Harvard Public Health Magazine, Fall 2013, Centennial Issue
Celebrating Our First Century
100 100 Celebrating Our First Century HARVARD PUBLIC HEALTH SPECIAL CENTENNIAL ISSUE FALL 2013 HSPH.HARVARD.EDU DEAN’S MESSAGE T FULL CIRCLE This special issue of Harvard Public Health is devoted to the School’s first century. It is not meant to be a comprehensive or exhaustive survey. Rather, we want to give readers—students, faculty, staff, and alumni, as well as those who are new to the School or simply want an overview of the field since 1913—a lively and broad perspective of HSPH’s accomplishments, as well as a glimpse of where it is headed in its second century. And because enlightened philanthropy underlies many of our achievements, our Winter 2014 issue will focus on how it has shaped HSPH and continues to open up intriguing new research directions. As we approach the School’s centennial, I have been reflecting upon the phrase “full circle”— Most obvious, of course, are the two formidable circles in the number 100. HSPH is the longest which seems relevant in so many ways to this momentous anniversary. continuously operating school of public health in the world. It was established at a time when triedand-true interventions such as sanitary engineering were being wed to a new scientific base stemming from the germ theory of disease and the exciting discoveries in microbiology that followed. To come full circle means to return to one’s roots. As this special keepsake issue of Harvard Public Health makes clear, the public health mission is both timely and timeless. The problems that preoccupied us a century ago still preoccupy us. Most of the titles of the 73 courses offered in our first catalog resonate in 2013, from Infant Mortality and Food Analysis to Climatology and Practical Health Administration. Back then, the aim was an education that would prepare students to be thinkers and doers— and that remains true, though the School has been continually refining its educational philosophy, changing in response to new needs and pedagogical insights. Today, HSPH aims to graduate “T-shaped leaders”: those with both in-depth knowledge in specialized areas and a broad set of skills that enables them to work across many disciplines. Around the world, advances in knowledge about how to protect the public’s health have doubled life expectancy. But in today’s interconnected world, this progress is imperiled by four major threats. One threat consists of old and new pandemics—from diabetes and obesity to avian flu and antibiotic resistance. In response, HSPH is challenging accepted wisdom and pushing back the frontiers of knowledge for the common good. We are building on lifesaving work that has slowed the spread of HIV/AIDS; harnessing cellphone technologies to better understand, and perhaps halt, the spread of malaria; and discovering molecular codes that influence how and when we get sick. Another threat involves harmful physical and social environments. Our faculty has documented how deprivation, discrimination, toxic physical and social conditions, and the choices we make about how we live all play a role in disease. The School is in the vanguard of efforts to both change individual behavior and address the larger structural forces at play. 2 Harvard Public Health A third threat includes poverty and humanitarian crises. The Humanitarian Academy at Harvard—the first comprehensive educational program for aid workers offered by a major global university—teaches humanitarian workers to operate effectively in crises and trains future leaders of aid agencies and government programs. Our Women and Health Initiative is working to change the circumstances that threaten the lives and livelihoods of women and families around the world. The fourth threat centers on failing health systems. HSPH faculty members are identifying ways to prevent costly and life-threatening medical errors, determining which prevention programs and medical treatments deliver better care more efficiently, and ensuring that access to affordable care is viewed universally as a right, not a privilege. The School is To come full circle means to return to one’s roots. As this special keepsake issue of Harvard Public Health makes clear, the public health mission is both timely and timeless. also reaching globally to health leaders at all stages of their careers, through programs that help them achieve policy goals by equipping them with new information, resources, and connections. If we have made progress against these four threats, it’s partly because of another circle—the circle of knowledge. This virtuous circle begins with research, the centerpiece of the School’s activities from the start. Scientific discoveries are taken up and replicated through education. They ripple out into the wider world through translation—both completing the circle and starting a new one, since on-the-ground experience feeds new research questions. The beauty of coming full circle also has a very personal meaning for me. On a fellowship at Children’s Hospital, my father, Dr. Silvestre Frenk, studied the metabolism and biochemistry of undernutrition in a building on Shattuck Street that had once housed HSPH. As babies, my twin sister and I spent most of our first year in Boston, often accompanying my mother to pick him up after work in his basement laboratory. Little did I know that I would come full circle geographically to serve as dean just a few blocks away. In 1984, when Mexico’s National Institute of Public Health was launched, another circle was drawn. Harvey Fineberg had just been named HSPH’s new dean. I traveled to Boston to ask him to serve on an international advisory committee for my fledgling institute. Harvey eagerly signed on—and with that simple act of generosity, helped ensure success during the crucial formative years of the institute. Thus began a circle of partnership and collegiality that is often at the heart of success in our field. A centennial is an occasion to circle around dreams and ambitions, successes and failures, teaching and learning, human well-being as it is and as it could be. To the faculty, students, and staff who have made Harvard School of Public Health the pre-eminent institution it is today, I am profoundly grateful. At the start of our second century, we look forward to drawing an even wider circle of visionary science and powerful ideas for a healthier world. Julio Frenk Dean of the Faculty and T & G Angelopoulos Professor of Public Health and International Development, Harvard School of Public Health 3 Fall 2013 HARVARD PUBLIC HEALTH Fall 2013 CENTENNIAL ISSUE CELEBRATING OUR FIRST CENTURY 2 Dean’s Message: Full Circle As the School’s centennial reminds us, the public health mission is both timely and timeless. 6 Then & Now U.S. vital statistics: surprises over the century. 8 The Founders & Deans of HSPH Over the last 100 years, the School’s leaders have brought diverse backgrounds and wide-ranging agendas. 12 First Women HSPH was the first School at Harvard to admit and credential a woman student, and the first School to hire a woman professor. 14 Infectious Diseases & Pandemics From polio and smallpox to HIV/AIDS and SARS, the School has made pivotal discoveries about the most vicious infections in every corner of the globe. 30 Health & How We Live What we eat and drink, whether we exercise, how we drive, what we inhale: Our shifting lifestyles are changing the picture of public health—and HSPH scientists have stayed ahead of the trends. CONTENTS IMAGES Page 4: D4Medical /Science Source, © Digital Vision/gettyimages.com © Pasieka/Science Source Page 5, column 1: © Bettmann/CORBIS, ©Ian Teh/Panos Pictures, Blend Images/Alamy Page 5, column 2: courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine 44 The DNA of Public Health Classic bench science and cutting-edge genetics research have set the School apart. 4 Harvard Public Health 50 Deadly Environments From its earliest days, the School has built a legacy on uncovering and responding to contamination in the work and home environments. 86 Transforming Public Health Education A century after its founding, HSPH has embarked on an exciting educational revolution. 100 A Century of Powerful Ideas How HSPH has changed the world—in words and pictures. 112 Image credits For more on the School’s history, go to hsph.harvard.edu/centennial. 62 Poverty, Disasters & Health Against All Odds The most powerful influences on population health are the broad social forces that shape our lives, as the School’s influential scholars and scientists in the field have showed. COVER IMAGES Row 1, L-R: Kent Dayton/HSPH (2); HSPH (2); ©Tim Gainey/Alamy; ©Harvard University/ Justin Ide; courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine; Kent Dayton/HSPH (2); HSPH; Kent Dayton/HSPH Row 2, L-R: Kent Dayton/HSPH (2); U.S. Postal Service; Eye of Science/Science Source; courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine; ©The Carter Center/L. Gubb; Kent Dayton/HSPH; courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine; BSIP SA/Alamy; courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine Row 3, L-R: iStock; Kent Dayton/HSPH; courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine; ©Harvard University; courtesy of Mary Revelle Paci; Kent Dayton/HSPH; iStock; Kent Dayton/HSPH; ©Richard Nowitz/National Geographic Society/ CORBIS, Francis A. Countway Library of Medicine; HSPH; 3D4 Medical/Science Source Row 4, L-R: ©Harvard University/Rose Lincoln (2); courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine; Kent Dayton/HSPH; ©Pasieka/Science Source; Kent Dayton/HSPH (3); courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine; ©Harvard University/Justin Ide (2); ©Jake Peters 74 Working the (Health) System HSPH researchers have been world leaders in decisionmaking science and in assessing the human impact of complex health systems. 5 Fall 2013 We’ve Come a Long Way AVERAGE U.S. LIFE EXPECTANCY Overall: 52.5 Male: 50.3 Female: 55.0 TOP CAUSES OF DEATH 1. Diseases of the heart 2. Tuberculosis INFANT MORTALITY (PER 1,000 LIVE BIRTHS) 99.9 deaths MATERNAL MORTALITY (PER 100,000 LIVE BIRTHS) 610 deaths Then MAIN CONSTITUENTS OF DIET (AVERAGE ANNUAL CONSUMPTION IN LBS.) Red Meat (beef, veal, lamb, pork, mutton) 143.7 Chicken & Turkey 19.4 Fats & Oils 36.8 Fruits (fresh, canned & dried) 142.8 Vegetables (fresh, canned) 205.5 Butter & Cheese 20.9 Caloric Sweeteners Sugar Cane & Beet Sugar (refined) 81.3 SMOKING PER CAPITA 260 cigarettes HOSPITAL BEDS 682,481 BACHELOR’S DEGREE OR HIGHER 2.7% of persons age 25+ TOTAL US POPULATION 97,230,000 TOP FIVE OCCUPATIONS Total workers 36.7 million Agriculture 11.3 million Manufacturing & hand trades 8.3 million Transportation & other public utilities 3.2 million Trade 3.5 million Construction 2.3 million PERCENT OF HOMES WITH INDOOR PLUMBING 1% PERCENT OF POPULATION IN URBAN VS. RURAL AREAS Urban: 45.6% Rural: 54.4% All figures refer to the U.S. “Then” ranges from 1900 to 1920. 6 Harvard Public Health AVERAGE U.S. LIFE EXPECTANCY Overall: 78.7 years Male: 76.3 years Female: 81.1 years TOP CAUSES OF DEATH 1. Heart disease 2. Cancer INFANT MORTALITY (PER 1,000 LIVE BIRTHS) 6.15 deaths MATERNAL MORTALITY (PER 100,000 LIVE BIRTHS) 21 deaths MAIN CONSTITUENTS OF DIET (AVERAGE ANNUAL CONSUMPTION IN LBS.) Red Meat (beef, veal, lamb, pork, mutton) 105.7 Chicken & Turkey 69.4 Fats & Oils 78.6 Fruits (fresh, processed) 257.0 Vegetables (fresh, processed) 390.9 Butter & Cheese 37.7 Caloric Sweeteners 130.7 Sugar Cane & Beet Sugar (refined) 63.5 Corn sweeteners, including high-fructose corn syrup NOW FASTEST-GROWING JOBS, PROJECTED INCREASE FOR 2020: Personal Care Aides: 70.5% Home Health Aides: 69.4% Biomedical Engineers: 61.7% 65.7 SMOKING PER CAPITA 1,691 cigarettes HOSPITAL BEDS 924,333 BACHELOR’S DEGREE OR HIGHER 30.9% of persons age 25+ TOTAL US POPULATION 316,160,000 TOP FIVE OCCUPATIONS Total workers 142.5 million Management, professional & related occupations 54.0 million Sales & office occupations 33.2 million Service occupations 25.5 million Production, transportation, material moving 17.0 million Natural Resources, construction & maintenance 12.8 million PERCENT OF HOMES WITH INDOOR PLUMBING 98.8% PERCENT OF POPULATION IN URBAN VS. RURAL AREAS Urban: 80.7% Rural: 19.3% “Now” ranges from 2006 to 2013. For further information and citations, go to www.hsph.me/then-and-now. 7 Fall 2013 The Founders & Deans of HSPH George Whipple, William Sedgwick, and Milton Rosenau Founders, 1913–1922 “This is a historic meeting, the beginning of what will be a great School.” So wrote George C. Whipple after a 1913 meeting of the administrative board of the fledgling Harvard–MIT School for Health Officers—which, in 1922, would become Harvard School of Public Health. An unusual triumvirate of scientists—Whipple, William T. Sedgwick, and Milton J. Rosenau, collectively known as The Founders (left to right, above)—made it all possible. Sedgwick, a renowned MIT biologist, served as chair; Rosenau, a Harvard Medical School professor and head of the Department of Preventive Medicine and Hygiene, became director of the School; and Whipple, Harvard professor of sanitary engineering, was secretary and treasurer. Sedgwick died in 1921, just hours after representing A century of leadership MIT at a State House meeting on education. Rosenau led HSPH’s epidemiology program from 1922 through 1935, then left Harvard to help establish the public health school at the University of North Carolina, Chapel Hill; he died in 1946. Whipple taught sanitary engineering courses at HSPH until his death in 1924. David Linn Edsall Dean, 1922–1935 Dean of Harvard Medical School since 1918, David Linn Edsall was appointed dean of the newly independent HSPH in 1922 and led both institutions through his retirement in 1935. Sanitary engineering, tropical medicine, and industrial medicine were major areas of research and training at HSPH under Edsall’s leadership. In his own lab, Edsall studied metabolism, hygiene and sanitation, and the health effects of 8 Harvard Public Health extreme heat. Cecil Drinker, who would succeed Edsall as dean, said of his predecessor, “He believed the profession of public health should be given a chance to find itself and should show that it could captivate the imagination of the best medical and engineering brains.” Edsall died in 1945. Edward G. Huber Acting Dean, 1942–1946 A former U.S. Army medical officer who commanded a hospital center in France during World War I, Edward G. Huber earned a doctorate at HSPH in 1925, while stationed in Boston. After retiring from the Army, he became an epidemiologist for the Massachusetts Department of Public Health and began teaching at HSPH. Named acting dean in 1942, after Cecil Kent Drinker resigned due to illness, Huber shouldered the difficulties of the World War II years—a depleted faculty, low numbers of students, and limited supplies. Yet he taught classes, fostered instruction and research in new branches of public health, and helped obtain funds from the Rockefeller Foundation that paved the way for the School to become fully autonomous from Harvard Medical School on July 1, 1946. Huber, sadly, did not live to see the School’s independence. He died suddenly several weeks later. Roger I. Lee Acting Dean, 1922–1923 Roger I. Lee chaired the special committee empowered in 1921 to plan the newly endowed, independent Harvard School of Public Health. For his prescient leadership, Lee, the Henry K. Oliver Professor of Hygiene, has been dubbed the “Father” of HSPH. Lee served as acting dean during David Edsall’s travel to Europe on educational surveys. To read more about Lee, go to page 93. Cecil Kent Drinker Dean, 1935–1942 Cecil Kent Drinker, professor of physiology at Harvard Medical School and at HSPH from 1923 to 1935, was an expert in industrial and work-related illnesses and hygiene. He discovered that steel mill workers became sick by inhaling manganese dust and fumes. Drinker determined that women painting luminous watch and clock dials were being poisoned from the radium-based paint they used. During World War II, his research on respiratory physiology led to the development of high-altitude oxygen masks and goggles for aviators. As HSPH’s first full-time dean, he expanded enrollment, admitted women as degree candidates for the first time, and raised admission criteria. After stepping down as dean, Drinker lectured at Cornell Medical School from 1948 to 1949 and served as a consultant to industrial organizations and the U.S. Navy from 1951 to 1953. He died in 1956. James Stevens Simmons Dean, 1946–1954 During a 30-year career in the U.S. Army, from 1916 to 1946, James Stevens Simmons, DPH ’39, studied malaria, dengue, and other tropical scourges and developed a preventive medicine program that safeguarded the health of more than 9 million U.S. soldiers during World War II. He also served as chief of the Preventive Medicine Service in the Army’s office of the Surgeon General from 1940 to 1946. At HSPH, he led an aggressive fundraising effort and helped create, with donor funding, the first-ever named professorship at HSPH, in honor of tropical medicine pioneer Richard Pearson Strong. Simmons also advocated for an expanded national commitment to train public health professionals. He wrote in 1953, “We must build up the nation’s health in order to ensure its future strength and security, and we continued 9 Fall 2013 A Century of Leaders at HSPH must work for an improvement of world health in the hope of ensuring a lasting world peace.” Simmons died of a heart attack in 1954 at age 64, while serving as dean. in 1968, associate dean; and in 1971, acting dean. Daggy retired from the faculty in 1981 and died in 2001. John C. Snyder Dean, 1954–1971 John C. Snyder modernized and expanded HSPH during his 17-year tenure at the School. He quadrupled the endowment, doubled the size of the faculty, and transformed the School’s physical plant from antiquated former hospitals to three modern buildings along Huntington Avenue. As a lieutenant colonel in the Army Medical Corps during World War II, Snyder helped develop new treatments for typhus. He began at HSPH in 1946 as head of the Department of Public Health Bacteriology. As dean, he established departments of demography and human ecology, behavioral sciences, and the University-wide Center for Population Studies. Interviewed in this magazine in 1997, Snyder said, “The thing that I am proudest of is what the students did— and are doing—in various parts of the world.” After stepping down, Snyder held a professorship in population and public health and advised on developing health programs in the Middle East. He died in 2002 at age 91. Howard Hiatt Dean, 1972–1984 Trained in clinical medicine, biochemistry, and molecular biology, Howard Hiatt has served in a number of positions on the Harvard University faculty, beginning in 1955. As physician-in-chief at Beth Israel Hospital from 1963 to 1972, he recruited physician-scientists to apply new scientific knowledge to patient care and extended the hospital’s involvement in Boston’s inner city. At HSPH, Hiatt bolstered quantitative analytic sciences, introduced molecular and cell biology into the School’s research and teaching, initiated programs in health policy and management, and fostered crossdisciplinary research. Since 1985, he has been professor of medicine at Harvard Medical School and senior physician at Brigham and Women’s Hospital. Hiatt played a major role in the success of Partners in Health, a Harvardaffiliated nonprofit that works with resource-deprived countries to fight disease and poverty. He serves as deputy director of the Brigham’s Global Health Equity Division of the Department of Medicine. In an October 2011 video interview, part of the History of the School Project, Hiatt said, “I see public health as an area that requires, first and foremost, a concern for human rights.” Richard H. Daggy Acting Dean, 1971–1972 Working in Dhahran, Saudi Arabia, for the Arabian American Oil Company for 17 years, entomologist Richard H. Daggy led preventive medicine efforts and served as medical director for the company. He helped establish standards for sanitation, pest control, and communicable disease prevention—including an effective malaria control and eradication program. Daggy was invited in 1954 to become a lecturer at HSPH, where he taught both entomology and tropical public health. In 1964, he became assistant dean for international programs; Harvey Fineberg Dean, 1984–1997 A 24-year veteran of the School with four Harvard degrees—AB ’67, MD ’72, MPP ’72, and PhD ’80— Harvey Fineberg presided as dean over rapid growth in the numbers of students and faculty, in the budget, and in fundraising. An expert on medical innovation and change, Fineberg has provided insight on 10 Harvard Public Health issues such as the best way to introduce new medical technology, how to decide which treatments to use in complex situations, and how to respond to emerging infections. He was instrumental in organizing Harvard University’s response to the early HIV/AIDS epidemic and in establishing, with Countess Albina du Boisrouvray, the FXB Center for Health and Human Rights. On his appointment as Harvard provost, Mark Rosenberg—then-director of the U.S. Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control—said that the secret of Fineberg’s success “is his relentless optimism and the incredibly creative and productive force it generates.” Fineberg left his HSPH deanship to become provost of Harvard and later president of the Institute of Medicine, a position he has held since 2002. James Ware Acting Dean, 1997–1998 Biostatistician James Ware spent a year as acting dean after Harvey Fineberg was appointed Harvard provost. Ware later returned to his role as HSPH’s Dean for Academic Affairs, a position he held from 1990 to 2008. In the 1980s, as a co-investigator for the Six Cities Study of Air Pollution and Health, Ware developed statistical methods for the design and analysis of longitudinal studies on the health effects of air pollution. He is currently Frederick Mosteller Professor of Biostatistics and associate dean for clinical and translational science. and AIDS. As HSPH Dean, Bloom made student financial aid a top priority; during the course of his 10-year tenure, student funding increased nearly threefold. He boosted active learning and case-based teaching, oversaw new public health initiatives in Africa, India, China, and the Mediterranean region, and emphasized such fields as genes and the environment, quantitative social sciences and bioinformatics, and global health. During his 1999 inaugural address to the School community, Bloom said, “I believe the Harvard School of Public Health has to be the ‘Public Health School for the Nation and the World.’ ” Bloom continues to pursue bench science as the principal investigator of a laboratory researching the immune response to tuberculosis, an infection that claims more than 2 million lives each year. He also co-leads the School’s introductory doctoral course on global health and population and an undergraduate course at Harvard College on global threats to health. Julio Frenk Dean, 2009–present Before becoming dean at HSPH, Julio Frenk served from 2000 to 2006 as minister of health in Mexico, where he oversaw health system reform that redressed social inequality and extended health care coverage to some 50 million previously uninsured people. Earlier in his career, he established the National Institute of Public Health of Mexico. In scholarly articles and in the media, Frenk—who is also T & G Angelopoulos Professor of Public Health and International Development at HSPH and Harvard Kennedy School—has underscored the importance of the vast health transition currently underway throughout the world. He has also championed the idea that health is central to economic development, national security, democratic governance, and human rights. At HSPH, he has shepherded new educational initiatives, including online offerings through HarvardX. In a Q&A in this magazine in 2009, Frenk said, “Good evidence can be translated into policy and practice. Evidence is the light that must illuminate our path.” v Barry Bloom Dean, 1999–2008 As an internationally recognized expert in immunology and infectious diseases, Barry Bloom, Joan L. and Julius H. Jacobson Professor of Public Health, has used both scientific evidence and advocacy to fight such global diseases as tuberculosis, malaria, 11 Fall 2013 First to Admit Women on the Same Basis as Men In November 1913, the Harvard-MIT School for Health Officers became the first academic program at Harvard to admit and credential women on the same basis as men. The credential awarded was the CPH—a certificate in public health. First Women First Woman to Receive a Harvard Credential Harvard University’s first credentialed woman was Linda Frances James, born in 1891, who received her certificate in public health from the Harvard-MIT School for Health Officers in 1917. Linda James, left, shown in Minnesota with her husband at right and a guest from China Progress by Degrees In 1936, HSPH became the second of Harvard’s professional schools to grant Martha May Eliot, former chair of the Department of Maternal and Child Health and first woman president of the American Public Health Association degrees to women. The first was the Harvard Graduate School of Education. 12 Harvard Public Health First Woman Professor “A woman on the Harvard faculty!” marveled the Boston Sunday Globe on March 23, 1919, describing the sensation created by the appointment of Harvard’s first female professor, Alice Hamilton, who served as assistant professor of industrial medicine on the faculty of the Harvard-MIT School for Health Officers and Harvard Medical School. Hamilton’s appointment, at the age of 50, was subject to three restrictions: She was not to be allowed into the Faculty Club, nor to participate in academic processions at commencement, and was not eligible for faculty tickets to football games. Today, about 60 percent of HSPH students are women. Background: Alice Hamilton, in the lab 13 Fall 2013 INFECTIOUS DISEASES & PANDEMICS 14 Harvard Public Health T Today, noncommunicable diseases account for two-thirds of all deaths globally. But in low-income nations, three largely preventable infectious diseases—lower respiratory infections, diarrheal infections, and HIV/AIDS— are the leading killers, with malaria, tuberculosis, and neonatal infections close behind. And as recent headlines have shown, new infections—from SARS to bird flus to deadly new strains of E. coli—continually emerge. From its very beginning, Harvard School of Public Health has bolstered efforts to control the most common and the most vicious infections in every corner of the world—with pivotal discoveries in the lab and advances in interventions on the ground. 15 Fall 2013 INFECTIOUS DISEASES & PANDEMICS THREE DEADLY SCOURGES SMALLPOX William Foege had a problem—a big problem. It was December 1966. Foege, who graduated from the School with an MPH in 1965, was serving in a remote part of eastern Nigeria on a medical mission and as a consultant to the U.S. Centers for Disease Control and Prevention (CDC). His assignment was daunting: to help rid that part of the world of smallpox, a painful, disfiguring infection that was one of humankind’s most devastating scourges. Health authorities believed that to achieve eradication, 80 to 100 percent of regional populations had to be inoculated. But in Foege’s jurisdiction, vaccine was in short supply. When smallpox erupted in a nearby village, Foege had to figure out how to hold back the epidemic. Spreading out maps of the district and working with two-way ham radios, he contacted missionaries and asked them to dispatch runners throughout the region to learn where else the disease had broken out. Using this information and analyzing family travels and market contacts, he made an educated guess about where the epidemic would jump. The task required, as he once recalled, imagining “how a smallpox virus bent on immortality” would behave. Foege’s team took an unusual approach, targeting for vaccination only residents in the affected villages and in villages where the disease would likely strike. Miraculously, four weeks later, though less than 10 percent of the population had been immunized, the outbreak screeched to a halt. Six months later, the entire region was smallpox-free. “Surveillance/containment,” as the method came to be known, revolutionized the smallpox eradication campaign by saving money and time. When the World Health Organization (WHO) officially declared smallpox eradicated in 1980, it was in no small part because of Foege’s daring calculations. It was just the start of Foege’s game-changing career. From 1984 to 1990, he led a partnership of U.N. agencies and nongovernmental organizations that raised worldwide immunization levels from 20 percent to 80 percent for six major childhood diseases—“the largest peacetime mobilization in the history of the earth,” according to James Grant, then the director of UNICEF. As CDC director from 1977 to 1983, Foege witnessed the emergence of Legionnaires’ disease, toxic shock syndrome, Lyme disease, the deadly E. coli O157:H7 strain, and HIV/AIDS. In 2012, Foege was awarded the Presidential Medal of Freedom, the highest civilian award in the United States. Mobilizing an international team of scientists and government officials in a targeted attack on a single microbe, the war on smallpox demonstrated for the first (and, to date, the only) time that it was possible to extinguish a pathogen through deliberate human activity. In October 1977, a hospital cook in Somalia contracted smallpox from two Ethiopian children who had fled to Somalian refugee camps after their nation’s civil war— the last case of naturally occurring smallpox on earth. Three years later, the WHO declared smallpox—an infection that had killed an estimated 300 million people in the 20th century alone—gone for good. continued page 18 16 Harvard Public Health E A woman in Ethiopia is vaccinated against smallpox in the 1970s as the global eradication campaign nears an end. E THE ART OF ERADICATION E•rad•i•cate: 1. to pull or tear up by the roots, to remove entirely, extirpate, get rid of. 2. in public health, to achieve zero disease globally as a result of deliberate efforts. Its formal name says everything: dracunculiasis, or “affliction with little dragons.” In the early 1980s, Guinea worm disease struck millions from western India to Senegal. Victims become infected when they drink from ponds or wells containing tiny freshwater crustaceans that themselves have swallowed microscopic worm larvae. In infected humans, the larvae grow inside the body to about a yard long, then migrate to the skin, where they eventually burst through, slowly and painfully. As Donald Hopkins examines children in Nasarawa, Nigeria in 2007. HSPH alumnus Donald Hopkins, MPH ’70, put it, “Guinea worm disease is one of the most terrible human afflictions.” He should know. Hopkins’ greatest legacy may be the eradication of Guinea worm disease. While at the U.S. Centers for Disease Control and Prevention (CDC), he launched in 1980 the Guinea Worm Disease Eradication Program, an exhaustive search for the worm in some of the world’s most inhospitable environments. From 1987 to 1997, he led the Guinea worm disease initiative at The Carter Center. With no vaccine in sight, eradication relies on simple filtering technologies and robust networks of community health workers. As a result of Hopkins’ dogged efforts, Guinea worm disease has fallen from 3.5 million cases in 1986 to fewer than 600 cases globally in 2012. In 2013, the number is expected to be even lower. Today, Hopkins directs all health programs at The Carter Center. Hopkins’ public health triumphs overlap and often intertwine with those of William Foege, whose surveillance/ containment immunization strategy ushered in the eradication of smallpox. Drawing on Foege’s inspiration and advice, Hopkins served as a medical epidemiologist and director of the Sierra Leone Smallpox/Measles Program from 1967 to 1969. In 1974, he became assistant professor of tropical medicine at HSPH, teaching the subject that originally drew him to public health. By 1978, Hopkins became the assistant director for international health at the CDC, reporting directly to Foege, and went on to serve as the agency’s deputy director from 1984 to 1987 and as acting director in 1985. Earlier this year, in an article in the New England Journal of Medicine starkly titled “Disease Eradication,” Hopkins wrote that “The unique power of eradication campaigns derives from their supreme clarity of purpose, their unparalleled ability to inspire dedication and sacrifice among health workers, and their attractiveness to donors, all of which are needed to overcome the barriers to successful eradication.” In 2013, polio and Guinea worm disease are the only officially sanctioned targets of eradication campaigns. What will it take to reach a target of zero? Not only international cooperation and political will, but also people like Bill Foege and Don Hopkins, who themselves seem infected by boundless optimism. As Foege is famously fond of saying, “Some things have to be believed to be seen.” And as Hopkins recently told a newspaper interviewer, “I’m sort of immunized against pessimism.” Donald Hopkins 17 Fall 2013 The iron lung pulled back thousands of polio victims from the brink of death. POLIO route. The infection was unusual because it actually claimed more lives as overall health conditions improved. In crowded tenements and rural slums, young children were exposed to the poliovirus within the first few years of life, when the disease causes few symptoms beyond a transient fever. By contrast, children of the middle and upper classes were protected from exposure to the virus during infancy. As they got older and went to school or summer camp or swam in public pools, they encountered large groups of children. First-time exposure to the poliovirus at an older age is more likely to trigger the most dreaded complications: muscle stiffness, pain, and eventual paralysis. In the first half of the 20th century, medicine was virtually helpless in treating polio’s complications, including the tortured suffocation that followed paralysis of the chest muscles. But in the fall of 1928, the clinical picture brightened somewhat, when a Harvard senior with polio entered Boston’s Brigham Hospital. In his room sat a giant tin box with a hole at one end and a motor at the other. Its inventor was Philip Drinker, a quiet, modest engineer and professor of industrial hygiene at HSPH. At the beginning of the 20th century, major epidemics of poliomyelitis were virtually unheard of. But within a few decades, it was the fifth-leading cause of infectiousdisease death in the United States, claiming thousands of lives each year in nearly annual epidemics. The 1952 polio epidemic was the worst outbreak in the nation’s history; of 57,628 reported cases, 3,145 died and 21,269 were left struggling with mild to disabling paralysis. Called “the summertime scourge,” polio often flared in the midst of the idyllic rituals of summer. Because water was believed to be a route of transmission, swimming holes, pools, and ponds were closed when epidemics erupted. But the threat loomed everywhere. As Philip Roth wrote in his 2010 novel Nemesis, “We were warned not to use public toilets or public drinking fountains or to swig a drink out of someone else’s soda-pop bottle or to get a chill or to play with strangers or to borrow books from the public library or to talk on a public pay phone or to buy food from a street vendor or to eat until we had cleaned our hands thoroughly with soap and water.” Poliovirus belongs to the enterovirus family, which infects the intestinal tract and is spread by the fecal-oral 18 Harvard Public Health INFECTIOUS DISEASES & PANDEMICS Drinker’s contraption aided the young man’s respiration by increasing and decreasing the pressure inside its sealed compartment (the first polio victim to use the respirator, an 8-year-old girl, was revived but soon succumbed). Officially called the Drinker Respirator, it came to be known by a more descriptive name: the iron lung. In 1964, Drinker recalled this early clinical success with the Harvard senior: “After a long siege in the machine, he recovered quite well and is today after almost thirty years very much alive.” The iron lung pulled back thousands of victims from the brink of death, and Drinker became an international celebrity. Scientists were soon to make an even more profound breakthrough. In the 1930s and ’40s, researchers were frantically working on a polio vaccine—but the science was stalled, because no one could grow the virus in a form that would permit mass production of vaccine. As a wave of polio swept the country in 1948, 32-yearold Thomas Weller was logging long hours in a lab at Harvard-affiliated Children’s Hospital, trying to develop a new way to culture viruses in test tubes. One day at the bench, when he was done injecting varicella, the chickenpox virus, into test tubes, he noticed four leftover flasks with human embryonic tissue suspended in a nutrient broth. He walked to the laboratory freezer and took out samples of poliovirus obtained from the brain of an infected mouse. Weller inoculated the extra flasks with the poliovirus. Then he added an innovative twist to the experiment: Instead of discarding the tissue every one or two days and keeping the fluids—the usual protocol—he kept the tissues in the flasks and frequently replenished the nutrient fluids. That way, slow-growing viruses were not inadvertently thrown out. The chickenpox cultures never took—but the polio cultures did, on Weller’s first try. The virus grew not only in brain tissue but also in cells derived from skin, muscle, and intestines. By finding a way to grow the virus in nonnervous tissue, Weller and his colleagues, John Enders and Frederick Robbins, paved the way for safe polio vaccines in the 1950s and ’60s. In 1949, Weller joined the HSPH Department of Comparative Pathology and Tropical Medicine, rising through the ranks as instructor, assistant professor, and associate professor. In 1954, the three scientists shared a Nobel Prize in Physiology or Medicine. The prize came just months after Weller had been named the Richard Pearson Strong Professor of Tropical Public Health at Harvard, as well as chair of the department. “These discoveries incited a restless activity in the virus laboratories the world over,” noted the award committee. “The tissue culture technique was rapidly made one of the standard methods of medical virus research.” The discovery made possible the creation of a polio vaccine. Today—like smallpox 50 years ago—polio is the bull’seye of a global eradication campaign that rests on vaccination. Since the launch of the campaign in 1988, new cases have dropped more than 99 percent. In 2012, a total of 223 polio cases worldwide were reported, with most from countries where the infection remains endemic: Afghanistan, Nigeria, and Pakistan. (In 2013, in something of a setback, Pakistan and several African nations saw outbreaks.) This past April, the Global Polio Eradication Initiative presented a plan to eradicate the disease by 2018—a fitting epilogue to the School’s storied achievements. continued HSPH’s Thomas Weller, left, with Frederick Robbins, center, and John Enders received the 1954 Nobel Prize in Physiology or Medicine for discovering new methods to cultivate the poliovirus. 19 Fall 2013 A World AIDS Day rally in Calcutta in November 2011. First held in 1988, when the United Nations General Assembly declared AIDS to be a global pandemic, World AIDS Day is now an annual event in most countries. HIV/AIDS In June 1981, the CDC issued a report with a deceptively bland title: “Pneumocystis Pneumonia—Los Angeles.” It summarized the first five reported cases of the horrifying pandemic later named acquired immune deficiency syndrome: AIDS. Around the globe, millions were already silently infected. AIDS has been public health’s perfect storm. The human immunodeficiency virus (HIV) that triggers AIDS devastates the body’s protective systems, ushering in not only systemic symptoms such as fevers and weight loss but also opportunistic infections and cancers that would normally be kept at bay. In the U.S., where the infection is most common among gay men, homophobic backlash initially slowed the political commitment to tackling the disease. And HIV/AIDS has disproportionately struck the poorest nations in the world, with 69 percent of infections in sub-Saharan Africa. From the start, as the immense proportions of the AIDS epidemic became apparent, HSPH helped lead a counterassault. The School’s laboratory discoveries have pointed the way for ongoing research into vaccines and treatments. Its epidemiologic modeling and data analysis helped describe the contours of the epidemic and the best interventions. And its public policy and human rights commitments have set standards worldwide. When the epidemic first surfaced, Max Essex, now the Mary Woodard Lasker Professor of Health Sciences at HSPH, had been toiling away in relative obscurity on a virus known as FeLV (feline leukemia virus), which causes AIDS-like immunosuppression in cats. A veterinarian and virologist by training, Essex was one of the first to suggest that the mysterious agent causing AIDS was a retrovirus. His work sped the discovery of the AIDS virus by the National Cancer Institute’s Robert Gallo and the Pasteur Institute’s Luc Montagnier. In 1986, for his role in identifying the cause of AIDS, Essex shared, with Gallo and Montagnier, the prestigious Albert Lasker Medical Research Award. Other crucial discoveries quickly followed. Collaborating with HSPH colleagues, Essex confirmed that the AIDS virus could be transmitted through continued on page 24 W 20 Harvard Public Health W INFECTIOUS DISEASES & PANDEMICS cured,” said Siane. ONE MAN’S STAND AGAINST HIV/AIDS When the Botswana–Harvard AIDS Institute Partnership (BHP) was launched in 1996, the official goal was collaborative research and training between the Republic of Botswana and the Harvard School of Public Health AIDS Initiative. But for Dichaba Siane—a 40-year-old hospital worker in the capital, Gaborone, who chairs the local Community Advisory Board (CAB)—the scientific teamwork has transformed not only his community and country, but also himself. According to Siane, the BHP has dramatically improved health and health care management in Botswana. Clinical trials using antiretrovirals to prevent mother-to-child transmission, for example, have shown that the rate of children born HIV-positive can be cut from 40 percent to less than 1 percent. “The research was done mainly in Gaborone,” he said, “but the benefits have cascaded through the entire country.” Treatment for tuberculosis—a ubiquitous and deadly opportunistic infection that Dichaba Siane has shadowed the AIDS epidemic—has also advanced. “The care has improved so much that if you are on treatment, you will complete your treatment and you will be And randomized trials using antiretrovirals to prevent viral transmission when one person in a couple is infected and the other is not have also altered the social and emotional landscape. “The study proved without any doubt that it is possible to protect oneself and one’s partner,” Siane added. But the most impressive development may be that thousands of Siane’s countrymen have volunteered for studies. Batswana, as people from Botswana are called, were reluctant to participate in early clinical trials because they feared having blood drawn. “Blood plays a very important role in the culture. It’s sacred. My blood should be with me—it should not be taken and kept somewhere else,” Siane explained. “However, we’re working through that. Now there are quite a number of people who are comfortable with blood draws, because they realize the importance of blood in terms of research and possible help for the future generation.” For Siane—who as CAB chairperson has informally served as educator, translator, diplomat, organizer, and advocate—the rewards have also been personal. “Working with the CAB has changed me. I’ve learned a lot about science. And I’ve learned that I have a responsibility to be in constant communication with my community. ” 21 Fall 2013 INFECTIOUS DISEASES & PANDEMICS HIV/AIDS Studies in Africa The School’s fieldwork in HIV/AIDS, which has received support from the President’s Emergency Plan for AIDS Relief (PEPFAR), the National Institutes of Health, the Bill & Melinda Gates Foundation, NIH, and other private philanthropists, is concentrated in three African countries: Nigeria, Botswana, and Tanzania. Initiatives in each country have transitioned their HIV care and treatment programs to local management, with HSPH researchers continuing to offer technical assistance. • In Nigeria, HSPH founded and led the AIDS Prevention Initiative in Nigeria (APIN) with local partners, and later expanded this partnership to create the Harvard/APIN PEPFAR program. This program established 32 AIDS treatment and care facilities around the country and played a significant role in the AIDS treatment program in Nigeria, a nation where the HIV infection rate dropped from 5 percent in 2000 to 4.1 percent in 2010. The program trained clinicians and developed systems of care that supported: o Lifesaving medicines to 100,000+ people o HIV care and services to 160,000 people o Counseling, testing, and diagnosis to o Treatment to prevent mother-to-child transmission for 20,600 pregnant women • In Botswana, HSPH formed a partnership with the government that has trained more than 1,450 nurses and health care professionals at rural antiretroviral therapy (ART) sites, scaled up testing capacity at 24 remote facilities, and provided extensive monitoring and evaluation by tracking data for more than 150,000 patients. • In Tanzania, HSPH worked with government and university partners to enroll 80,000 patients on ART, provide services at 185 facilities for preventing mother-to-child transmission, and establish 49 HIV care and treatment centers, all in the capitol city, Dar es Salaam. 1,005,600 people, including 390,000 pregnant women FROM INDIVIDUALS TO COMMUNITIES “Within an individual, we know the processes by which cells get infected with HIV, the virus replicates, and antiretrovirals (ARVs) interfere with that process. We need similar kinds of models at the community level that describe transmission across individuals. The goal is to learn at the community level what we’ve learned over the decades about individual therapy: how to optimize treatments and tailor them to individual characteristics.” — Victor De Gruttola Chair, Department of Biostatistics 22 Harvard Public Health A technician processes blood samples in the lab of the Princess Marina Hospital in Gaborone, Botswana, site of HSPH research on HIV/AIDS. 23 Fall 2013 INFECTIOUS DISEASES & PANDEMICS blood transfusions. In 1985, he co-discovered, with Tun-Hou Lee, now professor of virology, the gp-120 surface protein, which is now used worldwide for blood screening. In 1986, Essex, Phyllis Kanki, now professor of immunology and infectious diseases, and Richard Marlink, now executive director of the Harvard School of Public Health AIDS Initiative, discovered a second AIDS virus, HIV-2, which causes a million infections annually in West Africa. HIV-2 is less transmissible and less deadly than HIV-1. HSPH researchers have also identified a treatment program that prevents 99 percent of mother-tochild HIV transmission via breastfeeding. scheduled to take place in Boston. To protest the discriminatory policy, Essex canceled the meeting, which was later moved to Amsterdam. International collaborations have been the bedrock of the School’s basic research. In the early 1980s, HSPH established a presence in Africa to meet the challenges posed by the pandemic. The School established a model study in Senegal in the mid-1980s that is now one of the longest-running AIDS studies in Africa. HSPH also conducted the first HIV vaccine trial in southern Africa. In 1995, HSPH biostatistician Stephen Lagakos founded the Center for Biostatistics in AIDS Research to bring innovative statistical techniques to clinical trials in HIV/AIDS, while at the same time honoring the needs and welfare of patients enrolled in these studies. In 1996, the School launched the Botswana–Harvard AIDS Institute Partnership, a research and training program that was the largest of its kind in Africa at the time, as well as the first dedicated HIV research lab in southern Africa. The President’s Emergency Plan for AIDS Relief (PEPFAR) dramatically scaled up the School’s work in African countries hit hard by the disease. Beginning in 2004, HSPH received a total of $362 million from PEPFAR for work in Nigeria, Botswana, and Tanzania, led by Kanki. The School trained thousands of health care workers, developed monitoring and evaluation systems, refurbished and equipped clinics and labs, and collaborated with local hospitals and clinics. (See page 22.) Such progress gives scientists hope that the tide may be turning. “On the cusp of the fourth decade of the AIDS epidemic, the world has turned the corner—it has halted and begun to reverse the spread of HIV,” said a 2011 summary from UNAIDS. Still, in 2013, the toll remains incalculable. The majority of HIV-positive individuals are unaware that they are infected. The virus is the leading cause of death globally among women of reproductive age. Most people living with HIV, or at risk for infection, do not have access to prevention, care, and treatment. And more than three decades into this shattering pandemic, there is no cure. As HSPH enters its second century, it will continue to focus its research and education on stemming this relentless pandemic. v Max Essex, the Mary Woodard Lasker Professor of Health Sciences Though U.S. President Ronald Reagan didn’t deliver a major address on AIDS until 1987, it was painfully clear to scientists that the infection was fast becoming the leading public health crisis of the century. In 1988, to promote an interdisciplinary approach to a battle that had to be waged on several fronts, Harvard President Derek Bok announced the creation of the University-wide Harvard AIDS Institute (HAI), with Essex as chair. In 1992—a time when the U.S. banned visas for people infected with HIV/AIDS—the HAI-organized eighth International AIDS Conference was 24 Harvard Public Health A SIMPLE SOLUTION THAT HAS SAVED MILLIONS A A solution of table salt, sodium bicarbonate, glucose, and water. This simple elixir, known as oral rehydration solution (ORS), has saved tens of millions of people since the 1970s from death by cholera and other diarrheal diseases—now the second leading cause of infant and child death in the developing world. In a landmark paper published in The Lancet in 1968, Richard Cash (pictured at right), HSPH senior lecturer on global health, and colleagues reported for the first time the results of clinical trials in Bangladesh (then known as East Pakistan). They showed that this cheap and readily available solution saved up to 80 percent of intravenous fluid—a scarce and costly commodity—and if begun early in the illness, could eliminate the need for the fluid altogether. A simplified form of ORS—made up of a pinch of salt, a fistful of sugar, and half a liter of clean water—has been taught to millions of mothers to treat children at home. For his elegant research and subsequent work developing programs to teach people how to use ORS, Cash has received numerous awards, including Thailand’s 2006 Prince Mahidol Award and the 2011 James F. and Sarah T. Fries Foundation Prize for Improving Health. Richard Cash, senior lecturer on global health 25 Fall 2013 INFECTIOUS DISEASES & PANDEMICS The Disease Hunters A LIFE OF EXPLORATION “The sun came out early and fiercely . . . As the hours wore on and noon was reached at times one felt the desire to become a little hysterical and to repress a scream and throw oneself into the forest at the side of the trail.” So wrote Richard Pearson Strong in the 320-page diary he kept while leading the 1926–1927 Harvard African Expedition, which crisscrossed the remote interior of Liberia and then cut 3,500 miles across central Africa to end at Mombasa, Kenya. A pioneer in researching tropical diseases, Strong arrived at Harvard in 1913, becoming the University’s first-ever professor of tropical medicine. Traveling, researching, and publishing at a preter- A page from Richard Pearson Strong’s diary written during the 1926–1927 worth of achievements into a single career, Harvard African Expedition natural pace, he packed several lifetimes’ accumulating an encyclopedic knowledge of diseases that few Westerners would recognize: dengue and yellow fevers, leprosy, cholera, plague, Oroya fever, kala-azar, and various forms of dysentery. His specialty was onchocerciasis, or river blindness, about which he published dozens of papers clarifying the infection’s natural history and transmission patterns, and described in detail black fly habitats and breeding cycles. Between 1913 and 1938, Strong led five overseas expeditions to Africa and Central and South America. During World War I, he led a stunningly successful effort to control a typhus outbreak in Serbia. Today, much of Strong’s legacy appears tinged by the endemic racism of his era. Announcing Strong’s appointment, for example, a University alumni bulletin article stated that one of science’s greatest services to mankind was “overcoming conditions which made life in the tropics almost impossible for white men and dangerous and enervating even to natives.” Tropical disease researcher Richard Pearson Strong led overseas expeditions to Africa and Central and South America. 26 Harvard Public Health SWEEPING THE FIELD In fall of 1973, residents on the island of Nantucket were treated to a curious sight: a lone scientist traipsing through underbrush, waving a giant white flag. Its bearer, Andrew Spielman, wasn’t surrendering. Spielman, a vector-bornedisease expert at Harvard School of Public Health, was using the cloth to capture deer ticks—tiny arachnids he suspected of causing a human outbreak of babesiosis, a rare blood-borne disease that infected two Nantucket residents. After weeks in the field, Spielman discovered that white-footed mice, a common species on the island, were often covered with larval ticks that carried the disease. Through careful analysis, Spielman showed that ticks like these were responsible for cases of human babesiosis, a malaria-like parasitic infection. Later research at Yale University revealed that the same ticks were spreading the newly identified Lyme disease, which had just begun to emerge in southern New England. In response, Spielman began developing strategies to control the tick population, and by the late 1980s, stumbled on an ingenious solution with colleagues. They soaked cotton balls in pesticide, stuffed them into empty toilet paper rolls, and left them in the brush. Mice, which found the cotton irresistible for building nests, carried the pesticide back to their dens, where it killed off the ticks nestled in their skin. Within a single season, the researchers found, the number of deer ticks found on trapped mice had dropped by more than 90 percent. Spielman’s groundbreaking work didn’t stop at ticks, however. His later research also helped identify mosquitoes as vectors for both the Eastern equine encephalitis virus and, later, for West Nile virus—a disease he suspected was carried in the blood of roosting birds. Although Spielman personally tracked down the vector for a number of dangerous diseases before his death in 2006, he was always careful to frame his work within the larger context of public health. “I am not a mosquito specialist. I am not a tick specialist. I am a transmission specialist,” he mused in 1997. “That is what public health entomology is all about.” The deer tick, Ixodes scapularis Andrew Spielman sweeps the field for deer ticks on Nantucket. 27 Fall 2013 U INFECTIOUS DISEASES & PANDEMICS prevails.” difficult and costly to treat. descendants of their precursors.” THE HARD SCIENCE OF SAVING LIVES Understanding the basic biology of infectious disease has been a constant at HSPH since its inception. “We’re one of the few schools of public health that has integrated laboratory science and more classical public health disciplines, such as epidemiology and biostatistics. A lot of our work focuses on the interaction of the infectious agent with its host, and how that interaction leads to disease transmission and progression,” said Dyann Wirth, chair of the Department of Immunology and Infectious Diseases. Wirth is also the Richard Pearson Strong Professor of Infectious Diseases—an endowed position named in honor of the School’s legendary explorer/biologist (see page 26). The department’s most acclaimed faculty achievement—Thomas Weller’s discovery of how to grow the poliovirus in a cell culture system—was the breakthrough that led to the development of a polio vaccine. As Wirth explained, “The iron lung treated symptoms. But by discovering the biology, we prevented the infection. In the end, prevention always Yet a century after the School’s founding, prevention has continued to be a hurdle for malaria and tuberculosis (TB), two of the top three infectious-disease killers worldwide (rounding out the deadly trio is AIDS). In 2010, the malaria parasite killed an estimated 660,000 people—mostly children—and infected 219 million. In the same year, nearly 9 million people around the globe became sick with TB and some 1.4 million died. Meanwhile, a rising tide of multidrug-resistant tuberculosis—the primary cause of which is the inappropriate or incorrect use of anti-TB drugs—has made the infection The causative organisms of malaria and TB have evolved for thousands of years with their human host, perfecting ways to evade our immune system. HSPH has made groundbreaking discoveries on these evasive tactics. “In malaria, we’ve made two major contributions. One is a fundamental understanding of how drug resistance occurs and how it spreads. The other is the application of genomics to understanding natural infection in Plasmodium falciparum, the main malaria parasite, and the implications of that for vaccine development and for elimination and eradication,” said Wirth. “With TB, we have identified in the tuberculosis bacterium every single gene important for the organism’s survival. That discovery has created a tool that opens doors for new drugs and vaccines.” Another strength of the School is its interdisciplinary approach to infectious disease. In malaria, for example, a “genes to the globe” framework guides work across the University. “At Harvard, there are economists and Dyann Wirth, chair of the Department of Immunology and Infectious Diseases businesspeople and ethicists and social and behavioral scientists and people in government—all engaged in trying to solve malaria,” Wirth explained. “People in basic science are trying to understand how the parasite converts from replicating in the red cell to being available for transmission by the mosquito vector. At the same time, in business, a fundamental question is how to handle the supply chain. We have insecticide-treated nets and effective diagnostics and medicines: How do we deliver those in the right amount at the right time to the people who need them?” Infectious diseases, both deadly and chronic, have challenged humanity since our beginnings. As Wirth sees it, that threat is inherent in our coevolution with microorganisms. “For the most part, these infections have been with us long before there was any kind of intervention. The DNA of organisms represents a footprint of history, the cumulative selective forces. The genomes that exist today—be they humans or infectious organisms—are the survivors, the successful 28 Harvard Public Health CHASING EPIDEMICS IN REAL TIME As the AIDS epidemic tragically demonstrated, public health has usually been a step behind infections on the run. But today, with sophisticated molecular and communications tools, practitioners can virtually keep up stride for stride with emerging epidemics. In the spring of 2003, a deadly viral illness—severe acute respiratory syndrome, or SARS—swept out of China’s Guangdong Province and spread rapidly around the world. HSPH professors of epidemiology Marc Lipsitch and Megan Murray, using a sophisticated mathematical model to estimate the virus’s potential to spread, showed that the most effective means of blocking SARS transmission would be to isolate infected individuals and quarantine people likely to be exposed—strategies that, along with preventing transmission in hospital facilities, successfully contained the startling new epidemic. In the early spring of 2009, H1N1 influenza—the same subtype, though milder, that killed an estimated 50–100 million people worldwide in 1918—emerged in Mexico and swiftly spread around the globe. Lipsitch statistically modeled the severity and transmission of the virus, while Atul Gawande, professor in the Department of Health Policy and Management, led a World Health Organization team to quickly draft a patient care checklist for hospitals managing suspected or confirmed cases. In May and June of 2011, a novel strain of E. coli, dubbed O104:H4, triggered a brief but deadly outbreak of foodborne illness centered in Germany and France. In one of the first uses of whole-genome sequencing to study the dynamics of a foodborne outbreak, a team led by HSPH researchers and the Broad Institute traced the deadly path of the outbreak, which killed more than 50 and sickened thousands. And in the past few years, Caroline Buckee, assistant professor of epidemiology, has developed predictive models for the spread of malaria, using anonymous cell-phone data to track the movement of people in malaria-endemic regions. “Cell phones are ubiquitous,” she said. “Using them to monitor people’s mobility during an outbreak could transform infectious disease epidemiology.” Fenugreek sprouts were implicated in a 2011 foodborne outbreak of E. coli. THE HUMAN MICROBIOME MAPPING THE FUTURE Helping to write the next chapter of infectious disease research, Curtis Huttenhower, associate professor of computational biology and bioinformatics, is exploring the human microbiome—the 100 trillion microbial cells in and on our bodies. Research on the microbiome may transform our understanding of why we become sick and how doctors may someday tinker with our internal ecosystems to prevent or treat a vast range of conditions, from diabetes to asthma to obesity. “Our relationship with our microbes is not a war,” said Huttenhower. “It’s a well-defined truce.” 29 Fall 2013 I HEALTH & HOW WE LIVE In the last 100 years, we have changed the way we live—what we eat and drink, whether and how much we exercise, how we drive, what we inhale. Our shifting lifestyles contribute not only to heart disease but also to cancer, obesity, diabetes, and other conditions that collectively explain about half of all premature deaths in America. Worldwide, noncommunicable diseases are the top killer and on the rise. HSPH researchers have worked to understand the complex factors that steer behavior in unhealthy directions, and what can be done—educationally, medically, even politically—to shift course. 30 Harvard Public Health 31 Fall 2013 HEALTH & HOW WE LIVE D ASK A NURSE TAKING THE LONG VIEW Don’t smoke. Drink only in moderation. Maintain a healthy weight. Exercise regularly. Eat a diet rich in fruits and vegetables. Don’t overindulge in red meat or butter. We take most of these prescriptions for a “healthy lifestyle” for granted today. But they were not always so obvious. Much of what we now know about healthy living is owed to work begun in the first half of the 20th century by HSPH faculty and others using a method known as the longitudinal cohort study. This study teases apart both obvious and hidden risk factors for disease by following a specific group of people over an extended period of time. The concept of disease “risk factors” itself had its genesis in a famous cohort study called the Framingham Heart Study, which began in 1948 under the auspices of the National Heart Institute (now the National Heart, Lung and Blood Institute) and is currently in its third generation. An earlier example is the 1922–1935 Harvard Growth Study, which yielded some of the first benchmarks for growth and development in healthy children. how many friends they had. In 1989, Walter Willett, now chair of the HSPH Department of Nutrition, launched a companion study known as Nurses’ Health Study II, which enlisted another 116,000 participants to delve even more deeply into questions of diet and nutrition. The Nurses’ Health Studies and the follow-up Physicians’ Health Study, which recruited 22,000 men, have provided a treasure trove of epidemiological information, much of it running counter to conventional medical wisdom. (See sidebar, right.) What would become one of the largest and most important cohort studies examining the role of environment and behavior on disease began modestly in 1976, when a small group of researchers from HSPH, Harvard Medical School, and Brigham and Women’s Hospital, led by HSPH’s Frank Speizer, designed and launched a questionnaire for a small group of female nurses ages 30 to 55. The Nurses’ Health Study’s goal was to clarify the connection between smoking history, use of oral contraceptives, and subsequent disease. The study soon expanded to include 120,000 female nurses. The questions broadened to include participants’ medical history, health status, and individual habits such as whether they took vitamins or replacement hormones, whether they attended religious services, and BOSTON BROTHERS STUDY Immigration made possible one of the early studies in the 1960s analyzing the role of genes versus environment on chronic disease. The Boston Brothers Study—co-led by HSPH and Trinity College in Ireland—compared the health of 500 brothers who lived on either side of the Atlantic Ocean. With genetics relatively constant, researchers discovered that the U.S.-based brothers suffered higher rates of atherosclerosis, higher proportions of body fat, and higher numbers of abnormal electrocardiograms. While their diets were similar to those of their Irish kin, the U.S. brothers led much more sedentary lifestyles. This evidence helped establish the protective effect of exercise on heart disease. 32 Harvard Public Health E than with her own husband. TALES FROM A LONG RELATIONSHIP Emily O’Connell has had a longer relationship with the Nurses’ Health Study (NHS) The Quincy, Massachusetts–based school nurse has been married for 23 years. She’s been filling out the NHS questionnaire for more than 30, though she doesn’t remember exactly when she started. All she remembers is getting an invitation in the mail while she was a nursing student and figuring it would fulfill a degree requirement to take part in scientific research. “I had just completed my master’s degree and had suffered the experience of having to recruit participants for studies,” she recalled. “So I joined just to help out the researchers. I had no idea how influential it would be in the future. My close friends, who understand the importance of what I’m doing, really ooh and goo and are proud of me. They’re a little jealous that I’m part of this famous study.” For the last three decades, filling out that annual form on women’s health— first with paper and pencil, then on computer, while also offering up the occasional blood sample and saliva cheek swab—has become one of her proudest achievements. O’Connell, 62, displays an NHS plaque on the wall of her den, and every year when the questionnaire arrives, she finds herself nattering away about it to her friends, family, and anyone who will listen. “It probably takes me a week before and a week after to stop talking about it,” she said. O’Connell’s own health has remained stable; she doesn’t smoke, she doesn’t drink heavily, and she never eats junk food. Still, answering the survey questions has made her more aware of her personal choices. “I didn’t think about whether or not I ate a green vegetable every day or whether I ate an orange vegetable five times a week,” she said. “I just do.” But logging in her daily activity diary made her realize how little she exercised. “I was learning that I was a pretty sedentary person to start with,” she said. So for years, she’s been taking long daily walks along a beach near her house. O’Connell also decided against taking estrogen after menopause (as her mother had), after the NHS data suggested it may increase the risk of breast cancer. In fact, O’Connell’s doctor “was opposed to using hormone replacement therapy without extreme reason—because of the Nurses’ Health Study.” O’Connell plans to stay in the NHS for the rest of her life. She’s even told her husband to notify the investigators when she dies. That way, researchers can add the circumstances of her death to their data. Granted, it’s possible her husband will forget, she said, but enough people know how much she’s valued her role in women’s health research that “they will harass him if he doesn’t do it.” Emily O’Connell on the beach NURSES’ HEALTH STUDY AND PHYSICIANS’ HEALTH STUDY KEY FINDINGS NURSES’ HEALTH STUDY: • Smoking dramatically raises the risk of coronary artery disease and stroke—but the risk is reduced within a few years after quitting smoking. • Current use of oral contraceptives raises the risk of breast cancer and coronary heart disease, and current use of postmenopausal hormones increases the risk of stroke. • Obesity strongly increases the risk of coronary heart disease, but protects against hip fractures. • One or two alcoholic drinks per day reduce the risk of coronary heart disease, but raise the risk of breast cancer. • A Mediterranean-type diet reduces the risk of coronary heart disease and stroke, while refined carbohydrates and trans fats increase the risk of heart disease. PHYSICIANS’ HEALTH STUDY: • Daily low-dose aspirin decreases the risk of heart attack. • Vitamin C and E supplements do not prevent major cardiovascular events, cancer, or eye disease. 33 Fall 2013 LIFESTYLE DISEASES W FOOD FOR THOUGHT We owe the distinction between “good” cholesterol and “bad” fats, and the concept of the basic four food groups, to Fredrick Stare, Mark Hegsted, and their colleagues who worked in HSPH’s Department of Nutrition in the mid20th century. Stare, who founded the department in 1942, was an accomplished scientist known for breakthroughs uncovering the links between diet and heart disease in lab work with New World monkeys. But he also appreciated the importance of communicating nutrition information to the public in simple, easy-to-understand ways. He summed up his philosophy with the phrase “the simpler you can keep it, the better,” and he famously advocated a “sensible” approach to nutrition that included enjoying food and avoiding fads. He coined the term “Basic Four Food Groups,” compressing the government’s thencurrent “Basic 7” and underscoring the importance of a diet that balances fruits and vegetables, grains and cereals, dairy products, and high-protein foods such as meat, poultry, and eggs. The U.S. Department of Agriculture (USDA) has since updated its nutrition guidelines several times (see chart on page 37), and HSPH, in keeping with Stare’s legacy, has kept pace by offering alternative versions such as the Healthy Eating Pyramid, published in 2005, and the Healthy Eating Plate, released in 2011. Stare’s early work paved the way for hundreds of studies and scholarly reviews on diet and nutrition since, including a seminal report in 1966 by Hegsted and others that described a definitive link between dietary fat and serum cholesterol levels. Hegsted earned high praise for his mathematical equation demonstrating that saturated fats and dietary cholesterol from meats and eggs raised the levels of harmful cholesterol, while polyunsaturated fats in foods like fish lowered the total cholesterol level. He found that monounsaturated fats, such as in nuts and certain plant oils, likely did neither. YES TO MEDITERRANEAN DIET Our knowledge of diet’s role in health has expanded even further in the past 20 years. The virtues of meals rich in olive oil, legumes, whole grains, fruits, and vegetables— collectively known as the Mediterranean diet—have inspired healthier eating far beyond the borders of countries such as Greece, Italy, and Spain where such menus have long been popular. Walter Willett, chair, Department of Nutrition 34 Harvard Public Health HEALTH & HOW WE LIVE “Even the best available drugs, like statins, reduce heart disease by about 25 percent. This is in the same ballpark as the Mediterranean diet,” said HSPH Department of Nutrition Chair Walter Willett. “But the statins increase the risk of diabetes, whereas this diet can help reduce the risk.” Willett has taken over Stare’s role (and appropriately holds the Fredrick John Stare Professorship of Epidemiology and Nutrition) as one of the country’s leaders in nutrition research. He has long touted the benefits of a Mediterranean diet. BERTHA BURKE’S DIET FOR A HEALTHY BABY In the 1940s, HSPH’s Bertha Burke published a series of influential papers linking the quality of a mother’s diet to the health of her baby. She drew from the landmark Longitudinal Studies of Child Health and Development at the School that tracked 300 individuals from prenatal stages into adulthood—the first comprehensive study of normal childhood growth and development. Burke’s Daily Diet During Pregnancy pamphlet, first published in 1941, contains advice that largely holds up today, such as sticking to lean meats and limiting salt. But it also recommends a daily egg, potato, and three teaspoons of butter. Burke translated her findings for popular audiences, writing articles in women’s magazines and widely distributed pamphlets. She retired as professor emerita of maternal and child nutrition in 1961. Bertha Burke NO TO TRANS FATS AND SUGARY BEVERAGES As a nutrition activist, Willett also has focused on changing the food environment to make healthy fare more accessible, and unhealthy options less so. One of his major achievements has been to reduce the use of trans fats— produced by the partial hydrogenation of unsaturated fatty acid vegetable oils—which are in hardened vegetable oils, most margarines, commercial baked foods, and many fried foods. Willett helped show that an excess of trans fats raises the risk of high blood lipid levels, type 2 diabetes, and other illnesses. Policymakers have listened. In 2006, the U.S. Food and Drug Administration began to require nutrition labels to list all harmful trans fatty acids. Over the last 15 years, largely in response to Willett’s alarms, trans fats levels in the American diet have plummeted by 80 percent. Willett and colleagues at HSPH and nationally have also called on beverage makers to reduce the sugar and salt content of their drinks. “There is abundant evidence,” he said, “that the huge increase in soda consumption in the past 40 years is the most important single factor behind America’s obesity epidemic.” Still, more battles lie ahead. “The major players in the food system do not want any change, because soda, refined starches, and sugar provide huge profit margins. There are big economic and political obstacles in making change,” said Willett. But the public health stakes are high. “Heart disease, various cancers, eye diseases, birth defects—the list expands,” he said. “There’s almost nothing on which diet does not have an effect.” 35 Fall 2013 HEALTH & HOW WE LIVE GLOBESITY Despite the robust research on diet and health, the waistlines of Americans and people around the world continue While Hu and colleagues are trying to curb the rates of to grow at alarming rates—exacting a high price on obesity, others are studying how to treat obesity-related individuals and on health care systems. The Centers for diseases. One of the stars of this field is HSPH Professor Disease Control and Prevention reports that more than Gökhan Hotamisligil, who chairs the Department of one in three American adults are obese—a dramatic Genetics and Complex Diseases. about-face from a century ago, when malnourishment “The big question for me,” Hotamisligil said, “was was common. why, in the presence of even a few extra Worldwide, obesity has nearly pounds of accumulated fat, do you doubled globally since 1980, become prone to so many different according to the World Health diseases, including insulin resistance, Organization, with two-thirds of the diabetes, hypertension, asthma, neuroworld’s population living in coundegenerative diseases, and cancer?” tries where overweight and obesity Since arriving at the school in 1995, kill more people than underweight. Hotamisligil has hunted the complex Obesity-related conditions range from and elusive biological links between stroke and type 2 diabetes to heart obesity and insulin resistance—the A PINCH OF SALT disease and some cancers. first stage in developing metabolic HSPH Professor of CardiovasTo thwart the trend, HSPH has illness. He has bred special genetically cular Disease Prevention Frank developed an interdisciplinary altered mice that can gain weight and Sacks has demonstrated the links between diet and blood approach to researching the causes become obese and yet never develop pressure. He played a key role in and consequences of obesity, and or suffer the ill effects of obesitytwo studies begun in 1994 called to developing strategies for prevenrelated disease. He has uncovered DASH—Dietary Approaches to tion. HSPH Professor Frank Hu is new molecular pathways and Stop Hypertension. In the first study, among those leading the effort, identified control points that may the 459 participants were randomly and his work on the topic takes prove to be valuable targets for assigned to either a standard Amerian in-depth look at obesity’s risk can diet high in red meat and sugars, short-circuiting the connection and low in fiber; a similar diet but richer factors, including diet, physical between obesity and poor health. in fruits and vegetables; or the “DASH activity, sedentary behavior, He also studies the mechanisms diet,” which emphasized fruits, vegeand genes, as well as the newly behind inflammation—the body’s tables, and low-fat dairy foods, and limemerging risk factors of sleep complex biological response to ited red meat, saturated fats, and sweets. deprivation and the in utero the cellular stress and injury After eight weeks, both of the healthier environment. Hu has also caused by obesity, which is nonstandard diets reduced systolic and diastolic blood pressure, with the DASH diet collaborated with researchers different from the classic producing a more pronounced effect. The from China to study the inflammation caused by infecsecond study found that lowering sodium in particular threat that obesity, tion. Hotamisligil’s work could either the DASH or standard American diet metabolic syndrome, and lead to novel treatments for had an even stronger effect on reducing blood cardiovascular disease pose metabolic illness. pressure. The DASH study formed much of the to Chinese populations. continued on page 38 scientific basis for the Dietary Guidelines for Americans 2010, which recommends reducing daily sodium to less than a teaspoon. THE SECRETS OF METABOLIC DISEASE 36 Harvard Public Health A Visual History of Food Guides 1943 > The USDA introduces the “Basic 7” food guide, aimed at maintaining nutrition standards during the wartime period of food rationing. < 1955 HSPH researchers condense the Basic 7 food groups into a Basic Four, which the USDA subsequently adopts. 1977 HSPH professor Mark Hegsted helps map out the Dietary Goals for the United States, providing the basis for the 1979 Hassle-Free Daily Food Guide. 1992 > The Food Guide Pyramid is the USDA’s first set of guidelines to include recommended servings for each of the food groups. < 2005 The USDA unveils MyPyramid, with vertical wedges representing the food groups, and a figure scaling a set of stairs along its side to represent the importance of physical activity. 2005 > HSPH responds to the confusing new USDA pyramid with the Healthy Eating Pyramid, grounded in the best available scientific evidence about the links between diet and health. < 2011 The USDA’s MyPlate is released, replacing two decades of pyramids with a simpler approach representing an actual meal. 2011 > HSPH’s Healthy Eating Plate corrects key flaws in MyPlate by focusing on whole grains, healthy proteins and oils, and vegetables other than potatoes. The red running figure is a reminder to stay active. 37 Fall 2013 I DEADLY DRINKING: ALCOHOL AND PUBLIC HEALTH But Winsten’s work isn’t done. The next battleground: a campaign against “distracted driving,” including texting and cell phone use. THE DESIGNATED DRIVER In the mid–1980s, the practice of choosing a “designated driver” to prevent alcohol-related traffic fatalities was not yet part of American culture. By the end of the decade, “designated driver” had become a household expression in the United States, thanks to Jay Winsten, associate dean for health communication and the Frank Stanton Director of the School’s Center for Health Communication. Winsten’s center spearheaded a national campaign that created an enduring social ritual in the public consciousness. As Winsten explained, the slogan “The designated driver is the life of the party” was a “positive message that lent social legitimacy to the option of refraining from alcohol.” The campaign imported its underlying concept from Scandinavia. The designated driver program also demonstrated how a fresh idea could be rapidly disseminated through American society via mass communication. TV writers agreed to insert drunken-driving-prevention messages, including frequent references to designated drivers, into story lines of top-rated television programs, such as Cheers, L.A. Law, and The Cosby Show. A report from the Kaiser Family Foundation stated that Winsten’s campaign “is widely considered to be the first successful effort to partner with the Hollywood community to promote health messages in prime-time programming.” When the campaign launched in 1988, alcohol-related traffic deaths stood at 23,626 annually. By 1994, fatalities had dropped by 30 percent. That change was likely due to raising the legal drinking age, reducing the legal bloodalcohol level, stronger law enforcement, safer vehicles—and the designated driver campaign. BINGE DRINKING Stroll through a college campus on a typical Saturday night, and youthful intoxication seems rampant. About two in five college drinkers say they drink to get drunk. And in this age group, it doesn’t take much to become inebriated. Those who imbibe four or five drinks in a row—a level known as “binge drinking”—suffer clear alcohol-related harm, according to Henry Wechsler, then-lecturer in the Department of Society, Human Development, and Health (now called the Department of Social and Behavioral Sciences), who served as principal investigator in the School’s College Alcohol Study (CAS). Beginning in 1993, Wechsler and collaborators surveyed more than 50,000 college students and found that half of them are binge drinkers. The damaging consequences include reduced academic performance, trouble with police, unplanned sex, and serious injury. In the July 2008 issue of the Journal of Studies on Alcohol and Drugs, Wechsler and then-CAS co-director Toben Nelson wrote that “there is no one size fits all” solution to underage drinking on campus. But they found that schools and communities with the fewest problems often had state minimum-drinking-age laws, stronger enforcement of these laws, fewer alcohol outlets, and limits on irresponsible marketing practices, such as all-you-can-drink specials and “ladies nights,” when women drink for free. continued on page 42 38 Harvard Public Health HEALTH & HOW WE LIVE R Jan Withers LIFESTYLE DISEASES DRIVING HOME THE MESSAGE Retired police officer Carl McDonald stopped many a weaving driver during his years on the force in Texas. He said the argument against drinking and driving was a lot harder to make before Jay Winsten, HSPH’s Frank Stanton Director of the School’s Center for Health Communication, rolled out the designated driver campaign in 1988. “I would arrest people and they would complain, ‘Well, how am I supposed to get home? I live way out here and I went to the bar, blah, blah, blah. There’s no taxicabs, there’s no public transport,’” recalled McDonald, who now runs law enforcement initiatives for Mothers Against Drunk Driving (MADD). “The designated driver was the answer to that.” According to Winsten, MADD had helped prepare the ground for the designated driver campaign with years of highly visible work against drunken driving. But by the mid-to-late 1980s, those gains had begun to slip. The designated driver campaign (see page 38) quickly became a rallying point for communities, said McDonald. Tavern and bar owners would offer free sodas to anyone declaring himself or herself a designated driver. In one creative initiative, the Kansas State Police walked through bars in uniform and personally placed coasters with the “designated driver” message under the glasses of patrons. “MADD adopted the designated driver message back then, and it’s now part of everything we say,” said MADD President Jan Withers, whose 15-year-old daughter died in a drunken-driving accident in 1992. Withers added that the campaign helped the organization move away from a “scolding” tone toward more positive and constructive rhetoric. The designated driver campaign continues, as illustrated in a new partnership between the National Football League, MADD, and several alcoholic beverage companies. MADD representatives walk around football stadiums, engage groups of friends in conversation, and help them designate a nondrinking driver. That person will then get a wristband that not only stops the patron from ordering drinks at the concession stand but also enters him or her into a raffle for prizes. Still, the message is not getting through to everyone. McDonald cited a 2013 Florida study, conducted in a college town the night before a big football game, which found that although 65 percent of designated drivers had no alcohol in their systems, 35 percent had something to drink. “We say, ‘Take that extra step and make sure you have a designated nondrinking driver,’ ” said Withers. “We haven’t totally won the cultural war yet on drunken driving, but I think the evidence lies in the numbers,” McDonald said. Drunken driving deaths hover around 10,000 today, down from 26,000 in the early 1980s. Carl McDonald 39 Fall 2013 HEALTH & HOW WE LIVE I SMOKE SIGNALS It was the 1970s in Greece—a nation which, then and still now, boasts one of the highest smoking rates in the world. Not only was lighting up socially accepted, but tobacco was a major crop in some regions of the country. Dimitrios Trichopoulos, then a young cancer epidemiologist at the University of Athens, was trying to persuade his wife to quit the habit. When he said she was hurting herself—by then, the science was incontrovertible—she didn’t care. When he said she was hurting him, she didn’t believe him. So he set out to prove her wrong. In 1981, Trichopoulos, who is now the Vincent L. Gregory Professor of Cancer Prevention at HSPH, teamed with Brian MacMahon, then-chair of the Department of Epidemiology, to become one of the first scientists to show, through a case-control study, the risks of secondhand smoke. By looking at 51 nonsmoking women hospitalized with lung cancer in Greece, and comparing them with age-matched women hospitalized for other problems, MacMahon and Trichopoulos determined that the cancer-ridden patients were significantly more likely to have been exposed to their husband’s cigarettes. Follow-up studies went on to confirm the risks of smoke inhalation by children in smoking households or in nonsmokers who live nearby. “With these findings, smoking was no longer perceived as merely a bad habit that endangered an individual’s own health status,” wrote Robin Marantz Henig in The People’s Health. “It became instead a public health menace that endangered everyone.” TOBACCO BATTLES Since then, the tobacco industry has encountered other formidable foes inside HSPH—including Greg Connolly, who directs the School’s Center for Global Tobacco Control and has served as director of the Massachusetts Tobacco Control Program (where he was credited for cutting the state’s smoking rates in half). Connolly, once a smoker himself, has worked all over the world advising nations—from Ireland and Israel to El Salvador and the Philippines—on how to curb public smoking, secondhand smoke, and smokeless tobacco. In 2000, he was made a Commander of the Fourth Order by the King of Thailand for his efforts with the U.S. Congress, the World Health Organization (WHO), and the WHO-backed General Agreements on Tariffs and Trade (GATT) to halt U.S. trade sanctions imposed against Thailand for its refusal to import and advertise cigarettes. Connolly once explained the secrets of a successful anti-smoking campaign: “You have to build the capacity to do research locally, then add a heavy dose of aggressive anti-tobacco advertising to foster social change and build enough political will to raise taxes, ban smoking in public places, and offer people treatment for tobacco addiction.” 40 Harvard Public Health FROM TOTS TO TOBACCO Julius B. Richmond (1916–2008) waged a multifront battle for public health. Trained in pediatrics and child development, he was appointed in 1965 as the first director of the national Head Start program, the federally backed comprehensive program for low-income children. From 1977 to 1981, he served as U.S. Surgeon General, reinvigorating tobacco control efforts through the release of the 1979 Surgeon General’s report Smoking and Health, which presented scientific evidence of the many harms of smoking. From 1981 to 1988, Richmond was professor of health policy at HSPH. Today, the School’s highest honor, the Julius B. Richmond Award, recognizes individuals who, like Richmond, have promoted and achieved high standards for public health Julius B. Richmond conditions in vulnerable populations. 41 Fall 2013 HEALTH & HOW WE LIVE P CAN WE CHANGE OUR HABITS? Persuading people to change their daily habits is a daunting challenge, even when they know that short-term gain sometimes leads to long-term pain. “We’re not coldly calculating machines. We are motivated by the part of the human brain that is heavily present-focused,” said Ichiro Kawachi, chair of the Department of Social and Behavioral Sciences. Altering behavior—for example, getting kids to eat fewer sugary calories, increase fruit and vegetable consumption, or watch less TV—requires active learning, social support, and often subtle cues in the environment. As director of the HSPH Prevention Research Center (HPRC), Steven Gortmaker and colleagues have been teaming up with local community partners since 1998 to design and help implement both in-school and afterschool programs that offer strategies to reverse the obesity epidemic in kids. Gortmaker authored HPRC’s Planet Health curriculum, which is designed for middle schools. He and co-Principal Investigator Lilian Cheung, lecturer in the Department of Nutrition, created the Eat Well and Keep Moving curriculum for elementary schools. These plans have helped thousands of students improve their diets and cut TV viewing time. Teachers can easily fit these curricula into existing classroom programs in areas such as math and language arts. The curricula offer simple ways for students to learn about and change their daily routine, alongside their peers. Over a period of years, as an entire schoolful of students hears and incorporates the same ideas into their lives about eating less and exercising more, cultures can gradually change. More than 15,000 copies of the curricula have been purchased across all 50 U.S. states and more than 20 countries. Similarly, HSPH has teamed with YMCAs, which nationally provide more than 10,000 afterschool programs for children in the U.S. In 2005, HSPH joined with the YMCA of the USA to form the YMCA-Harvard Afterschool Food and Fitness Project to help afterschool programs embed more physical activity and wholesome snack and beverage choices in their programs. The project enables leaders, parents, and children at each Y afterschool site to choose strategies that will work best in their own program. Participants at one Y site may decide to offer water instead of juice at snack time to cut 42 Harvard Public Health ADDING YEARS TO LIFE— AND LIFE TO YEARS calorie consumption, while another may find a new way to incorporate 30 additional minutes of physical activity into the day. Education combined with a sense of empowerment results in lasting change. In 2012, more than 300 YMCA afterschool programs across the U.S. were using the Food and Fun curriculum, reaching an estimated 97,000 children. Beyond classroom and afterschool programs, Kawachi noted the kinds of simple changes in the greater world that could make a healthy difference: 1. Make an apple—not french fries—the default option that comes with a fast-food meal. We are more likely to accept the status quo than to go out of our way to change it. 2. Offer food on smaller plates and bowls—both in restaurants and at home. According to one study, container size can increase how much people serve and consume by 15 to 45 percent. 3. Give—and get—feedback. Research has shown a consistent relationship between dietary self-monitoring and weight loss, and between use of pedometers and increased physical activity. “We can be the architects of people’s decisions,” said Kawachi, “so that the natural choice tends to be the healthier one.” v Today, it’s conventional wisdom and a scientific truism that regular exercise is one of the healthiest habits around. But public health researchers weren’t always so certain that physical fitness was essential. One of the first to scientifically document a link between physical activity and a longer, healthier life was Ralph Paffenbarger Jr., a pioneering epidemiologist who taught at HSPH from the 1960s to the 1990s. His attention-getting formula: Every hour of vigorous physical activity earns the exerciser an ex- Ralph Paffenbarger Jr. tra two or three hours of life. When naysayers questioned whether that extra longevity consisted mostly of time spent exercising, the gentle yet tenacious researcher known as “Paff” to his colleagues observed that exercise not only “adds years to your life but life to your years.” In 1960, Paffenbarger launched the College Alumni Health Study, which tracked the health and physical activity habits of 52,000 men who entered Harvard University and the University of Pennsylvania between “One of the most beautiful epidemiological charts I’ve seen has two graphs, each representing a 50-year time span, overlaying each other. One graph shows the declining number of hours that Americans are sleeping at night—its line is going down. The other shows the percentage of Americans who are overweight or obese—its line has the same slope and curvature as the sleep line, but it’s going up. “The beauty of this chart is its simplicity. It encapsulates two important trends that we can’t deny are occurring. We have to be careful that we’re not oversimplifying their connection, but it begins the conversation.” 1916 and 1950. Findings from the ongoing study have conclusively shown that men who exercised strenuously, burning 2,000 calories a week, lived longer than those who didn’t. Similar findings have been documented for women through the School’s long-running Nurses’ Health Study (see page 32). Paffenbarger took his findings to heart. He began running regularly in his 40s and became an avid marathoner. Paffenbarger remained an adjunct professor at the School until shortly before his death in 2007, at age 84. Along with studies by Jeremy Morris of the London School of Hygiene and Tropical Health, Paffenbarger’s research helped prompt changes in federal health recommendations and laid the groundwork for the modern fitness movement. He and Morris were jointly honored in 1996 with the first International Olympic Committee prize — Michelle Williams for sport science. Chair, Department of Epidemiology Stephen B. Kay Family Professor of Public Health 43 Fall 2013 W 44 Harvard Public Health While at first nothing may seem more removed from the broad, humanistic canvas of public health than research on genetics, studies of the molecular mechanisms of disease occupy a central place at Harvard School of Public Health. By revealing the biological underpinnings of disease, genetics research is leading to new and improved methods to diagnosis, treatment, and prevention. Ultimately, this work could help corroborate and refine—or even rewrite—many of today’s standard public health recommendations. THE DNA OF PUBLIC HEALTH 45 Fall 2013 GENETICS I Genes to the Globe If smoking is the most common cause of lung cancer, why do only 10 to 20 percent of heavy smokers develop the disease? Can a genetic map of the malaria parasite lead to treatments that won’t trigger drug resistance? Why are rates of breast cancer higher in the United States than in other parts of the world—though, even in the U.S., most women do not develop the disease? Can genetic studies of obese mice inspire new diabetes drugs? HSPH is well positioned to answer these questions, because of the School’s twin strengths in classic bench science and cutting-edge genetics research. “We’re one of the few schools of public health that has wet labs, which use live biological material—and these labs have enabled us to study everything from poliovirus and environmental toxins to malaria and HIV/AIDS. We were also one of the first schools of public health to establish an independent capacity to genotype and do gene sequencing, in order to tie specific genetic variations to specific diseases,” said David Hunter, Dean of Academic Affairs and the Vincent L. Gregory Professor in Cancer Prevention. “That has given us the capacity to go from the genes to the globe.” A CENTURY-LONG HISTORY At HSPH, genetics research is as old as the School— though the title of the first such course in the 1913 catalog— Genetics and Eugenics—is a disturbing reminder of then-prevailing attitudes. Forty years later, a technological revolution catalyzed the field of public health genetics. It began in 1953, with the discovery of the helical structure of DNA, which led to recombinant methods that are now the backbone of basic research. Spurred by this breakthrough, HSPH has nurtured two vital strands of genetics research. During the 1960s through the 1990s, School faculty applied molecular techniques to a wide range of nonhuman organisms, from bacteria and viruses to yeasts and mice, to understand the biological machinery in human cancer, heart disease, diabetes, and other afflictions. This work is currently centered in the School’s Department of Genetics and Complex Diseases, established in 2004 and chaired by Gökhan Hotamisligil, 46 Harvard Public Health the James Stevens Simmons Professor of Genetics and Metabolism. “When we understand, at a mechanistic level, the basic biology of disease—how things work, how things are integrated—it will absolutely, positively transform what we know as public health,” he said. DECIPHERING THE HUMAN GENOME In the realm of human genetics, the key scientific breakthrough was the Human Genome Project—the 13-year effort completed in 2003 to identify all of the approximately 20,000–25,000 genes in human DNA. Mapping the first genome took billions of dollars and thousands of scientists. Today, sequencing a genome takes half a day and thousands of dollars—a price that is sure to plummet. “If we look back in another 20 or 30 years, we’ll divide time into before and after whole-genome sequencing became routine,” said Hunter. “After it becomes routine and costs just a couple hundred dollars for each person, there will be information that we would all be well advised to know.” Initially, that individual and actionable genetic data will likely relate to potential adverse reactions to drugs. But whole-genome sequencing may also open the door to sharper disease prediction. According to Hunter, “People and their health professional advisers will want to know about an individual’s profile of common gene variants. Each of these variants may confer only slightly higher risk of disease—but they add up in people who drew a bad hand and have many of these genes, or who have high-risk variants.” The dance between genes and environment is also a burgeoning field of research at the School. Scientists are interested not just in inherited genetic mutations, but also in what turns genes on and off. And they are expanding continued on page 49 “When we understand, at a mechanistic level, the basic biology of disease—how things work, how things are integrated—it will absolutely, positively transform what we know as public health.” GÖKHAN HOTAMISLIGIL Chair, Department of Genetics and Complex Diseases 47 Fall 2013 GENETICS T osteoporosis. A Selection of Genetic Discoveries at HSPH • The late Armen Tashjian Jr., chair of the then-named Department of Molecular and Cellular Toxicology, made pioneering discoveries about how toxic environmental chemicals and therapeutic agents induce molecular changes; he also played a key role in the development of two drugs for treating and preventing • William Hanage, associate professor of epidemiology, used whole-genome sequencing to help trace the path of an E. coli outbreak that sickened thousands and killed more than 50 people in Germany and France. • Dyann Wirth, chair of the Department of Immunology and Infectious Diseases and the Richard Pearson Strong Professor of Infectious Diseases, and Sarah Volkman, principal research scientist in the department, pinpointed sections of the genome of the malaria parasite that may play a role in drug resistance. • Peter Kraft, professor of epidemiology, participated in an international effort that uncovered 74 new genetic markers linked to three common hormonal cancers— breast, prostate, and ovarian—setting the stage for • David Hunter, dean of academic affairs and the Vincent L. Gregory Professor in Cancer Prevention, and colleagues discovered FGFR2, the most common gene variant associated with breast cancer. • Nan Laird, the Harvey V. Fineberg Professor of Public Health and professor of biostatistics, and Christoph Lange, professor of biostatistics, developed methods for discerning familial patterns of Alzheimer’s disease, asthma, and other diseases. novel treatments and targeted screening. • John Little, the James Stevens Simmons Professor of Radiobiology, emeritus, demonstrated that ionizing radiation induces malignancies in animals. • Max Essex, chair of the HSPH AIDS Initiative and the Mary Woodard Lasker Professor of Health Sciences, investigated the genetics of cancer-causing retroviruses—a pursuit that ushered in his groundbreaking studies of HIV/AIDS. Nan Laird, Harvey V. Fineberg Professor of Public Health 48 Harvard Public Health Textile factory in Guangdong, China, 2008 the conventional definitions of “environment,” such as air pollution or radiation exposure, to include diet, exercise, drugs, bacteria, UV sunlight, and workplace hazards, to name a few. “We’re in a great position to explore these areas, because our data sets are drawn from studies that have been collecting detailed information about exposures for 30 years,” said Peter Kraft, professor of epidemiology. GENETICS VS. OLD-FASHIONED PUBLIC HEALTH? Will these fast-paced advances in gene research herald the decline of traditional public health? Not at all. In fact, modern genomics may bolster the public health axiom of prevention, noted David Christiani, Elkan Blout Professor of Environmental Genetics in the Departments of Environmental Health and of Epidemiology. Christiani found a common gene variant that made Shanghai cotton textile workers more vulnerable to lung disease. The practical implication of that discovery, Christiani argued, is not to screen out workers who harbor the gene, but to impose stricter environmental standards overall. As he put it, “Protecting the most vulnerable among the population protects everyone better.” “Lung cancer and diabetes are two good examples of retaining current recommendations,” added Kraft. “You shouldn’t smoke and you should maintain a healthy weight. Regardless of your genes, that’s great advice.” As the era of public health genetics unfolds, we may find even stronger backing for today’s common wisdom—and new ways to protect the health of populations. v 49 Fall 2013 DEADLY ENVIRONMENTS 50 Harvard Public Health O On a crisp October afternoon in 1948, daylight barely trickled into the storefronts of Donora, Pennsylvania. Stagnant weather had trapped a noxious black cloud of emissions from nearby steel and zinc plants above the town, nestled in a valley just southeast of Pittsburgh. When the cloud finally lifted five days later, 21 townspeople were dead and countless others hospitalized. It was one of the worst air pollution disasters in U.S. history, and Harvard School of Public Health took notice. In the wake of Donora, a fresh wave of faculty research would lead both to a new understanding of air pollutionâ€™s impact on health, and to sweeping federal reforms restricting those emissions. Since the beginning, HSPH has built a legacy on its response to environmental disasters like these. Through years of influential research and public health activism, the school has transformed both science and policy, leading steadily to healthier environmental conditions in our cities, towns, and workplacesâ€”environments that, in the decades before Donora, could sometimes be deadly. 51 Fall 2013 Zinc furnace in Donora, Pennsylvania, 1945 DEADLY ENVIRONMENTS W DANGEROUS TRADES THE HAZARDS AROUND US When HSPH was founded in 1913, U.S. labor regulations were almost nonexistent. Coal dust choked the lungs of miners. Mercury poisoned the brains of felt hat makers. And lead, used in everything from freight car seals to pottery decoration, caused horrible convulsions in exposed workers. “While European journals were full of articles on industrial poisoning, the number published in American medical journals up to 1910 could be counted on one’s fingers,” recalled occupational health pioneer Alice Hamilton in her 1943 autobiography, Exploring the Dangerous Trades. Before joining Harvard’s faculty in the late 1910s, Hamilton had built her career studying the plight of American workers—first, by running a survey of lead poisoning in Chicago, then later by examining workers sickened by picric acid, a byproduct of making explosives. In the course of her studies, she exposed dangerous workplace practices and pushed tenaciously for industrial reform. In 1923, workers at a New Jersey clock and watch plant—mostly women—developed painful abscesses that disfigured their jaws and faces. Their teeth started falling out, and within months, the women became so sick, they could barely move. Future HSPH Dean Cecil Kent Drinker soon discovered the culprit: a new type of glow-in-the-dark paint made with radium, a radioactive element. When the workers painstakingly dabbed the paint onto clock and watch dials, the researchers found, they licked their brushes to “point up” for better detail, ingesting tiny bits of the radioactive substance. It slowly collected in their gums and jawbones, dooming the women to a painful death by radiation poisoning or cancer. Drinker’s survey of the workers provided one of the world’s first academic studies on the effects of radiation, helping open the world’s eyes to the terrible dangers it posed. By the end of the Second World War, Drinker and Hamilton’s legacy of research and activism left U.S. factories safer than ever before. New regulations for both chemical and radioactive exposure protected workers’ continued on page 56 “YOUR SCIENCE SCARES ME.” In the tradition of Alice Hamilton and Exploring the Dangerous Trades (see page 57), HSPH’s Joseph Brain headed to a North Carolina cotton mill in the 1960s to take environmental readings and talk to workers exposed to toxic cotton dust. “I discovered that they weren’t really glad to see us. The textile industries had already abandoned New England and had moved to Georgia and North and South Carolina, and the handwriting was on the wall: The industry was slowly moving abroad. A couple of women took me aside and said, ‘Your science scares me. I know these exposures are bad for me, but I need the work. I have children. I have to feed my kids. And I’d rather breathe this dust and have lung disease 20 years from now than lose my job.’ “It made me realize that when you implement change, you need to think of the whole ecosystem. You need to think of all the impacts. Measures that sound good may have a downside to someone. The School has always understood that to do our science, we need deep, persistent connections with workers, with industries, with countries.” Joseph Brain, Cecil K. and Philip Drinker Professor of Environmental Physiology 52 Harvard Public Health B rewarding.” HARVARD’S FIRST LADY By the time Alice Hamilton joined Harvard’s faculty in 1919, she was already one of the nation’s pre-eminent researchers in the field of occupational health. Her tenacious methods were legendary—in her study of workers suffering from diseases like lead poisoning, she sifted tirelessly through hospital records, climbed treacherous catwalks, and slipped covertly into factories around the country. “It was pioneering, exploration of an unknown field,” she recalled in her 1943 memoir, Exploring the Dangerous Trades. “No young doctor nowadays can hope for work as exciting and Hamilton’s steely determination in her fieldwork served her well at Harvard. As the University’s first female faculty member, she was forbidden to sit with her male colleagues at commencement, barred from entering the all-male faculty club, and even denied such perks as complimentary tickets to Harvard football games. In the face of these demeaning conditions, however, Hamilton continued her pioneering work at the University. In the early 1920s, she was involved in one of the world’s first systematic studies of industrial radiation poisoning, examined mercury poisoning in felt hat makers, and became an outspoken opponent of leaded gasoline. Later that decade, Hamilton served as the only female member on the health committee of the League of Nations, the precursor to the United Nations, and published her influential textbook, Industrial Toxicology, in 1934. On her retirement in 1935, Harvard made her a professor emerita (“a great honor [that] pleasantly ignores my sex,” she later chided), and she remained active in the field for years after as a consultant for the U.S. Department of Labor Standards. In 1970, Hamilton died at 101, but her legacy would live on. That same year, the U.S. government established the Occupational Safety and Health Administration and the Institute of Occupational Safety and Health—entities that remain devoted to the health of workers. Workers making felt and velour hats in Luton, Bedfordshire, England, circa 1920 53 Fall 2013 DEADLY ENVIRONMENTS Protecting Workers’ Health Throughout the School’s history, researchers have sought to keep workers safe and workplaces healthy. From pioneering efforts exposing the adverse effects of early-20th-century factory life to current studies on the heart health of firefighters, HSPH researchers have uncovered scientific evidence that has led to new safety regulations and standards, and promoted a cultural standard that values the health of workers at all levels. THESE ARE JUST A FEW OF THE NOTABLE ACCOMPLISHMENTS BY HSPH FACULTY IN OCCUPATIONAL HEALTH AND SAFETY: • Uncovered more than 70 processes in which thousands of workers were exposed to lead poisoning, ranging from painting and pottery making to installing lead trim in caskets and polishing cut glass. The findings led to the adoption of legislation safeguarding workers’ rights in the early 20th century. • Diagnosed the cause of the felt hat industry’s “mad hatter disease”—mental confusion and uncontrollable jerking of the arms and legs—as mercury poisoning. • Described the chronic effects of carbon monoxide poisoning in garages, printing establishments, tunnels, and mining. • Documented psychosis-producing carbon disulfide poisoning among workers in rayon fabric factories. • Conducted the first thorough investigation into radium poisoning (detailed at right). It was suspected to be the cause of horrific degenerative ailments, particularly of the jaw, suffered by female workers who painted dials on clocks and watches with radium-based luminescent paint. • • • • Illuminated the effects of altitude change and oxygen deprivation on pilots and passengers in airplanes. Researched fatigue and work efficiency among sharecroppers, and energy and heat dissipation in muscle tissue in steel mill workers, producing a body of knowledge that evolved into the modern field of ergonomics. Worked collaboratively with labor and management to improve worker safety in the rubber tire, meatpacking, and automobile industries. In three separate investigations, researchers from the School provided evidence linking worker health complaints such as respiratory problems and increased cancer risk to harmful workplace exposures. These toxic exposures included emissions generated by the hot-wire technique used for cutting polyvinyl chloride meat wrappers, and the metalworking fluid used by the autoworkers. Linked lung disease in Chinese textile workers to cotton dust exposure. These findings persuaded the Chinese government in 1986 to adopt U.S. standards and reduce cotton dust levels by 90 percent. 54 Harvard Public Health Deadly Occupation, Forged Report In the early 1920s, workers at U.S. Radium Corporation’s luminous watch dial factory were mysteriously falling ill and dying. Eager to halt a mounting scandal, company President Arthur Roeder contacted industrial hygiene expert Cecil Drinker to investigate. Drinker, along with fellow Harvard School of Public Health faculty members Katherine Drinker, his wife, and William Castle, agreed to visit the Orange, New At a time when many believed radium had healing properties and it was served up in tonics and spa treatments, the women thought nothing of painting their hair, nails, and teeth as a party trick. Cecil Drinker observed that every inch of the painters glowed, “even the corsets.” Drinker was convinced that exposure to continuous doses of radium was causing the women’s health problems, which included excruciatingly painful necrosis of the jaw. He issued a report to the company emphatically recommending safety precautions. Roeder, however, was not convinced. He insisted that a contagious infection contracted outside the factory must be to blame and referred to an internal report that refuted Cecil Drinker’s findings—a report he refused to show Drinker. When he learned of Drinker’s plans to publish the HSPH team’s report, Roeder threatened to sue. While Drinker reluctantly agreed not to publish the report, his HSPH colleague Alice Hamilton refused to back down. Through a contact in the National Consumers League, she learned that U.S. Radium had submitted Cecil Drinker’s report to the New Jersey Department of Labor—with the findings altered to present the company in a more positive light. Hamilton alerted both Drinkers. “[The New Jersey Department of Labor] has a copy of your report and it shows that ‘every girl is in perfect condition.’ Do you “Radium Girls” at work suppose Roeder could do such a thing as to issue a forged report in your name?” she wrote in a 1925 letter to Katherine Drinker. Confronted with the evidence that Roeder had Jersey, factory to observe the watch dial painters at work and to speak with their doctors. What they found was appalling. The factory was saturated with radium-contaminated dust—and no steps had been taken to protect the workers from radioactive material. Dial painters were encouraged to lick their paintbrushes to keep the points sharp, each time ingesting small amounts of the radium-based paint. Supervisors assured the all-female workforce—some as young as 15—that the paint was safe, and perhaps even beautifying. acted in bad faith, the Drinkers ignored the continued threat of a lawsuit and published the report. Upon receipt of the original research report, New Jersey’s labor commissioner ruled that all of Drinker’s safety recommendations be implemented, a move that led to the closure of the factory. Following an eventual lawsuit by former dial painters, the industry made further changes to improve worker safety. Radium-based paint was banned in the 1960s. 55 Fall 2013 health to a large extent, and job-related illnesses fell to an all-time low. Ironically, though, outside factory walls, regulations stayed lax, and dangerous chemicals were released into the air in communities around the country. As they were, HSPH would again find itself on the front lines. Hope for Tiny Lives THE AIR WE BREATHE In the years after the war, HSPH studies found direct connections between airborne pollutants and health problems like asthma, lung cancer, and chronic respiratory disease—findings that would later be the scientific bedrock for regulations mandated in the 1970 Clean Air Act. While the new act reined in some of the country’s worst air pollution, Benjamin Ferris, HSPH professor of environmental health and safety, felt more research was needed. Yes, caustic smog could kill, he noted—but how, exactly? In 1974, Ferris and a team of HSPH colleagues began to find out. In a study of epic proportions, the group spent more than a decade traveling to six cities around the Midwest and New England—in areas of low, medium, and high pollution—to record the respiratory health of more than 8,000 adults and 14,000 children. At the same time, Ferris and his team measured nearby levels of suspended particles (soot), sulfur dioxide, nitrogen oxide, and ozone. The study’s findings, published in 1993, were striking. Death rates in the most polluted of the six cities (Steubenville, Ohio) were 26 percent higher than in the cleanest city (Portage, Wisconsin), showing a strong link between community air pollution and shortened life expectancy. “The effects of air pollution were about two years’ reduction in life expectancy,” said Douglas Dockery, chair of the Department Mary Ellen Avery In 1963, First Lady Jacqueline Kennedy gave birth to a baby boy, premature by five weeks. Almost immediately, doctors realized something was horribly wrong—his underdeveloped lungs were failing him. Two days later, he died gasping for breath. While the Kennedys’ tragedy was visible on a national level, Mary Ellen Avery saw the same thing unfold in more private settings countless times. As a research fellow at Harvard School of Public Health in the 1950s, she had worked with premature infants in an attempt to discover exactly why some babies—like the Kennedys’ child—struggled to breathe after birth. At the time, most researchers believed the problem was due to a thin, glassy film over the inside surface of the lungs that stopped respiration. But by 1957, Avery had discovered the true cause of the disorder. Instead of the presence of a film, Avery found that respiratory distress syndrome (as the disorder is called today) was caused by a lack of surfactant, a foamy coating of proteins and phospholipids that help the lungs expand. Avery’s work soon led to the development of artificial surfactants that saved the lives of countless premature babies. Today, fewer than 1,000 U.S. infants die of the disorder each year, down from nearly 15,000 in the 1950s. “She believed that the best basic science would produce the best outcomes for children—usually in ways that could not be anticipated,” said Joseph Brain, former chair of the Department of Environmental Health, in 2011. In addition to her groundbreaking work in pediatric medicine, Avery, who died in 2012, was a pioneering leader in her field, becoming the first woman to serve as physician-in-chief of Boston Children’s Hospital, the first woman to chair a clinical department at Harvard Medical School, and the first woman president of the Society for Pediatric Research. 56 Harvard Public Health DEADLY ENVIRONMENTS Douglas Dockery, chair of the Department of Environmental Health of Environmental Health, who collaborated closely with Ferris, in a 2012 interview with Harvard Public Health. “It was much, much higher than we had expected.” Indoor air quality was also an important factor in participants’ health. Pollutants could be trapped inside homes and offices, where residents would inhale a concentrated dose of particulates, tiny solids and liquid droplets that emerge during combustion and stay suspended in midair. The particles’ microscopic size— in some cases, more than 100 times narrower than an average human hair—let them slip deep into the lungs, transporting dangerous chemicals into the body and causing harmful inflammation. In part based on the School’s study, the U.S. Environmental Protection Agency (EPA) passed new particulate regulations in 1997, a controversial move that sparked immediate political backlash. Meeting the new requirements wouldn’t be cheap, after all—retrofitting power plants, steel mills, and other heavy industrial sites would cost millions. As pressure rose from industry lobbyists and members of Congress, the Harvard team agreed to an independent reanalysis of its data by the Health Effects Institute (HEI), a research organization in Cambridge, Massachusetts. HEI—which was funded by both the EPA and the automotive industry—took three years to sort through the small mountain of data. But when the results were released in 2000, it had confirmed the Harvard team’s findings, quieting the storm of criticism that followed the study’s publication. Since then, follow-up studies by HSPH faculty have revealed even stronger links between particulate exposure and cardiovascular disease, and today, researchers are pushing for more stringent regulations. While Ferris and his team traveled the country to study air pollution and smog, however, a second group of HSPH faculty set out to tackle another urgent environmental issue—water pollution. By 1982, one of the nation’s most infamous cases reared up in Harvard’s own backyard. WATER, WATER, EVERYWHERE When the Boston suburb of Woburn, Massachusetts, installed new municipal wells in the mid–1960s, residents immediately complained. The water smelled and tasted bad, and it corroded pipes and faucets. Something about it continued just seemed wrong. A MASK FOR HIGH FLYERS Cecil Kent Drinker, Dean of the Harvard School of Public Health from 1935 to 1942, was one of the first physicians to investigate how the respiratory tract absorbs toxic dust and fumes. During World War II, Drinker conducted physiological research for the United States Armed Forces’ National Defense Research Committee. His work contributed to the development of highaltitude oxygen masks and goggles for Allied aviators. 57 Fall 2013 DEADLY ENVIRONMENTS Despite assurances of safety from city hall, more than a dozen Woburn children were diagnosed with leukemia after the wells went online, and residents’ suspicion of the water supply grew. In 1979, the town’s fears seemed confirmed: A construction crew uncovered barrels of toxic waste near the wells, and tests found high levels of industrial solvents in the water. But did those chemicals cause the rise in cancer rates? The riddle intrigued Marvin Zelen, a biostatistician at HSPH. He and colleague Stephen Lagakos soon dove into a statistical study of more than 7,000 Woburn residents, collecting family medical histories through phone surveys and door-to-door volunteers. Indeed, the study introduced the idea of citizen epidemiology— recruiting local residents to gather data. The study’s results showed that the townspeople were right all along. The more water a household received from the tainted wells, the higher its chances of childhood leukemia or birth defects. Zelen and Lagakos had used the survey data to draw a connection between water contamination and cancer, a finding that would help prompt the EPA to make Woburn’s watershed one of its first Superfund sites in 1982. “Opponents claimed no one had been shown to be seriously ‘hurt,’ ” Zelen said in a 2013 interview. “Then our paper came along.” A map shows in red dots the locations of plaintiffs’ houses in Woburn, Massachusetts where well water tainted with industrial chemicals was linked to cases of childhood leukemia. HSPH researchers Marvin Zelen and Stephen Lagakos enlisted more than 7,000 Woburn residents to collect family medical histories through phone surveys and door-to-door conversations— introducing the concept of citizen epidemiology. A trial about the Woburn case was later made into the book and movie A Civil Action. At first, Zelen’s results were not universally accepted, even by some HSPH colleagues. Brian MacMahon, thenchair of the Department of Epidemiology, argued that since Zelen and Lagakos’ volunteers were themselves Woburn residents, the study might be unduly biased. Other academics, however, rallied behind the pair’s work. “We commend Lagakos et al. for undertaking a difficult study with limited resources in a highly charged political environment,” wrote epidemiologists Shanna Swain and James Robins, Mitchell L. and Robin LaFoley Dong Professor of Epidemiology, in a series of comments published with the study in the Journal of the American Statistical Association in 1986. “To the extent that this study has sparked debate and brought the attention of the scientific community to the problem of documenting the adverse health effects of low-level environmental contamination, the authors have done a service.” While a subsequent trial and the EPA’s newly instituted oversight offered some recourse to Woburn residents, it may not have seemed like much to those who had lost loved ones to leukemia. Still, as frustrating as it may have been, the town seemed to have far more options than cities halfway across the globe. Similar sorts of industrial and environmental illnesses were commonplace in developing nations during the 1980s, and little help existed—except, that is, for the work of HSPH researchers. continued on page 60 58 Harvard Public Health I would sink. A MOTHER’S CRUSADE FOR CLEAN WATER In 1972, Anne Anderson’s life changed forever. Her 3-year-old son Jimmy, the youngest of her three children, was diagnosed with leukemia—and other children who lived nearby were suffering from leukemia, too. “Everywhere I went—to the library, to the church, to the grocery store—I met somebody who had a child with leukemia,” Anderson said. “That’s not normal.” She was convinced the spate of disease had something to do with Woburn’s reddish, foul-smelling water, which people had complained about for years. “It was chlorinated so much, it smelled like the Y,” she said. “It rotted our pipes and faucets.” Anderson started voicing her apprehensions—to the city, to the state, to the media. “It was hard, because I’m a very private person. Interviews and interviews and interviews, meetings and symposiums. Speaking in front of people was never my thing. But I was possessed.” Her efforts set in motion a long and tortuous chain of events: city, state, and federal investigations; an HSPH study; and At first, the only people who put stock in Anderson’s fears were her mother and her best friend. Town leaders were a court case made famous by Jonathan Harr’s book, A Civil Action, and the movie of the same name. reportedly insulting and insensitive; Massachusetts Department of Public Health officials were said to be unhelpful; neighbors didn’t want her to publicize her complaints about the water, because they were afraid their property values Finally, in 1979, the state shut down two of Woburn’s municipal wells after discovering they were contaminated with industrial solvents. Jimmy Anderson died in January 1981—nine agonizing years after he first became sick. Shortly after her son’s death, Anderson learned that two HSPH biostatisticians—Marvin Zelen, then-chair of the Biostatistics Department, and Stephen Lagakos—wanted to investigate whether there was a link between the contaminated water and the children with leukemia, and they wanted her help. At first she was reluctant. “I was so very raw,” she said. “But my minister, Reverend Bruce Young, told me, ‘If you don’t do it, who will?’” Along with half a dozen Woburn volunteers, Anderson worked with Zelen and Lagakos in planning the study and making phone calls to gather data. “We had a very comfortable relationship of respect and friendship,” she said. “I admired the two of them so much.” Using data from telephone interviews of 3,257 households, the researchers compared the percentage of water each household received from the contaminated wells over a 16-year period with a variety of adverse health effects, including leukemia. They found that the 15 Woburn children who had leukemia from 1969 to 1983 were exposed to an average of twice as much water from the contaminated wells as the average Woburn household. When the HSPH study revealed the correlation, said Anderson, “It was like a big weight was lifted off my shoulders.” The School’s study findings also marked a turning point for the community. “That’s when the people of Woburn admitted that something was wrong,” said Anderson. “You know, you don’t mess with Harvard.” Today, she believes that people in general are much more aware of the threat of environmental contamination because of what happened in Woburn. Anderson was devastated when she learned of Lagakos’ death in a car accident in 2009. She has nothing but praise for the two professors. “They were interested in little people with a big problem,” she said. “They listened to us. That meant so much.” 59 Fall 2013 TOXINS GO GLOBAL By the late 1980s, the rapid growth of industry in developing nations had triggered a new wave of environmental health concerns. Countries such as China began to face scenarios eerily similar to the industrial revolution in the United States: smog obscured skylines, chemicals tainted water supplies, and lax labor regulations endangered thousands of factory hands. In Shanghai’s massive cotton mills, said HSPH researcher David Christiani, Elkan Blout Professor of Environmental Genetics, respiratory disease was commonplace: workers came down with chronic cough, bronchitis, and an asthmalike condition called byssinosis, caused by bacterial toxins thrown into the air during cotton processing. In 1986, Christiani set out to examine those illnesses. After recruiting more than 1,000 employees from two Shanghai textile mills, he and a small team of researchers began the first study of respiratory health ever among Chinese textile workers. Christiani followed up with the cohort regularly for the next 30 years, providing valuable data on the relationship between bacterial compounds called “endotoxins” and lung disease. As his team soon discovered, repeated exposure to the toxins, which normally have only a short-term effect on Joel Schwartz, professor of environmental epidemiology GETTING THE LEAD OUT “Every time you fill up your car with gasoline, you can think of Joel Schwartz,” William Reilly, former administrator of the EPA, remarked several years ago. That’s because Schwartz, professor of environmental epidemiology, is the man behind a singular accomplishment: identifying an environmental exposure that threatened millions—lead in gasoline—and supplying enough evidence to ban it. Schwartz and his EPA researcher wife, Ronnie Levin—now a visiting scientist at HSPH—showed in the 1980s that banning the addition of lead to gasoline would, on net, save billions of dollars annually, by averting long-term economic losses from lead-induced IQ declines. Such visionary calculations propelled Schwartz—at the time himself an EPA employee—to become in 1991 the first federal worker to receive the MacArthur Award, a no-strings-attached “genius grant” of $275,000. This wasn’t the first time School faculty had taken a stand on lead. Industrial toxicologist Alice Hamilton (see page 53), who became Harvard University’s first female faculty member in 1919, strongly opposed the decision to allow leaded gasoline on the market in 1926. “You are nothing but a murderer,” she was overheard saying to General Motors director of research Charles Kettering in a hallway confrontation during a 1925 Public Health Service conference. The meeting was attended by more than 100 industry and public health representatives to consider the issue of tetraethyl lead, a gasoline additive sometimes referred to as “ethyl” or “loony gas,” after horrifying outbreaks of paranoid and delusional behavior among leadpoisoned workers. David Christiani, Elkan Blout Professor of Environmental Genetics 60 Harvard Public Health DEADLY ENVIRONMENTS Engineering Clean Water When sanitary engineer Gordon Fair joined the faculty of Harvard School of Public Health in 1919, one fact seemed certain: Water could sustain life, but in many cases, it could also take it away. In the late 19th century, contaminated drinking water caused outbreaks of dysentery, cholera, and typhoid fever in major cities worldwide, and the design of effective water and sewer systems— Fair’s expertise—had become a keystone of public health efforts. After arriving at Harvard, however, Fair quickly became frustrated by what he saw as the “unscientific” nature of the field, which had been based mainly on the wisdom and advice of elder engineers. During his 46-year tenure at the school, Fair helped codify sanitary engineering, transforming it from a field steeped in empirical experience to one based on data and quantitative analysis. As his son, Lansing, recalled in a 1997 interview, when Fair started at HSPH, most textbooks contained only two formulas. “Now, they have 1,600, and they all mean something,” he noted. In addition to refining the methods of sanitary engineering, Fair also helped revamp the role of the field within public health. Rather than focus only on hydraulics and intake velocities, he felt his peers should be concerned with larger water quality issues. By the mid–1950s, more than two decades before the birth of the environmental movement, Fair played a key role in bringing attention to water pollution in Lake Michigan, and later became a leading figure of the Harvard Water Program, an interdisciplinary group that helped manage water resources in everything from hydroelectric dams to public swimming pools. Although environmental engineering (as the field is called today) focuses as much on microbes and biochemistry as it does on structural design, Fair’s legacy lives on. Even now, his work influences the water management strategies of the Army Corps of Engineers, guiding them as they work to control floodwaters in rivers across the U.S. Gordon Fair, far right, with colleagues the lungs, could cause permanent damage. “We were the first to show that chronic lung-function loss was related more strongly to prolonged endotoxin exposure than to cumulative dust,” Christiani recalled in a 2007 interview. The study’s findings have implications that reach far beyond the textile industry, however—workers in other fields, from grain processing to plywood manufacturing, are also susceptible to byssinosis, Christiani noted, meaning that his work may help improve the health of thousands both in China and here in the United States. “We started with a very narrow objective, focused on one industry, but our findings now have bearing on the general public,” he said. “[It’s] truly rewarding.” Today, Harvard School of Public Health continues breaking new ground in environmental research. Here at home, it continues its tradition of studying toxins in our surroundings—from the effects of mining waste in Tar Creek, Oklahoma, to careful analysis of BPA, a compound found in some food-grade plastics that can cause hormonal changes in humans. HSPH also has international partnerships to study air pollution in Mexico City and water contamination in Bangladesh, as well as close collaborations with the National Health and Family Planning Commission of China (formerly the Ministry of Health) and Tsinghua University that began in 2005. That collaborative effort, part of the HSPH China Initiative, immediately kicked off a wide-reaching series of policy dialogues and studies to address environmental health in a nation facing rapid urbanization. v 61 Fall 2013 A child balances on a high wall to cross a shantytown in Rio de Janeiro, Brazil. 62 Harvard Public Health T POVERTY, DISASTERS & HEALTH AGAINST ALL ODDS The most powerful influences on population health are not the medical interventions that diagnose and treat disease. Rather, they are the broad social forces—war or peace, poverty or financial security, political oppression or fundamental human rights—that shape all of our life possibilities. In the U.S. and across the globe, Harvard School of Public Health has not only forged practical tools and strategies to alleviate suffering, but has also served as a moral voice in public health. The words inscribed in granite on the François-Xavier Bagnoud (FXB) Building—“the highest attainable standard of health is one of the fundamental rights of every human being”—come from the constitution of the World Health Organization, and form the bedrock of the School’s scholarship and fieldwork. 63 Fall 2013 HEALTH AGAINST ALL ODDS I WAR AND DISASTER TACKLING THE NUCLEAR THREAT It was a time of fallout shelters, “duck and cover” exercises in elementary schools, and an ominous Cold War standoff between the United States and the Soviet Union. It was the late 1950s and, quite by chance, an eminent cardiologist and professor by the name of Bernard Lown attended a talk by Philip Noel-Baker, a recent British Nobel Peace laureate. He came away shaken. “Compared to the threatening nuclear disaster, sudden cardiac death, preoccupying me at the time, seemed a small problem,” Lown recalled, more than half a century later. He decided to take action. In 1961, he mobilized a group of MDs—including Victor Sidel, Sidney Alexander, Jack Geiger, and Robert Goldwyn—into a group called Physicians for Social Responsibility, with the goal of convincing the public that nuclear war would decimate the population and poison the environment. “How could we as physicians make a difference?” said Lown in a 2010 speech launching the Bernard Lown Scholars Program and Visiting Professorship at HSPH. “We extrapolated the medical consequences of a virtual nuclear bombing of Boston. We concluded that there was no meaningful medical response to a catastrophe of such magnitude. And we published our results in the New England Journal of Medicine. “We became instant world experts on the topic,” added Lown, whose career highlights include developing the lifesaving direct current defibrillator. “Having demonstrated that in nuclear war there was no place to hide, our findings put an end to the underground shelter craze then exercising the American public.” The son of Lithuanian Jews who had emigrated to the United States in 1935, Lown also saw disturbing parallels between the proliferation of nuclear weapons and Nazi Germany’s annihilation of 6 million Jews. “We destroyed Hitler and we became Hitlerized in our ability to design mass extermination,” he said in the 2010 speech. “ Duck and cover” exercises were instituted in classrooms in the 1950s and 1960s, in an attempt to prepare students for a nuclear attack. In the 1970s, with the nuclear threat still looming, Lown reached out to an acquaintance—Evgeni Chazov, personal physician to Soviet leader Leonid Brezhnev and a collaborator on studies investigating sudden cardiac death. Lown asked Chazov if he’d consider joining forces with other U.S. colleagues—including Herb Abrams, Jim Muller, and Eric Chivian, founder of the Center for Health and the Global Environment at Harvard Medical School, as well as Drs. Mikhail Kuzin and Leonid Ilyin of the Soviet Union—to combat the nuclear threat. The result was International Physicians for the Prevention of Nuclear War (IPPNW), founded in 1980. “Remarkably, within four years we gained 150,000 physician members in 60 countries and educated a wide public on the nuclear threat,” Lown said. “We did some seemingly impossible things.” The doctors sounded a medical warning to humanity: that nuclear war would be the final epidemic, and that there would be no cure and no meaningful medical response. Their message reached millions of people around the world. In the words of former New Zealand Prime Minister David Lange, “IPPNW made medical reality a part of political reality.” In 1985, Lown and Chazov traveled together to Oslo to accept the Nobel Peace Prize on behalf of their organization. 64 Harvard Public Health WORLD WAR II AND TODAY Humanitarian assistance is in the DNA of Harvard School of Public Health. And one of the biggest public health and humanitarian relief efforts of the 20th century was the massive scale-up required to wage World War II. HSPH graduate and future dean Brigadier General James Stevens Simmons served as head of the Preventive Medicine Service of the Army’s Office of the Surgeon General—the top public health official in the armed services. Simmons would boast of having trained 30,000 officers and enlisted men in various public health specialties by mid-1944. When Oak Ridge, Tennessee, was chosen as the place to manufacture the fuel for the atomic bomb, it went from being a village of 19,000 to a bustling town of 78,000 almost overnight—and alum Bernard Blum, MPH ’38, was put in charge of keeping the inhabitants of the secret “atomic city” healthy. Granville Larimore, MPH ’42, served as chief of venereal disease education for the Army’s Office of the Surgeon General. Venereal disease was perhaps the most challenging infectious disease threat of the war, and in response, Larimore helped make a movie on venereal disease prevention, cleverly titled Pick Up. Ruth Parmelee, MPH ’43, was assigned to an 8,000person refugee camp in what was then called Palestine, where she encountered people infected with lice, scabies, and typhoid. She wrote in the Harvard Public Health Alumni Bulletin of measles and whooping cough epidemics that broke out before proper quarantines could be established. continued BRINGING AID TO THE WORLD’S MOST DANGEROUS PLACES January 1992. The scene in Mogadishu was as close as it comes to hell on earth. As Somalia’s civil war gathered force, “the fighting was a combination of direct slaughter and indiscriminate firing of very heavy weapons on a city built of sandy concrete,” recalled Jennifer Leaning, director of the François-Xavier Bagnoud (FXB) Center for Health and Human Rights, who traveled to the war zone on behalf of Physicians for Human Rights. Figuratively and literally, “the city crumbled. People were trapped, killed, mutilated, and brought to hospitals that were completely unequipped to handle complex casualties.” For the past 20 years, that experience has continued to inform Leaning’s work in ways that are crucial to the center’s mission. “What I saw in Mogadishu underscored my understanding that half measures to support a population in need are fraught with peril. It focused me on the importance of medical ethics and competence and the training of humanitarians. The people who were there were heroic. I honor them. But they knew what they were doing was not enough. They knew they were not at the top of their game.” Training humanitarian workers to be effective in such disasters has since become a key goal of both the FXB Center and the Harvard Humanitarian Initiative (HHI), which Leaning co-founded in 2005 with Michael VanRooyen, who now directs HHI. “How do you train people to work in humanitarian environments that are fluid and difficult?” says VanRooyen. “We need to recognize humanitarian assistance as a unique and specialized discipline. Students must Jennifer Leaning, at right, director of the François-Xavier Bagnoud Center for Health and Human Rights, in the Darfur region of Sudan know not only about humanitarian principles and the basic provision of services, but also about finance, personnel, diplomacy, culture, and very practical matters of security. They also need to be creative and to lead. The toughest challenge is teaching leadership.” Michael VanRooyen, director of the Harvard Humanitarian Initiative, in the Democratic Republic of the Congo in 2009 65 Fall 2013 HEALTH AGAINST ALL ODDS HSPH Professor John E. Gordon, who would go on to chair the Department of Epidemiology, organized units to search for communicable diseases in advance of troops moving into an area, recognizing that until the 20th century, infectious diseases took a greater toll on armies during war than did opposing combatants. Research that Gordon compiled after the war showed that if battle-related mortality were excluded, World War II marked the first conflict in which accidental trauma, such as vehicular accidents, drowning, falls, athletic injuries, and even suicides replaced non-battlerelated disease as a major cause of death in the military—part of his keen understanding of the social context of public health trends. Today’s humanitarian work by HSPH faculty, including those with the Harvard Humanitarian Initiative, mirrors the endeavors undertaken in war-torn areas nearly 70 years ago. At the François-Xavier Bagnoud Center for Health and Human Rights, the mission has evolved and expanded beyond its original focus on HIV/ AIDS, said director Jennifer Leaning, to include young people in crushing circumstances—such as girls in poverty-stricken rural India, the Roma in eastern and central Europe, and boys and girls victimized by sex trafficking. “We are focusing on children and adolescents in oppressive, wartorn, grotesque, stigmatized situations around the world.” continued on page 70 THE WAR AT HOME Urban poverty and violence have long gone hand in hand, but to identify solutions, we need to understand how these problems intersect. Perhaps no one has contributed more to this effort than Professor of Human Behavior and Development Felton James Earls, whose research challenged the soMourners leave a funeral for 15-year-old Hadiya Pendleton in Chicago in February 2013. Pendleton was fatally shot in what police say was a case of mistaken identity in a gang turf war. called broken windows theory that crime stems from community disrepair and disorder, arguing for its replacement with a theory of “collective efficacy”—the notion that neighborhood crime rates are tied to residents’ willingness to act for each other’s benefit, most particularly for the benefit of each other’s children. “It is far and away the most important research insight in the last decade,” Jeremy Travis, director of the National Institute of Justice from 1994 to 2000, told the The New York Times in 2004. Earls’ insights grew out of his massive Project on Human Development in Chicago Neighborhoods. Launched in 1994, the 10-year, $51 million epidemiological study, funded by the National Institute for Mental Health and the MacArthur Foundation, examined the causes and consequences of children’s exposure to violence. Not surprisingly, the recognition that urban violence is an urgent public health issue has deep roots at HSPH. Starting in the 1970s, physician Deborah Prothrow-Stith, as associate dean and professor of public health practice, advocated combating youth violence using strategies similar to those that had successfully curbed smoking and drunken driving. T THE PUBLIC HEALTH APPROACH TO GUNS “During most of the twentieth century, gun assaults were seen almost exclusively as a criminal justice problem, gun suicides as a mental health problem, and unintentional gunshot wounds as a safety issue. Since the mid-1980s, it has become increasingly recognized that the most promising approach to reduce firearm injury is to emphasize prevention, focus on the community, use a broad array of policies, and bring together diverse interest groups.” — David Hemenway Director, Harvard Injury Control Research Center from Private Guns, Public Health 66 Harvard Public Health T FIGHTING SEXUAL VIOLENCE IN THE CONGO The plight of women in the eastern Democratic Republic of the Congo (DRC) has captured headlines, as women have fallen prey to lawlessness and violence in the ongoing conflict that first broke out in 1996. Since its inception, an estimated 6 million lives have been lost and hundreds of thousands of women have been raped or sexually assaulted. Efforts at aid, though well intentioned, often fail to reflect the needs the women themselves consider to be most critical. Jocelyn Kelly, SM ’08, director of the Women and War Program at the Harvard Humanitarian Initiative, recalled one woman she spoke with in a focus group when she started traveling to the region. “Like many stories in the Congo, hers was one of the most horrific you could imagine. When I asked her what services she would find most helpful, I thought she might say, ‘I would like help paying my hospital bills’ or ‘I would like materials to rebuild my home.’ But without even pausing or thinking, the woman said, ‘I want to become literate. And I want education for my children.’” Kelly sees her role as communicating the needs of such women to the funders and highlevel policymakers who can make change happen. To this end, she splits her time between the violent, crisis-ravaged locations where she conducts field research and cities such as New York and Washington, DC, where she forcefully advocates for the needs of Congolese women with key players such as the World Bank and the United Nations Security Council. “Ideally, we act as a bullhorn, taking the voices of those affected by conflict and crisis into policy and programming circles,” she explained. Victories are hard-won but deeply satisfying. One example: A report about the stigma endured by Congolese survivors of sexual violence influenced a large government donor’s decision to fund holistic, family-centered programs for the women. For Kelly, making this type of direct impact keeps her going. “There have been times where on Tuesday, I’ll be on the ground in the DRC, speaking with women affected by the conflict—and on Thursday morning, I’ll be on a panel in Washington, DC, talking about what those women said to me,” said Kelly. “Those are some of the most wonderful moments of my job.” Jocelyn Kelly, director of the Women and War Program at the Harvard Humanitarian Initiative, speaks in 2009 with a commander of the Mai-Mai militia in Uvira, Democratic Republic of the Congo. 67 Fall 2013 HEALTH AGAINST ALL ODDS Fighters for Equity TACKLING TWO-TIER HEALTH CARE With the creation of the Medicare and Medicaid programs in 1965, the United States began its first large-scale experiment with a formal national health system. Almost overnight, it began subsidizing medical care for the elderly and poor. But for Alonzo Yerby, who served as a consultant to the Johnson administration during the drafting of the legislation, the policy Alonzo Yerby didn’t go far enough. “Health care for the disadvantaged … tends to be piecemeal, poorly supervised, and uncoordinated,” he wrote in an address to the White House Conference on Health in January 1966, six months after the legislation was passed. “We can no longer tolerate a two-class system of health care.” Yerby, who later became head of the HSPH Department of Health Policy and Management, remained troubled by the social injustice he saw within medicine. Creating a successful national health system, he felt, had to begin with addressing the day-today issues of people living in poverty. An effective health service must “strike not at the symptoms, but at the causes of the health crises of our metropolitan areas,” he wrote in 1965, setting the tone for his tenure at Harvard. “The social environment of the individual … influences his health and potential for recovery from disease.” Providing qual- U.S. President Lyndon B. Johnson, left, with former President Harry S. Truman, seated right, signs the Medicare bill into law in 1965. ity preventive care was essential, in Yerby’s eyes. So too was access to doctors, since long waiting times and frequent travel between specialists placed a heavy burden on the poor. Yerby died in 1994. His passion for equity and social justice in public health is perhaps his greatest legacy. During his 16 years on Harvard’s faculty, he inspired legions of students and left a lasting impression on his peers—and on his son, Mark, who followed in his father’s footsteps by earning an MD and MPH, and now maintains a private neurology practice in Portland, Oregon, where he adheres to the key principle of his father’s work. As Mark told Harvard Public Health Review in 1997, “He believed that public health was not just the purview of health professionals, but belonged to every physician.” 68 Harvard Public Health “ The tectonic plates are shifting, but it is at the intersection of health and human rights that the most radical transformation is occurring, and it is there that the future will lie.” —Jonathan Mann, 1996 BRIDGING AIDS AND HUMAN RIGHTS Jonathan Mann, physician and advocate, pragmatist and visionary, transformed the way the world looked at AIDS. As the first head of the Global Programme on AIDS for the World Health Organization (WHO), he illuminated the intersection of health and human rights. Mann joined the HSPH faculty in 1990 as a professor of epidemiology and international health. He became the first director of the School’s François-Xavier Bagnoud (FXB) Center for Health and Human Rights, which he founded in 1992 with the Countess Albina du Boisrouvray, whose generous $20 million gift Jonathan Mann, first director of the François-Xavier Bagnoud Center for Health and Human Rights made the center’s work possible. Mann died at age 51 in 1998, in the crash of Swissair Flight 111. In his leadership post at the WHO from 1986 to 1990, Mann forged the approach to AIDS now considered axiomatic: prevention, understanding the social and behavioral dynamics and patterns of sexual transmission, comprehensive surveillance, monitoring, and education, a robust program of biomedical research, and an emphasis on the rights of the individual. Today, as AIDS becomes a treatable chronic disease in many parts of the world, it is easy to forget the point at which a conscious decision was made to embark on what the Village Voice described as “a condom-based compassionate strategy to slow the spread of AIDS,” instead of opting for the repressive quarantine strategies that had many supporters. Mann “had an edgy agenda and an edgy analysis,” said Jennifer Leaning, the current director of the FXB Center. “He was critical of the pace of progress.” As Mann himself told the Second International Conference for Health and Human Rights, at Harvard University in 1996, “The tectonic plates are shifting, but it is at the intersection of health and human rights that the most radical transformation is occurring, and it is there that the future will lie.” More than 20 years after her gift, the Countess’s passion hasn’t waned. She remains an active presence in the work of the FXB Center and related activities around the world. “There’s so much to do,” she said. “But as I look at the women and children on field trips, I get the energy to go on.” 69 Fall 2013 POVERTY AND HUMANITARIAN CRISES OF PLACE AND RACE NEIGHBORHOOD EFFECTS If “geography is destiny,” words famously attributed to Napoleon Bonaparte, nowhere is this truer than in the realm of public health. “If there’s one overarching theme, it’s that place matters,” says Ichiro Kawachi, chair of the Department of Social and Behavioral Sciences. “Regardless of who you are as a person, neighborhood makes a big difference in your life chances and your health chances.” One recent strand of investigation took off in the 1970s with the discovery that even unusually high incomes do not protect the health of people living in poor neighborhoods, an insight that emerged from research by Lisa Berkman, now the Thomas Cabot Professor of Public Policy and Epidemiology and director of the Harvard Center for Population and Development Studies. Drawing on a survey of 7,000 adults, Berkman, then a graduate student at the University of California, Berkeley, and her colleagues found a link between income and health—something they had expected. But they were surprised to find that high incomes did not compensate for living in a poor area. On the other hand, the study also found that social connections such as good relationships with friends and family have a protective impact, resulting in longer and healthier lives. Berkman, former chair of the Department of Social and Behavioral Sciences (when it was called the Department of Society, Human Development, and Health), and her successor, Kawachi, established the scholarly framework on social determinants of health at HSPH. David R. Williams, the Florence Sprague Norman and Laura Smart Norman Professor of Public Health, has explored how socioeconomic status, race, stress, racism, and religious involvment affect physical and mental health. The Everyday Discrimination scale that he developed is currently one of the most widely used instruments in health research to assess perceived discrimination. The School’s faculty has also shown that just as living in poor, segregated neighborhoods is hazardous to health, so too is living in communities with high levels of income inequality—in part because having substantially less than your neighbors may create significant levels of stress. And HSPH researchers have demonstrated that health is framed not only by a home’s location, but also by what takes place inside that home. Domestic violence—a crime and human rights violation—also raises the risk of asthma, HIV infection, smoking, poor maternal health, and child mortality. In the late 1990s, Nancy Krieger, professor of social epidemiology, devised a method to portray the link between a community’s health status and its socioeconomic class—a project that arose out of her frustration over the dearth of socioeconomic data in U.S. health records. Krieger statistically linked census tract poverty levels with public health surveillance information, such as all-cause and causespecific mortality, cancer incidence, and low birth weight. She found that within a federal census tract (an area that usually includes about 4,000 people of similar income and living conditions), the poverty rate corresponds closely with residents’ health status. Based on this finding, the Public Health Disparities Geocoding Project, launched at HSPH in 2004, has enabled health departments to measure their progress over time, zero in on problems in specific locales, and clarify the links between poverty and disease. In Massachusetts and Rhode Island, for example, Krieger showed that more than half the cases of childhood lead poisoning, sexually transmitted infections, tuberculosis, nonfatal gun-related injuries, and HIV/AIDS deaths among the poorest residents would not have occurred if their risk had been the same as that of people living in the wealthiest enclaves. The geocoding method has been adopted in the U.S. and around the world by researchers and health departments, as well as by the National Cancer Institute. continued on page 72 “ “Regardless of who you are as a person, neighborhood makes a big difference in your life chances and your health chances.” – Ichiro Kawachi, chair, Department of Social and Behavioral Sciences 70 Harvard Public Health “I RACISM HARMS HEALTH “I remember thinking, as a young assistant professor, ‘Oh my God, you can actually measure racism?’ recalled Ichiro Kawachi. He was referring to the groundbreaking work two decades ago of his colleague, social epidemiologist Nancy Krieger. “Nancy made visible what was unspeakable, unspoken of, invisible. No one had done this before—they thought it was too sensitive, too difficult. She launched an entire field by saying, ‘If we think this is important, let’s measure it.’” Krieger’s ecosocial epidemiologic theory of disease Nancy Krieger Professor of Social Epidemiology Department of Social and Behavioral Sciences distribution—which analyzes how people literally embody their societal and ecological context, thereby producing population rates of disease—has influenced a generation of researchers. Explaining the comparatively high risk of hypertension among African Americans, for example, Krieger wrote in a 1994 paper, “Epidemiology and the Web of Causation: Has Anyone Seen the Spider?”: “A person is not one day African American, another day born low birth weight, another day raised in a home bearing remnants of lead paint, another day subjected to racial discrimination at work (and in a job that does not provide health insurance), and still another day living in a racially segregated neighborhood without a supermarket but with many fast food restaurants. The body does not neatly partition these experiences—all of which may serve to increase risk of uncontrolled hypertension.” In 1996, Krieger shook up the field with a study suggesting that bearing the brunt of racial discrimination raises the risk of elevated blood pressure, a partial explanation of why blacks suffer more hypertension than whites. The study showed that self-reported racial discrimination is just as harmful as any of the commonly named “lifestyle” culprits: lack of exercise, smoking, a high-fat or high-salt diet. Traditionally, epidemiology had “adjusted” for race and class to flush out specific biological pathways behind disease. Krieger argued that racism was itself a causal exposure for disease. She went on to develop a scientifically validated research instrument for measuring people’s experiences of racial discrimination—one now used by researchers studying a wide array of health outcomes, from hypertension to tobacco use to depression. Other HSPH faculty helped write Unequal Treatment, a landmark 2003 report on racial and ethnic disparities in American health care. Among its findings: Even after overcoming barriers to obtaining health care, African Americans and other minority populations were less likely to receive procedures such as coronary bypass operations, kidney dialysis, and kidney transplants. 71 Fall 2013 POVERTY AND HUMANITARIAN CRISES HEALTHY GROWTH OF PEOPLE AND SOCIETIES THE MEASURE OF A HEALTHY LIFE “Your child is in the 80th percentile for height and 75th for weight.” Nearly every parent of an infant or young child in the U.S. and many other parts of the world has heard words similar to those at his or her child’s well-baby visits and annual physicals. But few know the genesis of the charts that doctors use to assess their children’s progress toward normal health milestones—a 1930s project undertaken at Harvard School of Public Health. The brainchild of pediatrician-researcher Harold Coe Stuart, the Longitudinal Studies of Child Health and Development marked a new approach to pediatric public health. It was concerned with the manifestations of health, not simply sickness, and it replaced a focus on individual care with ongoing developmental research. To this end, Stuart—who headed the School’s Department of Child Hygiene, later known as the Department of Maternal and Child Health—followed a group of 324 children in Boston’s predominantly Irish middle-class Roxbury neighborhood from before birth through adulthood, starting in 1930. The project was holistic and intensely cross-disciplinary—involving social workers, public health nurses, anthropologists, dentists, psychologists, psychiatrists, and pediatricians—a reflection of Stuart’s conviction that children’s health involved the interplay of physical, emotional, social, and cultural factors. No comprehensive study of normal child growth had ever taken place before. “Pediatricians interested in research have been so preoccupied with the study of disease that they have not contributed as much as might have been anticipated to studies of normal development,” Stuart wrote. “It is surprising how little is really known about the effects of disease on growth, in view of the attention given to sick children.” He advocated that physicians, school health programs, and parents take regular measurements of a child’s height, weight, chest circumference, hip-width, and girth, stressing that diversion from a normal growth pattern might be a tip-off to underlying disease. And presaging more recent social trends, Stuart interviewed fathers and encouraged them to be part of the child’s upbringing. v GLOBAL NUTRITION In the late 1960s, when public health researchers were beginning to understand the significance of diet in resource-limited nations, a seminal report coauthored by three eminent HSPH-affiliated scientists— John E. Gordon, chair of the School’s Epidemiology Department from 1946 to 1958, and nutritionists Nevin S. Scrimshaw, MPH ’59, and Carl E. Taylor, MPH ’51, DPH ’53—exhaustively documented how malnutrition leaves victims more susceptible to infections such as tuberculosis and dysentery, and how infectious disease amplifies the effects of malnutrition. In the mid-1990s, HSPH’s Wafaie Fawzi and colleagues in Tanzania conducted the first clinical trial showing that when HIV-positive women take multivitamins, their chances of miscarriage or of delivering a premature or low-birth-weight baby were reduced by 40 percent. The researchers found that when HIV-infected individuals take daily multivitamin supplements, their disease progressed much more slowly and their chances of dying were greatly reduced. As a result of these findings, nutrition became Wafaie Fawzi, chair of the Department of Global Health and Population, and professor of nutrition and of epidemiology a core element of HIV/AIDS management with antiretroviral therapy and other interventions. Fawzi’s studies have also shown that during the critical “first 1,000 days”—the duration of pregnancy and the first two years of life—proper nutrition through breastfeeding, a healthy diet, and, when needed, vitamin supplements, dramatically boosts maternal health, decreases premature birth, improves survival and early mental and physical development, and enhances lifelong productivity. Put simply, says Fawzi, proper nutrition early on enhances a person’s prospects in life. “It is simple and inexpensive and doable.” 72 Harvard Public Health Population Visionary When Roger Revelle took the helm of the new Harvard Center for Population and Development Studies (known as the Pop Center) in 1964, he was already one of the world’s most eminent and eclectic scientists. His prominence in the climate-change conversation dated back to 1957, during his time as director of the Scripps Institution of Oceanography, when he co-authored a paper suggesting that oceans would absorb excess carbon dioxide generated by people at a much slower rate than previously predicted. Former U.S. Senator Al Gore, who had studied with Revelle in the 1960s, wrote about him admiringly in his 1992 best-selling book Earth in the Balance, crediting Revelle with inspiring his own future activism. In November 1990, the year before he died, Revelle received the National Medal of Science from President George H.W. Bush for, in Bush’s words, “being the grandfather of the greenhouse effect.” As Pop Center director, Revelle brought together a team of colleagues dedicated to the problems of population Roger Revelle growth and change. His focus was the plight of developing countries, and he strongly advocated enhancing education, agriculture, and industrialization in the developing world. For example, Revelle shared his insights about improved planting and irrigation methods, which reduced the salinization of Pakistan’s agricultural land and helped transform that country from a grain-importing nation to one with surplus grain to export—one of the most acclaimed successes of the 1960s “Green Revolution.” Revelle also opposed biologists such as Paul Ehrlich, who had concluded that humans would breed themselves into catastrophe. The population problem, Revelle countered, couldn’t be separated from the problems of poverty and underdevelopment. For all his awareness of impending challenges, Revelle—who, in addition to leading the center, was the Richard Saltonstall Professor of Population Policy until his retirement in 1978—was at heart an optimist. His answer to alarms about the “population bomb” was a broad agenda: feeding and caring for the growing numbers of humanity, especially those in the poorest parts of the globe. As he said in an interview with the Harvard Public Health Alumni Bulletin, “Because of the shrinking size of the world and its growing interdependence, and the fact that all the world’s resources are needed to support the world’s peoples, an effective way of distributing the world’s income more widely among nations must be found if there is to be world prosperity.” Today, the University-wide Pop Center, directed by social epidemiologist Lisa Berkman, is carrying out Revelle’s vision, with a focus on social and environmental determinants of health, population aging, migration, and women’s health and fertility. 73 Fall 2013 WORKING THE (HEALTH) SYSTEM 74 Harvard Public Health A A standard medical test that could have been done for a tenth of the cost. A doctor’s momentary lapse in attention that led to grievous injury—or even death. An upside-down health care bureaucracy that makes poor patients pay the most for treatment. The “medical-industrial complex” that brought miracle cures to the 20th century has also raised profound questions about value and values. Harvard School of Public Health researchers—operating at the intersection of medicine, economics, social science, law, and ethics—have been world leaders in decision-making science and in assessing the impact of increasingly complex delivery systems on population health and wellbeing. Our faculty has transformed national health systems around the globe. And our alumni have set an enlightened public health agenda, serving in the most prestigious leadership positions in the field and in governments worldwide. 75 Fall 2013 WORKING THE (HEALTH) SYSTEM F 85 Life Expectancy, by Country THE DOLLARS AND SENSE OF HEALTH CARE First it was headaches, then crippling fatigue so bad he could barely get out of bed. Finally, on Christmas morning 1961, John Myers awoke to a terrifying sensation—an uncontrollable cough, grotesquely swollen face, bloody nose, and racing heart. Myers had entered the final stages of kidney failure. At the time, his condition normally meant certain death. But Myers, profiled in a 1962 Life magazine article, would live on for years thanks to an experimental new treatment: long-term, out-of-hospital dialysis. Throughout the late 1960s and ’70s, U.S. Medicare and Medicaid programs expanded access to cutting-edge medical procedures like home dialysis. While these new technologies saved thousands of lives, they also created a paradox: The treatments weren’t cheap, and by 1973, their widespread use sent medical costs soaring to 11.3 percent of the federal budget—almost three times more than in the previous decade. (Today, the figure is 21 percent.) These spiraling costs posed difficult problems. How could the nation rein in expenses while ensuring quality treatment? Since the early 1970s, Harvard School of Public Health faculty have addressed questions like these through rigorous research into the scientific, political, legal, economic, and emotional issues that surround medical care. In the process, the School has helped shape today’s major debates around health policy, both in the U.S. and abroad. As a nephrologist, Howard Frazier saw firsthand how dialysis gave new life to patients with late-stage renal failure. He was troubled, however, by what he saw as a lopsided approach in the use of these treatments. As Frazier, then professor in the Department of Health Policy and Management, recalled in a 1997 interview, the nation was channeling thousands of dollars each year to treat sick patients in the early 1970s, but relatively little money to care that would have kept them healthy in the first place. “It was just a wasteful way of deploying very limited resources,” he said. “You can’t even afford three bucks to provide immunization for the kids across Huntington Avenue … and yet you could afford $35,000 to $40,000 a year to maintain someone symptomatically uremic but not dead.” How Much Health Do We Get for Our Money? Life Expectancy, by Country G G RE J BR E ITA PN SW FI SP N IS E BE L AU L S R KO ZE SL PO O R D N 80 H I C EN A CA U N T N ED LU X IS R O R SW L EX M ES T R H U N SV 75 TU ZL FR IR G A L ER PO K U SA C Z Infographic: Column Five 70 $1,000 $2,000 N $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 Total Health Expenditures per Capita Spending in U.S. Dollars and PPP Adjusted Total health expenditures per capita spending in U.S. dollars and purchasing power parity (PPP) adjusted (2010) 76 Harvard Public Health Howard Hiatt, then HSPH dean, shared Frazier’s frustration. In an effort to fight the growing inequity in American medicine, Hiatt teamed with Frazier in 1972 to form the Center for the Evaluation of Clinical Procedures (CECLIP), later renamed the Center for the Analysis of Health Practices. From its dusty basement office at 55 Shattuck Street, the group became a sort of internal think tank, recruiting faculty from many different disciplines to examine medical policy through the lenses of economics, statistics, management, biology, law, even engineering. By 1977, a University-wide seminar organized by Dean Hiatt produced a landmark book, The Costs, Risks, and Benefits of Surgery—a volume that laid the groundwork for evidence-based medicine, using as examples a wide range of surgical interventions, from gallbladder removal to hysterectomy. CECLIP also applied the concept of “cost effectiveness” research—a type of analysis that can help determine which programs have the biggest health bang for every buck spent on care. Research of this sort might, continued Shining a Light on Medical Errors Lucian Leape has made a career out of other people’s mistakes. Over the past three decades, his research has focused largely on strategies for reducing those all-too-common errors that kill tens of thousands of patients every year. Leape, adjunct professor in the Department of Health Policy and Management, began looking into medical errors as part of the Harvard Medical Practice Study, which examined the rates and root causes of malpractice in more than 50 New York hospitals during the 1980s. After analyzing nearly 30,000 patient records, the researchers found that roughly 4 in every 100 patients were injured as a result of their hospital stay, and twothirds of those injuries happened because of a preventable error. Leape and his colleagues also discovered that the malpractice system meant to address these problems was badly out of sync. On the one hand, there was a large number of “false positives”—malpractice claims against innocent doctors. On the other, there was an even bigger problem with “false negatives”—patients harmed by negligent care who had never filed any malpractice claim. The study led Leape to uncover the human factors engineering literature on preventing errors through improved designs of work systems. He recommended this approach for health care in ���Error in Medicine,” his seminal 1994 paper in the Journal of the American Medical Association. His policy prescription: Change some of medicine’s unexamined standard operating procedures—adopt checklists instead of individual memorization, for example, or reduce sleep deprivation. “Errors must be accepted as evidence of system flaws, not character flaws. Until and unless that happens, it is unlikely that any substantial progress will be made in reducing medical errors.” Lucian Leape 77 Fall 2013 WORKING THE (HEALTH) SYSTEM for example, weigh the costs and health benefits of coronary bypass surgery against a drug regimen that lowers patients’ overall cholesterol level in an attempt to identify the more effective treatment. The cost-effectiveness model, however, has seldom guided choices in medical practice in the U.S.—in part, many experts say, because it is difficult to change doctors’ “defensive medicine” practices and patients’ high expectations for treatment. Cost-effectiveness analysis also stops short of pinpointing factors that drive up expenses. Figuring out the comparative efforts and skills required to deliver a range of medical services, procedure by procedure, proved to be a nearly impossible task—until William Hsiao, the K.T. Li Professor of Economics at HSPH, took on the challenge in a groundbreaking and controversial study in 1986. PAYING UP: DOCTORS’ COMPENSATION In the mid-1980s, services and procedures could be paid at widely varying rates under Medicare and Medicaid. A doctor who spent an hour making a lifesaving diagnosis might be paid $40, yet that same doctor could earn more than $600 an hour removing polyps during a colonoscopy. So how could hospitals begin to determine the “real” value of each procedure? In 1985, HSPH’s Hsiao set out to answer that question. The key to measuring value, he reasoned with economic theory, lay in finding the average amount of work a physician had to do to perform a procedure. The more time, skill, knowledge, and effort it took, the more the physician should be compensated. Figuring out the exact amount of “work” a doctor performed was no simple task, so Hsiao cast his net widely. For months, he and a large team of researchers developed methods, conducted interviews, and surveys with thousands of doctors from dozens of specialties, painstakingly ranking each task. From this data, Hsiao’s team assigned each procedure a score called a “relative value unit,” or RVU. Installing a coronary artery stent would score 24 units; reading an EKG printout, a mere 0.5 units, and so on. Within three years, Hsiao and his colleagues had developed these scores into a system he called the “resource-based relative value scale” (RBRVS), a comprehensive list of RVUs for all the tasks covered under Medicare. Equipped with this scale, hospitals could tally up a total score per patient, multiply it by a set dollar rate (about $40 per RVU in 2009), and pay the resulting amount to a doctor—meaning Hsiao’s team had, for the first time, effectively standardized the cost of medical procedures. But the RBRVS—which Hsiao had conceived as a rational means of allocating medical dollars—took a paradoxical turn. Today, the system is blamed for the very problem it tried to halt: rising health care costs. In its continued on page 80 F POLLING PROWESS For nearly 30 years, Robert Blendon, senior associate dean for policy translation and leadership development, has been polling Americans about their views of public health, health care, and other related hot-button issues. “We’re living in a world where people believe in smaller government and lower taxes,” he said in 2012. “So you have to convince people that there are interventions that can actually save their lives.” 78 Harvard Public Health F “brain fog.” FIRST IN LINE FOR AFFORDABLE CARE For 15 years, Madelyn Rhenisch struggled with an illness that drained her of all physical and mental vitality, destroyed the successful career she had worked hard to build, and left her with no savings. All because she couldn’t afford health insurance. Then her luck changed. Now a 63-year-old resident of Boston, Rhenisch was the first person to enroll in the Massachusetts Commonwealth Care program, part of the pioneering 2006 health care reform, passed with bipartisan support, which provides subsidized coverage to lower-income residents who are uninsured. The program— dubbed “Romneycare,” after then-governor Mitt Romney— helped inspire the national 2010 Patient Protection and Affordable Care Act, known as Obamacare. Ironically, Rhenisch had worked her entire life as an activist on behalf of farmworkers and lower-income people. “I came of age in the ’60s and wanted to change the world for the better. I never imagined I would be in a position where I myself would be desperately in need of support and advocacy.” She was pursuing a doctorate and MBA simultaneously and was juggling several human resource positions when she became sick. The illness came on suddenly, in the winter of 1996. “It had snowed, so I shoveled a path to my car. When I came in, I was drenched with sweat and exhausted. I couldn’t get up for the rest of the day,” Rhenisch recalled. The overwhelming fatigue persisted, and new symptoms cropped up: severe muscle and joint pain, and a pervasive By 1998, she was forced to quit school, leave her jobs, deplete her retirement savings, and ultimately go into debt. Having lost school- and employer-based health insurance, she often had to choose between medicine and food. In 2006, Health Care for All (HCFA)—Massachusetts’ leading consumer health advocacy organization—asked Rhenisch to become the debut enrollee in the state’s new health insurance program. There she met John McDonough—now director of the HSPH Center for Public Health Leadership—who at the time served as executive Madelyn Rhenisch director of HCFA, where he played a key role in designing, passing, and implementing the state’s health- reform law. “He was so passionate about the issue,” said Rhenisch. “And he made me feel like a worthy person who had something important to contribute.” In 2008, after a series of medical tests that she could finally afford, Rhenisch got a diagnosis: untreated Lyme disease. Three years of combination antibiotic treatment have made her nearly whole again. But the memory of 15 years of physical and mental agony hasn’t faded. “Americans believe in bootstrapping your way to opportunity—that if you work hard and be good, everything will be fine,” Rhenish reflected. “But sometimes things happen, through no fault of your own. In a flash, you can slide over that line. As I learned firsthand, there’s a set of attitudes and judgments and hoops and rules and justifications that dehumanize people.” With the new law in place, others may not have to endure the bureaucratic neglect that brought Rhenisch so much distress. “If I had had adequate health care to pursue a diagnosis, I am sure the infection would have been found much sooner,” she said. “I wouldn’t have lost the prime earning and living years of my life.” 79 Fall 2013 WORKING THE (HEALTH) SYSTEM A QUESTIONING OUR ENCHANTMENT WITH HIGH TECHNOLOGY After spending more than 25 years as a doctor—eventually becoming physician-in-chief at Boston’s Beth Israel Hospital—Howard Hiatt knew firsthand the limitations of U.S. health care: a penchant for expensive, high-tech treatments, lack of rigorous evaluation of new clinical procedures, growing numbers of patients excluded from the system, and a failure to emphasize prevention. When Hiatt became dean of Harvard School of Public Health in 1972, he saw an opportunity to address those shortcomings. Transforming the School’s Departments of Biostatistics and of Health Policy and Management, he made public health the conscience of medicine. Immediately after his appointment, Hiatt founded the Faculty Seminar in Health and Medicine, a biweekly group of more than 100 researchers who looked at public health through an interdisciplinary lens. And through a series of faculty appointments, he imported powerful new research tools and methodologies of molecular biology and the quantitative social sciences into the School’s traditionally strong research on tropical diseases, cancer, toxicology, and environmental disease. “Many [health care] problems had not only biological and clinical basis, but political and economic … and historic underpinnings,” Hiatt told the Harvard Public Health Review in 1997. Hiatt’s efforts to broaden the School’s research portfolio— to include assessment of medical procedures, clinical trials of treatment drugs, and analysis of the economics of health care systems in the U.S. and abroad—are now seen as visionary. But some faculty members at the time resisted what they viewed as an unwelcome departure from the School’s historic trajectory. Among other issues, they didn’t think public health should be the “watchdog” of medicine. In 1978, they called for Hiatt’s resignation, in a letter to Harvard’s then-president Derek Bok. But Bok strongly supported Hiatt, who continued to reshape the School’s focus until stepping down in 1984. Hiatt currently serves as associate chief of Brigham and Women’s Hospital’s Division of Global Health Equity. original form, RBRVS would have led to a drop in specialists’ incomes and a rise in the incomes of primary care physicians. But according to Hsiao, powerful specialty groups altered the original values to create a flood of well-paid specialists and a drought of low-paid primary care physicians. THE CHECKLIST APPROACH While some HSPH efforts to reduce health care costs have yet to be widely adopted, others have caught on almost instantly. One is the drive to minimize surgical mistakes and the long-term medical expenses they generate. Each year around the world, well over 200 million major surgical procedures take place— sometimes at the patient’s peril. In industrial nations, 3–16 percent of inpatient surgeries result in major medical complications. In developing countries, 5–10 percent of surgical patients die. And around the world, infections and other postoperative problems pose serious health threats. About half of these complications may be preventable, through an astonishingly simple approach: safety checklists for medical practitioners. Beginning in 2007, under the leadership of Atul Gawande, professor in the Department of Health Policy and Management, HSPH and the World Health Organization (WHO) developed a 19-item surgical checklist. Before anesthesia, for example, the checklist requires confirmation that the patient has a safe airway and proper intravenous lines for resuscitation. Before making a skin incision, the surgery team must check off that it has verbally confirmed the patient’s name and the site of the procedure. In a 2009 paper in the New England Journal of Medicine, Gawande and his colleagues found that surgeons using checklists missed minor steps in only 6 percent of surgeries, as opposed to 23 percent without checklists, leading to a dramatic difference in outcome. The WHO Surgical Safety Checklist has since been introduced in more than 4,000 hospitals worldwide. continued on page 83 80 Harvard Public Health What’s So Hard about Health Care Reform? Change is usually slow. It moves in fits and starts and veers left and right. That’s how behavioral systems move. It’s true in every facet of our government: economic policy, foreign policy, transportation policy, education policy. And proposals for policy reform are almost always heavily altered by lawmakers, because we live in an extraordinarily large society—300 million people, who don’t always agree on the proper role of government or on the tradeoffs implicit in various policies. I know of no instance when a policy reform idea went soup to nuts without modification. — ARNOLD EPSTEIN, Chair, Department of Health Policy and Management The prospect of changing the health care system generates resistance because there are huge economic interests vested in the current structure: pharmaceutical, construction, equipment, information technology. It is the largest sector of the U.S. economy and 10 percent of the global economy. And health care is a major political issue. Health systems also deal with the most vulnerable aspects of human existence: birth, death, suffering, uncertainty in the face of disease. They are our most sensitive point of contact with science and with formal institutions. — JULIO FRENK, Dean, Harvard School of Public Health In the era of the iPhone, Facebook, and Twitter, we’ve become enamored of ideas that spread as effortlessly as ether. We want frictionless, “turnkey” solutions to the major difficulties of the world—hunger, disease, poverty. We prefer instructional videos to teachers, drones to troops, incentives to institutions. People and institutions can feel messy and anachronistic. They introduce, as the engineers put it, uncontrolled variability. But technology and incentive programs are not enough …. Every change requires effort, and the decision to make that effort is a social process. … [H]uman interaction is the key force in overcoming resistance and speeding change. (Excerpt from “Slow Ideas,” in The New Yorker, July 29, 2013) — ATUL GAWANDE, Professor, Department of Health Policy and Management 81 Fall 2013 WORKING THE (HEALTH) SYSTEM HPV Screening Saving Lives in Resource-Poor Nations Each year, approximately half a million women develop cervical cancer, a malignancy linked to high-risk strains of the sexually transmitted human papillomavirus (HPV). In wealthy nations, cervical cancer deaths have plummeted over the six decades that the Pap smear has been used for routine screening. But in countries lacking the resources to support organized screening, the cancer kills nearly 200,000 women each year. Pioneering work over the past 10 years by Sue J. Goldie, Roger Irving Lee Professor of Public Health and director of the School’s Center for Health Decision Science (CHDS), predicted that two promising interventions—a rapid DNA test for cancer-causing types of HPV or visual inspection after applying acetic acid to the cervix, followed by same-day treatment—could cut cancer risk by a Sue J. Goldie, Roger Irving Lee Professor of Public Health third. Empirical data from India confirmed a 31 percent reduction in cervical cancer deaths in 150,000 women with visual screening. Since then, the HSPH team has shown, based on analyses in 25 developing countries, that the most promising approach consists of screening women three times per lifetime, between the ages of 30 and 45. This work has led to a paradigm shift—from developing new technologies to forging new strategies for delivery. More than 50 studies by Goldie and colleagues have contributed to position statements on this issue by the World Health Organization, influenced investment choices by foundations and publicprivate alliances, and framed government policies. Most recently, Goldie and colleagues assessed the impact, affordability, and cost effectiveness of preadolescent HPV vaccination, showing that a decade’s delay in access would mean the loss of more than a million lives. They argued that if the vaccine’s price were lowered, HPV vaccination would be as cost effective as childhood immunization, one of our greatest public health buys. This catalyzed the decision of the Global Alliance for Vaccines and Immunization to prioritize HPV vaccination and influenced industry to drastically lower prices—from $100 per dose to as low as $4.50. A related program in middle- and high-income countries is being led by CHDS’ Jane Kim, associate professor in the Department of Health Policy and Management. “Doing nothing is a choice,” said Goldie, who also serves as director of the University-wide Harvard Global Health Institute. “And that choice has tragic consequences: for individuals, for families, and for society.” 82 Harvard Public Health The World Health Organization’s Surgical Safety Checklist can help avert mistakes in the operating room. Gawande and his team have more recently applied this commonsensical approach to childbirth. Of the 130 million births globally each year, nearly 350,000 result in the mother’s death and 3.1 million in infant death during the neonatal period. “At times, the problem is inadequate resources,” said Gawande in 2011, “but often the issue is a lack of hand washing or screening for use of available antibiotics.” In southern India, the checklist-based childbirth safety program—dubbed the BetterBirth clinical trial—has reduced deaths and improved outcomes of both mothers and infants. In the fall of 2012, Gawande and his team launched a new center—Ariadne Labs, a collaboration between HSPH and Brigham and Women’s Hospital—to house the checklist program. EXPANDING HEALTH CARE IN THE U.S. AND BEYOND Although keeping expenses under control will be essential for the sustainability of the U.S. Medicare program and more recent health care reforms, policies that focus only on lowering spending without accounting for the effects on health benefits and value may be counterproductive. Expanding access to efficient care is a far more important factor, says Katherine Baicker, professor of health economics. In a 2008 study in Oregon—a study already considered a classic in the field of health economics—Baicker and colleagues gathered data on low-income adults who were on a waiting list to be selected by lottery for Medicaid coverage. They wanted to gauge the effect of insurance coverage on health care use, physical and mental health, continued 83 Fall 2013 WORKING THE (HEALTH) SYSTEM and financial stability. Baicker and her colleagues found that those gaining Medicaid coverage used more care— from doctors to prescriptions to hospitalizations—than did the uninsured. With that coverage came substantial reductions in financial strain and improvements in mental health and self-reported physical health, though no detectable improvements in several chronic physical health conditions. Ashish Jha, professor of health policy and management, has used innovative metrics to improve health care—examining the effects of health care reform efforts on quality and costs of care and identifying interventions that reduce inequities in care. According to Jha, “An ounce of data is worth a thousand pounds of opinion.” HSPH faculty have also been heavily involved in the United States’ latest experiment in national health care. John McDonough, professor of the practice of public health and director of the School’s Center for Public Health Leadership, advised U.S. lawmakers on health reform. In 2014, President Barack Obama’s Affordable Care Act will go into effect, giving U.S. citizens new access to health insurance. Although the expansion of government-subsidized health care remains contentious in the U.S., dozens of other nations have adopted the concept with great success. Over the last 20 years, HSPH researchers have examined those national health systems extensively, from decadesold universal health programs in Canada, Australia, and Europe to the younger universal system of Taiwan—a health care finance model designed by William Hsiao, the School’s professor of health economics, and now seen as one of the most effective examples of national single-payer health care. Hsiao also designed a plan—the New Rural Cooperative Medical System—that covers most of the hundreds of millions of previously uninsured individuals in rural mainland China. “Many members of our faculty are physicians, who have a nuanced understanding of the clinic. Others have been pioneers in statistics, epidemiology, economics, law, and sociology,” said Arnold Epstein, chair of the Department of Health Policy and Management. “In combining those two sets of expertise, we’ve come up with important new ideas for reforming health systems here and abroad.” v A Rwandan mother and her child at a malnutrition clinic in northern Rwanda. While universal health care is contentious in the U.S., Rwanda has had such a system since 2008. 84 Harvard Public Health AMONG THE HSPH ALUMNI WHO HAVE HELD LEADERSHIP ROLES AROUND THE WORLD: Current Ministers of Health Afghanistan: Suraya Dalil, MPH ’05 Thailand: Pradit Sintavanarong, MPH ’89 Indonesia: Nafsiah Mboi, TF ’91 Past Ministers of Health Papua New Guinea: Clement Malau, MPH ’95, 2007–2011 Indonesia: Endang Sedyaningsih, MPH ’92, SD ’97, 2009–2012 Taiwan: Ching-Chuan Yeh, SM ’81, 2008–2009 Colombia: Beatriz Londoño Soto, MPH ’90, 2011–2013 India: K. Sujatha Rao, TF ’92, 2009–2010 CDC Directors (Five of the last 10) Jeffrey Koplan, MPH ’78, 1998–2002 James O. Mason, MPH ’63, DPH ’67, 1983–1989 William Foege, MPH ’65, 1977–1983 David Sencer, MPH ’58, 1966–1977 James L. Goddard, MPH ’55, 1962–1966 WHO Directors Gro Harlem Brundtland, MPH ’65, 1998–2003 Heads of State Cook Islands: Thomas Davis, MPH ’54, Prime Minister, 1978–1983, 1983–1987 Norway: Gro Harlem Brundtland, MPH ’65, Prime Minister, 1990–1996 Uganda: Speciosa Wandira-Kasibwe, SD ’09, Vice President, 1994–2003 Dots indicate countries of citizenship or birth of HSPH 2013 graduates. Global Impact through Education From its earliest days, HSPH has enjoyed a reputation as a global center for public education and research, in part a reflection of the strong support the School received from the Rockefeller Foundation to promote international research and training efforts. Each year, the School graduates candidates from 60-plus countries, with a third coming from outside the U.S. Learning is a lifetime pursuit, and the School has offered numerous opportunities for public health managers and leaders to hone their abilities. For example, the Global Flagship Course on Health Systems Strengthening and Sustainable Financing—a collaboration between HSPH and the World Bank Institute—has enrolled more than 20,000 health care leaders from more than 50 countries since 1997. Since 2005, the HSPH China Initiative has convened hospital and health systems leaders from the U.S. and China for exchanges to improve health in both countries. In the last two years, two new programs aimed at ministers of health and finance, run in conjunction with Harvard’s Kennedy School and the African Bank, have attracted some 40 cabinet-level leaders from Asia, Africa, and Latin America. 85 Fall 2013 H How has public health education evolved in the last 100 years? Where is it headed in the future? Six Harvard School of Public Health faculty deeply involved in the revolution now taking place in public health education offer their perspectives. 86 Harvard Public Health TRANSFORMING PUBLIC HEALTH EDUCATION Dean John C. Snyder, then head of the Department of Public Health Bacteriology, teaches a biostatistics class in 1947. 87 Fall 2013 TRANSFORMING PUBLIC HEALTH EDUCATION EDUCATION UNBOUND Q. HSPH has been teaching students for 100 years. How are the School’s teaching methods different today from a century ago? Ian Lapp: If the School’s three founders were to stroll around the campus today, probably the only thing they would recognize is the classroom—and with our new online learning platforms, even that feature is being transformed. James Ware: There’s interesting neuroscience that suggests that the way we learn is changing. Whereas we used to accumulate a body of facts, with the Internet’s availability, we can now accumulate a body of learning skills. Memorizing a bunch of facts isn’t that helpful. What you really need are strategies for acquiring and organizing and using the information you need, at the time you need it. The actual facts we teach people are very transient. What we hope is that we’re creating a foundation. Nancy Turnbull: We’ve had a revolution in our understanding of how people learn—in particular, how adults learn—which suggests that many of the traditional modes of education simply aren’t effective. If you’ve been given a lecture, after a week or so or maybe even a day, you retain only 5 percent of what you’ve learned. If you read, your retention isn’t high. But the more actively things happen—if content is demonstrated, if you’ve had discussion groups, if you actually do something—there’s lots more active learning. In the future, we’ll see lots more problem solving in the classroom, more case-based learning, more experiential learning. We’ll move students out in the field much more, taking what they’re learning, working in small groups to actually help organizations solve problems that they’re facing. Nancy Kane: There are wonderful things faculty can do: team teaching, case-based methods, simulations, games. But teaching in these ways takes real time and effort. It’s just as hard as running a research project. Julio Frenk: We’ve tended to construe higher education as a tube that has an opening on one end—admissions—and an opening on the other end—graduation. And we assume that something good happens to students when they are inside the tube. But we need more open architecture, where people come into and out of educational institutions during their entire lifetimes. Julio Frenk is Dean of HSPH. David Hunter is Dean for Academic Affairs. Nancy Turnbull is associate dean for professional education. 88 Harvard Public Health Q. What are the hallmarks of an HSPH education? Nancy Turnbull: Students and faculty are firmly rooted in the idea of using knowledge to make positive change in the world. Our faculty are, to a person, both thinkers and doers. And students come here because they want to learn from the people who are actually creating the knowledge. Ian Lapp: HSPH has always had a reputation for an impressively well-rounded curriculum. As our educational strategy is evolving in the 21st century, we’re formalizing that model and giving it additional emphasis. We want to graduate students with “T-shaped” competencies—meaning, deep knowledge in one area of specialty, but also the breadth of knowledge—the top of the “T”—to reach out to other disciplines, other fields of inquiry. In an increasingly complex and interdependent world, public health professionals must have this kind of well-grounded but flexible orientation. Julio Frenk: This is a school that truly encompasses everything from genes to the globe. It’s a microcosm of a university, because other than the pure humanities and the arts, you have every field of inquiry: biologists, chemists, physicists, social scientists, legal scholars, ethicists, and, of course, health professionals. And there’s this pioneering spirit at the school. A lot of new fields were invented here. The current comprehensive review of our educational strategy that’s under way keeps alive this tradition of exploring new frontiers in education. We want to bring to education the same rigorous assessment and evidence base that we bring to research. Q. Is the content of an HSPH education changing? Nancy Kane: For the past 20 years or so, public health has been taught in five silos: Biostatistics, Epidemiology, Environmental Health, Health and Social Behavior, Health Policy and Management. It was up to the student to take this knowledge base and translate it into a problem-solving mode. Here’s a classic example: You run a malarial control unit in Uganda, in a province with terrible endemic malaria. You have money from the U.S. government, funds to eliminate malaria by spraying with DDT and handing out bed nets and doing the other things. But there are problems. The population doesn’t trust the government because of the history of violence in that country. Organic farming is big in that province, and once you spray DDT, the farmers go out of business. There are inadequate resources to do the DDT spraying correctly. Residents worry about what DDT does to human health and the environment. And bed nets are not always comfortable to use. This situation brings in environment, policy issues of how to make decisions, political and communication issues that come from a history of tribal distrust. This is the reality of public health interventions—and students need to be prepared to adapt to difficult scenarios that are constantly in flux. continued Nancy Kane is associate dean for case-based teaching and learning. James Ware is associate dean for clinical and translational science. Ian Lapp is associate dean for strategic educational initiatives. 89 Fall 2013 TRANSFORMING PUBLIC HEALTH EDUCATION Ian Lapp: For most of its history, public health education has been disciplinebound. So now we’re seeking to recast the core curriculum. For example, it makes sense to teach biostatistics and epidemiology together, in the same room or online arena—because that’s how these subjects play out in real life. When you’re an epidemiologist, you can analyze and perhaps draw a conclusion from data only if you know the strengths and weaknesses of the study design. Q. Are online learning platforms, such as HarvardX, also revolutionizing the way students learn? David Hunter: Dramatically. With wider bandwidth in broadband connections available in much of the world, it is now possible to make high-resolution live or filmed video without the image being jerky or taking time to download. So, at its simplest level, lecture-style classes can be offered online to thousands of people all over the world at low cost. We’re very optimistic that these new technologies will also improve the education that students get in person. In theory, at least, the technology-intensive nature of HarvardX enables us to identify struggling students more quickly, and to distinguish between the more and less engaged students. For our residential students, we are introducing this fall Bio 200, one of the introductory biostatistics courses, as a “flipped” classroom. Instead of standard lectures in front of a big class, the lectures are online. Students watch those in the evenings instead of doing homework, and then they participate in a much more active learning style in the classroom when the lectures would normally have been given. Another flipped classroom will be the blended biostatistics-and-epidemiology introductory course. Q. Do these new technologies give the School greater global reach? Ian Lapp: Nearly every week, we receive requests from institutions around the world for help in teaching students the basics of public health. By developing HarvardX courses that our colleagues can incorporate in their curricula, we are helping improve the breadth and depth of content that can be offered worldwide. David Hunter: In public health, we want to get the word out to the most people possible. Our involvement in HarvardX is substantially about getting our core public health messages and methods to the widest possible global audience. Q. In public health education, is there a tension between research and practice—the ivory tower and the community? Nancy Kane: It’s not so much a tension within the institution—it’s a tension within the educational profession. Some schools are much more practice-focused and tied in to the county or state health department—their students intern as epidemiologists or food inspectors. Our school has always focused more on research and developing a new knowledge base. Research universities tend to be stronger at developing the research to inform the practice, rather than training people in the practice. Of course, public health needs both. Julio Frenk: I think it’s a false dichotomy. The world of ideas and the world of action are not separate, as we are often led to believe. Producing and preserving knowledge, making sure that we understand the past so that we can shape the present and the future: That, to me, gets us past ivory tower versus activist models of the university. I like to think more in terms of a circle of knowledge. At HSPH, we have a single product—knowledge—and an ONLINE LEARNING: HSPH LEADS THE WAY “Of all the Harvard schools, HSPH has been the earliest and most enthusiastic adopter of the HarvardX online teaching. We had one of the first two courses and two of the first six courses—that’s punching well above our weight in terms of faculty numbers. And we are on track to be the first school to get a version of the core curriculum into HarvardX format. Within Harvard, we aspire to lead.” —D avid Hunter Dean for Academic Affairs 90 Harvard Public Health integrated process around knowledge. That includes the production of knowledge, which is done mostly through research. It includes the re-creation of knowledge through education, because good education doesn’t only transmit knowledge, it re-creates it in the mind of the next generation. It includes the translation of knowledge. One form of translation is into new technologies, such as drugs, vaccines, software. Another type of translation is into evidence that guides decision making and action. With action, the world is changed. We then ask new questions, because the world has changed. Closing the circle, we’re back into the production of knowledge. James Ware: We try to do good in the world. And occasionally, someone like a Jonathan Mann, the passionate advocate for human rights, or Alice Hamilton, the pioneer in exposing occupational hazards, comes along—someone who really does take on the villains. That reinforces that notion that we’re championing the public good. So I don’t think of it as research versus practice. When you see how politics works, for example, you realize you have to be practical. If you want to get people vaccinated, you’ve got to figure out how to do it. It’s not enough to say, “Everybody should be vaccinated.” EDUCATING LEADERS “If you look at the array of leadership positions assumed by graduates of HSPH—directors of CDC, leaders of WHO, senior figures in universities all around the world—it is evident that preparation for responsible leadership is a hallmark of the School. There’s an expectation that you will be prepared to make a real difference in the world and that you should be prepared to take on those responsibilities when they arise and you have the opportunity to serve.” —H arvey Fineberg President, Institute of Medicine HSPH Dean, 1984–1997 Q. Does one need a missionary zeal to do public health—and can it be taught? Julio Frenk: Becoming a public health professional starts with a fundamental dissatisfaction with the way things are. If you are a conformist, and you don’t mind a huge gap between what could be achieved with our current knowledge and what we actually achieve with our current practice, then public health is not for you. That dissatisfaction has to be cultivated, because it’s a dissatisfaction that needs continued to be evidence-based and value-driven. MARKS THE SPOT When Harvard University and MIT launched the digital platform edX in 2012, they began with just two courses. One of these historic offerings was Harvard School of Public Health’s class in epidemiology and biostatistics, which drew more than 50,000 students around the world, some 5,000 of whom went on to pass the final examination. “I’d have to teach another 100 years to reach that many students in person,” marveled Marcello Pagano, professor of statistical computing and one of the instructors for Health in Numbers: Quantitative Methods in Clinical and Public Health Marcello Pagano, professor of statistical computing, Department of Biostatistics Research—which, like all edX courses to date, was offered free to anyone with an Internet connection. 91 Fall 2013 TRANSFORMING PUBLIC HEALTH EDUCATION Ian Lapp: What compels policymakers and what compels individuals to change is the human story. It isn’t good enough to be grounded in your epidemiology, biostatistics, and environmental health. If our graduates can’t figure out both the art and science of creating change, we haven’t done our jobs. This sense of public health mission also means that in the ongoing search for student talent, the School will not judge somebody only by the higher degrees they have, but by the experiences and creativity and passion that they bring to the place. Nancy Kane: The reason I like teaching here is the idealism. HSPH students want to save the world. We have students ranging from third-year medical students, who are often passionately idealistic, to 50- to 60-year-old seasoned professionals in the public health or the health delivery system worlds, who may not be as idealistic but are still inspired by what they learn here. They go out with renewed vigor, confident that they can make the world a better place. That’s what we do. We inspire people. v AGAINST LOST CAUSES “In my first speech to the School’s faculty and friends, I confessed that one of my attractions to public health was a long-standing passion to fight for lost causes. I quoted T.S. Eliot: If we take the widest and wisest view of a Cause, there is no such thing as a Lost Cause because there is no such thing as a Gained Cause. We fight for lost causes because we know our defeat and dismay may be the preface to our successors’ victory, though that victory itself will be temporary; we fight rather to keep something alive than in the expectation that anything will triumph. “It is gratifying to be able to say that public health is no longer perceived as a ‘lost cause.’ It is not yet, however, a ‘gained cause.’” — B arry R. Bloom HSPH Dean, 1999–2008 High-tech facilities are helping HSPH reach students around the world. 92 Harvard Public Health HUMANITARIAN ACADEMY Future humanitarian responders can learn valuable skills in the classroom, but they need to experience the chaos of crisis to prepare for the demands of fieldwork. HSPH fills that gap with an intensive course offered through The Lavine Family Humanitarian Studies Initiative, the flagship training and professional development program of the Humanitarian Academy at Harvard. The course culminates in a simulated humanitarian crisis held in a nearby state forest. Students work in teams to develop a refugee aid plan while contending with a host of distractions, from child soldiers to rogue journalists. The lessons are potentially lifesaving—for the students and the people they will serve. “Father” of Harvard School of Public Health In late 1921, with long-awaited funding of $1.6 million from the Rockefeller Foundation, an independent Harvard School of Public Health succeeded the Harvard-MIT School for Health Officers. Harvard University President Abbott Lawrence Lowell empowered a special committee to undertake the massive project of planning departmental composition and curriculum for the newly endowed degree-granting institution. No one played a larger role in this exhilarating transition than Roger Irving Lee, Henry K. Oliver Professor of Hygiene, who chaired the three-member committee. “Dr. Lee has been called ‘the father’ Roger Irving Lee of the Harvard School of Public Health both because the School was ‘his baby’ and because he was able to foresee what this infant would be when it grew to maturity,” read an article in the November 1949 Harvard Public Health Alumni Bulletin. In addition to Lee, the committee’s members were Milton Rosenau, one of the School’s three founders, and future dean Cecil Drinker. Lee was prescient on a wide range of issues. He voiced early support for admitting women, foresaw the relationship between public health and other social sciences, including economics, envisioned a separate department of what was then known as child hygiene, committed the School to industrial health (paving the way for HSPH’s ongoing contributions to workplace safety), and recognized the importance of working hand in hand with community services. Along with being a key architect of the HSPH that exists today, Lee was known for his kindness. From autumn of 1922 to the spring of 1923, he served as acting dean while Dean David Linn Edsall was occupied with educational surveys in Europe. On December 13, 1922—faced with a busy administrative agenda—his thoughts nonetheless turned to students, and he asked his secretary to be sure they were “looked out for” and had “as many invitations as possible” during the holiday season. “[W]hen this busy man can make it his job to see that students are taken care of during the holiday season, the sensitivity of his character is thus established,” the Bulletin piece continued. “If the humanism of this man emerges even when he is most involved with the plans for a complex endeavor, then his character begins to partake of greatness.” 93 Fall 2013 TRANSFORMING PUBLIC HEALTH EDUCATION Making the Leap VETERINARIANS AND PUBLIC HEALTH Mark Schembri, MPH ’11, never met James Steele, MPH ’42. But in his passion for understanding animalborne epidemics, Schembri is carrying on Steele’s powerful legacy. Steele—the lone veterinarian in a class of physicians at HSPH, and only the second vet to attend the School— is known as “the father of veterinary public health.” He launched the Veterinary Public Health division of the U.S. Centers for Disease Control and Prevention (a model adopted by the World Health Organization and other international agencies), served as the first Assistant Surgeon General for Veterinary Affairs, spearheaded research that led to the development of a safe and effective rabies vaccine, directed interventions that contained and prevented Veterinarian Mark Schembri, MPH ’11 such infections as brucellosis and salmonellosis, and in 1959 nearly died from a vicious form of H7N7 avian flu. Steele currently serves as professor emeritus at the University of Texas School of Public Health. Schembri’s passion for understanding zoonoses—infections transmitted from animals to humans—is a natural extension of Steele’s pioneering work. “Harvard leads the world in dealing with infectious disease outbreaks,” said Schembri, a veterinarian and horse specialist in Australia, explaining why he came halfway around the world for his degree. “Whether it’s cholera in Haiti or anthrax in New York, Harvard plays a role in prevention and response. I wanted to learn from one of the greatest universities how to approach these threats.” Three-quarters of emerging infections—from SARS to bird flu to HIV/ AIDS—begin in animals and then jump to humans. It is no exaggeration to say that the future of humankind will in part hinge on gaining a better understanding of the complex and mysterious paths of cross-species transmission. One of the earliest to recognize this truth was Steele. “Human and animal health are inextricably linked,” he observed. “They always have been. They always will be.” The same could be said of the passion that Steele and Schembri bring to their shared profession. Having, like the School itself, turned 100 in 2013, James Steele is believed to be HSPH’s oldest living alumnus. James Steele, MPH ’42—born in 1913, the School’s oldest known living alumnus 94 Harvard Public Health T Flexner’s vision. REPORTS HEARD ’ROUND THE WORLD The man whose muckraking 1910 report spurred a wholesale reform of U.S. medical education had never been a student in the system he critiqued. A veteran schoolteacher and principal from Kentucky, Abraham Flexner had a passionate interest in pedagogical strategy, fueled by study at Harvard and visits to schools in Europe. His unlikely career as a medical reformer began after his book The American College apparently caught the attention of the head of the Carnegie Foundation for the Advancement of Teaching, leading to an invitation to survey medical schools throughout the United States and Canada and make suggestions for their improvement. Medical Education in the United States and Canada —now known simply as the Flexner Report—was a stinging indictment of the era’s medical schools, which for the most part operated as for-profit diploma mills with notoriously lax standards. Flexner proposed that the multitude of vastly inadequate schools be replaced with far fewer but infinitely better university-based programs designed along the lines of German medical education. In particular, Flexner changed the doctor’s education from an apprenticeship model to an academic model, establishing rigorous science and other requirements. The Flexner Report gained regulatory support from the enactment of state licensing laws, leading to the closure of many schools, while others moved to align themselves with Two years after his report’s publication, Flexner ascended to the rank of secretary of the Rockefeller Foundation, where the reform impulse soon expanded to the newly burgeoning field of public health. In 1915, the Welch-Rose Report that evolved from Rockefeller Foundation deliberations outlined a system of public health education for the United States—essentially doing for public health what the Flexner Report had done for medicine. One notable feature of the new report was the competing visions of its two architects. While Wickliffe Rose favored an emphasis on public health practice, William Henry Welch favored an emphasis on scientific research, the approach that ultimately won Rockefeller support to create the Johns Hopkins School of Public Health in 1916 and, five years later, to establish Harvard School of Public Health independent from MIT, its partner since 1913. In 2010—a century after the Flexner Report changed the face of medical education—a global independent commission co-chaired by HSPH Dean Julio Frenk took its place in the series of historic reports aimed at reforming health education. Like the Flexner and Welch-Rose reports before it, the commission’s report, published in full in the December 2010 issue of The Lancet, targeted the most urgent health issues of the day. Among them: nations’ glaring lack of preparedness for new health threats emerging in a time of rapid demographic and epidemiological transition, and the need for “transformative learning” geared to producing professional leaders within a framework of interdependent professions and institutions. As the commission wrote, “[W]e call for a global social movement of all stakeholders—educators, students and young health workers, professional bodies, universities, nongovernmental organizations, international agencies, donors, and foundations—that can propel action on this vision and these recommendations to promote a new century of transformative public health education.” 95 Fall 2013 TRANSFORMING PUBLIC HEALTH EDUCATION ALUMNI/STUDENT VOICES Anne Newland, MPH ’13 “Medical school and residency are where you learn to take care of individuals. An MPH helps prepare you to take care of communities.” John Jackson, SD ’13, Horace W. Goldsmith Fellow “A lot of issues—not just medical treatment itself, but also large social forces such as access to care, poverty, and discrimination—shape people’s health. Finding a successful treatment is an important step in improving population health, but it’s one step among many. One of my research interests is the effectiveness and safety of psychotropic medications and interventions for mental health. I want to understand how they work, why they work, and in what settings, so that we can improve these treatments and the ways they are used.” Panji Hadisoemarto, SD ’14 “In my opinion, the best place to thrive is the place that is least developed. I like research, but I don’t want to do research for itself. I want to see change.” 96 Harvard Public Health Harvard School of Public Health GRADUATES BY THE NUMBERS 1914 TOTAL GRADS: 5 Women: 0 International: 0 1936 TOTAL GRADS: 26 Women: 2 International: 7 1968 TOTAL GRADS: 166 Women: 34 International: 32 2004 TOTAL GRADS: 413 Women: 223 International: 128 1915 First woman admitted (Linda James) First international students admitted (Sien-Ming Woo and En Tseng Hsieh) 1945 TOTAL GRADS: 23 Women: 13 International: 17 1975 TOTAL GRADS: 180 Women: 50 International: 75* 1953 TOTAL GRADS: 110 Women: 27 International: 47 1988 TOTAL GRADS: 217 Women: 101 International: 65* 1926 TOTAL GRADS: 5 Women: 0 International: 0 1996 TOTAL GRADS: 314 Women: 178 International: 103* 2013 TOTAL GRADS: 558 Women: 315 International: 219 *graduates of this class currently living outside the United States WORLD MUSIC Since 1961, Shattuck International House, a complex of furnished apartments owned and managed by HSPH, has served as a home away from home for more than 3,000 students and their families. Residents—about 60 percent of whom come from abroad—study together, celebrate milestones and holidays as a community, and stage talent shows and potluck dinners showcasing their diversity. 97 Fall 2013 P u CAMPUS SNAPSHOTS 100 YEARS OF STUDENT LIFE Thomas Davis, MPH ’54, arrived at HSPH two months tardy, but his $10 late registration fee was waived — presumably because he had just sailed more than 10,000 miles to get there. Davis, a surgeon from the Cook Islands, spent five months traveling with his wife, two sons, and two crewmen from Wellington, New Zealand. He was elected class president soon after his arrival, according to the Harvard Crimson, “following a bibulous beer party for him in the School’s staid lobby.” Davis returned to the Cook Islands after graduation, where he later served two terms as prime minister. u Prince Mahidol Songkla of Thailand (then Siam) kept a low profile while he was a student at HSPH’s predecessor, the Harvard-MIT School for Health Officers, from 1919 to 1921. Years later, classmate Roy Campbell recalled his surprise when the “smart, very nice fellow” he went to movies with revealed his royal lineage just before returning home. Campbell regretted that he had to decline Songkla’s invitation to visit due to the $600 ticket price. Although the prince lived to be just 37, he is revered as the “Father of Modern Medicine” in Thailand for his efforts to enact health care reforms and expand opportunities for public health and medical education in his country. “I recall Philip Drinker taking us through factories telling us to watch for dirt and accident hazards, and not to take notes in front of our hosts,” James M. Dunning, MPH ’47, wrote in a class note in the Spring 1978 Harvard Public Health Alumni Bulletin. “As an alternative to vacation between the terms, there were ‘volunpulsory’ field trips.” These visits—the predecessors to today’s WinterSession courses—included trips to the New York State public health laboratories, day-care nurseries in New York City, and sewage works and candy factories in Boston. (HSPH yearbook, 1955.) u “But most of all, I remember the times we spent in this room. Eating lunch. Trying to make coffee for 25 people with only three paper cups. I think that’s how it is in Public Health. We’re lucky to have such a good group of people, because otherwise it would be pretty rough. Somehow, we always manage to get coffee.” (HSPH yearbook, 1965.) 98 Harvard Public Health Joan Barenfanger, SM ’71, conducted epidemiological studies on trachoma in the oasis and desert villages surrounding the HSPH Microbiology Department’s field station in Dhahran, Saudi Arabia. “For me, it put the ‘public’ into public health to be in a country where 90 percent of the population” suffered from the infectious eye disease, she wrote in the Summer 1973 Harvard Public Health Alumni Bulletin. u At the 1974 year-end party, the highest-bid-upon item in the first-ever auction for the student loan fund was a bread baking lesson by Dean Howard Hiatt. Robert Reed, professor of biostatistics, entered two original sculptures in the auction. His creation, Aspiring Worms, which was made of Styrofoam packing material, was stolen during the event. u Posters at HSPH’s June 1988 Commencement ceremony honored alumna Heng Leng Chee, SM ’79, one of nearly 100 Malaysian citizens of Chinese ancestry arrested the previous October and placed under what the Malaysian government termed “preventive detention to avoid racial conflict.” An advocate of women’s rights and the welfare of the poor, Chee was investigating the socioeconomic determinants of health status in a squatter community in Kuala Lumpur at the time of her arrest. Letter writers in a campaign for Chee’s release included HSPH Dean Harvey Fineberg, Harvard President Derek Bok, and Massachusetts Senators Edward Kennedy and John Kerry. Chee was released in August 1988. u When physician Magdalena Serpa entered the class of 1985 at HSPH, it was an unusual homecoming. She was born in Boston in 1959 while her father, Fernando SerpaFlorez, a former secretary general in Colombia’s Ministry of Health, was an HSPH student. Serpa subsequently pursued a career in child health and nutrition policy. Dora Anne Mills, MPH ’97, earned her master’s studying part-time while maintaining her pediatric practice in rural Maine. The brutal commute was worth it for Mills, who told the Harvard Public Health Review in 1996 that her training would allow her to accomplish more through systemic change than she could through individual patient care. Mills later served as director of the Maine Center for Disease Control and Prevention for 15 years and is credited with reducing the state’s rates of tobacco use, teen pregnancy, and childhood obesity, 99 Fall 2013 A Century of Powerful A quick summary of some of the ways HSPH has changed our lives Overcoming Polio HSPH’s Thomas Weller shared the 1954 Nobel Prize in Physiology or Medicine with colleagues John Enders and Frederick Robbins of Harvard Medical School for their monumental 1949 discovery of a way to grow the polio virus in non-nerve-tissue cultures. Their work paved the way for the development of polio vaccines in the mid-1950s. Prior to this, the mechanical respirator known as the “iron lung,” which was invented by HSPH faculty member Philip Drinker and colleague Louis Agassiz Shaw and first used on an 8-year-old girl in 1928, was responsible for preserving the lives of thousands of polio victims rendered unable to breathe without assistance. SMALLPOX ERADICATION HSPH alumnus William Foege developed the “surveillance and containment” vaccination method, which played a critical role in the eradication of smallpox, saving tens of millions of lives worldwide since the last naturally occurring case of the disease was reported in 1977. 100 Harvard Public Health Ideas Healthier Eating HSPH has provided millions with simple guidelines on healthier eating and the scientific support behind those guidelines for more than 70 years. Established in 1942, the School’s Department of Nutrition is the oldest of its kind within an American medical or public health school. MILLIONS SPARED FROM CHOLERA DEATH Cleaner Air and Pollution Policy HSPH’s Six Cities Study demonstrated the dangers of small-particle pollution caused by fossil fuel combustion, as well as the risks of indoor pollution to human health. The landmark study provided key evidence for revisions to the U.S. Clean Air Act, which is credited with saving millions of lives and preventing tens of millions of cases of pollutionrelated illness. Oral rehydration therapy, a low-cost, low-tech solution developed by HSPH’s Richard Cash and colleague David Nalin, is credited with sparing tens of millions who would otherwise have died from dehydration due to cholera and other diarrheal diseases. saving premature infants An HSPH postdoctoral student by the name of Mary Ellen Avery helped prevent the deaths of more than 14,000 premature infants each year by discovering that the absence of a certain mix of fat and proteins in their lungs is the most common precursor of death in these babies. 101 Fall 2013 A CENTURY OF POWERFUL IDEAS taking on lyme disease HSPH’s Andrew Spielman in 1976 discovered the deer tick that transmits Nantucket fever, which was later shown to transmit Lyme disease as well. Spielman also recommended the now widely used strategy of culling deer populations to reduce Lyme disease. SARS HSPH faculty developed a mathematical model for predicting the spread of SARS, which helped public health officials plan effective strategies for containing the epidemic when it threatened lives and economies in 2003. SARS began in China, jumped to Hong Kong, and ultimately spread to 37 countries. fighting fat HSPH researchers were instrumental in proving and publicizing the dangers of trans fats, leading to bans, new food labeling standards, and the removal of these heart-harming fats from many restaurants and packaged foods. HSPH researchers also helped show that not all fat is “bad fat,” revolutionizing nutritional advice from the U.S. government and health experts worldwide. 102 Harvard Public Health AN ASPIRIN A DAY HSPH’s Charles Hennekens and colleagues demonstrated the protective effects of taking one aspirin daily, inspiring doctors to recommend this simple means of reducing the risk of heart attack, stroke, and other health problems to millions of people. Designated Driver Campaign HSPH made the phrase “Designated Driver” part of popular culture in the U.S., changing social norms and public policies around drunken driving. A campaign initiated by Jay Winsten, Frank Stanton Director of the School’s Center for Health Communication, in 1988 partnered with an array of Madison Avenue marketing firms, TV networks, and Hollywood media to curb alcohol-related traffic accidents by promoting the phrase. The concept of a “designated driver” was incorporated into the scripts of more than 160 episodes of popular shows. Six years into the campaign, new laws and stricter enforcement—and the designated driver campaign—had contributed to a 30 percent drop in alcoholrelated fatalities. FOCUS ON CANCER PREVENTION A pivotal HSPH report in 1996 compelled a greater emphasis on lifestyle changes in cancer prevention strategies by showing that more than half of U.S. cancer deaths result from behavior choices, including smoking, poor diet, obesity, and lack of exercise. Obese Mice and Disease Prevention HSPH’s Gökhan Hotamisligil and colleagues developed genetically engineered obese mice resistant to many of the ill effects of excess weight, improving our understanding of what happens when the body’s metabolic machinery is overwhelmed by excess nutrients and fats. 103 Fall 2013 A CENTURY OF POWERFUL IDEAS Genetic Detective Work HSPH formulated statistical methods that led to the identification of genetic variants that increase susceptibility to a wide variety of diseases, including breast cancer. The School also made fundamental discoveries that help explain the underlying causes of diseases connected to obesity, including type 2 diabetes and heart disease. Making Surgery Safer Surgical errors and complications were reduced by more than one-third in many operating rooms around the U.S. and worldwide, thanks to a surgical checklist initiative begun in 2008 and led by HSPH’s Atul Gawande and colleagues working with WHO. Right to Die, Patients’ Rights The School developed criteria that shaped guidelines for the nation’s first legislation on brain death, helping inform the “right to die” debate. 104 Harvard Public Health PATIENT SAFETY MOVEMENT HSPH launched the “patient safety movement” with the publication of the landmark Harvard Medical Practice Study in the early 1990s, which established the standard by which adverse events are measured and showed that a substantial number of patient injuries in hospitals are caused by preventable medical errors and substandard care. The Institute of Medicine’s 1999 report, To Err Is Human, put the number of hospital deaths caused by medical errors at an estimated 44,000–98,000 annually. bias in medical care The School exposed potential biases in how medical professionals treat poor and minority patients by providing evidence of disparities in rates of surgery and quality of care. $ 105 Fall 2013 Cost Effectiveness in Medical Care HSPH forged the discipline now known as health decision science with pioneering studies of the cost effectiveness of medical interventions. HEALTH MAKES WEALTH The concept of the “demographic dividend” pioneered by HSPH faculty member David Bloom and colleagues was featured in Time magazine’s “Ten Ideas That Will Change the World,” published in March 2011. The concept describes changes that could occur in developing countries as health improvements and falling infant mortality lead to a baby boom generation and eventually lower birth rates, fueling rapid economic growth. A CENTURY OF POWERFUL IDEAS Battling Binge Drinking The Harvard College Alcohol Study, led by HSPH’s Henry Wechsler, documented that binge drinking can be curtailed by a combination of actions, including changing the culture around drinking, instituting and enforcing strong drunken driving laws, passing laws preventing highvolume sales (drinks served in pitchers or buckets, putting restrictions on keg sales), and limiting irresponsible marketing practices such as 25-cent beers, ladies’ nights, and all-you-can-drink specials. The study also documented the extent of binge drinking among college students and its effects not only on the drinkers but on other students and nearby neighborhoods. inventing veterinary public health James H. Steele, MPH ’42, helped lay the groundwork for much of our understanding of how diseases jump from animals to people and spearheaded pioneering work leading to development of a safe, effective rabies vaccine. Steele, who was born in 1913, the same year that the Harvard-MIT School for Health Officers was founded, is among the School’s oldest living alumni. Eradicating Guinea Worm Disease HSPH alumnus Donald Hopkins, MPH ’70, has played a leading role in the Guinea worm disease eradication effort since 1986. At that time, there were 3.5 million cases of the disease worldwide; in 2012, there were fewer than 600. 106 Harvard Public Health Tackling tobacco More than 30 years ago, HSPH’s Dimitrios Trichopoulos published a paper that provided definitive evidence of a link between “secondhand smoke” and lung cancer in nonsmokers. Still on the front lines of the fight to control tobacco today, HSPH has worked with officials across the U.S. and around the world, including leaders from Armenia, China, El Salvador, Greece, Ireland, Israel, Philippines, Poland, and Taiwan to advance tobacco control strategies such as bans on smoking in public places. Leaders, Leaders, Leaders HSPH graduates have led dozens of local, state, national, and international health agencies, and even national governments. Two HSPH alumni have been heads of state. Five of the last 10 directors of the U.S. Centers for Disease Control and Prevention are HSPH alumni. One HSPH alumna headed the World Health Organization. Award Winners Faculty members have received the Nobel Prize or headed an organization that received the Nobel. Many more faculty and alumni have received major academic and research awards and honors, including the MacArthur Foundation “genius grants,” the Presidential Medal of Freedom, and many others. 107 Fall 2013 A CENTURY OF POWERFUL IDEAS documenting the global burden of disease HSPH faculty collaborated with more than 300 other institutions in 50 countries on the ambitious 2010 Global Burden of Disease Study, which provided key insights into the changing causes of disease and death around the globe. Revolutionizing Clinical Trials Research Through the efforts of HSPHâ€™s Marvin Zelen, Stephen Lagakos, and others, HSPH helped transform clinical trial research into a well-managed, statistically sophisticated branch of medical inquiry, setting the standard for data management in areas such as drug trials, cancer studies, and AIDS clinical trials. Curbing Cervical Cancer HSPHâ€™s Sue Goldie used predictive modeling to find the most cost-effective strategies to screen for and vaccinate against human papillomavirus, the virus linked to cervical cancer. Work by Goldie and colleagues has informed position statements on this issue by the World Health Organization, influenced investment choices by foundations and public-private alliances, and helped frame government policies in poor and middle-income regions, where the disease kills more than 200,000 women each year. health impact of heavy metals HSPH environmental health experts demonstrated the dangers posed to human health by heavy metals such as lead, arsenic, and manganese. Used predictive modeling to find the most cost-effective 108 Harvard Public Health oxygen and gas HSPH faculty developed protective oxygen masks used by U.S. pilots in WWII and invented protective gas masks for the Army’s Chemical Warfare Service. “ Thank God for Marvin Zelen!” HSPH’s Marvin Zelen and colleagues investigated a cluster of childhood leukemia cases in Woburn, Massachusetts, in the early 1980s, implicating the town’s contaminated water supply in a variety of adverse health effects. The high-profile case, which spurred Congress to expand Superfund legislation and funding, was later dramatized in the book and movie A Civil Action. Physician Payment System creating the first state-level single-payer health system A team led by HSPH’s William Hsiao crafted the plan for Vermont’s singlepayer health insurance system—the first of its kind in the U.S.—which was signed into law in 2011. According to the New England Journal of Medicine, administrators expect the program to provide both expanded health care services and net savings of $35 million in 2017, the program’s first year of operation. William Hsiao and colleagues also developed the resource-based relative value scale method, which is used to calculate compensation rates for medical procedures in most public and private insurance programs in the U.S. and many other countries. 109 Fall 2013 A CENTURY OF POWERFUL IDEAS Pioneering Aerospace Medicine In a career spanning more than 30 years—from the mid-1930s and the earliest days of commercial aviation to the early 1970s—Ross McFarland, who joined HSPH in 1947, contributed to the birth of aerospace medicine. McFarland studied how oxygen deprivation can cloud judgment, evaluated the size and illumination of instrument panels on planes to see if they were legible at extreme speeds, and worked with Pan American Airlines to study pilot fatigue on long flights. He corresponded with Amelia Earhart prior to her doomed flight around the world and was friends with Charles Lindbergh and many other pilots. The warning you hear on every commercial airline flight— “In the unlikely event of a drop in cabin pressure . . . ”—is the result of studies conducted by Ross McFarland. Ross McFarland 110 Harvard Public Health D professionals, and reporters. country in the world. good science.” The Nutrition Source Do a Google search on the terms “carbohydrate,” “sugary drinks,” “fats and cholesterol,” or “fruits and vegetables,” and one of the top results invariably will be The Nutrition Source. Launched by Harvard School of Public Health’s Department of Nutrition in 2001—when low-fat diets were popular, the harmful effects of trans fats were becoming apparent, and even the U.S. Department of Agriculture was issuing dietary advice that was not scientifically valid—the website provides evidencebased information for consumers, health Accepting no advertising or commercial sponsorship, The Nutrition Source offers objective, unbiased information on one of today’s most contentiously debated public health questions. Each month, it draws some 500,000 unique visitors. In the dozen years since it was established, the site has hosted visitors from every “Nutrition information in the media is loaded with sensationalized claims touting the benefits of this food or that. This is especially true with diet books authored by celebrities who don’t have science-based expertise,” explained the site’s editorial director, Lilian Cheung, lecturer on nutrition and director of Health Promotion and Communication in the Department of Nutrition. “Scientific studies can also be confusing and contradictory when journalists report on single-study findings without putting new evidence into the larger perspective of existing research on the subject.” At The Nutrition Source—http://www.hsph.harvard.edu/nutritionsource—HSPH faculty and other invited experts review all content before it is posted. Information is re-reviewed regularly, to ensure that it is timely and scientifically up to date. “We want to tell the truth,” said Cheung, “supported by 111 Fall 2013 IMAGE CREDITS DEAN’S MESSAGE 2: Kent Dayton/HSPH 42: Big Cheese Photo LLC/Alamy 43: Kent Dayton/HSPH; courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine 84: ©William Campbell/Corbis THEN & NOW 6: Anne Hubbard/HSPH 7: ©Jose Luis Palaez/gettyimages.com TRANSFORMING PUBLIC HEALTH EDUCATION 86–87: courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine 88: Kent Dayton/HSPH 89: Kent Dayton/HSPH; Aubrey Calo/HSPH 90: Kent Dayton/HSPH 91: Kent Dayton/HSPH; courtesy of Institutes of Medicine 92: Kent Dayton/HSPH 93: Aubrey Calo/HSPH; courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine 94: ©Harvard University/Rose Lincoln, staff photographer; Courtesy of James Steele 96: Kent Dayton/HSPH 97: Kent Dayton/HSPH, Harvard Public Health Alumni Bulletin 98–99: Harvard Public Health Alumni Bulletin THE DNA OF PUBLIC HEALTH 44–45: ©Pasieka/Science Source 46: iStock 47: Kent Dayton/HSPH 48: iStock; Kent Dayton/HSPH 49: ©Lou Linwei/Alamy FOUNDERS & DEANS 8–10: courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine 10: Institutes of Medicine 11: [all] Kent Dayton/HSPH DEADLY ENVIRONMENTS 50–51: ©Bettmann/CORBIS 52: Kent Dayton/HSPH 53: US Postal Service; ©Underwood & Underwood/Corbis 55: Argonne National Labs 56: courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine 57: Kent Dayton/HSPH, Museum of Science and Industry, Chicago/Getty Images 58: reprinted from SERC email@example.com/woburn/resources 59: ©onepamop/iStock 60: Kent Dayton/HSPH 61: courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine FIRST WOMEN 12–13: (background) Bentley Historical Library; University of Michigan; Courtesy the CDC; Minnesota Historical Society; Getty Images; ©The New York Times; ©2013 J. D. Levine Photography INFECTIOUS DISEASES & PANDEMICS 14–15: 3D4Medical /Science Source 16: ©Marion Kaplan/Alamy 17: The Carter Center/L. Gubb; Kent Dayton/ HSPH 18–19: courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine 20: ©Piyal Adhikary/epa/CORBIS 21: © David Clift 23: © Harvard University/Justin Ide, staff photographer 24–25: Kent Dayton/HSPH 26: courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine 27: iStock; Harvard School of Public Health 28: Kent Dayton/HSPH 29: Joerg Mikus/TAP/iStock; Kent Dayton/ HSPH A CENTURY OF POWERFUL IDEAS 100: ©Bettmann/CORBIS; The Granger Collection, New York; Eye of Science / Science Source 101: foodfolio/Alamy; one eye/Alamy; Tim Gainey/Alamy Getty Images; iStockphoto 102: Kent Wood/Science Source; ©Han Yiming/FEATURE-CHINA/epa/CORBIS; Kent Dayton/HSPH 103: Istock photo; Mode Images/Alamy; ©Z5556_Waltraud Grubitzsch/dpa/CORBIS 104: Tristan3D/Alamy; HSPH; Peter Stroumtsos/Alamy; Tips Images/Superstock 105: ©Paul Austring/First Light/CORBIS; Tim Graham/Alamy 106: ©Pascal Deloche/GODONG/Godong/ CORBIS; Inga Spence/Alamy; ©The Carter Center/L. Gubb 107: Istock; Kent Dayton/HSPH; ©Ted Spiegel/ CORBIS 108: ©The iSpot/Dan Bejar; BSIP SA/Alamy; Alamy 109: Superstock/Superstock; ©Tony Rinaldo/ HSPH 110: courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine; ©Museum of Flight/CORBIS 112: Kent Dayton/HSPH POVERTY, DISASTER & HEALTH AGAINST ALL ODDS 62–63: ©Ian Teh/Panos Pictures 64: © Bettmann/Corbis 65: © Harvard University/Justin Ide, staff photographer; gritty.com for Physicians for Human Rights 66: © John Gress/Reuters; Kent Dayton/HSPH 67: ©Harvard University/Justin Ide, staff photographer 68: courtesy of Harvard Medical Library, Francis A. Countway Library of Medicine ©AP/CORBIS 69: Jake Peters 70–72: Kent Dayton/HSPH 73: Photo courtesy of Mary Revelle Paci HEALTH & HOW WE LIVE 30–31: ©Digital Vision/gettyimages.com 32: ©Alan Schein Photography/Corbis 33: Kent Dayton/HSPH 34: ©Richard Nowitz/National Geographic Society/CORBIS, Kent Dayton/HSPH 35: ©Larry Williams/Corbis 36: iStock 37: U.S. Department of Agriculture 38: iStock 39: courtesy of Mothers Against Drunk Driving (MADD) 40–41: ©Nicholas Eveleigh/Alamy; ©JimHarrison WORKING THE (HEALTH) SYSTEM 74–75: Blend Images/Alamy 77: HSPH 79: Kent Dayton/HSPH 81: Kent Dayton/HSPH; Aubrey Calo/HSPH 82: Harvard University/Rose Lincoln, staff photographer 83: ©Genevieve Ross/AP/CORBIS 112 Harvard Public Health HARVARD PUBLIC HEALTH DEAN OF THE FACULTY Julio Frenk VISITING COMMITTEE Jeffrey P. Koplan, MPH ’78 Chair Nancy E. Adler Anita Berlin Joshua Boger Lincoln Chen Walter Clair, MPH ’85 Lawrence O. Gostin Anne Mills Kenneth Olden Barbara Rimer Mark Lewis Rosenberg John W. Rowe Bernard Salick Edward M. Scolnick Burton Singer Kenneth E. Warner BOARD OF DEAN’S ADVISORS Theodore Angelopoulos Katherine S. Burke Christy Turlington Burns Ray Chambers Gerald L. Chan, SM ’75, SD ’79 Lee M. Chin, SM ’75, SD ’79 Jack Connors, Jr. Jamie A. Cooper-Hohn Matthew Fishman C. Boyden Gray Stephen B. Kay Jeannie Lavine Jonathan Lavine Catie Marron Matthew McLennan Monika McLennan Richard L. Menschel* Roslyn B. Payne Barbara Picower Swati A. Piramal, MPH ’92 Alejandro Ramirez Carlos E. Represas Richard W. Smith Howard Stevenson Samuel O. Thier Katherine Vogelheim *emeritus Harvard Public Health is published three times a year for supporters and alumni of Harvard School of Public Health. Its readers share a commitment to protecting the health and improving the quality of life of all people. Harvard Public Health Harvard School of Public Health Office for External Relations 90 Smith Street Fourth Floor Boston, Massachusetts 02120 (617) 432-8470 Please visit http://www.hsph.harvard.edu/news/ magazine/ and email comments and suggestions to firstname.lastname@example.org. Dean of the Faculty Julio Frenk T & G Angelopoulos Professor of Public Health and International Development Vice Dean for External Relations Ellie Starr Associate Vice Dean for Communications Julie Fitzpatrick Rafferty Director, Strategic Communications and Marketing Samuel Harp Editor Madeline Drexler Assistant Editor Amy Roeder Senior Art Director Anne Hubbard Senior Digital Designer Alicia Doyon Assistant Director for Development Communications and Marketing Amy Gutman Principal Photographer Kent Dayton Contributing Photographers Aubrey Calo, David Clift, Tony Rinaldo Marketing and Development Communications Manager Daphne Mazuz Marketing and Communications Coordinator Danielle Stevenson Contributing Writers and Researchers Karen Brown, Laurie Covens, Todd Datz, Jack Eckert, Erin Graham, Elizabeth Gudrais, Karen Feldscher, David Levin, Daphne Mazuz, Debby Paddock, Tamara Tiska, Peter Wehrwein Copy Editor Michael Trotman © 2013 President and Fellows of Harvard College ALUMNI COUNCIL As of November 2012 Officers Elsbeth Kalenderian, MPH ’89 President Anthony Dias, MPH ’04 President-Elect Ramon Sanchez, SM ’07, SD ’11 Secretary Royce Moser, MPH ’65 Immediate Past President Alumni Councilors 2010–2013 Teresa Chahine, SD ’10* Sameh El-Saharty, MPH ’91 Chandak Ghosh, MPH ’00 2011–2014 Haleh Armian, SM ’93 Michael Olugbile, MPH ’11* Alison Williams, PD ’10 2012–2015 Marina Anderson, MPH ’03 Robert Buelow, SM ’12* M. Rashad Massoud, MPH ’93 *Class Representative For information about making a gift to the Harvard School of Public Health, please contact: Ellie Starr Vice Dean for External Relations Office for External Relations Harvard School of Public Health 90 Smith Street Fourth Floor Boston, Massachusetts 02120 (617) 432-8448 or email@example.com For information regarding alumni relations and programs, please contact, at the above address: Jim Smith, Assistant Dean for Alumni Affairs (617) 432-8446 or firstname.lastname@example.org www.hsph.harvard.edu/give 113 Fall 2013 114 Harvard Public Health 115 Fall 2013 Harvard University Office for External Relations 90 Smith Street Boston, Massachusetts 02120 Nonprofit Org. U.S. Postage PD Burlington, VT Permit No. 586 Change Service Requested Keep up to date on events Get More HSPH History Online planned for the Schoolâ€™s Centennial year and discover more HSPH history at www.hsph. harvard.edu/centennial. Explore an interactive timeline, dig into catalogs and other historical materials, and learn surprising facts from the Schoolâ€™s long record of accomplishments. Send ideas, questions, and comments to email@example.com.