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Harvard Public Health Review

Spring/Summer 2011

30 years of an epidemic

Also Inside:  Can Neighborhoods Hurt our Health? Coffee: The Good News Health Care with Dignity Waging Peace, Saving Lives

HARVARD

School of Public Health


Dean’s Message

HIV/AIDS at 30: Turning the Corner

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nniversaries compel us to reflect, to take stock, to inquire about how we can better carry out our missions. On the 30th anniversary of the first official report on what would be known as the HIV/ AIDS epidemic—published by the U.S. Centers for Disease Control and Prevention on June 5, 1981—I would like to reflect on how far public health and HSPH have come to address the epidemic—and on what remains to be done. A recent summary from UNAIDS states: “On the cusp of the fourth decade of the AIDS epidemic,

AIDS Institute Partnership, the AIDS Prevention Initiative in Nigeria (APIN), the School’s vital work in the President’s Emergency Plan for AIDS Relief (PEPFAR), and through other international collaborations, HSPH has trained thousands of health care workers in some of the most tragically affected parts of the world. HSPH researchers have identified a treatment program that prevents 99 percent of mother-to-child HIV transmission via breastfeeding. Our scientists have helped slow illness in Africa through innovative nutrition interventions. Former Dean Harvey Fineberg staked

disparities continue to mark who suffers from the infection and receives help, and who does not. This December 1–2, the School’s AIDS@30 symposium will convene hundreds of global health leaders, elected officials, scientists, artists, and activists. Our goal: to discuss what we have learned from AIDS and how to use those lessons to halt the epidemic. If we can translate knowledge into action, by the next major milestone in time, the world may be on its way to ending this catastrophic epidemic.

Enormous disparities continue to mark who suffers from the infection and receives help, and who does not.

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out enlightened AIDS policy, both through his prolific writing in scientific journals and through campus-wide collaborations. Jonathan Mann, who was the first director of the FrançoisXavier Bagnoud Center for Health and Human Rights, showed the world that the AIDS epidemic was, at heart, a social justice issue. And the School continues to lead the way in testing, treatment, and vaccine research. Yet, in many parts of Africa, Asia, and other developing nations, fewer than 30 percent of young men and women possess comprehensive and accurate knowledge about HIV. In resource-poor nations, drug treatment lags far behind the need. Here in the U.S., 3 percent of Washington, D.C. residents carry the AIDS virus, and African-Americans account for nearly half of all AIDS diagnoses nationwide—far disproportionate to their numbers in the population. Enormous

Julio Frenk Dean of the Faculty and T & G Angelopoulos Professor of Public Health and International Development, Harvard School of Public Health

For more on the AIDS epidemic at 30, see page 14.

Kent Dayton/HSPH

the world has turned the corner—it has halted and begun to reverse the spread of HIV.” Our School and its faculty have helped catalyze this turnaround. Since the early 1980s, HSPH researchers have made fundamental discoveries about the disease. In 1983, Max Essex provided key evidence that the infection is caused by a retrovirus; two years later, he co-discovered the gp-120 surface protein, which is now used worldwide for blood screening. In 1986, Essex, Phyllis Kanki, and Ric Marlink discovered a second AIDS virus, HIV-2, which causes most infections in West Africa. The School has been a major presence at the frontlines of the epidemic. In 1988, HSPH helped launch what has become the Harvard School of Public Health AIDS Initiative. Through the Botswana Harvard


Harvard Public Health Review

Spring/Summer 2011

14 AIDS at 30: Hard Lessons and Hope Thirty years into the crisis, HSPH faculty and alumni share their thoughts on the past, present, and future of HIV/AIDS.

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2 Dean’s Message HIV/AIDS at 30: Turning the Corner 26 HIV/AIDS: A Timeline

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30 Can Neighborhoods Hurt Our Health? Doctoral student Caitlin Eicher wants to understand how people’s perceptions of their local surroundings shape what they eat, how much they exercise, and other health behaviors. 34 Health Care with Dignity Alum Robert Taube helps homeless people build healthier lives—and self-esteem. 37 A Cure for Health Professional Education 40 Waging Peace, Saving Lives A renowned physician explains how defeating militarism could solve global health problems.

44 Coffee: The Good News 46 Promises Kept Prior recessions did not result in large global health aid cuts. Also in this Issue 4 Frontlines 11 Philanthropic Impact 47 Quote/Unquote 48 Alumni News 50 Continuing Professional Education Calendar 51 Faculty News

Image Credits: top, Chris de Bode/PANOS center, Kent Dayton/HSPH below, Anne Hubbard/HSPH


front lines An idea that will change the world

Clooney and HHI Shine Light on Civil Strife in Sudan

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David Bloom, Clarence James Gamble Professor of Economics and Demography In its March 17, 2011 issue, Time magazine called the concept of the “demographic dividend”—pioneered by David Bloom, Clarence James Gamble Professor of Economics

asting light on the potential for disaster in strife-torn Sudan, actor George Clooney’s human rights organization, Not On Our Watch, collaborated earlier this year with Harvard’s institution-wide Harvard Humanitarian Initiative (HHI) on a new human rights initiative called the Satellite Sentinel Project. The project analyzed near real-time satellite imagery and crowd-sourced data to monitor potential human rights violations following Sudan’s January referendum on independence for oil-rich southern Sudan. Also participating are the Enough Project, the UN, Google, and others. This was the first major effort to monitor security threats along a geographic border to help prevent humanitarian disaster. Averting civil strife has wide public health implications—including heading off civilian injury, disease, malnutrition, starvation, and the disruption of crucial NGO services.

and Demography, and chair of the HSPH Department of Global Health and Population—one of the “Ten Ideas That Will Change the World.” The “demographic dividend” is the economic boost that countries can receive when they shift from high rates of fertility and mortality— women having lots of children, many of whom die young—to low birthrates and longer life expectancies. When this demographic transition is taking place—thanks to improvethe resulting temporarily large share of working-age people can, under the right circumstances, fuel a strong economic transition as well. Others at HSPH who have contributed to the development of this idea include David Canning, Günther Fink, Jocelyn Finlay, Salal Humair, Larry Rosenberg, and Jaypee Sevilla.

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Learn More Online Visit the Review Online at http://hsph.me/frontlines for links to press releases, news reports, and the original research studies behind these stories.

Kent Dayton/HSPH, Reuters/Thomas Mukoya

ments in health and other forces—


Medical Liability: A Major Cost Driver or Not? It’s hard to separate fact from fiction when the fiction is loudly trumpeted while the facts remain scarce. In the case of the U.S. medical liability system—and its impact on overall medical costs as part of the health care reform debate—Michelle Mello, professor of law and public health at HSPH, and other researchers analyzed how much malpractice insurance overhead expenses, claims, legal fees, and “defensive medicine” tactics actually add to health care costs. Their research, published in the September 2010 Health Affairs, showed that these costs totaled just 2.4 percent of annual health care spending—suggesting that we must be, in Mello’s words, “realistic about what medical liability reform can achieve in terms of health care cost control.” That 2.4 percent is still $55.6 billion a year, Mello notes, “so there are good reasons to want to improve it” as well.

2.4%

Reinventing the wheel: biking for weight control

Diabetes and Depression: A Two-Way Street Does type 2 diabetes lead to depression? Or does depression lead Biking’s not just for fun anymore, accord-

to type 2 diabetes? Yes, and yes. According to researcher Frank

ing to a new study by HSPH researchers.

Hu, professor of nutrition and epidemiology at HSPH, the two con-

Their research suggests that bicycling

ditions are “both the causes and the consequences of each other.”

is also a good tool for premenopausal

Hu and fellow researchers followed 65,000+ women ages 50 to 75

women looking to control weight—so

in the Nurses’ Health Study based at Brigham and Women’s Hospi-

good, in fact, that as little as five minutes

tal over a 10-year period and confirmed the strong link between

of biking a day helps curb weight gain,

these two serious, often debilitating conditions. Even accounting

though more bicycling is better. Brisk

for risk factors for diabetes and depression frequently found in

walking can do the trick, too. Slow walk-

both groups—such as overweight and inactivity—the link held.

ing, not so much. The study appeared in

The research was published in the November 22, 2010, Archives of

the June 28, 2010, Archives of Internal

Internal Medicine.

Medicine.

Mending A Broken System: Hsiao Proposes Single-Payer Plan to Vermont

Getty Images, Michael Floreak

Vermont’s governor and state legislature asked an HSPH faculty member to help them overhaul their health care system—and William Hsiao, K. T. Li Professor of Economics at HSPH, enlisted a team of graduate students to help him in this monumental task. In January, Hsiao reported his team’s findings and presented to a joint session of the legislature three alternative health plans for Vermont lawmakers to consider: single payer, a public option, and a reform plan of his own design. In March, he published an article in the New England Journal of Medicine explaining that his team of health system analysts found that “the system capable of producing the greatest potential savings and achieving universal coverage was a single-payer system.” Vermonters are considering their next steps. Stay tuned.

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front lines TIME FOR A GUT CHECK Inflammatory bowel disease (IBD), in forms such as Crohn’s and ulcerative colitis, creates chronic misery for more than 1 million Americans—and increases sufferers’ risk of developing colorectal cancer. HSPH researchers, led by Wendy Garrett, assistant professor of immunology and infectious diseases, have identified specific species of microbes that appear to work together with microbes living in the gut naturally to inflame the colon and lead to IBD. They are also studying how microbial communities not only contribute to IBD and cancer but also how microbes can be used to treat these diseases. Some of their recent work was published in the September 16, 2010, issue of Cell Host & Microbe and the October 19, 2010, issue of PNAS.

Lifting Hiv/Aids Patients’ Depression Improves Odds for Treatment Success It’s well known that many HIV/AIDS patients suffer from depression. What’s surprising is the extent to which their depression is “massively underdiagnosed and undertreated,” says Alexander Tsai, psychiatrist and Robert Wood Johnson Health and Society Scholar in the Center for Population and Development Studies at HSPH. Tsai led a team of HSPH researchers studying people living with HIV/AIDS in San Francisco. The team’s work provided the first confirmation that receiving antidepressant medication helps many people living with faithfully, which in turn is critical for suppressing the virus. The study appeared in the December 2010 Archives of General Psychiatry.

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n Africa, HIV-infected pregnant women face a life-or-death dilemma: the standard medication that helps prevent HIV infection in their newborns raises the risk of the mother’s own drug-resistant infection later on. Shahin Lockman, assistant professor of immunology and infectious diseases at HSPH, has found a way to successfully treat African mothers with AIDS who’ve previously received the antiretroviral (ARV) drug nevirapine during labor. Lockman and other HSPH researchers have identified other, more successful combinations of ARVs to use instead of the standard nevirapine-based treatment, giving moms a better chance of fighting their own HIV/AIDS after giving birth. Their findings, together with a second report by a team from HSPH and Dartmouth, have led the World Health Organization to change its guidelines for treating HIV infection in certain women and children. The two studies, and an editorial, appeared in the October 14, 2010, New England Journal of Medicine.

Dorothy Zhang and Wendy Garrett

HIV/AIDS take their antiretrovirals

Combination Drug Raises Hope for Babies and HIV-Positive Moms in Africa


Offthe Cuff

H “

Walter Willett Chair, HSPH Department of Nutrition

ow would you improve the USDA 2010 Dietary Guidelines for Americans?

Kent Dayton/HSPH

The guidelines took baby steps in the right direction. For example, they are very clear about what foods should be increased: whole grains, fruits, and vegetables. They also said we should reduce refined grains—but the ideal diet would have almost no refined grains in it, because refined grains convey calories we don’t need, have adverse metabolic effects, and contribute to weight gain and heart disease and diabetes. The guidelines also recommend low-fat dairy and low-fat red meat—but they don’t say to eat less of the regular versions of red meat and dairy. One of my colleagues who’s a senior government official said, “You can talk about reducing red meat consumption, but if we say that, we’ll have senators from half a dozen western states on our doorsteps the next morning.” Dairy is probably the area with the most controversy and complexity of the evidence. The major justification for consuming large amounts of milk—three servings a day—is that it will reduce bone fracture risk. But there is, in fact, no evidence that consuming more milk reduces fracture risk. The requirement of 1,000–1,200 mg of calcium a day for adults is almost certainly too high. Learn More Online

Visit the Review Online at http://hsph.me/frontlines for links to press releases, news reports, and the original research studies behind these stories.

Spring | Summer 2011

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front lines David Hemenway is Professor of Health Policy and Director of the Harvard Injury Control Research Center. He is also the author of Private Guns, Public Health, which describes the public health approach to reducing firearm violence, and While You Were Sleeping: Success Stories in Injury and Violence Prevention, which portrays more than 30 heroes who have made the world safer.

Guns & Politics

David Hemenway Takes Aim at Gun Violence Q: W  e’ve had a series of high-profile mass shootings recently in the U.S. What policies might prevent these assaults?

David Hemenway

A: Many simple and sensible policies could help prevent and reduce the harm from these attacks. Every one of the more than two-dozen nations considered “high-income” by the Organization for Economic Cooperation and Development has figured out a way to have fewer of these shootings than the United States. For starters, you don’t let people buy guns with highcapacity magazines that allow them to fire scores of bullets without reloading. You make it very hard rather than very easy for questionable people such as the Tucson and Virginia Tech shooters to gain access to firearms. For example, you can have serious background checks. The Tucson shooter would never have passed a comprehensive background check because of past drug use, or been readily granted firearms by most other developed nations.

“Every one of the more than two dozen nations considered ‘high-income’ by the Organization for Economic Cooperation and Development has figured out a way to have fewer of these shootings than the United States.” Q: A gun is certainly more of a weapon than a car. So why don’t we regulate guns at least as strictly as we do cars? A: M  ost Americans, and indeed most gun owners, indicate that they would support the dozens of sensible gun policies that are discussed in my book Private Guns, Public Health. These measures include mandatory training, background checks for all gun transfers, a requirement that firearm serial numbers be difficult to erase, and that semiautomatics be unable to fire when the magazine is removed—unlike the situation now, in which many semiautomatics leave a single bullet in the chamber when the magazine is removed. Even the majority of self-professed National Rifle Association members back most of the measures. While some states have enacted some of the policies, none of these measures is a national requirement. In the United States, single-issue lobbies like the gun lobby often have incredible power and can override the desires of the general population. Q: So how can we make this debate less polarized?

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Harvard Public Health Review

Kent Dayton/HSPH

A: Unfortunately, I believe the gun lobby thinks it benefits from the polarization. They certainly promote it. They portray anyone who wants to talk about the public health problems related to guns as “anti-gun,” and “gun control” as wanting to take away people’s guns. The United States has a lot of guns—and a lot of cars. Public health is about trying to figure out how to live with cars, and about trying to figure out how to live, rather than die, with guns.


Q: Just as public health measures have helped people live more safely with cars, what can public health do to help society live more safely with guns—even if the discussion is polarized?

©Corbis

A: P  ublic health is about prevention, and one focus is to go upstream to try to stop the problems early. Say a 17-year-old Boston gangbanger shoots an 18-year-old. Some of the questions that public health asks are: Where did the gun come from? How did it get to an adolescent in Boston? Who is trafficking it? Virtually everyone is in favor of throwing gun traffickers in prison. A:  Another way we can help is through communication. When Boston public high school students carry guns, we want to know both why they do and how they are able to. We have a study showing that these students wildly overestimate how many of their peers carry guns, in the same way they wildly overestimate who’s having sex or who’s getting drunk. That misperception leads to more of them carrying guns, since most are carrying for protection against peers who they believe are armed. A:  One of the questions we always ask students is, “What kind of world do you want to live in—a world where it’s easy for teens to get guns or where it’s difficult or impossible for teens to get guns?” The large majority always wants it to be impossible—even most kids who have already carried guns illegally. I believe it is our fault as adults that we have created this dangerous environment for them. Adults in every other developed country have done better by their children. Thea Singer is a Boston-based science journalist and author of the new book Stress Less.

Among the more than two dozen highincome countries in the world: 80% of all firearm deaths occur in the U.S. 85% of all the women killed by firearms are U.S. women. 90% of all the youth ages 15–24 killed by firearms are U.S. youth. Source: Journal of Trauma, January 2011; 70(1):238–243

Learn More Online Visit the Review Online at http://hsph.me/frontlines for links to press releases, news reports, and the original research studies behind these stories. Spring | Summer 2011

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front lines A MOLECULAR SWITCH FOR AGING As we get older, why do our bodies tend to “turn off” cellular processes that protect against metabolic diseases like type 2 diabetes or heart disease? Chih-Hao Lee, associate professor of genetics and complex diseases at HSPH, along with graduate student Shannon Reilly and other colleagues, has discovered the off switch: it’s the protein SMRT. In studies on aging animals, SMRT switched off the protective work of certain other proteins called PPARS that help our bodies burn fats and reduce damage from oxidants. These findings, published in the December 1, 2010, edition of Cell Metabolism, may open doors for new drug treatments to stop or slow the development of metabolic disease.

South Africa’s Health Minister Speaks on AIDS

Frenk and Knaul featured in Science

In South Africa, “HIV is a disease suffered by women but caused by men. Most of the young Aaron Motsoaledi, Minister of Health, Republic of South Africa

girls who are HIV positive are actually orphans. It becomes a vicious cycle.

You’ve got women dying of AIDS and leaving their children alone. They become vulnerable to older men with money because they cannot survive. We’ve got lots of orphans who are developing HIV because they had sex at an early age with a married man. That’s a problem we are struggling with.”

—The Honorable Dr. Aaron Motsoaledi, MBCHB, Minister of Health, Republic of South Africa, delivering a Dean’s Distinguished Lecture at the Harvard School of Public Health on March 30, 2011

Learn More Online Visit the Review Online at http://hsph.me/frontlines for links to press releases, news reports, and the original research studies behind these stories.

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Harvard Public Health Review

Clockwise from top, BDFM/Gallo Images; Getty Images; Kent Dayton/HSPH

HSPH Dean Julio Frenk is featured in Science magazine’s March 25, 2011, special issue on the “Cancer Crusade at 40.” The article, “A Push to Fight Cancer in the Developing World,” highlights the work of Frenk and his colleagues on the Julio Frenk and Felicia Knaul Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries to move cancer up on the global health agenda. The article also features Felicia Knaul, who leads the Task Force Secretariat and is director of the Harvard Global Equity Initiative. The profile describes her experience as a woman living with cancer and global advocate for expanded access to cancer care, and Frenk and Knaul’s work as a couple.


philanthropic impact

HSPH friends and faculty met with Mochudi village elders in Botswana.

Making a Difference Against HIV/AIDS This February, I had the great privilege of traveling

The HIV/AIDS epidemic helped show us what can

to Botswana and Tanzania with a delegation of HSPH

be accomplished when a community bands together and

friends and faculty led by Dean Frenk. We saw first-

demands change. But change requires focused funding.

hand some of the great strides HSPH and our local

We have come a long way, but the road ahead is

partners have made there in the struggle against HIV/

also long. I urge you to give, in whatever way you can,

AIDS. The trip—and above all, seeing the impact of the

to keep the School on the front lines of the fight against

School’s work in preventing mother-to-child transmis-

this devastating epidemic and the many global health is-

sion—was truly inspiring for me. It was deeply gratify-

sues HSPH faculty and students are working to resolve.

ing to see the results of philanthropy in action.

Your help makes a difference, and is needed and appre-

In the last 30 years, AIDS has helped galvanize the

ciated more than ever in these challenging times.

philanthropic community and alert us to the power of solidarity and concerted action, symbolized by the red ribbons that became so common in the 1990s. In the early stages of the pandemic, philanthropy played a critical role in helping to focus attention on HIV/AIDS, fight the stigma associated with the disease, and develop community-based responses. And philanthropy continues to lead the way in funding prevention and other public health efforts, as well as supporting the development of new models for treatment and care—often before they

Ellie Starr Vice Dean for External Relations Office for External Relations Harvard School of Public Health

are adopted by government and other population-scale programs.

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philanthropic impact

Charina Endowment Fund Supports End-of-Life Care Project

A

simple surgical checklist—a tool that has dra-

Cancer Institute, and current

matically reduced hospital deaths and complica-

funder Partners Healthcare.

tions—may soon find a new and innovative use:

After the checklist is tested

improving end-of-life care for terminally ill patients.

with several pilot popula-

Developed by HSPH’s Atul Gawande, MD, MPH ’99,

tions, including patients with

associate professor in the Department of Health Policy

end-stage cancer, congestive

and Management, the checklist will help clinicians talk

heart failure, and Alzheim-

with patients about important end-of-life issues, such as

er’s disease, the researchers

maintaining mental awareness, being with family, and

hope to pursue an approach

leading as meaningful a life as possible in the final days and weeks. A $750,000 foundation gift from Richard Menschel, director and president of the Charina Endowment Fund, supports the work. The Margaret T. Morris

Atul Gawande

that can be used in any setting, both high-income and

low-income, in the U.S. and abroad. “The gift from the Charina Endowment Fund is

Foundation contributed an additional $40,000 to the

hugely important,” says Gawande. “We’re designing the

effort.

checklist to give clinicians a simple strategy to identify

The Health System Innovation Research Group End

patients’ greatest fears and goals for the end of life. And

of Life Care Project is a collaboration between HSPH,

we are seeking evidence that it works to help people

Susan Block, chief of palliative care at Dana-Farber

avoid what they most fear—especially suffering.”

Rethinking Malaria: ExxonMobil Convenes Global Leaders

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Dyann Wirth, Richard Pearson Strong Professor of Infectious Diseases, and chair, Department of Immunology and Infectious Diseases, speaks with Marc Roberts, professor of political economy in the Departments of Health Policy and Management and Global Health and Population.

top left, Rose Lincoln/Harvard News Office; bottom left and opposite Jared Charney

nce on the brink of elimination in many parts of the developing world, malaria has come back with a vengeance following the unraveling of the World Health Organization (WHO) Global Eradication Program in 1955. Today, the WHO estimates that the infection strikes nearly 225 million people each year. In 2009, the parasitic disease killed nearly 1 million people, the vast majority of deaths occurring in Africa. In search of new ways to eliminate this threat, malaria thought leaders and experts convened at Harvard University in January for a three-day conference. The “Rethinking Malaria: A Leadership Forum” and “Rethinking Malaria: The Science of Eradication Sym-


posium” brought together global leaders from public and private institutions to discuss and rethink the future of malaria. The Forum challenged participants to critically examine current structures, incentives, and implementation processes and to identify strategies for addressing obstacles to the elimination and eradication of malaria. The international malaria community has recently shifted its focus from reducing illness and death to interrupting transmission

Michael Reich, Taro Takemi Professor of International Health

Malaria experts gathered for a three-day conference on eradicating the disease.

of the mosquito-borne parasite. In discussing this paradigm shift toward eradication, participants described lessons learned from past eradication efforts in malaria and other infectious diseases, pros and cons of current strategies, and new approaches to eliminating the disease. While noting the progress made through the widespread use of insecticide-treated bed nets, they cautioned that communities that grow complacent in this

and other methods of prevention and control will face a resurgence of the disease. The conference’s culminating session highlighted new scientific opportunities, including the development of a first-generation malaria vaccine that could provide 50 percent malaria protection by 2015, and the need to quickly translate promising research into practical solutions. The conference was jointly organized and developed by Harvard

School of Public Health, Harvard Business School, Harvard Medical School, and the Harvard Global Health Institute. It included leaders from Ghana, Kenya, Nigeria, Papua New Guinea, Senegal, and Zambia as well as organizations such as the National Institutes of Health, the U.S. Centers for Disease Control and Prevention, WHO Roll Back Malaria Partnership, the World Bank, the U.S. President’s Malaria Initiative, Novartis, and the Bill & Melinda Gates Foundation’s Global Health Program. This event was made possible by a generous $200,000 gift from the ExxonMobil Foundation to the HSPH Department of Immunology and Infectious Diseases. ExxonMobil has given almost $5 million over the past 11 years to support HSPH’s efforts to fight malaria, a disease that disproportionately strikes the world’s poorest and most vulnerable populations. According to Suzanne McCarron, president of the ExxonMobil Foundation, “At ExxonMobil, we understand that overcoming complex challenges requires long-term diligent collaboration with deeply committed individuals. That’s why we’ve invested more than $100 million in organizations that have made a difference in the fight against malaria, and we’re proud to count Dean Julio Frenk, Professor Dyann Wirth, and Professor Sue Goldie as great allies.”

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In the Drakensberg mountains, an AIDS-ravaged region of South Africa, Lihle Mbele makes the journey to the hospital with her aunt to receive treatment for AIDS-related TB.

AIDS at 30: Hard Lessons and Hope

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Harvard Public Health Review

HIV/


AIDS Roundtable Participants Max Essex: A world leader in virology, Essex was one of the first scientists to suspect that a retrovirus was the agent causing AIDS. His research group identified gp120, a protein on the surface of HIV that provides the basis for diagnostic tests and epidemiologic monitoring as well as a vaccine target. Essex is the co-author of Saturday Is for Funerals, a portrayal of the AIDS epidemic in Botswana.

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hirty years after the first official reports about HIV/AIDS, we look back on the human devastation and forward to a changed social landscape. The infection has killed more people so far than has any other discrete epidemic, except for the Great Influenza pandemic of 1918–1919 and the Black Death of the Middle Ages. It has destroyed individuals, families, and societies. Yet HIV/AIDS has also raised public health to new levels of science, conscience, and innovation. Review editor Madeline Drexler asked distinguished Harvard School of Public Health faculty and alumni at the forefront of research

Harvey Fineberg: Dean of HSPH from 1984 through 1997, Fineberg is an eminent scholar in the fields of health policy and medical decision making. During his deanship at HSPH, he forged collaborations across the University and its teaching hospitals to address the growing HIV/AIDS epidemic. Phyllis Kanki: A virologist and expert in the pathogenesis and molecular epidemiology of HIV in Africa, Kanki has led AIDS research programs in Senegal for more than 20 years. She established and directed the AIDS Prevention Initiative in Nigeria, funded by the Bill & Melinda Gates Foundation. Since 2004, Kanki has led the Harvard President’s Emerging Plan for AIDS Relief (PEPFAR). Richard Marlink: As executive director of the Harvard School of Public Health AIDS Initiative, Marlink has led the evaluation and coordination of AIDS research and training programs for developing nations, and has organized policy and educational programs to address the treatment needs of HIV/AIDS patients. Bisola Ojikutu: Ojikutu, MPH ’03, an infectious disease physician at Massachusetts General Hospital, is a senior HIV/AIDS advisor with the John Snow Research and Training Institute. Her research interests center on disparities in health care access, both domestically and abroad, and she has advocated on behalf of underserved patients in resource-poor settings. Rochelle Walensky: Walensky, MPH ’01, is an infectious disease physician at Brigham and Women’s Hospital and Massachusetts General Hospital. Since 1998, she has been a member of the Cost Effectiveness of Preventing AIDS Complications (CEPAC) group at Massachusetts General Hospital.

/AIDS where the epidemic has taken us and where it is headed.

Chris de Bode/Panos

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AIDS at 30: Hard Lessons and Hope

Q:

HIV/AIDS has been one of the most catastrophic epidemics in all of history. Despite this tragic human toll, are there ways in which

HIV/AIDS changed public health for the better?

Fineberg: Yes, because it was the beginning of a new understanding of global

health—a commonality of risk and burden. The U.S. as a wealthy country and Uganda as a developing country: both faced the same disease problem, though in different ways. At the World Health Organization, Jonathan Mann, who would later join the School as founding director of the FXB Center, also helped define a new way of thinking about public health. He tried desperately to mobilize the world, awaken the world, to this looming disaster. He repeatedly described the inseparable nature of health and human rights. Marlink: The epidemic toppled myths in public health. People said we couldn’t do

anything about the epidemic in developing countries—we’ve shown that’s not true. People then said AIDS would pull resources away from malaria or childhood diseases and maternal health—we’ve shown that AIDS has dramatically increased total public health funding in Africa, including in these areas. AIDS has also brought about unprecedented international cooperation, such as the creation of UNAIDS and of the Global Fund to Fight AIDS, Tuberculosis and Malaria, among others. Walensky: Investments that have benefited HIV/AIDS patients have improved

health care in general. What is generally underestimated is what those resources have done for health care infrastructure, worker training, protocol development, clinical care sites, preventing children from being orphaned, preventing mother-to-child transmission, and making drinking water safe. Essex: I compare our response to HIV/AIDS to President Nixon’s war on can-

cer in 1972, which opened the floodgates for money on research. Rates of cancer deaths didn’t go down for a long time, but what did happen was a revolution in molecular biology. That revolution led to things that we wouldn’t have anticipated: biotechnology, the rejuvenation of pharmaceutical companies, a renewed emphasis on applied research. That’s where we are today with AIDS vaccines. Whatever knowledge is gained from a war on AIDS will help us make vaccines against cancer, heart disease, and other diseases.

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Harvard Public Health Review


“If you understand AIDS, you understand public health. There’s almost no aspect of behavior, policy, basic science, statistics, epidemiology, nutritional interventions— everything—that does not touch HIV/AIDS.” Max Essex Mary Woodard Lasker Professor of Immunology and Infectious Diseases, HSPH

FACT: 33 million people are living today with HIV/AIDS.

Q:

Let’s talk about specific

antiretroviral drug combinations

sustainable. Even today, the future of

responses to the epidemic.

given to pregnant and breast-feeding

treatment programs that have been

First, what are some things that

women prevented 99 percent of

built is highly uncertain. But when

have gone right?

mothers from transmitting HIV

you look at the numbers who are

to their infants, the WHO quickly

currently receiving care, though we

changed its prevention of mother-

have by no means reached universal

to-child transmission of HIV guide-

access, the progress is noteworthy.

lines, even before the studies were

Q:

Walensky: I was on the clinical

AIDS service in Baltimore in early 1996 when the first drug cocktail was FDA-approved. Literally, during my residency, HIV-infected patients went from universally dying to living. I probably won’t witness anything like that again in my

published. The bottom line is: We now have the science and the drugs to virtually eliminate pediatric AIDS.

career. Today, amazingly, there are

Ojikutu: Initially, as drugs were

more antiretroviral drugs for HIV/

rolled out internationally, this was

AIDS—even in its short history—

an emergency: Let’s get in there, get

than for all other viruses combined.

people drugs, and stop this from

Marlink: When studies such as the Kent Dayton/HSPH

one from the School’s Roger Shapiro showed last year in Botswana that

becoming a situation where people inevitably die. There were times in those early days when I was in clinics

Many things also went terribly wrong. Looking

back, how would you have rerun the world’s response to AIDS since 1981? Fineberg: In the United States,

the epidemic first became apparent in gay men. Ideally, political leaders, public health authorities, and enlightened gay leaders would have been much more aggressive early in continued

in sub-Saharan Africa and wondered if scale-up of treatment would be

Spring | Summer 2011

17


recognizing and working together to

Kanki: We needed to invest early

particularly sexual behavior. When I

control transmission. This idea that

on in Africa, where the epidemic

think about what often stops people

public health measures were anti-gay

was most severe. But international

from accessing HIV testing and

measures—we had to get over that

and U.S. leaders discouraged it. The

treatment and from addressing HIV

sooner. All of the distractions about

term that development people use is

prevention comprehensively, it is the

condoms, because they carry other

“absorptive capacity”—the ability

stigma that surrounds the associated

connotations, were shameful, be-

of a country to receive aid and use

behaviors, particularly homosexual-

cause lives were at stake. And we had

it effectively. There was—probably

ity. If we had addressed those nega-

a president who early on refrained

still is—a pejorative view that the

tive perceptions then, HIV would be

from uttering the word “AIDS.”

absorptive capacity of developing

less taboo today.

countries is limited. If you can get

Q:

Essex: National officials should

have mobilized a lot more research funds between ’83 and ’88. The

past that misconception, which is so damaging, then the sky’s the limit.

Typically in this epidemic, the affluent

West is portrayed as having

epidemic could have been controlled

Ojikutu: If I had been old enough

brought modern public health

better and fewer people would have

to be involved in the early epidemic

strategies to the epidemic in

been infected. There wasn’t nearly

in the U.S., I would have looked at

Africa. But what can the West

enough money early on to develop

this as an opportunity to educate

learn from Africa?

good drugs.

and to destigmatize human behavior,

FACT: A  n estimated 2.6 million were newly infected in 2009, and nearly two million died.

“During my residency, HIVinfected patients went from universally dying to living. I probably won’t witness anything like that again in my career.” Rochelle Walensky

Associate Professor of Medicine, Harvard Medical School; MPH ’01

Kent Dayton/HSPH

18

Harvard Public Health Review


Ojikutu: One of the things that I noticed almost im-

mediately, as a clinician, was that across Africa there is great emphasis on adherence to treatment. There are fewer treatment regimens available and fewer options

Jonathan Mann A fierce advocate saw HIV/AIDS not just as an Infection, but as an injustice.

if resistance develops. As a result, treatment programs

Jonathan Mann, physician

stringently focus on adherence counseling and support,

and advocate, pragmatist and

including health literacy, which isn’t necessarily the case in

visionary, transformed the way

the U.S. Patients with whom I interacted in sub-Saharan

the world looked at AIDS. As the first head of the

Africa oftentimes knew more about HIV treatment than patients do here.

World Health Organization’s Global Programme on AIDS, he illuminated the intersection of health and human rights. Mann joined the faculty of

Essex: I had direct contact with the president of

HSPH in 1990, as a professor of epidemiology and

Botswana during most of the epidemic. He was the

international health. In 1993 he became the first

first leader in southern Africa to recognize that AIDS required presidential-level leadership. By the late 1990s, he promised that he’d never make a speech to anybody about anything without talking about AIDS—and he

director of the François-Xavier Bagnoud (FXB) Center for Health and Human Rights, founded by the Countess Albina du Boisrouvray. He died at the age of 52 in 1998, in the crash of Swissair Flight 111. As Jennifer Leaning, current FXB Center director,

meant it. He talked to trade groups, farmers, everybody,

wrote in an obituary in the British Medical Journal,

and he always said something about AIDS. Botswana

Mann “created a new discussion at Harvard and

still leads Africa in the proportion of AIDS patients who

throughout the world’s academic community about

get treated, the proportion of pregnant women who get checked and receive drugs to prevent infant infections, and the proportion of adults who get tested to see if

the nature of illness and health and its relation to isolation and stigmatization.” In his leadership post at the WHO from 1986 to 1990, Mann forged the approach to AIDS now considered axiomatic: pre-

they’re infected.

vention; understanding the social and behavioral

Q:

dynamics and patterns of sexual transmission; com-

Recent scientific articles and news stories have touted the promise of pre-exposure

prophylaxis, or PrEP, with a combination drug that appears to protect high-risk individuals from

prehensive surveillance, monitoring, and education; a robust program of biomedical research; and an emphasis on the rights of the individual. “He had an edgy agenda and an edgy analysis,”

infection. Will PrEP change the trajectory of the

says Leaning. “He was critical of the pace of prog-

epidemic?

ress. He was also critical of WHO’s strategic reasoning, which viewed AIDS as one epidemic among

Walensky: PrEP is exciting. When the first trial results

others. Jonathan was saying: One has to look at this

were presented last summer in Vienna, the scientists

as an epidemic among the deeply marginalized.

received a standing ovation. I’ve never seen that at a re-

Sometimes, whole societies are marginalized. It’s

search conference, because it has been relatively rare that

not just an infection—it’s an injustice.”

a prevention has been documented to work. PrEP also

—Madeline Drexler

© Bernard Bisson/Sygma/Corbis

demonstrated the capacity to empower women in some settings. But the efficacy of PrEP also leads to questions: Will resources for preventing HIV infections di-

Kanki: If PrEP works and prevents infections, it will

vert resources away from treating those who are already

be wonderful—and in the long run it also could save

HIV-infected?

money. The real cost of antiretroviral therapy is health care infrastructure, doctors, nurses, pharmacists, and continued Spring | Summer 2011

19


labs. Effective prevention—whether

every young person who wants to

It should be used and it is cost-

it be PrEP, male circumcision, or

have children has some risk, and that

effective. But you can’t force people

vaccines—will decrease the burden

risk goes on for decades. You can’t

to do it, and I think there aren’t good

of those needing treatment and will

give all of them drugs all the time.

numbers yet about what fraction of

take advantage of the investments

Q:

adult males will agree to it.

in infrastructure and trained health care workers.

Last fall, we saw a spate of news stories about prom-

Marlink: The vaginal microbicide

ising developments in prevention,

studies represented two breakthroughs. One, it worked. It’s not a

FACT: Nearly 17 million children were orphaned  in 2009 by aids.

100 percent barrier, but medically it works. The other breakthrough is that it’s a female-controlled way

Essex: The fundamental consider-

including male circumcision and

of implementing an HIV preven-

ation with PrEP is the expense. You

female microbicides. What do you

tion method. Also, in Tanzania and

could argue that you should give it

make of these advances? And do

Botswana, HSPH researchers have

selectively to, say, commercial sex

you see other promising strategies?

shown that certain multivitamin

workers or high-risk injection drug users or men who have sex with men. But in places like southern Africa, it’s a generalized epidemic, meaning that

preparations can prolong the life

Essex: Male circumcision is definite-

of somebody living with HIV and

ly a positive development and seems

delay the time before a person needs

to offer protection to at least 55

antiretroviral drugs. Even the rate

percent to 60 percent of adult males.

AIDS in 1982: buried in the back pages

one, had confirmed that this was a disease that needed

August, 1982. Robin Herman, who is currently assistant

to be taken seriously. I’m sure that would have made

dean for research communications at HSPH, was then a metro reporter for The New York Times. She was assigned to cover a cluster of cases in New York City of a frightening new disease primarily afflicting homosexual men. When she wrote the word “AIDS” in her article, it was, in retrospect, a landmark moment: the first mention of Acquired Immune Deficiency Syndrome printed by the Times. For the story headlined “A Disease’s Spread Provokes Anxiety,” Herman interviewed a doctor and

a difference.” Editorial attention was instead focused on toxic shock syndrome, a bacterial infection linked to super-absorbent tampons. “The story was buried because the disease was affecting a marginalized group,” she says. “Whose suffering are we ignoring now because they are powerless? Those are the people whose health we have to champion.”

—Amy Roeder

Read the original article and listen to a podcast of Herman’s story at http://hsph.me/frontlines.

patients in Greenwich Village. “I could feel how intensely worried they were,” Herman says. “Nobody knew what caused it. There was no treatment. And it was lethal—quickly.” To have written that first article on AIDS, she adds, “sounds grand now. But what you can’t tell by reading the story online is that it was buried.” Running originally tion and was quickly forgotten. “When I look back at this story, I weep,” says Herman. “Imagine if the Times, by putting it on page

20

Harvard Public Health Review

Kent Dayton/HSPH

on page 31 in the Sunday paper, it received scant atten-


FACT: Ab  out two-thirds of people worldwide infected with HIV live in Sub-Saharan Africa.

“In the early days, they talked about the four H’s: Haitians, heroin addicts, homosexuals, and hemophiliacs. This pattern unfolds with every new disease: You project what is frightening onto the ‘other.’ ” Harvey Fineberg President, Institute Of Medicine; former Dean, HSPH

of dying from the infection was re-

television dropped their jaws. In one

functional lab and trained scientists.

duced in these studies by giving this

day, money wasn’t an issue anymore.

You’re ready to go.

vitamin intervention.

Today, the scale-up in numbers of

Q:

people being treated for HIV/AIDS

PEPFAR—the President’s Emergency Plan for AIDS

is still continuing in a linear rise.

Walensky: When I went to South

Africa in 2008, I went to a clinic in a township outside Cape Town. My

Relief—established by George

Kanki: The goal from the begin-

colleagues took me on a tour of their

W. Bush, provided $15 billion

ning was to quickly provide care and

“container”—it looked like a little

between 2003 and 2008 to fight

treatment to the many in need. The

mobile home, and it had all these

the global HIV/AIDS epidemic.

program also built infrastructure

PEPFAR insignias. Inside that con-

What were the major achievements

and trained thousands of health care

tainer was the capacity for laboratory

of this program?

workers. As the program moves into

tests, CD4 count, viral load, and

its second phase of country owner-

standard hematologies and chemis-

ship, our involvement will decrease.

tries. Because that clinic had those

But we have developed enough re-

tests, its patients were doing better.

lationships with people and built

The possibility and the potential

enough infrastructure so that at the

were so inspiring.

end of PEPFAR—if you had an NIH

Q:

Marlink: In his State of the Union

address in January 2003, President Bush used the B word: “billion,” when announcing the funding for the new international AIDS effort of the U.S. government. It wasn’t the M word, for “million,” it was the B word! Everyone who was watching

grant to look at neurologic tumors in Africa, or you had research opportunities for malaria or TB—you have a

Yet in the past few years, PEPFAR has been flat

funded. What will be the impact? continued Spring | Summer 2011

21


“The real cost of antiretroviral therapy is health care infrastructure, doctors, nurses, pharmacists, and labs. Prevention does away with virtually all of these.” Phyllis Kanki Professor of Immunology and Infection Diseases, HSPH, SD ’85

motivation for testing plummets and more people will get infected. In 2007, we published a study analyzing the impact if PEPFAR weren’t authorized from 2007 to 2012. We compared rapid-growth funding to constant, or flat, funding. We found that with flat funding, there would be 1.2 million additional AIDSrelated deaths over the subsequent five years in South Africa alone.

Q:

Why don’t we have an HIV vaccine?

Essex: The greatest difficulty is the

fact that HIV mutates rapidly and evolves immediately when any immune response is thrown at it. It mutates so rapidly that a virus that’s present in a single individual is, a few weeks later, different from the one that was present a few weeks before. New approaches are being

FACT: Among racial/ethnic groups, African Americans face the most severe burden of hiv and aids in the U.S., representing 12 percent of the population but accounting for 46 percent of people living with hiv. Kanki: If the goal of PEPFAR was

nurses and doctors see huge numbers

tested and evaluated at a laboratory

to treat all those who are in need,

of people—200 to 300 a day. They

level, but it will be at least 10 or 15

then we’re at the first quarter or half-

can’t continue that. Flat funding will

years before any of them are avail-

time. This was not the time for the

cause burnout in staff, decrease the

able as a vaccine in people.

program to be flat funded. The prob-

quality of care provided, and even

lem is, they want us to achieve the

deny care and treatment to those still

same target as the previous year. But

waiting.

if you added 15,000 new patients in the interim, you have a bigger patient base, and flat funding forces At our very-high-volume clinics,

Harvard Public Health Review

that brings the possibility of eradica-

Walensky: If treatment funding

tion into view—that seems unlikely.

flattens, there is the clear danger of

The most likely scenario is either a

rewinding the clock. If people come

treatment or preventive that is par-

to a clinic and they can’t get antiret-

tially effective.

rovirals, they will likely not return. And if treatment is unavailable, the

22

vaccine like a polio vaccine—one

Kent Dayton/HSPH

you to decrease your cost per patient.

Fineberg: If you are imagining a


Kanki: I think we’ll get a vaccine

They do not regularly miss doses

Ojikutu: One of the fallacies driv-

that will work. I don’t think it will

and they’re in the hospital for hip

ing racial and ethnic disparities in

be perfect, but the minute we can

replacement, for dialysis catheters,

HIV in this country is that it’s about

sink our teeth into something that

or for some HIV-unrelated reason.

lack of condom usage or about black

works a little bit, that will help. It

Yes, a vaccine is a noble and worthy

people having a higher number of

FACT: In 2009, 1 in 20 adults were infected in Sub-saharan Africa, more than 1 in 4 in Swaziland. would have to be at least 50 percent

pursuit, but we must be patient and

sexual partners. But disparities are

effective in a clinical IIB trial, which

recognize there is so much we can do

not solely about individual-level

would demonstrate efficacy with

right now.

behaviors—they reflect a bigger

lowered expectations for the percent-

Q:

problem. There is a higher back-

age of people protected.

According to the U.S. Department of Health

Walensky: It’s true, there is no

and Human Services, African

HIV vaccine; but there’s also no

American males have almost eight

vaccine for hypertension or diabe-

times the rate of AIDS that white

tes, and yet people live well with

males do, and African American

these chronic diseases. Many of the

females have more than 22 times

HIV-infected patients I’m seeing

the rate of white females. Why are

right now as inpatients are well con-

there such vast social disparities in

trolled on their treatment regimens.

the disease?

ground prevalence of HIV and other sexually transmitted diseases within our communities. You have stigma and discrimination against sexual behaviors, particularly against homosexuality. In a study published by the CDC, more than one-half of continued

“Across Africa there is great emphasis on adherence to treatment … Patients with whom I interacted in subSaharan Africa oftentimes knew more about HIV treatment than patients do here.” Bisola Ojikutu Assistant Clinical Professor of Medicine, Harvard Medical School; Commonwealth Fund/Harvard University Fellow in Minority Health Policy; MPH ’03

Spring | Summer 2011

23


FACT: In the U.S., more than one million people are living with HIV, and more than 18,000 die each year. HIV-infected black gay men were

concentrated sexual network. And

make addressing racial and ethnic

unaware that they were infected.

with the extraordinarily high rate of

disparities so challenging.

You also have poverty, which leads

incarceration, there are fewer avail-

to poor access to health care and to

able black men in the community, so

residential segregation, which means

relationships are fractured and there

Q:

that people who are at higher risk

may be a higher rate of multiple

Essex: The approach of using

are in one place, creating a more

concurrent partnerships. It is these

drugs to prevent mother-to-infant

complex, population-level issues that

transmission hasn’t adequately been

Looking forward, what’s going right today?

tested to see how it might stop inSaving Lives by the Numbers

fected adults from transmitting to

In the mid-1980s, HSPH biostatistician Stephen Lagakos enthusiastically

other adults. I think it will work.

chatted up colleagues about a new mode of communicating called email. “He wondered if it would be feasible to set up email among all of us who wanted to exchange ideas about how to prevent and treat AIDS,” recalls Max Essex, Mary Woodard Lasker Professor of Health Sciences. That prescient suggestion reflected Lagakos’s passion for reversing the epidemic. In 1995, he founded the Center for Biostatistics and AIDS Research (CBAR) to bring innovative statistical techniques to clinical trials in HIV/AIDS,

In the southern African epidemic, there’s a subset of people, about 20 to 25 percent, who have an extended acute phase and are infecting others for much longer. We think the most cost-effective strategy would focus on that subset of individuals. Walensky: HIV screening is key

while at the same time honoring the needs and welfare of patients en-

to success, both for receiving timely

rolled in these studies. Lagakos, who served as chair of the Department

care and protecting others from

of Biostatistics from 1999 to 2006, directed CBAR until his death in a car

infection. Guidelines have recently

accident in 2009. His vision, melding social justice and rigorous science,

promoted more testing and resulted

continues under current CBAR director Michael Hughes, HSPH professor of

in more resources being devoted

biostatistics. CBAR’s staff of about 75 biostatisticians and epidemiologists works with AIDS researchers, doctors, patients, federal funders, industry (in-

to testing. Today in the U.S., once people are offered an HIV test, they

cluding pharmaceutical and diagnostics companies), regulators here and

generally take it. We’re also being

abroad, policy makers, and educators. The center has had a hand in the

creative about how and where we’re

design, monitoring, and interpretation of hundreds of HIV/AIDS clinical

testing. For example, among the

trials—studies that have led to many of the major advances in treating

responses to the focused epidemic in

HIV infection and have shaped treatment management guidelines world-

Washington, D.C. are efforts to of-

wide. In collaboration with clinical and laboratory colleagues throughout the world, CBAR has contributed to a sharp reduction in mother-to-child transmission of HIV among mothers with access to treatment, and to the

fer HIV screening at the department of motor vehicles. In Texas, they

development of new global standards of care in combination antiretrovi-

screen everybody who walks into the

ral therapy. Building on these successes, CBAR has broadened its mission

emergency room. We are making

to provide advanced statistical expertise in the fight against other major

testing easy.

infectious diseases, including tuberculosis, hepatitis, and influenza.

—Carol Cruzan Morton is a Boston-based science journalist.

24

Harvard Public Health Review


Ojikutu: Today in the U.S., we

where all people living with HIV

Fineberg: What it will take to turn

have a National AIDS Strategy,

should have access to medications

around the epidemic are break-

which may lead to more effort and

that would dramatically reduce their

throughs in the science. A more avail-

energy being placed on the domestic

chances of infecting other people.

able, safer, less expensive treatment

agenda. A lot of that came from ad-

And if everyone who is living with

that actually interrupts transmission.

vocacy efforts from minority provid-

HIV is on treatment, infections

A reasonably effective vaccine. That

ers, advocates, and others who said,

dramatically drop and the epidemic

would accelerate the downturn.

“This is ridiculous. We have been

turns the corner. Ethically, logisti-

Ojikutu: What I see 30 years from

putting together national strategies

cally, financially, we need to plan for

now is going to depend on many of

for South Africa, for Botswana—for

that world.

the revolutionary advances that have

every country, basically—but not for

occurred this past year: vaginal mi-

in another 30 years?

crobicides, pre-exposure prophylaxis.

munities with infection rates just as

Q:

What will AIDS look like

high as some parts of Africa.”

Essex: I’m concerned about the ca-

the United States. Yet we have com-

Marlink: I’m hopeful about where

treatment is heading. If you were to find out in the near future that you were living with HIV, you would likely go on treatment immediately. In the years to come, I see a world

pacity of the virus to evolve. Some of the viruses already in Africa are easier to transmit than the ones in the U.S. If those viruses spread around the world and infect people, it could cause higher rates of infection.

If those types of interventions are interwoven with a comprehensive strategy to address population-level drivers of infection, and we simultaneously build stable health care infrastructure in the developing world, that’s going to change the epidemic. continued on page 52

“Of those who have AIDS in Africa without treatment, half will be dead in less than a year. People don’t realize that most don’t have access to care and treatment—and that it’s still an emergency.” Richard Marlink Professor of Public Health, HSPH, and executive director, Harvard School of Public Health AIDS Initiative

Spring | Summer 2011

25


HIV/AIDS

A Timeline: 1981–2011 • Informal distribution of clean syringes begins in Boston and New Haven.

1985

preventing transmission of HIV through sexual contact and blood transfusions.

26

Harvard Public Health Review

• First International AIDS Conference held in Atlanta. • First HIV antibody test licensed • AZT, the first drug used to treat by the FDA detects antibodAIDS, begins clinical trials. ies to HIV. Blood banks begin screening the U.S. blood supply.    •  C. Everett Koop issues “Surgeon General’s Report on • Public Health Service issues first AIDS,” calling for education recommendations for preventand condom use. ing mother-to-child transmission of HIV. • AIDS has now been reported in every region of the world.

• In West Africa, a second type of HIV—HIV-2—is discovered in commercial sex workers. 1987

• First antiretroviral drug—zidovudine, or AZT—approved by FDA. • World Health Organization launches Global Programme on AIDS.   • President Reagan makes first public speech about AIDS and launches Presidential Commission on HIV. • Ryan White, a 13-year-old hemophiliac with AIDS, is barred from school in Indiana. • Rock Hudson announces that he has AIDS and dies later this year. 1986

• President Reagan first mentions the word “AIDS” in public.

• FDA sanctions first human testing of candidate vaccine against HIV. • FDA creates new class of experimental drugs, Treatment Investigational New Drugs (INDs), which accelerates drug approval by two to three years.

Centers for Disease Control and Prevention, Bettman/Corbis, SSPL/Science Museum

• A major outbreak of AIDS among both men and women in •U  .S. Centers for Disease Control central Africa is reported. and Prevention (CDC) reports five cases of rare pneumonia in young gay men in the June 5 Morbidity and Mortality Weekly Report (MMWR) that later are determined to be AIDS. This marks the official beginning of the HIV/AIDS epidemic. By year’s end, a total of 159 cases of the new disease are recorded in the U.S. • Luc Montagnier and Françoise 1982 Barré-Sinoussi at the Pasteur • CDC  formally establishes the Institute in Paris isolate the viterm Acquired Immune Defirus that causes AIDS. They name ciency Syndrome (AIDS), which it lymphadenopathy-associated refers to four “identified risk virus (LAV). factors” of male homosexuality, 1984 intravenous drug abuse, Haitian • Robert Gallo of the National origin, and hemophilia A. Cancer Institute isolates the vi•C  ases of AIDS are reported in rus that causes AIDS. He names hemophiliacs, women, infants, it human T-cell lymphotropic and recipients of blood transfuvirus type III (HTLV-III). sions. • Scientists conclude that AIDS • Transmission of an infectious is caused by a new retrovirus, agent through blood and sexual which they later name human contact is strongly suspected. immunodeficiency virus (HIV). • F irst AIDS case reported in • U.S. Department of Health and Africa. Human Services Secretary Mar1983 garet Heckler predicts an AIDS vaccine will be ready for testing • The U.S. Public Health Service within two years. issues recommendations for 1981


1989

• First CDC guidelines for the prevention of Pneumocystis carinii pneumonia (PCP), an AIDSrelated opportunistic infection and major cause of illness and death. • Dancer and choreographer Alvin Ailey dies of AIDS.

• First clinical trial of combination antiretroviral therapy begins. • AIDS becomes number one cause of death for U.S. men ages 25 to 44. • FDA licenses first rapid HIV test, which provides results in as little as ten minutes.

1990

• AIDS Memorial Quilt displayed in Washington, D.C. for first time. •U  .S. bars HIV-infected immigrants and travelers from entering the country. •A  nd the Band Played On, a history of the AIDS epidemic by Randy Shilts, is published. • Entertainer Liberace dies of AIDS. 1988

• Ryan White Comprehensive Act of 1990 is enacted by Congress, providing federal funding for • The AIDS Coalition to Unleash Power (ACT UP) demonstrates at community-based care and treatment services. FDA headquarters in protest of the slow drug approval process. • To date, nearly twice as many Americans have died of AIDS as • The number of women living died in the Vietnam War.  with HIV/AIDS in sub-Saharan Africa is reported to exceed that of men.

• Tennis star Arthur Ashe announces he has AIDS.

•D  epartment of Justice rules that people with AIDS/HIV cannot be discriminated against in the workforce, housing, or financial matters.

• World AIDS Day first declared by • N  ew York City begins an WHO on December 1. experimental needle exchange program. •U  .S. Surgeon General and CDC mail brochure “Understanding AIDS” to all U.S. households; first and only national mailing of its kind.

1993

• President Clinton establishes White House Office of National AIDS Policy (ONAP). 1991

• Red ribbon introduced as the international symbol of AIDS awareness. • CDC recommends restrictions on HIV-positive health care workers and Congress enacts law requiring states to take similar action.

©Hisham Ibrahim/Corbis, ©Najlah Feanny/CORBIS SABA

• WHO estimates that nearly 10 million people are infected with HIV worldwide. • NBA legend Earvin “Magic” Johnson announces he is HIV-positive and retires from basketball. • Kimberly Bergalis, of Florida— believed to have been infected with HIV by her dentist, causing major public debate—dies. 1992

• 8th International AIDS Conference, scheduled to take place in Boston, is moved to Amsterdam because of U.S. immigration ban against people with HIV/ AIDS.

• President Clinton signs bill into law restricting people with HIV from immigrating or traveling to U.S. • In major U.S. cities, sexual transmission surpasses drug injection with contaminated needles as the leading cause of HIV infection among women. • Ballet dancer Rudolf Nureyev dies of AIDS. • “Angels in America,” Tony Kushner’s play about AIDS, wins the Tony Award and Pulitzer Prize. 1994

• U.S. Public Health Service recommends use of AZT by pregnant women to reduce perinatal transmission of HIV. • AIDS becomes leading cause of death for all Americans ages 25 to 44; remains so through 1995. • FDA approves an oral HIV test, the first non-blood-based antibody test for HIV.

continued Spring | Summer 2011

27


1995

• F irst protease inhibitor approved in record time by the FDA, ushering in new era of highly active antiretroviral therapy (HAART). •O  lympic diver Greg Louganis announces he has HIV. 1996

• 1 1th International AIDS Conference highlights effectiveness of HAART, creating period of optimism. • F DA approves the first nonnucleoside reverse transcriptase inhibitor (nevirapine), as well as a new viral load test that can measure the level of HIV in a patient’s blood. •C  ombination therapy is made available to HIV/AIDS patients for the first time, leading to a dramatic decline in AIDSrelated deaths.

• J oint UN Programme on AIDS (UNAIDS) is established to coordinate a global response to the pandemic.

•H  IV is no longer the leading cause of death for all Americans ages 25–44, but remains leading cause of death for African Americans in this age group. 1997

• AIDS patients continue to live longer thanks largely to the new combination anti-HIV therapies (HAART), dubbed drug “cocktails.”

• Experts estimate that at least half of all new HIV infections in the U.S. and worldwide occur among young people under the age of 25.

• A new study shows that 14 percent of individuals newly infected with HIV in the U.S. • In U.S., one-third of new HIV already exhibit resistance to at infections occur among women. least one antiviral drug. In sub-Saharan Africa, the epicenter of the global epidemic, 2002 55 percent of all HIV-positive • HIV is leading cause of death adults are women. worldwide among those aged 2000 15–59. • Millennium Development Goals, • UNAIDS reports that women announced as part of UN’s comprise about half of all Millennium Declaration, include adults living with HIV/AIDS reversing the spread of worldwide. HIV/AIDS, malaria, and TB.

1998

• Department of Health and Human Services Secretary Donna Shalala determines that needle exchange programs are effective in preventing HIV infection and do not encourage illegal drug use. But Congressional ban on federal funding of such programs remains in place. • African American leaders declare that AIDS constitutes a “state of emergency” for their communities.

• UN Security Council declares AIDS an international security issue because it threatens social, economic, and political structures worldwide. • UNAIDS and other global health groups announce an initiative to negotiate reduced AIDS drug prices in developing countries.

1999

• Scientists identify nevirapine as simpler, more effective, and cheaper than AZT for preventing mother-to-infant HIV transmission in developing countries. • More than 95 percent of all HIV-infected people now live in the developing world, which has also experienced 95 percent of AIDS deaths to date.

28

Harvard Public Health Review

• CDC reports that black and Latino men now account for more AIDS cases among men who have sex with men than white men. 2001

• UN Secretary-General Kofi Annan calls for a global “war chest” to fight AIDS. • World Trade Organization announces “DOHA Agreement,” which allows developing countries to buy or manufacture

2003

• President George W. Bush announces PEPFAR, the President’s Emergency Plan for AIDS Relief, a five-year, $15 billion initiative to address HIV/ AIDS, tuberculosis, and malaria, primarily in Africa and the Caribbean. • AIDSVAX, an experimental AIDS vaccine, fails to block HIV infection in first large-scale clinical trial of an AIDS vaccine. • UNAIDS and WHO announce the “3 by 5” Initiative aimed at providing antiretroviral treatment to 3 million people worldwide by 2005.

Shannon Stapleton/REUTERS

• Study in the Lancet shows that needle exchange programs in New York City reduce HIV infections and facilitate access to drug treatment and other health services.

generic medications to meet public health crises, such as HIV/AIDS.

REUTERS

• F DA approves HIV urine test and first HIV home testing and collection kit.

• F or the first time since the start of the epidemic, the number of Americans dying each year from AIDS declines, primarily because of new combination therapies.


HSPH Achievements in the fight against AIDS •D  iscovered that HIV/AIDS can be transmitted through blood and blood products. •P  rovided key research that led to the screening test used to protect the world’s blood supply from HIV/AIDS.

2004

•U  NAIDS launches The Global Coalition on Women and AIDS to raise the visibility of the epidemic’s impact on women and girls around the world. •U  N report warns of the growing AIDS crisis in Eastern Europe and the former Soviet Union. 2005

• F DA approves an HIV drug regimen manufactured by a non-U.S.-based generic pharmaceutical company. • CDC reports that more than one million Americans are living with HIV/AIDS. 2006

•C  DC recommends routine HIV screening for all adults aged 13–64, and yearly screening for those at high risk. 2007

• WHO and UNAIDS issue new guidance recommending “provider-initiated” HIV testing in health care settings. • WHO and UNAIDS recommend that male circumcision be considered for HIV prevention. 2008

•N  ew HIV incidence estimates for the U.S. show that the epidemic is worse than previously thought, with more than one million infected. 2009

• President Obama launches the Global Health Initiative (GHI), a six-year, $63 billion effort to develop a comprehensive approach to addressing global health in low- and middleincome countries, with PEPFAR as a core component. • Obama Administration lifts HIV travel and immigration ban, to take effect in 2010. • Congress OK’s use of federal funding for needle exchange in the U.S. 2010

• Encouraging studies are published on vaginal microbicides, prevention of mother-to-child transmission, pre-exposure prophylaxis, and male circumcision. • White House releases first comprehensive HIV/AIDS Strategy for the Nation. 2011

• Today, more than 33 million people are living with HIV/AIDS.

James Akena/REUTERS

•C  ongress reauthorizes PEPFAR for an additional 5 years at up to $48 billion; the legislation ends the statutory HIV travel and immigration ban.    

•P  resented the first evidence that HIV/AIDS could be transmitted through heterosexual intercourse. •C  onducted the first HIV vaccine trial in southern Africa. • Discovered a second human immunodeficiency virus, HIV-2, the cause of most infections in West Africa. Also discovered that HIV-2 seems to offer some protection against HIV-1. •E  stablished a model program in Senegal in the mid-1980s, led by world-renowned AIDS researcher Max Essex, which is now one of the longest-running AIDS programs in Africa. • F ormed a partnership with the government of Botswana—which had one of the highest rates of HIV infection in the world—to conduct collaborative, population-centered research and improve the country’s technical, medical, and structural capacity to address the epidemic. •P  rovided professional training and guidance to partner clinical sites in Botswana, Senegal, and Nigeria, which has led to the enrollment of 47,000 HIV-infected people, more than half of whom are now on antiretroviral therapy. •D  eveloped drug treatment regimens in Botswana that can dramatically reduce the rate of mother-to-child HIV transmission. By revising the standard AIDS drug regimen, health care workers can also save HIV-infected mothers who might otherwise die after developing drug resistance. •P  roved that certain AIDS drug combinations given to pregnant women block 99 percent of HIV transmission to breastfed babies.

Sources: Kaiser Family Foundation, http://www.kff.org/hivaids/

timeline/hivtimeline.cfm; Foundation for AIDS Research, http:// www.amfar.org/abouthiv/article.aspx?id=3598    

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Students

Can Neighborhoods Hurt Our Health? 30

Harvard Public Health Review


Doctoral student Caitlin Eicher wants to understand how people’s perceptions of their local surroundings shape what they eat, how much they exercise, and other health behaviors.

A

single mother living in public housing may want to feed her children healthy food, but if the nearest affordable grocery store is a crowded bus ride or expensive taxi trip

away, that goal may feel unattainable. At the end of a long day, she may turn instead to the corner store, with its easy-to-prepare packaged goods and candy by the register, or to one of the many fast-food restaurants on the block. And if she doesn’t feel safe on her street, is it any wonder that her children don’t get much outdoor physical activity? “Studying neighborhoods brings public health to a level that everyone can relate to,” says Caitlin Eicher, a doctoral student in Harvard School of Public Health’s Department of Society, Human Development, and Health (SHDH). “Everyone can offer an opinion based on their own experiences about how neighborhoods affect health. But by studying this academically, I am developing the tools to objectively answer questions that have always been in the back of my head.”

continued

Afton Almaraz/Aurora

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Some neighborhoods appear to promote obesity

Eicher is exploring one of the most urgent issues in public health today. Over the past 30 years, waistlines have expanded dramatically across the United States and around the world. In Massachusetts, nearly 60 percent of adults and one in three children are overweight or obese. And the burdens of all that excess girth—chronic diseases such as type 2 diabetes and heart disease, and the high medical expenses and lost productivity that come with them—are not shared equally across the population. Massachusetts Department of Public Health statistics reveal dis-

parities in obesity rates that track differences in income, level of education, and race. Some blame individual choices for these disparities, but SHDH researchers believe that people’s environments often set them up for failure. “Individual interventions to prevent obesity have not worked well,” says Ichiro Kawachi, professor of social epidemiology and SHDH department chair. “At the same time, we see enormous differences in obesity rates between neighborhoods. In Boston alone, there’s a twofold difference between residents in lowincome and higher-income neighborhoods. Even when we control

“Even when we control for factors such as income, race, and education levels, there appears to be something about certain neighborhoods that promotes obesity”

 Ichiro Kawachi, chair, Department of Society,

32

Harvard Public Health Review

Building a complete picture

Eicher is focused on teasing out these factors. For her dissertation, she is exploring whether living close to a supermarket leads to more fruit and vegetable consumption, and how perceptions about the safety and cohesion of a neighborhood can affect residents’ likelihood of using services such as public parks, which can help promote physical activity. In some neighborhoods, residents have scant access to nutritious foods.

She is analyzing data from a cancerrisk survey of 828 people who lived in 20 public and private lowincome housing sites in Cambridge, Somerville, and Chelsea, Massachusetts, between 2007 and 2009—a study she was involved in as a master’s student working with SHDH Professor Glorian Sorensen at Dana-Farber’s Center for Community-Based Research. She

Kent Dayton/HSPH

Human Development, and Health

for factors such as income, race, and education levels, there appears to be something about certain neighborhoods that promotes obesity.”


“Studying neighborhoods brings public health to a level that everyone can relate to.”

 Caitlin Eicher, SM ’08, SD ’13

Prevention vs. Prescription Before entering HSPH as a master’s student five years ago, Caitlin Eicher’s path seemed to point towards clinical medicine. She earned a degree in psychology from Brown University and was considering medical school while working as a research assistant on end-stage clinical trials at Memorial Sloan-Kettering Cancer Center. But the job’s emphasis on pharmacology rather than prevention frustrated her. “The patients I worked with didn’t have a lot of options. Prevention was not spoken of much at this stage of the game,” she says. “It disturbed me how little I would be

is also pulling in census data that details the social and economic characteristics of the neighborhoods and mapping distances to an array of food retail outlets and other neighborhood features to build a complete picture of residents’ health environments. According to the U.S. Department of Agriculture, 11.5 million people in the United States live in lowincome areas more than one mile from a supermarket.

able to make a difference.” She was able to return to HSPH for doctoral study thanks to the Julie E. Henry Scholarship for Maternal and Child Health. She was close to choosing another school for financial reasons when the scholarship came in. “It made all the difference in the world,” she says. “Staying here allowed me to hit the ground running.” Building on her master’s studies, she was able to take her doctoral exam early and will ultimately be able to graduate early. “Caitlin exemplifies the sort of public health student that we like to turn out,” says Kawachi. “Given her independence and the creative way that she approaches problems, I see her as a potential leader in understanding neighborhood-level influences on obesity.”

and convenience store shelves at eye level, even lowering the cost of proPricing, placement matter duce cannot guarantee that people Geography matters, but clearly it is just one of a complex array of factors at buy more of it. Encouraging healthy eating work. Some of the housing sites Eicher is studying are actually near supermar- habits is complicated, says Kawachi, kets. However, when the market is an Eicher’s adviser. “It’s not just a matter of either changing preferences or upscale food retailer, high prices and improving access.” Efforts to establish unfamiliar products can keep many public-private partnerships to bring who live in the neighborhood away. more grocery stores into underserved Research has shown that factors such as shelf placement influence neighborhoods and incentivize corner people’s food choices. With cheap and stores to provide healthier food are underway in Philadelphia, New York, tempting items lining supermarket and in Massachusetts, which launched

a new campaign in February led by the state’s public health department. Eicher is part of a growing group of researchers drawn to understand what drives people’s health behavior and to tackle the larger forces that lead to obesity in some neighborhoods, from food policies and school lunch programs to poverty and mental health issues. Amy Roeder is assistant editor of the Review.

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Alumni

Health Care With Dignity Alum Robert Taube helps homeless people build healthier lives— and self-esteem.

C

34

Harvard Public Health Review

80 sites, 11,000 clients

To many Bostonians, homeless people such as Hubbs are anonymous and marginalized. But to BHCHP’s 350 employees, they’re individuals who deserve attention, kindness, respect, and hope. The program helps more than 11,000 homeless people each year build healthier lives through care delivered at 80 sites around the city, from clinics to soup kitchens to heated grates. Its staff not only helped Hubbs recover physically and emotionally, but also helped her find an apartment where she now lives with three cats. As its longtime executive director, Robert Taube, PhD, MPH ’95 has, against steep odds, kept the nonprofit organization financially strong, innovative, and unwaver-

All photographs, Kent Dayton/HSPH

asey Hubbs’s world crumbled after her husband died, and she wound up living under a bridge in Boston. Her existence was grim, and she felt ashamed. “I smelled bad, I looked bad, and I lived in constant fear,” she remembers. “There was no food half the time.” When outreach staff from the Boston Health Care for the Homeless Program (BHCHP) found her freezing on the streets one night, they brought her to safety. For the next few years, Hubbs was in and out of the program’s medical respite unit as she grappled with homelessness, addictions, and cancer. Finally, she stabilized. “They gave me back my self-esteem,” says the 64-year-old. “They treat you like you’re part of the family. Even a dry pair of socks can save your life.”


ing in its commitment to providing high-quality medical, mental health, and dental services to a vulnerable population. This success has bred confidence in his intensely personalized approach to a widespread public health challenge. “I’ve become much more optimistic about our common desire to repair what’s broken in the world,” Taube says. “There’s something about this work that engages people from diverse backgrounds and makes our humanness more visible.” On a typical winter night in Boston, about 5,000 adults and 2,000 children are homeless. Although some stay with friends and relatives, others lodge in emergency shelters and motels, down alleys, and under bridges. They’re exposed to contagious diseases such as tuberculosis, violence, emotional stress, and frigid weather. The daily struggle to find refuge and food eclipses their medical needs; common and preventable illnesses tend to worsen, and chronic problems like diabetes or AIDS become difficult to manage. Research shows that homeless people live sicker and die younger than their housed counterparts. A prospective

10-year study of 119 street dwellers in Boston revealed they logged nearly 18,400 emergency room visits during the study’s first five years (1999 to 2003) and that more than 40 percent died. First racetrack clinic

One of 200-plus federally funded Health Care for the Homeless projects in the United States, BHCHP is a national model for its scope and ingenuity. Founded in 1985, it started the first respite unit for homeless adults too sick to return to the streets, the first racetrack clinic— at Boston’s Suffolk Downs—for migrant workers living in the stables, and the first electronic medical record system for coordinating homeless patients’ care. Taube continues that tradition by encouraging creative problem solving and launching new programs, including a clinic for homeless transgendered patients established in 2009. He also advocates for policy changes to benefit the homeless population. In the mid-1990s, for example, continued Robert Taube, MPH ’95 with patients at a Consumer’s Board meeting at Boston Health Care for the Homeless Program’s Jean Yawkey Place.

A Mid-Career Luxury After 13 challenging years working

a doctorate in counseling psychology

and management and says his most

at community health centers,

from the University of Texas at

helpful course was Professor Nancy

going back to school was a treat

Austin, Taube enrolled at HSPH on

Kane’s on analyzing financial docu-

for Robert Taube, PhD, MPH ’95.

a fellowship to sharpen his skills

ments: “I learned how to read an

“It felt wonderfully luxurious,” he

and better understand the theory

audit report and speak the language

recalls. With bachelor’s and master’s

behind his professional experience.

you need to solve financial problems

degrees from Temple University and

He concentrated in health policy

at an institutional level.”

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They treat you like you’re part of the family. Even a dry pair of socks can save your life.

Taube pressed for a checkoff box on a government form that helped people without addresses enroll in the Massachusetts Medicaid program. “In our part of the world, that was one of the most far-reaching pieces of advocacy in that decade,” says program president and founding physician Jim O’Connell, an instructor at the Harvard School of Public Health. “We went from having 15 to 20 percent of our folks insured to over 70 percent.”

impression that primary care medicine should be based not on profit-making, “but on the fact that all human beings need health care,” Taube reflects. He joined Boston Health Care for the Homeless in 1993 during his placement as a midcareer student at HSPH. A psychologist by training, he had run a community health center in Boston and was tapped to develop the program’s mental health and substance abuse services. Taube found the homeless patients’ resilience so compelling, and his colleagues so dedicated, that he never left. Taube also has a penchant for complicated topics like health care financing, and he stayed on after graduation to help the agency adjust to looming changes in the medical reimbursement system. He was named executive director in 1998. “I think I’m in the wrong place”

Light-filled atrium at Boston Health Care for the Homeless Program’s Jean Yawkey Place.

Health care as a human right

What drives Taube is a deep-rooted belief in health care as a human right, which began while he was growing up in Paterson, New Jersey, the son of Jewish war refugees who settled there in 1946. “My parents were communists and union organizers in Europe before the war, and they believed we have a responsibility toward one another,” Taube says. “That was part of the air I breathed.” He remembers a neighborhood physician who tended to Taube’s family from a leather bag and quietly left money on a dresser to pay for their prescriptions. The way Taube’s parents revered and counted on the doctor left a lasting 36

Harvard Public Health Review

Perhaps the best evidence of Taube’s leadership is the program’s hub, Jean Yawkey Place. It opened in 2008 after a $42 million campaign to renovate a historic structure near Boston Medical Center, one of BHCHP’s partnering hospitals. Much like a community health center, the building houses exam and consultation rooms, administrative offices, and a pharmacy; it also has a 104-bed respite unit for patients with complicated conditions such as broken bones, burns, or cancer, who might otherwise need expensive hospitalizations. Patients visiting Jean Yawkey Place enter a spacious, light-filled atrium and can pick up prescriptions, see their primary care doctor, visit a dentist, or talk confidentially with a counselor. During its first year, the center enabled BHCHP to serve about one-third more patients. But the more profound change, in Taube’s view, is how the setting supports people’s sense of worth. “When we first opened,” recalls Medical Director Monica Bharel, “patients would say, ‘I think I’m in the wrong place, because it’s so beautiful.’” Taube knows patients appreciate the care his organization delivers. “They also expect to be treated with dignity,” he says. “There’s a statement people make with their words or eyes that says, ‘I may be on the margins of society, but I respect myself and I demand that of you.’” Debra Bradley Ruder is a freelance writer specializing in health care, education, and end-of-life issues.


Health Professional Education

T

he training of doctors and other health care professionals must change dramatically to meet 21st-century medical and public health needs, according to a report issued in

A Cure for Health Professional Education

November 2010 in the Lancet. The conclusion came from an international commission of experts led by Harvard School of Public Health Dean Julio Frenk and Lincoln Chen of the China Medical Board. Among the report’s highlights: • $5.5 trillion is spent annually on health care globally, which is about 10 percent of the world’s economy. • Only about 2 percent of the $5.5 trillion is used to train physicians, nurses, midwives, and other health professionals who determine how that vast sum of money is spent. • Four countries have more than 150 medical schools; 36 countries have none. • 25 percent of physicians practicing in the U.S. were trained outside the U.S. • Some countries have unemployed doctors; others have almost no doctors.

“We are spending too little money on health professional education, and getting too little value for the money,” Anne Hubbard/HSPH

said Dean Frenk, at a conference at HSPH where the commission presented its report. “Health care is a laborintensive and talent-driven activity. We continued Spring | Summer 2011

37


A young student examines a pregnant woman in front of a class of students at the Midwifery School of Al-Fasher, where women, most of them victims of fistula and displaced by the ongoing conflict, are being trained as midwives.

Sven Torfin/Panos

simply have to spend more training these individuals, and do a better job of educating them for 21st-century needs.” He continued: “We need a global perspective on health professional education. Donor countries like the U.S. and others are spending

At the same time, wealthy countries are importing doctors from poorer countries to take care of patients in the developed world. “If one out of every four physicians seeing patients in the U.S. is educated outside the U.S., efforts that focus primarily on how doctors are

the report’s authors, because of fragmented, outdated, and static curricula that produce ill-equipped graduates. “The problems are systemic,” the commissioners write. “[There is] a mismatch of competencies to patient and population needs; poor teamwork; persistent gender stratification

Donor countries are spending billions to pay for AIDS treatments but spending very little on training the health professionals who will get these treatments to patients. billions to pay for AIDS treatments in Africa, for example, but spending very little money relatively speaking on training the health professionals who will work with patients and run the programs to get these treatments to patients.”

trained in the U.S. will miss a sizable percentage of the clinicians who are managing patients in this country,” noted Frenk. Systemic Problems leave graduates ill-equipped

But these problems are just part of a broader issue that the research unearthed. Changes are needed, say

38

Harvard Public Health Review

of professional status; narrow technical focus without broader contextual understanding; episodic encounters rather than continuous care; predominant hospital orientation at the expense of primary care; quantitative and qualitative imbalances in the professional labor market; and weak leadership to improve health-system performance.”


They add: “Laudable efforts to address these deficiencies have mostly floundered, partly because of the socalled tribalism of the professions— i.e., the tendency of the various professions to act in isolation from or even in competition with each other.” A Remoralization of Health Education

In a commentary issued with the report, Lancet editor Richard Horton wrote, “What this Commission argues for is nothing less than a remoralization of health professionals’ education. For decades, health professionals have colluded with centers of power (governmental, commercial, institutional, even professional) to

• Focus on competencies in areas such as leadership, problem solving, and teamwork, in addition to the technical and scientific information needed to be a good practitioner. • Break down silos among medical specialists, and between professionals such as doctors, nurses, midwives, and community health workers. • Train professionals to take advantage of the burgeoning availability of information and communication technologies, ranging from the ubiquitous cell phone to more sophisticated electronic medical records.

Interprofessionalism is key

To reach these goals, education must be interprofessional—with doctors, nurses, and other health professionals interacting more frequently during their training. Health professionals also need to develop the competencies to work with community health workers and be closely connected with them so both groups can be more effective. “When I was minister of health in Mexico and we passed legislation to fund universal insurance for millions of previously uninsured citizens, we quickly realized that all of our problems were not immediately solved,” said Dean Frenk. Mexico didn’t have enough primary care doc-

It will require many years and a global social movement to transform health professional education. preserve their influence. The result? A contraction of ambition and a failure of moral leadership.” The commission report was released to mark the centenary of the Flexner Report, which called for the transformation of medical education at the beginning of the 20th century. Medical education then was in many cases delivered by for-profit schools that did not focus on science-based teaching—and in many cases graduated practitioners more likely to harm than help their patients. Commission report authors and conference attendees recommend a transformation in health professional education. This transformation needs to:

• Encourage the belief that patients and populations are the center of the health care team, and that health professionals have a social responsibility to provide excellent care under financially constrained circumstances, rather than focusing more narrowly on conducting procedures and billing for them. • Coordinate with the goals of health ministries in individual countries. • Encourage global partnerships between academic medical centers, health ministries, insurers, government payers, and others.

tors and other health professionals to meet the increased demands for service. According to Dean Frenk, the U.S., with new health care reform laws, will experience similar difficulties because medical schools train many more specialists and far fewer primary care physicians than are needed to meet the needs of millions who previously did not have health insurance. The Flexner Report came out in 1910. Only after decades and much public outrage were its recommendations implemented. According to Dean Frenk, “We will need many years and a global social movement to make these changes take place.” Julie Fitzpatrick Rafferty is Associate Vice Dean for Communications at HSPH.

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D

uring his career, Harvard School of Public Health’s Bernard Lown has traveled two roads. The First Road unraveled the secrets of sudden cardiac death and developed the direct current (DC) defibrillator that became a lifesaving device worldwide. On

The Second Road, he worked as a peacemaker, co-founding an organization, International Physicians for the Prevention of Nuclear War (IPPNW), that won the 1985 Nobel Peace Prize for its role in slowing the nuclear arms race. Recently, Lown, who is professor emeritus at HSPH, spoke at the launch of the Bernard Lown Scholars Program and Visiting Professorship, established at the School to honor his exemplary career advancing public health. Below are excerpts from his talk about The Second Road, in which he shares observations and lessons learned as a public antinuclear activist—ideas that remain applicable today as wars and civil unrest envelop many parts of the world. For Lown’s complete talk, including his acknowledgments of many at HSPH who have been instrumental in his career, see http://webapps.sph.harvard.edu/accordentG2/deanslecture-20101105/index.htm.

Waging Peace, Saving Lives A renowned physician explains how defeating militarism could solve global health problems. In the late 1950s, quite by chance, I at-

We became instant world experts on the

tended a talk by Philip Noel-Baker, a recent

topic. We launched a physicians’ antinuclear

British Nobel Peace laureate. He intoned about

movement in the U.S., the Physicians for Social

an impending nuclear holocaust. Compared to

Responsibility (PSR). Having demonstrated

the threatening nuclear disaster, sudden cardiac

that in nuclear war there was no place to hide,

death, preoccupying me at the time, seemed a

our findings put an end to the underground

small problem.

shelter craze then exercising the American pub-

In 1961, I assembled a small group of doctors, young Harvard Medical School academics,

something to say on war and peace issues, and

to address the formidable nuclear challenge.

that furthermore, the public was ready to listen.

How could we as physicians make a dif-

Though the analysis of physicians and of

ference? We extrapolated the medical conse-

others had a substantial public impact, not a

quences of a virtual nuclear bombing of Boston.

single nuclear weapons system was dismantled

We concluded that there was no meaningful

as a result. What followed instead was the

medical response to a catastrophe of such mag-

greatest arms buildup in history.

nitude. And we published our results in the New England Journal of Medicine.

40

lic. We learned that health professionals had

Harvard Public Health Review

continued


Professor Emeritus Bernard Lown, founder of Physicians for the Prevention of Nuclear War, in a 1996 photo.

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Chance collaboration leads to disarmament

Quite fortuitously, I was in a position to take an initiative. For nearly a decade in the 1970s, I had cooperated with Soviet cardiologists investigating sudden cardiac death, sponsored by the National Institutes of Health. We were fortunate that our Soviet partner was Eugene Chazov, the physician to President Leonid Brezhnev and for much of the gerontocracy then in the Politburo. In 1981, together with other colleagues, the two of us founded the International Physicians for the Prevention of Nuclear War (IPPNW). Remarkably, within four years we gained 150,000 physician members in 60 countries and educated a wide public on the nuclear threat. We did some seemingly im-

possible things. Largely because of Chazov’s enormous political clout, we were able to telecast across 11 time zones an uncensored one-hour broadcast. More than 100 million Soviets watched a free, wide-ranging, hitherto forbidden discussion. If what I am describing sounds like smooth sailing, it was far from it. We were reviled in the American mass media as communist dupes. When our Nobel Peace Prize award was announced, The Wall Street Journal urged the Nobel committee to close up shop in shame for its immoral choice. A crescendo was reached when Chancellor Helmut Kohl of Germany appealed to the Nobel Committee to rescind the Prize.

Forging New Pathways in Cardiovascular Disease Below are excerpts from Bernard Lown’s talk about his distinguished work as a cardiologist, which he calls The First Road in his career. To hear the entire speech, see http://webapps.sph.harvard.edu/accordentG2/ deanslecture- 20101105/index.htm with survival. Our research in dogs led

cent emporium, the modern hospital.

to the development of the first effec-

Prevention, the foundation of a sound

tive direct current (DC) defibrillator.

health system, was scorned in practice

Once a dog’s heart was defibrillated,

as it was honored in preachment.

it recovered and survived despite the blocked coronary artery. The implica-

Since listening to a patient consumed

tion was momentous: sudden cardiac

much time and was minimally reim-

death was likely afflicting patients with

bursed, it became cursory, circum-

hearts too good to die.

scribed, and frequently bypassed.

Lown’s observations about

Hearts too good to die:

An early casualty was listening.

When doctors don’t listen, treat-

doctor-patient relationships in the

ment is compelled by the chief com-

1960s resonate even today.

plaint, which frequently has little to

The growing dominance of market

do with what troubles the patient.

Remembering how the defibrillator

forces was transforming health care.

This results in a multiplicity of tests

was invented

The human dimension of the doctor-

and procedures as well as referrals to

In the 1950s, cardiac death was

specialists. Another consequence is

denatured by overtreatment, endless

polypharmacy, resulting in a profusion

claiming 500,000 victims annually. The

tests, unwarranted referrals, and poly-

of adverse drug reactions that intensify

problem was ignored, largely because

pharmacy. At the epicenter were highly

the cycling of patients for tests and

it happened outside hospitals and was

trained specialists dealing with parts of

referrals. Necessarily this new paradigm

deemed the result of a massive coro-

disembodied patients. Emerging was a

undermines patient trust in the medical

nary artery thrombosis incompatible

sickness system centered on a magnifi-

profession.

42

Harvard Public Health Review

Team Static

patient relationship was rapidly being

the leading cause of fatality in the U.S.,


The Bernard Lown Fund in Cardiovascular Health at HSPH supports the Bernard Lown Cardiovascular Scholars Program, which trains qualified midcareer clinicians, scientists, nurses, and other health practitioners in public health strategies related to preventing cardiovascular disease in the developing world. The goal is to create an international community of Lown Scholars who will continue to interact around issues of cardiovascular health, particularly in the developing world. The Fund also supports a professorship at HSPH involved in research and teaching focused on the prevention of cardiovascular disease in the developing world, and supports international conferences devoted to cardiovascular prevention. Srinath Reddy, president of the Public Health Foundation of India, is the Bernard Lown Visiting Professor of Cardiovascular Health in HSPH’s Department of Epidemiology.

The hidden costs of militarism: Then and now

The world is no longer facing instant nuclear extinction. We roused multitudes to speak out against the awesome peril. Doctors from all around the globe contributed to unwinding the potential doomsday clock. We learned that to advance on any complex social and political issue demands rousing wide public awareness of the true stakes to their well-being and survival. Another key lesson was of the colossal destructiveness of militarism even in the absence of war, what the public health social activist Victor Sidel called “destruction before

and write. Twenty schools could be built for the annual cost of a single American soldier. For the cost of 1,000 soldiers, one could end the scourge of maternal deaths in Afghanistan. Wars are among the leading causes of premature deaths. At present, more than 90 percent of victims are civilians. Annual global military expenditures exceed $1.3 trillion. A small fraction of this colossal expenditure could resolve nearly all outstanding global health problems. Where then are the voices of medicine and public health? Where are the curricula educating young health

In Afghanistan, 20 schools could be built for the annual cost of a single American soldier. For the cost of 1,000 soldiers, one could end that nation’s scourge of maternal deaths. detonation.” The Cold War and the war on terrorism have so far claimed more than $20 trillion. Such a diversion of prodigious resources in large measure accounts for our dysfunctional schools, our backward energy policies, our unlivable inner cities, our failing infrastructure, and our ever-diminishing commons essential for healthy civic life. Today the U.S. spends $1.1 million annually to sustain a single soldier in Afghanistan, a country with the second-highest maternal mortality rate in the world and the third-worst global ranking for child mortality. In 2009, 1,600 young women died during childbirth for every 100,000 live births. According to the British Medical Journal, safe drinking water supplies reach only 23 percent of Afghans, and only one-quarter of adults can read

professionals on this vital sector of health and community well-being? Where is the dialogue spilling over to the wider community? Cultivating moral vision and commitment

In an epoch of quavering certitudes, we need to cultivate moral vision as well as moral commitment. This is the categoric imperative of our age. Moral practice has to begin with social engagement. I believe we are reaching the end of an economic and political era. The first Renaissance was driven by painters, sculptors, and poets. Why cannot the second Renaissance be driven by the health profession? Perhaps this new journey will begin with an ancient practice: a doctor listening to a patient. b Spring | Summer 2011

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Coffee

The Good News More than half of American adults drink coffee every day. Recent scientific studies suggest moderate consumption may help reduce some disease risks. Below find information and examples of study findings about some of coffee’s possible health benefits.

Diabetes

Heart Disease

Long-term coffee drinkers may be

Recent studies suggest that drinking cof-

at lesser risk of onset of type 2

fee does not have a harmful effect on heart

diabetes.

disease or stroke.

What the Research Says:

What the Research Says:

“Coffee (both regular and decaf-

“Long-term coffee consumption was not

feinated) has lots of antioxidants

associated with an increased risk of stroke in

like chlorogenic acid and magne-

women. In contrast, our data suggest that cof-

sium. These ingredients can actu-

fee consumption may modestly reduce risk of

ally improve sensitivity to insulin

stroke.” (Harvard School of Public Health 2009

and may contribute to lowering

study abstract)

risk of type 2 diabetes.” (Harvard School of Public Health 2004 study press release)

“Our results suggest a slight risk reduction for CHD mortality with moderate coffee consumption and strengthen the evidence on the lower risk of CHD with coffee and tea consumption.” (University Medical Center Utrecht 2010 study

Liver Cancer & Cirrhosis

abstract)

Drinking coffee regularly could lower rates of disease progression. What the Research Says: “Drinking coffee has been associated with reduced risk of hepatic injury and cirrhosis … although allowance for clinical history of cirrhosis did not completely account for the inverse association.” (Cinvestav-IPN Mexico 2010 study abstract)

Parkinson’s Disease Drinking caffeinated beverages may lessen the

Caffeinated coffee may play a role in pre-

risk of Parkinson’s disease.

venting symptomatic gallstone disease.

What the Research Says:

What the Research Says:

“In summary, in this large prospective investi-

“All coffee brewing methods show a

gation, we found a strong inverse association

decreased risk. The risk of symptomatic

between caffeine consumption and risk of

gallstone disease also declined with in-

Parkinson’s disease in men and a U-shaped

creasing caffeine intake … decaffeinated

relation in women. These associations are

coffee was not associated with decreased

consistent with a protective effect of moder-

risk … In this cohort of U.S. men, coffee

ate caffeine consumption against Parkinson’s

consumption may have helped to prevent

disease.” (Harvard School of Public Health

symptomatic gallstone disease.” (Harvard

2001 study abstract)

School of Public Health 1999 study abstract)

54% of Americans over 18 drink coffee every day. 44

Harvard Public Health Review

Kent Dayton/HSPH

Gallstones


$40 billion is spent in the U.S. on coffee each year.

Caffeine Comparisons The size of the beverage in the image at right represents how much or how little caffeine it contains. Sources: www.mayoclinic.com, www.energyfiend.com

=

or

or

or

330 mg

108 mg

76 mg

47 mg

47 mg

of caffeine in

of caffeine in

of caffeine in

of caffeine in

of caffeine in

a Starbucks

each cup of

each can of Red

each can of Diet

each cup of tea

“Grande” coffee

generic brewed

Bull (8.5 oz.)

Coke (12 oz.)

(8 oz.)

(16 oz.)

coffee (8 oz.)

Americans drink an average of 3.1 cups per day.

The Downsides While recent scientific studies have shown that coffee may have health benefits, data have also been collected that suggest there may be harmful effects associated with the caffeinated beverage, particularly if not consumed in moderation.

More Calories People who drink coffee regularly often also consume calorie-rich extras such as cream, sugar, and flavored syrup.

Birth Outcomes

Number of calories in extras (per tablespoon)

at increased risk of late miscarriage and

While data are not entirely conclusive, studies have shown that pregnant women who consume large amounts of caffeine may be stillbirth.

Heavy cream: 52 Half-and-half: 20 Whole milk: 9 Fat-free milk: 5 Sugar: 48 Plain nondairy creamer (powder): 33 Flavored nondairy creamer (powder): 45

Coffee Craving in the Genes? Two newly discovered genes appear to be related not only to how many cups of coffee and other caffeine-containing beverages and foods (such as chocolate) we consume each day, but how fast the body processes caffeine. People with a particular genetic variation drink about 40 milligrams more caffeine per day—about one-third cup more coffee—than those without the variation, according to lead author Marilyn Cornelis, research associate in HSPH’s Department of Nutrition. The study appeared in the April 2011 issue of PLoS Genetics.

The average price of a brewed cup of coffee is $1.38. Spring | Summer 2011

45


Promises Kept

Prior recessions did not result in large global health aid cuts.

T

he World Bank and World Health Organization have voiced fears that policy makers will break their commitments to support desperately needed global health services in low- and middle-income countries because of the ongoing global economic downturn. Yet, according to a recent study from the Harvard School of Public Health, there is surprisingly little historical evidence that economic recessions inevitably lead to reductions in health aid. In other words, if rich countries substantially cut their aid budgets in response to the recent financial crisis, it would signal a new and potentially worrisome trend. Meet basic needs first

46

Harvard Public Health Review

Bad samaritans on the horizon?

There are concerns that donor agencies will reduce aid in response to a political climate that calls for fiscal austerity in their countries, say the authors. “In particular, there is a risk that if the U.S. and EU countries reverse course on their commitments, donor countries will be viewed as ‘bad samaritans’—withdrawing support at a time when people need their help the most,” said McKee. “The financial crisis has given politicians ample excuses to break their aid promises,” said Stuckler. “We found that such a political choice cannot simply be justified on the basis of the past.” Todd Datz is Director of News and Online Communications at HSPH.

REUTERS/Ho New

“In order to achieve a sustainable economic recovery, governments must first take care of people’s most basic health needs,” said David Stuckler, assistant professor of political economy at HSPH and lead author of the study. “Our findings remind us that there are alternative ways to finance recovery than by cutting vital health services to the world’s poorest and most vulnerable groups.” The study appeared February 25, 2011, in an advance online edition of the Bulletin of the World Health Organization. To identify whether donating countries reduced their health aid in response to prior recessions, Stuckler and colleagues Sanjay Basu at University of California at San Francisco, Stephanie Wang at Caltech, and Martin McKee at the London School of Hygiene & Tropical Medicine, studied data on health aid and economic downturns from 15 European Union (EU) countries covering the past three decades, from 1975 to 2007. The study investigated the relationship of health aid to recessions, measured in three ways: episodes of recession, percentage

changes in per capita gross domestic product, and changes in unemployment rates in donor countries. The researchers found that there was surprisingly little evidence that economic downturns were associated with large cuts in aid, at least within the first several years of a financial crisis. Similar to present circumstances, they found that some countries appeared to reduce aid, while others increased it in a manner that did not seem to depend on the scale of the financial crisis they faced. Global health aid is critical to support ongoing healthcare infrastructure development and to sustain existing health programs in developing countries. According to 2009 reports of global aid budgets, Italy and Ireland have reduced development aid by 56 percent and 10 percent. On the other hand, the United Kingdom has protected its aid budget from cuts and Australia, Germany, and the U.S. have all made strong commitments to increase their support and protect vulnerable groups from the impact of the crisis.


“QuoteUnquote”

Why Public Health?

The new Harvard School of Public Health video series “Why Public Health?” asks students why they chose to enter the field. Tell us your story at http://facebook.com/harvardpublichealth. “Public health is a way to do it at a bigger level—to not only play the game, but change the rules of the game. What excites me about public health is that it is at the crux of what’s happening in the world today, whether it be pandemics, humanitarian or natural disasters, terrorist attacks. It’s about strategic thinking, high-level planning, changing the way we do things. It’s also about real technicalities. How do you deliver vaccines to a small village in Africa? How do you ensure that a patient is compliant with their medications?” —Nayana Vootakuru, MPH ‘11

“Public health chose me. I was working in Sudan as a medical doctor. I used to volunteer at the Juba Orphanage, which was the only orphanage in the whole of Southern Sudan. I remember a small kid named Moses who used to fall sick all the time with diarrhea, malaria. We realized that the problem was actually poor sanitation, lack of water—really basic and small things. We raised money and built a water tank at the orphanage. After that, the cases of diarrhea and gastrointestinal tract infections went down. This was my clarion call to join the public health field. With the training I’m getting in economics, in biostatistics, in ethics, I can go out there and, as they say, spread the gospel of public health—and become a better doctor, a better person, and make a greater contribution, not just to Africa, but to the entire world.” —Serufusa Sekkide, MPH ‘11

“I chose public health because, as a practitioner, I started to recognize that I think about the health of my patients beyond their individual risk factors. I think about their social background, where they live. Those factors can contribute to their health just as much as individual behaviors.”

—Brittany Seymour, MPH ‘11 Kent Dayton/HSPH

to see “Why Public Health” videos Visit http://hsph.harvard.edu/multimedia/video/2011/ whypublichealth/index.html.

Spring | Summer 2011

47


Alumni News 1953

ambulatory services at Cambridge

Lorraine Vogel Klerman, MPH,

Health Alliance (CHA), a Harvard-

DPH ‘62, died August 26, 2010 at

affiliated public health care system,

1975

1985

Steven Eastaugh, SM, a

Leslie Korn, MPH, returned from

professor in the Department of

Mexico where, on a year-long

age 81 from complications of can-

where he will provide medical

Health Services Management and

Fulbright Research Grant, she was

cer. Klerman was a champion of

oversight and direction for CHA’s

Leadership at George Washington

studying the effects of develop-

family planning and improved ser-

ambulatory care. Prior to this role,

University, published “Obamacare

ment on indigenous women’s

vices to mothers and children living

Osler was medical director of

2.0: The Need for a Second

traditional medicine practices. In

in poverty. As professor and direc-

Ambulatory Services at CHA and

Healthcare Reformation” in the Fall

2010 she published two books

tor of the Institute for Children,

has been involved in assessing,

2010 issue of Harvard Health Policy

with DayKeeper Press: Preventing

Youth and Family Policy at the

guiding, and improving the health

Review. Eastaugh has taught health

and Treating Diabetes Naturally,

Heller School for Social and Policy

of families and local communities

finance and economics for more

The Native Way and a bilingual

Management, Brandeis University,

for more than 30 years.

than 32 years and is a nationally

book, Plantas Medicinales de la

1974

acclaimed speaker, consultant, and

Selva. Korn is currently research-

agent of change. He also works for

ing and writing about traditional

the Greater Talent Network (gtn-

foods and medicines of the west

speakers.com), which has earned a

coast of Mexico and has posted

national reputation as an industry

photographs and writings online at

Year Awards for her work as presi-

leader among speakers bureaus.

drlesliekorn.com.

dent and CEO of Affinity Health

1983

1988

she received the school’s 2010 Mentoring Award. Klerman mentored hundreds of students in public health, and many have become leading pediatricians, psychologists, nurses, health economists, and health systems analysts.

Maura Bluestone, SM, was named a regional award winner and a national finalist in the 20l0 Ernst & Young Entrepreneur of the

1967

Plan. Bluestone founded the New

J. Jacques Carter, MPH, as-

Mark J. Eisenberg, MPH,

Myron Allukian, Jr., MPH,

York-based public health insurance

sistant professor of medicine at

professor of medicine at McGill

is president of the American

company for low-income individu-

Harvard Medical School and Beth

University and a staff cardiologist

Association for Community Dental

als. Her organization was the only

Israel Deaconess Medical Center,

at the Jewish General Hospital, in

Programs and treasurer of the

New York Regional Finalist from

received the 2010 Harvard Medical

Montreal, recently published The

North East Regional Board of

the health care industry and the

School/Harvard School of Dental

Physician Scientist’s Career Guide.

Dental Examiners. In 2010, he

only from a not-for-profit company.

Medicine Dean’s Community

This handbook provides a com-

was honored at a State House

Catherine Roberts-Clifton,

Service Lifetime Achievement

plete guide for a successful career

ceremony by the Massachusetts

SM, was elected to Penn

Award. Carter was honored for his

as a physician scientist and pro-

Dental Hygienists’ Association

Medicine’s Board of Trustees.

work with the Community Prostate

vides useful advice for every stage

for improving residents’ access

Clifton previously served as an

Cancer Screening and Education

of this challenging career path.

to oral health care. Allukian also

instructor in community medicine

Program. Carter was nominated

lectured at schools of public health

at Tufts University School of

by Russell Phillips, chief of the

1993

in Armenia, Cyprus, and Lebanon.

Medicine. She provides leader-

Division of General Medicine and

He appeared in 15 performances

ship to several charitable and

Primary Care, who said, “Dr. Carter

of the Urban Nutcracker in Boston

civic boards, including service as

exemplifies the spirit of community

last year.

a vice chair of the board of direc-

service through his tireless efforts

1973

tors of the Kimmel Center for the

to inform the underserved of cancer

Performing Arts, as a member of

risk and the importance of screen-

its executive committee, and as

ing to reduce this risk.”

named senior vice president for

chair of its education and audience committee.

48

Harvard Public Health Review

vice president of the University of Chicago Medical Center, was part of a special panel discussion entitled “A Healthy Chicago,” which took place on February 1, 2011. The program was sponsored by PNC Bank and presented by the Chicago Tribune’s “Chicago Forward: Conversations about the

All photos, Kent Dayton/HSPH

David Osler, MPH, was recently

Eric Whitaker, MPH, executive


Future,” a series of live gatherings of policy makers exploring issues

1999 Joseph West, SM, SD ‘04, an

Meet your Alumni Association Representatives

of great importance to the Chicago

epidemiologist at the Sinai Urban

region. Whitaker was joined by

Health Institute, was recently fea-

Dr. Mehmet Oz, Daytime Emmy

tured in a story on NPR-Chicago

award-winning host of “The Dr.

Public Radio WBEZ. He spoke

Oz Show,” and Donna Thompson,

about using his public health

CEO of Access Community Health.

degree with a community-based

1994

mobilization approach to reduce

would like to get more involved as a representative, committee

the impact of type 2 diabetes on

member, volunteer, donor, or mentor, contact the alumni office at

the health of residents of his native

alumni@hsph.harvard.edu.

Richard J. King, MPH, has joined the Health Care Department of the Stevens & Lee law firm in Wilmington, Delaware as a shareholder. King concentrates his practice in health law, with an emphasis on federal and state regulatory compliance and third party reimbursement, including

T

his is the first in a series of brief bios introducing your elected representatives on the HSPH Alumni Council. If you

North Lawndale neighborhood in

and the Fight Against Diabetes

Elsbeth Kalenderian, DDS, MPH ‘89 HSPH Alumni Council President-Elect

(also named The North Lawndale

In October 2007 Dr. Kalenderian was

Diabetes Community Action

appointed assistant dean for clinical affairs at

Chicago. West is program director of the project Block by Block: Neighborhood Cohesion, Activism

Medicare, Medicaid, and non-gov-

Project).

ernmental commercial players. He

2002

is responsible for the overall management of the dental practices, and

also represents health care provid-

the Harvard School of Dental Medicine. She

Col. Joyce Adkins, MPH,

ers in litigation matters in federal

for bridging basic and translational research with clinical research in

was honored with the 2011

and state courts and before the

patient care delivery. As an assistant professor in oral health policy

National Public Service Award

Provider Reimbursement Review

and epidemiology, she participates in the educational and research

at the American Society for

Board, federal administrative law

Public Administration banquet in

efforts of the school. In 2008 she was appointed interim chair for

judges, and state administrative

Baltimore on March 14. Her career

agencies.

includes more than 26 years of

1995

public service across 12 duty as-

Ulrich Schoch, MPH, was recently appointed medical director of a new day care center in Rorschach, Switzerland for refugees and asylum seekers. According to Schoch, Tagesklinik für Psychotrauma is the first facility of its kind in Switzerland. As the lead organization for refugees and asylum seekers in that nation, it will serve as a model for all states in Switzerland that will soon adopt the center’s mission and dedication for treating mental health problems in this underserved population.

signments in the Air Force and Department of Defense. Adkins has been recognized for her clinical

the Oral Health Policy and Epidemiology Department and became its Chair in 2011. Elsbeth’s term as President of the HSPH Alumni Association is fall 2011 through fall 2013.

Sean Dunbar, SM ’08 HSPH Alumni Councilor

skills in mental health, substance

Sean is currently an analyst at the Congressional

abuse, and behavioral medicine.

Budget Office in Washington, D.C. focusing on

Her accomplishments include

low-income health programs such as Medicaid

working to improve the mental

and the Children’s Health Insurance Program

health, post-traumatic stress dis-

(CHIP). He graduated from HSPH in June 2008

order, and traumatic brain injury

with a master of science in health policy and

programs at the U.S. Departments

management. Sean was elected by his class-

of Defense and Veterans Affairs.

mates to represent the Class of ’08 from Fall

She holds a PhD from Vanderbilt

2008–Fall 2011. He serves as Chair of the Alumni-Student Connections

University and completed a health policy fellowship at Harvard Medical School in occupational

Committee and volunteers as a leader of the newly formed HSPH D.C. Alumni chapter.

mental health.

Spring | Summer 2011

49


Michelle Albert, MPH, director

a well-trained mental health

center Department of Surgery.

2006

of behavioral and neurocardiovas-

workforce. Martinez is executive director of the Hogg Foundation for

S. Nassir Ghaemi, MPH, profes-

Anthony Chen, MPH, director

cular cardiology at Brigham and

Mental Health, as well as associ-

sor of psychiatry at Tufts University,

of health at the Tacoma-Pierce

Women’s Hospital and assistant

ate vice president for the Division

was one of 16 medical experts

County Health Department, was

professor of medicine at Harvard Medical School, was interviewed

of Diversity and Community and

by the Boston Globe in December

Engagement and a clinical professor

2010. In the article, “Putting the

at the University of Texas at Austin.

Stress on Stress,” Albert discusses how her research explores cardiovascular disease risk assessment in different racial and ethnic groups, and the role of chronic psychological stress in cardiovascular disease risk.

recently chosen by the QuantiaMD

featured by Northwest Asian

community to receive its esteemed

Weekly in September 2010. The

Community Choice Award for “in-

article describes his path to medi-

novation and excellence in sharing

cine and public health, including

2004

knowledge.” More than 1,000

his decision to earn an MPH at

Anthony C. Antonacci, SM, a

peers rated Ghaemi’s cases and

HSPH, which was influenced by his

nationally recognized expert in

presentations on mental health dis-

desire to intervene in cross-cultural

wound healing disorders, has been

orders with five stars. This landmark

and minority health medicine at

named medical director at Lenox

award signals a new era in medicine

the policy level.

Hill Hospital. Antonacci came from

by redefining how clinicians learn

Christ Hospital in Jersey City, NJ,

from and relate to one another.

Dr. Octavio Martinez, MPH,

where he served as senior vice

was appointed to the National

president of clinical affairs and

Committee on Mental Health

chief quality officer. A board-certi-

Needs of Older Americans in

fied surgeon, Antonacci has exten-

March. Convened by the Institute

sive experience in health care man-

of Medicine of the National

agement, including management of

Academy of Sciences, the commit-

medical affairs; quality and safety

tee will study the mental health

programs; oversight of regulatory

care needs of Americans over 65

compliance processes; clinical and

and make policy recommendations

business operational planning; and

for meeting those needs through

as chairman of a multisite medical

The Harvard Public Health Review is interested in hearing from you. Please send comments or class notes to: Amy Roeder, Assistant Editor Harvard Public Health Review 90 Smith Street Boston, MA 02120 Phone: (617) 432-8440 Fax: (617) 432-8077 Email: review@hsph.harvard.edu

Continuing Professional Education Programs, 2011 Where theory informs practice and practice informs theory June 2011

August 2011

June 6–10 Radiation Safety Officer Training for Laboratory Professionals

August 1–12 Building Design and Engineering Approaches to Airborne Infection Control

June 6–8 Advanced Hands-On CAMEO Training June 13–17 Comprehensive Industrial Hygiene: The Application of Basic Principles June 20–24 Guidelines for Laboratory Design: Health and Safety Considerations July 2011 July 25–29 In-Place Filter Testing Workshop

50

Harvard Public Health Review

August 15–19 Radiological Emergency Planning: Terrorism, Security, and Communication August 17–19 Measurement, Design, and Analysis Methods for Health Outcomes Research September 2011 September 12–16 Forces of Change: New Strategies for the Evolving Health Care Marketplace

September 12–15 Managing Ambulatory Health Care I: Introductory Course for Physicians in Community Health Centers September 29–30 Leadership for Productivity and Health Management: Issues, Innovations, and Solutions October 2011 October 3–6 Ergonomics and Human Factors: Strategic Solutions for Workplace Safety and Health October 23–28 Leadership Strategies for Evolving Health Care Executives

Customized programs are also available. All programs are held in Boston unless otherwise noted. Contact: Deputy Director Paul Tumolo (617) 384-8675 ptumolo@hsph.harvard.edu For additional information or to register, contact: (617) 384-8692 contedu@hsph.harvard.edu https://ccpe.sph.harvard.edu Harvard School of Public Health Center for Continuing Professional Education 677 Huntington Ave. CCPE-Dept. A Boston, MA 02115


Faculty News Awards and Honors

Baicker and Hotamisligil: Kent Dayton/HSPH; Cash, Courtesy of Richard Cash; Epstein, courtesy of Arnold Epstein;Kim: Susan Egan; Subramanian, Kris Snibbe/Harvard News Office

Katherine Baicker, professor of health economics in the Department of Health Policy and Management, was awarded in October one of eight grants from the State Health Access Reform Evaluation (SHARE), a national program of the Robert Wood Johnson Foundation (RWJF), for her study “Using Behavioral Nudges to Improve Disease Management: Cost-Effective Strategies for Improving Care of Low-Income Diabetes.” The SHARE program funds quick-turnaround, policyrelevant studies to help states implement national health reform. A paper co-authored by Baicker and published in Health Affairs in February 2010, “Workplace Wellness Programs Can Generate Savings,” was selected for the Outstanding Journal Article Award from the Care Continuum Alliance. Barry Bloom, Harvard University Distinguished Service Professor and Joan L. and Julius H. Jacobson Professor of Public Health, was named a Fellow of the American Association for the Advancement of Science “for his many contributions to and leadership in the areas of infectious diseases, vaccines, and global health.” Bloom was recognized at the Fellows Forum held in

February during the AAAS Annual Meeting in Washington, D.C.

The Casebook on Ethical Issues in International Health Research, edited by Richard Cash, senior lecturer on international health, and Daniel Wikler, Mary B. Saltonstall Professor of Population Ethics and Professor of Ethics and Population Health, and published by the World Health Organization, was cited as “Highly Commended” by the British Medical Association’s Medical Book Awards in December.

Arnold Epstein, John H. Foster Professor of Health Policy and Management and chair, Department of Health Policy and Management, was named in September to the new Government Accountability Office PatientCentered Outcomes Research Institute Board of Governors. Sarah Fortune, assistant professor of immunology and infectious diseases, was named a PopTech Science and Public Leadership Fellow in September. Fellows are

“high-potential early- and midcareer scientists working in areas of critical importance to the nation and the planet. They represent a corps of highly visible and socially engaged scientific leaders who embody science as an essential way of thinking, discovering, understanding and deciding,” according to the PopTech website. Sofia Gruskin, associate professor of health and human rights, was appointed to the Institute of Medicine’s Committee for the Outcome and Impact Evaluation of Global HIV/AIDS Programs in October.

Gökhan Hotamisligil, J.S. Simmons Professor of Genetics and Metabolism and chair, Department of Genetics and Complex Diseases, was awarded the 2010 Naomi Berrie Award for Outstanding Achievement in Diabetes Research, presented by Columbia University Medical Center in November. His 2006 article in Nature, “Inflammation and Metabolic Disorders,” was selected by Essential Science Indicators from Thomson Reuters in October as the most-cited paper in the research area of clinical medicine.

Jane Kim, assistant professor of health decision science in the Department of Health Policy and Management, received this year’s ASPH/Pfizer Young Investigator’s Award for Distinguished Research in Public Health. The honors recognize graduate public health faculty members for their teaching, practice and research excellence. She was honored at the ASPH Annual Meeting Reception, in Denver, in November. Joel Schwartz, professor of environmental epidemiology, was awarded a Doctor honoris causa from the medical faculty of the University of Basel Switzerland at a ceremony in November.

S.V. Subramanian, associate professor of society, human development, and health, won an Investigator’s Award in Health Policy Research from the Robert Wood Johnson Foundation in September. The awards recognize “scholars who will tackle some of America’s most difficult health concerns and inform policy on these issues,” according to the RWJF website.

Spring | Summer 2011

51


Promotions

Bookshelf

Manoj Duraisingh, associate professor of immunology and infectious diseases

Epidemiology and the People’s Health: Theory and Context Nancy Krieger

Stephen Gilman, associate professor of society, human development, and health

Oxford University Press 408 pages

New Appointments Jorge Chavarro, assistant professor of nutrition and epidemiology Alan Geller, senior lecturer on society, human development, and health Sebastien Haneuse, assistant professor of biostatistics Ana Langer, professor of the practice of public health and coordinator of the Dean’s Special Initiative in Women and Health, Department of Global Health and Population

John McDonough, professor of the practice of public health in the Department of Health Policy and Management, and director of the new Center for Public Health Leadership in the Division of Policy Translation and Leadership Development Benjamin Sommers, assistant professor of health policy and economics

Epidemiology is often referred to as the science of public health. But unlike other major sciences, its theoretical foundations are rarely articulated. While the idea of epidemiologic theory may seem dry and arcane, it is at its core about explaining the people’s health. It is about life and death, biology and society, ecology and the economy, and how myriad aspects of people’s lives—involving work, dignity, desire, love, play, conflict, discrimination, and injustice—become literally incorporated biologically into our bodies and manifest in our health status, individually and collectively.

Written by Nancy Krieger, an influential social epidemiologist and HSPH professor of society, human development, and health, this conceptually rich and accessible book is a rallying cry for a return to the study and discussion of epidemiologic theory: what it is, why it matters, how it has changed over time, and its implications for improving population health and promoting health equity.

AIDS at 30: Hard Lessons and Hope continued from page 25

Q:

UNAIDS recently called for a revolution in “HIV prevention politics, policies, and practices.” In your view, what would such a revolution look like?

Fineberg: The biggest revolution

would be a revolution that genuinely acted on the belief that every life had the same value as every other life. We would change the way we support countries, moving resources from armament shipments to injection equipment. Ojikutu: We would have a grander

vision of global health. It isn’t about emergency responses, it isn’t about dropping medications and equipment and supplies into a country. The revolution would 52

Harvard Public Health Review

establish stable, well-resourced primary health care systems throughout the developing world, so that prevention and treatment of chronic diseases like HIV can be available to all. Essex: Rhetoric like the word

“revolution” sometimes seems unrealistic, but it has benefits. I remember when the World Health Organization proposed the “3 by 5” program, in which 3 million infections would be prevented by 2005. They didn’t get there—they missed it by years. But if they hadn’t pushed that to the extent that they did, we’d be five years behind where we are now.

Q:

What have been the unique contributions of HSPH during the AIDS epidemic?

Kanki: With the School’s PEPFAR work, we learned a tremendous amount about scaling up a large, complex program in three different countries in Africa. If a clinic was going from, say, 35 patients to 350 patients a day by the end of the year, we learned to ask: Do they have a waiting room that can handle that? Do they have enough lab staff? Is there a pharmacy with locks and bars on the windows and refrigerators that can keep pediatric drugs cool? You learn how goods come into the country, how utilities work, whether the water supply is reliable. We


helped our colleagues determine if the programs were working, how to improve them within the confines of the local environment, hopefully, how to maximize their impact for the public health of the populations served. And over the past three decades, we have built up long-term partnerships with a number of countries in Africa and Asia—Senegal, Botswana, Tanzania, Nigeria, Thailand. Though these might have started out as researchbased projects, they expanded into multidisciplinary public health programs that included training, policy development, and health system strengthening.

Tracking the Long-Term Effects of Lifesaving Drugs For more than 20 years, George Seage, associate professor of epidemiology, has explored the behavioral and biological aspects of HIV transmission. In September 2010, he received an $82.2 million, fiveyear grant—the second-largest award to the School, after the federal PEPFAR grant—to study two questions: What are the long-term effects on children whose mothers were administered antiretroviral therapy (ART) during pregnancy? And what are the long-term effects of HIV infection acquired just before or after birth on the subsequent growth and development of adolescents? The award is part of the federal Pediatric and HIV/AIDS Cohort Study (PHACS). With the expanding global epidemic of HIV infection in children, PHACS has enabled re-

Fineberg: When I was Dean, I

searchers to systematically study

felt keenly that it was important to champion a University-wide initiative. It was the only way I could see to bring the full force of Harvard’s capacities onto what I believed to be the dominating health problem of our age. Although public health always considers itself multidisciplinary, it required deeper levels of expertise and breadth than any one faculty represented, even public health. But getting people together on this required a constant stirring of the pot.

the long-term consequences of

Essex: Being at a school of public health gave me more insight and more latitude to move rapidly in the research than if I had been in a more restricted institution. One of the things that I am grateful for here is the value of interdisciplinary research, and an appreciation and respect for the talents of colleagues who have very different skills. At the very earliest stages of the epidemic,

antiretroviral therapies administered early in life. According to Seage, “These are critically important questions. There are approximately 15 million HIV-infected women of childbearing age throughout the world, with slightly more than half receiving ART when they become pregnant. And there are more than 2.5 million children infected around the time of birth with HIV, only a small fraction of whom are on ART. PHACS will evaluate the safety and effectiveness of antiretroviral therapy among these populations.”

—Madeline Drexler some of the people who were most interested and sympathetic and creative were the biostatisticians. Marlink: The Harvard School of Public Health AIDS Initiative has had three “rules of engagement” with our partnerships in other countries. The first rule is that the partnership has to benefit the people of the country involved. The second

is that the partnership is not about a particular project or research question, but about a handshake and a relationship that’s going to continue beyond any one project. The third—and most important rule—is that we are not in charge. We get a lot more done when we are guided by the people who live the problem every day. b Spring | Summer 2011

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Harvard Public Health Review Dean of the Faculty Julio Frenk Alumni Council As of November 2010 Officers Royce Moser, Jr., mph ’65 President Elsbeth Kalenderian, mph ’89 President-Elect Anthony Dias, mph ’04 Secretary Mark S. Clanton, mph ’90 Immediate Past President Alumni Councilors 2008-2011 G. Rita Dudley-Grant, MPH ‘84 Sean Dunbar, SM ‘08* Maxine Whittaker, MPH ‘86

Visiting Committee Jeffrey P. Koplan, MPH ’78 Chair Ruth L. Berkelman Joshua Boger Walter Clair Nicholas N. Eberstadt Tore Godal Jo Handelsman Risa Lavizzo-Mourey Bancroft Littlefield Nancy T. Lukitsh Vickie M. Mays Michael H. Merson Anne Mills Kenneth Olden John W. Rowe Bernard Salick Burton Singer

Board of Dean’s advisors Jeanne B. Ackman Theodore Angelopoulos George D. Behrakis Katherine S. Burke Jack Connors, Jr. Jamie A. Cooper-Hohn Antonio O. Garza C. Boyden Gray Rajat K. Gupta Mala Gaonkar Haarmann Richard L. Menschel* Roslyn B. Payne Swati A. Piramal Alejandro Ramirez Carlos E. Represas Richard W. Smith Howard Stevenson Samuel O. Thier Katherine Vogelheim

*emeritus

2009-2012 Marina Anderson, mph ’03 Rey de Castro, SD ’00 Cecilia Gerard, SM ’09* 2010-2013 Teresa Chahine, SD ’10* Sameh El-Saharty, MPH ‘91 Chandak Ghosh, MPH ‘00 *Class Representative

For information about making a gift to the Harvard School of Public Health, please contact: Ellie Starr Vice Dean for External Relations Office for External Relations Harvard School of Public Health 90 Smith Street Fourth Floor Boston, Massachusetts 02120 (617) 432-8448 or estarr@hsph.harvard.edu For information regarding alumni relations and programs, please contact, at the above address: Jim Smith, Assistant Dean for Alumni Affairs (617) 432-8446 or jsmith@hsph.harvard.edu www.hsph.harvard.edu/give

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Harvard Public Health Review

The Harvard Public Health Review is published three times a year for supporters and alumni of the Harvard School of Public Health. Its readers share a commitment to the School’s mission: advancing the public’s health through learning, discovery, and communication. Harvard Public Health Review Harvard School of Public Health Office for External Relations 90 Smith Street Fourth Floor Boston, Massachusetts 02120 (617) 432-8470 Please visit www.hsph.harvard.edu/review and email comments and suggestions to review@hsph.harvard.edu. Dean of the Faculty Julio Frenk T & G Angelopoulos Professor of Public Health and International Development Vice Dean for External Relations Ellie Starr Associate Vice Dean for Communications Julie Fitzpatrick Rafferty Director, Strategic Communications and Marketing Samuel Harp Editor Madeline Drexler Senior Art Director Anne Hubbard Assistant Editor Amy Roeder Principal Photographer Kent Dayton Contributing Writers Debra Bradley Ruder, Carol Cruzan Morton, Thea Singer © 2011 President and Fellows of Harvard College


Barrie Damson has generously supported Harvard School of Public Health for close to 15 years. He enjoys the connections he forms with individual students—whether they’re from Angola or Pittsburgh—by giving to financial aid.

Barrie Damson on why he gives to financial aid for students at Harvard School of Public Health

“I

f you were to sum up in one word the work that’s done at the School, that word would be ‘preventative.’ To me, that’s such a key to the world we live in today. My own nature is to be as proactive as I can be, and I think that’s what the school represents: a desire to be there early, to be there with a great deal of knowledge, and to be broad-based.

“People who study at the School are truly committed. They face huge challenges, and when they succeed, their rewards are never monetary. To be part of that has a natural appeal to me. I want to work to make a difference in the world, and that’s what people in the school are doing.”

Please give to support financial aid today. To find out how, visit http://hsph.harvard.edu/give/ or call Erin Lyons at +1 (617) 432-8428.

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Join the Global Conversation The Forum at Harvard School of Public Health presents high-definition, broadcast-quality webcasts on timely public health issues and scientific controversies. Using the unique convening power of Harvard, The Forum brings together leading scientific and academic experts from around the world with those in positions to address the issues, change policy, and initiate action. The Forum’s webcasts can be viewed live and on-demand on all types of video devices. Online viewers are encouraged to send in questions for the panelists, suggest issues for future webcasts, and post commentary. Viewers can become members of The Forum by registering at http://www.hsph.harvard.edu/forum/register.cfm. Visit www.ForumHSPH.org to learn more and watch on-demand video of recent webcasts, including:

Boosting Vitamin D: Not Enough or Too Much?

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Harvard Public Health Review, Spring/Summer 2011