Editors’ Note

Ezekiel Emanuel is the Vice Provost for Global Initiatives and the Diane v.S. Levy and Robert M. Levy University Professor at the University of Pennsylvania. He is also an Op-Ed contributor to The New York Times. He was the founding chair of the Department of Bioethics at the National Institutes of Health and held that position until August 2011. From January 2009 until January 2011, he served as a Special Advisor on Health Policy to the Director of the Office of Management and Budget and National Economic Council. Dr. Emanuel has published over 300 articles in bioethics and health policy, and is the most widely published and cited bioethicist in the world. He has also authored or edited a total of 15 books, his two most recent being The Trillion Dollar Revolution and Which Country Has the World’s Best Health Care? He was the lead editor on The Oxford Textbook of Clinical Research Ethics. After completing Amherst College, he received his MSc from Oxford University in Biochemistry. He received his MD from Harvard Medical School and his PhD in political philosophy from Harvard University. In 1987-88, he was a fellow in the Program in Ethics and the Professions at the Kennedy School of Government at Harvard. After completing his internship and residency in internal medicine at Boston’s Beth Israel Hospital and his oncology fellowship at the Dana-Farber Cancer Institute, he joined the faculty at the Dana-Farber Cancer Institute. Dr. Emanuel was an Associate Professor at Harvard Medical School before joining the National Institutes of Health. He has received numerous awards including most recently the $1 million Dan David Prize for bioethics. He is a member of the National Academy of Medicine (formerly the IOM) of the National Academy of Science, the Association of American Physicians, and the Royal College of Medicine (UK). He received the AMA-Burroughs Welcome Leadership Award, the Public Service Award from the American Society of Clinical Oncology, and the John Mendelsohn Award from the MD Anderson Cancer Center. In 2007, Roosevelt University presented Dr. Emanuel with the President’s Medal for Social Justice. In 2013, the AMA recognized him with its highest bioethics award: the Isaac Hays, MD and John Bell, MD Award for Leadership in Medical Ethics and Professionalism.

Institution Brief

The University of Pennsylvania (Penn) is a private Ivy League university located in Philadelphia. Penn (upenn.edu) was America’s first university, founded by Benjamin Franklin, and is the fourth-oldest institution of higher education in the United States. It is noted for its schools of business, law, and medicine, each of which was the first in North America, and also developed the nation’s first liberal arts curriculum. About 4,500 professors serve more than 10,000 undergraduate and nearly 12,000 graduate and professional students. Penn is widely recognized as one of the world’s leading research universities and consistently ranks among the top 10 universities in the annual U.S. News & World Report survey.

How do you define resilience?

I think we need to distinguish resilience of individuals and resilience of institutions and organizations. Resilience of individuals requires a careful blending of character and environment. Resilient individuals need to be able to persist in the face of adversity and failure. This character trait often requires early childhood experience of adversity and encouragement to recover and persist. As a psychiatrist friend has repeatedly told me, good childhood training for resilience is a lot of “near misses.” One of the things I worry about is the impact of over-protective parents in reducing if not eradicating children’s experiences of adversity and failure – and recovery. If children don’t have that adversity, it is hard to become resilient.

We also need to be aware that the environment plays a huge role in the ability of individuals to persist in the face of adversity. Having a secure base is important to sallying forth and trying new things and picking yourself up when you fall down. People can confront adversity when they know it will not make them destitute or rob them of all opportunities.

F. Scott Fitzgerald’s infamous statement that “there are no second acts in America” was very, very wrong. One of the great things about America is that there were opportunities for second acts. The country allowed people to not be permanently defeated and gave them an opportunity to try again. That is the heart of equal opportunity. One of the things we have lost – or at least significantly diminished – in the last number of decades is the safety net that allows people the opportunity to try again. The erosion of the safety net for individuals has undermined the environmental factors that are key to individual resilience.

This links individual resilience with institutional resilience. Institutional structures and supports are necessary for individual resilience. We must not champion resilience and suggest it is all about individuals fending for themselves, and then dismiss those who fail as not having resilience. We need institutional structures and supports – that secure safety net – for there to be individual resilience and for the notion of resilience not to be a “blame the victim” situation.

One thing COVID-19 is revealing about American public health is the fragility of our federalist approach. Public health has always been shared between the federal government, states and localities. That could be a strength if there are overlapping responsibilities and programs that fill in for each other and duplicate roles so there are no cracks for people to fall through. But as COVID-19 has demonstrated, there is no overlap and plenty of cracks where responsibilities between the different layers of the government are not overlapping.

Part of this is funding and, more specifically, the miniscule public health funding. The CDC budget is about $12 billion for a population of 330 million – about $36 per American. It is not possible to have a resilient public health program, including one that is international, on such a small funding base. Obviously if we want a resilient public health structure to help people confront adversity like COVID-19, we need to spend more money.

But not everything is money. Resilient organizations require great leadership that clearly defines the mission and values of the organization, recruits top talent and gives them opportunity to lead programs consistent with the mission and values, and supports them in that even when they are inevitably criticized and attacked. What we have seen over the last year or so are the consequences of a lack of leadership and an undermining of competent leadership.

This leads me to my final thought: Resilience itself can be fragile. Institutionally, it requires investment of resources and competent leadership that knows the core values of the institution and advances them in the face of adversity. Going forward we need to cultivate leadership to ensure resilient institutions and, therefore, resilient Americans.