Harvard Public Health, Winter 2012
Public health in a place called happiness
HSPH.HARVARD.EDU 2012 Annual Gift Report HARVARD PUBLIC HEALTH Winter 2013 The Prostate Cancer Predicament Painting the Big Picture on a Navajo Reservation Public Health in a Place Called Happiness DEAN’S MESSAGE W A Legacy Worth Preserving hen I became the Dean of Harvard School of Public Health four years ago, my goal was that of a good physician: to first do no harm. The School has an amazing legacy of research that has saved the lives and eased the suffering of people all over the world. Its work has kept infants from being infected by the AIDS virus; drawn an easy-to-follow picture of a healthy diet; brought about clean air regulations in American cities; helped humanitarian aid workers work more effectively in fast-moving crises; and transformed ideas and practices across the spectrum of public health. That legacy must always be preserved. But maintaining the School’s place as public health’s premier research institution is just one of my my top objectives has been to steer the School toward greater diversification of its revenue sources, much also depends on our strong and committed donor community. This issue of Harvard Public Health recognizes the generous contributions of our loyal donors and alumni, who enable us to develop powerful ideas that make the world a healthier place. In the coming year, HSPH will be a pivotal part of an ambitious, University-wide fundraising campaign, with a public launch likely in the fall of 2013. With your gifts, we can continue to inform and influence everything from individual behaviors to health care systems to government policies. We can continue to convene global leaders from a wide variety of fields. We can continue our rigorous research and effective teaching of today’s and tomorrow’s public health leaders. And as Dean, I will continue to protect and expand the world-class science education and translation that improves the quality of life for all people. priorities. I have also focused on translating the School’s science into policies and interventions. This second aim is inseparable from the first. After all, HSPH has been successful at translating research to improve people’s lives primarily because we have developed an impressive scientific base to translate. In today’s complicated funding landscape, however, both of these institutional aspirations are being challenged. HSPH receives approximately 70 percent of its revenue from sponsored research, primarily from the U.S. government. And while one of Julio Frenk Dean of the Faculty and T & G Angelopoulos Professor of Public Health and International Development, Harvard School of Public Health HSPH has been successful at translating research to improve people’s lives because we have developed an impressive scientific base to translate. I thank all of you for helping make possible our shared mission. 2 Harvard Public Health HARVARD PUBLIC HEALTH Winter 2013 COVER STORY 14 Public Health in a Place Called Happiness HSPH alumni find a mission in the Himalayan kingdom of Bhutan. FEATURES 2 Dean’s Message: A Legacy Worth Preserving The School’s impressive record of research has saved lives and eased suffering. DEPARTMENTS 22 The Prostate Cancer Predicament 4 Frontlines 8 Philanthropic Impact 30 Continuing Professional Education Calendar To screen or not to screen? For prostate cancer, that is the bedeviling question. 28 Painting the Big Picture on a 10 Distilling the Truth About Water HSPH’s James Shine explains why access to safe water persists as a global health issue. 12 Alumni Award Winners 2012 Navajo Reservation Back Cover HSPH: Number One in Social Media As a doctor in Arizona’s Kayenta Health Center, student Anne Newland faces the spectrum of public health problems. Cover: Upasana Dahal; Photo shows Gepke Hingst, MPH ’95, former UNICEF representative, with schoolchildren in Thimphu, Bhutan. This page: main image, Madeline Drexler. All others, clockwise from top, Kent Dayton/HSPH; Shaw Nielsen; Kent Dayton/HSPH. FRONT LINES NEW ONLINE COURSE REACHES WORLDWIDE AUDIENCE AB Blood Types at Highest Risk for Heart Disease This fall, more than 50,000 students enrolled in the new course “Health in Numbers: Quantitative Methods in Clinical and Public Health Research”— but none of them showed up in class. Instead, they logged in to watch lectures and participate from computers around the world. The course, co-taught by E. Francis Cook, professor of epidemiology, and Marcello Pagano, professor of statistical computing, was one of two inaugural offerings by Harvard as part of edX, the online education platform launched last May by Harvard and MIT; the University of California, Berkeley joined in July. The new public health course, along with other edX offerings, will become part of a growing library of courses available in coming years. Knowing your blood type may help you manage your risk for heart disease. Recent research suggests people with blood type AB, B, or A may be more vulnerable—with type AB linked to the highest risk (20 percent). By contrast, people with blood type O may be at relatively low risk. The finding comes from an HSPH study led by Lu Qi, assistant professor in the Department of Nutrition and at Brigham and Women’s Hospital, and published by the American Heart Association. Qi said, “If you know you’re at higher risk [with A, B, or AB blood type], you can reduce the risk by … eating right, exercising, and not smoking.” I Author Describes Battle with Breast Cancer n her new book Beauty Without the Breast, Felicia Knaul documents her personal struggle with breast cancer, and the challenges faced by her family—including her children and her husband, HSPH Dean Julio Frenk. The book also focuses on the hurdles confronting women with cancer throughout the world. Poor women in low- and middle-income countries, she writes, encounter not only the disease, but also stigma and poor access to health care. Knaul is director of the Harvard Global Equity Initiative and associate professor at Harvard Medical School. Sleep Apnea and Poverty: a Double Threat to Health Sleep apnea—which occurs when the throat closes during sleep, resulting in snoring and periods when breathing briefly but repeatedly stops— is a relatively common and underdiagnosed condition that hits minorities and low-income individuals particularly frequently, according to a September 7, 2012, Huffington Post blog post co-authored by Michelle Williams, SM ’88, ScD ’91, HSPH’s Stephen B. Kay Family Professor of Public Health and chair of the Department of Epidemiology, and Susan Redline, MD, of Brigham and Women’s Hospital. Their blog post identified contributing factors such as exposure to tobacco smoke and higher levels of obesity as underlying causes of sleep apnea, with obesity itself potentially a result of the sleep deprivation sleep apnea causes. Sleep apnea can have profound health effects, including increased risk for high blood pressure, heart failure, stroke, diabetes, abnormal heart rhythms, pregnancy complications, and early death. Left, Aubrey LaMedica/HSPH; top, ©Justin Knight LEARN MORE ONLINE Visit Harvard Public Health online at http://hsph.me/frontlines for links to press releases, news reports, videos, and the original research studies behind Frontlines stories. 4 Harvard Public Health Mexico’s Milestone: Universal Health Coverage Lift Weights, Lower Diabetes Risk Seguro Popular, Mexico’s ambitious health insurance program, has achieved universal coverage in less than a decade, despite economic downturns and domestic crises. HSPH Dean Julio Frenk, in his previous role as Mexico’s Minister of Health from 2000 to 2006, was the architect of reforms that enabled the enrollment of 52.6 million previously uninsured Mexicans. However, according to a paper by Dean Frenk and other researchers and public health officials—published online in The Lancet on August 16, 2012, and in the print edition on October 6, 2012— issues regarding quality and access to care remain. Attention, men: Want to reduce your risk of developing type 2 diabetes by up to 34 percent? Try regular weight training. By up to 59 percent? Add regular aerobic exercise to the weight training. These are the findings of the first study of its kind by Harvard School of Public Health (HSPH) and University of Southern Denmark researchers. THE DOCTORS WE LOVE TO HATE General practitioners, surgeons, plastic surgeons, dermatologists, obstetricians/gynecologists: in Australia, these physicians tend to draw the most complaints from patients, according to an analysis compiled by David Studdert, HSPH adjunct professor of law and public health, and a research team from the University of Melbourne in Australia. The researcher described his team’s findings in an address at HSPH on July 3, 2012. Studdert unveiled the predictive tool his team developed to identify higher-risk doctors, whom he calls “frequent fliers.” Dubbed PRONE (PRobability Of New Events), it is a scoring system that factors in a doctor’s age, gender, and specialty, as well as prior complaints against the physician. Stick to Your Diet—Any Diet High-fat, low-fat, gluten-free, protein-rich: Diet crazes never go out of style. But according to Eric Rimm, associate professor in HSPH’s Departments of Epidemiology and Nutrition, there is no “magic bullet” for losing weight. The best diet, he said, is the one that you can easily stick to over time. “Adherence,” he said, “rules the day.” He spoke on July 31, 2012, at his HSPH “Hot Topics” summer lecture, “Deconstructing Popular Weight Loss Diets.” IN MEMORIAM Paul Densen Paul Densen, professor emeritus of community health and medical care, died on July 9 at the age of 98. Densen became the inaugural head of the Harvard Center for Community Health in 1968 and helped train and mentor its postdoctoral fellows in social science research. Densen also was deputy commissioner of health in New York City and held positions in the Veterans Administration and the Health Insurance Plan of Greater New York. A pioneering biostatistician, Densen introduced the concept of using statistical analysis to estimate and adjust actuarial health insurance risk. He served as a consultant to the federal government and the military on health maintenance systems. Densen received numerous awards and honors, including selection for membership in the Institute of Medicine, part of the National Academy of Sciences. 5 Winter 2013 Kent Dayton/HSPH; Illustration, Shaw Nielsen FRONT LINES HSPH Convenes World Health Leaders to Help Ethiopia There are more Ethiopian doctors in Chicago than in Ethiopia, said Keseteberhan Admassu, Ethiopia’s State Minister of Health. At a gathering of world experts assembled by HSPH’s Department of Global Health and Population and the Yale Global Health Leadership Institute in July 2012, Admassu described his country’s “brain drain” of emigrating physicians and other challenges to delivering and financing basic health services. Conferees from Brazil, Estonia, South Africa, Sri Lanka, Thailand, and the Organization for Economic Co-operation and Development shared their countries’ approaches with a selected group of Ethiopian health officials as Ethiopia begins to draft a 20-year plan to improve primary care delivery. With funding from the Bill & Melinda Gates Foundation, Ethiopia has enlisted Harvard and Yale to help it develop affordable and sustainable health care delivery solutions as the nation prepares to become a middle-income country. CHANGING FOOTBALL CULTURE Discussing the sport’s evolving commitment to player safety, National Football League commissioner Roger Goodell delivered the Dean’s Distinguished Lecture and fielded questions from HSPH faculty and students on November 15, 2012. Goodell noted that the league was doing more than ever to prevent concussions and other serious injuries, but added that football’s “warrior mentality” must also change. “We want players to enjoy long and prosperous careers and healthy lives off the field,” he said. FROM SURVIVAL TO GROWTH: EMPHASIZING A BABY’S FIRST THOUSAND DAYS In India and other low- and middle-income countries, undernourished women give birth to low-birthweight babies—who grow up to be underweight adults, often with reduced mental capacities and susceptibility to disease and premature death. In his August 14, 2012, “Hot Topics” lecture, “Linked Lives: Intergenerational Influences of Health in Low- and Middle-Income Countries,” SV Subramanian, HSPH professor of population health and geography, offered a solution: “It’s the first thousand days [of a baby’s life] that count … We have to get to homes of parents with new babies and deliver nutrition. If you wait until the child is in school, it’s too late. We want to move away from a ‘survival agenda’ to a ‘growth agenda.’” T Iron Imbalance in TB Patients: Too Much Is as Bad as Too Little uberculosis patients whose iron levels are too high or too low may be more vulnerable to faster disease progression or death, according to an HSPH study conducted in Tanzania between 2000 and 2005. Led by Sheila Isanaka, research fellow in the Department of Nutrition, investigators analyzed blood samples and data from 705 adults with TB—half HIV-infected, half uninfected. Low levels of iron were linked to an increased risk of treatment failure for all patients, and of TB recurrence in HIV-infected patients. High levels of iron were linked to an increased risk of death in all patients. Isanaka says these findings “highlight that iron imbalance—at either end of the continuum—may pose risks for TB patients and underscore the need to better understand the role of iron in TB pathogenesis and disease progression.” From left: REUTERS/Sarth Panyal; ©Tony Rinaldo 6 Harvard Public Health Offthe Science of the Spirit CUFF findings be applied? You are an epidemiologist who focuses on quantitative methods. Yet you study an area that seems almost unquantifiable: the intersection of religion and health. Can public health researchers objectively study spirituality? If so, how might their “ Over the last couple of decades, there have been hun- dreds of studies showing that religious participation has a protective effect on a variety of disease outcomes, including all-cause mortality, depression, cancer survival, and heart disease. These associations can be studied and have been studied quantitatively, but other questions remain open. It’s not yet clear what mechanisms govern this protective effect. Is it social support? Is it lifestyle and behavior? Is it prayer and meditation? Is it hope or belief or optimism? Is it self-discipline and self-regulation? What exactly is going on? These questions are also fascinating from a methodological perspective—because of the “soft” nature of religion and spirituality, and because it’s difficult to parse the effects of religious participation from those of community support and private spiritual practices. I feel little tension between my own religious life and my work as a scientist. I grew up in a Christian home, began as Protestant, shifted toward Anglicanism, and am now Roman Catholic. I go to church weekly, pray regularly, and read the lectionary readings each day. In fact, TYLER VANDERWEELE ASSOCIATE PROFESSOR OF EPIDEMIOLOGY DEPARTMENT OF EPIDEMIOLOGY DEPARTMENT OF BIOSTATISTICS I think that my participation in religious communities has given me insight into what our measures of religious participation really mean. It’s also been exciting to study these questions from a quantitative perspective, using a set of tools that I work with every day. Scientists often caricature religion. They treat it as a purely emotional or irrational phenomenon. But we need to critically reflect on why people believe what they do and how it changes their health-related behaviors and thoughts. LEARN MORE ONLINE Visit Harvard Public Health online at http://hsph.me/ frontlines for links to press releases, news reports, videos, and the original research studies behind Frontlines stories. Suzanne Camarata 7 Winter 2013 ” PHILANTHROPIC IMPACT NEW FINANCIAL AID GIFTS TO SUPPORT INTERNATIONAL STUDENTS, EPIDEMIOLOGY STUDENTS For some students, attending Harvard School of Public Health can pose a seemingly insurmountable financial burden. Some are doctors already in debt from years of medical school; others come from Ambassador John J. Danilovich and foreign countries and are Dean Julio Frenk not eligible for assistance from the U.S. government. Others simply don’t have the money. That’s why support for financial aid is high on the School’s list of priorities. Two new financial aid gifts will now help ease financial obstacles for students. John and Irene Danilovich have given $250,000 to create a new endowed fellowship fund to support international students. The Danilovich Fellowship will give preference to students from Botswana, Brazil, Costa Rica, Ghana, Morocco, and Tanzania. Ming and Snow Tsuang have contributed $100,000 for a new financial aid endowed fund to support epidemiology students. The Tsuang Financial Aid Fund will give preference to students studying psychiatric genetic epidemiology and behavioral genetics. Ming Tsuang, chair and director of behavioral genomics in the Department of Psychiatry at the University of California, San Diego, worked at HSPH from 1985 through 2003 and still holds an appointment at the School as director of the Harvard Institute of Psychiatric Epidemiology and Genetics, an institute he founded. Gifts such as those from the Daniloviches and the Tsuangs are crucial because they help HSPH maintain an “exceptionally diverse global student body that sets us apart from other schools,” says Dean Julio Frenk. Such gifts, he adds, “create a huge ripple effect when our graduates go on to lead public health efforts around the globe.” Sloan Foundation Grant Supports Research on Mass Transit-Microbiome Link A As a key player in the National Institutes of Health’s Human Microbiome Project, HSPH’s Curtis Huttenhower helped identify and analyze the more than 5 million microbial genes that exist in the human body—in the stomach and the mouth, on the skin, and elsewhere. Huttenhower, assistant professor of computational biology and bioinformatics in the Department of Biostatistics, is now taking the work a step further. Along with HSPH’s John Spengler, professor of environmental health and human habitation, and colleagues from the Broad Institute, Huttenhower will examine how city subways and other forms of mass transit alter the microorganisms that ride along with passengers. The work will be supported by a $250,000 grant from the Alfred P. Sloan Foundation. The new research, says Huttenhower, “will answer for the first time whether and how high-traffic urban surfaces can stably alter the healthy adult microbiome,” and how best to protect riders from risks to their microbial health. Top, ©Tony Rinaldo; at left and opposite, Aubrey LaMedica/HSPH Curtis Huttenhower, assistant professor of computational biology and bioinformatics The Sloan Foundation, through its Microbiology of the Built Environment program, aims “to grow a new field of scientific inquiry that examines the microbial systems found in our homes, offices, and other indoor areas where people spend the vast majority of their time,” says Paula Olsiewski, program director at the foundation. “Curtis’s research into the way in which urban transportation systems might transmit microbes is an exciting, relevant, and largely unexplored area of study that we are happy to support.” 8 Harvard Public Health Little Lists, Big Impact If health care workers use simple checklists during critical moments of care such as surgery and childbirth, they can greatly reduce death and complications among their patients. In study after study, Atul Gawande, professor of health policy and management at Harvard School of Public Health (HSPH) and a surgeon at Brigham and Women’s Hospital (BWH), has replicated this finding. Now, three new significant gifts will help support the efforts of Gawande and his colleagues as they launch a new center aimed at patient safety and improved health systems. The center is a collaboration between HSPH and BWH. Donors include Mala Gaonkar, AB ’91, MBA ’96, who pledged $5 million; Richard Menschel, MBA ’59, who pledged $2.5 million; and Blue Cross Blue Shield of Massachusetts, which pledged $1 million. These contributions follow another major gift made in 2011 in support of Gawande’s work: $14.1 million from the Bill & Melinda Gates Foundation to test the effectiveness of the childbirth safety checklist in 120 hospitals in India. SURGERY AND CHILDBIRTH: RISKY BUSINESS Atul Gawande, professor of health policy and management Every year, half a million people in the United States and another 7 million around the world either die or become disabled as a result of surgery. And of 130 million births, roughly 287,000 result in the moth- er’s death, 1 million in stillbirths, and another 3.1 million in infant deaths during the first 28 days of life. Gawande thinks many of these deaths and complications can be prevented if doctors and health care workers follow simple and low-cost procedures to ensure success and safety. Gaonkar, a partner and managing director at Lone Pine Capital LLC, is impressed with the “elegant simplicity” of Gawande’s checklist concept. “When I make contributions, I look for who is doing the strongest, most innovative work, and whether they have the capability to test their concepts in multiple locations around the world,” she says. “A great deal of money is being invested in pharmaceutical and biotechnology research these days, but very little is devoted to less glamorous ideas in systems innovation that have real potential to improve health care delivery around the world.” TACKLING FUNDAMENTAL ISSUES According to Menschel, managing director of the Charina Endowment Fund and senior director at Goldman Sachs, “Atul is tackling what I see as fundamental issues in health care—issues that others haven’t focused on or solved.” Adds Blue Cross Blue Shield CEO Andrew Dreyfus: “One of the big missing ingredients in the quality and safety movement has been the ability to scale up interventions that we know work. Atul and his colleagues have developed proven methods to rapidly deploy new safety measures.” “These new sources of funding will give us a chance to build an infrastructure to launch projects that work across more of health care,” notes Gawande. “Our goal is straightforward: We want to drive scalable solutions for better care at the critical moments in people’s lives everywhere.” 9 Winter 2013 Distilling the Truth About Water Q&A Water courses through every aspect of our lives, for good or ill. As senior lecturer on aquatic chemistry in the Health, James Shine has explored the of contaminants in rivers and lakes. According to Shine, the global water cycle is vast and mysterious—and as HSPH’s James Shine explains why access to safe water persists as a global health issue. Q: H ow much water does an average American consume each day? A: A bout 1,600 gallons. That figure surprises a lot of people. Most of us think about our direct-consumption use of water: How many times do I flush the toilet? How long is my shower? And those are obviously important for understanding how one person depletes local water resources. School’s Department of Environmental role of clean, safe, and accessible water in human health, focusing on the effects But if you start thinking larger, you’ll see that a drop of water that fell on a wheat field this afternoon is going to be part of my sandwich bread five months from now. If it’s a ham sandwich, a lot more water was used. It takes 52 gallons of water to make one glass of milk. It takes more than 600 gallons to make a quarter-pound hamburger. It takes 2,800 gallons to make a pair of jeans. Our daily lives carry a giant water footprint. crucial to our survival on the planet as the global carbon cycle, the mechanism by which carbon circulates through the earth’s atmosphere and plays a role in global warming. Shine spoke recently with Harvard Public Health editor Madeline Drexler. Q: P opulation and industrial production and per capita consumption keep going up. But the water supply is finite. Aren’t humans relying on basically the same amount of water that we were 10,000 years ago? A: Y es—although, of course, it’s not the same water. About 97 percent of the water on our planet is in the oceans. Another 3 percent is in the polar ice caps. We humans use the very small fraction of fresh water that is accessible groundwater and surface water, such as lakes and rivers—all told, about 0.1 to 0.2 percent of water on the earth. That amount has been stable since the last ice age, and although water is constantly cycling in and out of the different pools, we are altering the quantity and quality of available fresh water. 10 Harvard Public Health Q: W ill climate change alter the water cycle and therefore the amount of water that we can draw on? A: T hat’s the question. There could be more rainfall, more flooding, as well as more drought, meaning there will be winners and losers. As ice melt and river runoff increase in the North Atlantic, that less dense fresh water might ride on top of the warmer Gulf Stream; the Gulf Stream, which crosses the Atlantic, would no longer bring heat to Europe. In that scenario, Europe’s climate might be more like northern Canada’s, which would be a big public health problem. In other areas, changes in water flow can have harmful effects on human health in many ways. Areas at higher latitudes that receive greater amounts of rain may have more floods, creating stagnant backwaters that make better habitats for the vectors of malaria and schistosomiasis and other waterborne diseases. Q: H ow are we doing on the 2015 Millennium Development Goals (MDGs) that relate to water and sanitation? A: O n a global basis, the world has already met the MDG for safe water. China and India have made great strides in providing safe drinking water through direct piping of clean water or the use of deep wells; unfortunately, sub-Saharan Africa is not meeting its drinking water goal. “ It takes 52 gallons of water to make one glass of milk. It takes more than 600 gallons to make a quarterpound hamburger. Our daily lives carry a giant water footprint.” —James Shine As for sanitation, the problem is that, in the developing world, about 40 percent of people use open defecation or public latrines. In India, there are more cellphones than toilets. Worldwide, 2.5 billion people lack access to adequate sanitation and 1.8 million die annually because drinking water becomes contaminated. The sanitation goal clearly will not be met by 2015. The point is that we need to think of safe drinking water and sanitation together—as one problem. They shouldn’t be separate MDGs. Q: Y ou are a marine chemist by training. Was there an “Aha!” moment for you—a moment when you knew that you wanted to study water within the context of public health? A: Y es, I even remember when and where it happened. After I was an undergraduate, I worked in an environmental chemistry lab, testing people’s drinking water and well water. My job was to determine if the results were above a Kent Dayton/HSPH certain threshold or below it: above or below the line. After a while, I wanted to know, well, where did that line come from? Who decided where the line was going to be drawn? Good science must always be connected to the real world and to real lives. 11 Winter 2013 From left, Swati Piramal, MPH ’92; Donald Hopkins, MPH ’70; Patricia Hartge, SM ’76, SD ’83; and Ching-Chuan Yeh, MPH ’81. Alumni Award of Merit Winners Four alumni nominated by their peers received the Harvard School of Public Health Alumni Award of Merit—the highest honor presented to an alumna or alumnus—at this year’s Alumni Weekend, held September 28–29 at the School. Swati Piramal, MPH ’92, is working to change the trajectory of India’s health care, education, and public policy. Vice chairperson of Piramal Enterprises and director of the Piramal Foundation, she helps promote health in rural India through mobile health services, women’s empowerment projects, and support of community education to create young leaders. Donald Hopkins, MPH ’70, played an important role in the eradication of smallpox before coming to HSPH and went on to tackle Guinea worm, a parasitic disease that once afflicted millions. His efforts, first at the Centers for Disease Control and Prevention (CDC) and later at The Carter Center, have been pivotal in reducing reported cases of the disease from an estimated 3.5 million in 1986 to 1,058 in 2011. 12 Harvard Public Health Patricia Hartge, SM ’76, SD ’83, is a leader in the epidemiology of non-Hodgkin’s lymphoma, ovarian cancer, and a variety of other tumors. At the National Cancer Institute, where she serves as deputy director of the Epidemiology and Biostatistics Program, she has conducted research to reveal the environmental, genetic, and behavioral causes of these malignancies. Ching-Chuan Yeh, MPH ’81, a physician, served as Taiwan’s minister of health from 2008 to 2009 and was a key figure in developing the country’s national health insurance system. During the SARS outbreak in 2003, Yeh left his post as a lecturer at the Tzu Chi University and volunteered to work in a quarantined hospital to help manage the crisis. Additional Alumni Awards Included: EMERGING PUBLIC HEALTH PROFESSIONAL AWARD Priya Agrawal, MPH ’06, an obstetrician, gynecologist, and global women’s health professional, works to improve the health of mothers in developing countries. Most recently, she was asked to be executive director of Merck for Mothers, a $500 million, 10-year commitment to improving maternal survival globally. LEADERSHIP IN PUBLIC HEALTH PRACTICE AWARDS Maura Bluestone, SM ’74, launched The Bronx Health Plan (now known as Affinity Health Plan), a not-for-profit Medicaidmanaged care organization that was the first health plan licensed in New York to serve government-sponsored populations. She is currently chair of the Coalition of New York State Public Health Plan and is on the board of the Association for Community Affiliated Plans. Francisco Sy, SM ’81, developed and directed the Infectious Disease Epidemiology Program at the University of South Carolina School of Public Health. He has also evaluated national HIV/AIDS prevention programs at the Centers for Disease Control and Prevention. Sy currently directs extramural research in minority health and health disparities at the National Institutes of Health, which provide resources to address major public health problems. PUBLIC HEALTH INNOVATOR AWARD Anita Patil Deshmukh, MPH ’05, works with Partners for Urban Knowledge, Action and Research (PUKAR), an independent collective exploring issues related to urbanization, Kent Dayton/HSPH From left, Anita Patil Deshmukh, MPH ’05; Francisco Sy, SM ’81; Maura Bluestone, SM ’74; and Priya Agrawal, MPH ’06. with a focus on public health. By training local youth, known as Barefoot Researchers, in research design and data collection, PUKAR has documented the social determinants of health facing Kaula Bandar, an urban slum community in Mumbai, India. Its advocacy has led to the establishment of government health camps, a 90 percent childhood immunization rate, and the first legal access to water in the slum’s 50 years of existence. For more information on Alumni Weekend and extended biographies of the winners, visit http://hsph.me/alumni2012. 13 Winter 2013 HOW FOUR HSPH ALUMNI ARE HELPING BHUTAN— THE HIMALAYAN HOME OF “GROSS NATIONAL HAPPINESS”— ACHIEVE ITS LOFTY GOALS THE LONG ROAD TO HEALTH & WELL-BEING Madeline Drexler Prayer flags overlook the Paro Valley at sunset. 14 Harvard Public Health A Atti-La Dahlgren recalls the moment that his public health life took a sharp turn toward the Himalayan kingdom of Bhutan. It was May 2002, at the World Health Organization’s annual World Health Assembly. Dahlgren, MPH ’00, a global health physician in Geneva, was waiting for a bus home when a friend passed by and invited him, on the spur of the moment, to a closed-door meeting of health ministers. “I listened as several ministers stood up to talk. It soon became obvious that while the name of the minister or the country changed, each 15-minute speech was more or less the same—until the health minister from Bhutan took the floor,” Dahlgren recalls. “He spoke without notes. He explained that his was one of the poorest countries in the world. And he said he was going on a 560-kilometer walk across the country, village to village, to talk about the importance of public health. He spoke freely, from his heart. I was completely captured.” Call it karma. “When I became involved with Bhutan,” says Dahlgren, now president of the Inter- national Bhutan Foundation, “I learned that nothing happens by coincidence.” STEEP ODDS, IMPRESSIVE GAINS Bhutan’s may be one of the greatest public health success stories never told. And four Harvard School of Public Health alumni—Dahlgren, Gepke Hingst, MPH ’95, Kathy Morley, MPH ’10, and Michael Morley, MHCM ’11—have lately been at the center of the action. In different ways, each is playing a role in improving a public health system that has already made impressive strides against almost impossibly steep odds: financial, cultural, and topographic. Their shared mission has taken them off the beaten path. Asked to point to Bhutan on a world map, most people would be stumped. Half the size of Indiana, wedged between India and China, this compact nation of 700,000 has spent most of its history in self-imposed isolation. Never conquered or occupied, it tentatively began modernization in the 1960s. Internet and television didn’t arrive until 1999. continued 15 Winter 2013 Today, celebrated for its pristine environment and its vow to become a 100 percent organic food producer, Bhutan is probably best known for its guiding philosophy of “Gross National Happiness,” or GNH, which strives to balance economic development with spiritual well-being. But that novel policy is being put to the test. Newfound consumerism, fueled by rural-to-urban migration, is partly behind a wave of unprecedented public health challenges, from obesity to drug use. Vaulting from a preindustrial culture to the information age in just 50 years, Bhutan has become a living laboratory for dealing with the challenges of rapid modernization. “For a country that is not an easy place to get around, they have managed to achieve a 93 percent child immunization coverage—which is very impressive,” says Richard Cash, senior lecturer on global health at HSPH and an international leader in developing public health solutions for low-resource nations. “The most striking thing about Bhutan is that, as a part of their movement to secure Gross National Happiness, they have made affordable and accessible health care central to public policy,” adds Parveen Parmar, a faculty member of the Harvard Humanitarian Initiative. In 2009, as a consultant on emergency medical care to Bhutan’s Ministry of Health, Parmar traveled to hospitals and clinics throughout the country. “You get a sense that once a problem is identified, everybody is on board to find a solution. That top-down dedication is a model, not only for small, developing nations, but for larger ones as well.” CROSSROADS OF OLD AND NEW Kathy Morley, a Boston-based emergency medicine physician, and her husband, Michael Morley, an ophthalmologist, are working at this crossroads of old and new. Over the past decade, earning complementary degrees at HSPH “ Bhutan has the potential to serve as an inspiration and perhaps a model for other small countries, because it puts health and social well-being at the forefront of development.” —Atti-La Dahlgren, MPH ’00, president, International Bhutan Foundation All photographs, Madeline Drexler 16 Harvard Public Health G R O S S N AT I O N A L H A P P I N E S S A N D H E A LT H In Bhutan, happiness is considered a public good and a government duty. Indeed, the constitution directs the state “to promote those conditions that will enable the pursuit of Gross National Happiness.” Unlike in a nation that gauges progress solely by economic gains, Bhutan’s GNH-based model rests on the idea that society benefits most when material and spiritual development unfold side by side. “Bhutan is not a country that has attained GNH. Like most developing nations, we are struggling with the challenge of fulfilling the basic needs of our people,” explained Prime Minister Jigmi Y. Thinley at a UN meeting in April 2012. “What separates us, however, from most others is that Patients wait for treatment at the Bali Basic Health Unit, in the Haa District of western Bhutan. we have made happiness, the foundation of human needs, as the goal of social change.” Not only does the government survey the nation’s Gross National Happiness every other year, but all major policy proposals must pass a formal GNH screening before they are enacted. GNH’s nine measurable domains encompass not only health, but also psychological well-being, balanced use of time, education, cultural diversity and resilience, good governance, community vitality, ecological diversity and resilience, and living standards. (she in global health, with a focus on health systems; he in health care management), they have fashioned themselves as a public health team in their volunteer assignments abroad. After projects in Cambodia and Thailand to deliver advanced eye care surgery, they brought their expertise to Bhutan in 2004—drawn as much by its spiritual culture as by its pressing public health needs. Michael set up Bhutan’s first laser surgery equipment to treat diabetic retinopathy, and the couple collaborated with the WHO on a Rapid Assessment Avoidable Blindness survey. More recently, the Morleys have joined forces with the nongovernmental organization Health Volunteers Overseas to buttress Bhutan’s emergency care system. The collaboration, funded by the Washington, DC–based Bhutan Foundation, includes physicians at the Universitywide Harvard Humanitarian Initiative. With traumatic injuries—often the result of road accidents—a major cause of death in the country, Kathy helped develop a National Emergency Medicine Course for JDW National Referral Hospital in the capital, Thimphu. The hospital has no emergency medicine doctors—a situation reflecting a dearth of specialists throughout the nation. This past September, the education module was used to train some 20 physicians managing emergency and trauma care. The training will pay off not only with accident victims, but also with victims of other common emergencies, such as children choking or women suffering from ruptures caused by ectopic pregnancies. FEAR OF SEAT BELTS In Bhutan—where subtropical southern lowlands rise to sacred, unclimbed peaks exceeding 24,000 feet—many grievous injuries occur when cars veer off the country’s narrow, vertiginous roads. Bhutanese dislike wearing seat belts, fearing the belts will trap them in falling vehicles. Kathy Morley wants to conduct a study to see if that tenacious cultural belief is valid. “You need data to change people’s minds,” she says. “And when it comes to research, continued 17 Winter 2013 PUBLIC HEALTH IN BHUTAN: NUMBERS TELL THE STORY Though its tourist literature self-referentially declares that “Happiness Is a Place,” Bhutan is no idyllic Shangri-La: The country ranks 141st out of 187 in the United Nations Human Development Index, which assesses health, education, and income. Some 23 percent of the population lives below the poverty line. Despite these challenges, Bhutan has made impressive public health gains: Life expectancy in 1960: 33 years Life expectancy in 2012: 66 years Eliminated polio in 1986, leprosy in 1990, and goiter in 2003. In 2004, became the first country in the world to ban the sale of tobacco. In 2010, carried out the developing world’s first national cervical cancer vaccination program—immunizing approximately 90 percent of girls and young women ages 12 to 18 against the human papillomavirus. Has met 2015 UN Millennium Development Goals (MDGs) for infant mortality. On track to meet 2015 MDGs for maternal mortality. A pregnant woman receives a vaccination at the Yangthang Basic Health Unit, in the Haa District of western Bhutan. by working smarter—making relatively simple improvements that, ideally, cost no money.” The bar code project is expected to be most valuable in well-defined environments such as outpatient clinics and operating rooms. ISOLATION TO INSPIRATION Bhutan launched its health system in 1961, when the country was just beginning to open its borders. At the time, Western medicine was virtually nonexistent: the nation had two hospitals, two doctors, and two nurses. TB, leprosy, and malaria were common, and 80 percent of women suffered goiter from iodine deficiency. In the last half century, guided by a fierce commitment to public health and a royal family that has spearheaded many progressive health campaigns, that dire picture has spectacularly improved. Health care has been deemed a right, not a privilege; the government pays for all treatment (including treatment abroad), and there are no private medical practices. Bhutan’s system seamlessly integrates Western with cherished traditional therapies that date back 2,500 years and have been found effective for some chronic ailments, both physical and emotional. Perhaps most impressive, in dauntingly mountainous terrain, Bhutan has built a unique network of 178 basic health units—small, spare medical facilities that can provide vaccinations, midwife care, and simple medical Madeline Drexler the great thing about Bhutan is that it’s a small country and all health care is delivered through the same system, so you can do a study on a national basis. The only barriers are geographic.” Both Morleys are also working to improve the efficiency of Bhutan’s underfunded health care system. To this end, they created a prototype bar code system in which each patient receives a piece of paper that is scanned as he or she moves through treatment—a kind of high-end time stamp that will enable hospital managers to analyze and improve patient flow. “This was straight HSPH teaching,” says Michael Morley. “It’s not very sexy, but you can squeeze improvement in capacity and output just interventions—and 654 outreach clinics, located so that treatment is always available within a three-hour walk (not an unusual trek for the rural Bhutanese). Village 18 Harvard Public Health volunteers serve as intermediaries between often-isolated pockets of people and formal health care institutions. About 90 percent of Bhutan’s citizens have health coverage—with most of the remaining 10 percent highaltitude nomadic herders who cannot be easily reached. Today, Bhutan’s major health threats include acute respiratory infections (worsened by wood fires in the countryside), diarrheal diseases, and skin infections. But as in many developing nations, the afflictions of poverty are fast becoming eclipsed by the afflictions of excess and an increasingly sedentary lifestyle. Noncommunicable diseases such as cancer and heart disease account for 31 percent of deaths, and stroke, hypertension, and diabetes are on the rise. As Tashi Wangdi, head of the Internal Medicine Department at JDW National Referral Hospital, wrote in 2012, “Bhutanese might be seeing the beginnings of an unhappy bargain: of living longer, but of also being sick longer, and from new and frightening diseases.” To keep up with the shifting scenario, Bhutan needs to more than double its health workforce to reach WHO standards. With 2,000 medical workers in the entire country, including barely 200 doctors, virtually every THE PRICE OF EQUITY Fresh out of medical school, Gepke Hingst journeyed to war-torn Afghanistan in 1983, when the Afghan government and its Soviet backers were battling a Muslim insurgency. Though she had contemplated a position in Bhutan, at the urging of a Buddhist friend, what followed instead were stints in Africa and South Asia. Not until 2006 did she became UNICEF’s country representative in Bhutan. What took so long? “Sometimes,” she says, “karma makes you wait.” At HSPH in the mid-’90s, Hingst had focused on global health. “As a doctor, you’re told that disease is disease—social and economic background don’t matter. But when you work for a long time in developing countries, you see what I call the ‘repetition of horror.’ Harvard teaches you to address inequities and really arrive at public health.” In Bhutan, Hingst encountered a nation bent on avoiding the repetition of horror that springs from poverty and certain cultural norms. UNICEF is mandated continued “ When it comes to research, the great thing about Bhutan is that it’s a small country and all health care is delivered through the same system, so you can do a study on a national basis.” —Kathy Morley, MPH ’10, emergency medicine physician aspect of care is strained. In an effort to reverse the picture, the nation’s Royal Institute of Health Sciences in 2010 started a bachelor’s of public health program for workers in the country’s frontline basic health units, to upgrade their clinical and research skills. The course will prepare them for everything from outbreak investigations Kent Dayton/HSPH to home-based care for stroke victims. Kathy Morley, MPH ’10, and Michael Morley, MHCM ’11 19 Winter 2013 “ Because Bhutan’s population is so scattered and there aren’t that many people, you will never achieve cost effectiveness. The economy of scale doesn’t work here. This is the cost of equity.” —Gepke Hingst, MPH ’95, former UNICEF representative in Bhutan Upasana Dahal by the UN to advocate for children and to promote the equal rights of women and girls in political, social, and economic development. In Bhutan, this mission has taken Hingst on far-flung expeditions, such as 24-day excursions through high passes, ice-cold streams, and steep valleys to the remote districts of Laya and Lunana in the northwest peaks where Bhutan borders Tibet. She has trekked with outreach workers from a basic health unit on a two-day journey to a village of 19 households at an altitude of over 12,000 feet—all to vaccinate six children and attend to other essential needs. “They do it every month because there are 19 households there: 19 households that have the right to health care,” says Hingst. “They do family planning, AIDS education, vaccinations. They bring medicine. They treat eye problems and do dental care.” She adds: “Because Bhutan’s population is so scattered and there aren’t that many people, you will never achieve cost effectiveness. The economy of scale doesn’t work here. This is the cost of equity.” A TIDE OF CONSTRUCTION of construction and a torn cityscape of dust, debris, and spindly bamboo scaffolding. “For me, what Bhutan illustrates is that progress is not without a price,” says Hingst. “People are moving from rural areas to the cities. The challenges for children are dramatic. In urban areas, life is expensive—both parents start to work. Who is taking care of the child? Is it going to be a slightly older sibling or a young niece from the village who will sacrifice her own education—child nannies caring for three- or four- or five-year-olds? Where first we were talking about the need for vaccination and access to health care and schools, now we’re talking about the risks of drug abuse, juvenile crime, broken families.” According to a recent national survey, 18 percent of children are engaged in child labor and 30 percent of girls are married illegally before the age of 18. As Thimphu and other cities see growing numbers of children forced to fend for themselves emotionally, Hingst is most proud of UNICEF supporting Bhutan’s 2011 Child Care and Protection Act, which is intended to safeguard children against violence, abuse, and exploitation. But as the cultural fabric of Bhutan shows signs of fraying, health equity has acquired a new meaning. Today, the graceful terraced rice paddies surrounding the capital, Thimphu, are giving way to a massive tide “YOU DON’T HAVE TO SUFFER.” After raising money for the health minister’s 2002 walk across the country, Atti-La Dahlgren in 2006 founded the International Bhutan Foundation, which focused on programs devoted to child development 20 Harvard Public Health and to the welfare of youth and women. Today, he has turned his attention to educating the Bhutanese public about cancer—an almost taboo topic in the country. “Everybody knows somebody who has had cancer. But there’s a cultural belief that if you get sick, it’s a result of your actions in this life or in a previous incarnation. So it’s not talked about,” he says. “There’s an acceptance of suffering. We need to be able to explain, in Buddhist terms, ‘It’s OK to be treated, you don’t have to suffer.’” Compounding the problem, Bhutan has only two oncologists and no facilities for cancer treatment. According to Dahlgren, “Many people suffer from cancer but are either not diagnosed in time, wrongly diagnosed, or not diagnosed at all.” As a result, most patients are sent to India for costly late-stage interventions. “There’s a huge need for awareness—about types of cancer, prevention, and the need for better diagnostics and treatment,” says Dahlgren. He wants to establish a national cancer society to educate people and encourage patients to come out and speak about their disease. But Dahlgren says a national cancer treatment program would have to piggyback on the existing rudimentary health system, requiring more people, more equipment, and more labs—a daunting proposition in a country that is still desperately resource-poor. He is now reaching out to public health experts who can lend their skills to launching such an effort. DOING WHAT NEEDS TO BE DONE Despite these hurdles, material and cultural, the HSPH alums who have devoted much of their careers to Bhutan are not only optimistic about the country’s prospects— they feel that this nation has much to teach the world. “Compassion and the idea of looking after each other are integrated into the culture,” says Dahlgren. “Bhutan has the potential to serve as an inspiration and perhaps a model for other small countries, because it puts health and social well-being at the forefront of development.” Gepke Hingst, who left her UNICEF post in the fall of 2012 after an unusually long six-year assignment, agrees that Bhutan’s vision for public health is inseparable from its spiritual outlook. “Buddhism is founded on the idea of interdependence—interdependence with nature and interdependence with other people.” In Bhutan, she says, this sense of spiritual connectedness translates directly into public health practice. “Officials don’t shy away from difficult issues—they simply do what needs to be done. The beauty of Bhutan is that they mean it.” Madeline Drexler is editor of Harvard Public Health. Madeline Drexler 21 Winter 2013 T For many men diagnosed with prostate cancer, the treatment may be worse than the disease. To screen or not to screen? For prostate cancer—the second leading cause of cancer deaths in men, after lung cancer—that is the bedeviling question. The dilemma springs from the wide variation in the potential of prostate cancers to spread to the rest of the body. The vast majority of these malignancies, especially those discovered with the extensively used prostate-specific antigen, or PSA, test, are slowgrowing tumors that are unlikely to cause a man any harm during his lifetime. Yet in 10 to 15 percent of cases, the cancer is aggressive and advances beyond the prostate, sometimes turning lethal. MURKY DIAGNOSES diagnosis which cancers are likely to threaten a man’s health and which are not. As a result, almost all men with PSA-detected cancer opt for treatment, which can leave longlasting physical and emotional scars. Put simply: with prostate cancer, the cure may be worse than the disease. The dilemma was underscored in May 2012, when the U.S. Preventive Services Task Force (USPSTF) issued a strongly worded final recommendation against PSA-based screening for prostate cancer. According to the task force, “[M]any men are harmed as a result of prostate cancer screening and few, if any, benefit.” In a study of U.S. men who were randomly screened, the screening did not reduce prostate cancer death (though a similar study among European men did find a lower risk of cancer death). In any case, experts agree that prostate cancer has been vastly overdiagnosed as a result of screening. continued Betsie Van der Meer/Stone The dilemma has become more urgent in recent years as widespread screening with PSA in the U.S. and around the world has led to a sharp increase in the number of detected prostate cancers. Currently, there is no way to accurately determine at the time of 22 Harvard Public Health The Prostate Cancer Predicament 23 Winter 2013 “ One of the biggest challenges in oncology is to distinguish men who have a potentially lethal form of prostate cancer from those with a more slow-growing disease.” —Lorelei Mucci, ScD ’03, associate professor of epidemiology but never go on to develop prostate cancer. Second, even when the test correctly identifies prostate cancer, many of the diagnosed patients never develop the deadly form of the disease. “PSA screening has been a disaster,” says Hans-Olov Adami, former chair and now adjunct professor of HSPH’s Department of So what should patients and doctors do? At Harvard School of Public Health, the prostate cancer epidemiology team—which includes more than 25 faculty, postdoctoral fellows, and student researchers—is developing the science to answer that question, identifying both the risk factors behind the deadliest variations of prostate cancer and the lifestyle changes that may lower the risk of aggressive disease. “One of the biggest challenges in oncology is to distinguish men who have a potentially lethal form of prostate cancer from those with a more slow-growing disease,” says Lorelei Mucci, associate professor of epidemiology at HSPH. “Our AGGRESSIVE OR SLOW-GROWING? research aims to directly address that question, as well as to find opportunities to reduce risk of dying from cancer after diagnosis.” Epidemiology, who has opposed the test for 20 years. “We overdiagnose many men who would die of other causes.” In fact, a multinational study of cancer registries published by Adami, Mucci, and other HSPH colleagues in July 2012 found that the most common causes of death among prostate cancer patients—65 percent of patients in Sweden and 84 percent in the U.S.—are heart disease, diabetes, stroke, or other cancers. Yet these patients frequently underwent radical treatments for their prostate cancer—interventions such as radiation, surgery, and chemotherapy, which can produce severe side effects such as incontinence and erectile dysfunction. © Tony Rinaldo When it became widely available in the late 1980s, the PSA screening test was hailed as a simple way to uncover possible malignancy. But PSA screening, which was adopted without evidence of its usefulness, turned out to be a poor indicator of cancer, in two ways. First, it creates false positives in men who may simply have elevated antigen levels from other conditions, such as benign enlargement of the prostate gland. These patients often endure subsequent invasive biopsies 24 Harvard Public Health “While we are uncertain about the number of deaths that screening prevents,” says Adami, “we are certain that the price for any reduction in deaths from prostate cancer is very high.” A study published in August CLUES IN DIET AND LIFESTYLE a more virulent cancer. According to Giovannucci, “The question is whether there are two types of prostate cancer—an aggressive and nonaggressive form—or whether certain factors cause a nonaggressive form to become more aggres- To clarify the prognosis for a tumor, HSPH researchers are homing in on other factors that might affect susceptibility to prostate cancer, especially the aggressive form of the disease. Edward Giovannucci, WHAT MAY PROTECT AGAINST ADVANCED PROSTATE CANCER? PHYSICAL ACTIVITY AVOIDING OBESITY 2012 in the New England Journal of Medicine found no difference in survival between men who had surgery for prostate cancer and those under “watchful waiting,” in which the doctor withholds treatment while carefully monitoring the progress of the cancer. “This is a very perplexing observation,” Adami says, “because screening reduces mortality only if treatment makes a difference in outcomes. This indicates there are still big question marks in how doctors and patients should respond to this diagnosis.” As the USPSTF noted last May, “[R]esearch is urgently needed to identify new screening methods that can distinguish nonprogressive or slowly progressive disease from disease that is likely to affect quality or length of life.” AVOIDING SMOKING CONSUMING TOMATO SAUCE professor of nutrition and epidemiology, recently looked at nine diet and lifestyle factors. He found that smoking, obesity, and lack of physical activity raise the risk of developing CONSUMING COFFEE VITAMIN D sive.” Evidence provided by HSPH researchers suggests that an increase of insulin in the bloodstream, caused by obesity and physical inactivity, may encourage tumor growth. continued “ Men with at least three hours of vigorous physcial activity a week had at least a 60 percent lower risk of prostate cancer death.” —Edward Giovannucci, professor of nutrition and epidemiology 25 Winter 2013 Jennifer Rider, instructor in epidemiology at HSPH, has studied parasitic infection and prostate cancer. Giovannucci found that the overgrowth of blood vessels might be one of the most reliable indicators of whether a tumor will spread. After sifting through genetic and lifestyle factors that might lead to the growth of these vessels, they found that the antioxidant lycopene was the item most strongly associated with lower Other investigations have linked dietary factors to the disease. A 2011 study by HSPH research associate Kathryn Wilson, together with Mucci and Giovannucci, professor of nutrition and epidemiology Meir Stampfer, and other colleagues, disease; those who consumed one to three cups a day showed no difference in developing any form of the disease, but had a 30 percent lower risk of developing a lethal form. Another, more surprising, study revealed that consuming tomato blood vessel formation. Another factor that might determine the difference between a harmless and a lethal form of prostate cancer is the sexually transmitted parasitic infection Trichomonas vaginalis. By itself, the PROSTATE CANCER: A NUMERICAL QUANDARY 242,000 men in the U.S. will be diagnosed this year with prostate cancer found that men who drank coffee had a notably lower risk of aggressive prostate cancer. Those who consumed six cups or more a day were 20 percent less likely to develop any form of the disease, and 60 percent less likely to develop a lethal 28,000 will die from the disease A man has a 15.9 percent lifetime risk for diagnosis of prostate cancer sauce was associated with a markedly infection rarely produces symptoms lower risk of prostate cancer. In fact, men who had two or more servings of tomato sauce a week were about tate cancer, and about 35 percent less likely to die from the disease. A separate report in 2009 by Mucci and in men (who are often treated only after their female partners show signs of infection). In a 2009 study, ology Jennifer Rider, infected men had a much higher incidence of prosÂŠ Tony Rinaldo 20 percent less likely to develop pros- led by HSPH instructor in epidemi- 26 Harvard Public Health tate cancer spreading to the bone or death from prostate cancer. “The good news is that if the association between the infection and lethal prostate cancer is confirmed, there is an effective antibiotic treatment,” Rider says. TO TREAT OR NOT TO TREAT? increasing physical activity after diagnosis can substantially cut the risk of developing aggressive prostate cancer. “Men with at least three hours of vigorous physical activity a week had at least a 60 percent lower risk of prostate cancer death,” says Giovannucci. “It’s a strong association.” Among older patients especially, that activity can take the form of vigorous walking. Recently, Mucci has spearheaded an intervention with Adami and other colleagues in Sweden, Iceland, and Ireland in which men walk in groups with a nurse three times a week. In a pilot study, researchers found improvements in just 12 weeks in body weight, blood pressure, sleep, urinary function, and mental health. Scientists at HSPH are also searching for genetic and lifestyle genes to prostate cancer incidence and survival. Until all these associations come to light, doctors and patients will be confronted with weighty decisions about treatment. Surgery, radiation, or chemo might still be the wisest course of action in instances where the cancer has clearly already advanced, or when a patient is young and otherwise in good health. In situations where men are older or face a higher risk for other diseases, improvements in diet and lifestyle may be more effective not only in subduing the cancer but also in boosting general well-being. As Mucci puts it, “Our hope is that clinicians will use the prostate cancer diagnosis as a teachable moment to reflect on the global health of the patient.” “Up until now, with a few notable exceptions, doctors have myopically focused on treating prostate cancer,” says Adami. “They are willing to spend tens of thousands of dollars on chemotherapy that has minimal effects on cancer mortality, often with substantial side effects. But we ignore entirely the fact that large groups of prostate cancer patients die from other causes that actually are preventable.” By focusing on lifestyle changes, he adds, men can achieve three goals A man has a 2.8 percent lifetime risk of dying from prostate cancer simultaneously: diminishing the risk of dying from common conditions such as heart disease and diabetes, improving quality of life overall, and perhaps also improving the prognosis for prostate cancer. In particular, stopping smoking and 40 to 50 men with prostate cancer have to be treated to save the life of 1 man markers that help predict how aggressive a patient’s prostate cancer will be. For example, an ongoing project led by Mucci and Adami draws on detailed cancer registries in Nordic countries, including an analysis of 300,000 twins, to tease out the relative contribution of different Source: SEER Cancer Incidence Review, 1975–2009, National Cancer Institute Michael Blanding is a Boston-based journalist and author of The Coke Machine: The Dirty Truth Behind the World’s Favorite Soft Drink. 27 Winter 2013 O Once upon a time, Anne Newland wanted to go to film school. But because life unfolds with its own logic, she instead became a doctor with the federal Indian Health Service (IHS). And shaped by her experience working with Native Americans and the unique system that serves them, she realized the importance of focusing on population health. Today, Newland is working toward a masterâ€™s degree at Harvard School of Public Health (HSPH). Painting the Big Picture on a Navajo Reservation Left: Kent Dayton/HSPH; all others courtesy of Anne Newland 28 Harvard Public Health THE RIGHT QUESTIONS A Mongan Commonwealth Fund Fellow in Minority Health Policy, Newland, MPH ’13, has served as a physician at the Kayenta Health Center in Arizona for eight years, and as acting clinical director for the past three. A remote outpost with a downtown consisting of a small strip of stores, Kayenta is located about 25 miles south of Monument Valley, in the heart of gorgeously sculpted red-rock country. But the movie-set scenery belies deep public health problems. Teen suicide, domestic violence, depression, isolation, substance abuse—all are pressing issues on the reservation. “We have therapists, psychiatrists, and substance abuse counselors at the health center, but services need to be greatly expanded,��� Newland says. In particular, the seriously mentally ill—the patients Newland describes as “train wrecks about to happen”— need better support. With no involuntary commitment laws, tensions have erupted over whether such decisions lie with “Just sad, sad, sad,” Newland says. She thinks better regional planning to arrange hospital admissions could help alleviate such problems—and she hopes her degree in health policy and management will help her develop systems that deliver more prompt and effective care. Newland also wants to improve automobile safety. “I’d like to see more kids in car seats, not sitting in the front seat of a truck. And I’d like to see more people wear seat belts.” Adding more passing lanes to the region’s two-lane highways, she says, could help reduce car accidents. And because many people on the reservation don’t have running water at home, she’d like to improve access to monitored water—because unmonitored wells and springs are more likely to be contaminated. A larger, more complex issue is possible chronic uranium exposure from contamination left in the wake of mining conducted between the 1940s and the 1980s. The “ Medical school and residency are where you learn to take care of individuals. An MPH helps prepare you to take care of communities.” Anne Newland, MPH ’13 Scenes of the Kayenta Health Center, in Arizona. the tribal authority or the state. There’s also a chronic shortage of inpatient beds. All told, these problems have left mentally ill patients in limbo. Newland recalls one woman with seizure disorder— “she was notorious for being difficult”—who would often wind up in the emergency room. Once, when Newland tried to stitch up a gash on the woman’s head, the woman threatened to hit her, so Newland backed off. Sadly, one day the woman suffered a seizure, collapsed near her wood stove, sustained serious burns over much of her body, and died shortly afterward. BUILDING COMPASSION Though Newland is enthusiastic about studying at HSPH, she admits it was hard to leave Kayenta and her daily interactions with patients to pursue her studies. radioactive ore was sought for atomic weapons across some 27,000 square miles of Navajo lands in the Four Corners area—including the Skyline Mine about 25 miles from Kayenta—and many Navajo either worked as miners or lived and raised their families near the mines and processing mills. Newland hopes her public health training will help her better understand epidemiologic research around this issue—and perhaps someday conduct her own. continued 29 Winter 2013 “I love my patients,” she says. “What I enjoy most about being a primary-care physician is that I get to establish deep, long-term relationships. Navajo people are reserved; they don’t let you in easily. But they have a great sense of humor and, in the right moments, they really let you in.” She adds: “When you are able to know people and help them through their health struggles, it builds compassion. Life is really, really hard sometimes, and when your health is affected, you can lose your equilibrium. In primary care, you get to help people regain their peace of mind. Taking that walk with many patients has been a powerful EXECUTIVE AND CONTINUING PROFESSIONAL EDUCATION PROGRAMS JANUARY 2013 January 13–25 Program for Chiefs of Clinical Services January 25–27 Teaching by Case Method: Principles and Practice for Health Educators FEBRUARY 2013 February 3–8 and May 13–17 Leadership Strategies for Information Technology in Health Care MARCH 2013 March 11–14 Analyzing Risk: Principles, Concepts, and Applications March 14–17 Healthy Kitchens, Healthy Lives: Caring for Our Patients and Ourselves March 18–20 Effective Risk Communication: Theory, Tools, and Practical Skills for Communicating About Risk March 25–28 Management and Leadership Skills for Environmental Health and Safety Professionals APRIL 2013 April 1–4 Prevention Through Design for Construction MAY 2013 May 6–10 Guidelines for Laboratory Design: Health and Safety Considerations JUNE 2013 June 3–7 Radiation Safety Officer Training for Laboratory Professionals June 3–7 Comprehensive Industrial Hygiene: The Application of Basic Principles June 10–13 Intensive Course on Health and Human Rights: Concepts, Implementation, and Impact emotional experience.” And while she is still a film devotee, adding an MPH to her MD will likely prove far more rewarding than the MFA she once contemplated. “Medical school and residency are where you learn to take care of individuals,” Newland says. “An MPH helps prepare you to take care of communities. My goal is to build skills to take back to a community that needs it.” Customized programs also are available. Foster the growth of your executives and your organization as a whole by developing a custom program that will address the specific challenges you face in today’s marketplace. CCPE brings custom programs to organizations around the globe. All programs are held in Boston unless otherwise noted. For a complete list of topics and faculty, or to register, visit: https://ecpe.sph.harvard.edu/ e-mail: email@example.com call: 617-432-2100 Harvard School of Public Health Executive and Continuing Professional Education 677 Huntington Ave. Boston, MA 02115 © Tony Rinaldo Karen Feldscher is senior writer at HSPH. 30 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 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 Gerald L. Chan Lee M. Chin Jack Connors, Jr. Jamie A. Cooper-Hohn Mala Gaonkar Antonio O. Garza C. Boyden Gray Stephen B. Kay Jeannie Lavine Jonathan Lavine Catie Marron Richard L. Menschel* Roslyn B. Payne Swati A. Piramal Alejandro Ramirez Carlos E. Represas Richard W. Smith Howard Stevenson Samuel O. Thier Katherine Vogelheim *emeritus 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 Beulow, SM ’12* M. Rashad Massoud, MPH ’93 *Class Representative Harvard Public Health is published three times a year for supporters and alumni of the 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://hsph.harvard.edu/ news/magazine/ and email comments and suggestions to firstname.lastname@example.org. edu. 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 Assistant Director for Development Communications and Marketing Amy Gutman Principal Photographer Kent Dayton Contributing Photographers Upasana Dahal, Aubrey LaMedica, Tony Rinaldo Contributing Illustrators Shaw Nielsen Marketing and Communications Coordinator Rachel Johnson Contributing Writers Michael Blanding, Luisa Cahill, Karen Feldscher © 2012/2013 President and Fellows of Harvard College 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 Clare Rosenfeld Evans, SD ’16 Clare Rosenfeld Evans was just 7 when she was diagnosed with type 1 “juvenile” diabetes. Almost immediately, her challenge became her calling. Days after being released from the hospital, she volunteered for the American Diabetes Association. As a teen, she worked on a successful campaign to establish the United Nations’ annual World Diabetes Day. But it was on a precollege trip through El Salvador, Tanzania, and Bangladesh that the Eugene, Oregon native homed in on her goals, having discovered a dramatic contrast between the health care that she’d received and that accorded diabetics in the developing world. “It was an eye-opener,” she recalls. “I was struck by the forces dictating the kind of health outcomes a person could expect—things like poverty, racism, and geopolitics.” Today, thanks to the John F. and Virginia B. Taplin Fellowship, Clare is a doctoral student in HSPH’s Department of Society, Human Development, and Health, where she is studying the causes of global health inequalities. “Fellowships do much more than help students get degrees,” Clare says. “They are an investment in the future—and in our dreams.” Please give to support financial aid today. To find out how, visit http://hsph.harvard.edu/give or call Morgan Pendergast at 617-432-8436. 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 HSPH: NUMBER ONE IN SOCIAL MEDIA Harvard School of Public Health was crowned the most social-media-friendly school of public health in the first-ever ranking by the website MPHProgramsList.com. The site scored 57 schools on their social media activity, awarding points for the number of followers and posts on popular platforms. You can connect to HSPH on Facebook, Twitter, LinkedIn, YouTube, Instagram, Google Plus, and Pinterest. This magazine is available on the Kindle bookstore, and through mobile apps for iPhone and Android. Learn more at http://hsph.me/socialmedia.