Good evening. Distinguished guests, family and friends, faculty and staff of the Johns Hopkins School of Hygiene and Public Health and last, but not least, my friends and fellow students, the class of 1999 - the last, the best, the Class of the Millennium.

In front of you, you have a speaker who has been a little bit of everything. I have been a left-handed Puerto Rican medical school graduate, the winner of the Chamber Pot award at the University of Michigan, a nephrologist at Georgetown with an IQ higher than my BUN, the first woman Surgeon General of the United States, and most recently, the first DrPh candidate at this our alma mater. So you see, I am probably a lot like you, still trying to figure out what I’m going to be when I grow up!

I am impressed that this class of 498 graduates represents 54 countries, that so many of you will be receiving awards of excellence tonight and that among you, there are so many minorities. But more than anything I am impressed that 60% of this graduating class are women. I congratulate the women, and thank the men–after all, it shows that men of quality do not fear women who seek equality!

It is an honor for me to join you today. I share your pride in these fine men and women who will carry your legacy into the future; Johns Hopkins. . . your graduating Class of 1999. This class is like your former Surgeon General--small enough to be personal, yet big enough to be powerful.

Seventeen years ago I sat where you sit today. It was a different world, we faced different issues--AIDS was just beginning, there wasn’t managed care, and doctors made house calls! Johns Hopkins prepared us then, and today it will prepare us for the many vexing problems that we will face.

Graduates, I stand before you today to congratulate you, to counsel you, and to challenge you.

Congratulations: When you leave the Meyerhoff today, you will be able to do two things: call yourself a true public health professional, and start to pay off your student loans.

I don’t have to remind you that your future, and that of public health, will be filled with complex issues. Although much has been done, much more is expected of us. At the turn of the millennium, unlike past decades, the problems of public health will demand the collective might of us all.

As I look out into the sea of faces here today, I see some of the leaders who will help remold and shape our communities in a new image. An image that reflects the capacity for caring and commitment, that we Hopkins graduates are known for around the world–but one that, however real, we must zealously protect. The challenges facing us are too great.

After all, the health care environment is totally different. Physician autonomy is being threatened. There is increasing competition for the precious dollars for health care and research and for the practice of medicine. Public problems like substance abuse and AIDS continue to strain our resources and our families, and violence, lest anyone forget recent events, affects even the most vulnerable and the precious members of our society.

And I’m sure you’ve heard by now that despite our efforts, not all patients are getting the health care they need. But not all has changed for the worse.

There are still some touchstones in the health care profession that remain sacred -- that remain unchanged from one generation to the next. And the most important of these is the one undeniable fact: we who dedicate our careers to the health of our fellow citizens, are practicing a pretty special profession . . an extraordinary profession, indeed.

We are blessed with the opportunity to enter peoples’ lives in a most intimate way. The trust placed in us is the legacy we have inherited from past generations of our colleagues. We must protect that trust, nurture it, and make it grow. It is both a blessing - and a blessed responsibility.

The single greatest challenge for health care professionals today, lies in finding ways to adapt to the pace of change, and yet still make sure that evolving delivery systems and shifting health priorities are supported by the essential values of our ancient healing relationships.

We must remember that the therapeutic effects of machines and gadgets must be enhanced by the touch of the healing hand or the spoken word. And while we have an obligation to advance the technology and the science of public health, we must always maintain the human element of the work we do. In reality, we must keep up with new scientific discoveries and exploding technologies--without forgetting the faces behind the data and the names behind the statistics.

It has been said, service is the rent we pay for living--and that service will set us apart. Service to ourselves, and our families, service to country, and service to God. The importance of this service attitude is painfully obvious in today’s world. My friends, there is a spiritual vacuum in America’s society today. There is too much of "what can I get?" rather than "what can I give?" We must remember that, the test of making a living is how much you get. The test of making a life is how much you give.

In order to succeed, we must rediscover the true practice of medicine and public health--which is much greater than the treatment of illness alone--or we will be practicing health care and medicine in a vacuum. I submit that our God-given vocation goes beyond our ability to cure! "Remember, our patients will not care how much we know until they know how much we care."

So, while I congratulate you most warmly today, I urge you to embark upon a lifelong quest of learning, of healing... but, above all, of caring.

And, now, my counsel: Colleagues, we must remember that our work as professionals defines us as human beings. As it has been said, "much of the good and the bad that you will ever do in this world will come through your work."

How will you view your work? The author Robert Bella describes three types of work: First there’s the job, where the goal is simply earning a living and supporting your family.

Then there’s the career, where you trace your progress through various appointments and achievements.

Finally, there’s the calling, the ideal blending of activity and character that makes work inseparable from life.

As health care professionals, with a very visible responsibility to uphold the public trust, I hope you are not just looking for a job. I hope you are not just planning a career.

I hope each and every one of you has a calling–an altruistic calling. I know that you will do well. Your faculty has seen to that. But I pray you will do good.

One word of caution, though–from one who sat where you are sitting just 17 short years ago -- the world owes you nothing! To expect the world to treat you fairly because you’re a good person and a graduate of Johns Hopkins University is like expecting a raging bull not to charge you because you’re a vegetarian!

That is why, while I fervently wish you much happiness in your work, I caution you not to look for happiness for happiness’ sake. If you do good, happiness, believe me, will seek you. So work hard, and beware of those enemies of tranquility: avarice, ambition, envy, anger, and pride; and avoid Kuschner’s pillars of despair: complacency, mediocrity, and above all, indifference.

Now, I would like to challenge you: I am reminded of some very simple, yet profound observation of Mark Twain, who said:

experience come from? Experience comes from bad judgment."

I can tell you that if we are going to meet the Nation’s complex and difficult public health challenges, we’re going to need healthy doses of both: experience and judgment.

We are witnessing a staggering demographic, medical and political revolution--and like it or not, we will all be swept into its currents.

Colleagues, although it may be impossible to determine precisely what the true challenges will be, allow me to share with you four specific challenges that I see along the way... challenges that might have a direct effect on the way we deliver care, and, in addition, might have an impact on the way we respond as a public health community.

Challenge No: 1: We must respond to the changing demographics in this diverse Nation of 267 million people--with more than half of the population women, with close to 15 percent of our population African American, more than 9 percent Hispanic, 3 percent Asian or Pacific Islander, and more than 1 in 10 over the age of 65–we simply cannot afford to cling blindly to values and perceptions that are out of touch, or to rigidly follow outdated practices. Instead we need to adapt, to create, and to innovate.

We must also learn to accommodate the special needs of America’s emerging majorities. We need to move toward designing programs for communities where we have walked in their shoes and on their streets. Let’s not only learn the language, but also the culture.

Let’s view patients as partners in health care. Too often, patients complain that they are viewed as supplicants of care who are seen at the convenience of the provider. That the overall atmosphere at some medical care facilities is not conducive to a patient’s self worth, to the care of the poor, to the needs of working mothers, and/or to the tolerance of the language illiterate. Let’s go back to understanding the impact of all aspects of human suffering before inserting them as mere statistics into action plans for health care reform.

Franklin D. Roosevelt said: "The test of our progress is not whether we add to the abundance of those who have much. It is whether we provide enough to those who have little."

Challenge No. 2 threatens to shake American medicine to its core: the challenge of access for all our citizens to adequate health care. Care that is comprehensive, family-based, community-centered, culturally sensitive, and under one roof.

A health care system that is portable, efficient and secure, and meets the five "A’s"- -available, accessible, affordable, accountable, and to be sure--affable as well.

We need to forge a health care system where there is an appropriate balance between meeting the health care needs and restraining the cost of care without jeopardizing the number of health professionals, the access to the health care provider, or the availability of teaching and/or research.

To do this we might have a battle looming in front of us. Many of us in this audience can remember in the mid-1970's, when the public held physicians in high esteem, right next to members of the clergy. Confidence in the ability to make a decent living was always assumed--all we had to do was to "hang up a shingle" and patients would come.

Academic medicine seemed to offer the best of both worlds: plenty of time for research, some teaching, and limited practice responsibilities.

Today, it all appears to be somehow jeopardized: the independence, the time, the easily acquired grants, the life-style, even the security.

Today we face a complexity of health care options and health plans unprecedented in human healing history - almost as many and as varied as patients and health care professionals themselves! Today we have an image of fast-paced, high-tech, dollar-conscious medicine--that sometimes seems to leave little room for the needs of the human equation.

The business of health care delivery has grown leaner. Sometimes meaner. The marketplace is looking for value--which should translate into high quality, cost-effective care, but from the patients’ perspective does not appear to be good old time health care.

Ultimately, however, the degree to which health care succeeds or fails for patients and caregivers depends on the answer to one very important question. And that is:

Can we, the health care providers, maintain the traditional

humanistic qualities of medicine within an increasingly

corporate structure? I say we can!

To start, we must take care of people, not covered lives, but people. We must extend our reach and influence as health care professionals to positively impact not only those we see in our offices, clinics, and hospitals, but also those who live in our neighborhoods and communities.

We must become a voice for the disenfranchised--the young, the poor, the disabled, and the elderly--those who might be shut out of the health care system through no fault of their own. We must use our voice in Washington, our State Houses, and local communities.

Remember, "Politics is too important of an issue to be left to politicians." The same can be said of health care in the 1990s and beyond. This rings true even more now when issues like the patients’ bills of rights, patients’ records confidentiality, are on the front burner of Congress. We all need to be part of the solution. To paraphrase an old American Indian saying - "Do not tell me what to do, unless you have walked a mile in my moccasins!"

My third challenge to you is one that I addressed as your Surgeon General: the challenge of violence in our society... a threat that unravels the fabric of society, casts a shadow on every home and community, and steals our peace of mind.

Too often, health care professionals think violence is the responsibility of other groups--the police, the court, politicians, the media, and the church. I would suggest, however, that this thinking needs revision.

Violence is a disease--no more, no less--but for way too long it has been treated like a long-held secret. Until we start talking about it.... until we start treating it like the disease it really is, it will continue to devastate families and destroy lives.

Colleagues, it is no small problem that homicidal violence is now a leading cause of death among our youth. There are many causes, but it is the acceptance of violence in our society that disturbs me. The average American child watches approximately 22,000 hours of television before finishing high school, twice the time spent in the classroom. By the age of 18, this includes 200,000 acts of violence and 40,000 murders. During those 22,000 hours of the most impressionable period of their lives, children are not just being entertained–they are soaking up information, attitudes and beliefs about work, about life, about how people treat one another, about how problems get solved, and most of the time, without parental supervision.

I am afraid that one of the things they are learning from T.V. is that violence is a great problem solver or at least the preferred conventional way of solving crime, punishing evil, and dealing with conflict. The cases of Littleton, Colorado and Conyers, Georgia are devastating examples of this. In the past, we have been effective advocates for the physical environment. To cleaner air and cleaner water, let’s add healthier families and empowered communities.

It is time to use the tools we have mastered as public health professionals to help parents, and to help make them more responsible for their children’s actions. It is time to advocate for less glorification of violence in the media, and more control over violence on the internet–and in our society, it is time to reduce children’s reliance and access to guns as a problem solver. Above all, let’s stop accepting violence as part of life and start becoming part of the solution.

My fourth and final challenge is to learn to work together. For in the future, we will no longer be the sole proprietors of the state of the world’s health. After all, keeping the world healthy is too big a job for any one segment of the profession to handle alone.

We need primary care physicians, specialists, researchers, educators, and experts in public health, all working together to deliver health care as our profession. We must not only collaborate, but we must also cooperate because health care is improved when we work as a team.

Like great orchestras, the world health care profession is made of accomplished players who contribute their individual talents towards a larger goal.

Sure there is time for solos, but we can’t afford to each play our own tune. Latin America, Europe, Canada, Asia, Africa, cannot stand alone. We must not only learn to talk to one another, but also learn from one another as well. While we may speak with accent, we do not think with an accent!

So, there you have it. Four challenges from your former Surgeon General. A "hit list" if you will, but of the healthiest variety. The going will be tough, but I as I look out at the Class of 1999, I am encouraged.

Sitting before me I see our new generation of clinicians, professors, researchers, communicators, administrators, and perhaps, even the next Surgeon General. I believe you are ready to meet these and all the other challenges that lie in wait for you.

In doing so, don’t forget to keep alive the joy, the excitement, the beauty, and the creativity of the art and science of public health. And remember, we public health professionals, graduates of Johns Hopkins, are bound to serve a higher good–the health and welfare of people of the world. I believe that we must keep the health care profession a sacred institution, not only for those of us that work in it, but more importantly, for all those who depend on it.

So today, graduates, let’s light a path so that others can follow. Because it is not enough to say that we are going to reach out to more people, but we must actually do it and set an example for others.

Today, it has been my distinct honor to congratulate, counsel, and challenge. The rest is up to you. May you seize this day and all others that are t follow to bring honor to your alma mater, joy to your family and friends, comfort to your patients, and true happiness to yourselves.

Above all, I pray that you do not lose your sense of who you really are, where your roots are, where you came from, and who helped you in getting to this point. Most importantly, do not forget the impact of this great institution in molding your life and professional future.

Johns Hopkins University School of Public Health, Class of 1999 -- May you think clearly... act decisively... and care tenderly. For without knowledge there is no future, and without caring, there is no hope.

Thank you very much, and God bless.