Harvard Public Health Review, 75th Anniversary Issue, Vol. I, 1954-1971

HE S U M M E R OF 1 9 5 4

brings the televised spectacle of Senator

Joseph McCarthy's hearings on un-American activities, deepening U.S. concern about communist expansion in Southeast Asia, and the launch of the brilliantly successful nationwide polio immunization campaign. The American Zeitgeist combines patriotic fervor and Cold War anxiety with an almost limitless faith in the ability of government and technology to resolve societal ills. By 1 9 6 7 , U.S. Surgeon General William H. Stewart boldly predicts imminent victory over all infectious diseases.

Under Dean John Crayton Snyder, the Harvard School of Public Health rides this wave of public confidence and federal funding to new levels of prominence and success, adding faculty, buildings, and departments. By 1 9 7 0 , the School's enrollment has reached 1 7 0 , more than 10-times the enrollment when the School was founded, and graduates occupy key positions in the Centers for Disease Control, World Health Organization, and in governments worldwide.

Expansion and Gtobatization

Taming the Summer Scourge

1954 Mass testing of polio

Thomas Weller, John F. Enders, and Frederick C. Robbins

James L. Whittenberger, chair of the Department

vaccines begins, using

awarded the Nobel Prize for research that enabled the

of Physiology, develops a "sit-up respirator" for

the "killed virus"

development of the polio vaccine.

emphysema sufferers. The invention is featured in

version developed by Jonas Salk.

Mewstvee/r, 7/Ye, and on C 8 S television.

^

T WAS M A R C H 3 0 , 1 9 4 8 . T o the

! relief of Boston baseball fans, ] Ted Williams was back in the ! Red Sox line-up for an exhibition game. Massachusetts lawmakers were debating a bill that would make it legal to disseminate information about birth control. Around the country, worried Democrats were talking about abandoning the increasingly unpopular president, Harry Truman, and mounting a draft-Eisenhower movement.

A gusty, south wind was finally shaking the resolve of a late-spring, Boston cold spell. Thirty-two-yearold Thomas Weller was working in the second-floor lab in the old Carnegie Building. Affiliated with Children's Hospital, the lab had been set up a year earlier by Weller and John F. Enders, a brilliant, unorthodox scientist who had left his job in the bacteriologic department at Harvard Medical School to set up this lab. Because he came from a wealthy family, Enders had been cast by his rivals as being a bit of a dilettante.

Weller remembers the lab as having old soapstone sinks and a decidedly grim view of a power plant. The windows had to be kept shut for fear of contamination, but smoke from the power plant would still occasionally seep in. In the summer, the temperatures inside the lab could be sweltering.

Mass po/;'o yaccwafwM, w a J e poss/Me

research at f^e Matiow cowtyMgr owe JreaJ

^efpe^ f^g wost

Yet some exciting events were beginning to happen. Enders and Weller had set up the lab to grow and isolate disease-causing viruses in the same way as a previous generation of scientists—Louis Pasteur and Edward Koch—-had launched the bacteriological age of medicine by growing and isolating disease-causing bacteria in nutrient media. Earlier that month, Weller had had some gratifying success in growing mumps virus in tissue culture for the first time. N o w he was working on his pet project, trying to grow varicella, or the chicken pox virus. " I wanted to get embryonic skin and muscle tissue for the varicella work, thinking that if there is skin in the culture, maybe the virus would grow in it," says Weller.

Faded memory has obscured why and at whose initiative Weller took the next step. But regardless of vagaries of distributing credit, Weller made medical history by opening the freezer on that March day, removing some mouse brain infected with the Lansing strain of the polio virus, and putting it in tissue culture flasks left over from his varicella experiment. There was no eureka moment, says Weller, just painstaking caution. Some days later, Weller recalls that he "took the fluid, injected it in the brains of some laboratory mice, and starting six days later they became paralyzed. Then you repeat it two or three times before you accept the results that it wasn't a fluke."

It was, indeed, no fluke. In a wonderful example of scientific serendipity, Weller and his colleagues had shown for the first time that polio virus could be grown in test tube-like

conditions in tissue that was neither brain nor nerve cells. It was an experiment that would change the fundamental understanding of polio.

Previous researchers had only been able to grow the virus in nervous tissue. Since polio resulted in paralysis it seemed as though this was, fundamentally, a nervous system disease.

Weller and his colleague's experiment showed otherwise, by definitely demonstrating that polio virus grew in other types of tissue. And soon other experiments would show that polio virus first multiplied in the throat and the lining of the intestine before migrating into the blood and then the nervous system.

The successful propagation of polio virus in tissue culture would prove to be the key to the successful development of a polio vaccine. And for the nascent held of virology, this and related experiments by Enders, Weller, and Frederick Robbins would help lay the groundwork for practical, test-tube study of viruses using tissue culture. Weller himself went on to be the first person to grow and isolate a number of other important viruses, including varicella (at last), rubella, and some of the cytomegaloviruses.

The work on rubella virus and the cytomegaloviruses, agents that cause fetal damage and cerebral palsy, was recognized in 1963 with the receipt

by Weller of the Ledlie Prize, Harvard's highest faculty award that is given every two years to the faculty member who has made the most valuable contribution for the benefit of mankind.

Six years later, the significance of that March 1948 experiment was

Dean Simmons suffers a heart attack while on a

Harvard physicians, including Joseph Murray who

U.S. Supreme Court

global tour. He dies several months later on the way

would eventually win the Nobel Prize, perform first

unanimously rules that

home from a family vacation. John Crayton Snyder

successful kidney transplant at Peter Bent Brigham

racial segregation of

is appointed Dean.

Hospital in Boston.

public schools is illegal in landmark civil rights case, Brown v. Board of

heralded around the world when WeHer, Enders, and Robbins went to Stockholm to receive the Nobel Prize for medicine and physiology. For the 3 6-year-old WeHer, the fame of being a Nobel Laureate was both an honor and a burden.

award,' but I obtained it on my own merits." Weller's one-third share of the 1 9 5 4 prize was worth about $12.,000. A father of four children, WeHer told Bosfo?? G/o^e that he would use the money to help pay for his children's education. In truth, he says now, there wasn't all that much left over after he paid for plane fare to Sweden and for clothes appropriate to the ceremony for himself and his wife, Kathleen.

^ ^ ^ ABILITY, Weller seems to ^ ^ ^ ^ have been ideally suited for a distinguished career in science. He was born and raised in Ann Arbor, Michigan, where his father was chairman of the pathology department at the University of Michigan medical school. Weller's first scientific passions were ornithology and parasitology, and he has said the happiest times of his life were the

Nutrition department researchers publish a paper

Dean Snyder and a

USDA survey finds that

recommending revising the USDA's basic food groups

team of HSPH faculty

10percentofU.S.

from seven to four—breads, grains, and cereals;

complete a four-week

families live on nutri-

meat, fish, and poultry; fruits and vegetables; and

trip to the Middle East

tionally poor diets,

dairy products. A year later, the USDA releases its own

to study trachoma.

down from a decade

A remembrance of Weller written

by Eli Chernin, a former colleague in the Department of Tropical Public Health, describes Weller as "subdued" the day he answered the call from Sweden. Chernin wrote: "As his TPH (Tropical Public Health) coHeagues gathered around—none of us had seen a Nobelist before, Weller slumped into a chair and remarked to no one in particular, in his quiet uninHected voice, 'Now, I guess we'll have to show them it wasn't a Hash in the pan.'"

Even today, WeHer seems wary of the Nobel Prize being the laurel, and the label, that obscures the rest of his work. In a recent interview, WeHer stressed that his July 1 9 5 4 appointment as Richard Pearson Strong Professor of Tropical Public Health and chair of the Department of Tropical Public Health actually predated the announcement of the Nobel Prize by a few months. "I was very pleased that [my appointment] came through before the Nobel Prize," he said. "Post-Nobel, it might be said that 'he got it because he got the

^ ^ ^

Y CIRCUMSTANCE AND

No/?e/ L<!M?*eatM /0/777 E E n J e r s

Hosp/ta/ /Moratory.

1955

Basic Four.

ago.

summers he spent working at the University of Michigan Biological Station in northern Michigan. But to a young man living in the iater years of the Depression, a career in science looked a whole lot less secure than a career in medicine. A practical, down-to-earth person, Weller says, " I selected Harvard because, as I remember, tuition was $400 a year whereas at Hopkins it was more. I didn't even apply to Hopkins."

It was during a medical school summer vacation that Weller had his first taste of tropical public health. As a Rockefeller Foundation fellow, he worked in various malaria control programs in Florida. Malaria was a major public health problem in the 1 9 3 0 s in the South. A b o u t 3 , 9 0 0

people died of malaria in 1 3 southern states in 1934, and U.S. health officials at the time estimated a million people were infected with the mosquitoborne disease. A few years later, while in the Army during World War II, Weller also worked in malaria control overseas.

Though he never earned a public health degree, Weller has all the zeal of a convert when it comes to the field.

"I became completely convinced that there is a public health ethic that will never be taught properly in medical school," says Weller. " A physician has to take care of the individual patient to the best of his ability and financial resources. But a public health worker has to take care of a sick community."

Weller also had the drive and curiosity of a researcher. "I was trained as a pediatrician," he says. "And at

that time, the viruses that cause the common pediatric diseases had not been isolated. It was still a mystery.

There was a challenge right at our doorstep that would have tremendous benefit to mankind if it could be solved."

The fact that polio was caused by a virus was old news by the time Weller came on the scene. Viruses, in general, had been first characterized as transmissible, disease-causing agents back in the 1890s. Karl Landsteiner, an Austrian researcher, is credited with first identifying the polio virus in 1908. But the scientific understanding of viruses was full of gaps. Even though many diseases, such as chicken pox, were considered viral, the causative viruses had not been isolated.

In the case of polio, this patchy comprehension led to all kinds of theories about how the disease was spread.

For example, Milton Rosenau, who was to become the School's first professor of preventive medicine and epidemiology, proposed in 1912. that polio was spread by the house fly.

Decades later, Lloyd Aycock, an associate professor under Rosenau, flirted with the idea that polio was a milkborne disease.

These debates and misconceptions were fed by the relatively primitive methods for growing and maintaining viruses. Whereas bacteria will grow easily in warm, nutrition-laden gels and fluids, viruses need living tissue to grow and reproduce. For researchers working in the early part of this century, that meant first identifying the best source of virus from a patient, collecting the virus from an

1956 A rain-collecting device on the roof of Harvard's

Professor James L. Whittenberger and Assistant

Gordon McKay Laboratory is used to measure radio-

Professor Benjamin G. Ferris, Jr., travel to Argentina as

active fallout from an atomic cloud over Boston.

physiology consultants during a three-month polio

Analysis by faculty in the School's Department of

epidemic.

Industrial Hygiene shows that the "small additional exposure to radiation" from atomic weapons testing programs "does not constitute a health hazard."

infected person, inoculating an animal with it, and then keeping it alive by transferring, or "passing," it from animal to animal.

Using live animals, particularly monkeys, to study and produce viruses was expensive to the point of being impractical. Says Weller, "With polio there were certain strains that had been adapted to grow in mice. But the great majority of strains would only go into monkeys. A rhesus monkey cost around $30. And to titrate a specimen of polio virus, you might need 80 monkeys. So that became unrealistic."

Just getting enough virus to isolate and study was also critical. In addition, before vaccines could be developed against many viral diseases, researchers had to figure out how to mass produce virus so it could be rendered into a formâ&#x20AC;&#x201D;either dead or weakenedâ&#x20AC;&#x201D;that wouldn't cause illness but would still be close enough to the real thing to spur a lasting immunological response. ^ ^ ^

TARTING IN THE LATE 1 9 2 0 S ,

^ ^ ^ ^ scientists experimented with ^ ^ ^ "tissue culture," which consisted of living tissue floating in a nutrient-rich fluid. Scientists had their own recipes for this fluid. Horse sera was one key ingredient in Welter's brew. "We had a good rapport with the state lab [in Jamaica Plain]," he explains. "They had a stable of horses that they were immunizing to make tetanus and diphtheria antitoxin. They had one horse that had good cellgrowing sera so that was sort of set aside for our use."

I

Choice of tissue varied, but human fetal tissue was often used because embryonic tissue grows easier and faster than mature cells. The fact that Weller and other tissue-culture researchers were using tissues from spontaneous miscarriages or abortions—the term used then was "interruptions"—was a sensitive, potentially explosive, subject. Even now, Weller is circumspect about discussing the matter, but he notes that neither he nor his colleagues hid anything when they wrote up their findings: "Read the article. The facts are all there." Indeed, the January 2.8, 1949, article in describing the research that won the Nobel Prize states plainly that "tissue from embryos of 1 . 5 to 4.5 months as well as from a premature infant of 7 months gestation were used." Later in 1949 Weller published a paper indicating that polio viruses also would grow in foreskin tissue cells culled from routine circumcisions. And a few years later, the virus produced for the first large-scale testing of the polio vaccine in 1 9 3 4 was grown in cultures of cells from monkey kidneys.

But getting a tissue culture to work wasn't just a matter of finding the right ingredients. It was also figuring out how best to " c o o k " the recipe.

Here, too, Weller was an innovator.

The common practice in virology labs was to remove the bits of infected tissue every couple of days and and transfer them to new cultures. But knowing that he was working with a slow-growing virus, Weller maintained the virus-infected tissue and instead changed the nutrient-rich

fluid in which it was growing. All of this was done using the simplest of lab equipment—tiny 2.5-milliliter glass flasks. Later Weller and others got good results using "roller tubes," which involved putting the cultures horizontally into a large, slowly rotating wheel.

HHHHHj

HE GUIDING HAND OF

FORTUNE was working in two remarkable ways on H March 30, 1948, when Weller removed a bit of polio-infected mouse brain from the freezer to start the history-making experiment. First, because Weller was focused on chicken pox, which seemed to flourish best in skin tissue, the available tissue cultures were of non-nervous tissue.

Second, the kind of polio virus that grew in mice, the so-called Lansing strain, did not have a strict affinity for nervous tissue. Twelve years earlier, Albert Sabin and a colleague had successfully grown polio virus in tissue cultures, but the strain at their disposal would only grow in nervous tissue.

Welter's description of the Nobel Prize-experiment is muted by personal modesty and plain-spoken matter-of-factness. But the fact is that the significance of growing polio virus in non-nervous tissue culture was not immediately apparent to many. The article in 3c;'s7!<re was only two pages long, had six references, and was sandwiched in between two long-forgotten articles. "It was a short, preliminary report," says Weller. In his definitive history of polio research, Yale professor John Paul described how he was not impressed when he

heard about the experiment while visiting John Enders at his summer house in Waterford, Connecticut.

"I was stupidly unaware of the implications that this finding held," Paul wrote in A HVsfory "At least, it did not appear to me as an electrifying piece of news." Weller says Enders deserves credit for recognizing that the results were, in fact, a very big deal: " I think Dr. Enders saw the significance sooner than we did."

Part of the reason for the delayed recognition of the importance of the tissue culture experiment was that

1957 Martha May Eliot

The Daniel and Florence Guggenhiem Foundation

succeeds Harold Coe

gives a $250,000 grant to establish the Harvard-

Stuart as chair of the

Guggenheim Center for Aviation Health and Safety

Department of Mater-

at the School.

nal and Child Health.

The standard virology textbook

by Rhodes and Van Rooyen calls the demonstration of cytopathic changes in cell culture the "most striking aspect" of WeHer and his colleagues experiments. John Paul, who depended on Weller for much of his account of the tissue culture experiments, makes much the same point. He wrote that the demonstration of "specific injury that could be readily recognized under the high power of the light microscope" made possible "quantitative determinations as to how much polio virus existed in a given culture; to a way in which neutralization tests could be performed in vitro, and to countless other advances." Paul continued, "And, wonderful to say, came the realization that at long last monkeys, which had been so essential in the poliomyelitis laboratory, could be replaced by tissue cultures..."

Weller, meanwhile, went on to become a tissue culture researcher and a virus and parasite hunter par excellence.

For 2.3 years, he had one, continuous grant from the National Institutes of Health simply titled, "The Use of Tissue Culture to Study Human Pathogens."

But even as Weller was making history by finding the breakthrough recipe for culturing the polio virus, the held was changing. Instead of scrounging for vintage horse sera and embryonic tissue, researchers were starting to use cancer cells that, due to their genetic malfunctions could, theoretically, grow forever. N o w various genetic engineering techniques, including polymerase chain reaction (PCR), are used to track down and identify viruses. Contemporary researchers have foresaken the techniques for home-brewing tissue culture media mastered by WeHer and the scientists of his day.

the full signihcance woutd only emerge with another batch of experiments.

Yes, it was signihciant that polio virus could be grown in non-nervous tissue.

But in subsequent work, WeHer, Enders, and Robbins would also show that polio virus growing in cells resulted in countable, microscopically visible "cytopathic" changes in infected tissue.

"The real importance of tissue culture is that you always have a source of the infectious agents," notes Sam Telford m , a parasitologist at the School. "Instead of having to wait for a person to become infected, you just go to your incubator, pull out a tube, and voila! you have what you need."

Weller said the possibility of developing a polio vaccine was discussed by people in Enders' lab, but it was decided that "it wasn't our kettle of hsh." Jonas Salk and Albert Sabin would go on to have a bitter, lifelong rivalry over who deserved credit for successfully developing the best vaccine, but there is no doubt that the tissue culture experiments performed by WeHer and his colleagues laid the groundwork for the vaccine.

Professor Hugh R.

In an article in the Ma/vard PuM/'c Hea/f/? /)/umn/

Congress establishes

Leavell returns from a

8u//ef/n, Jerome Peterson, M.P.H.'39, identifies 26

the National Cancer

one-year sabbatical in

HSPH alumni working with the World Health

Institute.

India during which he

Organization.

severa/ ^OMsawcf peop/g cowfrac^eJ po/?'o /row; /wproper/y prepared f a c c w e MO^ s^op f^e pM^^ /or

served as a consultant on health to the Ford Foundation.

"We made our own medium and everything," says WeHer, with just a hint of nostalgia. " N o w people buy the cell culture, they buy the media, they buy the works. Nobody spends time washing glassware and starting cultures."

Peter Wehrwein

:

Potio In Wallace Stegner's novel Cross/ng fo ^a/e^y, a young woman contracts polio during a weekend camping trip. The narrator describes finding her "on her back, her parted lips enameled with fever, her breath coming hoarsely through her mouth. She heard me, and her eyes opened, but after the first wincing look they closed. I was not sure she recognized me; and when I put my hand on her forehead to feel how hot she was, she rolled her head away and cried out with pain."

Throughout the 1920s, 1930s, and 1940s, the nation experienced nearly annual polio epidemics, affecting tens, perhaps hundreds, of thousands of people and leaving some 10,000 victims paralyzed. By 1962, however, after vaccines became widely available, the annual caseload dropped to 465, and over the next few years, the United States averaged a mere 40 to 50 cases a year. Today, with the exception of the rare vaccine-related case, polio has all but been eradicated from the developed world; although it remains a problem in the developing world.

Poliovirus belongs to the enterovirus family, which includes Coxsackie, meningitis, and hepatitis A. Enteroviruses infect the intestinal tract. The most common form of polio, called abortive poliomyelitis, resembles, and is no more worrisome than, a common cold. A small percentage of cases of abortive polio are accompanied by stiffness and even a moderate, temporary paralysis.

In paralytic polio, the most serious form of the disease, the virus causes lesions along the central nervous system that cause paralysis of the large muscles of the legs and, less frequently, the arms. Muscles of the respiratory system can

also be affected, making breathing impossible.

Respirators can sustain breathing in these otherwise terminal cases; sometimes until the muscles heal themselves and other times, permanently. In a particularly serious manifestation of the paralytic form called bulbar polio, the cranial nerves, which control the action of the pharynx and the vocal cords, are affected. In these cases, the paralyzed throat muscles restrict patients' ability to swallow or clear secretions from their mouths, resulting in drowning or asphyxia. It took a while following the introduction of the iron lung for physicians to realize that it was useless in treating cases of bulbar polio.

Severity of paralysis varies considerably from case to case. Infants and young children suffer more serious polio manifestations while older children tend to be less severely affected.

Adults, such as Franklin Delano Roosevelt, who was stricken in 1921 at the age of 39, are severely affected, often resulting in paralysis or death.

During the 1940s, children and fearful parents called polio the "summertime scourge."

Swimming holes, pools, and ponds, were closed during polio epidemics, as water was popularly believed to be a route of transmission. Contaminated milk was also implicatedâ&#x20AC;&#x201D;a theory most strongly supported by the epidemiologist W. Lloyd Aycock, who before coming to the School's Department of Preventive Medicine and Hygiene was director of the Poliomyelitis Research Laboratory of the Vermont State Board of Health.

The earliest suspected description of a case of polio, according to John Paul's in M/'sfory of Po//o, is etched on a stone slab from the Egyptian Eighteenth Dynasty (1580-1350 B.C.). It depicts

a man, most likely a priest, with one normal leg and "a withered and shortened left leg, with his foot held in the typical equines position characteristic of flaccid paralysis." According to Paul, cases of what were most likely polio, or "infant paralysis" as it was also called, appear in medical records from the early eighteenth century. What seems to be the first large-scale polio epidemic occurred in 1894 in Rutland, Vermont, a small town 125 miles north of Boston. Dr. Charles S. Caverly, the state's public health officer, reported 132 cases. According to Paul, it was the largest number of cases of polio ever reported at one time anywhere in the world. But it was the 1916 epidemic, which touched 28 out of every 100,000 inhabitants of the northeastern United States, that marked polio's emergence as one of the most feared and destructive infectious diseases. Over the next half century, the nation would experience nearly annual full-scale assaults.

Polio virus is transmitted through the oralfecal route, which opens a panoply of possibilities for infection: handshaking, sharing tableware, biting one's nails, food contamination, or any other means where hands come close to the mouth. Ironically, improved sanitation due to public health measures may have inadvertently fostered polio's rise. One commonly held theory is that before the turn of the century improvements in sanitation, infants were regularly exposed to polio virus and developed lifelong immunity. (Aycock believed that infants and children were infected several times throughout their early years, and this repeated infection created antigenicity.)

Knowledge of how to treat the paralytic polio patient came about slowly; for the patients,

1958 Brian MacMahon,

Tropical disease researcher Eli Chernin discovers that

A $500,000 grant from The Rockefeller Foundation

S.M.H/53, succeeds

streptomycin inhibits growth and reproduction of

funds a Division of Environmental Hygiene at the

John Gordon as chair

snails that carry the tropical disease schistosomiasis.

School to study problems associated with "peacetime

of the Department of Epidemiology.

uses of nuclear energy."

Today, thanks to successful vaccination programs, polio's former power to inspire fear has been greatly diminished. In 1988, the World Health Organization resolved to accomplish global potio eradication, and since then, rates of wild-type virus have declined international^ by 82 percent, aided by massive efforts like the one in China in which 83 million children were vaccinated in a single day, and in India, where 88 million children received vaccinations. To date, 145 coun-tries in the world are polio-free, according to the WHO.

recovery was often titled with pain, fear, and humiliation. Legs were covered in plaster casts, or tightly strapped into braces, making them rigid enough to support weight. Pervasive in treatment strategies throughout the 1930s and 1940s was the idea that the patient had to will him or herself to get well. In Stegner's novel, the polio patient recounts trying to walk again: "Some parts of the therapy were alt right, but some were so rough and callous they almost killed me. They'd put you on a treadmill, for instance, with rails to hold on to, and you were supposed to try to walk. There was a nurse behind you with a hand on your belt, but she never kept you from falling. They were careless, they didn't hang on tight.Weal) felt. I found out later they did that on purpose, to harden your wilt. Unless you'd grit your teeth and take any amount of punishment and failure and still go on trying, they knew you'd never improve."

Roosevelt was a major force behind the establishment of the Nationat Foundation on Infantile Paralysis in 1937, an organization dedicated to advocacy for polio victims.

Roosevelt's law partner from his pre-political days, Basil O'Connor, used his connections with leaders in business and politics to lead the organization into national prominence. It

conducted training programs and produced brochures for physicians and nurses about the intricacies of making a poliomyelitis diagnosis and the use of the iron lung. In 1938, Roosevelt launched a nationwide fund-raising campaign by calting on Americans to donate their dimes to fund these training centers. Comedian Eddie Cantor called Roosevelt's appeal the "March of Dimes"; in 1979, the Foundation officially adopted the moniker.

Yet despite this success, polio has not been erased from the public health lexicon. In parts of the Indian subcontinent and in Central and Western Africa, polio continues to be a significant health problem.

Even the United States, despite the early and wide acceptance of vaccination, has not been entirelyspared. In1971,22 unvaccinated people in Texas contracted paratytic polio. In Holland, a religious community that eschews vaccination suffers periodic epidemics; one in 1978 affected 110 people, 79 of whom were left paralyzed.

1959 Thomas 0. Nevison, Jr.,

Associate Professor Elizabeth Prince Rice completes

Cuban revolutionary

Alaska and Hawaii

class of 1959, is medi-

three-month, around-the-world tour of health and

Fidel Castro ousts

become the 49th and

cal officer on an expe-

welfare programs in Asia and the Middle East.

Fulgencio Batista.

50th U.S. states.

dition to the summit of Hidden Peak, second highest of Kashmir's Karakorum Range.

John Crayton

Dean ^ ^

^

1954-1971 S A YOUNG MAN,

Snyder

John Crayton Snyder wanted

Snyder was extremely kind and considerate at a time when

to be a surgeon just like his father. But a talent

the prevailing American attitude toward Chinese—

for research, a bout of scarlet fever, and a great

especially during the Korean War—was cool, if not hostile.

^ ^ scientist's deathbed plea to Snyder all worked

"He was always trying to be very protective of me and

to change the would-be surgeon's plans. Instead of perform-

my wife," said Chang, who remembers Snyder personally

ing operations, Snyder wound up presiding as dean of the

intervening to help him and his wife with various passport

School of Public Health for 1 7 years, leaving behind a legacy

and immigration issues. Associate Professor Grace Wyshak,

of new facilities, academic centers, faculty expansion, and

s.M.H.'^6,

overall educational excellence that imprinted the School with

"gentleman." "You had the feeling," she says, "that he

much of its present-day character and personality.

was upright, civil."

Friends and former colleagues invariably use the

says Snyder always struck her as being a

Snyder was born in 1 9 1 0 in Salt Lake City, but,

words "formal" and "proper" in describing Snyder. Then

surprising for those times and that place, he did not grow

a junior faculty member who viewed Snyder mainly from

up in a Mormon—or even particularly religious—house-

a distance, Professor John Little, in the Department of

hold. His grandfather had disavowed Mormonism after

Cancer Biology, remembers Snyder as someone who com-

defying Brigham Young's orders to undertake a third, year-

manded respect and "had dignity and a certain stern

long mission away from his family. His father, Crayton

countenance." Alexander Leighton, brought to the School

Snyder, became a successful surgeon. Snyder still remem-

by Snyder to head up a newly created behavioral sciences

bers his father's response when a patient scolded him for

department in the 1960s, describes him as a "very clear

being on rounds Sunday morning instead of at church:

thinker" and "very devoted" to the School. Robert Chang,

"I am in my church, all the time, wherever I am."

a retired professor of medical microbiology at the Univer-

The family moved to Pasadena, California, when

sity of California at Davis, came to the School in 1 9 5 0 as

Snyder was a boy, because Salt Lake City's high altitude was

one of Snyder's first graduate students and stayed to work

unhealthy for his brother who developed congestive heart

under him for the next 18 years. As a scientist, says Chang,

failure due to rheumatic fever. Crayton Snyder was a busy

Snyder was careful and conservative. As a mentor, he adds,

surgeon by his son's account, beloved by patients and

1960 Henry Lee Shattuck International House opens as a residence for foreign students.

William M. Schmidt succeeds Martha May Eliot as chair of the Department of Maternal and Child Health.

fp/dem/'o/og/'c Mef/?<x&, a textbook that ushers in the era of chronic disease epidemiology, is published.

Brian MacMahon and two faculty members, Johannes Ipsen, and Thomas F. Pugh are co-authors.

Snyder remembers working for him as an emotionally

studious about keeping up-to-date with the latest research and techniques. They were the kind of paternal footsteps

draining experienceâ&#x20AC;&#x201D;any mix-up or dead-end loomed

that attract willing followers. Says Snyder, " A t an early age,

twice as large with Zinsser's death just around the corner.

I decided I was going to be a surgeon."

Snyder recalls the promise that Zinsser extracted from him in late August 1940, before he left for Hamilton, Montana,

That was still the plan after Snyder graduated from Harvard Medical School in 1 9 3 5 , but then, somewhat

to work at a Public Health Service lab there. Zinsser

gradually, his career started to take a different path. While

clasped Snyder on the shoulder and made him promise to

an intern on the surgical service at the Massachusetts

continue to work on the disease until "typhus is licked."

General Hospital, Snyder contracted scarlet fever and was

Zinsser died on September 2., 1 9 4 0 .

quarantined for six weeks in Boston City Hospital. Caused by bacteria, scarlet fever causes nausea and vomiting, as

HOUGH IT WOULD TAKE t h e d e v e l o p m e n t of

well as the reddish rash that gives the disease its name.

broad-spectrum antibiotics after World War II

Largely controlled now by antibiotics, it was a significant

to "lick" typhus, the work Snyder and others did

health threat through-out the 1940s, killing from 4,000 to

during the war sharply contained a disease that

6,000 Americans each year. Snyder went home to California

in previous wars had raged with epidemic ferocity. Snyder

to complete his recovery, and when he returned to Boston

served with The Rockefeller Foundation in Spain and with

and the Massachusetts General Hospital, it was as a research fellow.

Snyder said it was during his stint at Mass General that the idea of a career in research, rather than surgery, took hold. His knack for it was evident. Snyder successfully developed and designed a hrst-of-its-kind machine for measuring the cardiac output of unconscious patients and published his work in an article in the /oMHM/ o^

^ ^ ^

HORTLY THEREAFTER,

Snyder

was

recruited

by

the

famed bacteriologist Hans Zinsser to join the ^ ^ ^

International Health Division of The Rockefeller Foundation, where he assisted Zinsser in his

research on louse-borne typhus, a disease of special concern during wartime (see sidebar page 84). Zinsser, who taught courses at both Harvard Medical School and the School of Public Health, was a charismatic, inspiring professor.

Years later, former students would describe his lectures as the most brilliant they had ever heard. Zinsser was also a first-class researcher, who had done ground-breaking work on syphilis, rheumatic fever, and tuberculin reactions.

Unfortunately by the time Snyder joined him, Zinsser

^egaw

pM^f/c AeaM? career zM^es^'ga^mg

was also a dying man, slowly succumbing to leukemia.

Construction begins on nutrition laboratories (now Building II).

School's endowment has grown to $8.7 million.

[

John F. Kennedy elected president of the United

I

States.

Indonesia launches 10-year, WHO-sponsored malaria eradication campaign.

^acfer/a/

Typhus Typhus has stalked people through some of the darkest chapters of history, particularly in Europe. It raged during theThirty Years War. It plagued Napoleon's catastrophic 1812 invasion of Russia. During World War I, typhus swept through Russia and Eastern Europe, infecting 30 million people and killing one of every ten it infected. And during World War II, typhus struck heavily in the Nazi concentration camps.

bacterium called R/'c^eHs/'aproi/i/azeAvV. Lice become infected with R/'dreHs/'aprowaze/r/Vwhen they feed on an infected person and die after 10 to 14 days. But before they die, they feed at least three times a day and spread the bacteria to others through their feces. Because louse bites itch, the bacteria-laden feces usually enter the bodies of unsuspecting typhus victims when they scratch the bites.

Now typhus ranks as one of the world's lesser health threats because, under the right conditions, it can be successfully controlled by delousing methods and treated with broadspectrum antibiotics. But before the post-World War II boom in antibiotic development, curbing typhus was one of the great, ongoing dramas of health research and action. Some of the key figures in that drama were affiliated with HSPH, notably Richard Pearson Strong, George Shattuck, A. Watson Sellards, Hans Zinsser, and John C. Snyder.

Hippocrates used the word typhus, which in Greek means smoky or hazy, to describe the confused state of mind associated with a fever, and for centuries, two distinct diseases, typhus and typhoid fever (caused by ia/mone//a fyp/?/) were lumped together. The fever, headache, and muscle pain associated with typhus are not unusual and could be associated with any number of fever-inducing diseases. Typhus bacteria infect endothelial cells, but beyond that, they are not very discriminating, so several organs, including the brain and the heart, may be damaged. The result is a scrambled set of symptoms ranging from renal failure to myocarditis. Left untreated, typhus is a vicious disease with a case-mortality rate of up to 70 percent.

A relatively mild form of typhus lives in rats and is spread by fleas, but the more dangerous form of the disease—and the variety that wreaks such havoc in times of war and hardship—is spread by lice. Called either epidemic or louse-borne typhus (other names include classic typhus, jail fever, and tarbardillo), the infectious agent of this form of typhus is a

tend to be more common in times of war or famine. That was exactly the situation in Serbia in 1915 when Strong, Shattuck, Sellards and Zinsser were sent there by The Rockefeller Foundation as members of the American Red Cross Sanitary Commission. All three scientists were members of what was to become the School's Department of Tropical Medicine, while Zinsser was later to teach bacteriology and immunology at the School. According to Strong's account of the trip in Typ/ws few/* tv;'f/; Par&'cu/ar Reference fo fhe Serb/an fp;'dem;'c, a typhus epidemic started among Austrian soldiers held prisoner by the Serbians and then spread to the civilian population, many of them refugees.

About 150,000 people died in the epidemic, and, at its height, as many as 9,000 were falling ill each day. Shattuck, Sellards, and Zinsser set up a make-shift lab in a Serbian hospital to examine tissue and blood samples from dead

Behind the predilection typhus has for human misery and strife is the fact that the conditions that typhus-transmitting lice enjoy—crowded, unclean, with few chances for people to wash themselves or their clothes—

the U.S. Typhus Commission in Egypt, Italy, and Germany.

During the war, Snyder helped design the studies

It was while working in Egypt that Snyder Hgured out

that proved the effectiveness of Herald Cox's anti-typhus

that one effective way to control lice was to dust the seams

vaccine, and, while at the School, he was involved in the

of clothing with talcum powder laced with DDT. Toxicity

research that proved people harbor the typhus bacteria long

tests were conducted to make sure the powder was safe.

after they recover from the disease. It was working on

DDT was a critical piece in typhus control efforts and

typhus that fully converted Snyder, the former would-be

worked especially well in limiting an outbreak in Naples

surgeon, to the public health viewpoint. He realized that

in 1 2 4 3 - 1 9 4 4 . "It was improper use, primarily in agricul-

while one doctor and potent drugs might cure a typhus

ture, that gave DDT—rightly so—its bad name," Snyder

patient one person at a time, it made more sense to have

notes. It was also discovered later that lice develop resistance

three or four public health workers prevent the epidemics

to the insecticide.

1961 Industrial hygiene Chair Philip Drinker, biostatistics

James L. Goddard,

Chair Hugo Muench, and tropical public health

M.P.H/55,appointed

Bernard Lown and

Professor Donald Augustine retire from the faculty.

head of the CDC, the

graduate H. Jack Geiger,

first of five successive

found Physicians for

alumni who will head

Social responsibility

the agency.

Faculty member

and living typhus victims. Strong, meanwhile, mounted what was in effect a mass debusing campaign that was a logistical masterpiece; an observer described the Strong-led efforts as "miraculous." It was understood that the lice that spread typhus could be killed by high heat, so Strong hastily organized delousing centers in "factories, ware-houses and breweries, and wherever facilities for obtaining steam were available." He converted railroad cars into mobile "sanitary trains." Clothes were hung in an air-tight refrigerator car for steaming. Meanwhile, in another railcar, people showered and were sprayed with kerosene ("an additional precaution for killing the vermin," wrote Strong) before putting back on their disinfested clothes.

The Serbian epidemic slackened off during the summer, a pattern common to typhus outbreaks since warmer weather eases overcrowded living conditions. But Strong's efforts were credited with keeping typhus from coming back in epidemic proportions.

After the war, Zinsser continued to do research on and write about typhus. In 1934, he correctly hypothesized that Brill's disease was, in fact, not a separate disease but a form of typhus that reemerged in people who had had typhus years before. Zinsser's 1935 book /?afi,

A/'ce and M'sfory is a parody—albeit a serious one—of heroic biographies with "the life history of typhus fever" as its subject. Before he died, Zinsser urged Snyder to keep doing research on the louse-borne disease.

Given the experience with typhus during World War I and during European wars in general—it made sense that military officials would make typhus prevention a priority during World War II. All Allied troops were given the typhus vaccine developed in 1937 by Herald Cox. And in 1942, President Roosevelt appointed a special commission to control and research typhus. Snyder worked for that commission throughout much of the war. His research helped establish that DDT was an effective delousing chemical. Dusting clothes with a DDT-laced powder became the standard way for staving off typhus outbreaks during the war (the problem of DDT-resistant lice emerged several years later).

In 1945, Snyder spent 54 harrowing days with the U.S. forces liberating the Nazi concentration camps. Snyder was in charge of making sure the advancing troops were properly trained and equipped to detouse the camp prisoners. Given the ripe conditions for typhus in the camps, it was often a scramble with lifeand-death consequences. Snyder was among those who liberated Dachau. His valiant efforts

before they occurred. "The patient becomes the community, the state, or the nation," he says.

(which included an all-night trip to Paris) to get anti-typhus supplies and medical personnel to Dachau helped curb the typhus epidemic there.

Typhus outbreaks also occurred in civilian populations in North Africa, Yugoslavia and Italy during World War II. But among the Allied troops, anti-typhus efforts were a remarkable success. There were no deaths from typhus among U.S. military personnel and all told, only 104 cases during the entire war.

Since 1950, and the discovery of tetracycline and other broad-spectrum antibiotics, typhus has receded somewhat as a major health threat, particularly in the developed world. But it has far from disappeared.

Andean countries, particularly Bolivia, and the Himalayan regions of Asia continue to be plagued by typhus. And in Ethiopia, a country that has contended with famine and civil war for years, typhus has again demonstrated its taste for human misery, afflicting thousands of people, especially in refugee camps.

PW

Well, Snyder thought, "if I put myself to sleep, think what I might do to students!" He decided his lectures would have to be a little less "encyclopedic."

^ ^

FTER THE WAR, in 1 9 4 6 , Snyder was appointed

latest information on infectious diseases and bacteriology.

Health Bacteriology. As a teacher, he prepared

Because of the risk of infection, laboratory work was

^ ^ meticulously, writing out his lectures in long-

*.

Snyder tailored his course to give physicians the

to head the School's new Department of Public

notoriously dangerous, and one of the issues Snyder stressed

hand and then practicing his delivery into a dictaphone.

was lab safety. (Snyder had contracted typhus during a

One night, he recalls, he fell asleep while listening to the

laboratory experiment in Spain, an experience that he hoped

recording. One of his children came in and woke him up

no one else would have.) Photographs of Snyder lecturing

saying, "Daddy, daddy, wake up. Your speech is over."

show him dressed in a surgical-type gown. Snyder says he

1962 First manned

Dedication of the Nutrition Building (now Building II)

spaceflights by Russian

and Building I. The latter, only four stories high, will

and U.5. astronauts.

grow to its current 14 stories over the next decade.

was trying to set a very visible, good example for his

students were about 30 to 40 percent of the class, distin-

students. Improving the School's labs so they were safer to

guished people in their own right, and they were forced to

work in was one of Snyder's pet projects, and he says he

find housing in miserable places," Snyder told Robin Henig,

was constantly pressing university officials for changes.

author of T^e Peop/e's PfMM?.- A Me77!Oz?* o/^PMM;'c He^M?

Occasionally, he would win small victories, such as getting

H<37*ZA3?-J, a recently published history of the School.

hard-to-clean wood tabletops in laboratories replaced with easy-to-sterilize stainless steel.

Snyder was named dean in October 1 9 5 4 , a few months after the sudden death of Dean James Stevens Simmons. It was a heady era when American faith in health

that endowing profes-

^ ^ ^

NYDER DECIDED INITIALLY

^^^

sorships would be among his top priorities. When

^^^

he pitched the idea at a faculty meeting early in his deanship, however, the response he remembers

and medical scienceâ&#x20AC;&#x201D;and science more generallyâ&#x20AC;&#x201D;was

was: "Where are we all going to work?" Facilities as well

sky-high. The country was euphoric about the successful

as professorships would have to be a top priority, Snyder

completion of a large-scale trial of the Salk polio vaccine

decided. At that time, the School was housed in two

that summer, and the School was basking in the reflected

converted hospital buildings: the former Infants' Hospital

glory of Professor Thomas Welter's shared Nobel Prize for

at 5 5 Shattuck Street, which is now part of Children's

research that made the vaccine possible. But financially, the

Hospital, and the old, brick Huntington Hospital facing

School was on shaky ground. Because of a 10-year

the avenue of the same name, which was demolished to

Rockefeller Foundation grant, Dean Simmons had managed

make room for the School's new buildings. During his

to expand the School, adding new departments and hiring

17-year term as dean, Snyder would not only oversee a

new professors. But the grant was running out. Only nine

quadrupling of the School's endowment, but also a building

professors had tenure and only one professorship was

program unmatched in the School's history. In physical

endowed. Student housing was also a problem. "Foreign

terms, most of what is now thought of as the School of

tA!

Prow j<?6o fo J 9 7 1 , .Swy^er

otw a

^M/Mwg

1962 Nobel Laureate Thomas Weller, chair of the Department of Tropical Public Health, and colleague Frank Neva isolate the rubella virus.

In separate studies, Weller discovers that mental retardation and cerebral palsy are common consequences of prenatal infection with cytomegalovirus.

HSPH tuition has nearly doubled in the last decade, reaching $1,400 a year. Enrollment hovers between 100 and 120 students.

Public Healthâ&#x20AC;&#x201D;Buildings I and II, the Kresge Building,

of chronic diseases that was beginning to take root was

and Shattuck Houseâ&#x20AC;&#x201D;is a legacy from Snyder's deanship.

gathering momentum, but controlling and preventing

Still, fund-raising was not his forte. Snyder almost

infectious diseases still remained the pivotal mission of

reHexively pushes the credit on to coHeagues such as

much of public health. Building on his work in typhus and

Fredrick ). Stare and WeHer. Synder rose to the occasion,

picking up a project initiated by Dean Simmons, Snyder

however, when money was needed to complete the Health

was a key figure in the joint Harvard-Aramco Trachoma

Sciences buildings. In his interview with Henig, Snyder

Research Program to control trachoma in the Middle East

described his personal, whirlwind tour of corporate

and elsewhere. Trachoma, a bacterial disease spread by

America during the summer of 1966 after King Faisal of

Hies as well as by contaminated hands and towels, is the

Saudi Arabia had premised his gift on how much money

main cause of blindness in the hot, sandy regions of Africa

the School could raise "from the great American industries

and Asia. Working with WeHer and Professor Roger Nichols,

currently working in Saudi Arabia."

Snyder also established the Center for the Prevention of

Regardless of how credit is distributed, the achieve-

Infectious Diseases near the end of his deanship, in 1970.

ments during Snyder's deanship are extraordinary: the School's physical plant was transformed from provisional, antiquated former hospitals to three modern buildings; the faculty doubled in size; and the number of tenured faculty grew from 9 to

Endowed professorships grew from

only one to a dozen.

During much of Snyder's deanship, WeHer was the

^ ^ ^

UT SNYDER WAS NOT AFRAID to break new intel-

lectual ground. In 1962, he created the Department ^ ^ ^ of Behavioral Sciences (which evolved into the ^ ^ ^ ^ current Department of Health and Social Behavior).

That same year, he founded the Department of Demography and Human Ecology (now the Department of Population

academic anchor of the School, and Snyder describes

and International Health) and a year later, the university-

WeHer as being his "trusted adviser." The shift to the study

wide Center for Population Studies (now the Harvard

The Department of Demography and Human Ecology,

The Kresge Center for Environmental Health is formed

later renamed the Department of Population Sciences,

under the direction of Professor James Whittenberger

established under the temporary direction of Dean

to unify and advance the school'swork in environ-

Snyder.

mental health.

Center for Population and Development Studies). The

While he, like many other Americans, came to believe that

latter was, in many ways, Snyder's crowning achievement:

the Vietnam War was a terrible mistake, he did not have

it gave the study of the inter-relationships between demog-

any sympathy for the "storm-the-gates" tactics of some of

raphy and health a permanent, high-profile academic

the student protesters. He was offended by the "don't-

home. Though the thinking about population has changed

trust-anyone-over-30" attitude and the rampant "establish-

since the founding of the center over 30 years ago, Snyder's

ment" bashing. And Snyder still speaks with emotion about

vision of an institution that will "draw upon the resources

the Harvard student strike in 1969 during which some

of the university as a whole" and "search for answers to

protesters took over University Hall in Harvard Yard.

the very complex population questions facing our scientists

"Anyone who tried so hard to get buildings for students

and political leaders" has been fulfilled.

to study in and then finds that they want to trash them—

Snyder was motivated to found the center partly by

that is an offense to my memory," says Snyder, while

a sense of ethics. He had come to believe that public health

noting that some of the demonstrators were not students.

researchers and officials had a responsibility to address

After the protests he took his first and only sabbatical,

explosive population growth because successful disease

and in June 1 9 7 1 , Snyder resigned to return to academic

prevention and vaccination programs were in part respon-

activities, ending a deanship that spanned over one-fifth

sible for falling mortality rates. In a lecture at Riverside

of the School's history.

Church in New York City in 1 9 5 9 , Snyder asked, "should

Snyder stayed active, serving as the medical director

the profession of public health concern itself with rapidly

of the Center for Population Studies and holding a profes-

increasing populations, particularly in those areas where

sorship in population and public health. Working with

health measures are being introduced with such profound

Hilton Salhanick, Frederick Lee Hisaw Professor of

effects? M y answer is yes."

Reproductive Physiology, Snyder designed field trials of a drug that reduced the important pregnancy hormone,

^ ^

^

s DEAN, Snyder enjoyed a good rapport with

progesterone, that he and Salhanick had hoped would make

students, hosting dinners and Christmas parties

for a more effective contraceptive. Snyder was also an

at his home. In the early 1960s, he traveled

adviser to University Associates for International Health,

for three months, visiting recent graduates to

an organization focused on developing health programs

see if the School's curriculum was, in fact, relevant to practical public health work. Snyder took a special interest

in the Middle East.

Snyder guided the School through a building boom and

in Shattuck International House (see story page 91), some-

great faculty expansion. The School's main auditorium—

times arranging afternoon concerts of classical music. He

the educational hub of the institution in many ways—aptly

and his wife Virginia—known to everyone by her nickname

bears his name. But Snyder says what he hopes his deanship

Ginty—helped organize and equip a play area for young

will be most remembered for did not happen anywhere

children in Shattuck House.

inside School walls. " I guess the thing that I am proudest

But in the later part of the 1960s, Snyder became dismayed at a particular segment of the younger generation—or at least how it manifested itself at Harvard.

of is what the students did—and are doing—in various parts of the world," he says.

Peter Wehrwein

1962 Associate Professor Carl Taylor, D.P.H/53, and family

Longtime faculty mem-

drive from London to India's Punjab, where Taylor will

ber Jane Worcester,

Spring is published. The

spend a year studying internships in Indian medical

D.P.H.'47, promoted to

book warns of environ-

colleges. The 8,000-mile trip takes them through

professor of biostatistics

mental consequences

Istanbul, Ankara, Tabriz,Teheran, Kabul, and the Kyber

and epidemiology.

of DDT and ignites

Pass.

Rachel Carson's 5</enf

public concern about dangers of pesticides.

jane Worcester

HEN BIOSTATISTICIAN JANE WORCESTER b e g a n

"vital statistics" as the held of biostatistics was then

her 46-year career at the Harvard School of

called, and by 1 9 3 4 she had co-authored her first paper

Public Health, Herbert Hoover was president,

with department Chair Edwin Bidwell Wilson. In all

a hrst-class stamp cost 2. cents, and a "computer" was a

Worcester published 68 papers. Wilson, a brilliant statisti-

person, usually a woman, who did the computational

cian with eclectic interests who came to the School after

drudge-work that machines do today. Beginning as one of

an early career oriented toward mathematics and physics,

those human calculators, Worcester blazed a path to success

was co-author on 2.7 of those papers. Other faculty lumi-

that eventually led her to an appointment as chair of the

nariesâ&#x20AC;&#x201D;including Nutrition Department Chair Fredrick J.

Department of Biostatistics. Along the way, she earned a

Stare, Epidemiology Department Chair Brian MacMahon,

doctorate in epidemiology, collaborated with some of the

and Professor of Environmental Epidemiology Ben Ferrisâ&#x20AC;&#x201D;

School's leading faculty, made significant contributions to

would later join the roster of Worcester's co-authors.

research on chronic diseases, and had a profound impact on the life of the School and its students.

Worcester arrived at the School in 1 9 3 1 , one of a

Yvonne Bishop, s.M.'6i, a colleague of Worcester for 2.0 years, says Worcester's frequent appearances as a second author reflected the heavy demand for her advice

number of Smith College graduates recruited for their

and input and Worcester's conviction that valid medical

strong training in statistics. She quickly showed a flair for

research needed to be grounded in statistics. In the 1960s

1963 School's endowment

Rand pressure chamber

Nobel Laureate John F.

Thomas Weller

reaches $11.5 million,

used to treat President

Enders, former head

awarded Harvard's

with six endowed

Kennedy's infant son,

of the Department of

George Ledlie Prize by

professorships, up from

who is suffering from

Bacteriology, produces

Harvard President

$8.7 million in 1960.

hyaline membrane

first successful measles

Nathan Pusey.

disease.

and 1 9 7 0 s , for example, Worcester worked closely with MacMahon's epidemiology department as it pioneered the epidemiologic study of chronic disease.

As a scholar, Worcester's strength lay not in virtuoso theorizing but in sound, critical thinking and healthy skepticism. In a 1 9 6 6 article for N e w EwgfawJ /oMrfM/ Worcester implored researchers to take statistical analysis into account before they begin a study—a plea that biostatisticians still voice today.

In the same article, Worcester warns against going overboard with statistical analysis, dredging data for answers to questions not originally considered and jumping recklessly from association to cause-and-effect conclusions. "The test of significance, at best, suggests an association; it does not distinguish between cause and effect," she wrote.

Worcester's skepticism extended to the field's emerging love affair with electronic computing, which permitted complex computational functions at the push of a few buttons. Robert Hoover, s.M.H.'70, D.E.R'76, director of the biostatistics and epidemiology program at the National Cancer Institute, says, "Jane taught that you needed to know what assumptions were being made by the statistical techniques you were using. Because

they are all based on some assumptions."

In 1 9 7 4 , Worcester succeeded Robert B. Reed as chair of the Department of Biostatistics. At the time, the department was a fraction of the size it is today—it would be several years before only the advent of large-scale clinical trials research would spur the department's expansion into one of the larger HSPH departments. Teaching absorbed much of the faculty's time. All the students in the School were required to take an introductory biostatistics class—still a requirement for today's students—for which Worcester designed much of the course material, conscientiously revising and updating it, says Bishop. The department also functioned as a kind of universitywide statistical resource: any member of the faculty could tap the department for statistical advice. ^ ^ ^

^ ^ ^

ORMER STUDENTS r e m e m b e r

Worcester fondly as a captivating lecturer and "archetypal mentor." Bishop, who knew Worcester well, says she was first and foremost a teacher who trained students to think "statistically, which meant to think logically." N a n Laird, Henry Pickering Walcott Professor of Biostatistics and current chair of the biostatistics department, whose career at the School overlapped briefly with Worcester's, remembers her as having a wonderfully acerbic wit and sense

of humor. Another former student and colleague, James Warram, s.D.'88, says Worcester was extremely careful with her words. "If you went into her office, and she didn't want to answer you, you would just get silence."

Worcester could also be exceptionally warm. Bishop recalls that Worcester was a person of especially good taste and manners and an extraordinarily supportive friend and colleague. "She would do anything to help anybody," says Bishop, who says she benefited tremendously from Worcester's guidance and friendship.

Worcester was particularly good at helping women and non-M.D. students break down the "only male" and "only M.D." barriers that exisited at the School at that time, says Bishop.

"She had a phrase that she used to counter all fears and anxieties: 'You can do it,' pronounced very firmly."

Worcester retired in 1 9 7 7 and moved to Cape Cod. She died on October 8, 1 9 8 9 , in Falmouth at the age of 88.

Peter Wehrwein

1963 Despite the recent report by U.S. Surgeon General

President Kennedy

U.S. civil rights leader

assassinated in Dallas,

Martin Luther King, Jr.,

Luther L. Terry linking smoking to lung cancer and

Texas. Seventeen

leads march on Wash-

other diseases, annual U.S. cigarette consumption

international students

ington and delivers

peaks at 524 billion—4,345 cigarettes for every

and numerous alumni

"I have a d r e a m . . . "

American adult.

wire Dean Snyder their

speech.

sympathies.

Home Away from Home Henry Lee Shattuck tnternationa) House

An acfwe soc;aJ

was a Mfa/ part o/Tntematzona/ House's ear/y SMcress.

A

Jty

^

S S O O N AS S H E A R R I V E D a t

Henry Lee Shattuck Internationa!

House on a warm autumn day in i960, Virginia R. Hannon, s.D.H.'68, knew she had made the right decision. "It was lively," said Hannon. "There were children everywhere and four or five languages being spoken—all at once. The smells of spices and cooking foods drifted out of the apartments.

It was electrifying."

In the 1 9 5 0 s and 1960s, as today, one-third of the students at the Harvard School of Public Health came from outside of the United States.

Unfamiliarity with Boston and discriminatory rental practices led many of them to over-priced, ill-kept, outof-the-way apartments, where students' spouses and children lived in virtual isolation.

To counter these difficulties and help create an atmosphere that would embrace the School's international students, Dean John C. Snyder launched a fund-raising effort headed by his friend Henry Lee Shattuck, a well-known Boston financier, Harvard College alumnus, and former treasurer of Harvard College. Shattuck— the twin brother of George C. Shattuck, legendary clinical professor of tropical medicine at the School for more than three decades—committed a large share of the more than $300,000 needed to purchase and renovate three adjoining apartment buildings in Boston's nearby Fenway neighborhood. Shattuck was joined in the effort to bring an international residence into existence by George

1964 Renowned oceanographer Roger Revelle is named Richard Saltonstal! Professor of Population Policy and director of the Harvard Center for Population Studies.

Harold Coe Stuart receives the Martha May Eliot Award from the American Public Health Association.

President Lyndon Johnson signs landmark Medicare/MedicaidAct, which will take effect the following year.

Gulf of Tonkin Resolution marks escalation of U.S. war effort in Vietnam.

^

?

Boston pMaM^rop/s^ Hewry Lee f/acz'ng page; spearbeaJeJ fbe /MnJ-raMZMg ^rwe fo pMrcbase an J rewcwate ^ e

aw J 207 Par^ Drwe ^ a t becawe /nferMa^owa/ HoMse.

Gund, Charles F. Wilinsky, A . M .

Sonnabend, the Edsall family and the Littauer Foundation.

In July i 9 6 0 , the king and queen of Thailand paid a visit to the residence, which was in the process of being renovated. The King's late father, Prince Mahidol, was the first Thai student to attend the School.

A brief ceremony was held under a canopy in front of the building. Two months later, residents from more than 20 countries entered the flower!ined walkway of Henry Lee Shattuck House and were greeted by Professor and Mrs. Philip Drinker, who served as the house's resident faculty family for the first year. Since then, Shattuck House has been a home away from home for more than 3,500 of the School's 6,000 graduates.

Hannon, a graduate of Spelman College, was one of the 1 4 1 people

who called Shattuck House home in its first year. She was delighted to find that her apartment had gleaming hardwood floors and bay windows and was furnished down to pots, pans, and utensils, and that the House included music rooms, a library, and a play room for children.

"The biggest factor in choosing to live in Shattuck House," said Hannon, " w a s that I wanted to live in an international setting. It was a marvelous opportunity to learn about other cultures and traditions."

An active social life quickly became a defining characteristic of Shattuck House, as residents hosted parties, most having an international flair, in the common areas on the ground floor. According to Hannon, there were holiday celebrations from around the world, cooking classes, and all-night study sessions. The Snyders, with the enthusiastic parti-

cipation of the faculty wives, hosted annual Saturday picnic luncheons in early October, arranging for residents to travel by bus from the Shattuck House to sites in Dublin, N e w Hampshire, where some of the students had their first view of the fall colors in N e w England, and a few even had a swim in Dublin Pond.

Abdul Rahman Al-Awadi, M.p.H.'6$, who came to Shattuck House in September 1 9 6 4 , remembers fondly the feeling of community that greeted him. Al-Awadi attributes a lot of the house's spirit at the time to Director-in-Residence Margaret Dale Penrose, the widow of Dr. Stephen B.L. Penrose, president of the American University in Beirut, Lebanon.

From 1 9 6 2 until her retirement in 1 9 7 8 , she helped to organize social gatherings that featured exotic dishes and native garb. She stayed at the

1965 Article in the Ma/vard PuN/'c /Vea/f/! /S/t/mn/ Bu//ef/n

The Department of

Countway Library

by Alfred K. Neumann, M.P.H/60, and Samuel G.

Behavioral Sciences is

dedicated.fr/Ma,a

McClellan, M.P.H.'61, states that "public health

established under the

memorial to John F.

workers can and must play a vital role in the struggle

direction of Professor

Kennedy given by

to nurture, encourage, and safeguard the equal

Alexander H.Leighton.

Swedish businessman

human rights of all men."

Johan Throne-Hoist, unveiled at the School.

house to cook Thanksgiving Dinner, and heiped newly arrived students to become more familiar with American styles of cooking and dress. Al-Awadi recalls in particular the special birthday celebrations for the children and an end-of-the year party where people taught traditional folk dances from their countries to their neighborsâ&#x20AC;&#x201D;the precursor to International Night. " I think that my experience at the School was enhanced by living at Shattuck House," said Al-Awadi.

"Living there was a unique opportunity to gain understanding of other cultures, especially because the year that I was there the residents were particularly diverse. Being a part of such a close community is an experience that I have savored."

Riitta-Liisa Kolehmainen-Aitken, D.p.H.'yy, who lived in Shattuck House in the 1970s, says the residence's extraordinary sense of community among the residents was particularly important for the students' spouses, most of whom were women who stayed at home during the day. Despite their cultural differences, they formed a tight-knit group. They would shop together and look after each other's children. "Without the community of Shattuck House, many of these women would have been very isolated, alone, perhaps for the hrst time in their lives, in a large foreign city," she says.

was stricken with pneumonia. One of the chi ldren had brought the disease home from school, and it spread because everyone was trying to help out the child's family by bringing food and taking care of the children. " N o one complained, though," said Hannon. "That's just the kind of place it was. It was a real community."

Two of Shattuck House's more colorful characters were Fletcher and Marie Napier, the residence's on-site managers. According to Kolehmainen-Aitken, the Napiers were more like surrogate parents or grandparents to many of the residents. They were the ones who knew whose heart was breaking, who was going with whom, and who was having trouble with classes or was worried about his family back home.

It was Fletcher who in the mid-1970s decided to turn the vacant lot adja-

Of course, in such a tightly knit community, more than just advice was shared. Hannon remembers that during her second winter, nearly everyone on her floor, including herself,

Ernst Tyzzer and Roger Irving Lee (left), both present at the first meeting of the School in 1922, die. Lee, acting dean when the School opened, was known as the "father of the School of Public Health."

cent to the building into a playground.

He cleared the lot, completed the landscaping, and built the playground equipment himself. Fletcher later became known for shocking some of the residents newly arrived in the states when he took to wearing a headband with a feather in his shoulder-length hair. He and Marie were elected honorary members of the class of 1978.

Dan Beaudoin, who assumed responsibility for Shattuck House after Fletcher's untimely death in 1989, vividly recalls the arrival of Clement Malau, M.p.H.'95, a native of Papua New Guinea. "Clement came to the door, and I started to help him up the stairs with his bags. The hrst thing that Clement told me about himself was that his grandfather had been a head hunter. Clement immediately had my full attention," recalls Beaudoin.

During his time at Shattuck House, Malau was one of four students who initiated a weekly cultural exchange that took place on Saturdays. Each weekend, representatives from a different country would set up in the house's community area on the ground floor and talk about their country, show pictures, demonstrate traditional music or dances, and finish up with a traditional meal. Beaudoin recalls curry dishes that made his eyes water and learningâ&#x20AC;&#x201D;through harsh experienceâ&#x20AC;&#x201D;that people from some cultures prefer to drink soured milk.

Henry Lee Shattuck International House remains in the memory of its residents as a place of community and exchange, an integral part of their

Surgeon General's warning appears on cigarette packages.

World population reaches 3.3 billion.

experience at the School, and it continues to provide a welcome and supportive home for students today.

"When some of the students drop by my office in the late fall, fearing that they are not smart enough or quick enough to keep up with their studies, or they are missing their families who are thousands of miles away, I tell them the same thing Dan

did, ' N o one's left since I've been here.' Sometimes that's all it takes," said Kate Vitkosky, who now oversees the house. "That and the support and companionship of about 70 other people having the same fears and doubts. This is the real strength of Shattuck House."

MarceHa J. Bernard

Recent res^e^s o/fwfeTTM^ofMf HoMse.

1966 David J. Sencer, M.P.H.'58, succeeds James Goddard

Alonzo S. Yerby, M.P.H/48, former commissioner of

as head of the CDC. That year, the CDC launches the

hospitals for New York City and a member of President

smallpox eradication programs.

Johnson's National Advisory Commission on Health Manpower, named professor and chair of the Department of Health Services Administration.

HSPH f a c u i t y d r i v e e p i d e m i o i o g y ' s m i d - c e n t u r y s w i t c h to t h e s t u d y of chronic d i s e a s e s .

S H t F U N G G E A RS % HB S HEN N O E L W E I S S CAME t o

the School in 1968 as a M W new M.D., he was ready to immerse himself in the the study of health-care systems. When he left three years later, he had a doctorate in epidemiology and a new set of career plans.

"The bottom line is that, as far as I am concerned,! got the best epidemiology education in the world available at that time," says Weiss, now professor of epidemiology at the University of Washington School of Public Health.

Since the School's founding, epidemiology has been one of its undeniable strengths. But in 1 9 5 8 , with the appointment of Brian M a c M a h o n as department chair, the department became a powerhouse of epidemiology scholarship and education. During the 3 1 years that M a c M a h o n served as department chair, i z o students earned their doctorates in epidemiology at the School; many, like Weiss, went on to have distinguished and influential academic and research

Powerful personalities, some brilliant thinkers, and a steady flow of government training grants all spurred the department's rise to prominence. More fundamentally, however, M a c M a h o n and his colleagues played a pivotal role in the discipline's mid-century shift in focus from infectious to chronic disease.

Since the nineteenth century, when John Snow discovered that drinkers of London's Southwark and Vauxhall Company's water had a higher risk of cholera than customers of other water companies, epidemiology's

National Institutes of Health and 10 U.S. corporations

Industrial hygiene

WHO assembly calls

give $1.2 million to construct and equip a primate

chair Leslie Silverman,

for intensified effort to

research facility in the Department of Nutrition.

who helped devise

eradicate smallpox.

safety procedures and standards for nuclear reactors, dies.

:

forte had been the study of infectious disease outbreaks. M a c M a h o n and his colleagues argued that epidemiologists also needed to study the distribution and determinants of chronic diseases, such as heart disease and cancer, which, since the 192.0s, had become the industrialized world's leading killers. Ep;Je7w'o/og3C M e ^ o J s , the i 9 6 0 textbook that M a c M a h o n wrote with two other members of the School's epidemiology department, Thomas F. Pugh and Johannes Ipsen, eloquently made the case and developed a vocabulary for this shift. " I can describe MacMahon's role in bringing about the [epidemiologic] transitionâ&#x20AC;&#x201D;he was probably the most important single individual," says Philip Cole, M.p.H.'67, D.p.H.'yo, a former student and professor at the School w h o is now at the University of Alabama at Birmingham.

M a c M a h o n built the "premier chronic disease epidemiology department in the country," says Thomas M a c k , M.p.H.'69, a professor of preventive medicine at University of Southern California School of Medicine.

Drawing a starting line for something as gradual as epidemiology's shift from infectious to chronic diseases is difficult; the exact beginning of an idea is almost always nebulous. Some historians credit Wade Hampton Frost, the hrst chair of the epidemiology department at Johns Hopkins, with laying the foundation for modern epidemiology.

In an interview for Peop/e's H e a / ^ , a recently published history of the School, M a c M a h o n marked

1900

Leading causes of death. United States Pneumonia/Influenza

11.8%*

Tubercutosis

11.2%

Heart Disease

9.4%

Stroke

7.6%

Diarrhea/Enteritis

6.3%

Nephritis

5.9%

Cancer

4.5%

Accidents

4.2%

Diphtheria

1.9%

Other

37.2%

'percent of total deaths

" H H H

H

0%

the classic 1 9 5 0 British study of lung cancer and smoking by Richard Doll and Bradford Hill as epidemiology's major turning point. In the same interview, M a c M a h o n also credits John Everett Gordon, his predecessor as chair of the epidemiology department, with being "one of the hrst and more persistent" to assert that epidemiologic techniques could be applied to non-infectious diseases.

Gordon published a series of papers on the epidemiology of everything from suicide to post-partum depression, noted M a c M a h o n . However, he added, as "an infectious disease person," Gordon lacked the training to carry out these ideas. In 1 9 4 9 , at a meeting of the epidemiology section of the American Public Health Association, Gordon commented that although "the main direction of effort in epidemiology is still toward

10%

20%

30%

40%

communicable diseases...it becomes increasingly evident that a limitation of activities to the infections is no longer warranted."

HEN M A C M A H O N LEFT the

State University of N e w W W York's Downstate Medical Center in Brooklyn to chair the School's epidemiology department, he had his work cut out for him.

Although not an imposing physical presence, the British-born MacMahon impressed students and colleagues with his lucid thinking and penetrating analysis. Weiss remembers M a c M a h o n as " a brilliant classroom teacher" who was a master at weaving in illustrative examples. Robert Hoover, s.M.H.'yo, D.P.H.'y6, recalls how M a c M a h o n would quickly bring some avant-garde presentation down to earth with an incisive ques-

1967 The Program in Law,

Elizabeth Prince Rice,

South African surgeon

U.S. population passes

Public Health, and

associate professor

Christiaan Barnard

200 million, having

Medicine established

emerita, receives the

performs first success-

doubled in only 50

under the direction of

APHA's Martha May

ful heart transplant.

years.

William J. Curran,

Eliot Award.

S.M.H.'58.

1960

Leading causes of death. United States Heart Disease

37.6%*

Cancer

16.5%

Stroke

8.7%

Pneumonia/tnfluenza

3.6%

â&#x20AC;&#x201D; <

Car Accidents

2.9%

Diabetes

1.7%

H "

Suicide

1.3%

H

Chronic Liver disease

1.2%

Chronic Lung disease

1.1%

Other

25.4%

< 10%

tion: " H e would ask, 'But exactly who were the cases and who were the controls?' And there woutd be this sitence. And more often than not the guy wouldn't know. They had become overty infatuated with process."

James Warram, S.M.H.'66, S.D.'88, who was on the faculty for eight years in the 1960s and eariy 1 9 7 0 s , recalts the time he showed MacMahon a draft of a paper: " H e came down to my office. He was disgusted with the paper and it showed on his face and he sort of threw it down on my desk.

It spitted att over the floor."

M a c M a h o n was embarrassed, and Warram surprised. But Warram, now an epidemiotogist at the Joslin Diabetes Center in Boston and an adjunct professor at the School, says he valued getting MacMahon's honest opinion.

20%

30%

40%

But MacMahon did not throw his intellectual weight around. Quite the opposite, according to Hoover, director of the biostatistics and epidemiology program at the National Cancer Institute. "I have never met a more honest scientist in my entire life than Brianâ&#x20AC;&#x201D;intellectualty honest and otherwise. And with that comes humility," he says. Mack of u s e , said M a c M a h o n "suffered fools gladlyâ&#x20AC;&#x201D; better than almost anyone I have ever known. But there was also never any doubt about what he thought about their w o r k . " Warram agrees: " H e was direct, but atso very kind."

MacMahon's department boasted a number of prominent epidemiologists. Professor George Hutchison was a strong, precise thinker who, says Warram, complemented MacMahon, functioning as a kind of epidemiologic parliamentarian,

checking facts and making sure that alt the rules were followed. "George's bibliography is quite short," notes Hoover, "but every one of his papers was an absotute masterpiece." Jane Worcester, who served as chair of the biostatistics department, was another stalwart (see profile page 89). And Finnish-born Olti Miettinen was a formidable scholar and personality, known for his combative debating style.

Warram fondly recalls the joint "epi-biostat" lunches as one of the best parts of his experience at the School. Though classes were taught in 5 5 Shattuck Street, the faculty offices for the two departments were in the old Huntington Hospital building, or " N o . 1 Shattuck Street," a graceful otd building that Warram remembers as having big windows and fireplaces in the rooms. The lunches, held in a second-floor room that looked out onto Huntington Avenue, were fun, exciting, and, surprisingly, never intimidating, given the high standards of the company. " Y o u could say dumb things and not have to worry about that. You woutd be forgiven," Warram says. That accepting attitude reflected the sense of familiarity bred by a much smaller institution. Warram's 1 9 6 6 graduating ctass had only 83 students compared to the ^oo-person class sizes of today. "These people [the senior faculty], knew each of us. They knew our foibles and our strengths. They were very supportive," he says. "One of the remarkable things about the School was having access to these luminaries," notes Hoover.

1968 U.S. measles cases drop

HSPH graduates Gretchen, S.M.H/66, and Warren,

U.S. civil rights leader

Television coverage of

to 22,000 from 400,000

D.P.H/67, Berggren establish a Department of

Martin Luther King, Jr.

Tet Offensive in Vietnam

in 1962 a s a r e s u l t o f

Community Health at the Albert Schweitzer Hospital

is assassinated.

begins turning U.S.

Enders vaccine.

in Deschapelles, Haiti. For the next two decades, the

public opinion against

Berggrens will work to lower deaths from tetanus,

the Vietnam War.

tuberculosis, diarrhea, and malnutrition.

The shift from infectious to chronic disease epidemiology did not occur because a few influential epidemiologists willed it into existence. To a large extent, it was the only rational reaction to the changing profile of the causes of mortality in Europe and the United States during the first half of this century. Gordon made this clear in his 1 9 4 9 address to the APHA's epidemiology section. In 1 9 0 0 in the United States, five of the ten leading causes of death were infectious diseases, he said. By 1 9 4 8 , only two—pneumonia and influenza (seventh) and tuberculosis (eighth)— were in the top ten.

Applying epidemiologic methods to chronic diseases created all sorts of new, knotty problems, both practical and theoretical, for epidemiologists.

As M a c M a h o n pointed out in a lecture several years ago, infectious disease epidemics usually happened over a matter of hours, days, or weeks. "The current epidemics of lung cancer and cardiovascular disease, among others," he said, "have taught us that the time scale of epidemics may rather be measured in years or decades." Ideas about the natural history of epidemics also had to change. Whereas a previous generation of epidemiologists had been trained to think of epidemics in terms of the triad of host, agent, and environment, " M a c M a h o n changed that to person, place, and time," says Cole. "The important distinction is that he put time into the picture."

Infectious disease-oriented epidemiologists were used to thinking in terms of attack rates, notes Cole.

1969 In an article in the January Ma/vard Pt/N/'c Wea/f/! /t/Hmn/ Bu//ef/n, Assistant Professors Joseph Brain, S.D.Hyg.'66, and David Leith report on an expedition to the Bering Sea to study the respiratory systems of arctic marine mammals aboard the floating laboratory

/S/p/M

Fro?M n g ^ f ; P o w e r E p ^ e T w w / o g y D e p ^ r ^ w e w f C ^ w s D w ^ Y W o s T n c ^ o p o M ^ o s , s . M . ' 6 S , aw^BrMw MacMa^ow, s.M.'jj,

cMrrewi

If 80 percent of the people w h o ate the potato salad at a picnic got sick, the food poisoning attack rate among the potato-salad eaters was 80. That rate would have been set in contrast to the attack rate among non-potato salad eaters, say, 5 percent. Time is not terribly problematic because the symptoms of food poisoning will invariably show up in a day or two, or not at all. But with chronic diseases, the time frame of observation is critical. Cancer and heart disease develop years, perhaps even decades, after the disease-inducing exposures. Cut short the observation period, and you'll miss the epidemic. Moreover, the exposures themselves—smoking, poor diet, lack of exercise—are experienced over years.

Dedication of Health Sciences Laboratories.

Since 1960, over 90,000 square feet of space has been added to the School.

A/exawJerM.

D.p.H.'Si.

In Me^oJs, M a c M a h o n stresses incidence rates— the number of new cases of a disease in a population over a specified period of time—over attack rates. An attack rate is, of course, a kind of incidence rate, but it only implies the time element that becomes an explicit variable in MacMahon's equations. Because it captures how quickly people are becoming ill, the incidence rate offers the best clues to causal factors, argued M a c M a h o n and his co-authors.

"Where the problem is epidemiologic, the rate of choice is incidence," they wrote.

But M a c M a h o n also realized that putting time into the equation could distort observations. H o w diseases are classified changes over the years,

The Department of Industrial Hygiene is redesignated the Department of Environmental Health Sciences, with Associate Professor Dade Moelier as chair.

carefully compare those people with similar but cancer-free subjects, the so-called controls. "The case-control study really revived epidemiology," says use's Mack.

for example. Better, cheaper, or more available diagnostic equipment and tests can create "epidemics of diagnosis." MacMahon makes some suggestions for how to deal with these kinds of issues, many of which come under the general heading of "bias," but there are no pat answers.

Contemporary epidemiologists still struggle with how to design the unbiased study.

Ultimately, chronic disease epidemiology required a much more sophisticated way of observing diseases that were relatively diffuse and slow-moving. The case-control study, for example, allowed researchers to assemble a group of, say, several hundred lung cancer cases and then

NCi's Hoover notes that the advent of the chronic disease case-control study was, in part, a matter of going back to the future. Whereas by the 1950s, infectious disease epidemiology had become increasingly mechanistic—a matter of probing blood and tissue for the culpable microorganism—the case-control study brought back many of the classic epidemiologic issues: picking a representative sample, correct classification of cases, and perhaps above all, finding suitable controls. Part of the reason MacMahon and others at Harvard were so talented at the "new" chronic disease epidemiology, says Hoover, is that they were so well-grounded in these classic issues. "They viewed epidemiology as intellectual process, a way of thinking and understanding health and disease, and if you understood the basic principles and methods, you could apply it to anything," he says. ^

ACMAHON'S ELOQUENCE w a s

also exceptional in a held in t 8 which clunky, dry expression is the rule. Says Mack; "Brian's language doesn't get hung up on the punctilious subtleties. You don't have to read something 2.4 times to understand what he is saying.

One of MacMahon's most felicitous phrases was "web of causation" to describe multiple, interacting causes of disease. In Met^oJs, MacMahon used the web

metaphor to extend the then-prevailing concept of a "chain of causation."

MacMahon wrote that each component—or [ink—generates a myriad of effects, not all of them necessarily reiated to the disease of interest.

Moreover, each component is itself "the result of a complex genealogy of antecedents." Together, he wrote, the "whole genealogy might be thought of more appropriately as a web, which in its complexity and origins lies quite beyond our understanding."

Noel Weiss says he still uses the web of causation idea in his classes, and the phrase entered epidemiology's lexicon.

As a researcher, MacMahon practiced what he preached, working primarily on breast cancer and its relationship to endogenous hormones.

He has said the choice was partly because "it looked like an easy problem" and partly because he hoped epidemiology would have the same success explaining breast cancer in women as it did in explaining lung cancer in men. MacMahon did ground-breaking research showing the influential role of reproductive experience in breast cancer. His studies revealed that breast-cancer risk varied with the age at which a woman first menstruated and gave birth.

Recently, epidemiology's shift in focus has had to be reconsidered. The growing attention to chronic disease epidemiology accompanied a deepening neglect of infectious diseases. In her best-selling book, Cow/Mg P/%gMg, f o r m e r HSPH j o u r n a l i s m

fellow Laurie Garrett gave a scathing account of misplaced confidence

Twenty-second World

Huntington Building at

U.S. Astronaut Neil

Harvard students

Health Assembly held in

1 Shattuck Street is

Armstrong is the first

occupy administrative

razed to make room for

man to walk on the

buildings in Cambridge

the Kresge Education-

moon.

to protest war in

Boston.

Facilities.

Vietnam.

I ^t-

among top U.S. public heaith ofhcials in the 1960s regarding the apparent victory over infectious diseases. "It was part of the euphoria of molecular reductionism that you believed if you hnd a disease, you can find a molecule to control it," says Richard Levins, the John Rock Professor of Population Science at the School and a member of the Working Group on New and Emergent Diseases.

While conceding that health researchers must be prepared for the emergence of epidemics such as AIDS, Dimitrios Trichopoulos, Vincent L. Gregory Professor of Cancer Prevention and Epidemiology and former chair of the epidemiology department, believes that, in general, the shift to chronic disease epidemiology has been beneficial. A close friend and former student of MacMahon who coauthored the most recent edition of /og/c Mcf^oJs, Trichopoulos, s.M.'68, chaired the epidemiology department from 1989 until 1996. He says mortality rates from cancer and heart disease in the United States, Europe, and an increasing number of socalled devel-oping countries, justifies concerted researchâ&#x20AC;&#x201D;epidemiologic and otherwiseâ&#x20AC;&#x201D;into these chief causes of death. Moreover, this research has paid off in millions of lives saved and extended, says Trichopoulos. The identihcation of smoking as the cause of lung cancer

has paid huge health dividends as smoking rates have dropped.

Trichopoulos predicts that cancerrelated dietary hndings should also start to pay off as new guidelines emphasizing fruit and vegetable consumption are promulgated. As for heart disease, Trichopoulos says credit for the four-decade decline in U.S. mortality rates can probably be evenly split between epidemiologists' identihcation of risk factors and the

medical community's development of new drugs and operations such as coronary bypass.

As Noel Weiss points out, all the rigor developed in chronic disease epidemiology over the past 40 years benehts not just investigators in heart disease and cancer, but anyone who wants to do a well-designed study of an infectious disease. It is the science of epidemiology, in general, that has advanced, not just one aspect of it.

"The fact is that the more laborintensive, held-study, going-toremote-parts-of the-world, kind of research is still going on. People are still researching AIDS in Africa and other major infectious diseases. There are people investigating outbreaks in the U.S. all the time. It is just that now, compared to decades ago, we are using epidemiology not just to deal with the outbreaks but also to study the cause of more endemic diseases."

Peter Wehrwein

1970 Article in the Harvard PuN/c Wea/f/7 /S/umn; 6u//efm

founders.' Haryarcf

by Donald Hopkins, M.P.H.'70, and Leonard Glass,

Sdtoo/ofPuM'c/VM/f/],

M.P.H.'70, calls attention to low minority enrollment

by Professor Jean A.

at the School; only 3.6 percent of U.S. students are

Curran, describes the

minorities.

School's evolution from 1909 to 1946.

Professor of Nutrition Jean Mayer appointed Special Consultant to President Richard Nixon.

+)

T i !

T A

0\ :

1' i

4!

Y i 1 I ) Y T

My Year at the Harvard School of Public Health Adapted from an unpubtished memoir written in 1987 by veterinarian Mitton Werrin, who earned his M.P.H. at the Schoo) during the 1955-56 schoo! year. Werrin went on to a successfut career as an epidemiotogist with the Phitadetphia Heatth Department. He died on

A ^ t the appointed time, I took my last took at the worid I had known and entered the beautiful Greek Revival building at $$ Shattuck Street. The targe foyer was filled with men, women, and children, along with alt their worldly possessions. The room was in chaos, the noise overwhelming. Everyone was trying to register.

1 noticed quickly that many people wore strange but colorful clothing. I heard strange accents and languages.

Everyone seemed to be just as bewildered as I. To those in chargeâ&#x20AC;&#x201D;faculty wives, school secretaries, and the formidable Mrs. Margaret Barnabyâ&#x20AC;&#x201D;this was

March 8, 1995.

an annual state of affairs. Once the volunteers started to work, the chaos and turmoil were overcome. I hied the relevant papers and received numerous instructions and papers in turn. A few days later, at a student reception,

1970 U.S. Occupational Safety and Health Act (OSHA) signed by President Richard Nixon.

U.S. life expectancy at birth is 70.9years and infant mortality is 20 per 1,000 live births.

102 s' y

we were greeted cordially by the faculty, many of whom were worldfamous scientists. I shook the hands of Nathan Pusey, president of Harvard University, and Dean John Snyder. It was my first opportunity to meet some of my classmates, who came from all corners of the world.

Soon classes started. The first six weeks were devoted to a series of lectures by the heads of each major departmentâ&#x20AC;&#x201D;epidemiology, nutrition, sanitary engineering, and the rest. We attended lectures by social workers, public health nurses, public health educators, and maternal and child health aides. Each group explained in detail what they were striving for and how they provided assistance to the public. Before entering the School, I had only a faint idea of what these people were doing, so their lectures were a complete revelation.

Professor of Human Nutrition Fredrick Stare and his staff gave a

series of interesting lectures on nutrition, with emphasis on nutritional diseases common in many parts of the world: kwashiorkor and the many enteric diseases which led in turn to all sorts of exotic deficiency conditions. I learned the value of nutritional surveys, in which careful evaluation could point out deficiencies in the diet of a whole community. Some things never seem to change. The lectures were global in scope; it was not uncommon to study a disease found in some isolated area of the Orient, presented by a professor who had just returned from the affected area with all sorts of data that had been collected on the spot.

One of the most important series of lectures was given by Dr. Gerald Caplan, an expert on psychosocial problems that beset large groups of people. The students listened intently as he lectured on the mourning process, on the mental and sometimes physical problems that hospitalized

children suffer, and on children's conduct upon separation or loss of a parent. The entire class was required to attend the lectures given by Dr. Benjamin Paul, a social anthropologist, who introduced us to the new field of ecology. From the very start I sensed that I would have trouble with biostatistics, but fortunately I wasn't the only one. Most of my classmates had the same premonition.

At the start of my studies in epidemiology, Department Chair Dr. John Gordon asked me to write a term paper on any subject I chose.

He seemed delighted when I told him I would like to write about industrial anthrax in Philadelphia. As computers for data processing were unknown then, I had to write, compile, make charts and graphs, edit the material, and punch out the whole thing on a rickety, secondhand, portable typewriter. Once I got started, everything went smoothly, and I started to enjoy the arrangement.

A few weeks after classes started, we elected class officers. Committees were chosen and plans were made for a series of class dances, a Christmas party, and a spring clambake. Plans were made to publish the class yearbook. One school tradition was a series of presentations at gatherings called student forums. Here the foreign students gave talks about their countries. Foods native to their countries were served and native costumes were worn. Occasionally, a diplomat would attend and give an oration on the virtues of his country. On India night, the class was introduced to future Indian

HSPH

1971 Derek Bok succeeds

Britain's Royal College of Physicians declares

President Richard Nixon

Nathan Marsh Pusey as

cigarette smoking a hazard on par with the great

signs the National

President of Harvard

nineteenth century epidemic diseases typhus and

Cancer Act, beginning

University.

cholera.

the "war on cancer."

Ep/dew/o^ogy E. Gordon

JeaJs aw A JMwce

Prime Minister Indira Ghandi, who gave an impassioned speech about the beauties and cultural heritage of her country. The forums were very popular, and gave an insight into the health situation in each country.

What made Harvard different from other institutions of learning?

As soon as classes started I noticed that the relationship between faculty and students was that of a close-knit family. The faculty emphasized that they learned more from the students than by any other means; thus they treated us as equals. The faculty was never condescending. They were always available, ready to assist and understand our problems. One day I entered the office of Dr. John Enders, world renowned researcher on the

polio virus, and asked a question about the virus. He took the time to answer and then gave me a list of articles on the problem.

Another factor that made Harvard different was the socialization between the faculty and students.

Some of my fondest memories are of the get-togethers at our teachers' homes. We would sit around a table, drink wine, eat cheese, and chat for hours about our experiences. I was amazed at the stories related by the foreign students, who told about their problems in the administration of health in their countries.

The final semester was rapidly coming to an end. The last few weeks were hectic as the day of comprehensive exams approached. All social

festivities came to a halt as everyone concentrated on the final struggle.

I was still afraid of statistics and thus gave this course the most attention.

After ail the exams were completed, the students gathered around to discuss their answers to this or that question. The excitement bordered on mass hysteria; all we could do now was wait and hope. After we loafed around for two days, the grades were posted. I had passed every course. That night I packed my books and belongings, said farewell to my landlady, and took the plane back to Philadelphia.

I would return in two weeks for the graduation exercises.

D e a n J o h n Snyder resigns to devote time to popula-

Time-line photo credits: AP/Wide World: pages 31,54,90. Archive Photos: pages 19,40,45,46, 50, 53,

tion problems a n d prevention of infectious disease.

Richard H D a a a v serves as actina dean ^ H -

61, 72,83,91,96,97. Brown Brothers: pages 13,20. Corbis-Bettmann: pages 18,24,25,47. Courtesy of Harvard Archives: pages 28,71. The Francis A. Countway Library of Medicine, Boston: pages 10,12, 1 4 , 1 6 , 3 0 , 3 2 , 4 8 , 7 4 , 7 7 , 7 8 , 9 3 , 9 4 . Franklin D Roosevelt Library: page 27. Giraudon/Art Resource, NY O 1997 Estate of Pablo Picasso/Artists Rights Society (ARS), New York: page 35. Harvard News Office: