John, Chandy C.

English

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Something Small That Matters

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Am. J. Trop. Med. Hyg., 102(2), 2020, pp. 253–256doi:10.4269/ajtmh.19-0888Copyright © 2020 by The American Society of Tropical Medicine and HygienePresidential AddressSomething Small That Matters†Chandy C. John*Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IndianaThank you, Pat, for that wonderful introduction and for all thatyou’ve done for me and for this Society as a leader and guide.It has been a tremendous honor to serve as president of thisgreat society. As I end my term with this address, I decided totakeabit of a risk. This addresswill bedifferent fromall precedingpresidential addresses.Forone thing, sure tobewelcomedbyall,it will be the shortest address on record. For another, it will take adifferent approach to the form of a presidential address.I’vebeen thinkinga lotaboutwhereweareheadingasaSociety,big S, and society, small s, and it seems to me that we are at acrossroadsrightnow,wherewhatwedoandwhatwestandforwillmakeagreatdifference for the future. In theworld today, science isroutinely attacked, and demagogues rally around the promise ofdemonizing the other. In such a world, our work in doing, com-municating, and putting into public policy good science that savelives, and our work in reiterating the basics of human rights for alland the interconnected nature of our world, which precludes di-vision into an “us” and “them,” is more important than ever.I titled my talk “Something small that matters” because Iwant us to think about these issues and this vision in terms ofthe big changes we can and must make, but also in terms ofthe small things we can do everyday that matter. The furtherI’ve gotten into mymedical and research career, the more I’verealized that most of the time, the work our group does willcontribute one small piece to the understanding of disease orepidemiology or pathogenesis, and it will have its little part inthe bigger picture, but it will only be just one small part. Butscience is mostly a process of increments, one bit of learningbuilding on another. So our small project—or yours—may notchange the world, but if it adds knowledge, it’s worth doing.And someday, you may make that big breakthrough, but ifyour whole career is a career of small moments of somethingnew, that’s fine too. It’s something small, but it matters.I think, as a physician-scientist, I have been able to see thismost clearly in my dual roles. I went into research because Iwanted to be part of the solution to the problems I was seeingin my patients and, particularly, in patients I took care of inAfrica and Asia when I worked there. The huge burden ofmalaria I saw inNigeria cementedmydecision tomakework inthis areamy life goal. And doing the research has been hugelyrewarding, one of the great joys of my life. But we haven’tsolved the problem yet. There’s been a lot of progress in un-derstanding malaria and in reducing malaria cases anddeaths, but our work has been only a small part of that. Wehope for bigger outcomes, such as success in eliminatingmalaria in the highland areas of Kenya, where we’ve workedfor the past 23 years, or of reducing malaria deaths andneurodevelopmental complications in our study areas inUganda and beyond. But those successes are still some yearsaway, if indeed they occur at all. My work of taking care ofpatients, the one on one of seeing that individual child gettingbetter, because of the work that doctors and nurses and phar-macists do, helpsmesee the value in the smaller scale. Just liketaking care of that single child has its own reward; doing thosesmall studies; working with smart students, residents and fel-lows; and learning new things that don’t have immediatetranslation, yet help us understand some aspect of malariabetter—each of these has its worth. We never stop aiming big,but everyday we can do that something small that matters.I see this, too, in the way the center I work in at IndianaUniversity was developed. I’m the director of the Ryan WhiteCenter for Pediatric Infectious Diseases and Global Health.People often ask me about the rich donor who endowed ourcenter, and I’m always happy to reply that the rich donor isthousands of college students, my beloved Indiana Universitydance marathoners. Over the years, these college studentshave raisedmillions of dollars, first for our center, to do clinicalwork and research that prevents and treats infectious dis-eases in children, and now for the whole department of pedi-atrics, to improve the health of children in Indiana and aroundthe world. The dance marathons started as a tribute to RyanWhite, an Indiana hero who was the first child in the UnitedStates to make people publicly aware of the costs of HIV inchildhood. He and his mother, Jeanne White, fought for anormal life for every person with HIV. And his life, work, andmessage directly led to funding that has improved the lives ofmillions around the world with HIV. One little kid in Indiana didthat. Ryan White’s doctor was the founder of our division,Marty Kleiman. Ryan’s friend, Jill Stewart, talked to Dr. Kleimanabout how best to honor Ryan’s legacy and started theIndiana University DanceMarathon in his honor, with a few ofher college friends, to raise funds to do research in pediatricinfectious diseases and to prevent and treat infections suchas HIV. That first year, it raised $25,000. This year, it raisedmore than $4 million for our department of pediatrics. Andthis was all from college students who want to make a differ-ence in their world. That growth from a small operation to apowerhouse fundraiser is wonderful and powerful, but if it hadonly been the $25,000 that was raised, that would have beenimportant all by itself. It was something small that mattered.As I think about our Society and theworkwe aim to address,I look at things in the same way—the big goals and the smallsteps that get us there. The initiatives I focused on, in additionto the ongoing and primary initiative of great science andclinical work that serves the underserved, are increasing en-gagement and retention of trainees and low- and middle-income members, moving toward certification of a medicalspecialty in global medicine and increasing funding to supportall of this. A president serves for 1 year. These goals will beworked on over many years.* Address correspondence to Chandy C. John, Ryan White Ctr forPed ID andGlobalHealth, IndianaUniversity School ofMedicine, 1044WWalnut St, R4 402D, Indianapolis, IN 46202. E-mail: chjohn@iu.edu†Presidential addressgivenat the 68thAnnualMeetingof theAmericanSociety of Tropical Medicine and Hygiene, November 23, 2019.253We’ve made a start on bigger goals with committees for in-ternational members, trainee members and global medicinecertification, and with the hire of a development officer to in-crease fundraising. Thecommitteeshaveproposedspecificfirststep initiatives that the board has included in our strategic plan,and many more will come over the next several years. I’m con-fident that these will make our Society stronger and better inthesekeyareas.But thepresidents’challengewasaway togetaconcrete start on three of these key initiatives right in this year ofmypresidency. Thepresident’s challengewill support additional100 trainee travel awards over the next 5 years, and 75 of thoseawards will go to trainees from low- and middle-income coun-tries. So, it’s addressing trainee and LMICmember engagementand retention, and it’s fostering a culture of giving to our Societyby its members. Thanks to your generosity, and in particular thegenerosity of the board and our past and incoming presidents,we have crossed the $90,000 mark, 60% of the way to our goalof $150,000. I encourageyou tocontinuegiving so thatwe reachthemark this year, to fund awards through 2023. It’s a start, andan important one, toward our bigger goal. It matters.In the spirit of small things that matter, I want to shift now tothe unorthodox component of this address that I warned youabout at the start.Myfirst lovehasalwaysbeen thearts.My life hasbeenenrichedimmeasurably bymy partner, AndrewHisey, and one of themanyways he’s enriched my life is through his music. He’s a classicalpianist,andthegloriousmusicheplayshasbeenthesoundtrackofmy life for the past 26 years. Sadly, I don’t share his exceptionalmusical gifts, so the surprise for this address is not that we’rehauling in a piano forme to do a recital.Mygifts in the arts, suchas theyare, havebeen in the areaofwriting, andone formof art Iparticularly love is poetry. Poetry is in some ways a good ana-logue toscientificwritingbecause inboth,onestrives toprovidethefindings in themost conciseandaccuratewaypossible. Thedifference is that science typically aims to be dry and “just thefacts.”We judge the quality of science based on what the datashow and the implications of the study findings. Poetry, incontrast, isall aboutemotion. It’sa terribleway tocommunicatescience—hence, the lack of science manuscripts in poetryform—but it canbeahighlyeffectiveway tocommunicate ideasand moments and the meaning behind the things we do.When I think about a presidential address, and what itleaves for the listener after the address is over and how itmight read to a quizzical Society member 10 or 20 yearsdown the road, I think that the images provided by poetrymight best give a sense of the issues we face and what weneed to do to address them.With that in mind, I’ve made the radical decision to offer thepresidential address as a series of 10 poems that relate to keyissueswe face as aSociety. I decided to focus on the really bigpicture: whoweare, whowe serve, and howandwhywe servethem. I’ll give a brief introduction to each poem, to set them incontext. And I’m prepared afterward to bear the “slings andarrows”of outragedSocietymembers.Makeof the poemswhatyou will. I hope they provide food for thought and help us all toconsider ourwork in a differentway. Butmaybe they’ll just crashand burn. You can tell me at the end—and I’m sure you will.Iwant tostartbyconsideringwhoweserve.Weserve thepoor,the underserved, and the vulnerable. We don’t talk a lot aboutthis, but it underlies everythingwedo.Our keynote speakers, theBangs, and our distinguished guest speaker, Francis Collins,brought this idea to the forefront.With thatmind, twopoems: thefirst is called, “To the emaciated boy with the skull fracture.”To the emaciated boy with the skull fractureTo the emaciated boy with the skull fractureYour smile undid meAt once, I was not a doctorDeducing the cause of your feverI was instead witness to a sweet, sad miracleA boy whose defense was his wall of solitudeLetting joy peep out like a shy ducklingIn that quiet moment when smile met smileIwant tomoveon from that poem to a connectedone, aboutwhoweserveandwho leadsus. Tobeagreat society,wehaveto grow and cherish our future leaders, and those we servemust be among our leaders.Thispoemiscalled“Mighty,brilliant,ebonyandcinnamongirls.”Mighty brilliant ebony and cinnamon girlsMamaI see the way you hold your baby girlShe contains multitudesLet us protect her from the lust ofMosquitoes for her bloodBacteria for her strengthViruses for her defensesParasites for her powerBitter men for her innocenceRapacious men for her wealthIt is her wealth they squanderHer future they lay wasteHer identity they try to eraseMamasYour mighty, brilliant, ebony and cinnamon girlsLet us nourish themLet them nourish usI’ll move on to twopoems that consider howwedoandwhatwedo.Thefirst, called“Malaria,” isabout thewonderandpassionof science, and the second, “I see you,” is about how excellenceand integrity in science are a commitment to those we serve.PresidentChandyC.John,MD,MS,FASTMH,delivershisPresident’sAddress during the 2019 Annual Meeting in National Harbor, MD.254 JOHNMalariaI will decode the spiky messagesThat trapped my motherI will deflect the probing fingersThat snared my fatherI will defuse the hidden landminesThat maimed my brothersI will expose each precious weaponUntil you have nothing leftThis is a blood battleI see youI see youDetecting coding errorsInspecting miscalculationsEyeing dilution problemsWe’ll redo the experimentWe’ll correct the calculationsWe will not say a word until we knowEvery detail is rightUgandan childI am examining your lifeAnd you are examining meI have no room for errorExcept, inevitably, in medicine and science, we all do makeerrors. Andwedon’t talk about them. Andwedon’t talk about thereality that ourwork in evensmall thingscanbedisappointingandthat life in science and medicine often feels like a long string offailures, broken intermittently, we hope, by a few successes. Onthe topicofwhoweare, Iwant to talkabout facing failurehonestly.I’m the president of ASTMH, and I’m sad to report my inboxstill features plenty of rejection letters. And this is true of sci-entists of much greater stature than me. We don’t talk about itenough. So, I thought it might be cathartic, especially for stu-dents and postdocs, to hear the next poem.It’s called “Rejection letters.”Rejection lettersYour font was too smallYour font was too bigYou used the wrong fontYour conclusions are unsoundYour conclusions are sound, but don’t matterYour conclusions are sound, anddomatter, butwe’re ignoringreviewers todayYour findings are different from the other studyYour findings are the same as the other studyYour findings lack impactYour findings have impact, but not enoughYour findings have enough impact, but we know the other guyYour findings might have been important butSince you pointed out the flaws, we’re agreeing with themWell, honest to GodWhat were you thinking?Mymom and dad always believed in my potential, and thatbuffered a lot of the rejection along the way, and it still does. Ilearned from them how important it is, no matter how big orcritical the task at hand, to take the time to make people feelwelcomed and cared for. I’ve learned that as well from FrancisCollins, Jim Kazura, Cindy Howard, Pat Walker, JanetGilsdorf, Carol Kauffman, andmany other mentors. And that’ssomething I’ve valued in this Society from the start: the sensethat I’m welcomed, that we welcome everyone, and whetheryou’re aNobel prizewinner or a newstudent, you arewelcomeand valued. The sense of welcome can come from somethingbig and bold, like the sign announcing the conference thatshows many different types of people, or a little gesture like asmile or a greeting.Mymom is amaster at doing thingsbig andsmall to make people feel welcome and accepted. This poemin honor of that very needed skill is called “The small things.”The small thingsThis was the ritual:Mom would kiss her two little boys goodbyePull her sari into the carAnd start her drive to the hospitalSunil and I would run frantically behindUntil she stopped, mid-drivewayGot out of the carKissed us tenderly on the head with those soft, soft lipsAnd then said goodbye, againIt must have gotten oldHaving to stop each timeAs she was rushing to the hospital to see patientsBut she did itEvery single daySometimesThe small things matterSo muchWhen I thinkofwhoweare, I thinkof thosewe’ve learned fromas mentors. When you move into a mentor role yourself, yourealize all those things your mentors had to deal with that youdidn’t knowabout, andhowcalmly theydid it, protectingyou fromthe stress by absorbing it themselves. As I’ve understood theirvulnerability,my respect for them increased. The next poem is formy dad, but also for all of thosewho’ve guided us along the way.The day I learned my Dad was SupermanWhen I was in fifth grade,A friend pointed out my Dad’s bowed legsI ignored the friend for daysI was Mama’s boyI studied Dad from two steps awaySome days, I caught a glimpse of what was behindDoctor DadOther days, he was a wallDad was earnest in a way that made me cringeSometimesOr stern and cold, whichAlso made me cringeA little thing could draw out the fire insideASTMH PRESIDENTIAL ADDRESS 255Often enough to make you carefulRare enough to surprise youDad was not tough, his jaw was not squareHe was small, thin, friendly, aloofQuiet, loquacious, cautious, eagerHe insisted, always, on being himselfHe was there, for us to be proud ofOr not, he would not changeI was on my own, living far away from himWhen Mom called to tell me about the heart attackI wanted to believe it was nothingHours later, I saw himIn the hospital roomWith the thin, blue gownWe had seen so many timesOn our own patientsHis face was washed outLike driftwood on a seashoreSo tired, so stubbornly braveThat I burst into tearsBecause I knew thenAll those yearsHe had beenInvincibleI want to end with poems about what matters most: why wedo what we do. The first is called “We save a life, but then.”We save a life, but thenWe want you toHear notesSad, wild, longingSee worldsBright, free, daringGrab truthSoft, rough, mottledTaste loveBold, pink, lusciousWe save a life but thenIt needs something to live forWhat is it you live for?The last two poems speak to our world now. I’ve empha-sized climate change as the key issue of our time, somethingour Society must work on in ways small, like carbon offsetsand reducing travel, and big, like getting into the science ofhow it affects the diseases we study, and working on advo-cacy to combat thismost threatening of all issues to ourselvesand thosewe care for andwork for. Five, 10, and 20 years fromnow, we’ll be judged by what we did to save our planet, thisbeautiful worldwe live in and are a part of.We’ll also be judgedby whether we were willing to be honest about our mistakesand weaknesses. This poem is called “The loon.”The loonSwimming back to the shore, I saw a loonHis black head raised, white feathers aboveThe brown and black of his breastPlacid as a decoyCalling across the lakeAs if trying out his voiceHe did not sense me approachingSlicing the water with my slow strokesHe continued his plum-toned calls to no oneQuiet dips of his black head into the waterUntil, so close I thought I would alarm himI splashed a few timesThe loon jerked up his headLike a cartoon lady who gathers her skirts andFlees at the sight of a mouseHe paddle-skied frantically across the lakeWings churning, feathered wheels under his chariot bodySearing the lake water beneath himHis calls desperate and crackedThirty feet away, he stoppedSmoothed his feathersHis calls, measured and regular againEchoed across the lakeWoot-oooooo!He dipped his head back into the waterLike a rebukeFriend loon,I understand youI, too, must remainUnperturbedBut let me tell you this:In that one brief moment of fearYou were magnificentI want to thank you again for honoring me with the job ofpresident of this great Society and end with a poem called,“Let us not speak tonight of eternity.”Let us not speak tonight of eternityLet us not speak tonight of eternityInstead, let us talk ofBlood-red cardinals swooping into fiery orange canopiesThe anxious hammering of the red-bellied woodpeckerOn the white sidingThe smooth currents that lift the red-tailed hawkTo its roosting place atop the burnt brown hospital bricksSink into the beauty before youTender, treacherousDelicate, cruelEvery little thing susceptibleAnd tell me your pledge to this sacred worldTell me your pledge to this sacred world.Thank you.ReceivedNovember 25, 2019.Accepted for publicationNovember 26,2019.Published online December 19, 2019.This is an open-access article distributed under the terms of theCreative Commons Attribution (CC-BY) License, which permits un-restricted use, distribution, and reproduction in anymedium, providedthe original author and source are credited.256 JOHN

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Something Small That Matters

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