Harvard Public Health, Winter 2012
Public health in a place called happiness
HSPH.HARVARD.EDU 2012 Annual Gift Report The Prostate Cancer Predicament Painting the Big Picture on a Navajo Reservation HARVARD PUBLIC HEALTH Winter 2013 Public Health in a Place Called Happiness DEAN’S MESSAGE A Legacy Worth Preserving W hen I became the Dean of Harvard School of Public my top objectives has been to steer the School toward Health four years ago, my goal was that of a good greater diversification of its revenue sources, much physician: to first do no harm. The School has an also depends on our strong and committed donor amazing legacy of research that has saved the lives community. 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. 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 But maintaining the School’s place as public health’s premier research institution is just one of my influence everything from individual behaviors to health care systems to government policies. We can continue to convene global leaders from a wide variety HSPH has been successful at translating research to improve people’s lives because we have developed an 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 impressive scientific base to translate. 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 I thank all of you for helping make possible our shared mission. 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 2 Harvard Public Health Julio Frenk Dean of the Faculty and T & G Angelopoulos Professor of Public Health and International Development, Harvard School of 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 To screen or not to screen? For prostate cancer, that is the bedeviling question. 4 Frontlines 8 Philanthropic Impact 30 Continuing Professional Education Calendar 28 Painting the Big Picture on a Back Cover HSPH: Number One in Social Media 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 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 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 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.” from computers around the world. The course, co-taught Author Describes Battle with Breast Cancer I 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 of epidemiology, and Marcello 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. 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. 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 Left, Aubrey LaMedica/HSPH; top, ©Justin Knight by E. Francis Cook, professor watch lectures and participate AB Blood Types at Highest Risk for Heart Disease Mexico’s Milestone: Universal Health Coverage 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. Lift Weights, Lower Diabetes Risk 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 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.” 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. Kent Dayton/HSPH; Illustration, Shaw Nielsen 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 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. FROM SURVIVAL TO GROWTH: EMPHASIZING A BABY’S FIRST THOUSAND DAYS 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. Iron Imbalance in TB Patients: Too Much Is as Bad as Too Little T 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.” 6 Harvard Public Health From left: REUTERS/Sarth Panyal; ©Tony Rinaldo 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.’” CHANGING FOOTBALL CULTURE Offthe Science of the Spirit CUFF 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 findings be applied? “ 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 Suzanne Camarata 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. 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. 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 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 Top, ©Tony Rinaldo; at left and opposite, Aubrey LaMedica/HSPH 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. 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 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- Atul Gawande, professor of health policy and management 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.” 9 Winter 2013 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.” Distilling the Truth About Water HSPH’s James Shine explains why access to safe water persists as a global health issue. Q&A Water courses through every aspect Q: H ow much water does an average American consume each day? of our lives, for good or ill. As senior A: A bout 1,600 gallons. That figure surprises a lot of people. lecturer on aquatic chemistry in the Most of us think about our direct-consumption use of water: How many times do I flush the toilet? How long is my shower? School’s Department of Environmental And those are obviously important for understanding how Health, James Shine has explored the one person depletes local water resources. role of clean, safe, and accessible water water that fell on a wheat field this afternoon is going to be in human health, focusing on the effects sandwich, a lot more water was used. It takes 52 gallons of contaminants in rivers and lakes. According to Shine, the global water But if you start thinking larger, you’ll see that a drop of part of my sandwich bread five months from now. If it’s a ham 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. cycle is vast and mysterious—and as 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 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 global warming. Shine spoke recently small fraction of fresh water that is accessible groundwater with Harvard Public Health editor to 0.2 percent of water on the earth. That amount has been Madeline Drexler. and surface water, such as lakes and rivers—all told, about 0.1 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. 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 “It takes 52 gallons of water to make one glass of milk. It takes more than 600 to adequate sanitation and 1.8 million die annually because drinking water gallons to make a quarter- becomes contaminated. The sanitation goal clearly will not be met by 2015. pound hamburger. Our daily 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 lives carry a giant water footprint.” —James Shine 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 From left, Anita Patil Deshmukh, MPH ’05; Francisco Sy, SM ’81; Maura Bluestone, SM ’74; and Priya Agrawal, MPH ’06. Community Affiliated Plans. Francisco Sy, SM ’81, developed and directed the Infectious with a focus on public health. By training local youth, known Disease Epidemiology Program at the University of South Car- as Barefoot Researchers, in research design and data col- olina School of Public Health. He has also evaluated national lection, PUKAR has documented the social determinants HIV/AIDS prevention programs at the Centers for Disease of health facing Kaula Bandar, an urban slum community in Control and Prevention. Sy currently directs extramural re- Mumbai, India. Its advocacy has led to the establishment of search in minority health and health disparities at the National government health camps, a 90 percent childhood immuni- Institutes of Health, which provide resources to address major zation rate, and the first legal access to water in the slum’s public health problems. 50 years of existence. PUBLIC HEALTH INNOVATOR AWARD Anita Patil Deshmukh, MPH ’05, works with Partners for Kent Dayton/HSPH Urban Knowledge, Action and Research (PUKAR), an independent collective exploring issues related to urbanization, 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 “The most striking thing about Bhutan is that, as its vow to become a 100 percent organic food producer, a part of their movement to secure Gross National Bhutan is probably best known for its guiding philosophy Happiness, they have made affordable and accessible of “Gross National Happiness,” or GNH, which strives to health care central to public policy,” adds Parveen balance economic development with spiritual well-being. Parmar, a faculty member of the Harvard Humanitarian But that novel policy is being put to the test. Newfound Initiative. In 2009, as a consultant on emergency medical consumerism, fueled by rural-to-urban migration, is care to Bhutan’s Ministry of Health, Parmar traveled to partly behind a wave of unprecedented public health hospitals and clinics throughout the country. “You get challenges, from obesity to drug use. Vaulting from a a sense that once a problem is identified, everybody is preindustrial culture to the information age in just 50 on board to find a solution. That top-down dedication is years, Bhutan has become a living laboratory for dealing a model, not only for small, developing nations, but for with the challenges of rapid modernization. larger ones as well.” “For a country that is not an easy place to get around, they have managed to achieve a 93 percent child immuni- CROSSROADS OF OLD AND NEW zation coverage—which is very impressive,” says Richard Kathy Morley, a Boston-based emergency medicine physi- Cash, senior lecturer on global health at HSPH and an cian, and her husband, Michael Morley, an ophthalmolo- international leader in developing public health solutions gist, are working at this crossroads of old and new. Over for low-resource nations. 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 for JDW National Referral Hospital in the capital, in health care management), they have fashioned them- Thimphu. The hospital has no emergency medicine selves as a public health team in their volunteer assign- doctors—a situation reflecting a dearth of special- ments abroad. After projects in Cambodia and Thailand ists throughout the nation. This past September, the to deliver advanced eye care surgery, they brought their education module was used to train some 20 physicians expertise to Bhutan in 2004—drawn as much by its managing emergency and trauma care. The training spiritual culture as by its pressing public health needs. will pay off not only with accident victims, but also with Michael set up Bhutan’s first laser surgery equipment victims of other common emergencies, such as children to treat diabetic retinopathy, and the couple collabo- choking or women suffering from ruptures caused by rated with the WHO on a Rapid Assessment Avoidable ectopic pregnancies. Blindness survey. More recently, the Morleys have joined forces with FEAR OF SEAT BELTS the nongovernmental organization Health Volunteers In Bhutan—where subtropical southern lowlands rise to Overseas to buttress Bhutan’s emergency care system. sacred, unclimbed peaks exceeding 24,000 feet—many The collaboration, funded by the Washington, DC–based grievous injuries occur when cars veer off the country’s Bhutan Foundation, includes physicians at the University- narrow, vertiginous roads. Bhutanese dislike wearing seat wide Harvard Humanitarian Initiative. belts, fearing the belts will trap them in falling vehicles. With traumatic injuries—often the result of road Kathy Morley wants to conduct a study to see if that tena- accidents—a major cause of death in the country, Kathy cious cultural belief is valid. “You need data to change helped develop a National Emergency Medicine Course 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. A pregnant woman receives a vaccination at the Yangthang Basic Health Unit, in the Haa District of western Bhutan. Despite these challenges, Bhutan has made impressive public health gains: by working smarter—making relatively simple improve- Life expectancy in 1960: 33 years ments that, ideally, cost no money.” The bar code project is Life expectancy in 2012: 66 years expected to be most valuable in well-defined environments Eliminated polio in 1986, leprosy in 1990, and goiter in 2003. such as outpatient clinics and operating rooms. In 2004, became the first country in the world to ban the sale of tobacco. ISOLATION TO INSPIRATION 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. country was just beginning to open its borders. At the Bhutan launched its health system in 1961, when 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 Has met 2015 UN Millennium Development Goals (MDGs) for infant mortality. of women suffered goiter from iodine deficiency. In the last half century, guided by a fierce commit- On track to meet 2015 MDGs for maternal mortality. ment to public health and a royal family that has spearheaded many progressive health campaigns, that dire 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 teaching,” says Michael Morley. “It’s not very sexy, but you can squeeze improvement in capacity and output just 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 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 Madeline Drexler and improve patient flow. “This was straight HSPH picture has spectacularly improved. Health care has been volunteers serve as intermediaries between often-isolated THE PRICE OF EQUITY pockets of people and formal health care institutions. Fresh out of medical school, Gepke Hingst journeyed to About 90 percent of Bhutan’s citizens have health war-torn Afghanistan in 1983, when the Afghan govern- coverage—with most of the remaining 10 percent high- ment and its Soviet backers were battling a Muslim altitude nomadic herders who cannot be easily reached. insurgency. Though she had contemplated a position in Bhutan, at the urging of a Buddhist friend, what followed Today, Bhutan’s major health threats include acute instead were stints in Africa and South Asia. respiratory infections (worsened by wood fires in the Not until 2006 did she became UNICEF’s countryside), diarrheal diseases, and skin infections. But as in many developing nations, the afflictions of poverty country representative in Bhutan. What took so long? are fast becoming eclipsed by the afflictions of excess and “Sometimes,” she says, “karma makes you wait.” At HSPH in the mid-’90s, Hingst had focused on an increasingly sedentary lifestyle. Noncommunicable diseases such as cancer and heart disease account for 31 global health. “As a doctor, you’re told that disease is percent of deaths, and stroke, hypertension, and diabetes disease—social and economic background don’t matter. are on the rise. As Tashi Wangdi, head of the Internal But when you work for a long time in developing coun- Medicine Department at JDW National Referral Hospital, tries, you see what I call the ‘repetition of horror.’ wrote in 2012, “Bhutanese might be seeing the beginnings Harvard teaches you to address inequities and really of an unhappy bargain: of living longer, but of also being arrive at public health.” In Bhutan, Hingst encountered a nation bent on 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 avoiding the repetition of horror that springs from poverty and certain cultural norms. UNICEF is mandated continued country, including barely 200 doctors, virtually every “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 of construction and a torn cityscape of dust, debris, and equal rights of women and girls in political, social, and spindly bamboo scaffolding. economic development. In Bhutan, this mission has taken “For me, what Bhutan illustrates is that progress is not Hingst on far-flung expeditions, such as 24-day excur- without a price,” says Hingst. “People are moving from sions through high passes, ice-cold streams, and steep rural areas to the cities. The challenges for children are valleys to the remote districts of Laya and Lunana in the dramatic. In urban areas, life is expensive—both parents northwest peaks where Bhutan borders Tibet. She has start to work. Who is taking care of the child? Is it going to trekked with outreach workers from a basic health unit be a slightly older sibling or a young niece from the village on a two-day journey to a village of 19 households at an who will sacrifice her own education—child nannies altitude of over 12,000 feet—all to vaccinate six children caring for three- or four- or five-year-olds? Where first we and attend to other essential needs. were talking about the need for vaccination and access to “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 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 education, vaccinations. They bring medicine. They treat children are engaged in child labor and 30 percent of girls eye problems and do dental care.” are married illegally before the age of 18. As Thimphu She adds: “Because Bhutan’s population is so scattered and other cities see growing numbers of children forced and there aren’t that many people, you will never achieve to fend for themselves emotionally, Hingst is most proud cost effectiveness. The economy of scale doesn’t work here. of UNICEF supporting Bhutan’s 2011 Child Care and This is the cost of equity.” Protection Act, which is intended to safeguard children against violence, abuse, and exploitation. A TIDE OF CONSTRUCTION But as the cultural fabric of Bhutan shows signs of “YOU DON’T HAVE TO SUFFER.” fraying, health equity has acquired a new meaning. After raising money for the health minister’s 2002 Today, the graceful terraced rice paddies surrounding walk across the country, Atti-La Dahlgren in 2006 the capital, Thimphu, are giving way to a massive tide 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 out to public health experts who can lend their skills to turned his attention to educating the Bhutanese public launching such an effort. about cancer—an almost taboo topic in the country. “Everybody knows somebody who has had cancer. But DOING WHAT NEEDS TO BE DONE there’s a cultural belief that if you get sick, it’s a result Despite these hurdles, material and cultural, the HSPH of your actions in this life or in a previous incarnation. alums who have devoted much of their careers to Bhutan So it’s not talked about,” he says. “There’s an acceptance are not only optimistic about the country’s prospects— of suffering. We need to be able to explain, in Buddhist they feel that this nation has much to teach the world. terms, ‘It’s OK to be treated, you don’t have to suffer.’” “Compassion and the idea of looking after each other are integrated into the culture,” says Dahlgren. “Bhutan Compounding the problem, Bhutan has only two oncologists and no facilities for cancer treatment. has the potential to serve as an inspiration and perhaps According to Dahlgren, “Many people suffer from cancer a model for other small countries, because it puts health but are either not diagnosed in time, wrongly diagnosed, and social well-being at the forefront of development.” Gepke Hingst, who left her UNICEF post in the fall of or not diagnosed at all.” As a result, most patients are sent 2012 after an unusually long six-year assignment, agrees to India for costly late-stage interventions. “There’s a huge need for awareness—about types of that Bhutan’s vision for public health is inseparable from cancer, prevention, and the need for better diagnostics its spiritual outlook. “Buddhism is founded on the idea and treatment,” says Dahlgren. He wants to establish a of interdependence—interdependence with nature and national cancer society to educate people and encourage interdependence with other people.” In Bhutan, she says, this sense of spiritual connect- patients to come out and speak about their disease. But Dahlgren says a national cancer treatment program edness translates directly into public health practice. would have to piggyback on the existing rudimentary “Officials don’t shy away from difficult issues—they health system, requiring more people, more equipment, simply do what needs to be done. The beauty of Bhutan and more labs—a daunting proposition in a country that is that they mean it.” is still desperately resource-poor. He is now reaching 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? diagnosis which cancers are likely to For prostate cancer—the second threaten a man’s health and which leading cause of cancer deaths in are not. As a result, almost all men men, after lung cancer—that is the with PSA-detected cancer opt for bedeviling question. treatment, which can leave long- The dilemma springs from the wide variation in the potential of lasting physical and emotional scars. Put simply: with prostate cancer, the cure may be worse rest of the body. The vast majority than the disease. The dilemma was of these malignancies, espe- underscored in May 2012, when cially those discovered with the the U.S. Preventive Services Task extensively used prostate-specific Force (USPSTF) issued a strongly antigen, or PSA, test, are slow- worded final recommendation growing tumors that are unlikely against PSA-based screening for to cause a man any harm during prostate cancer. According to the his lifetime. Yet in 10 to 15 percent task force, “[M]any men are harmed of cases, the cancer is aggressive as a result of prostate cancer and advances beyond the prostate, screening and few, if any, benefit.” sometimes turning lethal. In a study of U.S. men who were prostate cancers to spread to the randomly screened, the screening did not reduce prostate cancer death The dilemma has become more (though a similar study among urgent in recent years as wide- European men did find a lower spread screening with PSA in the risk of cancer death). In any case, U.S. and around the world has led experts agree that prostate cancer to a sharp increase in the number has been vastly overdiagnosed as a of detected prostate cancers. result of screening. Currently, there is no way to accurately determine at the time of 22 Harvard Public Health continued Betsie Van der Meer/Stone MURKY DIAGNOSES 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 research aims to directly address that Epidemiology, who has opposed the doctors do? At Harvard School of question, as well as to find opportu- test for 20 years. “We overdiagnose Public Health, the prostate cancer nities to reduce risk of dying from many men who would die of other epidemiology team—which includes cancer after diagnosis.” causes.” In fact, a multinational more than 25 faculty, postdoctoral study of cancer registries published fellows, and student researchers—is AGGRESSIVE OR SLOW-GROWING? by Adami, Mucci, and other HSPH developing the science to answer When it became widely available in colleagues in July 2012 found that the that question, identifying both the the late 1980s, the PSA screening most common causes of death among risk factors behind the deadliest test was hailed as a simple way to prostate cancer patients—65 percent variations of prostate cancer and the uncover possible malignancy. But of patients in Sweden and 84 percent lifestyle changes that may lower the PSA screening, which was adopted in the U.S.—are heart disease, risk of aggressive disease. without evidence of its usefulness, diabetes, stroke, or other cancers. “One of the biggest challenges turned out to be a poor indicator Yet these patients frequently of cancer, in two ways. First, it underwent radical treatments for who have a potentially lethal form creates false positives in men who their prostate cancer—interven- of prostate cancer from those with may simply have elevated antigen tions such as radiation, surgery, and a more slow-growing disease,” says levels from other conditions, such chemotherapy, which can produce Lorelei Mucci, associate professor as benign enlargement of the pros- severe side effects such as incon- of epidemiology at HSPH. “Our tate gland. These patients often tinence and erectile dysfunction. endure subsequent invasive biopsies 24 Harvard Public Health © Tony Rinaldo in oncology is to distinguish men “While we are uncertain about the CLUES IN DIET AND LIFESTYLE a more virulent cancer. According number of deaths that screening To clarify the prognosis for a tumor, to Giovannucci, “The question is prevents,” says Adami, “we are HSPH researchers are homing in whether there are two types of certain that the price for any reduc- on other factors that might affect prostate cancer—an aggressive and tion in deaths from prostate cancer is susceptibility to prostate cancer, nonaggressive form—or whether very high.” especially the aggressive form of certain factors cause a nonaggres- the disease. Edward Giovannucci, sive form to become more aggres- A study published in August WHAT MAY PROTECT AGAINST ADVANCED PROSTATE CANCER? PHYSICAL ACTIVITY AVOIDING SMOKING CONSUMING COFFEE AVOIDING OBESITY CONSUMING TOMATO SAUCE VITAMIN D 2012 in the New England Journal professor of nutrition and epidemi- sive.” Evidence provided by HSPH of Medicine found no difference in ology, recently looked at nine diet researchers suggests that an increase survival between men who had and lifestyle factors. He found that of insulin in the bloodstream, caused surgery for prostate cancer and those smoking, obesity, and lack of physical by obesity and physical inactivity, under “watchful waiting,” in which activity raise the risk of developing may encourage tumor growth. continued 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.” “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 disease; those who consumed one to blood vessel formation. dietary factors to the disease. A 2011 three cups a day showed no differ- Another factor that might study by HSPH research associate ence in developing any form of the determine the difference between Kathryn Wilson, together with disease, but had a 30 percent lower a harmless and a lethal form of Mucci and Giovannucci, professor risk of developing a lethal form. prostate cancer is the sexually of nutrition and epidemiology Meir Stampfer, and other colleagues, Another, more surprising, study revealed that consuming tomato 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 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 had a notably lower risk of aggres- lower risk of prostate cancer. In fact, in men (who are often treated only sive prostate cancer. Those who men who had two or more servings after their female partners show consumed six cups or more a day of tomato sauce a week were about signs of infection). In a 2009 study, were 20 percent less likely to develop 20 percent less likely to develop pros- led by HSPH instructor in epidemi- any form of the disease, and 60 tate cancer, and about 35 percent ology Jennifer Rider, infected men percent less likely to develop a lethal less likely to die from the disease. A had a much higher incidence of pros- separate report in 2009 by Mucci and 26 Harvard Public Health ÂŠ Tony Rinaldo found that men who drank coffee tate cancer spreading to the bone increasing physical activity after genes to prostate cancer incidence or death from prostate cancer. “The diagnosis can substantially cut the and survival. good news is that if the association risk of developing aggressive pros- between the infection and lethal tate cancer. “Men with at least three to light, doctors and patients will prostate cancer is confirmed, there hours of vigorous physical activity be confronted with weighty deci- is an effective antibiotic treatment,” a week had at least a 60 percent sions about treatment. Surgery, Rider says. lower risk of prostate cancer death,” radiation, or chemo might still be the says Giovannucci. “It’s a strong wisest course of action in instances association.” where the cancer has clearly already TO TREAT OR NOT TO TREAT? “Up until now, with a few notable Among older patients especially, Until all these associations come advanced, or when a patient is young exceptions, doctors have myopically that activity can take the form of and otherwise in good health. In focused on treating prostate cancer,” vigorous walking. Recently, Mucci situations where men are older or says Adami. “They are willing to has spearheaded an intervention face a higher risk for other diseases, spend tens of thousands of dollars with Adami and other colleagues improvements in diet and lifestyle on chemotherapy that has minimal in Sweden, Iceland, and Ireland in may be more effective not only in effects on cancer mortality, often which men walk in groups with a subduing the cancer but also in with substantial side effects. But we nurse three times a week. In a pilot boosting general well-being. As ignore entirely the fact that large study, researchers found improve- Mucci puts it, “Our hope is that clini- groups of prostate cancer patients ments in just 12 weeks in body cians will use the prostate cancer die from other causes that actually weight, blood pressure, sleep, urinary diagnosis as a teachable moment to are preventable.” function, and mental health. reflect on the global health of the By focusing on lifestyle changes, Scientists at HSPH are also patient.” he adds, men can achieve three goals searching for genetic and lifestyle A man has a 2.8 percent lifetime risk of dying from prostate cancer 40 to 50 men with prostate cancer have to be treated to save the life of 1 man Source: SEER Cancer Incidence simultaneously: diminishing the markers that help predict how risk of dying from common condi- aggressive a patient’s prostate cancer tions such as heart disease and will be. For example, an ongoing Michael Blanding is a Boston-based journalist and author of The Coke Machine: The Dirty Truth Behind the World’s Favorite Soft Drink. diabetes, improving quality of life project led by Mucci and Adami overall, and perhaps also improving draws on detailed cancer registries in the prognosis for prostate cancer. Nordic countries, including an anal- In particular, stopping smoking and ysis of 300,000 twins, to tease out the relative contribution of different 27 Winter 2013 Review, 1975–2009, National Cancer Institute 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 “Just sad, sad, sad,” Newland says. She thinks better A Mongan Commonwealth Fund Fellow in Minority Health Policy, Newland, MPH ’13, has served as a physician at the regional planning to arrange hospital admissions could Kayenta Health Center in Arizona for eight years, and as help alleviate such problems—and she hopes her degree acting clinical director for the past three. A remote outpost in health policy and management will help her develop sys- with a downtown consisting of a small strip of stores, Kay- tems that deliver more prompt and effective care. Newland also wants to improve automobile safety. “I’d enta is located about 25 miles south of Monument Valley, in the heart of gorgeously sculpted red-rock country. But the like to see more kids in car seats, not sitting in the front seat movie-set scenery belies deep public health problems. of a truck. And I’d like to see more people wear seat belts.” Teen suicide, domestic violence, depression, isolation, substance abuse—all are pressing issues on the reserva- 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 tion. “We have therapists, psychiatrists, and substance abuse counselors at the health center, but services need to have running water at home, she’d like to improve access to be greatly expanded,” Newland says. monitored water—because unmonitored wells and springs are more likely to be contaminated. In particular, the seriously mentally ill—the patients A larger, more complex issue is possible chronic Newland describes as “train wrecks about to happen”— need better support. With no involuntary commitment laws, uranium exposure from contamination left in the wake of tensions have erupted over whether such decisions lie with 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 short- radioactive ore was sought for atomic weapons across age of inpatient beds. All told, these problems have left some 27,000 square miles of Navajo lands in the Four mentally ill patients in limbo. Corners area—including the Skyline Mine about 25 miles Newland recalls one woman with seizure disorder— from Kayenta—and many Navajo either worked as miners or “she was notorious for being difficult”—who would often lived and raised their families near the mines and process- wind up in the emergency room. Once, when Newland tried ing mills. Newland hopes her public health training will help to stitch up a gash on the woman’s head, the woman threat- her better understand epidemiologic research around this ened to hit her, so Newland backed off. Sadly, one day the issue—and perhaps someday conduct her own. woman suffered a seizure, collapsed near her wood stove, sustained serious burns over much of her body, and died BUILDING COMPASSION shortly afterward. 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. 29 Winter 2013 continued “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 emotional experience.” And while she is still a film devotee, adding an MPH to her MD will likely prove far more rewarding 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 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 Karen Feldscher is senior writer at HSPH. 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 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: firstname.lastname@example.org call: 617-432-2100 30 Harvard Public Health Harvard School of Public Health Executive and Continuing Professional Education 677 Huntington Ave. Boston, MA 02115 © Tony Rinaldo needs it.” March 25–28 Management and Leadership Skills for Environmental Health and Safety Professionals HARVARD PUBLIC HEALTH DEAN OF THE FACULTY Julio Frenk VISITING COMMITTEE Jeffrey P. Koplan, MPH ’78 Chair ALUMNI COUNCIL As of November 2012 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 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 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 2012–2015 Marina Anderson, MPH ’03 Robert Beulow, SM ’12* M. Rashad Massoud, MPH ’93 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 email@example.com. 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 *Class Representative Assistant Director for Development Communications and Marketing Amy Gutman For information about making a gift to the Harvard School of Public Health, please contact: Principal Photographer Kent Dayton 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 firstname.lastname@example.org For information regarding alumni relations and programs, please contact, at the above address: Jim Smith, Assistant Dean for Alumni Affairs (617) 432-8446 or email@example.com www.hsph.harvard.edu/give 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 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 Nonprofit Org. U.S. Postage PD Burlington, VT Permit No. 586 90 Smith Street Boston, Massachusetts 02120 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.