As prepared for delivery.
President Garber and fellow alumni, thank you for this chance to speak. Alumni Day has apparently drawn a record 9,000 attendees this year. I think I know why. Lately, I too have been hungry to connect with others in this community. Certainly, this is a chance to reminisce and catch up with friends. But we are also here to rally around this institution in a perilous time.
Let me tell you some of what I have seen. I am a child of Indian immigrants who’d come for medical training, and I was raised in rural Ohio where they practiced. I too became a doctor and came to have more than three decades at Harvard in surgery and public health. What I learned here led to an opportunity, in January 2022, to take a leave to lead global health at the US Agency for International Development.
It was the best job in medicine you likely had never heard of. I led 2500 health professionals in more than 65 countries. With less than half the budget of the Mass General Brigham— about $24 per American taxpayer—they saved lives by the millions and contained disease threats all over the world.
Before I departed the agency, on January 20 of this year, I briefed the Senate Foreign Relations Committee on several initiatives poised to transform global health: for example, the rollout of a breakthrough, single-shot drug that prevents HIV for a year, which has the potential to end the AIDS pandemic; preparations for three promising TB vaccines in trials; deployment of an inexpensive package of therapies proven to reduce post-childbirth hemorrhaging—the leading cause of maternal deaths—by 60 percent. The incoming administration had every reason to advance such initiatives. Congress had already allocated the funding, with bipartisan support.
Instead, we got surgery with a chainsaw. I watched from the sidelines in horror as the new administration, ignoring Congressional directives, purged the staff, terminated 86 percent of USAID’s programs, kneecapped the rest, and shuttered the agency. In doing so, they dismantled America’s largest civilian capacity abroad, our primary vehicle of soft power, dedicated to advancing global stability, peace, economic prosperity, and survival. And they did it in a way that maximized human suffering, loss of life, and waste of taxpayer dollars.
During this terrible time, I talked to many former colleagues at USAID, who were under immense pressure to take troubling actions outside established procedures— for example, to dismiss fellow employees or to recommend terminating lifesaving programs under the fiction of eliminating fraud and waste. They needed an ear and sometimes advice. And I found myself relying more on my experience with surgical patients than with public health policy. This is what I’d like to tell you about today.
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I graduated from Harvard Medical School 30 years ago this month. What I loved most about med school was the invitation into people’s lives and the chance to help solve some of their most frightening problems. Every clinical rotation provided ample opportunity. But it was the operating room that captivated me.
I remember, for example, the case of a college student with infectious mononucleosis. The infection had caused his spleen to enlarge and rupture, and he arrived in the emergency room in hemorrhagic shock. The team could barely detect a blood pressure.
By the time we had him on the operating table and under anesthesia, he was on the verge of cardiac arrest. The surgical resident opened the young man’s belly in two decisive moves: with a knife, he made a swift slash down the middle, through the skin, from the rib cage to below his belly button, then with open scissors, he pushed upward through the linea alba—the fibrous tendon that runs vertically between the abdominal muscles. Blood burst out of him, and the resident plunged his hand into the opening. The attending surgeon stood across from him, asking in an eerily calm, quiet voice, “Have you got it?”
“Now?”
“You have thirty more seconds.”
Suddenly, the resident had freed the spleen and lifted it to the surface. It was fleshy and heavy, with blood pouring from its torn capsule. The attending surgeon put a clamp across its tether of blood vessels. The bleeding stopped instantly. The patient was saved.
I mean—how can you not love that? Fixing people with your own hands. I had to learn how to do that.
Surgery was indeed deeply gratifying work. I fixed a lot of people. And yet I wasn’t prepared for how many people would come to me with problems I could not fix: chronic or incurable diseases, issues of frailty, terminal conditions. How was I supposed to help with those problems? What did it mean to excel at that?
I explored these questions by writing about them. For my book Being Mortal, I interviewed more than 200 people with unfixable health problems. I also spoke with their family members and scores of people trained to help them—geriatric social workers, palliative care doctors, hospice nurses.
Among the people I spoke to, for example, was an 89-year-old woman I’ll call Mrs. Kitteridge. She had congestive heart failure, debilitating arthritis, a series of falls, and no choice but to leave her Delray Beach condo for a nursing home. She had picked a place up here near her daughter. It was safe, had excellent ratings, and nice staff.
But a month into her stay, Mrs. Kitteridge was wretchedly unhappy. She wanted more from life than mere physical safety. “I know I can’t do what I used to, but this feels like a hospital not a home,” she told me. The nursing home’s priorities were avoiding bedsores, maintaining weight, preventing falls—important medical goals, but well short of a meaningful life.
Mrs. Kitteridge had traded an airy condo she’d decorated herself for a small beige room with a stranger for a roommate and a single cupboard for her belongings. Her days were governed by a rigid schedule: waking, dressing, meals, medications, “activity time,” bed. But she felt she still had so much to offer. “I want to be helpful, play a role,” she said. She used to make jewelry and volunteer in a library. Playing bingo and watching movies couldn’t be all there was anymore.
We continually fail to recognize that people have other priorities besides living longer. The experts I spoke to for Being Mortal taught me how to elicit these priorities by asking the right kinds of questions. Questions like: What is your understanding of what lies ahead with your health? What are your fears, should your situation worsen? What are your hopes? What are you willing and not willing to sacrifice for the possibility of more time? What is essential to you for your quality of life?
When I asked Mrs. Kitteridge what was essential to her life, she was clear: “Friendships, purpose to my days, and privacy,” she said. It was the best living will ever. She’d spelled out exactly what her caregivers should help her preserve and never sacrifice.
Over the decade since Being Mortal was published, I have come to realize that these discussions are not just for those facing serious illness or disability. The same sorts of questions apply to anyone facing a crisis: What is your understanding of what lies ahead? What are your fears and hopes, if your situation worsens? What are you willing and not willing to sacrifice? What is essential to you?
Over the last five months, I have discussed these questions with my former colleagues facing crisis at USAID and then elsewhere as the administration expanded its disruptions. Friends at the National Institutes of Health and the Centers for Disease Control, for example, have struggled to decide what policies and requests they would accept to preserve their life’s work, as science and public health are slashed and subjected to political controls. And I have discussed similar questions with leaders outside the federal government, as they determine what they would and would not countenance for the sake of their professions and organizations.
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In recent months, the White House has issued punitive executive orders against major law firms for employing or representing people and organizations that the President considers adversaries. These orders have directed federal agencies to terminate contracts with any organization using these law firms’ services, and to block the firms from accessing government buildings and necessary information.
I spoke to a senior partner in one of those firms as its leaders considered what to do. Would it brave the existential threat posed by these orders and fight them in court, or would it, like many firms, attempt to neutralize the threat through an agreement with the administration to accept restrictions and an obligation to do pro bono legal work for the President?
The lawyer told me that he and his partners had been anticipating an attack for some weeks and were already asking those difficult questions: What were their priorities besides survival? What were they willing and unwilling to sacrifice? He had been at the firm for decades, and he recalled some of the people they had represented over the years — the weak who had stood up to the powerful, victims of illegal government actions, people whom no one else would represent. “We remain that firm today, and we must remain that firm tomorrow,” he said.
Plus who knew what was to come? “If we fight,” he said, “we could lose partners, we could lose clients, we could go out of business. But then again, if we capitulate, we could lose partners, we could lose clients, we could go out of business.”
The discussions were hard, the partner later told me, but the answer was ultimately easy. When the executive order finally came, his firm was one of four that decided to fight. They would not sacrifice their integrity or core principles.
Their decision did cost them clients. But it also attracted new ones. Interest in working at the firm is up. And their people can hold their heads high.
A federal court ultimately declared the executive order against the firm unconstitutional, but no one was under any illusions: They are not home-free. The President may find new ways to punish them. In fact, he has found new ways to make the firms that capitulated pay. And they will be paying the price of their capitulation for years to come.
Now Harvard has been targeted alongside many other universities. I returned to Harvard and the Brigham and Women’s Hospital in January and learned last week that my own research center’s work, reducing mortality for surgical patients, had been defunded along with all the rest of the public funding that sustains this institution’s world-changing work in research and science. International students, including current students, may no longer be allowed to study here. Even the accreditation of top universities is now under threat.
So we here, too, have had to ask ourselves, as a community and as individuals: What are our priorities besides survival? What are we willing and not willing to sacrifice? What is essential to us? Do we brave this existential threat and challenge these vindictive and illegal actions in court or do we try to neutralize the threat by submitting to the administration’s draconian demands?
The discussions have been hard, but the answer was ultimately easy. I want to express gratitude to President Alan Garber and the Corporation, who chose to fight rather than capitulate. Our commitment to tackling serious issues of antisemitism, Islamophobia, and other forms of prejudice must not waver. However, the integrity and independence of this centuries-old institution of teaching, scholarship, and discovery are non-negotiable.
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In the past five months, I have had the misfortune to have a front row seat as the current regime has moved to weaken—and even outright dismantle—core foundations of humanitarian assistance, science, public health, law, and higher education. On the other hand, that has allowed me to speak from direct experience about the senseless destruction of essential capacities, vital norms and rules, and already tens to hundreds of thousands of lives.
We are a nation in crisis. A struggle is taking place between a rules-based social order and power-based order. On one side, we have our institutions founded on the principle that all human beings are created equal, are endowed with unalienable rights, and deserving of liberty, dignity, and self-determination. On the other, it seems, we have might makes right, a proudly amoral, ruthless, Mad Max world of winners and losers, the dominators and the dominated, with no higher goal than power, wealth, and attention.
I have faith, however, that our better angels will ultimately prevail.
(1) Because, as Tacitus warned the emperors of Ancient Rome, authority founded on force and empty of ideals is hated, short-lived, and unstable;
(2) Because chaos, destruction, and denial of reality do not deliver a better life;
(3) Because we have had 250 years as a nation founded on a core idea of universal equality and do not want to squander this legacy for which so many previous generations have sacrificed their lives to sustain; and
(4) Because the power-based understanding of human motivation is impoverished and wrong.
People want to live in a society guided by hope not fear. And, as Mrs. Kitteridge affirmed, we all need to live for a larger purpose beyond ourselves and what we can acquire, something worth making sacrifices for.
In my surgical practice, I have navigated serious illness and crisis with many people, and it is a process. It seems to me that we as a community and as a nation are going through a similar process. The disease we face is dangerous. It has already inflicted considerable harm. We are working through assessing that reality and accepting that life as we knew it has changed. We must grieve the loss of former certainties and come to clarity about our purpose and priorities going forward into an uncertain future. But navigating it is far easier when we know who we are and what we stand for.
Institutions and nations, like human beings, are perishable. But unlike with human beings, death is not inevitable. They can live on. They are how we endure.
