Harvard Public Health Review, 75th Anniversary Issue, Vol. I, 1922-1938

Exp!oration and tnnovation

HE YEAR is 192.2. Warren G. Harding is in the White House, Prohibition reigns, and on Broadway, T^p Zz'cg/eM FoH^s starring Wiil Rogers sets the tone for the "Roaring Twenties."

Although heart disease has recently overtaken tuberculosis as America's ieading cause of death, infectious diseases are stiH the world's killers eiite.

Vaccines for polio, measles, diphtheria, and rubella are still decades away, and the memory of the 1 9 1 8 influenza pandemic that claimed some 22 million lives is still fresh in the public's mind.

In the fall of 1 9 2 2 in Boston, the first class of men and women begin classes at the newly launched Harvard School of Public Health. The successor to the eight-year-old Harvard-MiT School for Health Officers, the School shares a dean, administrative structure, and, for the first year, classroom and laboratory space with Harvard Medical School. Over the next decade and a half, the School will emerge as a leading research and training center in the fields of sanitary engineering, tropical medicine, and industrial hygiene, laying the groundwork for three quarters of a century of achievements in public health at home and abroad.

ng and the EFORE THE J E T PLANE m a d e it

possible to traverse continents overnight, explorer-scientists such as Richard Pearson Strong covered ^

-OHm****^

thousands of miles by boat, train,

and even foot to study tropical diseases that few Westerners would recognize. Between 1 9 1 3 and 1 9 3 8 , Strong led five overseas scientific expeditions to Africa and Central and South America, including the 192.6-192.7 Harvard African Expedition that crisscrossed the remote interior of Liberia then cut 3,500 miles across central Africa to end at Mombasa, Kenya.

The expeditions formed the backbone of Strong's impressive 2.5-year career at Harvard.

When he was named the university's first profes-

1922 The Harvard School of Public Health is founded. David

U.S. mortality rate from tuberculosis falls to 97 per

Linn Edsall is dean. With a budget of $162,800, the

100,000, down from 202 in 1900, while the death

new School boasts 13 departments and 16 students.

rate from heart disease reaches 155 per 100,000, up

Women are admitted, but not eligible for degrees.

from 123 in 1900.

Tuition and expenses for the year are $300.

sor of tropica] medicine in 1 9 1 3 , he initially hoped to

too long, no trouble too great to take and watch over a

establish a Harvard-affiliated school devoted entirely to

patient," according to an anonymous biographical sketch

tropical medicine, along the lines of those that had recently

written in 1 9 3 3 . Even in retirement, Strong was relentless,

been established in Europe and Great Britain. Instead, he

teaching classes in tropical medicine at the U.S. Army

settled in to lead a department in the newly founded School

Medical College during World War II and revising to the

of Public Health, throwing his considerable energy behind

point of rewriting Edward R. Stitt's 1,747-page DMgwosM,

building up an area of research that remains strong to this

Pre^eMf/ow <3%J Treafwew? o/^ Tropzcaf D/sMses, one of

day. In 192.6, Strong joined forces with renowned tick-

the primary reference books of the time.

borne disease researcher Ernest Tyzzer to form the Depart-

Four years after his death, at a ceremony marking

ment of Comparative Pathology and Tropical Medicine.

the Belgian government's $2.0,000 gift to endow a chair

The department's members included Lemuel R. Cleveland,

in Strong's name at the School, Shattuck, his long-time

an expert on insect-borne protozoa; Jack Sandground, a

colleague and fellow traveler paid tribute to Strong's steely

round-worm expert who would accompany Strong on

resolve: "When Richard undertook a task, he carried it

several of his expeditions; A. Watson Sellards, a yellow

through with all his strength and was never deterred by

fever expert; and Clinical Professor of Tropical Medicine

difficulties. In the field, he was a stoic."

George Cheever Shattuck.

Traveling, researching, and publishing at a preter-

The son of a U.S. Army colonel, Strong was educated at the best schools: Hopkins Grammar School as a prep

natural pace, Strong packed several lifetimes worth of

school student; Yale University as an undergraduate; and

achievements into a single career, accumulating an encyclo-

Johns Hopkins Medical School, where, in 1 8 9 7 , he

Age of the Exptorer-Scientist pedic knowledge of tropical diseases while making a

graduated with the first medical school class. Early on

specialty of onchocerciasis, or river blindness. In a time

he demonstrated an interest in tropical medicine—his

before Medline databases made it relatively easy to put

undergraduate thesis at Yale was on cholera. Following

such scholarship on display, Strong wrote dozens of papers

medical school, he joined the Army and was sent to

clarifying where and why onchocerciasis was prevalent,

Manila to establish research laboratories during the

including Onc^ocercMs/s, a 2.34-page report of his

Spanish-American War. Strong resigned from the Army

investigaton of the disease in Central America.

Sandwiched between his Conradian journeys were Strong's World War I heroics, which included a stunningly

a couple of years later, but would spend a total of 1 4 years in the Philippines doing tropical medicine research.

That Strong would be drawn to tropical medicine is

successful effort to control a typhus outbreak in Serbia

easy to understand. The European powers had conquered

and an investigation of the cause of "trench fever" among

and carved up Africa in the 1880s. Colonial-era govern-

British and French troops, for which he was decorated

ments had a keen interest in keeping their colonists and

by the American, British, and French governments. In

the labor supply—the native populations—healthy. The

what little spare time he had, Strong apparently also acted

American acquisition of the Philippines, Puerto Rico, and

as personal physician for many of his friends, displaying

Guam after the Spanish-American War created similar

"meticulous care and unselfish devotion. N o hours were

imperial interests and impulses in this country. At about

U.S. life expectancy at birth is less than 60 years and infant mortality is 76 per 1,000 births.

Mo^ froM^/e w g ^^ 7 ^^OM^gfS C O W W g

we^ ^ r o M g ^ / r o w

â&#x20AC;&#x201D; Richard Pearson Strong, diary of the 1926-1927 Harvard African Expedition

the same time, Louis Pasteur's discoveries had launched

immunologic reactions to diseases; and Charles Brues,

the germ theory of disease and the bacteriological era in

a zoologist. On his longest and most arduous sojourn, the

medical research. European and American scientists were

192.6-192.7 Harvard African Expedition, Strong was

eager to go out into the world with their microscopes and

accompanied by two zoologists, a botanist, and a photo-

discover new disease-causing microorganisms. Where

grapher in addition to Harvard colleagues Shattuck,

better to go than to the tropics, with its exotic diseases

yellow-fever researcher (and future Nobel Prize-winner)

(at least to Westerners) and alarming epidemics?

M a x Theiler, and Belgian-born Joseph Bequaert, an entomologist who would later become the

When Strong was a teenager, Patrick

curator of insects at the Harvard Museum

Manson, sometimes called the father of

of Comparative Zoology.

Western tropical medicine, was developing his theory that mosquitoes spread

While some of Strong's expedi-

malaria. When Strong was in prep school, Theobald Smith (who would

tions were broadly investigatory, ^

others focused on specific diseases.

become an influential figure in the

The 1 9 1 3 South American expedi-

early years of tropical medicine at

tion, for example, was organized

Harvard) and Fred Kilborne

to investigate Oroya fever and

discovered that a tick spread Texas

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two anemia-

cattle fever. The year that Strong

and fever-producing diseases that

graduated from medical school,

in their later stages sometimes were

Ronald Ross dissected dapple-

mistaken for smallpox. On that

winged Anopheles mosquitoes and

expedition, co-sponsored by the

identified the parasite that causes

United Fruit Company, Strong and his

malaria.

^

colleagues spent most of their time studying hospitalized patients and those

Strong, already specializing in

who had died from the diseases. They

tropical medicine, clearly fell under the spell Pejfsow Sfrowg

of expeditionary research. In his first year at Harvard he led an expedition through Colombia,

1872-^94$

Ecuador, and Peru, and from then on Strong was almost always on the moveâ&#x20AC;&#x201D;so much so that teaching

studied blood, conducted autopsies, and performed any number of histological studies.

Dozens of attempts also were made to inoculate

a menagerie of animals with the diseases, with

assignments had to be re-shuffled during his long absences.

mixed results. They succeeded with VefrMgi? PefM^MM^,

His colleague, Shattuck, kept pace, leading three expedi-

but not with Oroya fever.

tions to the Yucatan Peninsula in

1 9 3 0 , and 1 9 3 1 .

Strong's expeditions were multi-disciplinary long

Strong did have some success in identifying the cause of Oroya fever. In his report on the expedition, he charac-

before the word entered the academic lexicon. The first

terized it as "essentially a parasite of the red-blood cell"

expedition to South America, for example, included Strong;

and classified it as falling somewhere between a bacterium '

Tyzzer, the parasitologist; Sellards, whose expertise was in

and a protozoan. It would be 1 3 years before Japanese-

1923 The School moves into newly renovated Infants'

Alice Hamilton leads a

Hospital building at 55 Shattuck Street in Boston,

faculty survey of health

which will serve as headquarters for the next 30

conditions at the

years.

General Electric Plant in Schenectady, New York.

American bacteriolo-

more people are at

gist Hideo Noguchi

work at the planta-

^^GU^EMALA^

would succeed at

tion and in the

cutturing the organ-

coffee Held, where

ism, providing the

they are exposed to

cruciai evidence that

the bites" of the

Oroya fever and

black fly.

VeTYMga PgfWMfTM

Strong also

were the same

conducted an

disease. In another

experiment on two

experiment reminis-

coffee plantations

cent of Ross's and

to see if removing

Reed's earlier work

the nodules that

on malaria and

formed in the most

yellow fever, Strong

seriously infected

arranged to have

people would lower

mosquitoes feed on

the rate of infection.

a patient sick with

Strong believedâ&#x20AC;&#x201D;

Oroya fever. Later he dissected the mosqui-

Map

c;'rc<2

jre^M M^ere owc^ocersM.SM was preM/e?!f.

correctlyâ&#x20AC;&#x201D;that infected humans

toes, looking for the parasite in its gut, which might

were the reservoir of the disease, and he was able to show

indicate that mosquitoes spread the disease. But no

a lower rate of infection in both people and flies in areas

parasites were found, and sand-flies were later proved

where nodules had been removed. Asserting that nodule

to be the vector.

removal is simple, safe, and fast, Strong argued that

Strong's 1 9 3 1 expedition to Guatemala and 1 9 3 4

onchocerciasis could be controlled if doctors would

expedition to the Belgian Congo were targeted at the little-

routinely remove nodules from patients in areas where

known disease onchocerciasis. The disease first had been

the disease is endemic.

described in the Western medical literature in 1 9 1 5 in

Perhaps the key finding that came out of the

Guatemala, where it apparently became a concern of

Guatemala expedition was made by Jack Sandground, an

coffee plantation owners. But because it tends to affect

assistant professor of tropical heiminthology in Strong's

only people who live and work in heavily infested areas,

department. Essentially, Sandground settled a taxonomic

onchocerciasis was not considered to be much of a health

dispute, proving that there was no difference between

threat to white colonists.

what had been previously identified as distinct species of

The Guatemala expedition was primarily epidemio-

the onchocerciasis parasite.

logic and ecological. In Owc^oce^cMSM, his report on that expedition, Strong devotes dozens of pages to the details

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of the black fly habitat and breeding cycles. He also care-

'

fully observed the coffee plantation workers and drew the connection between disease rates and the workers' sea-

NTERNATIONAL TRAVEL OF ANY KIND c o u l d b e

arduous in the first half of the century, but Strong's 1 9 3 4 expedition to the Belgian Congo, his last,

undertaken when Strong was 62 years old, was a grueling

sonal schedule: "The only seasonal influence that appears

ordeal. Again accompanied by a team of scientists, he set

to be definite...is that at the time of the year the coffee is

out to study onchocerciasis in a set of villages apparently

ripe and collected and prepared for use or export, many

untouched by European colonial or missionary

Hans Zinsser succeeds

Tetanus toxoid devel-

President Harding dies in office and is succeeded by

Harold C. Ernst as

oped by Gaston Ramon

Vice President Calvin Coolidge.

Professor and Chair of

of the Pasteur Institute.

the Departments of Bacteriology and Immunology.

in the understanding of the ecology

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influences. Just reaching the coast of Africa required a 16-day ocean

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voyage. Once there, Strong and his

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colleagues spent another week

fo

traveling by trains, autos, and—

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according to a newspaper account of

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the seven-month expedition—"boats

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with native paddlers." Even for the

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well-traveled Strong, this destination

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was impressively remote.

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" T h e experiences encountered

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in this region, isolated from civiliza-

infection rates were so high—among people and black flies—Strong left Africa believing that the only w a y to control the disease was to eradicate the breeding ground of the fly—a strategy subsequently adopted by international health organizations and African governments until the late 1980s.

Strong's disease-specific expeditions were, in spirit and intent,

tion, were entirely unique and perhaps could not be encountered in

narrowly scientific investigations.

p s T z e f m f w g /o7*c<?

any other part of the world," he

Fo72g

wrote in his report on the expedition,

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The seventh Hamilton Rice Expedition in 192.5, which went up the Amazon and Negro rivers of South

published this time as a supplement to the Awen'c^w /oMrw^f o/^

of the disease in Africa. Because the

As

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72007Z M7<3S Strong organized a make-shift

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laboratory in a mud-walled hut and

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then went about diagnosing and

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America, and the 1 9 Z 6 - 1 9 2 . 7 Harvard African Expedition were more like adventures, imbued with a sense of the fantastic and occasionally a hint of foreboding. Strong and his colleagues collected and recorded

treating onchocerciasis. In contrast to <372<^ ^O T'epfCSS <3 SC7-M772

the roughly 40 percent infection rate

information on almost everything they saw and experienced, from

he had seen among Guatemalans, he gradually recognized that nearly

/ o f e s ? <3f

every inhabitant of these African villages was infected with the para-

S M ^ O^

— Strong diary.

site. The lab that Strong set up was

Harvard African Expedition

tribal customs to the parasites found in wild game, all of which was later documented in beautifully illustrated, encyclopedia-sized books published

swamped each day with hundreds of

by Harvard University Press. They

people seeking help for their failing

also brought back hundreds of animal and botanical specimens.

eyesight.

"This large number of patients, closely huddled together upon the ground, sitting in the open usually with

TRONG'S VIVID, FIRSTHAND OBSERVATIONS of the

no shelter from the rays of the sun, would patiently wait

Harvard African Expedition were recorded in a 32.0-

their turns for treatment, often throughout the entire day,

page diary, now part of the rare book collection of

and only return to their homes as darkness approached,"

Harvard's Countway Library. The main objective of the

wrote Strong.

expedition was to explore the interior sections of Liberia,

Strong's expedition to the Congo provided important

where Strong's friend, industrialist Harvey Firestone, had

proof about how grave a problem onchocerciasis was in

recently taken out a 99-year lease on a million acres of

Africa. He and his colleagues also filled in important gaps

land to grow rubber trees. For more than four months,

1924 Cecil and Katherine Drinker and William B. Castle conduct first comprehensive investigation of radium poisoning among watch dial painters in Orange, New Jersey.

T o w e ^ y /^r

mosf ^f^mc^we

o / L / ^ e r M ^re ^er

f ^ e w o ^ e /eefs n e a r e r ^o H&a^e?? wore

/oyes^s W

j ^ y w ^ e ^ e efse

^e^M^/M/ /ores^s. f ^ e coM^^ry

7

^ei/er ^ e e n

eOMM^ry. — Strong diary. Harvard African Expedition

Strong and his coHeagues slogged through Liberia's hilly,

the tail, which is the usual custom for the first elephant in

stream-laced interior. Wielding his microscope like a

camp," he wrote.

weapon, Strong studied everything: human blood, snake blood, horse spleen. The maps are unrehabte, so they have

},] 1 2 3 4 EXPEDITION to the Belgian Congo was

to depend on compasses. Strong writes in frustration that

Strong's last adventure. After he retired in July

it is impossible to "travel in a straight line" to any village

1 9 3 8 , Ernest Tyzzer, who accompanied Strong on

in Liberia. On one foray, when some streams are too deep

his first expedition to Central America, succeeded him as

and wide to cross, Strong describes how he and his

head of the Department of Tropical Medicine. At the

coHeagues climbed "twenty to thirty feet into the trees

urging of George C. Shattuck, money was raised from

which grew along the banks and then descended by

former students and the Belgian government for a Richard

dropping down from hanging branches on the other side."

Pearson Strong Professorship. In 1 9 3 9 , Strong's long-time

Strong was very sick much of the time, and his diary

colleague, A. Watson Sellards—a fellow Johns Hopkins

chronicles his stoic efforts at self-diagnosis—he thinks it is

graduate who first worked with Strong in the Philip-

dengue fever, then malaria—and self-treatment with large

pines—was named the first Richard Pearson Strong

doses of quinine that affected his vision and left him nearly

Associate Professor of Tropical Medicine. Strong's life as

deaf. As he battles sickness, sweltering weather, and

an emeritus professor was full of awards, honors, and

adversity, Strong displays discipline, determination, and

tributes. Later, at age 72, he came out of retirement to

remarkable endurance. In just one day he travels miles to a

teach tropical medicine at the Army Medical School in

small village called Binda, examines a boy with yaws and

Washington, D.C. He died in Boston on July 4, 1948, after

another person with leprosy. He draws blood from a

a long battle with cancer.

poisonous snake and from a horse.Then he comes back to

Strong's scientific legacy is somewhat mixed.

the base camp and dresses the ulcerous sore of the chief's

Although a

wife. "So you see I had a busy day," he writes, "and not

Strong to the legendary Walter Reed, Strong himself was

time to think."

circumspect about his career. In November 1 9 3 6 , in an

Posf obituary favorably compared

address to the American Academy of Tropical Medicine,

After exploring Liberia, Strong and his coHeagues proceeded across Africa, traveling up the Congo River and

Strong modestly noted that "many of us have not attained

through Africa's lake district—present-day Burundi and

that measure of success in research that we have sought"

Rwanda. Much of the travel was by boat and train. In the

and made a plea for the "inner satisfaction" that can come

diary, Strong writes with some lyricism about the beauty

through scientific research. Strong is generally credited

of the Congo and the lake district, camping under fig trees,

with discovering the bacterium that causes Oroya fever,

and swimming at sunset. He also describes the party's

although he tends to be overshadowed by Noguchi, who

attempts at lion and elephant hunting. Strong doesn't have

cultured the bacteria and showed that it also caused

any luck with lions, but he does shoot an elephant. "At

V<?7*?*Mg% P e r w M M .

dinner my face was not rubbed with elephant's blood from

In conjunction with the U.S. Department of Agriculture'sBureau of Chemistry,faculty in the Department of Industrial Hygiene study potential health hazards of zinc foil wrappers for food.

S3

HSPH epidemiologist W. Lloyd Aycock shows that polio occurs most often during early spring and summer.

Onchocerciasis Richard Pearson Strong brought onchocerciasis to the world's attention 70 years ago.Yet until recently, it has languished as

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a neglected disease, partly because it primarily affects people in the world's poorest regions. A 1992 article in the

Journal of Infectious Disease described -4T onchocerciasis as a disease that occurs "au bout de la pisteâ&#x20AC;&#x201D;at the end of the road and beyond."

Today a graduate of the School, Donald Hopkins, M.P.H/70, is a leader in the world-wide effort to control onchocerciasis, or river blindness, which affects an estimated 400,000 in equatorial Africa and Latin America and is the fourth-leading cause of blindness worldwide. The disease is caused by infection with Onchocerca i/o/vu/tvs worms and spread by pesky Simulium black flies.

The flies pick up the larval form of the worm, or microfilariae, when they bite an infected person. The parasite develops over the course of a

His greatest contributions to pubiic health stem from

week to the stage infectious to humans. When the fly bites the next person, it transmits the larvae, which mature to adult worms that can live up to 12 years in a person. The females, which can grow as long as 10 inches, mate with males, and produce huge numbers of microfilariae. Some but not all of the adult worms coil up in bunches and produce unslightly nodules that are the most visible feature of the disease.

"One or two black fly bites are not enough to cause disease," said Hopkins in a recent interview. "Hundreds of infectious bites are usually necessary to get enough fertile female worms into the body that will, in turn, result in high numbers of microfilariae. The casual visitor

j

to an area with blackflies might be annoyed by fly bites but is not really at risk of getting onchocerciasis or going blind. You need to live in the affected area for years to be at risk. This is a disease of poor

^

rural people."

Strong believed that the best way to control onchocerciasis would be to remove the nodulesâ&#x20AC;&#x201D;a favored form of onchocerciasis control for decades in Central America. Frank Richards, deputy director of the Atlanta-based Carter Center's Global 2000 River Blindness Program headed by Hopkins, said nodulectomy "makes complete biological sense" but has not been rigorously tested. Until fairly recently, another

of the white man's burden in the tropics is the constant

his onchocerciasis research. Although Strong was not the

menace of tropical diseases" and goes on to say that

first to observe and describe onchocerciasis, he made

"science is doing one of its greatest service to mankind

valuable contributions to understanding its natural history

in overcoming conditions which made life in the tropics

and transmission. Some histories credit Strong with

almost impossible for white men and dangerous and

discovering that black flies spread the parasite that causes

enervating even to natives...." Racism was endemic to the

the disease, although in his own writings, and much

era and culture, and Strong was a product of his time.

to his credit, Strong says that Donald B. Blacklock was

Nonetheless, it is hard for any contemporary reader not

actually the hrst to identify black flies as the vector.

to cringe when reading a Strong report that describes

More crippling to Strong's historical legacy from a

the Kru people of Liberia as "negroid, thick and sturdy

contemporary standpoint, however, is the racist outlook

and unattractive" or, in another report, the claim that

that pervades so much of his scientific writing. In fact,

the indigenous people in Guatemala are "on the whole...

many contemporary historians argue that the whole

rather a listless indolent people...."

A disastrous incident in the Philipines nearly un-

enterprise of tropical medicine was animated by imperialist objectives and racist attitudes. The article announcing

hinged Strong's early career. In 1 9 0 6 , as head of the

Strong's appointment to the Harvard faculty in 1 9 1 3 in

Bureau of Laboratories, Strong tested a cholera vaccine on

the university's alumni bulletin states that "no small part

2.4 Filipino inmates of Bilibid Prison. The vaccine had been

1924 Tropical Medicine Professor Richard Pearson Strong

George Chandler Whipple, Gordon McKay Professor

leads the Hamilton Rice Seventh Expedition of South

of Sanitary Engineering and one of the founders of

America up the Amazon and Negro Rio rivers.

the Harvard-MIT School for Health Officers, dies at age 59.

strategy for controlling onchocerciasis centered on stamping out the black flies. The World Bank, the World Health Organization, and other groups have poured millions of dollars into aerial insectide spraying programs over the past 30 years. The spraying programs have reduced transmission significantly in some places. But, notes Richards, spraying can be ineffective in thickly forested areas because the insecticide can't reach the breeding sites. Moreover, once the spraying stops, the flies can come back.

Now those involved in onchocerciasis control are pinning their hopes on a drug called ivermectin. Originally developed by Merck & Co. as a veterinary drug, used among other things to stave off heartworm disease in dogs, the drug was found through routine screening—subsequently confirmed by extensive testing—to work against onchocerciasis. A single dose annually kills the worm's microfilariae and prevents release of new microfilariae from the adult female worm.

In an infected person, this can mean prevention of onchocerciasis^ worst results—visual damage and skin disease. Ivermectin may also help to curtail transmission—with fewer microfilariae circulating in a person's body, the biting black flies are not as likely to pick up the infectious organism. In 1987, Merck moved to make the drug available worldwide for free.

Hopkins, a veteran of the successful campaigns to eliminate smallpox and Guinea worm disease, stresses that the goal with onchocerciasis is control, not eradication. He said there hasn't been any reliable measurement of the number of people who have benefited so far.

Instead, he measures progress in terms of the number of people who have received ivermectin—60 million in the eight-year period between 1988 and 1996.

One of ivermectin's virtues is that it is a relatively simple drug to distribute and administer. But in some of the countries where it is most needed, notably Liberia and Sudan, warfare and internecine conflicts have gotten in the way of all health services, including ivermectin distribution. Even in more peaceful places there are obstacles. "Some of the villages most affected by river blindnesses are the hardest to reach," notes Richards. Ivermectin is in such demand in some countries that health officials have had to contend with theft and a growing black market. Said Hopkins," Part of the challenge of all this is to develop sustainable distribution programs." Still, onchocerciasis is one disease that health officials believe they have on the run. Says Richards, "The outlook is very bright."

PW

accidently contaminated by plague, and the subsequent

chair John David, the current Richard Pearson Strong

death of 1 3 prisoners caused an uproar. An investigating

Professor of Tropical Public Health, who investigates

committee accused Strong of criminal negligence, and

debilitating tropical diseases that affect millions of the

Strong was said to have been driven "pretty near crazy"

world's least fortunate people.

by the episode. The charges were eventually dropped,

The dedication to

Ep/JgTwo/ogy, a book co-

but the Bilibid Prison vaccine deaths are the Achilles heel

authored by Brigadier General James Stevens Simmons,

of Strong's biography, a weak spot that attracted the

S.D.'^^, chief of the army's Preventive Medicine Program

attention and harsh judgment of medical historians.

and future dean of the School, acknowledges Strong's

Perhaps, as a current faculty member pointed out

"untiring and productive labors in this field since

recently, Strong's best and most durable legacy is the

1899...have contributed richly to the health of our troops,

School's continued success in tropical medicine and

to the sanitary improvement of the tropics and to the

tropical public health. Strong was a world-class scientist

future welfare of mankind."

and leader in public health; he set a high standard by

A brief editorial in the

H e m / J four days after

combining research in the laboratory and in the field.

Strong's death may have summarized him best: the writer

He exuded a truly extraordinary sense of curiosity and

noted that while politicians and statesmen steal headlines,

scientific adventure—an excitement and drive for scientific

it was "the day-to-day plodding of specialists like Strong

discovery that continues today in the work of department

who keep broadening the usable areas of the globe."

Peter Wehrwein

Seth M. Fitchet, a 1921 graduate of Harvard Medical School, is the first and only recipient of the bachelor of public health degree from the School of Public Health.

^ ^ ^ ^ ^ ^ ^ ^ ^ ^

Agroupofsixcardiolo-

^ ^ H T ^ ^ ^ H

gists in New York City founds the American HeartAssociation.

Dean, 1935-1942

Ceci! Kent Drinker ^

AMES STEELE, a master of public health degree

] candidate, had been at the School only a few months when his young wife, Aina, was hospitalized with tuberculosis. Student health insurance at the time didn't cover health care for spouses, and Steele's fellowship barely paid for rent and food. The doctor's bills were quickly adding up, and Steele was on the verge of leaving the School when help arrived unexpectedly, in the person of Cecil Kent Drinker.

"Dean Drinker saw me through my travails," Steele, M.p.H.'^z, later wrote in a personal memoir of his career.

"He assured me that money would be available from his personal account to pay the doctors and sanitarium bills."

1925 Under the direction of Kenneth Bla.ckfan, physician-

On the recommendation of Dean Edsall, Harvard

in-chief at Children's Hospital, HSPH faculty members

President Abbott Lawrence Lowell approves a

Philip Drinker and Constantin Yaglou, right, construct

$100,000 addition to the Antitoxin and Vaccine

the first "air-conditioned nursery" for premature

t

infants.

M ^ !

Laboratory at Forest Hills, Boston.

Drinker was nearing the end of his seven-year tenure as dean when he came to Steele's aid. By year's end, he would resign his administrative post to return to his research on respiratory physiology. But the incident speaks volumes about the taciturn Drinker's generosity of spirit, commitment to students, and the degree to which his life had become entwined with the institution at which he spent the majority of his career.

Born in 1 8 8 7 , the third son of a Quaker family, Drinker completed his undergraduate degree at Haverford College and his medical training at the University of Pennsylvania, where he finished first in his class, earning four of the university's five merit awards. He then journeyed to Boston to start a residency at the Peter Bent Brigham Hospital.

While in medical school, Drinker was engaged to Katherine Rotan, a recent graduate of Bryn Mawr College and aspiring scientist who would become his wife and life-long collaborator in the laboratory.

During the couple's long courtship, they dutifully wrote messages to each other in their personal journals at the close of each day, exchanging journals when they met to catch up on the day-to-day details of each other's lives. Cecil's last journal entry, written shortly after they married, reads: " N o w we are settled in our apartment near the School, both of us studying medicine and more truly happy and contented than we have

been in our lives. It passes all the dreams." As if to underscore the couple's shared commitment to their scientific careers, one of Drinker's aunts gave them a wedding gift of $500 to support their research.

In 1 9 1 6 , Drinker joined the faculty of Harvard Medical School's physiology department, and two years later, when department chair Walter Bradford Cannon was called into active military service, Drinker was made acting head of the department.

His willingness to step in on short notice and his remarkable energy—he shouldered the full teaching load with only two student assistants-—led to a rapid rise in the faculty. When the Division of Industrial Hygiene was launched as a semi-independent unit of the university, Drinker was selected to direct the effort. nn

ROUND THAT TIME, D r i n k e r ,

# % working with Medical ^ ^ School Dean David Linn Edsall, published his first important paper, a study of manganese poisoning in steel mill workers. Drinker, who specialized in respiratory dynamics, suspected that the worker's symptoms—languor, muscular tremors, and a "peculiar, slapping gait"—resulted from the absorption of manganese dust through the lungs and gastrointestinal tract.

In 192.2., the Division of Industrial Hygiene was incorporated into the newly established Harvard School of Public Health, and it quickly became one of the School's strongest areas.

By 192.3, Drinker was a full professor

The Scopes "Monkey Trial" prosecution of a Tennessee school teacher for flouting state's law prohibiting the teaching of evolution pits former three-time Democratic presidential candidate William Jennings Bryan, right, against Chicago attorney Clarence Darrow.

and chair of the Department of Applied Physiology with an additional appointment in industrial hygiene. His dual appointments and the recruitment of Drinker's younger brother, Philip, created strong links between the departments of industrial hygiene and physiology. George Cheever Shattuck, clinical professor of tropical medicine, would later write that "in their earliest days, the departments (of physiology and industrial hygiene) were hardly separable, joined as they were by their smallness, by the family ties of Cecil, Katherine, and Philip Drinker, and by their singleness of interest in the new and developing science of preventive medicine for industry."

In January of 192.3, Drinker was part of a team of faculty comprising Alice Hamilton, Roger Irving Lee, Edwin B. Wilson, Wade Wright, and brother Philip that surveyed the health of workers in General Electric's Schenectady plant. The following year, Drinker gained national prominence for his investigation of radium poisoning among women who painted luminous watch and clock dials. The study, now regarded as a classic in the field, revealed that the common practice of "pointing up"—running the paint brush between the lips to get a smooth point—led to the ingestion of minute quantities of radioactive radium that were incorporated into

14 so o^' ^

the facial bones, causing necrosis of the jaw. Katherine Drinker and William B. Castle collaborated on the study, which also identified the atmosphere in the factories as a source of exposure.

and a firm grounding in the basic sciences. Drinker's tenure also brought a broadening in the School's curriculum to include lectures in sociology and a course in medical writing taught by Katherine Drinker.

The New Jersey-based U.S. Radium Corporation, which had hired Drinker to do the initial study, first dismissed the findings as preliminary, then asked him to conduct further tests. The results were the same. Drinker eventually published his findings in the JoMrfM/ o/Tw^MS-

Most importantly, Drinker helped steer the School through the Great Depression and the tumultuous early years of World War II, a period that severely strained the School's financial and intellectual resources.

But the stress of his responsibilities coupled with deteriorating health (partly due to a long struggle with alcohol) forced Drinker to resign his deanship in 1942.. However, he continued to teach and research at the School for another five years, retiring in 1 9 4 7 . In retirement, Drinkerâ&#x20AC;&#x201D;who, like his brother, had inherited an artisan's genesâ&#x20AC;&#x201D;built laboratories in his homes in Brookline and Falmouth, Massachusetts, where he worked on photographing capillary circulation in living frogs.

Hygz'gwe, and several years later, Drinker and fellow faculty member Alice Hamilton were key witnesses in a law suit against the company that was one of the first to award damages to employees injured through their jobs.

Drinker went on to publish important research on the health effects of heat, humidity, and carbon monoxide poisoning and on the role of lymph and capillary circulation in infection. During World War II, as a member of the National Research Council Committee on Aviation Medicine, he collaborated with colleague Leslie Silverman to develop high-altitude breathing equipment that became the prototype for oxygen masks worn by U.S. bomber and fighter pilots. The pair also worked out breathing requirements for protective gas masks for the Army's Chemical Warfare Service.

XeMfDw?^?; iSSy-i^yd

rn HH rn ITH E D S A L L ' S RETIREMENT

m n n H in 1 9 3 5 , the 48-year-old W W Drinker added a new role to his repertoire, becoming the School's first full-time dean. (Edsall had divided his time between the medical school and School of Public Health.) A meticulous organizer with an eye for detail and a reserved, almost formal demeanor, Drinker brought stability to the rapidly growing institution. His term as dean compassed significant changes for the School, including expansion of enrollment from 50 to 9$ students a year, the admission of women as candidates for degrees, and the raising of admission criteriaâ&#x20AC;&#x201D;to require that all candidates possess a minimum of a bachelor's degree

In 1 9 5 6 , Drinker's wife and longtime colleague, Katherine, succumbed to leukemia; Cecil, apparently crushed by this loss, died several weeks later. After his death, Drinker's colleague Stanley Cobb, compared Drinker's skills to those of an artist.

"In the laboratory, it was incredible to watch him," said Cobb. "He could do anything with those hands. He was miles ahead of the rest of us."

MarceHa J. Bernard

1926 Richard Pearson Strong

Professor ofVital Statistics Edwin B.Wilson assists

leads Harvard African

the Massachusetts Department of Health in the

Expedition through

design of punch cards and data collection for patient

Liberia and across sub-

records in state mental health facilities.

Saharan Africa.

GORDON FA)R N A RECENT TRIP TO PARIS, Peter R o g e r s , a p r o f e s s o r of city

^^ H

H

^^

and regional planning in Harvard's Division of Engineering and Applied Sciences, was having a drink at an outdoor cafe when he struck up a conversation with a man who turned out

^^^^^^^

to be a former top-ranking health official in Colombia. When

Rogers mentioned that he was a professor at Harvard, the man exclaimed, "You're from Harvard. Well, you must know Gordon Fair!"

The association between Harvard and Gordon Fair is just as strong for

Across the River

hundreds of other health officials and sanitary engineers around the world. For almost half a century, Fair taught sanitary engineering at Harvard, beginning with his appointment in 1 9 1 9 to the Harvard-MIT School for Health Officers, and ending in 1 9 6 5 , five years before his death. Fair was an entertaining, erudite teacher who treated a lecture as a performance to be perfected. But his influence on sanitary engineering went far beyond the classroom. According to Rogers, Fair deserves a lion's share of the credit for the mid-century sea change in sanitary engineering, when what had been a field dependent largely on received wisdom, empirical experience, and trial-by-error became one based on science, equations, and formulae.

Rogers notes that engineering precedes science; it is easier to build something than to figure out how and why it works. Fair's accomplishment was not inventing new sanitary engineering systems, but identifying the principles

A^cwe

Pro/e^^o^ E^M/^rJ Moore,

L. C^awg, aw J GorJoM o/^e Dep^r^wewf EMgweerwg, wAw^ ^ejJ^Mar^re^ w Pzerce

that would make a system work the w a y it was supposed to. " H e was the first person to put sanitary engineering on a scientific basis," says Rogers, w h o was Fair's teaching assistant in the early 1 9 6 0 s and succeeded him as Gordon M c K a y Professor of Environmental Engineering.

Assistant Professor

U.S. biologist Hermann

Gordon Fair named

Joseph Mulier discovers

head of the School's

that x-rays produce

Department of Sanitary

genetic mutations.

Engineering.

16 ^ sh ^

Fair earned a world-wide audience for his methods with the publication in 1 9 5 4 of Wafer $M/?p/y ^wJ W^sfcwfVfer Aiming for much more than just a textbook, Fair and his co-author, John C. Geyer, a Johns Hopkins professor, produced a "great synthetic w o r k " that effectively codified sanitary engineering, says Rogers. Fair's younger son, Lansing Fair, recalls his father saying that the textbooks he had used as a student only had two formulae. " N o w we have over 1 , 6 0 0 , " Fair remembers his father saying, "and they ail mean something." Revised editions of Fair and Geyer's book are still in print, and while environmental engineering, as the field is now called, has moved on since Fair's day (the underlying chemistry is much more complex), Rogers say that a sewage system built today based on principles outlined in W^fer ^Mpp/y "would work perfectly."

Water, of course, sustains human life. But under some circumstances— such as rapid urbanization—water can also snatch life away, spreading cholera, dysentery, typhoid fever, and a host of other diseases. Sanitary engineering emerged in the mid-ipth century as England and the United States industrialized and urbanized and pioneers such as John Snow exposed the dire health consequences of a contaminated water supply and its close corollary, poor sewage removal and treatment. During this so-called Great Sanitary Awakening, sanitary engineering and public

health were as interwoven as epidemiology and public health are today, a fact reflected in the joint HarvardMassachusetts Institute of Technology origins of the School and the focus on sanitary engineering of two of that institutions three founders, William Sedgwick and George C. Whipple.

—1 AiR's CAREER straddled this 1 early linking of sanitary JL engineering with public health and the eventual separation of the two fields. A South African native educated in the best technical schools in Germany, Fair earned a bachelor of science degree in 1 9 1 6 conferred jointly by Harvard and M!T, which, at that time, shared engineering courses.

Three years later, he received his first faculty appointment as an instructor of sanitary engineering. Historian Jean Curran, author of FoMMJers; H^rtwd* o/^ PM^/zc says that from the outset, Fair's duties were centered in Harvard's School of Engineering in Cambridge (later changed to division status by President James Bryant Conant). For most of his career, Fair had offices in Pierce Hall, one of the grand, old red-brick buildings on Oxford Street.

Fair's geographical and institutional separation from the School was symptomatic of the gradual parting of the ways between mainstream public health and sanitary engineering. The break up was partly the result of sanitary engineering's success, at least in Europe and the United States. As water supplies became cleaner and sewage removal

1927 Philip Drinker invents the Drinker respirator, which will become known as the "iron lung."

William A. Hinton, director of the state Wasserman Laboratory and instructor at the medical school and School of Public Health, invents the Hinton Test, making possible widespread diagnosis and treatment of syphilis.

and treatment more effective, sanitary engineering became much more about engineering. Meanwhile, academic public health in this country became more concerned with chronic disease and the microbiological aspects of infectious disease. This schism was accentuated at Harvard by the strong and conflicting views of Whipple and David Linn Edsall, the dean of the medical school and first dean of the School. According to Curran (who based his account on interviews with Fair), Whipple wanted to build the School of Public Health where the business school now stands, with strong links to the university's Department of Government and other Cambridge programs.

Edsall and his successor as dean, Cecil K. Drinker, saw public health as linked to medicine and gave the School the Boston and Longwood Campus focus it has today.

Fair strove to bridge the gap. He was dean of the engineering school for several years and served as master of the college's Dunster House from 1948 to i960. But Fair also had strong ties to the School of Public Health as head of the School's sanitary engineering department. He taught at the School, and many of his Pierce Hall colleagues were on the School's faculty. Lansing Fair remembers "tall, gangly" Philip Drinker being a dinner guest on occasion. And Fair and his students were regularly featured in the School's A/M7MM; and viewed, de facto, as part of the School. In the early 1960s, Fair even went as far as uprooting himself

first scientists to draw attention to the pollution problems in Lake Michigan. He was also one of the driving forces behind the Harvard Water Program of the mid-1950s, which took a then-novel, interdisciplinary, systems analysis approach to the resource management of water.

Everything from hydroelectric power to recreational swimming was in the program's purview, and some of the program's ideas were used in the Indus River Basin in Pakistan, where thousands of acres of farmland were going out of production because of the increased salinity of the water.

GorJoH M.

/row /e/2,

from his long-time Pierce Hall environs to a first-floor office in the School's Building One. DMpos<3/ is unmistakably an engineer's book, full of discussions and equations on hydraulics, wave action, and intake velocities, but Fair's understanding of the public health roots of sanitary engineering are evident. Fair also was the author of the chapters on sewage and refuse disposal for Pret/eMfwe MeJ/cwe PM^&r H&3M7, the encyclopedic volume originally edited by Professor of Epidemiology and Preventive Medicine Milton J . Rosenau, one of the founders of the Harvard-MIT school. And when he was invited to

FoMw^^ow M<?/arM

give the prestigious Chadwick Public Lecture in 1 9 5 9 in London, Fair didn't talk about hydraulics. He talked about the public health risks and benefits of fluoridation, atmospheric pollution, and ionizing radiation, which he grouped under the heading "microchemical challenge."

Fair's career predated the beginnings of a popular environmental movement and the era of tougher environmental regulation. The first Earth Day was in April 1 9 7 0 and the landmark Clean Water Act that forced better sewage treatment nationwide was passed in 1972. (though Rogers notes that Fair's textbook would have been on the shelf of almost anyone w h o designed one of those new systems or improved treatment plants). Fair, however, was one of the

The execution of accused murderers Nicola Sacco and Bartolomeo Vanzetti at Massachusetts' Dedham prison sparks nationwide protests. Fifty years later, Sacco and Vanzetti are exonerated.

As a Department of the Interior official, future faculty member Roger Revelle also worked on the Indus River Basin project. Rogers says the broad-based approach to water management taken by Fair and the Harvard Water Program influences Army Corps of Engineering thinking to this day.

Today, water pollution is an ascendant area of interdisciplinary research and discussion at the School, with Associate Professor Tim Ford and others leading the way. Recent international outbreaks of cholera and a renewed focus on infectious diseases are putting sanitation back on the public health agenda. "Worldwide, many health problems are still caused by bad sanitation," noted Rogers. " H o w many people die of diarrhea each yearâ&#x20AC;&#x201D;seven million?

What is needed still, in many places around the world, is low-cost sanitation."

Peter Wehrwein

HH y

^^

^

X /^L/ V

v

HEN A L I C E H A M I L T O N SET OUT in 1 9 1 5 to i n v e s t i g a t e t h e

health of peopie working in munitions factories, World War I was raging in Europe, and the United States arms industry was running at fuH tilt. In the frantic effort to produce vast

quantities of explosives, worker safety barely registered as an afterthought.

A pacifist who openly opposed the war—a view common among the social reformers of the day—Hamilton had her work cut out for her. Just finding the factories was a challenge. "If there was anyone in Washington who knew where explosives were being produced and loaded...he kept the secret," Hamilton would later write in her wonderfully engaging autobiography, Exp/onng Dangerous Th?Jes. But showing the kind of nerve, determination, and ingenuity that characterized her long career and life—she would live to age 101—Hamilton plunged ahead. When she went to New Jersey to conduct her investigation, she kept a lookout for "canaries," the nickname for men tainted yellow by working with picric acid, a chemical commonly used in making explosives. She also scanned the skies for the telltale yellow or orange plumes of a munitions plant, which, she later wrote, was "like the pillar of cloud by day that guided the children of Israel. I would hear vaguely of a nitrating plant in the New Jersey marshes and I would spot the orange fumes and make my way to them."

At about the same time, another future member of the School's faculty, Philip Drinker, was also involved in a war-related effort, analyzing the methods

1927 The Rockefeller foundation approves a second

Charles Lindbergh

endowment grant of $1,090,000 to the School to be

completes first non-

added to its original H ,785,000 gift.

stop solo trans-Atlantic flight.

used to make the silk, linen, and cotton fabric that formed

The decade from 1 9 1 0 to 1 9 2 0 is generally viewed

the outer skin of airplanes. Hamilton and Drinker embody

as the time when occupational health emerged as a main-

two different impulses and traditions in workplace health

stream concern in the United States. Muckraking journalists

research, and perhaps even more broadly, public health.

and government investigations were beginning to cast a

Drinker, trained as a chemical engineer, fits intoâ&#x20AC;&#x201D;and helped

light on the underside of the country's industrial prowess.

defineâ&#x20AC;&#x201D;the field of industrial hygiene, which focuses on

In 1 9 1 1 , the deadly fire at the Triangle Shirtwaist Co.

engineering solutions in the workplace (see story page 24).

in New York City, which killed 1 4 6 people, shocked the

Hamilton, on the other hand, was the prototypical held

nation, exposing how wretched and unsafe working con-

investigatorâ&#x20AC;&#x201D;a self-described explorer of the nation's

ditions could be. Unlike England and many industrialized

largely unregulated factories and workplaces who hts best

countries in Europe, the United States had few labor laws

into the tradition of occupational health and epidemiology.

and little research had been done here in occupational

While Hamilton necessarily became an expert on several

disease. Hamilton's writings are peppered with references

industrial processes, her eye was generally on the worker

to the yawning gap between European and American

and on disease. Hamilton was also intensely political,

worker protection and research.

progressive, and even radical. She opposed American involvement in World War I, protested the 192.7 execution of Sacco and Vanzetti, voted for Socialist Party candidate Norman Thomas in 1 9 3 2 , and was pro-union and a feminist throughout her life. Her circle of friends included Jane Addams, Felix Frankfurter, and other members of the intelligentsia.

Jazz

star-

Harvard's involvement in industrial hygiene and occupational health dates back to the School's predecessor institution, the Harvard-M!T School for Health Officers.

The first curriculum covered occupational accidents, industrial poisonings, and the effects of ventilation on tuberculosis. In 1 9 1 8 Professor Emeritus Frederick Shattuck raised

Birth control pioneer

ring A! Jolson, is the

Margaret Sanger

first talking picture and

organizes the first

will popularize the

World Population

talkies.

Conference.

20 ^ ^ ^

$ 1 2 5 , 0 0 0 from a number of New England industrialists to establish a Division of Industrial Hygiene at Harvard Medical School.

Led by physiologist and future dean Cecil K. Drinker, the division was one of the institutional seeds for the founding of the School in 192.2.

Additionally, the School's first dean, David Linn Edsall, had an abiding interest in industrial medicine and actively promoted the area. Edsall, who had established an industrial disease clinic at Massachusetts General Hospital before World War I, is credited with recruiting Hamilton to Harvard, despite the fact that she would be breaking the university's gender barrier.

Other key people in the formative years of industrial hygiene and occupational health at the School included Gordon Fair, best known for his work in sanitary engineering but initially recruited to the School as an expert on vital statistics and industrial sanitation; Louis Agassiz Shaw, who was a key assistant to the Drinker brothers; and, a few years later, Constantin P. Yaglou, who did groundbreaking research on workplace air temperatures. ^H**^

PIDEMIOLOGY HAS BEEN

H^i H '

analogized frequently to detective work; in the case # of Alice Hamilton and other early occupational health researchers, the comparison rings true. Often going on little more than intuition and anecdote, these investigators used their eyes, ears, and common sense to ferret out horrendous working conditions. Hamilton,

in particular, worked tirelessly not only to inspect factories but also to track down workers in their homes and communities.

This early brand of "shoeleather epidemiology" was successful partly because the exposures to hazardous substances were so high and the health consequences so grievous, notes Professor Richard Monson, a contemporary epidemiologist at the School who has specialized in occupational health. The conditions in factories in the first decades of the twentieth century often were so bad that workers were literally being poisoned, sometimes getting sick right on the job or just a few hours later.

Hamilton became interested in what she called "industrial diseases" while living in Jane Addams' Hull House in Chicago. "Living in a working-class quarter, coming in contact with laborers and their wives, I could not fail to hear tales of the dangers that workingmen faced," she wrote in D^MgeroM.s TraJes. She first made her mark in 1 9 1 0 , working for the governor of Illinois' Occupational Disease Commission.

The commission divided up the known poisons, and Hamilton was assigned lead. The exposures that Hamilton was dealing with were so high that it wasn't uncommon for workers to have terrifying neurological symptoms—comas, convulsions, "lead palsy." Combing through hospital records, interviewing labor leaders, and talking to apothecaries (who played a major role in healthcare in working-class districts), Hamilton and her assistants were.

in effect, conducting case studies without the controls. They identified as many lead poisoning cases as possible, then went to the factories where sick people worked and studied how and why the worker might be exposed to lead.

The work involved poking around in some of the most obscure nooks and crannies of industrialized Chicago: " I was put on the trail of new lead trades, some of which I had never thought of—for instance, making freight-car seals, coffin 'trim,' and decalcomania papers for pottery decoration," Hamilton wrote in Dangerous The sense of excitement she conveys is exhilarating. "It was pioneering exploration of an unknown field," wrote Hamilton. " N o young doctor nowadays can hope for work as exciting and rewarding." ^

^

AMILTON WOULD GO o n

to do a larger national [ study—she called them M H "surveys"—of lead poisoning for the federal government, and then, during World War I, to investigate the munitions industry.

A major theme in her research—as well as in Drinker's—was that dust and poor ventilation were the major causes of occupational disease.

While employers had tried to shift the blame for lead poisoning to their workers' poor handwashing habits, Hamilton's research put the onus back on the employer by showing that the air in some factories was so full of lead dust that workers got sick simply by breathing. "There can be no intelligent control of lead danger

1928 Wilson G. Smillie appointed the first full-time

Scottish bacteriologist

professor of public health administration. Smillie

Alexander Fleming

would introduce use of the case teaching method

discovers penicillin.

for students in the department.

GroMp porffYHf

Hoo^erS ResMrc^ CowTwMee ow ^ocM/ TrewJs

in industry unless it is based on the principle of keeping the air dear from dust and fumes," she wrote in DaMgeroMS TraJes. Despite her alarm at some of the working conditions she saw and her strong pro-worker beliefs, Hamilton favored a discreet, almost decorous approach to changing factory conditions. This may have been due partly to the lack of legal or statutory recourse at the time, and partly to her personality and the constraints imposed on women of her era.

Colleagues described Hamilton as an extraordinarily gentle person, and Barbara Sicherman, an insightful editor of a collection of Hamilton's letters, comments on Hamilton's "dread of conflict" and a temperament "predisposed to work by persuasion rather than confrontation."

Hamilton's approach is captured vividly in D^MgeroMX when she describes a 1 9 1 1 inspection of a factory. "It was a dreadful place," she wrote, "old, dusty with the dust of years, no attempt at any control of

the obvious dangers, just hopelessly bad." And Hamilton was even more upset when she saw the contrast with the gleaming horse stables, "where great dappled gray horses were standing on a clean, brick floor, eating from clean mangers and rubbed down till their coats shone." Back in her hotel room, Hamilton wrote that she was tempted right then and there to expose the situation in a muckraking article for McC/Mre's magazine, which was then famous for its influential exposes. But on "soberer reflection I gave it up," she wrote in her autobiography. "The result would be only a temporary flurry, no lasting reform, and it would make any further work on my part impossible."

NSTEAD, SHE VISITS the o w n e r ,

but doesn't have the heart to tell him about the horrible conH , ditions in his factory. " I could no more have told him what his plant really was like than I could have told him his beloved child was a criminal," Hamilton wrote. Eventually she meets

Hawz/^ow, ceM^y; o ^ e r s wof

with the person who is in charge of the day-to-day operation of the plant and, at his request, gives him a written report. Hamilton wrote: "He accepted my written report and at once began to follow its recommendations. That place was radically reformed, at the price of one single interview."

Sicherman has written that after Hamilton came to Harvard her career took a turn away from "pioneer investigator to that of codifier, troubleshooter and consultant."

Hamilton was, after all, $0 years old when she was appointed assistant professor, and she had lost the connection to one of the primary sponsors of her research, the federal Labor Department, during the Harding Administration. But the pace and range of her work while at the School was still remarkable. She investigated mercury poisoning in the felt hat industry. In 1 9 2 $ , when the introduction of lead into gasoline was a bitterly contested issue, pitting public and occupational health experts and advocates against

Hypobaric-hyperbaric pressure chamber installed at

Investigators at the

Herbert Hoover elected

School. James H. Rand, Jr., president of the Remington

State Antitoxin and

president of the United States.

Rand Coporation, pays for the $30,000, 31-foot-long

Vaccine Laboratory

cylindrical chamber, which is used for high altitude

develop a placental

and diver decompression studies.

extract that is a precursor to immune serum globulin.

of individual cases. But in these steel towns, and in the soft-coal towns of Illinois, my inquiry as to mental symptoms or palsy in men who had been gassed (by carbon monoxide) aroused only puzzled surprise."

/wfenor o/^ we^/ /i^c^ory o/t^e ear/y ipoos. industry, Hamiiton took a strong stand against ieaded gasoline. " N o lead industry has ever, even under the strictest control, lost all its dangers," Hamilton said at a conference organized by the surgeon general.

Three years later, she successfully pushed for a similar conference on radium poisoning. In 192.9, Hamilton's landmark /w^MS^M/ Tb%;'cofogy textbook was published.

An advocate of birth control since her Hull House days, Hamilton was connected to numerous birth control organizations. In 1 9 3 0 , President Herbert Hoover named her a member of the Research Committee on Social Trends, a blue-ribbon group that was charged with doing social science

1929 In an effort to balance the number of international and U.S. students at the School, The Rockefeller Foundation agrees to fund two training fellowships specifically for U.S. physicians.

surveys on virtually every aspect of American life. Even as late as 1940, when she was 7 1 years old, Hamilton was involved in a study of workers with silicosis.

But in the later stages of her career, Hamilton also started to run into the limits of her mode of research, which was based on industrial hazards so flagrant that the diseases they caused were readily apparent. Now, partly because of her efforts, the exposures were lower, the substances less hazardous, and the effects more likely to be seen in the long-term. In D<3MgeroMS TMJes, she wrote: "When 1 had gone into a lead-smelting town and inquired about lead colic or palsy, or 'lead fits,' everyone knew what I meant and many could tell me

In 1 9 3 7 , in what Hamilton calls her "last detailed study of a poisonous trade," she set out to document psychosis-producing carbon disulfide poisoning in the "artificial silk" or rayon industry. Eventually, by her account, the industry changed its way of making rayon so workers were not exposed to hazardous fumes. But Hamilton writes about the many roadblocks and setbacks along the way, and she ends on a somewhat cryptic note of relief rather than triumph: "The story of this investigation is all too recent history to recite in detail, for it is not a pretty history and it was curiously bound up with a not very creditable political situation."

Almost 60 years later, on July 1 1 , 1995, the U.S. government recognized Hamilton's pioneering achievements by issuing a 5 5-cent postage stamp bearing her likeness. The stamp was unveiled at the School, and, while the legend identifies her broadly as a "social reformer," to the many professionals who followed in her footsteps, she is best remembered as the intrepid public health pioneer who revolutionized understanding of workplace health.

Peter Wehrwein

Dean Edsall tells the president of the University of Western Ontario that, in his opinion, the trend is away from independent schools of public health and toward coordination with medical schools.

Persistent Peri!

Lead has one of the longest, most insidious histories of any industrial public health hazard. It's been postulated that the Romans unwittingly poisoned themselves into decline and fall through the ubiquitous use of lead in plumbing and containers. In the mid-18th century, Devonshire, England, was gripped by a decades-long epidemic of "colic" until George Baker discovered that the cider in the country was being contaminated with lead from a particular kind of millstone.

Alice Hamilton started the tradition of lead poisoning research in the United States at the beginning of the century, and today, there is a temptation to list lead poisoning prevention and control among public health's triumphs, at least in the industrialized world. After all, many fewer people are exposed to lead at work, and even among those who are exposed, the exposure levels are a fraction of what they were in Hamilton's day. "If you go into a lead industry today, you are not going to see the overt symptoms of lead poisoning that Alice Hamilton saw," says Aaron Sussel, a lead expert for the National Institute of Occupational Safety and Health (NIOSH). "You may find workers who are lead poisoned, but it will be at much lower levels and with much subtler effects." following the gradual phasing out of leaded gasoline and lead paint over the past several decades, lead exposure among Americans in general has also declined. One of the government's best gauges of population-based health, the National Health and Nutrition Examination Survey, found an average blood level of 17 micrograms per deciliter in 1976-1980. When the same kind of survey was done in 1989-91, the average blood lead level was just three micrograms per deciliter. "That is a huge drop!" says Associate Professor Joel Schwartz, who, as an EPA scientist in the 1970s, did some groundbreaking studies linking blood lead levels to leaded gasoline.

Still, pockets of dangerously high lead exposure persist. Poor people—particularly

children—living in older, substandard housing are at risk because of aging lead paint. Lead poisoning remains one of the leading examples of how environmental contamination disproportionately affects minorities. And while there are fewer "dangerous trades" than in Hamilton's day, lead exposure is still a significant problem among construction workers and other people who work around older structures, according to Sussel. Ironically, one of the most dangerous contemporary occupational exposures came about in reaction to widespread concern about the potential dangers associated with scraping old paint from bridges, water towers, or other steel structures. The resulting "solution"—containing the paint chips and dust by enclosing the work area—spared the public at the expense of workers, says Sussel.

At the same time, more sophisticated and sensitive studies have revealed that even very low lead exposures may have neurological and health consequences. As recently as the early 1970s, a safe blood lead level was considered 25 micrograms per deciliter; now the threshold has been lowered to 10 micrograms per deciliter. Schwartz, who inveighs against the "toxicological fallacy" that everything has a safety threshold, notes that 10 micrograms is still 500 to 1,000 times what might be considered the natural background level found in preindustrial societies and environments.

At the School, Schwartz is working on various cost-benefits studies of lead and lead-screening. Associate Professor Howard Hu is one of the leading lead researchers in the country. Hu has conducted several studies that involve using K-X-ray fluorescence to measure lead levels in bone, research that has hundreds of implications and applications.

One intriguing possibility proposed by Hu is that menopausal women, who lose massive amounts of bone tissue, effectively experience a gradual, low-level lead poisoning as lead leaves the skeleton.

"What Alice Hamilton seemed to have a knack for is finding the classic occupational health problems," notes Sussel, who works in a building named for Alice Hamilton and sees her portrait in the lobby every day he goes to work. "They just don't go away. Even 50 or 60 years later, they still exist."

PW

Samuel Albert Levine of

U.S. stock market crash

Harvard Medical School

on October 29 marks

notes the first link

the beginning of the

between hypertension

Great Depression.

and fatal heart disease.

T WAS AN ODD-LOOKtNG contrap-

tionâ&#x20AC;&#x201D;a cylindrical, sheet-metal tank with a small aperture at one end and vacuum-cleaner hoses sticking out of the back. According to at least one eyewitness, it could be heard running from half a mile away. Its inventor, a tall, young man with a thick shock of dark hair and a strong jaw line, rolled the machine into the hospital room of its first patient, an eight-year-old girl suffering from respiratory paralysis due to polio. Within seconds of being inserted in the machine, the girl began to breathe normally. A few minutes later, she asked for ice cream.

Philip Drinker, an assistant professor in the Department of Ventilation and Illumination at the emerging Harvard School of Public Health, was the bold young engineer whose breathing apparatus was undergoing its first clinical trial on that day in 1 9 2 8 at Children's Hospital.

As news about this amazing machine spread, orders came in from hospitals around the country; the patent was transferred to Warren E. Collins, Inc., which would eventually build 3,000 Drinker respirators.

The article describing the Drinker's successful experiment, "Use of a New Apparatus for the Prolonged Administration of Artificial Respiration," which Drinker wrote with colleague Charles F. McKhann, appeared on M a y 1 8 , 192.9, in the AssOCMif?'oM (JAMA).

Drinker would spend his entire professional life around machines, specifically, machines that made and measured dust. But it would be this particular one, the "Drinker respirator," which later became known as the iron lung, for which he is most remembered.

In 1932. a polio epidemic swept the northeastern United States and the New York Consolidated Gas Company, which subsidized Drinker's research and held the patent on his invention, commissioned Warren E. Collins, Inc., of Boston to begin manufacture of the Drinker respirator.

According to Drinker's sister, Catherine, Drinker conceived the idea of using his respirator on polio victims after responding to an emergency call from Kenneth D. Blackfan, physician-in-chief at Children's Hospital, about a drop in temperature in one of the hospital's air-conditioned rooms for premature infants, (see sidebar page 2.8). Walking through the wards of Children's Hospital, Drinker was horrified by the sight of children in polio-induced respiratory paralysis. "He could not forget the small blue faces, the terrible gasping for air," wrote Catherine in her memoir, F<3?w7y

Breathing Easy T h e o f

t n v e n t i o n

t h e

! r o n

L u n g

1930 Assistant Professor Harold Coe Stuart launches the

Mahatma Gandhi leads a 165-mile march to India's

First analog computer

landmark Longitudinal Child Growth and Develop-

western coast as part of an ongoing campaign of civil

developed.

ment Study, the first major study of the growth and

disobedience to protest British rule.

development of the healthy child.

For the next two decades, until the development of an effective vaccine, the Drinker respirator, modified over time, would be a lifesaver for thousands of polio victims. Yet the concept behind its design, said Drinker, was "simple." As an engineer, Drinker approached the body's respiratory machinery with the same mindset he would any other mechanical device.

The principle behind the respirator was to alternate negative and positive air pressure inside the tank "in a manner that seems to be physiologically normal," wrote Drinker and Louis Shaw, a physiologist, in a 1 9 3 8 article describing the respirator's evolution. Negative pressure inside

the tank induced respiration by forcing the expansion of the diaphragm and the thorax. Allowing the air inside the tank to return to atmospheric pressure caused the expiration.

The Drinker respirator grew from a device called a plethysmograph that Philip's brother Cecil had built.

A paralyzed cat placed inside the plethysmograph could be kept breathing by using a hand-held syringe to vary the air pressure inside the box.

Philip believed the same principles could be applied to induce human respiration. Since 1 9 2 6 , Philip had been working under the auspices of the Rockefeller Foundation to

fMwgs

develop better methods of resuscitation. The New York Consolidated Gas Company was particularly interested in this research because they were looking for a device that could save people injured in gas leaks and by electric shock. Drinker assured them a human-sized model of the cat-breathing device could do just that, and he began construction.

He started with a wooden crate, and then had the sheet metal tank built

1931 U.S. infant mortality

New York City's Empire

rate stands at 61 per

State Building opens.

/Mecf ewtzre warJs orJer t o M c t w : s o^parafy^'c

1,000 live births.

* J

26 pc

to his specification in the Harvard machine shop.

The rubber collar for the patient's neck created a great deal of consternation for the respirator's inventors; it had to be snug enough to create an airtight seal, but ioose enough not to cause strangulation. Older brother Cecil, in fact, had responded to a tetter from Philip asking for his advice on the problem by saying the entire project was insotvable because any collar tight enough to prevent air from leaking would interfere with blood flow to the brain. Luckily for the thousands whose lives were saved

Parents respiratory Stress afMe to JroMWMg, car^ow 77!07!0x;Je pozsoMmg, an J wafMra/ gas /ea^s were a/so treated

by the iron lung, Cecil's letter wasn't received until after Philip had found a ring that worked. The optimal diameter for the rubber collar was based on data on shirt collar sizes provided by the Cluett Peabody Company. The optimal diameter of the head hole came from information provided by the Knox Hat Company.

"It seemed impossible to obtain data of this sort from medical sources," wrote Drinker and Shaw.

Calculations of how much negative pressure was needed to induce inhalation were based on a set of experiments that drew on the emergency life-saving skills of firefighters from the Consolidated Gas Company of Boston. Emergency workers were asked to apply pressure to a scale as

t^e /roM /MMg.

they would to the chest of someone in need of resuscitation.

Another Boston manufacturing company specializing in the production of respiratory equipment, J.H. Emerson, Co., would eventually devise a simplified, less expensive respirator by replacing Drinker's blowers with bellows and substituting a leather diaphragm for Drinker's motor and vacuum cleaner hose. (It's actually the Emerson respirator, not the original Drinker respirator, that is on display at the National Museum of Health and Medicine.)

"Incidentally, I don't know the origin of the horrible name 'iron lung,'" wrote James L. Wilson several years later. Wilson was one of several physicians who attended the iron lung's first patient until she died.

1932 To reduce expenses, the Administrative Boards of the

U.S. unemployment

Medical School and School of Public Health propose

reaches 15 million, and

shortening employee vacation allowances from one

34 million Americans

month to three weeks, but the measure meets with

have no income.

strong disapproval.

Outside the lab, Drinker was a dedicated woodworker who passed down his skillful turns of a saw and lathe to his son, Philip A. Drinker, who in turn taught his daughter, Elizabeth.

Today, Elizabeth is a successful furniture maker in Maine, while Philip is one of only a few craftsmen in the world who makes hand-tooled alpenhoms, the long curved horns used by herdsmen in the Alps.

OM^ o/^expenwew^ OM CJ^ cow wi^ coHeagMe LoMM

"I think some reporter first used it."

However it came to be, the term iron lung became synonymous with the Drinker respirator, both in the clinical and lay lexicon.

Philip Drinker became famous virtually overnight, but it was an uncomfortable fame, one perhaps he even felt he didn't deserve. "As time passed, Phil began to look on what he called 'all this fuss about the respirator' as out of focus," wrote his sister Catherine. "He said that in forty years' work at the School of Public Health the 'damn machine' was only one thing, and it just happened. If I'd been a physiologist instead of an engineer it wouldn't have happened. I'd have thought it impossible.'"

]

Warren E.Collins, Inc.,

Franklin Delano

H

NLIKE HIS BROTHER, C E C I L ,

who was organized and liked everything planned, t H Philip Drinker "banged ^ ^ ^ ^ along, enjoying life as it came," wrote Catherine in E^wz'/y Por&wY. "In college he was known as the noisiest man on campus" who wanted his classmates to like him more than he wanted to be successful, she added. Drinker's initial ambition was to be a mining engineer, but when his father told him such an occupation would require him to follow the mining trade all over the globe, Philip chose chemical engineering instead.

of Boston, begins to

Roosevelt wins first of

manufacture the iron

four presidential

lung.

elections.

In his professional career, the senior Drinker seems to have been brash, forthright, and sincere. He was a specialist in ventilation systems, who often served as a subject in his experiments, recording his own inhalations of the worst of toxic environments. (He was the first test subject to get inside the respirator.) In his quest to understand and prevent lung disease in industrial workers, he was often at the forefront of the emerging field of industrial hygiene.

Much of his research was conducted in a laboratory in the basement of the old Infants' Hospital building, where the fledgling School of Public Health was housed. A 1 9 1 4 article that Drinker wrote about the laboratory includes seven photographic illustrations, two diagrams, one chart, and a complete floor plan, and it speaks volumes about Drinker's mechanical ingenuity and inventiveness. The hospital's kitchen was transformed into a chemical laboratory. The laundry was changed into a room for studying "smokes, fumes, and dusts."

And the hospital's dumbwaiter provided ventilation for a hulking, 9-foot by 1 1 - f o o t by i$-foot "gas chamber."

The ceilings in all the rooms were

28 oc ?! ^ ^

painted in white and the walls yellowâ&#x20AC;&#x201D;except in the "illumination laboratory" where all the walls and furniture were painted black, so as not to interfere with the light-sensitive equipment used to study vision and the optical properties of smokes and fumes. ^ ^ ^ ^

VER T H E NEXT t w o

#

^ decades, Drinker and his H colleagues conducted an A n amazing, occasionally ^ ^ ^ ^ amusing, array of experiments in this subterranean laboratory. Their interests were eclectic, though the value of proper ventilation was the recurring theme. The approach was to break down an industrial process or potential hazardous exposure to its most testable elements, run an experiment, and make copious measurements. A typical example is a 1 9 3 8 study on the ventilation of motion picture projection booths. There was apparently concern about toxic gases emitted by the hot, carbon arcs used in movie projectors. Rather than conduct a survey of motion picture booth operators, Drinker recreated the conditions of a projection booth in his lab. He then took temperature and gas measurements from a variety of spots in the room. Despite the elegance and rigor of the experimentâ&#x20AC;&#x201D;or perhaps because of itâ&#x20AC;&#x201D;the results were not dramatic. If the projector's lamp was properly ventilated, there

was " n o sensible escape into the r o o m " of nitrogen tetroxide, Drinker concluded in an article in T/?g JoMrfM/ o/Tn^MsfrM/ Hyg/ewe 7bx;co/ogy.

Comfort Zone

In similar studies, Drinker sought out the laborer's demons of the day: silica, lead, dust, magnesium, and metal fumes. He went into coal mines and shipyards, cotton textile mills, and smelting and refining foundries.

He studied the fine bits of metal inhaled by welders and the dust created by pneumatic stonecutting tools.

He strove to determine "permissible standards of dustiness" in the workplace.

At the same time Philip Drinker was working to mechanically mimic human respiration, another experiment in engineering at the School of Public Health was trying to reduce the high death rate of premature infants. Like the development of the iron lung, the experiment would involve a unique symbiosis between physicians at Children's Hospital and engineers in the School's Department of Illumination and Ventilation, in an effort to use technology to correct a failure of human physiology.

In 1932. Drinker devised a less expensive apparatus for measuring dusts, fumes, and smokes in the air than the costly laboratory-sized electric precipitators by attaching a rheostat to an $8 "luminous tube transformer" used for operating neon signs. Two years later, Drinker and colleague Willis G. Hazard published a paper describing a more efficient machine to record dust, for which they received a patent in 1 9 3 7 .

Kenneth D. Blackfan, physician-in-chief at Children's Hospital, recognized that premature infants were dying when their body temperatures fluctuated, and believed their inability to regulate their body temperature accelerated their demise. With very little body fat to conserve heat, a relatively large skin surface from which heat is eliminated, and an immature nervous system that could not produce shivering, crying, or other heatproducing exercise, premature infants easily became hypothermic. Conversely, the premature infant's immature sweat glands lacked the ability to cool their bodies effectively when the external temperature rose, resulting in hyperthermia. These extremes could exhaust the infant's energy reserves and leave it vulnerable to respiratory and other infections.

Drinker's other inventions included devices to measure air quality in shipyards and, working with his brother Cecil, the prototypes for the L - 1 2 , A-9, and A - 1 0 oxygen masks used during World War II for highaltitude bombing. He also designed a solarium on the southern side of the roof of Infants' Hospital in which babies born in winter could be lain in the sunlight to soak in the ultraviolet rays that would prevent rickets.

Blackfan sought Drinker's assistance on solving the problem, and Drinker set about designing a room in which the air tempera-

1933 Influenza virus isolated.

James Bryant Conant succeeds A. Lawrence Lowell as president of Harvard University.

I

Prohibition repealed.

ture could be tightly controlled, thus doing the delicate work of heat regulation for the infants. Three rooms were built in Childrens' Hospital for the care of premature infants, and Constantin P. Yaglou, a young instructor in the Department of Industrial Hygiene, was put in charge of them.

Yaglou, who had earned a master's degree in mechanical engineering from Cornell University, had come to the School in 1925 after a four-year stint in Pittsburgh at the Research Laboratory of the American Society of Heating and Ventilating Engineers. While

there, he worked on establishing a temperature index and "comfort zone" that outlined the air conditions required to maintain thermal equilibrium between a person and their environment with the least physiologic effort.

Yaglou would adapt these basic principles linking the ratios of air movement, temperature, and humidity to human comfort levels to the tiny infants in Blackfan's care.

The three rooms, called "conditioned nurseries," were supported by an elaborate ventilation system housed in the basement of the hospital that had the capacity to produce T^e co/^'TiowJ ??Mr.sen<?s Jw^opfc?

Dnn^er. <j??J CoMSfawfW %g/()M Mwe /oz'grMMfMrs fo wot^en; w/jMf

25 changes of air an hour to adequately control the rooms' temperature and humidity.

Each room could be heated to a maximum of 110°F and cooled to 75°F—circulating air was cooled in the summer by a spray of cold water and warmed in the winter by heating elements. As the air circulated through the room, it drew in the heat from the warm walls, glass, lights and the room's occupants, while its humidity was reduced.

Yaglou was assigned to monitor and manage the rooms, and for seven years he and Blackfan conducted carefully controlled experiments in which infants' responses to heat and cold were observed as the temperatures and humidity levels were raised and lowered. The investigators developed a detailed table of their observations, creating a sort of comfort zone for premature infants, and in November of 1933, Yaglou and Blackfan's classic article, "The Premature Infant: A Study of the Effects of Atmospheric Conditions on Growth and on Development," appeared in the ^men'can Jot/ma/ of P/seases /n Oi/V&en.The principles described in Yaglou and Blackfan's paper were widely adopted and would lay the groundwork for the development of smaller, infant-sized rooms, or incubators, that allowed for the temperature control to be adapted to individual needs.

TR

1934 Report of the Visiting Committee to the School of

Severe drought

3,900 people die of

Public Health decries the nation's "pitifully small"

unleashes dust storms

malaria in the Southern

number of trained public health personnel relative

in Kansas, Texas,

states of the United

to its need.

Colorado, and Oklahoma

States.

that destroy 300 million acres of farmland.

Indeed, in developing the iron lung, Drinker was continuing a pattern he had shown in his work with dust control systems and ventilation machines: fine-tuning, adapting, and altering machines to try to make them better and more effective. Drinker himself maintained that his only claim of discovery was to measure the precise pressure changes needed to induce respiration. But the iron lung, and its inventor, became famous because of its immediate impact on the treatment of polio patients. The dreadful symptoms of respiratory paralysis were all immediately relieved once the patient was inserted into the respirator. "...before I realized what was happening...I was in the huge cylinder with only my head sticking out Such comfort! I was no longer struggling to breathe and the whole thing seemed simply wonderful. So wonderful that I cannot remember a night before, or since, of such sheer comfort," writes Regina Woods in her book, /row fMstJe frow LM?2g.

The iron lung was also used to treat patients with other acute forms of respiratory distress, including those suffering from carbon monoxide poisoning, electric shock, drowning, morphine poisoning, and, as the New York Consolidated Gas Company had hoped, victims of gas leaks. The respirator was used in at least one instance noted in the medical literature to save the life of a woman who had attempted suicide by sticking her head in a gas oven.

Drinker also devised an emergency respirator "to tide someone over for a day or a week until a respirator could be provided." The pictures of the emergency respirator resemble a 4-H project: a wooden box that looks like a packing crate with a hole cut in the middle surrounded by a coarsely cut strip of rubber ("made from the inner tube of a moderate-sized car") and a hose from a hand-sized vacuum cleaner ("costing about $ 1 $ at any department store or electrical shop.")

Over the years, adaptations were made to the iron lung: A trip to the dock slip on Atlantic Avenue inspired James Wilson to suggest adding portholes to allow nurses and physicians to wash and administer medications to the patient inside. Wilson also wanted the respirator designed so that it could tilt, allowing different positioning of the patient to drain mucus and reduce bed sores. Mirrors were added to increase patients' views, and warning bells and red alarm lights signaled a fall in pressure. t ^ ^ H H ODAY, the iron lung has all but disappeared from the clinical landscape as vaccination has nearly eradicated polio and intubation has become the common form of artificial respiration.

For generations of Americans born after â&#x20AC;&#x201D;the year the Salk vaccine became widely availableâ&#x20AC;&#x201D;images of stricken children in iron lungs lined up in polio wards are historical curiosities. True to Drinker's legacy, however, the School's Department of Environmental Health continues to do pioneering work on the problems of respiration and ventilation.

Associate Professor Robert Banzett is working on increasing comfort levels for people who are intubated and devising mechanics that enable them to talk more easily. Professor Jeffrey Fredberg is a pioneer in high frequency ventilation, the future of artificial respiration.

And Department Chair Joseph Brain, Cecil K. and Philip Drinker Professor of Physiology, studies the lung's response to inhaled gases, dusts, and microbes at a level that would have astounded and delighted Drinker. Brain, who was stricken with polio during the last great epidemic of 1 9 5 5 but was spared the disease's paralyzing effects, says that the collaboration between Philip, the engineer, and Cecil, the physiologist, is still "the essence" of much of the Department's current work.

"These are the ideas upon which the School was founded," he adds.

"For me Philip and Cecil always represent that collaboration."

Drinker, who never completely understood the fuss over his "damned machine," was ultimately happy to see it become obsolete.

The development and widespread use of polio vaccine in the mid-19 $os, made possible by a trio of Drinker's Harvard colleagues, would ultimately make paralytic polio a rarity (see story page 74). In a 1 9 5 9 address to the American Academy of Occupational Medicine, Drinker said, "I have the vast satisfaction of seeing [the iron lungj rapidly being relegated to a respected place in the museum because of advances in medicine."

Terri L. Rutter

1935 David L. Edsall (left) retires as dean

Alcoholics Anonymous

of the School and is succeeded by Professor

founded in New York,

of Physiology Cecil K. Drinker.

A Partner Not a Patron HE ROOTS OF PUBLIC HEALTH

in the United States stretch back to the colonial era, when Boston silversmith Paul Revere was named head of the city's Board of Health. But the modern public health movement more or less dates from the turn of the century, with the rise of the social reform movement and the establishment of formal schools for training public health professionals. Officially the claim of being the nation's first school of public health belongs to the Johns Hopkins School of Hygiene and Public Health, which opened its doors in 1 9 1 8 . But five years earlier, the Harvard-MIT School for Health Officers—the forerunner of the Harvard School of Public Health—admitted its first class of eight students, making it the first formally organized training program for public health professionals in the country.

To some degree, however, both Hopkins and Harvard were following the lead of another institution that got its start in 1 9 1 3 . That was the year that Standard Oil magnate John D. Rockefeller set aside the princely sum of $ 3 $ million to establish The

Rockefeller Foundation. By 1 9 1 9 Rockefeller had added another $ 1 4 0 million to The Foundation's endowment. Over the next three decades, The Foundation would pour millions of dollars into projects related to world health, agriculture, education, and peace and underwrite the

President Roosevelt signs the Social Security Act, which provides an economic safety net for unemployed and retired Americans.

i

K my to.. .Mse wowey /oy t^e good/ o/my /eMow ??M7!."

—John D. Rockefeller, founder of The Rockefeller Foundation.

32 oo ?

establishment of schools of public health at Hopkins, Harvard, and numerous other universities around the country and world.

Rockefeller's interest in promoting health may have stemmed from his close acquaintance with fellow philanthropist Frederick T. Gates, a thundering Baptist preacher with a longstanding interest in the sciences.

At the very first meeting of The Foundation's Board of Trustees, Gates, who would become Rockefeller's principal philanthropic adviser, declared that disease was "the root of all human ills" and that "if science and education are the brain and nervous system of civilization, health is the heart. It is the organ that pushes the vital fluid to every part of the social organism."

Rockefeller's first foray into public health was a 1909 hookworm eradication campaign in the rural South led by Wickliffe Rose and conducted under the auspices of the Rockefeller Sanitary Commission. A Southernborn philosophy teacher with a reputation as a "sloganeer," Rose would later coin the phrase "a partner, but not a patron"â&#x20AC;&#x201D;a concept integral to The Foundation's philanthropic activities. Under Rose's guidance, the Rockefeller Sanitary Commission tackled one disease after anotherâ&#x20AC;&#x201D; from hookworm to malaria to typhus.

The experience led Rose to recognize that the greatest impediment to improved health in America was not lack of money or knowledge, but a dearth of trained public health professionals. At his instigation, The Foundation's General Education

Hcrtw^ PresMfeMf A&^ott Lgwewce LoM'g// ZM^^MWe?!^/ 27! MWTMMg /or

Sc^oo/ o/^

Board, under Gates's direction, began reviewing locations to establish a school of public health in the United States. Despite the best efforts of Harvard President Abbott Lawrence Lowell and Medical School Dean David Linn Edsall to direct funding toward the establishment of a program at Harvard, the award for the first school of public health went to Hopkins, partly because of its southern location, which made it a better laboratory for many of the public health scourges of the day, and partly because of Rose's close ties with Hopkins' William H. Welch. ^

^

ARVARD CONTINUED its

^ ^

discussions with Foundation H President George E. Vincent, however, and in July 192.1, Vincent announced an award of $ 1 . 1 6 million in endowment, $500,000 to cover

the costs of renovating and equipping space for the new program, and an additional $25,000 a year for five years to help cover the operating costs of a reorganized School of Public Health at Harvard. Over the next three decades, The Foundation would grant the School more than $4.7 million.

Much of this went to build up the School's general endowment, renovate and expand its physical plant, and cover day-to-day operating expenses. But Foundation funds also supported student fellowships and a range of innovative research projects and centers, including Harold Coe Stuart's Longitudinal Growth Study, the launching of the Department of Nutrition, establishment of a center to study the health effects of radiation, and creation of the Harvard Center for Population Studies.

But, in keeping with The Foundation's philosophy of partnership rather than patronage, the Rockefeller influence extended beyond financial support to include a continuous flow of faculty, students, and knowledge. Over the School's first half century, its relationship with The Rockefeller Foundation and the closely affiliated Rockefeller Institute for Medical Sciences was characterized by nearly continuous exchange and collaboration. Indeed, a partial list of faculty who migrated between the three institutions includes some of the most influential figures in the history of the School and the modern field of public health.

The primary conduit for faculty exchange was The Foundation's International Health Division (iHD).

1935 International High Altitude Expedition to the Chilean

Milton J. Rosenau, one

Andes examines the effects of altitude change on

of the founders of the

human behavior. Future faculty member Ross A.

School of Public Health,

McFarland is a member of the expedition.

retires from the faculty.

An outgrowth of the Rockefeller Sanitary Commission, the IHD spearheaded The Foundation's work on malaria, yellow fever, typhus, influenza, tuberculosis, and other infectious diseases. The legendary Frederick Fuller Russell, developer of the "triple typhoid vaccine" and tHD's influential director from 192.3 to 1 9 3 3 , would join the School's faculty as professor of preventive medicine and epidemiology in the mid-i<?30s, filling the void left by the retirement of Milton J. Rosenau.

Russell taught at the School from 1 9 3 5 to 1 9 3 8 , when he ceded the post to John Everett Gordon, but he would later rejoin the faculty to teach epidemiology during World War II. Another important figure who would come to the School through the IHD was John Crayton Snyder, who would serve as dean of the School from 1 9 5 4 to 1 9 7 1 (see article page 82). In 1 9 3 9 , seeking to avert another devastating typhus epidemic in wartorn Europe, Wilbur Sawyer, the director of the IHD, asked Professor Hans Zinsser to train an individual in all aspects of typhus control. Zinsser selected Snyder, whose subsequent work for the IHD and the U.S. Typhus Commission in Mexico, Spain, Italy, Egypt, Iran, and Germany led to his appointment at the School in 1946,

as head of the new department of microbiology. That same year, two other members of the IHD staff, Hugo Muench and Hugh Leavell, also joined the School as heads of the Departments of Biostatistics and Public Health Practice, completing the reorganization of the HSPH as an independent entity in the university.

Fredrick J. Stare, founder of the School's Department of Nutrition, did a three-year post-doctoral fellowship in The Foundation's IHD in England, Hungary, and Switzerland before joining the School. The Foundation would later fund the creation of the nutrition department and also provide a travel grant that enabled Stare to study nutritional programs around the country. Another legendary Rockefeller figure, tuberculosis researcher and antibiotics pioneer Rene Dubos, professor of pathology at the Rockefeller Institute

T/?g PoMMf^atz'ow's Wi'fM/ grant wc/M^ecf Syoo.ooo to rewoMte awJ e<?M;p y j S^attMe^ Street, serfe as t^e Sc%?oo?'s %?o?we /or 40 years.

German pharmacologist Gerhard Domagk discovers antibacterial sulfa drugs, which will revolutionize treatment of infectious diseases.

in the 1930s, was named the George Fabyan Professor of Comparative Pathology and Tropical Medicine at the School in 1 9 4 2 .

The flow of personnel between the School and Rockefeller entities was by no means a one-way affair: in 1 9 3 8 faculty member and future Nobel Laureate M a x Theiler left the School's Department of Tropical Medicine to join the laboratories of the Rockefeller Institute in New York, where he would become part of the team that developed the yellow fever vaccine. Theiler's research at the Institute built on his work at the School from 1 9 2 3 to 1 9 3 7 . During World War II, at The Foundation's request, Dean Cecil K. Drinker agreed to let Harold Coe Stuart serve as a clinician on The Foundation's Health Commission to Europe. Stuart was dispatched to southern France to study the nutritional and health

needs of the area's children and later returned with the American Red Cross to implement the commission's recommendations.

Students also benefited from The Foundation's largesse. From the outset, The Foundation funded fellowships for international students, contributing greatly to the School's reputation as a global center for public health education and research. So strong was the international influence, however, that in the late 192.0s, an effort was made to encourage more doctors from the United States to enroll. Among those who benefited from The Foundation's support were future faculty members Stanley Cobb, who later developed the School's first industrial psychiatry course, and Thomas Weller. Welter, who worked in the malaria laboratory of Mark F. Boyd, the first recipient of a certificate from the Harvard-MIT School for Health Officers, would later share the Nobel Prize for his polio virus research and serve as chair of the Department of Tropical Public Health for 27 years (see article page 74).

Vlado A. Getting, D.p.H.'40, founding editor of the H a r t w J PMM;c He^M? AfMfWMz also enjoyed the support of The Foundation while he was a student at the School. Getting would go on to serve as health commissioner of Massachusetts from 1943 to 1953, clinical professor of public health practice at

the school and interim head of the Department of Epidemiology during World War II, and chair of the Department of Community Health Services at the University of Michigan School of Public Health. ^ ^ ^

URINGTHE1950SAND

1960s,

^

with the dramatic success of infectious disease control programs (in large measure due to research and programs funded by The Foundation) and the widespread availability of health care in the industrialized world, The Foundation turned its attention to the problem of an exploding world population. In 1963, Foundation President J. George Harrar declared, "The problem of numbers [of people] must be faced and decisions must be made which are in the best interests of humanity....

[Uncontrolled population increase can only lead to chaos, and thoughtful leaders everywhere are giving serious attention to ways by which to brake the velocity of human reproduction."

At the instigation of Dean Snyder, The Foundation supported a pilot project at the School to explore practical methods of slowing and reducing population growth. This effort evolved into the Harvard Center for Population Studies (now known as the Harvard Center for Population and Development Studies).

To lead the new center, Snyder picked Roger Revelle, a scientist of broad vision who is credited with developing the theory of global warming.

1936 Ann Hoague Stewart and Hester Balch Curtis are the first women to receive the M.P.H. degree, 15 years

Harvard University celebrates 300th

after the School's faculty recommended to Harvard

anniversary,

officials that women be admitted as candidates for the master and doctor of public health degrees.

Continuing the reciprocal association the School and The Foundation have enjoyed for more than 70 years, in January 1997, center director Lincoln C. Chen, Taro Takemi Professor of International Health, will take a twoyear leave of absence to assume the position of vice president for The Rockefeller Foundation.

In recent years, The Foundation has committed more than $ 1 million to support faculty in the departments of Tropical Public Health and Population and International Health, to fund workshops for public health leaders from around the world to discuss new and emerging diseases, and to explore innovative A I D S research focused on women in the developing world. The Foundation also continues its support for promising students in public health.

The long, fruitful partnership between the School and The Foundation has fundamentally shaped the School's character and success.

For more than 7$ years, The Foundation's creative philanthropy in combination with the School's strengths in the classroom and held have been a formidable force to advance the public's health in the United States and around the world.

Marceita J. Bernard

HE WINTER OF

1 9 3 0 was a harsh one for most Americans, and spring brought little relief. More than 8 million adults were unemployed, and those who did work earned little more than $ 1 6 a week. Lines formed outside of soup kitchens and destitute people reduced to begging lined the streets in many cities, as the nation entered the heart of the Great Depression.

While despairing men and women held out hats to passersby or lost hope (in 1 9 3 1 alone, some 2.1,000 Americans committed suicide), the nation's children also paid a heavy toll. In 1 9 3 1 , the U.S. infant mortality rate stood at 61 deaths for every 1,000 live births, and it would not decline significantly for the next few years.

The previous year, President Herbert Hoover, seeking "to hnd out what is being done for children, what should be done, and how to do it," had T^e Great Depression &roMg/?f despair an^ poverty to MMtoM MMW^ers o/wMt^ers aw^ cMJrew.

Women and ChiMren First Harotd Coe Stuart, !V!artha May E!iot, and the Devetopment of the Department of Materna! and Chi!d Heatth

Spanish Civil War

British Broadcasting

begins.

System sets up the

During Pregnancy." More than 100,000 copies of the

world's first television

pamphlet will be distributed to pregnant women over

system.

the next two decades.

HSPH nutritionist Bertha Burke publishes "Daily Diet

35

^ ^ ^

initiated the third White House Conference on Children, focusing on chitd health and protection. A result of the conference was the launching of several nationwide longitudinal studies to identify factors that interfere with normal growth and development and to determine how health professionals could prevent these ill effects.

That same year, two pioneers in children's healthâ&#x20AC;&#x201D;one a researcher, the other an adept and dynamic administratorâ&#x20AC;&#x201D;were each working to address children's health problems resulting from increased poverty due to the Depression. Both were trained in pediatrics and in public health.

One worked in Washington, D.C. the other in Boston, but they were linked by their compassion for and commitment to children. Their collaboration over the next 2.5 years would influence the care and health of mothers and children into the current decade.

The catalyst that would bring together Harold Coe Stuart, the pediatrician-researcher, and Martha May Eliot, the pediatrician-administrator, was the Social Security Act of 1 9 3 5, part of President Franklin D. Roosevelt's New Deal answer to the Depression. Specifically their collaboration would center around Title V of the Act, which secured federal funds to develop state-level programs for the care of mothers and children.

Discretionary funds, called training grants, were earmarked for training physicians, dentists, and other health professionals in the basic principles of public health. The funds were

administered by an office within the Department of Labor called the Children's Bureau, where Eliot had worked since 192.4. As she rose through the Bureau's ranks, eventually reaching the level of chief, she would use her position to direct a share of the Bureau's training grants toward Stuart and the Harvard School of Public Health. Stuart, in turn, would be a driving force behind the development of the first Department of Maternal and Child Health in the country. Together, they would chart the future of maternal and child health. ) N 1 9 3 0 in Boston's Roxbury neighborhood, Stuart embarked on an innovative study looking at factors that influenced the development of children. Tall, erudite, possessed of a gentle, goodnatured disposition, Stuart had recently been appointed assistant professor in child hygiene at the School of Public Health. A graduate of Columbia's College of Physicians

V^/cafMM exawHMes <7 c M J w 19J4. and Surgeons, he had trained at the renowned University Children's Clinic in Vienna under Bela Schick, who developed the method for testing children for immunity to diphtheria.

Stuart had arrived in Boston in 192.2., as head of the outpatient department and allergy clinic at Children's Hospital, where he began to notice how allergies to food and other environmental factors could affect a child's growth pattern. He also saw how allergic responses could change as a child grew. Beginning in 1 9 2 8 , he also oversaw the well-child clinic of the Boston Health Department.

Although somewhat shy, Stuart was an energetic lecturer and advocate on behalf of children. At a 1 9 3 3 meeting of the New England Pediatric Society, Stuart stated: "It is inconceivable that a Society such as this should approach the problem of health service from any other stand-

1937 HSPH Alumni Associa-

The School raises admission requirements for all

tion meets for the first

training programs: from now on, a bachelor's degree

time in New York City.

and preparation in the basic sciences are prerequisite for the Certificate in Public Health, while a medical degree is required for both the master and doctor of public health degrees.

point than that of meeting the needs of children in the best possible way."

The landmark Longitudinal Growth Study would embody Stuart's broad vision of child health. Based at the Children's Medical Center, the study tracked the growth and development of 3 1 4 infants born of 2.16 mothers from Boston's predominantly Irish, middle-class Roxbury neighborhood. Beginning in pregnancy, mothers were interviewed at length about their home environments, eating patterns, and general health.

Over the next two decades, these children and parents regularly returned to the Children's Medical Center to be interviewed and examined by pediatricians, nutritionists, social workers, anthropologists, dentists, psychologists, and psychiatrists.

The defining feature of the study was its focus on healthy development rather than pediatric disease. N o comprehensive study of normal childhood growth development had ever been conducted. Stuart questioned how one could understand childhood disease if there was no basic understanding of health for purposes of comparisonâ&#x20AC;&#x201D;a point emphasized at the 1 9 3 0 White House Conference.

"Pediatricians interested in research have been so preoccupied with the study of disease that they have not contributed as much as might have been anticipated to studies of normal development," wrote Stuart in an analysis of some early results of the study. "It is surprising how little is really known about the effects of disease on growth, in view of the attention given to sick children."

He advocated that physicians, school health programs, and parents take regular measurements of a child's height, weight, chest-circumference, hip-width, and girth, stressing that diversion from a normal growth pattern might suggest underlying disease. Among other things, the study provided the basis for the development of reference growth charts, now regularly used by pediatricians and other health professionals to track child development.

Another important finding came out of a study led by Bertha Burke, the department's nutritionist. Published in 1 9 4 3 , the study provided some of the first information about how mothers' diets affected their newborns. Through detailed food questionnaires and diet surveys, she investigated the relationship between maternal nutrition and the health

of newborns. Only 14 percent of the mothers enrolled in the study ate diets that were considered excellentâ&#x20AC;&#x201D; a daily caloric intake between 2,800 and 2,200â&#x20AC;&#x201D;and that included enough of the what investigators called "important" foods: meat, vegetables, dairy. Forty percent of the mothers were found to be malnourished, and a higher proportion of their babies were born premature, stillborn, or "functionally immature."

The maternal nutrition study reflected Stuart's belief that all aspects of a child's environment affected his or her growth and development. At a time when social workers focused more on the quantity of light and the cleanliness of the floors in a home, Stuart asked his investigators to evaluate family relationships and parenting skills. Stuart interviewed fathers and encouraged them to be a part of the

HaroM Coe S&Mrf

presents Jata co//ecfeJ z'w

Growth StM^y.

National Foundation on Infantile Paralysis, which focuses mainly on polio, founded.

Degrees of Change 38 sc

^

Martha May Eliot's behind-the-scenes influence not only helped create a department at the Harvard School of Public Health, it profoundly changed the makeup of the School's student body. It was Eliot's sponsorship of student Hester Balch Curtis, a pediatrician whom she had met while they were both at Yale, that broke a 15-year deadlock between the School and the University's Board of Overseers over the issue of granting degrees to women.

Although women had been training at the School since 1915, when it was the Harvard-MIT School for Health Officers, they were allowed only to earn certificates of public health, not degrees. At the launching of the Harvard School of Public Health, in 1922, the faculty had unanimously but equivocally approved accepting women as non-degree candidates,

child's upbringing. Burke's maternal nutrition study even included an analysis of how much of the weekly household income was spent on food.

Professor Emerita IsabelIc Valadian, M.p.H.'53, studied under Stuart and went on to chair the Department from 1 9 7 3 to 1 9 9 1 . Valadian says that Stuart developed an understanding of child "wellness" long before it became a mainstream concept of medicine.

"Dr. Stuart had great vision," says Valadian. " H e was ahead of his time."

At 6'2." tall, Stuart towered over the children he studied (and most of his colleagues), but, says Valadian, in his interactions with children, he

"until such time as women can be admitted in all equality with men" throughout Harvard. In a letter to Rockefeller Foundation President George Vincent, Medical School and School of Public Health Dean David Linn Edsall indicated that he did not "know of any noteworthy person connected with Harvard University who desires to make Harvard... a coeducational institution."

In 1924, women were permitted to register as "special students" and earn a doctorate in hygiene through Radcliffe College, but they were still denied the master and doctor of public health degrees. This status quo prevailed until Curtis' arrival in 1936. The maternal and child health training grants provided by Title V of the 1935 Social Security Act presumed that women would be allowed to earn degrees. This financial incentive, combined with Dean Cecil K. Drinker's and the faculty's unanimous support, finally

tipped the balance, and, in 1936, the Corporation and Board of Overseers approved the awarding of master and doctor of public health degrees to women. (Harvard's Graduate School of Education was the first of the university's professional schools to grant women degrees, beginning in 1921. The School of Public Health was second, followed by the medical school in 1949).

At the 1936 commencement, Curtis and physician Ann Hoague Stewart were the first women to receive the M.PH. Stewart had finished her coursework two years earlier and had successfully petitioned the Administrative Board to complete the coursework for a master's degree in public health, in the event that women were ever allowed to earn degrees.

TR

always brought himself to their eyelevel. She recalls a time when Stuart, noting the downcast look of one of the boys enrolled in his study, spent about a half-hour sitting on the steps outside the clinic with the boy, listening as he talked of a problem at home.

and Biostatistics Chair Robert Reed, began conducting 10-year follow-ups on 12.6 of the study's original 1 3 4 subjects to track their growth and development into maturity. Valadian's research culminated in the publication in 1 9 7 7 of Growth <3?!J

"The reason the Longitudinal Growth Study was so successful was his commitment to the children," says Valadian. " H e was very, very kind."

Fro??! CoMcep^o??

M^fMnYy. Building on Stuart's belief that a focus on disease overshadowed education in the fundamentals of child health, the book is an innovative-self-guided instruction manual on the human systems, filled with quizzes, charts, and graphs outlining the decades of data that come from the growth study.

In 1 9 6 5 , when the study's participants were all in their 30s, Valadian and her colleagues in the department, including nutritionist Johanna Dwyer, s.D.'69, now director of the Frances Stern Nutrition Center at the N e w England Medical Center,

1937 Amelia Earhart's plane

Diabetics treated for

is lost over the Pacific.

the first time with insulin.

M

H W H ARTHA M A Y

ELIOT arrived at the Children's Bureau in 192.4 when the organization was still coordinating its agenda for the future of advocacy work for chitdren. "These were days of e x p i r ing possibihties, days of questioning, days of refreshing advice...days of great satisfaction," Eliot later wrote of her early days there.

The Bureau was born through the lobbying efforts of a stalwart collective of women's organizations, including the National Consumers' League, the Women's Trade Union League, the YWCA, the Female Benevolent Society, and the Female Moral Reform Society. Initially drawn together out of concern for the "lapses of morality" in their communities caused by prostitution and alcohol, these women were also concerned about public health issues such as clean food and pure milk, industrial pollution, and child labor.

One of the Bureau's first concerns was dealing with the nation's astonishing rates of infant and maternal mortality. In 1 9 1 5 , the first year the Bureau compiled figures, for every 1,000 live births, six mothers died and 1 0 0 babies didn't live through their first year. The Bureau had always had a strong investigative arm, and under Eliot's influence, it began looking at social factors such as the effect of mothers going off to work and leaving their "latchkey children" behind. Eliot was particularly interested in the development of "healthy personalities" in children, believing, as she wrote in 1949, that "...if we are to change the attitudes of the rank and file of citizens toward

world security and peace, sooner or later we must launch a preventive mental-health service for parents and children which will have as vast proportions as the present-day program to prevent physical disease in infancy and childhood."

In her capacity as director, Eliot controlled the distribution of Title V funds for children's health programs, and she specifically wanted to use them to build and support a fullHedged department dedicated to the research and teaching of maternal and child health principles within a school of public health. Although a portion of funds appropriated from the Bureau had always been earmarked for training physicians, dentists, and nurses in public health, the Conference on Better Care for Mothers and Children, held in January 1 9 3 8 , convinced Eliot that the Bureau needed to do even more.

"We have the knowledge and skills in this country to protect the health and growth of our children,"

wrote Eliot a few years later in the /oM7*72%/ o^PeJMfWcs. "What we lack is the plan and resources to train sufficient physicians, nurses, and other professional and administrative personnel " Initially, she approached Johns Hopkins, her medical school alma mater; but when Hopkins eschewed her offer, she contacted Harvard.

Stuart and his coHeagues were eager to accept her proposal. Until that point, the School's Department of Child Hygiene had not strayed much from the original focus of its first chairman, Richard Smith. Although Smith, a pediatrician, went outside his field to gather lecturers in nursing and public health law as it related to children, maternal health, and obstetrical care, the department focused primarily on traditional child hygiene, which included children's nutritional needs, inspections of school buildings to assess their cleanliness, and the administration of vaccines and other measures to control com-

May E/z'ot

coHeagMes Joe Lester Granger CoM/erewce o /

SocM/ Workers

1938 The Whittier Street Community Health Center in

Assistant Professor and future Nobel Laureate Max

Boston, under the direction of George Kahn, becomes

Theiler leaves the School for the Rockefeller Institute,

an affiliated training center for the School.

where he will be part of the team that develops the yellow fever vaccine.

40 cc ? ^

municable disease. Smith paid particular attention to children with special needs; his courses included visits to the Florence Crittenton Home for illegitimate children and to the Judge Baker Foundation for retarded children.

At Stuart's instigation, in 1 9 3 8 a subdivision of maternal and obstetrical teaching was created in the department. The next year, lectures emphasizing the protection of the mother as well as the fetus were integrated, and in 1 9 4 0 , Samuel B. Kirkwood, the first instructor in obstetrics and maternal health to come to the department, began teaching an advanced seminar on clinical and administrative problems in the field.

A good foundation had thus been laid for Eliot to see the department's potential to fulfill her plan. In 1 9 4 4 , the department was officially renamed the Department of Maternal and Child Health, and Stuart was named as its head. With the name change came a corresponding shift in the kinds of courses offered. Attention was paid to normal pregnancy and labor, delivery, and the diet and hygiene of pregnancy. Also included were discussions on abortions, stillbirths, and neonatal deaths and interrelations between maternal and fetal health.

Among the stipulations of the training grants was the requirement that the department count among its faculty a physician, a nurse, a social worker, and a nutritionist. Burke, a nutritionist, had been working with Stuart since the beginning of the

Longitudinal Growth Study, and so was already well established in the department. In 1 9 4 6 , Elizabeth Prince Rice was recruited from her position as director of medical social work in N e w Haven. A public health nurse and a medical care specialist, who held appointments in the Department of Public Health Practice, rounded out the bill.

Beyond funding the faculty, the Bureau provided stipends for studentsâ&#x20AC;&#x201D;those who were married received extra, those with children received even more. In fact, until the mid-1960s, the Bureau's training grants were the primary source of support for the Department.

"The Bureau funded everything," says Valadian. "Eliot had the attitude that no deserving student should be denied." Although federal reorganizations since the late 1960s have resulted in a shifting of responsibility for the administration of Title V funds, the department has enjoyed a continuous line of government funding since its inception.

s ^ ^

TUART AND

E n o T ' s efforts to advance the health and well being of children reached a fitting culimination in 1 9 5 7 , when Eliot succeeded Stuart as chair of the department. Eliot stayed only three years before retiring. She was replaced

by William Schmidt, who strengthened the department's focus on social and community aspects of child development. In 1 9 6 4 , Stuart was awarded the Martha M a y Eliot Award of the American Public Health Association for his leadership in maternal and child health.

1938 Cancer becomes the

The Munich Agreement signed by Neville Chamberlain

second-leading cause

and other European leaders forces Czechoslovakia to

of death in the U.S., a

surrender the Sudetenland to Adolf Hitler's Nazi

position it will hold for

Germany.

the rest of the century.

In the 80 years since the birth of the Children's Bureau and the 75 years since the launching of the School, the health of mothers and children has improved dramatically in the United States. Today children rarely die from measles or diphtheria, and the rate of maternal deaths related to pregnancy and child birth has also dropped significantly. And yet there are still many obstacles to optimal child development, and in seeking to resolve them, the department's research and training follows Stuart's example of adapting to meet children's health challenges at eye-level. Marie C. McCormick, the Sumner and Esther Feldberg Professor of Maternal and Child Health and the current chair of the department, is studying the physical and psychological functioning of the growing numbers of lowbirthweight infants born in the nation's hospitals. Other department faculty are trying to resolve persistently high rates of infant mortality, especially among minorities, and the longstanding problem of youth violence and anti-social behavior.

"The health of mothers and children cannot be taken for granted," says McCormick. "Enhancing their well being needs continued inquiry into and teaching about the factors influencing normal cognitive, social, and physical development."

Terri L. Rutter