Brodhead: A Shared Fate Between Academics, Athletics, Medicine and Location

In annual address to faculty, president discusses university's connection with medicine, sports and Durham

President Brodhead greets Steve Nowicki and Walter Sinnott-Armstrong before his annual address to the faculty Thursday. Photo: Les Todd/Duke University Photography
President Brodhead greets Steve Nowicki and Walter Sinnott-Armstrong before his annual address to the faculty Thursday. Photo: Les Todd/Duke University Photography

In my annual addresses to the faculty I’ve tried to lay out my thinking about large questions facing the university. In recent years I’ve talked about Duke and race, globalization, and the cost of education at selective private universities and the value proposition of the liberal arts. Last year my address was about leadership transitions in the senior administration, the construction boom on campus, and the goals of our fundraising campaign—people, places, and funds, as I called it for short.

The number three seems to have stuck in my head, for this year I want to speak to three areas that aren’t strictly academic but that have been involved with this university since its founding. To end your suspense, I’ll name the three adjacencies: health care, athletics, and our home city of Durham.

Medicine was built into the founding act of envisioning Duke University, and in its early years, medicine did as much as anything to make Duke known. As part of his plan to revive the school’s fading fortunes, John Franklin Crowell, the graduate student recruited to be president of Trinity College when it was still located in Randolph County, had the idea of starting a medical college and teaching hospital at Trinity in 1891. After Trinity moved to Durham, the idea continued to be talked about, and when President Few conspired with James B. Duke to transform Trinity College into a fully ramified research university, they planned for a medical school to be added when there were sufficient funds.

When Mr. Duke died in 1925, a codicil in his will provided an extra $4 million for this project, with Mr. Duke’s indenture to the Duke Endowment underlining his commitment to bring high quality health care to the Carolinas. Armed with this funding, Duke built a medical complex continuous with the new West Campus and welcomed the first class of medical students in 1930. As Crowell had foreseen, an academic medical center required a teaching hospital, and Duke Hospital also opened its doors for patients in1930, in July.

Of all the acts of outrageous optimism and pure nerve that accompanied the founding of Duke, none quite exceeds the thought of building from nothing, on the site of a cleared pine forest, a medical center that would vie with the best in the land. But that’s what happened here. There were of course favoring conditions: the professionalized, research-based model of medical education projected by the Flexner Report in 1911 was still relatively new at this time, and Duke had the advantage of being able to build to this model unencumbered by baggage from an older medical world. The level of aspiration at which Duke Medicine was pitched and the financial resources that accompanied that aspiration made it possible for President Few to recruit top leaders from leading schools, specifically the brilliant young doctors whose paths to advancement had been blocked at Johns Hopkins.

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The original Duke School of Medicine graduating class, in 1933. Photo courtesy Duke University Archives

In consequence, Duke Medicine did not start off humbly and slowly evolve, as had been the case with Trinity College. It appeared full blown as a high-end, up-to-the-minute medical facility (an accreditation agency placed Duke in the top quarter of American medical schools only five years after its opening), and major national advances began to come out of Duke very early on. Deryl Hart, the Johns Hopkins doctor recruited as the first chair of surgery, introduced ultraviolet lights into operating rooms at Duke in 1936, a major step forward in controlling post-operative infections. When this upstart university began to win a national reputation, Duke medicine led the way.

But in order to become a home to high-end medical research and education, Duke had to go into a business related to academics but not identical with it: namely, the business of health care. Fast forward eighty years, and Duke is as eminent as ever in medical research and patient care, and we are ever more deeply involved in the business of health care delivery—and thus, subject to the vicissitudes of that rapidly transforming sector.

A curiosity I have been well positioned to observe is that while the Great Recession of 2008-9 had an almost immediate impact on the university side, the medical part of the Duke economy was at first not so badly hit. You may recall that during the first two years of the recession, when there were no raises in the university, employees of the health system continued to see salaries advance, and the ARRA stimulus bill, which disproportionately benefited medical research, further hid the bad news to come. As things began to rebound on the university side, medicine has entered its own, belated period of economic challenge, with storm clouds menacing every phase of its operations: new uncertainty about the funding of graduate medical education, a changing health care system certain to cut reimbursement levels to which we have long grown accustomed, and a continued slump in research funding from federal agencies that has been aggravated in the post-sequester era.  (The NIH reached its high water mark in 2003, with research funding declining over 20% in real dollars from then to now).

This confluence of challenges was sufficiently concerning that in February 2013, Chair of the Board of Trustees Rick Wagoner appointed an Ad Hoc Committee led by trustee Jack Bovender to study the impact of known and potential challenges on the Duke University-Duke University Health System relationship. Questions to be considered included: as the current health care transformations unfold and operating margins grow thinner, will the Health System be able to support academic research in the School of Medicine at a sufficient rate? If the Health System needs to grow the scale of the population served to be competitive in the market, might we need to contemplate new partnerships as a means to expansion? And if we grow in this way, how can we assure that the priority Duke gives to the research mission would be protected? At the outer limit, might the business end of Duke Medicine finally become so large and so responsive to its own different logic that the idea of a symbiotic relation of university and health system might finally prove untenable?

At the end of a deep dive I’ve never seen equaled in comprehensiveness, the ad hoc trustee committee looked dire possibilities in the face but came to a cautiously reassuring conclusion. A stress test conducted by outside experts predicted that the health system would be able to manage whatever changes are brought by the Affordable Care Act without disastrous impact on its finances. This meant that while the health system needs to continue to build its competitive position, there is not a strong case for us to grow on terms that would dilute our academic mission. So far from seeing our health care business and research activity inevitably growing further and further apart, this group reaffirmed their inevitable interdependence and called for clearer provision for financial support of the academic side. To optimize these reciprocal benefits, the committee concluded that we need to take better care to coordinate strategic planning in the medical school and health system, and to strengthen the coordination of governance on the university and health system side.

In effect, the ad hoc committee report represented a reaffirmation of the core dream of an academic medical center. Academic medical centers are sites of health care delivery and medical research and the training of expert future medical practitioners, but the point is, these things do not just happen side by side. In the ideal version, patients get their care in a place where people are asking the fundamental questions that lead to new and better models of care, and research is practiced in such a way as never to lose sight of the human condition it can aim to ameliorate. Every part of the academic medical center equation is under fierce new pressure that could lead to a fracturing of their fragile alignment. This makes it more essential than ever for these activities to be managed so as to be mutually supportive.

Let me mention two more or less direct consequences of the trustee study. In response to its deliberations, a key step has been taken to make surer provision for academic support. Through a transfer of more than $500 million from the DUHS balance sheet, the university is planning for the creation of a permanent quasi-endowment to support the academic mission of the School of Medicine. Augmented with $200 million from SOM reserves and $40 million from the university’s earnings on its reserves, this fund will generate roughly $45 million in annual support to the SOM for the indefinite future—a measure of predictable, long-term security our School of Medicine has never had.

Second, the deliberations of this committee were enormously useful to me in a task I’ve had this past year: finding a new Chancellor for Health Affairs. When we learned that Victor Dzau would be leaving to become President of the Institute of Medicine, I took preliminary soundings on the proper shape for this key leadership role. Among others, I spoke to presidents of other universities noted for their biomedical strength. Many, as you know, have a separate dean for the medical school and CEO for their health care business who report up through different paths, and I was eager to learn what they saw as the advantages of different organizational structures.

One helpful colleague told me that having one person over both of these operations is the ideal arrangement if you can find the perfect person, but in the normal run of things, it just makes more sense to have two separate chiefs. Then how do you manage things that have high institutional value that require collaboration across domains, I asked—things like our Cancer Institute or Translational Medicine Institute, to name no more? With commendable candor, he replied, Oh, we don’t have many of those.

I put this together with the lesson of the ad hoc report and the conclusion seemed clear: just for the reason that the health care delivery business and academic medical research are threatening to pull further apart, the highest success will come to the place that is able to hold all the parts together, to make the components of an academic medical center work together in a mutually beneficial fashion. So when we began to look at chancellor candidates, we were looking not just for impeccable professional credentials, but specifically for people who could manage to this sense of shared mission and common purpose.

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New Chancellor for Health Affairs Eugene Washington, right, is greeted by Matthew Kan, a Duke MD-PhD student, and 2012 Nobel Prize Laureate Dr. Robert Lefkowitz. Photo: Duke University Photography

Eugene Washington, our new Chancellor who will start at Duke on April 1, has every qualification one could imagine for this wide-ranging position: a distinguished researcher and department chair in OB/GYN, he became the first provost at the biomedical research powerhouse UCSF, then dean of medicine and CEO of the health system at UCLA, and national co-chair of PCORI, the Patient-Centered Outcomes Research Initiative, one of the key visualizers of a new national practice based not on treating illness but promoting health. To this all, I’d add that he is a proven uniter and inspirer, someone with a long track record of listening to others to elicit their best thought, then making them want to work together for the highest communal good. We will not be spared the challenges of health care reform or the newly difficult environment; but Gene Washington’s leadership will give Duke the best possible chance to face new facts with creativity, imagination, and a keen sense of our ultimate goals.

I promised three items, so let me hasten to my second. In the history of this university, a domain that has a surprisingly close structural analogy to medicine is athletics. Duke elected to have a medical school and hospital in the act of defining itself as Duke; put another way, Duke built medicine deep into its institutional identity—and exactly the same is true of athletics. You may not remember that football, then the ultimate high-visibility college sport, was banned at Trinity College by President John Carlisle Kilgo in 1895, a ban reluctantly continued by President Few until 1920. But when Trinity College was reborn as Duke University, a crucial part of the planning involved the restoration of high-end athletic competition. The football stadium, the first structure put to use on Duke’s newly built campus, holds down the south end of West Campus as medicine holds down the north. And just as Few went to the celebrated Johns Hopkins, the frontrunner of new-model medical schools, to hire a leader, Wilburt Davison, to create a tradition of excellence and put the new university on the map, Few went to Alabama, the Johns Hopkins of intercollegiate football, to recruit the football coach who would take Duke to the front of the pack: Wallace Wade.

William Preston Few was no fool. He knew that to establish its name and its claim to greatness, Duke needed strengths in addition to its strictly academic strengths, and he saw athletics as a means to build a sense of internal community and to win this school national acclaim. Thanks to this deep incorporation of athletics in the establishment of Duke’s identity, this university has had a continuing inter-involvement with another world that’s not wholly academic—with the result that as with health care, we are subject to the dynamics and vicissitudes of the intercollegiate athletics market.

Perturbations in the intercollegiate athletics scene have brought challenges to the schools that play Division I sports. This is not a new story, but in the last few years, the money available through media contracts has put college sports increasingly in the entertainment business, with pressures on university priorities that can be highly distorting. We can all name universities that have savaged academic budgets while continuing to build sports facilities with embarrassingly large price tags. We can all name universities that admit students to play high-visibility sports who have no realistic ability to benefit from educational opportunities or interest in doing so.

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The 2014 Duke women's golf team, winners of the NCAA championship. Photo: Duke Athletics

Given the potential of sports programs to sully academic reputations, some ask, why not get out of this business altogether? My reply would be, if there are self-defeating ways to link athletics to academics, those aren’t the only ways—and we would lose a significant richness from our mix if we were to subtract this portion of our program. I myself was not a student athlete, but in 20 years of presiding over residential universities with highly miscellaneous programs of activity and engagement, I have come to understand that athletics can be far more than just a pastime or recreation—can be a mode of education complementary to more strictly intellectual ones. Men and women learn things through athletic competition that aren’t so easily learned in other ways. These include  the pleasure of high performance; the ability to recognize excellence and to embrace the discipline necessary to achieve it; the logic of teamwork; the ability, in success or failure, to keep getting up and trying again; the ability to start with a strategy and revise it improvisationally, on the fly, as circumstances change. These aren’t the only things worth knowing, but they are highly valuable life equipment. It’s not for nothing that in ancient Greece and parts of Europe a seat of learning and athletic competition is called a gymnasium.

The problem is that for a university, there’s no embracing athletics at the highest competitive level without becoming involved in contemporary intercollegiate practice. But even as we participate, a school has choices as to how to manage its participation. I am proud to represent a university where student athletes have graduation rates as high or higher than non-athletes and where the great preponderance of athletes are serious, accomplished students. You will recall my mentioning that of Duke’s 640 varsity players, 495 or 77% were included on the ACC Academic Honor Roll.

Keeping the balance requires continual attention as new threats and opportunities emerge in the intercollegiate scene. You will remember that this past year, the 65 universities in the five so-called power conferences were recognized as having semi-autonomous standing within the NCAA, able to pass regulations in some areas that will affect their students alone. It is easy to see how autonomy could open the door to abuse. This could be the means for the schools with the highest media revenues to shower funding on athletes in revenue sports in ways that would make them little different from paid performers, with less and less in common—and less and less contact—with the student body at large.

This January I attended the first meeting of the Autonomy Conferences to cast votes on Duke’s behalf. I am cautiously pleased to report that at this first outing, the power conferences avoided such measures and favored more constructive ones. The measures that were approved include tighter policies on athletic concussions; permitting schools to offer athletic scholarships thae cover the full cost of attendance; and the one that mattered most to me, a measure that forbids universities from revoking a student’s athletic scholarship for reasons of athletic performance. If a school can withdraw  students’ scholarships the day they are no longer  strong contributors to the team that recruited them, it’s a naked confession that the school had no interest in or commitment to the student other than for what they could do on the court or field. In a better world, the offer of an athletic scholarship is a commitment to stand by a student until he or she finishes his or her education, as has long been the case at Duke.

My larger point is that over the course of their histories, different universities court involvement with their own sets of extra-academic activities, such that when these relations grow problematic, severing the Gordian knot is seldom an option. The art is to make the relation work. This is certainly true for my third example, the city of Durham.

Most universities are located where they were founded—Harvard is in Cambridge, Stanford is in Palo Alto, UNC is in Chapel Hill—but one of Duke’s peculiarities is that this school was founded elsewhere, in rural Randolph County, and operated there for over 50 years. Just as it chose to have health care and chose to have big-time sports, Duke’s ancestor Trinity College chose to be located in Durham. The ambitious little college packed up its bell and the several thousand books of its library, loaded them onto a boxcar, and moved to this city in the 1890s in order to be connected to more dynamic parts of contemporary America (Durham was a New South city), and, not coincidentally, to have access to philanthropic support from New South wealth. The consequence was that here again, Duke acquired an enduring codependency through an originating choice.

For many years, Duke must have appeared little connected to its chosen home. In the early 20th century Durham was a vibrant center of black culture and commerce, was indeed so prominent in the world of black business enterprise that it was known as the “Black Wall Street.” But in the depths of segregation, any Duke connection with black Durham—beyond the manual labor force that it depended on—must have seemed tenuous at best. When the Georgian East and Gothic West Campuses were built in the late 1920s, they were separated by a mill village attached to the factories on Erwin Road. This was a territory equally alien to the university culture of that time.

When the tobacco and textile economies collapsed in Durham, Duke’s lack of urban connectivity became paradoxically a kind of asset, at least in the short term. In the 1970s and 80s, as cities became focal points for social pathologies, universities that were more visibly urban in setting and signature—Columbia, Chicago, Penn, Yale—paid large public relations prices for their dangerous, depressed locales. When Duke hit the cover of the New York Times Magazine as the new “it” school in 1984, it was partly because it was set in a Gothic wonderland, standing apparently clear of its urban surround.

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The Durham Performing Arts Center.

But as urban decline abruptly reversed course in the US in the last 20 years, Durham’s missing downtown became a serious negative for this university, and a century after moving here, Duke came to understand the need to invest in its place. During Nan Keohane’s presidency and with John Burness in the lead, Duke began investing to reverse cycles of social decay in twelve proximate neighborhoods through the Duke-Durham Neighborhood Partnership. Through the genius of Tallman Trask, Duke also invested in rehabilitation projects downtown with decisive effect. Duke’s commitment to lease one-fourth of the one million square feet of the abandoned American Tobacco site led to the securing of the rest of financing for the ambitious project that reignited Durham as a commercial attraction. Comparable Duke participation helped advance the building of the Farmer’s Market and the Durham Performing Arts Center, which opened to the public in 2007.

From this start, with a brief timeout for the economic downturn, Durham has become a veritable boomtown for investment and activity. Two thousand three hundred residential units have been built within two miles of downtown within the past three years. Four hotels have opened or are soon to open within a mile of downtown. Durham’s locavore food scene, the subject of much free publicity and national acclaim, continues to recruit new restaurants virtually by the week. (Your president enjoyed being informed at one of these on a January evening that he could happily have a table if he did not mind the three hour wait.) As new residents and new entertainment and nightlife bring new dynamism to the downtown, the last undeveloped bits are coming to new life as scenes of commercial activity and employment.  

In a choice that would have seemed unimaginable a short while back, the Duke School of Medicine decided that instead of building a new research building on campus, it would rehabilitate the last great tobacco warehouse, the Carmichael Building in West Village, into high-end lab space where it could co-locate faculty doing research on metabolomics, physiology and human genetics — one attraction being that private sector companies could locate in adjacent space to share research projects and commercial development of discoveries. The new tenants in the Carmichael Building have raised the number of people for whom working at Duke means working downtown to north of two thousand five hundred. The Chesterfield Building, long Durham’s greatest eyesore, a dead, dull tomb for the vanished age of the cigarette, is under construction now and will soon form part of a new archipelago of biomedical research and development spaces mixing academic and industry participants. Startups, which spring up most luxuriantly in high-density collision spaces with highly educated, innovative neighbors, will have a natural new home in what is being called the Durham Innovation District. Duke’s own Innovation and Entrepreneurship Initiative will open such a space of connectivity in downturn Durham within the year.

As we help bring these new realities to life, we can glimpse a Durham that never was but that will benefit us immensely as it comes into being: a center of economic and cultural vitality that draws smart people from around this country and the world and gives their creative ideas a place to develop. If Duke and Durham are bound to each other in a shared fate, we’ve entered a chapter where both sides can see newly positive prospects, possibilities both parties have helped create through a vision of constructive partnership. Durham is not yet the new Austin let alone the new Silicon Valley, but the selection of this city as one of four new sites for Google Fiber development shows that it is not only we who see the potential concentrated here.

Duke has an important role to play in every aspect of this city’s and this region’s development. It was dismaying to learn that in the school grading program recently mandated by the North Carolina legislature, many Durham public schools got grades of C, D or F. There can be no great surprise here. Since the principal insight of these grades seems to be that affluent towns already known to have the best public schools do indeed have the best-performing public schools, with the converse holding true for areas of concentrated poverty, the exercise seems at once punitive and stupefyingly tautological. But even if we do not like the grading system, we all have a role to play in advancing more equitable schooling for this city and its people. Duke cannot do this alone, but our partnerships with the Durham Public Schools in early education programs, summer and after-school academies, and our many shared research and literacy initiatives are crucial contributors to a better civic future.

With health disparities having emerged as one of the most devastating and intractable forms of social inequality in America in our time, Duke and Duke Medicine and even Duke Athletics have a crucial role to play in partnering for a healthy community. Eugene Washington, who has won recognition for his work on behalf of community health in Los Angeles, will find many willing and innovative partners in Durham. If we want to benefit from our home, we must be active to make it the community it can be.

I conclude with this. We are the inheritors of choices made long ago on Duke’s behalf. There is no un-choosing those choices: they are so deeply woven into the fabric of this place that the theory of their separability is a simpleton’s mistake. But just because these choices have been so decisive in their impact, it is essential that we manage their consequences toward this university’s greatest good. That’s our work here together every day. Thanks for letting me share a few glimpses from where I sit.  And I thank you for your concerted work to lift this university toward its highest purpose.