2018 Commencement Address
Janine Jagger, M.P.H., Ph.D.
Thank you President Grigsby for your kind introduction. Members of the Board of Trustees, guests, and friends; it is with pride that I come to celebrate and honor the academic achievement of the graduating class of 2018. I return as a pilgrim from the class of 1972 to the place where my academic life was born and nurtured by those who knew me long before I was a “genius.”*
As I followed a career path in healthcare and public health, Moravian College likewise advanced and expanded in many areas including its programs leading to healthcare professions and a major expansion of resources dedicated to Health Sciences. My path led to the field of epidemiology which is the research arm of public health. It is a field of inquiry and discovery; a toolbox of research methods for dissecting and describing health phenomena. Epidemiology can be practiced as a descriptive science or it can be taken to the next level and used as a road map leading to solutions. I chose the road map - epidemiology with a cause. I became a public health activist which is simply the act of implementing change in the interest of an at-risk population. The acquisition of methods and strategies of change became an essential part of my training.
I have been warmed by fires I did not build. My mentors were many; a few invested generously in me but there were others who never knew they shaped my world by example or provided a revelatory moment. I spent years working on automotive safety and the prevention of brain trauma and the promotion of air bag technology. One such revelatory moment occurred when I was sitting next to Joan Claybrook at lunch during a meeting of the organization, Advocates for Highway and Auto Safety. Joan Claybrook is a titan of consumer safety; a relentless safety advocate. She was director of the National Highway Traffic Safety Administration in the Carter Administration and thereafter was President of Public Citizen, spearheading consumer protection policies for decades. In the course of lunch conversation I heard Joan say, “If there’s one thing I regret . . .” I immediately tuned in, astonished that she had a regret – she continued, “. . . . it’s not being more bold.” In utter astonishment, I said, “Joan, when have you ever not been bold?” To which she replied earnestly, “Every day.” I can’t say that I’ve risen to the standard that Joan set for herself but I can say that I weigh action versus inaction in a new light; one that includes accountability for doing nothing.
When the AIDS epidemic reared its head in the 1980s our hospital at the University of Virginia suddenly became very concerned about the risk of healthcare personnel contracting HIV from patients – the most common way this happened was from needlestick injuries. I was present as junior faculty at the earliest discussions of the infectious disease division debating new policies and strategies to protect healthcare personnel from this alarming new risk. I chimed in, from my perspective, suggesting that safer designs of needle devices could be an approach to reducing needle injuries. A senior professor in infectious diseases promptly cut me off saying, “That’s pie in the sky. Don’t waste our time. That’s not our business.” Shortly afterward some colleagues informed me that the professor in question was one of the foremost infectious disease experts in the world, if not the foremost. His words resonated in an unsettling way – if not our business then whose? From my perspective it was our business. If we can redesign cars to prevent brain injuries, we can redesign needle devices to prevent needlestick injuries. This conflict in perspective instantly reoriented my attention. The protection of healthcare workers from infections transmitted by medical devices and blood exposures became my business as of that day.
"If no one gets annoyed with you, you are probably not doing much."
I set out to do what epidemiologists do – I started by counting needlestick injuries, identifying and classifying device categories, looking for patterns of when and how the injuries occurred. I teamed up with colleagues to do extensive observations in the clinical setting watching how needles were handled and used. I am not a healthcare worker. I don’t provide patient care. The most serious occupational risk I face is perhaps a paper cut. I needed insights of a clinician. I had doubts about being able to spot any obvious safety risks. After all, millions of highly trained healthcare workers had been using these needle devices for decades and the technology must be well honed for safety and efficiency by now. We started our observations in a clinical care unit where there was a patient with an IV set running fluids. The IV line had several segments and it looked like there were pieces of adhesive tape stuck to it at certain intervals. “What’s that?” I asked. “That is where two segments of IV tubing are connected. We hang a medication and it runs into the main IV line.” “And you tape the lines together?” “No, no – there’s a hypodermic needle connecting the two lines and we tape the connection to keep the needle in place so the needle won’t pull out.” “And that’s permitted?” Her answer: “That is standard practice.” “What?? Standard practice where?” Her answer: “Everywhere.” “How long have you been doing this for?” “Since I can remember.” “Why didn’t you say anything?” Her response: “We use what we’re given – that’s our job.”
I went back to the needlestick data and searched for injuries from needles on IV lines and added them up. They accounted for more than one quarter of all needlesticks. And that wasn’t all. It was worse for patients. The lines would sometimes pull out and could result in unobserved discontinuation of medication – possibly medication controlling vital functions. Some needles broke off inside an IV line and traveled down the line and into the patient. All risks considered, this was arguably - and I am making an assumption here - the dumbest configuration of medical equipment ever.
The search for alternative equipment didn’t take long since there were already some needleless IV line connectors on the market that addressed all of the known risks. The final blow to the needles on IV lines was accomplished shortly thereafter with one letter to the FDA requesting a national safety alert on hypodermic needles used for connections in IV lines. The requested FDA safety alert was sent out to hospitals across the country and in one stroke the source of one-quarter of needlesticks was wiped off the charts. And by the time the professor who claimed safer devices were not our business retired, every sharp device he used in his clinical practice was replaced by a safer alternative and a national law had been passed making them a requirement.
This early experience spoke volumes. I learned that the healthcare environment was loaded with glaring hazards that went unnoticed because it was no one’s job to look after the well-being and safety of healthcare workers. There is a professional culture in which the healthcare worker accepts the sacrifice of his or her well-being for the benefit of the patient. There is a culture in which it is unseemly for healthcare workers to dedicate effort to their own health and safety. But their problem became my business.
Along with this job came a growing realization of the value of healthcare workers to our lives and our society that we barely consider. We know what to expect when the electricity goes out – no light, no heat. But what would happen if suddenly there were no healthcare services - no one to deliver them? We depend upon trained and dedicated healthcare personnel for our lives and our well-being. We cannot even count the number of times our own lives may have been saved during a lifetime of preventive care and interventional care provided by healthcare personnel. To all the graduates headed for healthcare fields and all guests here today already in healthcare fields I would like to say that I am proud to work for you.
My work on behalf of healthcare workers has taken me to every continent and I have had the privilege of working and collaborating with healthcare professionals in many countries. The standards of training in healthcare fields tends to be very high so I would not want to minimize the professional stature of healthcare professionals in other countries. But I do want to acknowledge the exceptional professional standards met by our own healthcare workforce which are second to none in the world.
But despite the exemplary standards met by our healthcare professionals, they exist in a healthcare system that is dysfunctional and deteriorating. Many of our health status indicators including average life expectancy are declining. Every family feels the insecurity about whether they will be able to continue to afford health insurance or the costs of healthcare not covered by it. Inexplicable cost escalation in the price of prescription drugs and the changing terms of insurance coverage have made the cost of some life-saving medications unaffordable. Declining access to life-saving treatments is now reflected in the decline in national health indicators. This is the legacy that is left to our new generation of healthcare workers and health scientists and we are counting on you to take up this daunting challenge.
And to all of you graduating today, whether in healthcare or other field, understand your capacity to bring about change. You have a unique perspective. Your experience, your training, your skills, and talents, your life story – all combine to give you a unique perspective that has value for the very reason that it is unique. Find your business. Take whatever steps forward that will make a better world. Expect resistance. If no one gets annoyed with you, you are probably not doing much. Expect disappointment. Success is the survival of disappointment. Be bold. And finally, make an investment in the future: be a mentor, plant a seed, pay it forward.
In gratitude to those who came before me who built the fires that lit my path; in expectation of great things from you who now step forward, in whom we place our hope; I say a special thanks to President Grigsby for my opportunity to be bold today. Congratulations to you all.