Beyond The Oath: A Letter to My Fellow 2012 Graduates

May 30, 2012

Dear Friends,

Twenty-five years ago last month, Larry Kramer, playwright and activist, stood up at the Lesbian, Gay, Bisexual and Transgender Community Services Center in New York City and asked two-thirds of the room to do the same. He told those who were standing that they would all be dead in five years: “If my speech tonight doesn’t scare the shit out of you, we’re in trouble. If what you’re hearing doesn’t rouse you to anger, fury, rage, and action, gay men will have no future here on Earth. How long does it take before you get angry and fight back?” The AIDS Coalition to Unleash Power (ACT UP), an advocacy group that worked to bring fair treatment and funding for people with AIDS, was born.

As Jim Eigo, one of the founders of ACT UP, recently explained, “a critical mass of people with AIDS recognized: my body, the site of a devastating disease, has become the site of a social struggle as well.” Using their bodies in protest, ACT UP forever changed the regulatory framework for drugs, and the relationship between ordinary people and the healthcare system.  They changed the system from an unjust one, to a less unjust one.

More than 10 years later, across the Atlantic, South African activist Zackie Achmat, influenced strongly by the tactics of both the Anti-Apartheid movement and ACT UP, started the Treatment Action Campaign, whose protest songs (in four-part harmony) have echoed the world over; echoed in falling drug prices, echoed in the ability for ordinary citizens to make claims on their governments regarding health. The movements guided by Mr. Kramer and Mr. Achmat have not only helped to secure treatment for people with HIV in their home countries, they have helped to do the same around the world.

'Storm the NIH' ACT UP at NIH © National Institutes of Health Library

During my last months as a student at the Mailman School, I read and re-read the public health oath that we took during orientation and again at Commencement. I had been trying to understand exactly what I signed up for when I chose public health: what does it  mean to be in the company of my fellow graduates, what is it that I (a biostatistician) should have in common with friends from other public health disciplines, and what responsibilities do we all bear?

While the oath was created only four years ago, the message sprouts from beliefs that I think have been widely held by leaders and practitioners throughout the field for some time; the idea that “Health is a human right. The public health community exists to safeguard that right.”

Yet through the lens of the HIV/AIDS epidemic, the oath seems at odds with the recent history (and the present!) of struggle by those most devastated by the virus to have their voices heard, and to have their health taken seriously. If the public health community truly believed and allowed itself to be guided by the principles that underpin the oath, then how could it have failed so dismally to act quickly, decisively and morally to a human crisis – the HIV crisis?

“There is a feeling among members of any of a number of professions or just the general population” explained Dr. Anthony Fauci, a leader in the National Institutes of Health at the height of the crisis in the late 80s, “that patients with AIDS, many of whom are homosexual, are a little bit different… [this] has led to a little bit of a complacency about the approach towards this disease.”

To me, this history’s distance from us now, and also its haunting closeness, should give us pause. If a community of people who aimed to take care of other people’s health was capable of failure at such scale around the world, aren’t we capable of those same mistakes today?  What lethal silences will we commit daily in our well-intentioned careers? Who is it that is “a little bit different” than “us”? Who is the “us” that we imagine? Does “us” include my friend who runs a tiny HIV program for men who have sex with men in the town of Thika in Kenya? Does it include Johannesburg sex workers who band together to improve their own health and that of their colleagues? If it does, what will we do to make sure that all our knowledge and ideas and voices will not be dominated by those of us who hold privilege over others?

What should we do now to ensure that when we are written about in 50 years time, we will read our deeds without shame? How can we be righteous? How can we avoid the need for Zackie Achmats and Larry Kramers?

Maybe the oath is a good start. Maybe if we read it earnestly and figure out what all its implications are to our practice, we will not repeat mistakes. But maybe it goes deeper; maybe what is needed is the kind of introspection about ourselves, our power, and our capacity to fail that most of us are ill-equipped to do.

Either way, here we are, about to get intimately involved in other people’s lives – most of whom we will never meet, most of whom we know only through our 2×2 tables. I hope we will each grapple with the history and the politics of what we do.

Good luck to us all, and in the words of my hero/heroine RuPaul, the American actor, drag queen, model, “don’t f— it up”.

Yours in (qualified) optimism,
Keletso Makofane, MPH ’12