00:12When I moved to Harare in 1985,
00:16social justice was at the core
of Zimbabwe's national health policy.
00:20The new government emerged
from a long war of independence
00:24and immediately proclaimed
a socialist agenda:
00:27health care services, primary education
00:30became essentially free.
00:32A massive expansion
of rural health centers
00:36placed roughly 80 percent
of the population
00:39less than a two-hour walk
from these facilities,
00:42a truly remarkable accomplishment.
00:45In 1980, the year of independence,
00:4825 percent of Zimbabwean children
were fully immunized.
00:52By 1990, a mere decade later,
00:55this proportion stood at 80 percent.
00:58I felt tremendously privileged
to be part of this transformation,
01:05The excitement,
the camaraderie, was palpable.
01:10Working side by side
with brilliant Zimbabweans --
01:13scientists, doctors, activists --
01:16I felt connected not only
to an African independence movement,
01:21but to a global progressive
public health movement.
01:26But there were daunting challenges.
01:30Zimbabwe reported its first AIDS case
in 1985, the year I arrived.
01:35I had taken care of a few patients
with AIDS in the early 1980s,
01:39when I did my medical training
at Harlem Hospital, but --
01:44we had no idea
what lay in store for Africa.
01:49Infection rate stood at about
two percent in my early days there.
01:55to one out of every four adults
01:58by the time I left Harare 17 years later.
02:04I'd told hundreds of people
in the prime of life
02:08that they were HIV-positive.
02:10I saw colleagues and friends die,
02:13my students, hospital patients, die.
02:18In response, my colleagues and I
set up a clinic.
02:22We did condom demonstrations.
02:24We launched school education
and workplace interventions.
02:30We did research. We counseled
the partners of infected men
02:34about how to protect themselves.
02:36We worked hard, and at the time,
I believed that I was doing my best.
02:41I was providing excellent treatment,
02:45But I was not talking
about structural change.
02:51Former UN Secretary Kofi Annan
has spoken candidly
02:55about his personal failure
02:57leading to the Rwandan genocide.
02:59In 1994, he was head
of the UN peacekeeping department.
03:03At a 10-year memorial for the genocide,
03:06he reflected, "I believed at the time
I was doing my best,
03:10but I realized after the genocide
03:12that there was more
I could and should have done
03:16to sound the alarm and rally support."
03:22The AIDS epidemic caught
the health community unprepared,
03:27and today, when the World
Health Organization estimates
03:30that 39 million people
have lost their lives to this disease,
03:35I'm not alone in feeling
remorse and regret
03:40at not having done more earlier.
03:43But while living in Zimbabwe,
03:46I didn't see my role
as an advocacy or a political one.
03:50I was there for my technical skills,
03:52both my clinical and my research
epidemiology skills.
03:57And in my mind, my job
was to take care of patients
04:02and to do research to better understand
the population patterns of transmission,
04:07and I hoped that we'd slow
the spread of the virus.
04:11I was aware that socially marginalized
populations were at disproportionate risk
04:16of getting and dying of AIDS.
04:18And on the sugar plantations,
04:20which really more closely
resembled feudal fiefdoms
04:24than any modern enterprise,
04:2660 percent of pregnant women
04:29tested HIV-positive.
04:32I worked to show how getting infected
was not a moral failure
04:36but instead related
to a culture of male superiority,
04:40to forced migrant labor
and to colonialism.
04:43Whites were largely unscathed.
04:46As health professionals,
04:48our tools were pitifully weak:
04:52imploring people to change
their individual behaviors,
04:56use condoms, reduce number of partners.
04:58Infection rates climbed,
05:02and when treatment
became available in the West,
05:06treatment that remains
our most potent weapon
05:10it was unaffordable
to the public sector across Africa.
05:16about the unequal access
to these life-saving drugs
05:21or about the underlying
economic and political systems
05:24that were driving infection rates
05:27in such huge swaths of the population.
05:33I rationalized my silence
05:35by reminding myself
that I was a guest in the country,
05:38that sounding the alarm
could even get me kicked out,
05:41keep me from doing good work,
05:43taking care of my patients,
05:45doing much-needed research.
05:48So I didn't speak out
05:49about the government's
early stance on AIDS.
05:53I didn't voice my concerns loudly enough.
05:57Many doctors, health professionals,
06:00may think I did nothing wrong.
06:03Our pact with our patients,
06:05the Hippocratic Oath and its variants,
06:08is about the sanctity
of the patient-doctor relationship.
06:13And I did everything I could
06:17for each and every patient of mine.
06:24that epidemics emerge
along the fissures of our society,
06:28reflecting not only biology,
06:30but more importantly
patterns of marginalization, exclusion,
06:35discrimination related to race,
gender, sexuality, class and more.
06:42It was true of AIDS.
06:44It was true just recently of Ebola.
06:48Medical anthropologists
such as Paul Farmer,
06:51who worked on AIDS in Haiti,
06:53call this structural violence:
06:56structural because inequities are embedded
07:00in the political and economic
organization of our social world,
07:05often in ways that are invisible
to those with privilege and power;
07:11and violence because its impact --
07:14premature deaths,
suffering, illness -- is violent.
07:21We do little for our patients
07:24if we fail to recognize
07:26these social injustices.
07:28Sounding the alarm is the first step
towards doing public health right,
07:35and it's how we may rally support
07:38to break through
and create real change together.
07:43So these days, I'm not staying quiet.
07:46I'm speaking up about a lot of things,
07:50even when it makes listeners
uncomfortable,
07:53even when it makes me uncomfortable.
07:57And a lot of this
is about racial disparities
08:00and institutionalized racism,
08:03things that we're not supposed
to have in this country anymore,
08:06certainly not in the practice of medicine
08:13and we pay for them in lives cut short.
08:18That's why sounding the alarm
08:21about the impact of racism on health
in the United States,
08:25the ongoing institutional
and interpersonal violence
08:30that people of color face,
08:32compounded by our tragic legacy
08:36of 250 years of slavery,
08:4090 years of Jim Crow
08:42and 60 years of imperfect equality,
08:46sounding the alarm about this
08:49is central to doing my job right
08:52as New York City's Health Commissioner.
08:55In New York City, premature mortality --
that's death before the age of 65 --
09:00is 50 percent higher
for black men than white ones.
09:04A black woman in 2012
09:07faced more than 10 times
the risk of dying related to childbirth
09:13And though we've made enormous strides
09:16in reducing infant mortality rates,
09:20a black baby still faces
09:22nearly three times the risk
of death in its first year of life
09:27as compared to a white baby.
09:31New York City's not exceptional.
09:33These statistics are paralleled
09:37by statistics found
across the United States.
09:42A recent New York Times analysis
09:45reported that there are 1.5 million
missing black men across the country.
09:53They noted that more than one
09:56out of every six black men
09:58who today should be
between the ages of 25 and 54 years
10:04have disappeared from daily life,
10:07lost either to prison or premature death.
10:12There is great injustice
10:15in the daily and disproportionate violence
faced by young black men,
10:19the focus of recent protests
under the banner #BlackLivesMatter.
10:25But we have to remember
10:26that enduring and disparate rates
10:30and the occurrence and outcome
of common medical conditions --
10:34heart disease, cancer, diabetes, HIV --
10:37diseases that may kill slowly and quietly
10:41and take even more
black lives prematurely.
10:46As the #BlackLivesMatter
movement unfolded,
10:50I felt frustrated and angry
10:54that the medical community
10:55has been reluctant
to even use the word "racism"
11:00in our research and our work.
11:02You've probably felt something
every time I've said it.
11:06Our medical students
held die-ins in their white coats,
11:09but the medical community
has largely stood by passively
11:13as ongoing discrimination
continues to affect
11:17the disease profile and mortality.
11:21that the trend towards personalized
and precision medicine,
11:26looking for biological or genetic targets
to better tailor treatment,
11:31may inadvertently cause us
to lose sight of the big picture,
11:36that it is the daily context,
11:39where a person lives, grows,
11:45that most importantly
determines population health,
11:50and for too many of us, poor health.
11:54As health professionals in our daily work,
11:58whether in the clinic or doing research,
12:01we are witness to great injustice:
12:05the homeless person
who is unable to follow medical advice
12:08because he has more pressing priorities;
12:11the transgender youth
who is contemplating suicide
12:16because our society is just so harsh;
12:18the single mother who has been made
to feel that she is responsible
12:23for the poor health of her child.
12:26Our role as health professionals
12:29is not just to treat our patients
12:33but to sound the alarm
12:35and advocate for change.
12:41our societal position
gives our voices great credibility,
12:45and we shouldn't waste that.
12:48I regret not speaking up in Zimbabwe,
12:52and I've promised myself
12:54that as New York City's
Health Commissioner,
12:57I will use every opportunity I have
13:03and rally support for health equity.
13:06I will speak out against racism,
13:09and I hope you will join me,
13:11and I will join you
when you speak out against sexism
13:14or any other form of inequality.
13:17It's time for us to rise up
13:21and collectively speak up
13:24about structural inequality.
13:27We don't have to have all the answers
13:33We just need courage.
13:36The health of our patients,
13:39the health of us all, depends on it.
