Nils Daulaire, M.D., M.P.H
From InspireYou
Dr. Nils Daulaire, president and CEO of the Global Health Council, located in White River Junction, VT, and Washington, DC, will give the commencement address to the graduating class of UVM's College of Medicine at 2:30 p.m. Sunday, May 18, at Ira Chapel on the UVM campus. The speech is timely in its topic as it relates to the human face of SARS.
I want to thank you for inviting me to share with you your last day as medical and graduate students at the University of Vermont College of Medicine. You've already selected your residencies, but I'd like to talk to you today about the kind of doctor you can choose to be, the kind of doctor most needed in the world today.
And I'd like to begin by telling you the true story of three doctors whose decisions -- made over just the past three months -- have changed the world.
Seven people stood waiting for an elevator in a hotel lobby. One of them coughed. Together for a chance moment, the group quickly scattered to sightseeing buses, business lunches and airport terminals. Within hours, some had flown half the world away. Within days, three of the seven were dead, including the man who coughed. That, according to epidemiologists, is how Severe Acute Respiratory Syndrome -- SARS -- spread from the Chinese countryside to the world. And the man who coughed was a doctor.
Our first doctor was a 64-year-old professor of medicine named Liu Jianlun, a specialist in respiratory ailments at Guanzhou city hospital in the province of Guangdong. Dr. Liu had been very busy in the first weeks of this year, coping with the sudden appearance of an aggressive atypical pneumonia. By February, he had personally treated scores of cases. They showed up with non-specific symptoms: fever, cough, headache. They rapidly worsened, developed respiratory distress, and, in a remarkably high proportion of cases, died. Treating his sick patients, Dr. Liu undoubtedly did what you have been trained to do: He focused on each patient's symptoms and applied his clinical skills to managing their care. Most of his patients got better. In the narrow sense of what a doctor is supposed to do, he did the right things. He just didn't do the one thing that really would have mattered. He didn't put it all together. He didn't see the pattern and the implications of something he was right in the middle of, an emerging health disaster that he was in the unique position to suppress before it really got started. He never thought globally. So Dr. Liu never thought twice about going to Hong Kong in late February for his niece's wedding. He checked into the hotel and went sightseeing. But the next morning, with a high fever and all-too-familiar flu-like symptoms, he checked himself into a nearby hospital and asked to be isolated. But it was too late. He had already infected that group of fellow travelers in his hotel. In that chance group of seven people, one was traveling to Singapore, another to Hanoi, still another to Germany. One of those travelers brought the virus all the way to Toronto. The cough heard 'round the world. Dr. Liu died several days later, and some weeks after that he was identified as "Patient Zero," the outbreak's "index case." Ironic that a doctor should be SARS' ticket to the world.
The next link in our chain of doctors was the physician who would do more than any other individual to help keep SARS from spreading utterly out of control.
Among the elevator passengers at the Hong Kong hotel was a Chinese-American businessman who often traveled to Hanoi. He was in Vietnam a few days later when his symptoms began, and was admitted to the hospital. Dr. Carlo Urbani was the World Health Organization's infectious disease specialist posted in Hanoi. An Italian expert on infectious and parasitic diseases, Dr. Urbani had thought globally from the time he left medical school. He had worked for WHO and then Medecins Sans Frontieres in a half dozen countries. He developed a reputation for putting the pieces of a pattern together, for seeing the big picture. In recognition of the many ways that Dr. Urbani had put his international outlook to compassionate, healing use over two decades, Dr. Urbani was chosen by MSF to accept the 1999 Nobel Peace Prize on their behalf. In his speech at Oslo, he said the prize symbolized the idea "that health and dignity are indissociable in human beings, and that it is our duty to stay close to victims and guarantee their rights." The next year, he took up the World Health Organization's Hanoi post as expert in communicable diseases for Laos, Cambodia, and Vietnam. And so, in late February, Dr. Urbani was asked to consult on the case of the Chinese-American businessman with an atypical pneumonia. He quickly grasped the severity -- and the global implications -- of this previously unknown syndrome. He advised the Hanoi hospital staff to take all available protective measures and went every day to collect samples and strengthen infection control procedures. He counseled Vietnamese health officials on the need to isolate patients and screen travelers, regardless of the effect on Vietnam's economy and prestige. And, critically, he immediately informed the World Health Organization's global infectious diseases surveillance system -- the first alarm leading to global action against the disease that would soon be known as SARS. In mid March, after weeks of daily close contact with SARS patients, Dr. Urbani traveled to Bangkok for a conference. There he himself developed the symptoms he had recognized as the signature of a new killer and was hospitalized. Aware of what he and those around him faced, he issued instructions as to how he was to be isolated for the protection of the Thai health providers caring for him. Less than three weeks later, Dr. Carlo Urbani was dead. He was 46 years old.
By this time, SARS was known to have infected about 1500 people in 15 countries. More than 50 had died. But Dr. Urbani's action ensured that the outbreak in Vietnam was rapidly contained, and, thanks to the alarms he rang, the world was put on alert and the outbreak was soon traced back through the Hong Kong hotel to its origin in southern China. There, although both rumor and good epidemiology indicated that China's outbreak must be by far the world's most severe, the Chinese health minister was insisting that the problem was minor and under control. In fact, treating the outbreak as a state secret so their trade and tourism wouldn't be disrupted, Chinese officials were stonewalling international requests for information, cooperation and free access to the epidemic's epicenter. Acting on government orders, Chinese hospitals faced with visits from World Health Organization doctors were hustling SARS patients into ambulances, to be driven around the streets until the foreigners went away. The lies and evasion might have gone on indefinitely, while the outbreak established itself ineradicably in the world's most populous nation, if it hadn't been for the action of our third doctor.
In the first days of April, a 72-year-old military doctor named Jiang Yanyong sent a signed e-mail to a Chinese television station, declaring that health officials were grossly underreporting SARS infections in Beijing. Dr. Jiang's e-mail was never reported by the state-run TV station, but it was leaked to the international media, and from there to the world. Other whistleblowers, encouraged by Dr. Jiang's example, began sending reports from around the country, and by mid April, the government was forced to make a shattering admission of deception and incompetence. The real figures for SARS infections and deaths in Beijing, the government admitted, were at least ten times higher than reported. Beijing's mayor and the nation's health minister were fired, and China began a massive publicity campaign to mobilize its people against SARS. This shake-up has been called the most significant political event in China since Tiananmen Square. When asked about the risk he was taking by speaking out, Dr. Jiang said, "I am not afraid. I want the world to know the truth." Since then, he has been put under surveillance and warned against speaking to foreign media. No information is currently available concerning his whereabouts or well-being.
This story isn't over. SARS is still with us. As of today, the reported infections total nearly 8,000 cases in 25 countries, from Mongolia to the USA. More than 600 are known to have died. Case fatality is now estimated at higher than 14 percent. The struggle to contain and, if possible, eradicate the outbreak rages, with the stakes being exposure of the global population to a disease that could kill over 60 million people around the world.
For now, though, we can pause to contemplate the lives of three doctors crucial to the world's experience of SARS. What do their stories tell us about doctors' work in the world today? The first doctor saw his role as that of the classic physician: His work was person-to-person, one case at a time, a matter of applying his healing skills to individuals who came for his care. He did not see the emerging pattern, and in all likelihood he didn't think of this as his responsibility. The second doctor was a seeker of patterns, ready to follow their implications wherever they might lead. He considered not just the patient before him, but the potential chain stretching into the future, and took action on all their behalf. The third doctor looked beyond the disease and its victims, to the society and power relationships which served as its culture medium. The right we should all have, to live under responsible government that cares more about the health and welfare of its citizens than about maintaining its own power, was being trampled. He saw that fear, lies and silence were the perfect medium for the virus' transmission, just as it has been for AIDS in country after country over the past two decades. He made the connection between health and politics, and chose as a physician his obligations to humankind over his obligation to the State.
Here at home, as physicians we treat daily the many symptoms of inequity and deprivation -- but are we willing to ask what these diseases may mean? Are we looking for the patterns behind the individual patient? Are we ready to speak up for the social changes that are needed bring about a healthier society? Are we willing to speak truth to power?
You are swearing an oath today, pledging to consecrate your lives to the service of humanity. Make that oath count.
As a doctor, you have a duty that goes far beyond providing the best clinical care for the patient in front of you. You are charged with the protection of those further along the chain of connection, of society as a whole. You have a responsibility to understand how your patients' ills reflect greater realities, problems and even injustices. You have an ethical obligation as a healer to speak and act on what you see, even if doing so threatens your peace of mind, your career advancement -- or worse.
SARS is today's news, but around the world, entirely preventable and treatable diseases are decimating generations, crippling economies, destabilizing nations. AIDS. Childhood diseases. Unsafe pregnancies. But the lives they are taking are overwhelmingly among the poor and disenfranchised, living in communities far from the world's centers of privilege and power. They die off-camera, out of our mass-media sight, and seemingly out of mind. We went into medical school because we wanted to make the world a better place, to do good. We often come out of it wanting just to be better clinicians and to pay off our debts. To do well. We can do better. As you leave here today, I want to urge you always to think globally, to see the background with the foreground. That greater sense of mission is not a childhood dream, not an ideal to outgrow as you face the realities of practice and family, but an essential part of your work as a doctor in this world.
Think about our three doctors, and ask yourself how you feel about the decisions they made. Now, like them, you have important choices to make. I'm asking you to choose to make the world a better place for all its citizens.
Congratulations and good luck.
