Funding of 26 acute care hospitals in Chicago to assist in their efforts toward establishing capacity to transmit data of public health significance to CDPH;
  • Partnering with the Centers for Disease Control and Prevention (CDC), GE Healthcare and the Alliance of Chicago in a pilot evaluation the feasibility of targeted, pubic health-oriented clinical decision support for ambulatory providers, delivered at the point of care through Electronic Health Records;
  • Supporting Stroger Hospital of Cook County and two major Federally Qualified Healthcare Center (FQHC) networks (ACCESS Community Health Network and the Alliance of Chicago) in their efforts to establish robust transmission of immunization administration data to the Illinois immunization registry;
  • Engaging with the Illinois Office of Health Information Technology in statewide efforts to build a sustainable Health Information Exchange (HIE);

What is the future of public health in Chicago?

[Slides 6 and 7]

During my tenure at the Chicago Department of Public Health, which has been about a year and a half so far, I have stressed the importance of focusing on public health strategies that effectively address the actual causes of death, rather than what is found on a death certificate. Groundbreaking work done by McGinnis and Foege at CDC in the early 1990’s, and fine-tuned since then, demonstrated that the actual causes of death are largely related to individual health behaviors and social circumstances — not genetics, not access to health care.

Dr. Thomas Frieden, Director of CDC, looked at these, took it all in, but then went further and asked:  “now that we have a better understanding of the actual causes of death, how can public health, charged with improving the health of the population, best intervene?”

[Slide 8]

The most effective interventions, at the base of the pyramid, address the social determinants of health and the way that our society is structured.  Taking this approach to heart, I challenged our team at the Chicago Department of Public Health to develop a draft of a public health agenda that best meets this current understanding of effective public health interventions. And while our emphases have been near the bottom on the pyramid, I recognize that there is a need for effective programs at each level.

If you follow Chicago government, you might know that Mayor Emanuel committed to releasing a public health agenda for the City of Chicago in the next 100 days (well, 97 days by now since he’s been in office for 3 days already!) Our public health agenda is a blueprint for action intended to serve as a framework for a focused, yet comprehensive, approach to how the Chicago Department of Public Health will lead and work with partners to improve the health and well-being of the people in Chicago.

Our public health agenda:

  • identifies priorities to guide our public health work over the next five years;
  • sets measurable targets, achievable by 2020, to improve the health and well-being of Chicagoans;
  • sets policy, programmatic and educational & public awareness strategies that can be measured and monitored; and
  • serves as a vehicle to engage communities, partners, and other public health stakeholders in health improvement efforts.

The priorities presented in this agenda were identified through an assessment of public health data and resources, as well as current or potential stakeholder involvement. Reflecting a multi-tiered public health approach, for each priority area, this agenda presents strategies organized into three sections:

  • ·      Policies, including regulatory changes and laws that will be pursued to improve the public’s health;
  • ·      Programs and services that will be delivered, and
  • ·      Education and public awareness

I am sure it is no surprise to anyone if I share our priorities with you. I am talking about Obesity Prevention, Tobacco Use, HIV Prevention, Teen Pregnancy Prevention, Cancer disparities with a use case on breast cancer disparities in Chicago. I am also talking about heart disease and stroke, about violence prevention and about access to healthcare among others.

These are exciting times in Chicago. In 97 days, our City will have a clear public health agenda. We will have a focused set of priorities. We will make our targets public. We want the public to hold us accountable. Chicago invests around $200M every year in our public health system. We owe it to Chicagoans to do our best to stretch those dollars and get the best return on investment. This is my commitment to you today. As you get ready to start the next phase in your career, I call on all of you to join me in this journey. I guarantee you it will be a lot of hard work but a lot of fun and we will get a healthier city.

 

There are many ways to have an impact on health:

  • ·      Treating the sick –
  • ·      Preventing the illness in the first place through screenings
  • ·      Population-based prevention strategies

I hope in your work in public health, regardless of the setting, you keep in mind the concept of the “third revolution” (Breslow) in public health. Now that we have made significant progress in addressing communicable disease (first revolution) and made progress in chronic diseases (second revolution), we are poised to embark on the third, where communities are healthy and the goal is promoting health and not just preventing disease: “Health promotion reaffirms considering not only how to avoid being sick, a negative concept, but also how to expand the potential for living, a positive view: The main difference between health promotion and disease prevention is the premise of health promotion regarding health as a resource of everyday life”.

We all know the impact of clinical medicine on public health.  To promote health, we need to think beyond just clinical medicine. We have to be involved in social policy.  All social policy is public health.  Fiscal policy is health policy.  Education is public health. Housing is public health.

Perhaps in your schooling, or on your own, you saw the film “Unnatural Causes: Is Inequality Making Us Sick?” Through four hours of excellent documentary film making, it makes crystal clear what needs to change in our society if we are going to be truly healthy:

  • ·      It’s less poverty
  • ·      It’s quality housing
  • ·      It’s quality education
  • ·      It’s viable communities filled with resources geared to the needs of the particular population

I grew up in Lebanon in the midst of a civil war. I saw the impact of violence on individuals, on families, on community and on the whole country. I suffered the impact of violence myself.  I saw the impact on my own family, in my own community.

In medical school at the American University of Beirut, I spent time seeing patients in Palestinian Refugee camps in Beirut. I talked to so many people who lived their whole lives in an environment where I might not choose to live.  I saw firsthand the impact of forced migration on health.

In Houston, at Baylor College of Medicine, I trained in a community health center serving mostly Mexican immigrants who struggled to make a decent living. I learned about homelessness by providing clinical services to people living in shelters, under bridges, in cars and on the streets.  I saw firsthand the impact of poverty and lack of housing on individuals.

In Rockford, at Crusader Community Health, I served as a medical director of a community health center network. I learned about more migrant communities. I learned more about public housing. I learned more about HIV/AIDS.  I saw firsthand the impact of poverty on different communities.

At Heartland Alliance for Human Rights and Human Needs, I worked with immigrants and refugees on the North side of Chicago. I also worked with many of the Heartland Alliance global health team:

  • ·      the team working on HIV Prevention among Men who have sex with men in Nigeria
  • ·      the team working on sexual and gender-based violence in Sulaymaniyah, Iraq,
  • ·      the team working on torture and trauma treatment in Momostenango, Guatemala
  • ·      the team working on Maternal Child Health in Patzcuaro, Mexico
  • ·      the team working on child soldier reintegration in Srilanka

I visited with some of these sites and learned from the Heartland staff and most importantly I learned from the participants in these programs.  What I learned from all of these experiences is simple.

To empower individuals to achieve their human rights, and to empower communities to achieve their potential, we cannot think about health care alone. We have to think about healthcare. We also have to think about housing. We have to think about economic security. We have to think about legal protections.  This is what public health is all about.  This is what we need to address as public health people.

I hope that with your public health education and approach you will keep in mind that a healthier society is a society where healthier choices are the default choices.  A healthier society is a society where children have good schools to attend, and safe neighborhoods to play in.  A healthier society is a society where parents have enough resources to provide their children with a rich experience in life.

What do you need to do to be a better person?  What will you do to build a healthier society?  How can you contribute to social justice?  What role will you play to advance human rights?  Join me today in dreaming big for our communities.  I always did. I always will.

From being a little kid playing on the beach of a small Mediterranean town in Lebanon, dreaming about a safer Lebanon to the conversation I had the last week with Mayor Emanuel when he asked me to stay as part of his Cabinet, I always dream big for our community.

Today is a milestone in your career. Please join me in dreaming big.


adonis49

adonis49

adonis49

December 2020
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