[Congressional Record (Bound Edition), Volume 158 (2012), Part 8]
[Extensions of Remarks]
[Pages 11482-11484]
[From the U.S. Government Publishing Office, www.gpo.gov]




             RECOGNIZING THE LEADERSHIP OF DR. DON BERWICK

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                         Tuesday, July 17, 2012

  Mr. STARK. Mr. Speaker, Don Berwick was Acting Administrator of the 
Centers for Medicare and Medicaid Services for President Obama. 
Unfortunately, the minority party in the U.S. Senate was able to 
prevent him from being confirmed into the post and so he was forced to 
leave at the end of 2011.
  I've copied below a recent commencement address at Harvard Medical 
School by Dr. Berwick.

[[Page 11483]]

  If Dr. Berwick doesn't embody the spirit we want for our medical 
professionals--as well as our public servants--I don't know who does.
  I urge my colleagues to read this speech. Driving people like Dr. 
Berwick out of public service is not something of which anyone should 
be proud.

                       [From JAMA, June 27, 2012]

                               To Isaiah

                    (By Donald M. Berwick, MD, MPP)

       THANK YOU FOR LETTING ME SHARE THIS GLORIOUS DAY with you 
     and your loved ones. Feel good. Feel proud. You've earned it.
       In preparation for today, I asked your dean of students 
     what she thinks is on your mind. So, she asked you. The word 
     you used--many of you--was this one: Worried. You're worried 
     about the constant change around you, uncertain about the 
     future of medicine and dentistry. Worried about whether you 
     can make a decent living. You've boarded a boat, and you 
     don't know where it's going.
       I can reassure you. You've made a good choice--a 
     spectacularly good choice. The career you've chosen is going 
     to give you many moments of poetry. My favorite is the moment 
     when the door closes--the click of the catch that leaves you 
     and the patient together in the privacy--the sanctity--of the 
     helping relationship. Doors will open too. You'll find ways 
     to contribute to progress that you cannot possibly anticipate 
     now, any more than I could have dreamed of standing here when 
     I was sitting where you are 40 years ago.
       But look, I won't lie; I'm worried too. I went to 
     Washington to lead the Centers for Medicare & Medicaid 
     Services, full of hope for our nation's long-overdue journey 
     toward making health care a human right here, at last. In 
     lots of ways, I wasn't disappointed. I often saw good 
     government and the grandeur of democracy--both alive, even if 
     not at the moment entirely well.
       But, like you, I also found much that I could not control--
     a context torn apart by antagonisms--too many people in 
     leadership, from whom we ought to be able to expect more, 
     willing to bend the truth and rewrite facts for their own 
     convenience. I heard irresponsible, cruel, baseless rhetoric 
     about death panels silence mature, compassionate, scientific 
     inquiry into the care we all need and want in the last stages 
     of our lives. I heard meaningless, cynical accusations about 
     rationing repeated over and over again by the same people who 
     then unsheathed their knives to cut Medicaid. I watched fear 
     grow on both sides of the political aisle--fear of authentic 
     questions, fear of reasoned debate, and fear of tomorrow 
     morning's headlines--fear that stifled the respectful, civil, 
     shared inquiry upon which the health of democracy depends.
       And so, HSDM and HMS Class of 2012, I'm worried too. I too 
     wonder where this boat is going.
       There is a way to get our bearings. When you're in a fog, 
     get a compass. I have one--and you do too. We got our compass 
     the day we decided to be healers. Our compass is a question, 
     and it will point us true north: How will it help the 
     patient?
       This patient has a name. It is ``Isaiah.'' He once lived. 
     He was my patient. I dedicate this lecture to him.
       You will soon learn a lovely lesson about doctoring; I 
     guarantee it. You will learn that in a professional life that 
     will fly by fast and hard, a hectic life in which thousands 
     of people will honor you by bringing to you their pain and 
     confusion, a few of them will stand out. For reasons you will 
     not control and may never understand, a few will hug your 
     heart, and they will become for you touch points--signposts--
     like that big boulder on that favorite hike that, when you 
     spot it, tells you exactly where you are. If you allow it--
     and you should allow it--these patients will enter your soul, 
     and you will, in a way entirely right and proper, love them. 
     These people will be your teachers.
       Isaiah taught me. He was 15 when I met him. It was 1984, 
     and I was the officer of the day--the duty doctor in my 
     pediatric practice at the old Harvard Community Health Plan. 
     My nurse practitioner partner pointed to an exam room. ``You 
     better get in there,'' she said. ``That kid is in pain.''
       He was in pain. Isaiah was a tough-looking, inner-city kid. 
     I would have crossed the street to avoid meeting him alone on 
     a Roxbury corner at night. I'm not proud of that fact, but I 
     admit it. But here on my examining table he was writhing, 
     sweating in pain. He was yelling obscenities at the air, and, 
     when I tried to examine him, he yelled them at me. ``Don't 
     you f-----g touch me! Do something!''
       I didn't figure out what was going on that afternoon. 
     Nothing made sense. I diagnosed, illogically, a back sprain, 
     and I sent him home on analgesics. Then, that evening, the 
     report came: an urgent call from the lab. Isaiah didn't have 
     a back sprain; he had acute lymphoblastic leukemia. And we 
     didn't have his phone number.
       The police helped track him down that night, to a lonely 
     three-decker, third floor, a solitary house in a weedy lot on 
     Sheldon Street in the heart of Roxbury. Isaiah lived there 
     with his mother, brothers, and his mother's foster children.
       What followed was the best of care . . . the glory of 
     biomedical science came to Isaiah's service. Chemotherapy 
     started, and he went predictably into remission. But we knew 
     that ALL in a black teenager behaves badly. Unlike in younger 
     kids, cure was unlikely. He would go into remission for a 
     while, but the cancer would come back and it would kill him. 
     Three years later, he relapsed.
       I drove to his apartment one evening in 1987 and sat with 
     Isaiah and his graceful, dignified mother around a table with 
     a plastic red-checkered tablecloth and explained the only 
     option we knew for possible cure--a bone marrow transplant, 
     not when he felt sick, but now, at the first sign of relapse, 
     when he was still feeling fine. He was feeling fine, and I 
     was there to propose treatment that might kill him.
       They didn't hesitate. Isaiah wanted to live. He got his 
     transplant, from his brother. His course was stormy, 
     admission after admission followed, then chronic 
     complications of his transplant--diabetes and asthma. His 
     Children's Hospital medical record that year took up five 
     four-inch-thick volumes. But he got through. Isaiah was 
     cured.
       We became very close, Isaiah and I, through this time and 
     for years after--long conversations about his life, his 
     hopes, his worries. He always asked me about my kids. And his 
     mother, close, as well. An angel--a tough angel raised by her 
     sharecropper grandfather on a North Carolina farm, who read 
     Isaiah the riot act when she had to and who fiercely 
     protected him--and who, during the darkest times of his 
     course, continued to tend her ten foster children, as well as 
     her own.
       I came to know Isaiah well, but it wouldn't be quite right 
     to call us friends--our worlds were too far apart--different 
     galaxies. But my respect and affection for Isaiah grew and 
     grew. His courage. His insight. His generosity.
       But there is more to tell.
       Isaiah smoked his first dope at age 5. He got his first gun 
     before 10, and, by 12, he had committed his first armed 
     robbery; he was on crack at 14. Even on chemotherapy, he was 
     in and out of police custody. For months after his transplant 
     he tricked me into extra prescriptions for narcotics, which 
     he hoarded and probably sold. Two of his five brothers were 
     in jail--one for murder; and, two years into Isaiah's 
     treatment, a third brother was shot dead--a gun blast through 
     the front door--in a drug dispute.
       Isaiah didn't finish school, and he had no idea of what to 
     do for legitimate work. He got and lost job after job for not 
     showing up or being careless. His world was the street corner 
     and his horizon was only one day away. He saw no way out. He 
     hated it, but he saw no way out. He once told me that he 
     thought his leukemia was a blessing, because at least while 
     he was in the hospital, he couldn't be on the streets.
       And Isaiah died. One night, 18 years after his leukemia was 
     cured, at 37 years of age, they found him on a street corner, 
     breathing but brain-dead from a prolonged convulsion from 
     uncontrolled diabetes and even more uncontrolled despair.
       Isaiah tried to phone me just before that fatal convulsion. 
     He had my home number, and I still have the slip of paper on 
     which my daughter wrote, ``Isaiah called. Please call him 
     back.'' I never did. He would have said, ``Hi, Dr Berwick. 
     It's Isaiah. I'm really sick. I can't take it. I don't know 
     what to do. Please help me.'' Because that is what he often 
     said.
       Isaiah spent the last two years of his life in a vegetative 
     state in a nursing home where I sometimes visited him. At his 
     funeral, his family asked me to speak, and I could think of 
     nothing to talk about except his courage.
       Isaiah, my patient. Cured of leukemia. Killed by 
     hopelessness.
       I bring Isaiah today as my witness to two duties; you have 
     both. It's where your compass points.
       First, you will cure his leukemia. You will bring the 
     benefits of biomedical science to him, no less than to anyone 
     else. Isaiah's poverty, his race, his troubled life-line--not 
     one of these facts or any other fact should stand in the way 
     of his right to care--his human right to care. Let the 
     Supreme Court have its day. Let the erratics and vicissitudes 
     of politics play out their careless games. No matter. Health 
     care is a human right; it must be made so in our nation; and 
     it is your duty to make it so. Therefore, for your patients, 
     you will go to the mat, and you will not lose your way. You 
     are a physician, and you have a compass, and it points true 
     north to what the patient needs. You will put the patient 
     first.
       But that is not enough. Isaiah's life and death testify to 
     a further duty, one more subtle--but no less important. Maybe 
     this second is not a duty that you meant to embrace; you may 
     not welcome it. It is to cure, not only the killer leukemia; 
     it is to cure the killer injustice.
       Antoine de Saint-Exupery wrote, ``To become a man is to be 
     responsible; to be ashamed of miseries that you did not 
     cause.'' I say this: To profess to be a healer, that is, to 
     take the oath you take today, is to be responsible; to be 
     ashamed of miseries that you did not cause. That is a heavy 
     burden, and you did not ask for it. But look at the facts.
       In our nation--in our great and wealthy nation--the wages 
     of poverty are enormous.

[[Page 11484]]

     The proportion of our people living below the official 
     poverty line has grown from its low point of 11% in 1973 to 
     more than 15% today; among children, it is 22%--16.4 million; 
     among black Americans, it is 27%. In 2010, more than 46 
     million Americans were living in poverty; 20 million, in 
     extreme poverty--incomes below $11 000 per year for a family 
     of four. One million American children are homeless. More 
     people are poor in the United States today than at any other 
     time in our nation's history; 1.5 million American 
     households, with 2.8 million children, live here on less than 
     $2 per person per day. And 50 million more Americans live 
     between the poverty line and just 50% above it--the near-
     poor, for whom, in the words of the Urban Institute, ``The 
     loss of a job, a cut in work hours, a serious health problem, 
     or a rise in housing costs can quickly push them into greater 
     debt, bankruptcy's brink, or even homelessness.'' For the 
     undocumented immigrants within our borders, it's even worse.
       For all of these people, our nation's commitment to the 
     social safety net--the portion of our policy and national 
     investment that reaches help to the disadvantaged--is life's 
     blood. And today that net is fraying--badly. In 2010, 20 
     states eliminated optional Medicaid benefits or decreased 
     coverage. State Social Services Block Grants and Food Stamps 
     are under the gun. Enrollment in the TANF program--Temporary 
     Assistance to Needy Families--has lagged far behind the need. 
     Let me be clear: the will to eradicate poverty in the United 
     States is wavering--it is in serious jeopardy.
       In the great entrance hall of the building where I worked 
     at CMS--the Hubert Humphrey Building, headquarters of the 
     Department of Health and Human Services--are chiseled in 
     massive letters the words of the late Senator Humphrey at the 
     dedication of the building in his name. He said, ``The moral 
     test of government is how it treats people in the dawn of 
     life, the children, in the twilight of life, the aged, and in 
     the shadows of life, the sick, the needy, and the 
     handicapped.''
       This is also, I believe, the moral test of professions. 
     Those among us in the shadows--they do not speak, not loudly. 
     They do not often vote. They do not contribute to political 
     campaigns or PACs. They employ no lobbyists. They write no 
     op-eds. We pass by their coin cups outstretched, as if 
     invisible, on the corner as we head for Starbucks; and 
     Congress may pass them by too, because they don't vote, and, 
     hey, campaigns cost money. And if those in power do not 
     choose of their own free will to speak for them, the silence 
     descends.
       Isaiah was born into the shadows of life. Leukemia could 
     not overtake him, but the shadows could, and they did.
       I am not blind to Isaiah's responsibilities; nor was he. He 
     was embarrassed by his failures; he fought against his 
     addictions, his disorganization, and his temptations. He 
     tried. I know that he tried. To say that the cards were 
     stacked against him is too glib; others might have been able 
     to play his hand better. I know that; and he knew that.
       But to ignore Isaiah's condition not of his choosing, the 
     harvest of racism, the frailty of the safety net, the 
     vulnerability of the poor, is simply wrong. His survival 
     depended not just on proper chemotherapy, but, equally, on a 
     compassionate society.
       I am not sure when the moral test was put on hold; when it 
     became negotiable; when our nation in its political discourse 
     decided that it was uncool to make its ethics explicit and 
     its moral commitments clear--to the people in the dawn, the 
     twilight, and the shadows. But those commitments have never 
     in my lifetime been both so vulnerable and so important.
       You are not confused; the world is. You need not forget 
     your purpose, even if the world does. Leaders are not leaders 
     who permit pragmatics to quench purpose. Your purpose is to 
     heal, and what needs to be healed is more than Isaiah's bone 
     marrow; it is our moral marrow--that of a nation founded on 
     our common humanity. My brother, a retired schoolteacher, 
     tells me that he always gets goose bumps when he reads this 
     phrase: ``We, the people . . . We--you, and me, and Isaiah--
     inclusive.
       It is time to recover and celebrate a moral vocabulary in 
     our nation--one that speaks without apology or hesitation of 
     the right to health care--the human right--and, without 
     apology or hesitation, of the absolute unacceptability of the 
     vestiges of racism, the violence of poverty, and blindness to 
     the needs of the least powerful among us.
       Now you don your white coats, and you enter a career of 
     privilege. Society gives you rights and license it gives to 
     no one else, in return for which you promise to put the 
     interests of those for whom you care ahead of your own. That 
     promise and that obligation give you voice in public 
     discourse simply because of the oath you have sworn. Use that 
     voice. If you do not speak, who will?
       If Isaiah needs a bone marrow transplant, then, by the oath 
     you swear, you will get it for him. But Isaiah needs more. He 
     needs the compassion of a nation, the generosity of a 
     commonwealth. He needs justice. He needs a nation to recall 
     that, no matter what the polls say, and no matter what 
     happens to be temporarily convenient at a time of political 
     combat and economic stress, that the moral test transcends 
     convenience. Isaiah, in his legions, needs those in power--
     you--to say to others in power that a nation that fails to 
     attend to the needs of those less fortunate among us risks 
     its soul. That is your duty too.
       This is my message from Isaiah's life and from his death. 
     Be worried, but do not for one moment be confused. You are 
     healers, every one, healers ashamed of miseries you did not 
     cause. And your voice--every one--can be loud, and forceful, 
     and confident, and your voice will be trusted. In his honor--
     in Isaiah's honor--please, use it.
       Donald M. Berwick, MD, MPP

                          ____________________