Harvard Public Health Review, 75th Anniversary Issue, Vol. II

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Harvard Public Health Review W e cannot a!!ow hea!th to remain a secondary dimension as w e focus our resoive into a n e w century. Heaith is pivota!

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Harvard School of Public Health Evolution of a Global Leader

ALUMNI COUNCIL OFFICERS

VISITING COMMITTEE 1997-98

Joel F. Finlay, M.p.H.'$2.

Pras^eMf

Stephen B. Kay

Joan M. Altekruse, M.p.H.'g^ Roslyn U. Fishman, M.r.H.'/n Myron Allukian, Jr., M.P.H/67

COUNCILORS 1995-98 George E. Hardy, Jr., M.p.H/70 Steve U. McKane, M.p.H.'yc) Susan L. Warren, M.p.H.'p^ 1996-99 Norma M . Swenson, M.p.H/73 Thomas J. Van Gilder, M.p.H.'$i6 i997"00 Richard W. Clapp, M.p.H.'7^ William H. Faidi, M.p.H.'c<8 Marty Makary, M.p.H.'$)7 Gail Price, s.M.'86 Mervyn F. Silverman, M.P.H.'6$ REGIONAL REPRESENTATIVES Francisco J. Ramos-Gomez, M.p.H.'$o Christopher T. Spina, M.P.H.'pi

Abdul Rahman Al-Awadi, M.p.H.'g^ Theodore Angelopoulos Gerald L. Chan, s.M.'7^, s.D/79 Phyllis D. Collins Kenneth H. Cooper, M.p.H.'62.

Prudence S. Crozier Albina du Boisrouvray William H. Foege, M.p.H.'6^ Arthur L. Goldstein Abraham D. Gosman Vincent L. Gregory, Jr. Robert Z . Gussin Virginia R. Hannon, s.M.'gi, s.D.'68 Jack R. Harrison Teresa Heinz Julie E. Henry Alice S. Huang Julius H. Jacobson 11 Sherman A. James Joyce C. Lashof Sandra O. Moose Woodrow A. Myers, Jr. Robert D. Reischauer Bernard Salick Melvin R. Seiden Jaime Sepulveda, M.p.H.'8o, s.M.'8i, s.D.'85 Huey-Jen Jenny Su Flossie Wong-Staal

DEAN DESIGNATE Barry R. Bloom EDITOR Kevin J. Sottak SENIOR WRITERS Terri L. R utter Peter Wehrwein CONTRIBUTORS Sarah Abrams Marcella Bernard John Lauerman Harriet Washington Robert Zalisk DESIGN Anne M. Hubbard Copyright

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Harvard School of Public Health Boston, Massachusetts AH Rights Reserved The PM^/zc Pfaa^/? is published biannually by the Office of Development and Alumni Relations.

Letters to the editor and requests for additional copies should be mailed to the Communications Office, Harvard School of Public Health, 1 1 6 Huntington Ave., Boston, M A 02116.

DEAN'S COUNCIL Barrie M. Damson John H. Foster O. Milton Gossett Vincent L. Gregory, Jr. Beth Martignetti John H. McArthur Richard L. Menschel Jane Bryant Quinn Paul G. Rogers Martin E. Segal Lois E. Silverman Eliot I. Snider Frank Stanton Ladislaus von Hoffmann Robert C. Waggoner William S. Woodside

CORRECTION It was incorrectly reported in Volume 1 of the 75th Anniversary H<2?TW(f HiMM? ReM'eM/ that Jane Worcester, professor of biostatistics from r c ^ i to 1 9 7 7 , died at age 88. She died in 1989 at age 78.

Harvard Public Health Review 75TH ANN!VERSARY)SSUE

VOL. H

From the Dean 1972-1984 A T a t e of Six Cities Howard Haim Hiatt: Dean, 1972.-15)86 William Curran: The Father of Health Law Protecting the Medical Commons Armen Tashjian Alonzo Yerby: Champion of the Poor Living Schweitzer's Legacy Nantucket Fever Front

Center: HSPH and the Centers for Disease Control and Prevention

1985-1997 50

The Gathering Storm

58

Harvey Vernon Fineberg: Dean, 1 9 8 6 - 1 9 9 7

64

Richard Levins: Dialectics of Disease

67

Marvin Zelen: Health by Numbers

70

Prevention as Politics: The Re-awakening of Public Health's Political Conscience

78

Global Arena: HSPH and the World Health Organization

83

Mortal Lessons: HSPH Faculty Confront a Uniquely American Scourge

91

Camera Ready: Timothy Johnson, M.p.H/74

93

Six Decades of the HSPH Alumni Association

From the Dean < ' M D E L I G H T E D T O PRESENT THE S E C O N D HISTORICAL ISSUE O F T H E ] H^w^rJ

Hg^^/? Rwz'ew, which concludes the 75-year retrospective

H of the Harvard School of Public Health. The first volume, published in the winter of 1 9 9 7 , surveyed achievements from the School's founding in 1 9 2 1 through the conclusion of Dean John Snyder's tenure in 1 9 7 1 . This volume completes the series by recounting important contributions from 1972. through 1 9 9 7 . Included are profiles of the School's last two deans, Howard H. Hiatt and Harvey V. Fineberg, and articles detailing the contributions of faculty and alumni to the understanding of environmental disease, violence, health care systems, health law, emerging diseases, and A I D S . There are also articles highlighting the productive relations between H S P H graduates and the world's premier public health agencies, the World Health Organization and the Centers for Disease Control and Prevention.

One cannot help but be impressed by the diversity of personalities, abilities, and achievements represented in these pages. I can think of no other field that draws together such a rich variety of scientific disciplines, professional expertise, and personal experiences. Equally notable is the School's contribution to the dramatic transformation of public health over the last quarter century, a period that has seen the introduction of molecular biology, sophisticated statistical analysis, and large-scale, prospective epidemiologic studies that have redrawn the boundaries of health inquiry and revitalized interest and faith in the public health enterprise. That the School today stands positioned to help lead this enterprise into the 2.1st century is, I think, a tribute to the thousands of men and women whose dedication and industry during our first 75 years have provided a solid foundation for our continued success.

Acting Dean James Ware

RESIDENT R I C H A R D NIXON'S HISTORIC VISITS

H H ^ to China and the Soviet Union begin to ease Cold War hostilities and provide an auspicous start to the year 1972.. In June, however, the arrest of five men inside the Watergate Arms hotel marks the beginning of a new presidential drama that eventually leads to Nixon's resignation. The fall of Saigon in 1 9 7 $ ends the U.S. w a r in Vietnam, but in Cambodia, the Middle East, Northern Ireland, Africa, and parts of South America blood continues to flow as a result of revolution, terrorism, and state-sponsored violence.

Despite a worsening U.S. health care crisis and a disastrous national Swine flu vaccination effort, the seventies provide the stage for public health's greatest triumph: the global eradication of smallpox.

However, even while the world celebrates this victory, a more sinister infectious disease threatâ&#x20AC;&#x201D; AIDSâ&#x20AC;&#x201D;is taking root.

At the School of Public Health, H o w a r d Hiatt, the School's fifth dean, harnesses the new molecular research capabilities to solve some of the more intractable public health challenges. Hiatt also positions the School to begin "diagnosing" and "treating" the nation's ailing health-care system.

In doing so, he will help redefine the parameters and practice of public health.

% HA H H E R E D I D r r A L L B E G I N ?

W W Did it arise out of a deadly London smog that killed 4,000 people in the space of a few days in early December 1952.? Could it have sprung in part from the long-standing interest in pulmonary physiology sparked by polio research? Was it Energy Crisis-induced anxiety over the impact of burning increased amounts of high-sulfur coal in a period of high-priced oil? Or a sense among 1970s scientists and policymakers that the science base for

1972

Harvard President Derek Bok (right) appoints Howard H. Hiatt, professor of medicine at Harvard Medical School, as the fifth dean of the Harvard School of Public Health.

a taie of

six cities

American air pollution standards was insufficient?

Whatever the reasons, in late 1 9 7 3 ' Professor Frank Speizer found himself driving to Logan Airport while then-Department of Physiology head James Whittenberger read a proposal so fresh (in that pre-personal computer era) that some reordered paragraphs literally had been cut and pasted together. The proposal Whittenberger conveyed to Washington, composed by Speizer and his colleague, Benjamin Ferris,

Alexander Leighton and Jane Murphy, who hold appointments in the Department of Behavioral Sciences, begin studying the social, cultural, and psychological consequences of the war-time defoliation program using Agent Orange in Viet Nam's Mekong Delta.

described what was to become one of the most influential, innovative, and longest-running experiments concerning the health effects of air pollution in America: the Harvard Six Cities Study.

The Six Cities Study was an expansion of Ferris's pioneering effort to bring modern laboratory techniques and tools into people's homes, both for sampling air quality and for monitoring health effects. For the first time in this country, public health researchers directly correlated environmental exposure to toxins with health impacts. The work, which continues today, set a standard for research in air pollution that is emulated throughout public health and around the world.

As the study's principal investigator, Ferris was an important part of this hands-on research philosophy.

A pediatrician by training, Ferris had been recruited by Whittenberger to what was then the Department of Physiology from Boston Children's Hospital in 1948 because of Ferris's interest in pulmonary function in children with polio. Prior to the invention of the polio vaccine, Ferris had instructed physicians in caring for paralytic polio victims using the iron lung.

"He had a very good background," recalls Whittenberger, now at the University of California, Irvine. "And I didn't know how hard a worker he was at that point, but he proved to be a very thorough scientist."

When the Salk and Sabin vaccines all but extinguished the polio threat, Ferns expanded his horizons. On a 1 9 5 7 trip with Whittenberger to a

The United States withdraws troops from Vietnam.

coal-mining region of Wales, he saw entirely new techniques being used to study the impact of air quality.

"They started out by selecting a probability sample of coal miners, and once they determined the sample size, they made an effort to get everyone in the group examined," Whittenberger recalls. "Previously, this kind of study would have been a matter of examining a number of people at certain exposure levels; that kind of data couldn't be generalized to a larger population. So this was a new concept, and a major methodological improvement."

Impressed and energized, Ferris returned home where he immediately began a similar study not far from his wife's summer home, in the New Hampshire paper mill town of Berlin. Initially, the Brown Paper Co. refused Ferris' request for access to systematically sample air quality and monitor worker health in its factory.

Ferris, reasoning that pollutants were still coming out of the smokestack, began studying the community surrounding the mill. When he demonstrated the adverse health impact of sulfur dioxide emissionsâ&#x20AC;&#x201D;[including lowered lung function]â&#x20AC;&#x201D;the paper company agreed to reduce them.

ERRIS H A D BEEN BITTEN BY T H E held epidemiology bug, and he applied his own exacting standards to its execution. But when the Environmental Protection Agency ( E P A ) instituted a large-scale study of air pollution's health effects in the mid-i$6os, Ferris was one of many scientists who was highly critical.

The C H E S S (Community Health and Environ-mental Surveillance

Systems) Study was an attempt by E P A to provide scientific justification for the air quality standards set by the 1 9 6 7 Clean Air Act. However, Ferris and other critics in academe and industry charged that the study put the conclusion cart before the raw data horse. Specifically, exposure thresholds that had been set by the E P A for airborne toxins appeared to have limited correlation to the study's observations.

"The criticism had to do with data collection problems, machine calibrations, training, and the use of standardized questionnaires," recalls Speizer, now Professor of Environmental Science, Edward H. Kass Professor of Medicine at Harvard Medical School, and Codirector of the Channing Laboratory.

"And then, on the analysis side, some very funny things that none of us thought could possibly be there were forced on the data to fit the E P A ' s threshold models. I don't think there was any true malicious intent to defraud, but it was a very difficult problem."

Senate hearings followed, and before long the National Institute of Environmental Health Sciences (NiEHs) was founded to assume the EPA's biomedical research burden.

While the discredited CHESS study's findings were never released, strong national interest in air pollution persisted. Large amounts of high-sulfur coal were being mined for electric power production, and it appeared that even more coal might be burned in the wake of the Arab-Israeli War of October 1 9 7 3 , which severely damaged US relations with many oilproducing countries in the Middle

Report of President Bok's Committee to Study the Future of the School of Public Health recommends closer cooperation with Harvard Medical School, but calls " w e a k " the case for outright merger. The 12-member committee, chaired

by President Bok, includes HSPH faculty members Roger Nichols, Thomas Mack, Jean Mayer, Dade Moeller, Robert Reed, and Alonzo Yerby; Julius Richmond of the medical school; and experts from The Commonwealth Fund, Rockefeller Foundation, Cornell Medical College, and the University of Pittsburgh.

East and played a role in precipitating the late-i970s Energy Crisis.

A key research objective was to gain more knowledge about sulfur dioxide; many attributed the deadliness of the London smog and another pollution disaster that occurred in 15)48 in the mill town of Donora, Pennsylvania, to this chemical.

"The big thing was to decide whether it was sulfur dioxide or smoke," that had precipitated the deaths, Whittenberger says. "That's basically what the Six Cities Study was supposed to do."

T h e n - N i E H S director David Rail believed that such an important study should not be done in a government laboratory, but in a university setting with support, peer review, and funding from N I H . When he asked whether Ferris and Speizer would perform the study, Whittenberger assumed that the answer would be a polite " n o . " " I didn't think they would be interested in such a large undertaking," said Whittenberger. The study as proposed called for at least 1 0 years of

work, and it would be three years until any descriptive data could be published, five years or more before any papers concerning the impact of air pollution would be ready. As a career move, it was a gamble. " I suppose we were a bit naive," says Speizer, "but we assumed it was worth doing, and it never crossed Ben's or my mind that we wouldn't take a shot at it."

Speizer and Ferris soon discovered that a national air quality network they had hoped to use had been dismantled. This, however, turned out to be a blessing in disguise, since it allowed them to conceptualize and design their own monitoring systems and measurements, with the help of other faculty from the School. " I was an assistant professor just starting out," says John Spengler, s.M.'73, now Professor of Environmental Health and Director of the Environmental Science and Engineering Program. "I was doing some work on the exposures of commuters in Boston, and Ferris asked if I would play a role."

Fern's f r / g ^ Joseph e^pTweMf /or wieasMn'Mg /Mwg /MMCfWW.

"Iron lung" inventor Philip Drinker, professor of industrial hygiene emeritus, and world-renowned typhus and onchocerciasis investigator George Cheever Shattuck, clinical professor of tropical medicine emeritus, die.

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Working on the 13TH floor of Building 1 , Spengler and his team of doctoral students and young engineers designed and built a variety of personal air monitoring systems and home sampling equipment. A key challenge was keeping the disruption to a minimum, particularly for those subjects who were asked to wear personal air samplers.

"Essentially we put the batteries, electronics, and pumping system into a box about the size of a Tupperware container and added some shoulder straps," Spengler says. "It was very quiet, and it had to be because people took them to church, work, their bedrooms, everywhere they went." ^ ^

OON AFTER COMING TO THE School in the Fall of 1 9 7 4 , epidemiologist Douglas Dockery became involved in the study. His days were spent traveling to the study sitesâ&#x20AC;&#x201D;Watertown, Massachusetts; Portage, Wisconsin; Topeka, Kansas; Kingston/Harriman, Tennessee; St. Louis, Missouri; and Steubenville, Ohioâ&#x20AC;&#x201D;setting up air pollution moni-

HSPH faculty vote to replace the existi ng " Sat Isfactory/U nsatisfactory" grading system with tetter grades, but students balk.

Burglars caught break ing into Democratic Party headquarters in the Watergate office building.

Contributions of the Six Cities Study Particulate M a t t e r and Suifur Dioxides

Acid Aerosols Development of methods for measuring ambient acid aerosol concentrations.

Decline in lung function of children following particulate and sulfur dioxide episodes in Steubenville, Ohio.

Collection of daily concentrations for at least one year in each city.

Suggestive evidence that respiratory symptoms my be associated with acid aerosol concentrations.

Respiratory illness reporting among children increased by approximately a factor of two between least polluted and most polluted communities.

Nitrogen Dioxide Respiratory symptoms and lower lung function among children associated with use of gas stove, a source of NO2.

increased incidence of respiratory symptoms associated with daily particulate and sulfur dioxide concentrations. increased daily mortality associated with Particulate air pollution shown in Steubenville, St. Louis, Missouri; and Kingston/Harriman, Tennessee.

Respiratory symptoms seem to increase with measured indoor NO2 concentrations.

indoor Air PoHution a n d Environmenta) Tobacco S m o k e Association between smoking indoors and particulate concentrations, and gas stoves and NO2 concentrations quantified.

Effects of passive smoke exposure on respiratory health of children documented.

Evaluation of respiratory health effects of indoor pollution quantified with indoor particulate and NO2 measurements.

Effects of indoor aero-allergens on respiratory health of children quantified.

Ozone Acute declines in lung function of children observed in low-level ozone exposures in Kingston/Harriman, Tennessee.

tors in people's homes and doing Personal exposure measures.

It has always amazed me how 'nterested and cooperative people ^ e r e , " says Dockery, now Associate Professor of Environmental Science and Epidemiology, " W e would go mto people's homes and set up equipment; we would have all "Ms of boxes and noisy pumps, and they were still very happy to Parttcipate. There were people w h o ^ o u l d drill holes m the side of their houses just to make our samPl'ng easier, and they would stay the program for a year or more."

Bangladesh (formerly " S t Pakistan) and Sri Lanka (formerly ^ y l o n ) proclaimed '"dependent r e p u b l i c .

" H e was the calm one," recalls Speizer, "and 1 was the excitable one.

1 would come into his office and yell and scream about problems, and after we talked for a while, everything seemed all right."

him a memorable figure, and an annual report he produced on fatal mountain-climbing incidents contributed greatly to safety in the sport.

He frequently combined his climbing ability and respiratory research when he single-handedly carried his 55pound spirometer—an instrument for measuring lung capacity—to the top floor of Watertown tripledeckers in order to test study subjects. His dedication to the study led him to personally interview thousands of the more than 2.0,000 children and adults enrolled in the study.

Ferris's accomplishments as a mountaineer alone would have made

" H e made a point of going to each of the cities once a year to interview

But no researcher or subject was more enthusiastic about the study than the principal investigator himself. Benjamin Ferris—who died in 1 9 9 6 — w a s a man of Renaissance proportions: a physician, a photographer, an enthusiast of food and wines, and, by all accounts, a gentle and caring person.

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U.S. Supreme Court declares w a y in which the death penalty is imposed is unconstitutional.

Surgeon General's report w a r n s of dangers of "sidestream s m o k e " to nonsmokers.

U.S. birthrate i s 1 5 . 8 per 1,000 according to t h e National Center for Health Statistics.

8 ^ ^

subjects, working incredibly long hours far into the night for a couple of weeks," says Dockery, who accompanied Ferris on many held trips around the country. "His forte was getting people to participate.

First, he would administer the questionnaire and talk with people; then, after he had gained a rapport, he would ask them if they would mind doing one more little test, and bring out the spirometer. Fm sure that if he started out with that huge piece of equipment, many of them never would have participated. He was very gentle and everyone really enjoyed working with him."

all, the study showed that indoor air quality was far more important to overall health than outdoor air; most people simply spend much more of their time indoors, and pollutants often become concentrated inside homes and workplaces. The study also indicated a strong, positive correlation between levels of air pollution and mortality: deaths from lung cancer, pulmonary disease, and heart disease were 2.6 percent higher in Steubenville—a city so polluted that air-born sulfates turned lead-based housepaint black within a year—than in Portage, the cleanest city in the study.

As Whittenberger had predicted, it was years until the Six Cities Study produced data on the health impact of air pollution. When it did, however, the results were different from what anyone had expected. First of

However, rather than indicating sulfur dioxide as the culprit emission, the Six Cities Study directed attention to so-called particulate matter, now recognized as a dangerous form of air pollution. Specifically, the study highlighted the hazards of socalled P M 1 0 particles, which are 1 0 microns in diameter and smaller.

This lethal relationship between particulates and cardiovascular mortality has been replicated in studies performed in cities around the world.

Following the release of the study's results in 1 9 9 3 , says Dockery, the American Lung Association brought suit against the Environmental Protection Agency to update its standards on particulate matter pollution, which had not been reviewed in accordance with the Clean Air Act in well over five years.

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1973

Elimination of federal funding for teaching and student aid to schools of public health creates an impending financial crisis at the School. The School stands to lose $2.4 million in federal funds by 1976.

"The quality and quantity of the data were both very impressive," says Mort Lippmann, a New York University Medical Center professor of environmental science who served on the E P A ' s Clean Air Scientific

^MOcMifg Pro/eMor o/^EMtwoMfMgM^ Ep^gw/o/ogy DoMgV^K Dockery Advisory Committee. "This was the largest epidemiologic study of the effect of pollution on individuals that was available. It was done very carefully over a long period of time, and it had to be taken very seriously." ^ ^

IX CITIES S T U D Y D A T A W A S A L S O cited in the E P A ' s standards for nitrous oxide and for ozone. At a recent School of Public Health symposium, current N I E H S director Kenneth Olden praised the study for laying a firm scientific foundation for regulatory policies. Numerous foreign countries have consulted the study when reviewing their limits for particulate matter pollution. The study developed important research tools that went into the hands of public health researchers everywhere.

Biostatistical innovations—such as longitudinal data analysis, compensation for missing data and "smoothing" techniques—as well as air sampling techniques that were developed for the Six Cities Study are now used

Sears tower completed in Chicago

in a variety of research settings.

In the laboratory of Joseph Brain, s.D.'66, Chair of the Department of Environmental Health and Cecil K. and Philip Drinker Professor of Environmental Physiology, dust from the study's filters has been used in animal models to study pulmonary disease. Conversely, these animal studies have suggested further modifications in sampling and data analysis in the Six Cities Study.

At the outset it was expected to be 12. years," says Dockery, "and that we did do. But what was surprising was how many offspring and

"t"re dean Harvey V. Fineberg joins the as assistant professor of wealth services administration

spinoff studies of the Six Cities Study there are."

The Five Cities Study and TwentyFour Cities Study have examined the long-term effects of acid aerosols on schoolchildren in the United States and Canada. All three studies continue to yield data that strongly influences the direction and content of American air quality policy, including the possible adoption of standards that may restrict emissions of smaller P M 2 . 5 particles.

"The debate on lowering the P M standard is based on this environmental epidemiology program, and

I don't think it's overstating the case to say that the Six Cities Study data has been one of the bedrocks of the Clean Air Act," says Brain.

"The research that has been done by the Ferris' disciples has spawned a method and approach that's been used all over the world, and all of us are the beneficiaries."-^

Roger Revetle, Richard Saltonstal) Professor of Population Policy and Director of the Center for Population Studies, becomes president-elect of the American Association for the Advancement of Science.

10

Howard Haym Hiatt ean,

T WASN'T PRESIDENT

1972

KENNEDY'S

1984

sion of the Peter Bent Brigham

speech at Berlin's B r a n d e n b u r g

Hospital and about Harvard's plan to

G a t e s , but history w a s made on a

build a new energy plant on Brookline

local scale on a warm spring day in

Avenue. A lot of folks were worried

1 9 7 9 when H o w a r d Hiatt stood to

about the health implications, and

address a group of Mission Hill resi-

there was a general feeling that

dents inside Boston's Mission Church.

Harvard wasn't listening." In March,

Perched on a low bluff overlooking

community activists had sent Hiatt

Harvard's

and medical school Dean Daniel

sprawling

Longwood

Medical Campus, the Church stands

Tosteson angry letters threatening to

at the foot of the working-class, multi-

disrupt graduation to protest the ener-

ethnic M i s s i o n Hill neighborhood.

gy plant's construction. Hiatt, in char-

Hiatt, a tall, august man then in his

acteristic fashion, responded swiftly,

seventh year as dean of the School of

appointing Smith, then supervisor of

Public Health, spoke about the importance of building

the School's mailroom and a Mission Hill resident, as

partnerships between the School and the Mission Hill

community liaison and authorizing a series of outreach

community. But the substance of his talk was, for the

efforts that brought together faculty, staff, and Mission

most part, eclipsed by the man himself: although

Hill residents. Even after the immediate crisis passed,

Harvard's medical and public health schools had stood

Hiatt continued to push for meetings with community

shoulder to shoulder with Mission Hill for several

representatives, says Smith.

decades, to the best of anyone's memory, Hiatt was the

"Hiatt didn't just talk about it, he got out there and

first dean of either school to venture inside the Mission

got involved," he says.

Church.

The chance to get involved was what had brought

Director of Community Programs Bruce Smith, who

Hiatt to the School of Public Health in the first place.

accompanied Hiatt that day, recalls the importance of the

A brilliant physician and scientist, Hiatt was a professor

visit to the community and the School: "At the time,

at the medical school and physician-in-chief of Beth Israel

Mission Hill residents were up in arms about the expan-

Hospital when new University President Derek Bok

Professor of Engineering in Environmental Health Dade Moeller appointed to the Advisory Committee on Reactor Safeguards of the U.S. Atomic Energy Commission.

H

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Martha May Eliot, professor of maternal and child health emerita, receives the American Public Health Association's Centennial Award.

William M. Schmidt, professor and chair of the Department of Maternal and Child Health, receives the APHA's Martha May Eliot Award.

HSPH enrollment reaches 258.

offered him the School's deanship in 1972.. It was a bold move for Bok— Hiatt was an outsider to public health—and a risky gambit for Hiatt, who would be giving up a highprohle career in medicine for a much less certain future. In the end, Hiatt says he accepted the deanship because it offered the opportunity not only to shape an institution, but to focus an entire held."

During his iz-year tenure, Hiatt went a long way toward realizing these goals. With the help of colleagues from throughout Harvard University, he transformed the School's Departments of Biostatistics and Health Policy and Management and in the process made public health the watchdog and conscience of Medicine. Through a series of brilhant and controversial appointments, he imported the powerful new research tools and methodologies of molecular biology and the quantitative social sciences into the School's traditionally strong research on tropical diseases, cancer, toxicology, and environmental illness. He aggressively broadened the School's training programs in health policy and management by introducing twoyear master's degree programs and executive courses for mid-career Professionals. And he authorized a series of outreach activities that bought the School into closer contact with the community right outside hs front doors.

several scholars Hiatt recruited who have become pillars of the School's present-day research and training mission. Another was a young decision scientist from Harvard's Kennedy School of Government named Harvey Fineberg, who would eventually succeed Hiatt as dean.

"One of Howard's most important legacies to the School of Public Health was the quality of appointments he made to this faculty, at every level," says Fineberg, who joined the School's faculty in 1972.. " H e brought leading scientists and scholars into the field, and attracted outstanding young talent to our ranks." Yet in attempting to redraw the boundaries of public health, Hiatt met with resistance from traditional-

ists, including some of the School's most respected faculty members, and found himself at the center of a conflict that to some degree clouded his many achievements as dean. rn rn m H E N H I A T T T O O K O V E R A S W W D E A N in the fall of 1972., the 50-year-old School of Public Health was at a crossroads of sorts. In some respects, the institution had never been stronger, with three new buildings—courtesy of Hiatt's predecessor, John Crayton Snyder—and a distinguished senior faculty and alumni body that had made signal contributions to the understanding and control of disease. Yet public health as a field had, to a great extent, fallen victim to its own success. The remark-

Bosfon's M;'ss:'ow C^Mrc/?, w^gre HMff /or <3 c/oser cooperafzoM C07M7?{K7M'fy /ixcu/fy.

I think Howard was responsible or bringing schools of public health mto the modern era," says Milton ^emstein, Henry J. Kaiser Professor ^ H e a l t h Policy and Management. einstein, an economist, was one of

Supermarket barcodes are introduced.

U.S. Food and Drug Administration issues regulations standardizing nutritional information on food packaging.

U.S. Supreme Court /?oe y. decision establishes a w o m a n ' s right to privacy in seeking an abortion during the first 6 months of pregnancy.

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able global gains against measles, smallpox, polio, and malaria had fostered a perception that infectious diseases—the traditional locus of public health research—were on the brink of elimination. Federal funding for public health education and research had begun to dry up. Why support more research and programs on problems that would soon be irrelevant? When policymakers and the public at large thought of health care, they thought primarily of doctors and hospitals, not departments and schools of public health.

Meanwhile, the revolution in molecular biology unleashed by the discovery of DNA-manipulation techniques was transforming the health sciences. Increasingly, the search for the causes and cures of illness focused on the spiraling genetic matrix that governs human biology and physiology. And, for the most part, this search was being conducted in hospitals, medical schools, and independent laboratories, not schools of

1974

Professor of Nutrition Jean Mayer heads an international task force to evaluate child nutrition in relation to programs sponsored by WHO, UNICEF, UNESCO, FAO, the World Bank, and other international agencies.

public health. Hiatt, a leading proponent of this "new biology," had spent the past decade adapting its tools and techniques to clinical research with great success and felt that public health could reap similar benefits, particularly in combating tropical diseases, environmental toxins, and cancer. But Hiatt was by no means wedded to the bench. Twentyfive years as a practicing physician had made him acutely aware of the shortcomings in American medicine—its penchant for expensive, high-tech treatments; the lack of rigorous evaluation of new clinical practices; the growing numbers of patients excluded from the system; the lack of emphasis on prevention.

"I saw that many of my fellow doctors were not thinking about what they did from a broad perspective," he says. "For example cardiac surgeons understood very well what the underlying defect was in the coronary patient, but had little knowledge of the effectiveness of their treatments."

At the annual end-ofthe-year party, students John Boice, Sally Sharpe, and Cheri Papier perform Boice's ballad to epidemiology:

He had recently returned from a one-year sabbatical at London's Imperial Cancer Research Fund, where, while honing his bench skills, he had taken a close look at the British health-care system. What he observed crystallized his belief that doctors alone could not solve America's impending medical crisis, but would need the help of economists, policymakers, statisticians, lawyers, and a variety of other professions. In public health, Hiatt saw the ideal arena in which to achieve this marriage of medicine and social science. And in Derek Bok, he found a colleague who shared his enthusiasm for collaborative, crossdisciplinary research.

"Howard reached out and got many people around the university interested in and excited about public health issues as an area of applied scholarship," says Bok. " I think this was exactly the right strategy to employ."

Hiatt was certainly not the first person without a degree in public health to hold the office of dean of the School. In fact, of the six permanent deans in the School's 75-year history—David Linn Edsall, Cecil Kent Drinker, James Stevens Simmons, John Crayton Snyder, Hiatt, and Harvey Vernon Fineberg—only Simmons, s.D.'^^, had graduated from a school of public health.

Hiatt, however, was unique in never having worked within a traditional public health arena. But throughout his career as a clinician, researcher, and teacher, he had distinguished himself as a man of searching vision who defined health and health care in the broadest possible terms. He

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had also cultivated strong ties with faculty across the university, and he had earned a reputation for making things happen. Bok says Hiatt combined "imagination and high academic standards" with a "capacity to inspirit and inspire young faculty."

"Howard is a real bearcat about getting things done," says long-time colleague Frederick Mosteller, who chaired the departments of biostatistics and health policy and management under Hiatt. " H e ' s very decisive about moving forward, and he works hard at the hardest parts of any job."

Bearcat" seems an unlikely appellation for the soft-spoken, 72-year°ld former dean. Tall and trim, with handsome, aquiline features and a rehned, almost genteel demeanor, T-f t ^natt is a congenial and charismatic Presence. Interviewed recently in his office at Bngham and Women's Hospital, he hardly looked a day older than when he retired from the School in 1 9 8 4 — a n d even then he ooked more like a man in his forties ^han his hfties. He is variously ^scribed by friends and colleagues as 'hght-hearted," "gentle," an "extraordinarily kind and caring person," and someone w h o "spreads credit around very generously." In conversation he shifts comfortably between ^ c u s s i n g his latest professional °rays—among other things he is heading up an effort to look at the Reality of life of terminally ill patients and an American Academy of Arts arid Sciences task force on problems affecting children—and the achievements of his three children and eight grandchildren.

Yet scratch the stately surface, and Hnd a man of formidable intensi-

Cincinnati surgeon Henry Heimlich introduces "Heimlich m a n e u v e r " to clear t h e airways of choking victims.

ty and drive. " H o w a r d ' s very passionate and principled in his beliefs," says long-time friend Barbara Rosenkrantz, professor of the history of sciences emerita at Harvard University. In the late 1 9 7 0 s and early 1 9 8 0 s , Hiatt was one of only a handful of physicians to speak out against the continuing nuclear weapons build-up, which he called, memorably, "the final epidemic."

Professor John David, chair of the Department of Tropical Public Health, credits Hiatt with "bringing a moral character to the debate on nuclear arms" in the early 1 9 8 0 s , and says that "one of Hiatt's strengths was his willingness to speak out on controversial issues. I congratulate him on that."

O R N I N 192.5 I N P A T C H O G U E , N e w Y o r k , Hiatt grew up in Worcester, Massachusetts, where his father, w h o had immigrated from Lithuania a decade earlier, settled after serving in World War I. He entered Harvard College in 1 9 4 4 , and, after only two years, w o n entry to Harvard Medical School as part of an accelerated program to supply doctors to the armed services.

By the time he earned his medical degree, however, World War II was over, so the 2.3-year-oM M . D . embarked on a fairly conventional career path: internship and residency in internal medicine at Boston's Beth Israel Hospital followed by a research fellowship at Cornell Medical College and a faculty appointment at the University of Chicago Hospital. In 1 9 5 0 , however, with the outbreak of the Korean War, he joined the U.S. public health

service and was posted to the National Institutes of Health, where he got his first taste of bench science, studying cellular metabolism in the laboratory of biochemist B.L. Horecker. Energized by the experience, Hiatt returned to Boston and Beth Israel at the invitation of the hospital's legendary physicianin-chief, Herrman L. Blumgart, to set up one of the nation's first medical oncology research and training units.

Throughout the 1 9 5 0 s , Hiatt's research focused on endocrinology and neoplastic growth—how normal cells turn cancerous. In particular, Hiatt was studying the synthesis of a sugar molecule called ribose, a building block of ribonucleic acid, or R N A . This work would lead him to France's Pasteur Institute, where he worked with two of the luminaries of modern biology, future Nobel Laureates Jacques Monod and Francois Jacob. As a traveling fellow in M o n o d ' s laboratory in 1 9 6 0 - 6 1 — a period Hiatt describes as the " h e y d a y " of molecular biology— Hiatt was on the research team that discovered messenger R N A . This discovery, which provided a critical link in understanding how information encoded in D N A is used by the cells, has been described as a "monumental scientific event." And, at 35 years old, Hiatt was still a relatively young scientist. "It was very heady stuff," he says.

Back at Harvard, Hiatt continued his rise through the medical school's ranks. In 1 9 6 3 he was named Herrman L. Blumgart Professor of Medicine and physician-in-chief at Beth Israel Hospital, where, according to colleagues, he was instrumental

Harvard Six Cities Study of air pollution launched under t h e direction of Professor of Environmental Science Benjamin Ferris. The study will revolutionize understanding of the health impacts of airborne pollutants, indoors and out.

in creating a cutting-edge biomedicai and clinical research program looking at the molecular roots of disease. And yet the higher he rose in medicine, the more troubled he was by what he saw as a system in crisis. Making sense of this system and fixing some of its glaring gaps would become one of the major themes of his deanship at the School of Public Health.

U R I N G H I S F I R S T YEAR AS D E A N , Hiatt convened a series of panels to examine the School's research and teaching programs and evaluate their ability to meet the public health challenges facing the nation and world. As a result of this analysis, he says, he came to the somewhat radical conclusion that public health wasn't a discipline per se, but a set of complex problems each of which required a slightly different blend of skills to resolve. "Since many of these problems had not only biological and clinical bases, but political and economic and anthropological and historical underpinnings, it seemed to me that, to address them, you would need input from these other areas," says Hiatt. While many of these disciplines fell outside of the traditional public health canon, the expertise did exist elsewhere at Harvard; the question was how to tap into it.

One of Hiatt's first acts as dean was to initiate, with Mosteller, a University-wide Faculty Seminar in Health and Medicine to begin looking at the many problems plaguing the nation's health care system.

The seminar, which met bi-weekly, was modeled on an earlier effort

by Mosteller and Kennedy School Professor Daniel Patrick Moynihan.

It was an instant hit, drawing more than 1 0 0 participants from Harvard's various faculties and teaching hospitals, including physicians, economists, lawyers, management experts, biologists, and engineers. At the same time, Hiatt launched the interdepartmental Center for the Evaluation of Clinical Procedures (later renamed the Center for the Analysis of Health Practices), which would be the focal point for an innovative health-care policy research and training effort that would be one of Hiatt's primary legacies to the School and the field. (See article, page 2.0). Led by Professor Howard Frazier, the center was a model of interdisciplinary scholarship, bringing together clinicians with decision scientists, economists, statisticians, and policy analysts.

"Howard was one of the people who realized early on the importance of the quantitative social sciences to public health," says Rosenkrantz, whom Hiatt brought to the School in 1 9 7 6 to teach the history of public health to health policy students.

Rosenkrantz's appointment reflected Hiatt's penchant for pulling in scholars from outside the traditional public health canon to bring new perspective and skills to bear on complex problems. Among the long list of eclectic appointments made

by Hiatt were population biologist Richard Levins, now John Rock Professor of Population Sciences (see article, page 64); management expert Nancy Kane, a business school graduate and lecturer in the Department of Health Policy and Management; economist and former

Watergate scandal forces resignation of President Richard Nixon on August 9.

Vice President Gerald Ford assumes the presidency.

U S A I D head David Bell, now professor emeritus; and former insurance actuary William Hsiao, now K.T. Li Professor of Economics and Health.

(Another Hiatt appointee, the late Herb Sherman, a former M.I.T. engineer with a genius for solving complicated problems, has been described as the "guru" of the clinical practice evaluation group.)

"One of Howard's strengths is his ability to appropriate expertise from other disciplines to solve a problem," says Mosteller. "He sees many parallels between fields."

Even when he stayed within the traditional bounds of public health, Hiatt often broke fresh ground.

Mosteller, whom Hiatt lured from his post as chair of Harvard's statistics department to build up the School's biostatistics department, would later chair the Department of Health Policy and Management (previously the Department of Health Services Administration). In both cases, Mosteller would guide the development of strong research programs focused on improving aspects of health-care delivery. To introduce molecular biology and immunology techniques into the School's tropical disease and toxicology, Hiatt recruited former medical school colleagues John David and Armen Tashjian, both leaders in their respective fields.

In a similar vein, Hiatt appointed distinguished biochemist John Cairns, whom he had worked with at the Imperial Cancer Research Fund, to strengthen the School's budding cancer biology effort. To lead an interdisciplinary program in the environmental health sciences, Hiatt secured former Manhattan Project

chemist Donald Hornig, w h o had recently stepped down as president of Brown University.

Hiatt also showed a discerning eye for young talent: in addition to Fmeberg and Weinstein, the list of budding scholars that Hiatt brought to the School who have gone on to assume key posts includes N a n Laird, chair of the Department of Biostatistics; Arnie Epstein, chair of the Department of Health Policy and Management; and M a x Essex, chair of the Department of Immunology and Infectious Diseases.

Hiatt says his goal was "to bring together the best and brightest minds available to work on major public health challenges." His vision for the School, outlined in his 1 9 7 5 dean's report, was of a flexible, truly interdisciplinary institution that drew outside expertise on an as-needed basis to confront specific problems, ^ o t everyone agreed with this approach, however. A sizeable portion of the faculty, including some of ^ e School's most senior professors, viewed Hiatt's efforts to refashion the School as high-handed and dismissive of past and present achievements.

Hns was partly a clash of powerful Personalities, aggravated by severe nnancial stresses that had forced Hiatt o make some unpopular administrat e decisions. (Between 1 9 7 2 and ^977, the School lost an estimated J-5 million in revenue due to the elimination of federal public health training grants.) But at heart, it was a smuggle to define the fundamental ^ s i o n and priorities of the Schoolâ&#x20AC;&#x201D; ^ e e d of public health as a field, latt's vision was broadly inclusive; ^ to some members of the faculty,

the School's burgeoning work in clinical trials of treatment drugs, assessment of medical procedures, the economics and organization of health-care systems in the United States and abroad, immunology and molecular biology, however impressive, just wasn't public health.

Rosenkrantz, who has studied the evolution of public health in the United States, says that the field, by virtue of the diversity of problems and professional and scholarly disciplines it embraces, has always been vulnerable to internal divisions. "Public health is a contentious area," she says.

By the middle of the 1 9 7 7 - 7 8 academic year, the debate had turned acrimonious, and in June the undercurrents of dissension spilled over: right after commencement, a group of faculty sent a letter to President Bok demanding Hiatt's removal from office.

Within the polite confines of the academy, this was tantamount to a coMp

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1975

Sebastian S. Kresge Education Building is dedicated, completing the building program initiated by former dean John Snyder.

J ' e f a f . Hiatt, who was vacationing in Europe at the time, was caught off-guard and deeply wounded by this turn of events.

H N H I S 1978 D E A N ' S R E P O R T (BY ) tradition submitted at the start of the next academic year), Hiatt made public many of the details of the previous spring's events, in the hope that airing the dispute would speed the healing process and help the School move forward. The report notes that on August 24, after spending the summer reviewing the situation, Bok called a special meeting of the faculty to announce his decision: he was sticking with Hiatt.

(According to a faculty member who was present, the announcement was greeted with utter silence.) Hiatt was vindicated, but the faculty remained divided, and Hiatt's dream of a fully integrated institution was cut short.

The 1 9 7 8 dean's report begins with

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As part of Boston's desegregation plan for public schools, faculty at t h e School work with students and teachers at Roxbury High School to provide educational field trips and tours.

the question "What are the boundaries of public health?" and ends with the sober acknowledgement: "a definition of public health that would attract unanimity has not been achieved, nor is it likely to be, for it almost surely must undergo continuing change as contemporaneous health problems change."

Hiatt continued as dean for another five years and continued to push forward on a number of important fronts, including sowing the seeds for some of the School's most successful community outreach effortsâ&#x20AC;&#x201D;Project L I F E and the Longwood Medical Area-Mission Hill Food Drive. He spearheaded the creation of the interdepartmental Division of Biological Sciences, which sought to coordinate and strengthen research and training in the biological sciences at the School. Tashjian, whose work has helped redefine toxicology research, says that Hiatt's commitment to strengthen basic biologic research represents one of his most important legacies to the School and the held of public health. David, whose department is now developing diagnostic tools and vaccines based on immunologic and molecular biologic techniques, agrees: "This has added an important new dimension to tropical disease research. In this respect, Hiatt's vision has absolutely succeeded."

Equally noteworthy are the many curriculum reforms Hiatt introduced at the School. Early in his deanship,

Julia Ojiambo, M.P.H.'69,assistant minister of housing and social services in Kenya, is first Kenyan w o m a n appointed to a ministerial post.

he introduced an experimental, university-wide course in health policy and management designed to prepare bachelors-level students for careers in medical management. He also launched the executive programs in health care management and a two-year program in health services administration, both of which sought to provide sound management skills to hospital administrators.

In 1 9 8 4 Hiatt stepped down as dean, passing the mantle to his former protege, Fineberg. He remained on the School's faculty until 1 9 9 4 , and, in conjunction with Brigham and Women's Hospital, where he still serves as senior consultant in medicine, he initiated and later led the Harvard Medical Practice Study, which provided some of the first information about the risks of being injured during hospitalization and the inequities in the way malpractice claims were resolved. He also launched the Clinical Effectiveness Fellowships, in an effort, he says, to "push" physicians into the School to learn the basics of medical evaluation.

There are few parts of the School today that do not bear some imprint of Hiatt's leadership. Yet Hiatt himself has somehow faded, slipped off the screen. Bok says that Hiatt "showed great courage and perseverance" in leading the School through a difficult but necessary period of transition and "deserves enormous credit" for laying the foundations for the

Saigon falls to North Vietnamese troops, bringing an end to the Vietnam War.

School's present-day research and training. Mosteller says the passage of time has validated Hiatt's longterm vision of pubhc health: "It seems to me now even more farseeing than at the time."

Hiatt, however, is circumspect in discussing his long career at the School, treading carefully around sensitive issues, conscious that his opinions are likely to be seen as self-serving or defensive. He is, as Mosteller said, gracious in crediting others for the many successes of his deanship, from Levins ("an extraordinary population biologist who has enriched the held immeasurably") to Tashjian ("he revolutionized the held of toxicology") to Bruce Smith, who accompanied him on that spring day in 1 9 7 9 and whom Hiatt refers to as "one of the School's unsung heroes." As for his own contributions, however, he prefers to let time and others judge. " I consider myself very lucky," he says with a smile. " M a n y of these achievements are just an evolution.

It didn't happen because I was there.

It was only because I was around at a time when they were in currency that I could take advantage of the widespread interest."

Kevin S o t t a k

Nineteen-year-old Harvard dropout and computer whiz William Gates founds Microsoft, which will grow into the world's largest computer software producer.

N A SHORT, 1981 ESSAY IN THE N E W E N G L A N D J O U R N A L O F M E D I C I N E , THE late William J. Curran weighed in on what was then and still is today one of American medicine's most emotionally and ethically charged debates: the terminally ill patient's "right to die." The issue had been brought to the fore m the late 1970s as a result of several high-profile cases—most notably that of Karen Anne Quinlan—in which families had sought the court's sanction to withhold or remove medical treatment from dying loved ones. The article, one of nearly zoo published between 1964 and 1988 under the heading "Lawmedicine Notes," is vintage Curran: succinct, reasoned, remarkably free of legal and medical jargon, and punctuated with biting irony.

Curran begins by reviewing recent rulings on the right to die, including a lower New York court decision granting a family's petition to remove an 8 3-year-old heart attack victim from a respirator—but only after following an elaborate and arcane set of legal procedures. Curran, who always favored the simplest, most elegant solution, criticizes this decision as a "witches brew of procedural ingredients that would, if ever followed step by step, exhaust

The Father of Heatth Law Witiiam Curran

ah resources and patience committed to individual litigation since the Jarndyce and Jarndyce case." Jarndyce and Jarndyce is, of course, the famously Protracted lawsuit in

HoM^e that is described in the novel as a "scare-

crow of a suit" that has "in the course of time, became so complicated that no man alive knows what it means." In a sardonic aside, Curran suggests that mercifully, perhaps, most of the terminally ill patients would have before these quixotic efforts to protect the patients' dignity and lives "vere completed."

Mozambique, c a p e ^ d e , the People's ^ l i c of Angola, and Papua become ' " ^ p e n d e n t republics

According to an EPA report, 79 U.S. cities have polluted water.

President Ford signs the Toxic Substances Control Act, which phases out the production and sale of PCBs and imposes strict regulations on chemical industry.

The "right to die" debate is one of numerous medico-legal controversies that Curran, who has been cailed the "father of legal medicine," helped inform and ultimately shape through his scholarship and writing during his long career. With a law degree from Boston College, a master's degree from Harvard Law School, and a degree in public health from the School for good measure, Curran was well-qualified to understand the intersection between two fields whose broad areas of overlap include some of the most hotly debated issues of the past 40 years: abortion rights, human subjects research, definition of death, and A I D S discrimination.

When Curran began his studies at the School in 1 9 5 7 as the only attorney in his class—and to the best of anyone's knowledge the first lawyer to earn a degree at the School—the medico-legal field existed essentially to support the trial process.

"Lawyers and doctors interacted primarily in the courtroom. Medical experts provided forensics testimony at murder trials or testified at malpractice suits," said Curran, in an interview shortly before his death in 1996. "I knew there was room for law and science to work together in more positive ways." It was on the basis of this belief that Curran developed and directed the Law-Medicine Research Institute at Boston University in the early 1960s.

According to Professor of Law and Public Health Troyen Brennan, Curran's successor as director of the Law and Public Health Program at the School, the timing was right to broaden the definition of health law.

"The research at Tuskegee, which had

Boston ordered to bus 21,000 students, as part of racial integration plan.

followed the course of syphilis in poor, African-American men whose disease went untreated, was beginning to come to light," said Brennan.

"This led to an outcry from the public and the scientific community that resulted in regulations concerning the use of informed human subjects in scientific research. Bill Curran nearly single-handedly guided the development of these policies."

In 1968, when Curran joined the School's faculty, his appointment was split between the departments of Health Policy and Management and Maternal and Child Health. Five years later, the School's Program in Law and Public Health—a specialized training program for lawyers leading to a master's of public health degree—was incorporated into the Department of Health Policy and Management. Curran directed this program until he retired to emeritus status in 1 9 9 1 . ^ ^ URRAN'S FORMER STUDENTS H remember him as a gentleman^ ^ ^ ly scholar with a personal interest in each of them. "Professor Curran was a friend," explained Joan Rachlin, M . p . H . ' 7 8 , executive director of Public Responsibility in Medicine and Research, a non-profit organization dedicated to educating the medical and legal professions, industry, and the public about the ethical, legal, and policy dimensions of appropriate and ethical research.

"The opportunity to study with Professor Curran was actually what attracted me to the program at Harvard, and, apart from the intellectual experience of the program, he went out of his way to make the

Production of first monoclonal antibodies sparks a revolution in diagnostic and therapeutic medicine.

lawyers in his charge, perhaps 1 0 out of the entire student body, feel as though they belonged. I also particularly appreciated and admired the extent to which Professor Curran championed the careers of women lawyers in the health-care field, which had been a traditionally male bastion."

Larry Gostin, a long-time colleague of Curran, who now directs the Law and Public Health Program at Georgetown and Johns Hopkins, recalls Curran's Friday afternoon teas. "Every Friday, you could find Bill making tea and offering cookies and conversation to his students in the program," said Gostin. "This kind of personal interaction and commitment is so often lacking in highpowered academic settings, but Bill never succumbed to that mind set."

By the late 1980s, concern on the international level about the spread of A I D S led to the enactment of harsh laws in several nations, including the United States, restricting immigration and travel of Hiv-positive individuals.

In some instances, legislation was adopted treating the transmission of H i v as a criminal offense. In 1988, the World Health Organization ( W H O ) designed its first international collaborating center for health legislation. With A I D S as it first focus, the Center was placed at the School, largely because of Curran's reputation as a health-law innovator and an expert on individual rights, including the intersection of health and human rights. In the 1960s, Curran designed and taught the School's first course in human rights law as it pertained to health. Curran was selected to serve as the first director of the Harvard

Altair 8800 is the first personal computer on the market. The Apple PC will follow in 1977 and the IBM PC in 1981.

University-WHO International Collaborating Center for Health Legislation, with Gostin as associate director. One of the Center's first accomplishments under Curran was the completion of a worldwide survey of A t D S legislation, undertaken at the request of Jonathan Mann, M . p . H . ' 8 o , Franqois-Xavier Bagnoud Professor of Health and Human Rights, who then served as director of the W H o ' s Global Programme on A I D S and had been a participant in Curran's ground-breaking health and human rights seminar. "To paraphrase Newton, we can see as far as we can because we stand on the shoulders of giants. At this school, Bill Curran is the giant on whose shoulders the Franqois-Xavier Bagnoud Center stands," said Mann.

According to Brennan, there is not an aspect of health law on which the Work of Curran or his students has not had an effect. In 1968, Curran served as the legal representative on the Harvard Ad Hoc Committee on Bram Death. The Harvard criteria ecame the basis for the nation's first egislation on brain death in Kansas *n 1970 and subsequently provided the basis for legislation across the country which allowed physicians to etermine death based on a patient's ack of response to external stimuli, spontaneous movement, and respiratory effort in conjunction with an ^ ectroencephaiogram showing no 째rain a c u i t y .

^ ^ ^ URRAN'S WORK ON THE RIGHTS H of the mentally ill produced ^ ^ ^ landmark legislation locally and internationally. In the early 1960s, Curran identified flaws in Massachusetts' laws regarding the rights of the mentally ill as they pertained to the duration of committal, patients' rights to refuse treatment in most circumstances, their rights to hearings to determine the appropriateness of continued in-patient treatment, and the rights of those arrested and awaiting trial who were referred for psychiatric evaluation prior to trial. Curran also wrote regarding the assumed loss of civil rights that at the time accompanied referral for psychiatric treatment, including the automatic revocation of one's drivers license and the barring of a psychiatric patient from making a will or marrying. Curran was appointed to the Legal Studies Unit of the Massachusetts Special Commission on Mental Health. Nearly all of the unit's recommendations, which addressed concerns Curran had identified regarding patient's rights, became law. By the late 1970s, Curran's influence on mental health law had extended to the international front with his co-authoring of the influential Law and Mental Health: Harmonizing Objectives, which reported the results of an international survey of mental health legislation for the W H O and sped worldwide reform of mental health laws. In

1979, Curran was among a group of legal experts drafted by the International Commission of Jurists and the International Institute of Higher Studies in Criminal Science to develop guidelines on the rights of persons with mental illness. Twelve years and numerous re-drafts later, the text was adopted by the United Nations General Assembly as the "Principles for the Protection of Persons with Mental Illness for the Improvement of Mental Health Care."

Curran's influence on the Massachusetts laws was considered so great that T^e New Yor^ wrote after his death in September 1996, "In Massachusetts, whose laws became models for national and international legislation, he left his fingerprints on so many statutes dealing with issues like psychiatric commitments, qualifications of physician's assistants, minimum professional standards for medical examiners, patient's rights, and drug addiction rehabilitation, that the state's health and medical laws could be called the Curran code."

Brennan agrees: "we take for granted now that there is a legal definition of brain death and regulations regarding psychiatric commitment or the use of human subjects for scientific research. But before Bill Curran, there was no context in which to examine these difficult issues. He gave us that."

Marcetla Bernard

1976 ofltrf chair of the Department Nutrit t ^ faculty. Professor of i<on Jean Mayer leaves to become the 10th P ^ d e n t of Tufts University

China's Chairman Mao Zedong dies.

National Institutes of Health bans some forms of recombinant DNA research for fear of creating virulent, drug-resistant super-pathogens.

Cambridge City Council places a three-month moratorium on genetic research at Harvard.

HNBMBH Fearing an epidemic of deadly swine flu, President Ford and CDC head David Sencer, M.P.H.'58, launch an ill-fated national vaccination campaign; 48 million Americans are vaccinated, 535 develop a rare paralytic side-effect, and the epidemic never materializes.

National Academy of Sciences calls for ban on aerosols, a major source of ozone-depleting chlorofluorocarbons.

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S A N E P H R O L O G I S T , H O W A R D F R A Z I E R H A D SEEN T H E SLOW, W R E N C H I N G

decline of patients with end-stage renal disease many times. First the nausea * ^ and vomiting, then the mental disorientation so distressing to families and loved ones, and then the last breath. Doctors did their best in those days, "tweaking and poking and shifting things around a little bit so people didn't die as fast," says Frazier, an emeritus professor of health policy and management at the School of Public Health. But end-stage renal disease was just that: end-stage.

Then the dialysis machine was developed, and in 1 9 5 4 , the first successful kidney transplant was Performed at Peter Bent Brigham Hospital. In the years to come, nephrology would go from being medicine that cared to medicine that cured. Money, equipment, and medical talent flowed into the specialty, ^ h e n there was an outcry over a shortage of dialysis machines and treatment in the early 1970s, Congress responded by setting up a special Medicare-type fund just for end-stage renal disease patients. heady mixture, this combination of money and technology, but for razier it also meant a disturbing Paradox.

There I was, enormously relieved y the shifting of an ethical burden— ecause resources were available, and ^ hasn't my responsibility to somew scrounge and come up with t em. On the other hand, it was just a wasteful way of deploying very 'mited resources. To put someone of ° chronic dialysis—which people argued you have to do because the jeatment is there—is just not sensi^ e. You can't even afford three ^cks to provide immunization for e kids across Huntington Avenue

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^ , ' ^ t l o n approves use of Inderal ^

beta-blocker, for blood pressure.

Epidemic of a highly fatal infectious disease among Sudanese cotton workers is the first known outbreak of Ebola virus disease.

in the projects, and yet you could afford, $ 3 5 , 0 0 0 to $40,000-a-year to maintain someone symptomatically uremic but not dead."

Frazier wasn't the only one troubled by the cognitive dissonance in the American approach to health: the dazzling prowess of curative medicine and the relative neglect of what might be done to keep people from needing that medicine. It was also on the mind of the School's new dean, Howard Hiatt. A top-rank molecular biologist and former chief of medicine at Boston's Beth Israel Hospital, Hiatt was neither ignorant nor dismissive of the post-war accomplishments of American medicine. But he was also aware of the blind spots. Precious little was being done in the way of systematic analysis of medical treatments—what they cost, what the real gains were. And there was the related issue of people who weren't getting this care.

"Here we were within the network of Harvard's teaching hospitals, paying extraordinary attention to the patients, but we had very little involvement with people who didn't come to us—especially people who didn't get into the system at all," says Hiatt.

Over the next decade or so, the Harvard School of Public Health became the place where the blind spots, paradoxes, and cross-currents of the American health-care system were put under the bright, searching lights of systematic evaluation and examination. In a research effort unprecedented both in terms of scope and method, faculty at the School studied how decisions were made in American medicine, the motivations behind those decisions, and the consequences both for patients' and the nation's health.

To do the job, Hiatt unabashedly imported talent from other parts of Harvard and techniques from other disciplines, most notably from statistics, economics, and decision theory. He galvanized the effort by organizing, with statistician Frederick Mosteller's help, the Seminar in Health and Medicine, a kind of university-wide think-tank of 1 0 0 or so professors and clinicians who met regularly for about three years.

The School's Department of Public Health Administration, renamed the Department of Health Policy and Management, was transformed into a hot-bed of original research and scholarship. Members of the seminar

John Crayton Snyder, professor of population sciences and dean of the School from 1954-71, retires. The Kresge Building's main auditorium is named Snyder auditorium.

Nurses' Health Study launched under the direction of Professor Frank Speizer.

the same intensity and scale of effort," he says. Hsiao credits Hiatt and his vision of rigorous study of health care and medicine with "revolutionizing the field of public health."

H

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and department faculty wrote prolifrcally and played a major part in shaping a body of research about the cost-effectiveness of American health-care. Some of the landmark books included Cosfs, BfMe/^s o^M^gery; Hyperfe?!s;'o7!; A Po^cy Perspec^we; and C/w^'c^J Dec/s/ow AM^/y^M. Franz Ingelfinger, the editor of New Ewg/^wJ JoMrw^/ o/^MeJz'cwe was receptive to this new, quantitative approach to medicine and provided Hiatt, Professor Milton Weinstein, and Harvey V. Fineberg, then a young health policy professor, a highprofile forum for their ideas.

The School's health policy researchers also made waves outside of academic circles. Professor William Hsiao's Resource-Based Relative Value Scale ( R B R v s ) changed how Medicare pays doctors and underscored the need for more pri-

1977

tn response to a growing world "energy crisis" newly inaugurated president Jimmy Carter proposes a national energy program to reduce U.S. dependence on imported oil.

mary-care physicians. The School's extensive study of medical errors in New York State hospitals made national headlines in 1 9 9 0 and injected reliable data into the nation's fractious debate over medical malpractice. Professor Robert Blendon, the Roger Irving Lee Professor of Health Policy and Management, emerged as the nation's foremost expert on the nuances of American attitudes about health care and medicine during the prolonged debate over health-care reform during the first two years of the Clinton administration.

As the Sturm and Drang over the nation's medical costs mounted in the 1970s, other schools and institutionsâ&#x20AC;&#x201D;most notably the Rand Corporationâ&#x20AC;&#x201D;also started to study and measure the workings of the American health-care system. Frazier says the School set the pace. " I don't think there was a single place with

H tSTORICAL PRECEDENT DID

exist for evaluating medicine. ! Ernest Codman, an iconoclastic surgeon at Massachusetts General Hospital, was ahead of his time in the 1 9 1 0 s when he argued for systematic data collection and analysis on surgeons. About a decade later, the privately-funded Committee on the Costs of Medical Care generated for the first time some statistics now taken for granted: total national expenditure on health-care ($3.6 billion in 192.9); a breakdown of how those expenditures were divided between physicians and hospitals; and some telling numbers on how medical expenditures varied with income.

Roger Irving Lee, the Boston physician and Harvard Corporation member so influential in founding the School, was a member of that committee and a prominent advocate of applying economic thinking to health and medicine. In the 1950s, Paul Lembcke, a surgeon at Johns Hopkins, proposed the use of "medical audits" as a way of comparing the performances of physicians and hospitals. At about the same time, Henry K. Beecher, an anesthesiologist at Massachusetts General Hospital, asked a young Harvard statistician named Frederick Mosteller to help him and members of his department design and analyze studies of anesthesia and analgesics.

Starting in about 1 9 7 0 , however, several forces came to bear to give

j) World Health Organization records last known case of smallpox in Somalia.

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Elvis Presley dies.

these questions about the cost and quality of medicine a new edge and relevance. The nation's medical bill had skyrocketed, with total health expenditures almost tripling between i960, when $2.7.1 billion was spent, and 1 9 7 0 , when the figure reached $74-4 billion. The creation of the Medicare and Medicaid programs in 1965 meant that taxpayers were footing a growing chunk of that bill.

When the Medicare-style program for kidney dialysis patients was created m 1972., Congress was told it would cost $2.00 million. Four years later, the actual costs were double that amount. Dialysis became a case in Point for what might happen to the nation's balance sheet if technologically sophisticated, medically effective, but expensive clinical care became widely available. ^et Americans were in a " l o v e " Phase of the country's love-hate relationship with medical technology.

Heart transplants and coronary bypasses were dazzling treatments for the nation's number one killer.

President Richard Nixon's 1 9 7 1 announcement of a war against cancer promised to deliver magic bullets to slay number two. If Americans Were enthusiastic about medicine's ^echnical virtuosity, it was partly ecause they weren't seeing the bills, ^ least not directly. World War II^ra tax laws that made insurance Premiums tax-deductible allowed a ^stem of employer-based health msurance to flourish. Fewer and ewer patients had to pay for their th care out of their own pocket.

Hiatt was among a relative few o saw a darker side to the medical pending spree on medical care. In

South African political leader Stephen Biko dies while in police custody.

his 1 9 7 5 monograph, "Protecting the Medical Commons: Who is Responsible?" published in The N e w England Journal of Medicine, Hiatt analogized the American appetite for medical care to Garrett Hardin's now-famous parable about herdsmen ruining their common pasture by pursuing their self-interest. "Surely nobody would quarrel with the proposition that there is a limit to the resources any society can devote to medical care," wrote Hiatt, "and few would question the suggestion that we are approaching such a limit." " I honestly think that H o w a r d envisioned that eventually the rise in medical costs and technology would be unsustainable," says Weinstein. "[But] the political and social currents were all going in the opposite direction; that is, more technology is better and medical care is 'free' because someone else pays for it."

In taking this somewhat contrarian approach, Hiatt had to basically start from scratchâ&#x20AC;&#x201D;and without

spending a lot of money. He settled on the idea of an interdisciplinary seminar and selected Mosteller to lead it. A few years earlier, Mosteller had played a key role in a famous Harvard seminar on education. With his experience in medicine and delight in solving statistical research problems, Mosteller was doubly qualified to lead a similar kind of seminar at the School. In the fall of 1972., the Seminar in Health and Medicine held its first meeting.

"It wasn't very grand," recalls Hiatt, "because we didn't want people coming for a steak dinner. We wanted them to come to w o r k . " Mosteller says the first couple of meetings there were some grumblings from fellow professors about what the seminar would do exactly. " I said the point was to do what professors do, which is to profess, write papers and books," says Mosteller. When it convened as a whole, the legislaturesized seminar met in Snyder Auditorium, but much of the real work

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HSPH entomologist Andrew Spielman identifies the G^mmm/tick as the vector of Lyme disease, a parasitic illness first described t w o years earlier in Old Lyme, Connecticut, by researchers at Yale University.

Frazier, who was on Hiatt's staff when he was chief of medicine at Beth Israel Hospital in Boston, was recruited to lead it, a position he held for eight years.

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was done by smaHer groups organized around topics. Formally, the seminar lasted about three years, but some of the smaller groups have kept on meeting. (Mosteller's surgery group still meets on occasion.)

Among the slew of papers and books produced by seminar participants that laid the groundwork for what is now called "evidence-based" medicine was the landmark 1 9 7 7 book, Cos?s, Bewe/^s o/ ^Mrgery. Co-edited by Mosteller, John P. Bunker (who chaired the seminar its second year), and Benjamin A. Barnes with chapters written by other members of the surgery group, the book laid out the main ideas of cost-benefit, decision analysis and applied them to a range of surgical interventions, including coronary bypass, cholecystectomy for silent gallstones, radical mastecto my for breast cancer, and hysterectomies.

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Space Shuttle makes its first flight atop a Boeing 747.

Frazier credits Mosteller for the seminar's success: " H e is the only person I know who can enter a room on one side and leave it on the other, having gotten commitments to write four chapters of a book and made arrangements for two collaborations!"

The other organizational device used by Hiatt was the extra-departmental center. Soon after becoming dean, Hiatt launched the Center for the Evaluation of Clinical Procedures ( C E C U P ) . At least in the beginning, "center" suggested something a good deal more grand than the underlying reality. Weinstein remembers sharing a basement office in the School's old main building at 5 5 Shattuck Street with Peter Braun, now a lecturer at the School. "We were the Center for Evaluation of Clinical Procedures!" he says. C E C L i P was later renamed the Center for the Analysis of Health Practices, and

Weinstein says Frazier was an effective "father figure" to the young investigators at C A H P ; Hiatt provided the intellectual spark. Mosteller says Frazier's practical medical know-how was essential to the successful grant application that kept the C A H P going. He also advised the cadre of young investigators on their research projects and papers, says Mosteller, though on a behind-thescenes basis because he rarely signed on as co-author. " H o w a r d put in a lot of time improving other people's w o r k , " says Mosteller. Fineberg, a member of the Center from 1 9 7 3 1 9 7 8 , says it was an exceptionally close-knit and talented group of researchers who continually batted around new ideas, testing and challenging them.

Gradually, the approaches and some of the key personalities involved in these satellite operations were folded into the main organization of the School. Mosteller again was a key figure, serving as chair of the biostatistics department for several years in the late 1 9 7 0 s and recruiting Marvin Zelen from the State University of N e w Y o r k at Buffalo. Zelen would turn the biostat department into a world leader in randomized clinical trials, one of the mainstays of cost-effective, evidencebased medicine. Mosteller chaired the Department of Health Policy and Management from 1 9 8 1 to 1 9 8 7 , steering it toward an emphasis on research and original scholarship.

Lung cancer death rate for U.S. w o m e n reaches 15 per 100,000, a ten-fold increase since 1930. For men, the death rate for lung cancer is approaching 70 per 100,000.

U.S. FDA bans saccharin in food and toothpaste following a Canadian study that links cydamates to bladder cancer.

^ ^ ^ NE OF THE RESPONSES TO THE H H growing sense of an eroding ^ ^ commons and medical spending reaching its limits was the development of cost-effectiveness research. In vastly over-simplified terms, cost effectiveness research was a w a y of Ending the biggest " b a n g " in health gain for each " b u c k " of health expenditure.

Weinstein, in a seminal 1 9 7 7 article in the New England Journal of Medicine, co-authored with William Stason, put it this way: "...the underlying premise of cost-effectiveness in health problems is that for any given level of resources available, society wishes to maximize the total aggregate health benefits conferred." A typical problem might be comparing how many years of life are gained by coronary bypass operations to a program aimed at lowering everyone's cholesterol levels.

Weinstein says cost-effectiveness health research involves wedding epidemiology to clinical information: Ptdemiology gives researchers a handle on the size of the health problem mey are dealing with, while clinical mformation is used to factor in the effe,ctiveness of the various treatments available. In doing cost-effectiveness analyses, the various nuances of ^ ealth" also have to be considered, s the goal just to reduce mortality and have people live longer? Or does ealth mean being able to run up the stairs? Weinstein and other cost-effect.rveness experts have worked at per^tmg a comprehensive, quantitative ^easurement of health outcomes.

E i n s t e i n has also developed elaborate questionnaires to gauge and ^ " l a h z e the trade-offs people make Whe considering quality of life. So, for example, Weinstein might ask,

" H o w much severe nausea are people willing to endure for an extra year of life?"

Calculating the costs involved is no less complicated. Tallying up the direct medical costs of the treatment and the costs associated with any side effects is relatively straightforward. But then the costs of treating the more serious illness that was avoided by early treatment has to be subtracted. N o w add back in the costs of treating diseases that wouldn't have had a chance to occurâ&#x20AC;&#x201D;say cancerâ&#x20AC;&#x201D;if the patient had died from the earlier condition.

Because there is usually a lag between cost and benefit in medicine (especially when chronic illnesses are involved) all these cost calculations must be discounted to take into account the lower value of future dollars.

Weinstein's 1 9 7 6 book, Hyperfewszow.- A Po&ry Perspective, co-authored with Stason, was the full-blown debut of cost-effectiveness research. In it, Weinstein and Stason published their findings that community screening programs were not a cost-effective w a y for dealing with hypertension. Instead, their numbers showed that targeted approaches aimed at high-incidence populations were more cost-effective. This was the first of several instances in which Weinstein's research challenged conventional public health wisdom. In 1 9 9 1 , Weinstein published research showing that the most cost-effective cholesterol-lowering strategy should be aimed at treating heart attack victims, not folks with high cholesterol readings who hadn't had a heart attack. His paper induced a government panel to put a new emphasis on so-called secondary prevention. And

Coifs, a n d Benef/fs of W g e r y , edited by Frederick Mosteller, John Bunker, and Benjamin Barnes of the School's Center for t h e Analysis of Health Practice is the first in-depth study of t h e cost and benefits of surgical procedures.

this February, Weinstein was coauthor of a study published in the /oM7*7Mf o / ^ e Awenc^M MeJzcaJ As50CMf;'07? that suggested that the marked decline in heart disease mortality in the 1980s was due in surprisingly small part to healthier lifestyles. Rather, Weinstein and his co-investigators found that the mortality decline was mainly attributable to advances in the medical treatment for heart disease, including drugs and bypass surgery. "That is heresy at a school of public health," says Weinstein, "but that is what's happening, we think, based on the data we have and the model we built." ) H SIAO, A N E W C O M E R TO ACAD^ ^ eme after working in ! Washington, D.C., and in the insurance industry as an actuary, admired the brilliance of the kind of cost-effectiveness studies that Weinstein and Stason were doing.

Yet he was troubled by what he saw as the field's underlying idealism. " I gradually appreciated that costeffectiveness analysis has a fundamental underlying presumption, namely, that the truth shall set you free," says Hsiao with a laugh. " M y perception of human beings is that truth matters, but so do incentivesâ&#x20AC;&#x201D;money and risk.

That means how you pay doctors and hospitals may have a greater influence on how they practice medicine."

And American medicine was full of distorted incentives that, for example, paid doctors handsomely for reading an E K G , which can be done in a couple of minutes, but paid poorly for carefully examining and diagnosing a new patient complaining about a fever and muscle pains.

William Foege, M.P.H/65, succeeds David Sencer as head of the Centers for Disease Control and Prevention.

In 1 9 7 7 , Hsiao co-authored a paper with Stason tided "Rational Price for Physician Services" that sketched out a framework for a more rational schedule for physician payment that Hsiao called a relative value scale. "It was like a pebble dropping into the ocean," Hsiao told Robin Marantz Henig, author of T^g People's He^M?, a book about the recent history of the School. "It was read by my mother and my wife.

Neither one understood it." But by 1986, the ripples from Hsiao's had become waves as his system was about to be used to adjust Medicare payment schedules. Almost $7 million in special Congressional funding had turned Hsiao's little-noticed academic efforts into a busy, policy-making enterprise employing 1 0 faculty members (mostly on a part-time basis) and a similar number of full-time researchers.

Three years later, Hsiao' brainchild, renamed the Resource-Based Relative Value Scale, or R B R V S , became the system for Medicare payment. The main thrust of Hsiao's

plan was to shift Medicare payments away from specialty services and specialists to primary care and the doctors who provide it. Hsiao says the full effect of his plan was blunted by changes made by Congress under lobbying pressure from medical specialists. Even so, Hsiao figures the annual savings due to R B R V S runs in the range of 1 0 to $0 times the government's $7 million investment in its development.

The effect of Hsiao's payment scheme is now being felt throughout the medical system as insurance companies and managed care organizations use R B R V S , or modified versions of it, to set payment schedules for their member physicians. Hsiao also gets credit for being among the first to effectively highlight the surplus of specialists in American medicine.

"If you look now, there is no more debate about having too many specialists," notes Hsiao. " The question now is how do we close down the training slots."

Hsiao's focus is now overseas as he advises governments in China, "YoM to renw^ p^ysKMws /or Jo;'wg EcOMOTWSt RMOMrce BaseJ Re^fwe ^ca'/e see^s to co77!pe72Mte pw?Mry care doctors.

1978

FoHowing commencement, a group of senior HSPH facutty petition Harvard President Derek Bok to remove Dean Hiatt. After investigating the matter, Bok asks Hiatt to remain as dean and Hiatt accepts.

Taiwan, and several other countries dealing with health-sector reform as booming economic growth and a shift toward market economics erode existing, government-run systems. Cultural values and professional ethics notwithstanding, incentives and risk avoidance have the same pull on doctors and hospitals everywhere, Hsiao says. In China, for example, too many patients are given intravenous fluids for no good medical reason. Why? Because, says Hsiao, doctors there are paid something extra if the patient is hooked up to an IV line.

Hsiao rejects the notion that he has a cynical view of doctors. "I wouldn't say it is cynicism. I would say it is realism. By acknowledging that physicians are human, rather than believing that they somehow rise above all temptation, we deal with health care in a much more efficient and rational way," he says " Y o u have to reward physicians for doing the right thing. When you reward them for doing the wrong thing, you are pushing a stone up the hill."

INANCIAL INCENTIVES ARE N O T the only reason things sometimes H go awry in health care. As in any endeavor, people make mistakes through inattention, oversight, and outright negligence. In health care, however, the stakes are higher than in most fields. Slip ups can cause serious harm or even death.

Studies of mistakes and mishaps in medicine had been done, most notably by Don Harper Mills in California. But in the 1980s, researchers at the School launched an investigation of "adverse events" in

Elkan Rogers Blout, former vice president for research at Polaroid Corporation named dean for academic affairs.

hospitals that set a new, higher standard for malpractice research. A surge m the price of malpractice insurance Premiums paid by doctors was the jumping off point for a more general interest in reforming the malpractice system. Once again taking the broad, university-wide approach he used 'n other areas, Hiatt teamed up with James Vorenberg, then the dean of Harvard L a w School, to form the Harvard Medical Practice Study Group. But the group soon was ensnared in sharp differences of opinion about what exactly the malpractice problem was and how it might be mended. Doctors and other health Professionals saw a need for capping damage awards and alternative, less litigious ways of settling claims.

Lawyers wanted stiffer sanctions against bad doctors and easier access to the courts. The division existed, in Part, because neither side had much m the way of hrm facts. "[We] were mired in these controversies because ^e suffered from the same informat'on gap tbat was afflicting legislators and courts," says the preface to A ^easMre o / A M p r a c & r e , a 1 9 9 3 book about the School's malpractice ^search co-authored by Hiatt and sortie of his co-investigators.

To RH the gap, Hiatt and others ecided to do a study aimed at mg out how much medical injury Occurred, the seriousness of those mjuries, and who among the injured ^ e d . When they proposed doing eir study in Massachusetts, the esearchers got a frosty response: doers and hospitals were worried the study would waylay pending legisla째n that would cap pain and suffer'ng awards. Then Hiatt met David

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Axelrod, the N e w York State Health Commissioner. Axelrod, a powerful health official who was pushing for improvements in N e w York hospital care on a number of fronts, embraced the project and persuaded the N e w York state legislature to spend several million dollars on it. "[The] most important resource that N e w Y o r k offered us was David Axelrod," says Besides Hiatt, the Harvard Malpractice Study research team included Professor of Law and Public Health Troy Brennan; Biostatistics Department Chair Nan Laird; Adjunct Professor of Health Policy Lucian Leape; and Howard Frazier.

Hsiao assisted during the planning phase. Paul Weiler, a professor at the law school, and Benjamin Barnes, an associate professor of surgery emeritus at Harvard Medical School, also played key roles. The study had the kind of elegant yet sturdy design that pleases epidemiologists at an aesthetic as well as scientific level. The investigators randomly selected the hospitals to be studied. If they had depended

First test t u b e baby is born in London.

on volunteers, the results might have been biased by hospital administrators avoiding the researchers, fearing that they might discover high negligence rates in their institutions. The researchers also went to great lengths to make sure that their review of hospital records was as objective as possible, training a group of medical records analysts especially for their project. Using a set criteria of 1 8 clinical "events," the analysts made an initial determination about whether the hospital record suggested that an "adverse event" might have occurred. Those suspicious records were, in turn, looked at by two physician-reviewers. T o limit the chance of the physician-reviewers' bias creeping into the study, the researchers developed the Adverse Event Analysis Form to lead the doctors on a step-by-step review of the record. Leape says one of the key innovations of the study was to recruit local physicians to review the records, which both saved money and took advantage of physicians' expertise.

First human retroviruses described by National Cancer Institute scientist Robert Gallo, w h o will later be a co-discoverer of the AIDS virus.

28

^ ^

The reviewing of the records began in earnest during the summer of 1988.

By the time the study was finished, the researchers had sifted through some 30,000 patient records from hospitals. The dragnet found 1,2.78 "adverse events," about one-fourth of which were identified as injuries caused by provider negligence. Put another way, the study suggested that 4 out of every 100 New Yorkers hospitalized in 1984 were injured during their hospital stay and one-quarter of those injuries was the result of negligence.

The researchers then took the next step to see how this epidemiology of medical injury played out in the legal system. What they found was a malpractice system badly out of sync. On the one hand, there were a large number of "false positives"â&#x20AC;&#x201D;malpractice claims against innocent doctors.

In fact, most of the malpractice claims hied with New York state officials were not based on any real injury.

Fewer still involved negligence. On the other hand, the researchers found an even bigger problem with "false negatives"â&#x20AC;&#x201D;patients who had been harmed by negligent care who hadn't filed any kind of claim of malpractice.

The researchers calculated that just 1 in $0 cases of negligent medical care resulted in a malpractice claim . " [We] found several times as many seriously disabled patients who received no legal redress for their injury as innocent doctors who bore the burden of defending against unwarranted malpractice," they wrote in A Measure When the results of the malpractice study were first published in 1990, they made front page news in T^e New Yor^ T;'?Me5. The study spawned

1978

"The Children of Santa Maria Cauque: A Prospective Field Study of Health and Growth," a landmark study

by Leonardo Mata, S.D.'62, describes the impact of diarrhea and dysentery on the health of Costa Rican children. He will later receive the prestigious UNESCO Science Prize for his work.

a new round of debate about the malpractice system, as well as a stream of like-minded research. The School's researchers argued in medical journal editorials and elsewhere that their Endings pointed to the need for a new, no-fault system for dealing with malpractice that would more speedily and reliably compensate victims. But the combination of a leveling off of malpractice premium prices, which cooled physicians' interest in the subject, and Axelrod's disabling stroke in 1 9 9 1 slowed the political momentum for legislated malpractice reform.

Even so, Leape says physicians, health-care officials and hospital administrators are beginning to show an interest in reducing medical errors.

For one thing, studies like the one Leape published in the /oMHMJ o/ Awen'c^M AssocMff'ow earlier

what he heard there: "We are getting there. People are now saying that this is a problem we have to deal with."

VALUATION OF HEALTH CARE now seems as much a part of the ^xn School's mission, and public health more generally, as research on infectious disease and nutrition. It is easy to forget just how novel systematic study of health-care and medicine was 2.5 years ago. Weinstein remembers that shortly after he came to the School in 1 9 7 3 , a prominent member of the powerful epidemiology department sarcastically asked him to "say something to me in policy analysis."

Hsiao says the attitude was so chilly when he Arst came to the School that for years he thought he must have been wearing the wrong deodorant.

^ ^

this year provide evidence that cutting down on errors can save a hospital money. In the J A M A article, Leape calculated that a 700-bed hospital could save $z.8 million a year by setting up systems to avoid preventable adverse drug events. In the JAMA article, Leape explained that the Harvard Medical Practice Study found that drugs were the leading cause of adverse hospitalrelated events. On a national scale, Leape said drug-related morbidity and mortality cost an estimated $76.6 billion. By comparison, he noted in the J A M A paper, the cost of all diabetes care has been estimated at $45.2. billion.

Times have changed. The Department of Health Policy and Management now boasts z6 primary and 1 0 secondary faculty members, and among students, the H P & M classes are consistently the most popular. More fundamentally, the School has helped bring what Dean Fineberg has called an "ethic of e v a l u a tion" to medicine and health-care more generally. In a 1992. Institute of Medicine report, Fineberg defined the ethic of evaluation as "widespread commitment and expectation among physicians, health care institutions, and the public that medical practices must be evaluated for effectiveness, safety and cost."

Last October, Leape was the keynote speaker at a conference on health care error prevention in Rancho Mirage, California, attended by many vips in the health-care and hospital industry. Leape was heartened by

"Adopting a systematic, pervasive strategy for evaluation wilt require public and private resources," F i n e b e f g continued, "but the return in terms of extended lives, reduced suffering and cost savings will be substantial."^

Residents of Love Canal, New York, are evacuated following reports linking birth defects and illnesses to toxic waste exposure. Subsequent studies will call into question these associations, but Love Cana! will become a byword for environmental poisoning.

OXIC C O M E S F R O M T H E LATIN ! word for poison, and toxicology is often described as the study of chemical injury. Over the past two decades, Professor Armen Tashjian, Jr., has deftly steered the School's toxicology program toward research that analyzes "chemical injury" at the most basic levelâ&#x20AC;&#x201D;at the cell membrane, in the cytoplasm, and along the spiral staircase of D N A . His insistence that toxicology needed to peer mto the black boxes of the most fundamental molecular and cellular Processes has required a good deal of Persistence. Skeptics, some of them holding important purse strings, ^ould ask "but is that really toxicology?" Tashjian's research agenda also has meant his program is something of a David among the Goliaths that roam the biomedical research Y°rld of cell and molecular biology.

You just have to be a little bit smarter and work a little bit harder," says Tashjian with a smile.

Tashjian was born in Cleveland 1 9 3 z and named for his father, an Armenian immigrant who swam across the Bosporus Strait to escape mkish authorities and went on to establish a successful engineering and architectural business. A scholarship ^ Philips Exeter Academy put ashjtan on the road to a blue-ribbon education: after Exeter, he attended a e College for three years and then ^ent to Harvard Medical School. ashman had thoughts of a research ^areer early on, but he really caught research bug while on a postdoctoral fellowship at Harvard Medical oh On the surface, a researcher's ^ork might seem to be a rather Peaceful, if somewhat solitary,

endeavor: it's just you, the lab, and your cells or molecules. But Tashjian points out that research is actually a high-wire act, full of excitement but also anxiety. "Here you are, a young person, entering a world of discovery. And you know the chances of success are 10- or ioo-to-one against you." The key, he said, is to find both a mentor who can help and a problem that can be solved.

"If you begin to work on a problem, and it begins to be solved, you get an extraordinary sense of elation that comes with discovery: nobody has ever seen this before, I thought of this, I did it! There is a shiver of excitement. It is almost an orgasmic experience to go through that," he says.

Tashjian says he had several mentors, but the key person was Paul Munson, an expert on calcium metabolism on the faculty of Harvard's School of Dental Medicine. Calcium metabolism is heavily influenced by hormones, and the whole held of hormone research and endocrinology was booming in the early 1960s as technological advances in protein chemistry and immunology started to make it much easier to measure and characterize hormones in blood.

Munson, Ernest Knobil, Roy Greep (who would go on to hold the John Rock Professorship of Population Sciences from 1967-197Z), and other investigators had turned the dental school into a "mecca of endocrinology," notes Tashjian.

Early in his career, Tashjian's niche was the parathyroid hormone.

Produced by four small glands in the neck, the parathyroid hormone plays a key role in regulating calcium levels

Twenty-six years after sailing from Wellington, New Zealand, to Boston Harbor to attend the School, alumnus Thomas Davis, M.P.H/53, is elected Prime Minister of the Cook Islands and is made a knight of the British Empire.

in the blood. Tashjian quickly became one of the world's leading authorities on parathyroid hormones as his research yielded novel assays for the hormone and shed new light on its mechanism of action.

Lawrence Levine, a biochemistry professor at Brandeis who has collaborated with Tashjian for over 30 years, remembers when Tashjian first approached him about learning some immunology: "He was so damn bright. In five years, he knew more immunology than I did!" says Levine.

Tashjian took over Munson's lab in 1965 when he left Harvard.

Tashjian's interest soon extended to calcitonin, another calcium-regulating hormone produced by the thyroid gland. And like many others in his held, he was also intrigued by findings that hinted that cancer cells disrupted normal calcium metabolism. In 1 9 7 1 , Tashjian led a research team that discovered in 1 9 7 1 that calcitonin levels could be used to identify a pre-cancerous condition in families at risk of getting a rare, inherited form of thyroid cancer.

(The prostate-specific antigen ( P S A ) test for prostate cancer is based on the same general concept.) People with the pre-cancerous condition could have their thyroid glands removed, avoid cancer, and lead normal lives. Though the calcitonin test has now been supplanted by genetic tests, it probably saved several thousand lives while it was still in use.

Tashjian's transfer to the School of Public Health came about when he agreed to help his friend and colleague, H S P H Dean Howard Hiatt, build up the School's basic biology research. As a member of the search

1979

Religious fundamentalists depose the Shah of Iran and take hostage 63 Americans in the U.S. embassy in Teheran.

committee to select someone to lead a new Laboratory of Toxicology, Tashjian had argued persuasively that the person chosen shouldn't be a traditional toxicologist, but someone prepared to take advantage of the exciting new developments in molecular and cellular biology. Hiatt, a molecular biologist, agreed wholeheartedly. During his absence from one of the committee meetings, Tashjian's name was added to the list of candidates for the job, and the rest is history.

ASHJIAN DESCRIBES HIS FIRST years as head of the School's toxicology lab diplomatically "as an interesting challenge for me." The program had to be built up from scratch, he says. What's more, he says he wanted to build it in an unconventional way, attracting people who were top-shelf molecular and cellular biologists and "not necessarily toxicologists by any formal identification." Government funding agencies looked askance at his approach, however and for a couple of years Tashjian's applications for training grantsâ&#x20AC;&#x201D;the lifeblood of many research labsâ&#x20AC;&#x201D;were rejected.

"The reviewers said, 'None of your people are toxicologists. How can you expect to be training toxicologists?' " says Tashjian. Eventually, Tashjian was rewarded not only with training grants but also with kudos for setting the pace in modern toxicology by emphasizing detailed study of cellular and molecular mechanisms of injury.

Under Tashian's direction, the Laboratory of Toxicology evolved into the Department of Molecular and Cellular Toxicology, with a research staff of 55 and an annual sponsored

research budget of almost $ 1 million.

Professors Leona Samson and Bruce Demple, experts on D N A damage and repair, are leaders in the held of genetic toxicology. Associate Professor Robert Schiestl has developed the D E L assay, a new genetic test for determining whether a chemical might cause cancer. In September 1 9 9 7 , this department merged with the Laboratory of Radiobiology to create a new, larger Department of Cancer Cell Biology under the direction of Professor Jack Little. Tashjian is once again free to focus on his own research, which is still centered around calcium regulation, but now at the intracellular level. He also sits on a Food and Drug Administration advisory committee in hopes of making new molecular tests the norm in toxicity testing, which still depends on giving high doses to lab animals.

Tashjian, a veteran of uphill fights, acknowledges that it is sometimes difficult to compete in the world of high-powered, genome-sequencing basic research. But he says an abiding concern with practical applications and opportunities to work with other public health disciplines creates some special advantages for public healthoriented toxicology. A few years ago, he recalls, a chance lunchtime discussion in the School's cafeteria between a member of his department and a member of the epidemiologic team investigating elevated bladder cancer rates among rubber workers in Akron, Ohio's, tire factories led to the identification of a new mutagen.

"I don't think that happens too often elsewhere," Tashjian says with a smile.

Peter Wehrwein

A contingent of Chinese physicians spend a year at the School as part of an exchange program initiated

by Dean Hiatt and coordinated by Associate Professor William Hsiao. The following year, four Harvard faculty will travel to China to complete the exchange.

Donald Hornig, science adviser to Presidents Kennedy and Johnson and former president ot Brown University, n a ^ to direct the School's Interdisciplinary P r o g ^ in Health.

^ ^

H E R E IS S E R I O U S Q U E S T I O N AS

black U.S. medical colleges in existence at the time. He graduated in 1946, and the following year enrolled at the Harvard School of Public

^ to whether the best medical care, handsomely delivered to the slumdwellmg indigent, has any meaning in the face of conditions that breed disease and despair far faster than they can be cured or ameliorated." These words, appearing in the August 1965 issue of the /oMrw^/ o/" expressed the passion and frustration of their author, the 'ate Alonzo Smythe Yerby, M.p.H/48. ne timing was significant: a month earlier President Lyndon Johnson had signed the Medicare/Medicaid act— the most sweeping revision to social security since it was installed in 1 9 3 5 .

However, Yerby, who had been a consultant to the Johnson Administration in drafting the legislation, Relieved that the hnal act fell short of 'ts original ideals. Although Medicare Was designed to subsidize medical care or elderly Americans, little thought was given to the particular needs of '"digent people who couldn't afford even the low monthly fees required for Participation in the plan. According to a history of Medicare written by the epartment of Health and Human ervices, Medicaid—which appropriates funds specifically for health care the poor—was "almost an aftert J ^ Yerby likened Medicare/ e icaid to the seventeenth century Poor Law, which provided handouts and other alms to the ^ stitute, and criticized the system r reducing something as essential to th as medical care to the status th ^ ^ addition to undermining Recipients' dignity, said Yerby, ^ edicaid's medical "handouts" did ^hing to solve the underlying Problem of poverty.

t t U ^ 'S awarded peace prj^.

Health. As a student, Yerby was a protege of Franz Goldman, associate professor of medical care in the Department of Public Health Practice.

At Goldman's suggestion, Yerby went to Germany, first as a held medical officer for the U.N.'s International Refugee Organization, where he supervised the medical services for displaced persons in refugee camps, followed by service as deputy chief of medical affairs of the Office of the U.N. High Commissioner on Refugees.

CHAMPION OF THE POOR Addressing the White House Conference on Health in 1965, Yerby, then Commissioner of Hospitals for New York City, declared: "We can no longer tolerate a two-class system of health care. Let the word go forth...that America is prepared to assure all of its citizens equal access to health services as good as we can make them, and that the poor will no longer be forced to barter their dignity for their health."

Born in Chicago, Yerby was the youngest of four children. After finishing high school, he went to the University of Chicago and then to Meharry Medical College in Nashville, Tennessee, one of only two

An accident at Pennsylvania's Three Mile Island nuclear power plant damages the reactor's radioactive core. Little radiation is released, but the accident raises alarms about the safety of nuclear energy.

In 1966, Yerby left public service to return to the School of Public Health as professor and head of the Department of Health Services Administration (forerunner to the Department of Health Policy and Management), a position he held for the next 1 6 years. At the time, H S P H Dean John Snyder told TZ?e New Yor^ TzTwas that Yerby's appointment "...reflects our concern that new and imaginative approaches are needed to establish closer relationships between health professions and hospital administrators on the one hand, and community leaders on the other."

Yerby—a man whose professional formality masked a warm sincerity beneath—was the only black tenured faculty member at the School, a distinction noted by minority students at the School and throughout Harvard University, who sought him out as a role model and adviser on career issues. Carolyne Arnold, M . P . H . ' 7 3 , a former student of Yerby's, says she was teaching at

Popu/af/on P/ann/ng, co-authored by alumni Leslie Corsa, Jr., M.P.H.'52, founding chair of the Department of Population Planning at the University of Michigan.

^ ^ ^

32 ^ ^ ^

Howard University when she first began hearing about Yerby, who was making a name for himseif as a leader in public health and as a member of the "small club" of black professionals in academia at the time. Many of the students who sought Yerby's guidance came, in one way or another, from the rising civil rights movement.

But while Yerby was deeply troubled by social injustice, particularly in terms of health care and poverty, he steadfastly counseled moderation in achieving the objectives of social justice.

"We were all creatures of the 1960s," says Arnold. "The notion of confrontation was part of the way we saw the world. But Professor Yerby wasn't like that. He didn't encourage us to jump up and down."

Yerby's eldest son, Mark, says his father's tactics were intended to catalyze rather than polarize the situation. "If the goal is to achieve change and social justice, if you're strident, the opponent becomes defensive, so you can't reach any solution," he says. "That's the lesson I learned.

People focus on the advocates, not the thing they're advocating for."

Monteal May, Yerby's wife of over $0 years, adds: "The black people we knew were professionals. They weren't suffering," she says. "People were concerned with preparing yourself for the future. We didn't think in terms of skin color. The battles we were fighting were to improve ourselves."

As a teacher, Yerby was known for his vast practical knowledge of health-care systems around the world.

He taught a popular course focusing on health systems administration, the highlight of which was an annual held trip to Quebec during intercession.

In conjunction with Sidney Seymour Lee, who before leaving to become associate dean for community health at McGill University was clinical professor of hospital and medical care administration at the School, Yerby enabled H S P H students to witness firsthand the evolving Canadian health care system based on universal coverage.

"It was really a very broadening and enriching experience," says Arnold.

The held trips also spawned a "steady stream" of Quebecois to the School, says Fernand Turcotte, M . p . H . ' y i . "We had come to the States to learn how to do it; we came back to Canada to do it." Turcotte, now a professor of social and preventive medicine at the University of Laval in Quebec, which hosted the American students in the 1970s, says that the training he and his fellow Canadians received at the School enabled them to establish public health programs at medical schools throughout Canada based on what they had learned at the School.

Yerby eventually became disillusioned with academic medicine, but he never lost his love for teaching. After resigning from the School in 1982., he

continued teaching at the Uniformed Services University for the Health Sciences in Bethesda, Maryland. "His students were his greatest legacy," says his son Mark. Alonzo Yerby died in February 1994.

Reflecting on his father's beliefs and on the Medicare/Medicaid system that his father criticized so passionately, Mark Yerby, who has a private neurology practice in Portland, Oregon, says: "It's not economical to care for people who are poor.

You can't have more than 1 0 percent of your patient population be on Medicaid. Do we act differently towards those patients? The answer is, 'yes,' because the clock is always ticking overhead."

Moreover, he says, the whole system has become an administrative nightmare. While sitting in his office late one evening, he searches through a book of H C F A codes to locate the required set of numbers and letters that identify a patient's diseaseâ&#x20AC;&#x201D; hereditary spastic paresis. He cannot find it.

"When Dad was involved, people who went into administration had an M . D . and an interest in how the whole operation should run," he says, hnaliy closing the thick book. "Today, those folks have M B A s . " But despite his frustration, Yerby says he still believes in one major tenet of his father's work: "He believed that public health was not just the purview of public health professionals, but belonged to every physician."

Terr! L. R u t t e r

1980

At graduation, 266 students (124 women) receive degrees, nearly triple the number of degrees awarded in 1960.

World Health Organization

declares smallpox officially eradicated. HSPH graduates William Foege, Donald Hopkins, and Ralph Henderson have helped lead the 7-year effort to eliminate the disease, which once claimed 500,000 lives a year, the first (and only) disease to date to be eradicated by human efforts.

^^

O O K , Y O U W A N T T O GET R I G H T T O T H E P O I N T ? " ASKS

Farmer met Gretchen Berggren a dozen years ago

Paul Farmer, pausing only briefly during his rounds

when he was lying on his sick bed in Port au Prince.

at Brigham and Women's Hospital. His words come

" F d heard of them, of course," he says. "Gretchen is

quickly, as if anticipating interruption by his beeper or a

known as the Mother Superior of Public Health in

Page. "Humble service. And, data driven. That's what you

Haiti. But I look up and here's this woman at the end of

want to remember. Gretchen and Warren remind us that

my bed singing in Creole what sounds like a lullaby. It

you can care about the world and still be good scholars."

was a song for mothers of newborns about preventing

For a quarter century, Gretchen Glode Berggren, s . M . H .

66, and Warren Berggren, M . P . H . '63, D . p . H . '67, have

diarrhea."

The Berggrens' work and quiet example encouraged

combined their appointments at Harvard with continuous

and guided Farmer in his own efforts to establish new

service across the third world, from Afghanistan to Zaire.

assistance programs. (The recipient of a MacArthur

But their home base, from 1 9 6 7 right up to the present,

Foundation Fellowship, Farmer still spends half his time

has been the Hopital Albert Schweitzer in Deschapelles,

in Haiti.) But Farmer, who was originally trained as a

Haiti. And during their time there, over 2.00 H S P H stu-

medical anthropologist, recalls one bit of direct advice

dents have served at the hospital under their tutelage on

Gretchen Berggren once gave him. "I hope," Gretchen

held projects lasting from several months to several years.

said to him, "we won't lose you to impracticality."

International Physicians for the Prevention of Nuclear War (IPPNW) founded by Professor Bernard Lown and Russian scientist Eugene Chazov.

34

Recew/wg f^e Zw^erwa^'owaf HeaM? A w a r J /row M o ^ e r

healers to use a stethoscope, so they

^

Teresa was owe

hope."

w

o/ ^ e wawy pomts w ^ e

could see for themselves that the heart was still beating and there was In 1962. the Berggrens came to study disease prevention at the

Berggrews' careers.

School. "So much of what we had been working with," says Warren, "was illness that should never have happened." In 1 9 6 7 , with a grant from the N t H and the encouragement of Tom Weller and Hilton Salhanick, heads of the departments of Tropical Public Health and Population

That the Berggrens value practical-

began his medical service at a mission

Sciences, they left for the Hopital

ity perhaps can be attributed to their

in Badja Baya in the north, among

Albert Schweitzer in Deschapelles.

Midwestern upbringing. They come

hills along the great bend of the

Their first year there, Warren says,

from Nebraska, the American heart-

Ubangi River. The two were married

the hospital saw 650 children with

land. Gretchen is from Chadron in

in early 1959 in Brussels, where

tetanus, 550 of them newborns.

the northwest, where the land rolls

Gretchen was studying tropical medi-

"With the hospital doing its best, we

round like great green ocean swells

cine at the Prince Leopold Institute.

were able to save half of them."

into the Black Hills of the Dakotas.

The following year, they began their

Warren comes from Aurora in the

work together in Kimpase, in a Congo

they saw, but it was one that should

Willa Cather country of the south-

shortly to become independent.

have been "easily" prevented simply

east, where, he notes drily, a local saying held that the land was "so flat, you could see so far that you could see the back of your head."

Amidst the turmoil and strife that followed independenceâ&#x20AC;&#x201D;including

Tetanus was not the only illness

by vaccinating mothers. The Berggrens began a vigorous tetanus

once having to be helicoptered away

immunization and education pro-

to safetyâ&#x20AC;&#x201D;Warren and Gretchen per-

gram, reaching out to indigenous

severed in their commitment to heal-

midwives, setting up information and

a - OR BOTH GRETCHEN AND WARREN,

ing: attending to births and injuries,

immunization stations in the market-

the church had been a center of

performing surgery, and serving the

place, going directly to villages.

family and community life as they grew up, and it was from listening to

isolated countryside.

Today, the hospital hasn't seen

"That's when we learned,"

one case of tetanus in nine years,

reports about missionary efforts

Gretchen says, "how important

even though its population area is

abroad at church gatherings that they

getting to the people themselves is.

independently decided to become

over three times larger than the

A family would take their sick child

medical missionaries. They met in

70,000 people it served when the

back home when their indigenous

medical school at the University of

Berggrens started.

healer said it was dead. But the

Nebraska at Omaha. Warren was

child's chances actually might still

three years ahead of Gretchen, and

modern record-keeping and other

be good; we could save it."

practices that facilitate the use of

when he finished his internship he left for the Belgian Congo, where he

Lech Walesa founds Solidarity labor union in Poland.

The Berggrens also introduced

She pauses, then continues. "We

social science measures in evaluating

could save lives simply by teaching

the effects of public health p r o g r a m s .

Mount St. Helen's erupts May 18th in Washington State.

Of the many studies that have resulted, perhaps the most influential was their 1 9 8 1 N e w England Journal

constant inspiration." Warren politet^Br

ly sidesteps the question. " I don't

*

think I'm very effective at preach-

of Medicine article, "Reduction of

ing," he says. Besides, he has work to

Mortality in Rural Haiti Through A

do. He's about to leave for

Primary Health Care Program," co-

Bangladesh to evaluate a program

authored with Douglas Ewbank. It

that attempts to improve nutrition by

demonstrated with acceptable social

bringing mothers of malnourished

science rigor that their interventions

children together with more success-

had had positive effect; and, it estab-

ful mothers in the same village.

-A-"/

lished their efforts m Deschapelles as

"Two-thirds of Third-World children are malnourished," says Gretchen.

a model for others.

"All need better nutrition. This is

Today, the people of Deschapelles

where we need to be working."

know the hospital's public health building as " K a y Berggren," Creole

"They don't talk about them-

"the Berggrens' house." Over the

selves," says Dr. Lachlan Forrow,

Past three decades, the Berggrens

Executive V.P. of the Albert

also have raised two daughters;

Schweizer Fellowships. "But on peo-

taught at the School (she was affiliat-

Gretc^ew awgf Warrew Berggw: at ippg HSPH A/MWM; Day, w^ere tAey receweti t^e A/Mww; Awar^ o/MenY.

ples' talk-to-do ratio, they score very

ed with the Harvard Center for Population and Development Studies from 1 9 7 4 - 1 9 8 9 , he was an associate

high." Forrow admires the Berggrens for having "consistantly created a life

Medicine; and, having perhaps the

out of their values," for really living

Professor of tropical public health

greatest personal resonance because

out the Albert Schweitzer admoni-

and population sciences from 1972.

it was presented to them by Mother

tions they'd been inspired by in their

to 1 9 8 1 ) ; guided public health stu-

Theresa, the International Health

youth: "reverence for life," and " m y

dents through held work and special

Award. This spring, the Berggrens

life is my argument."

Projects; and worked with U N t C E F

received the H S P H Alumni A w a r d of

^nd similar organizations, including

Meritâ&#x20AC;&#x201D;the highest honor bestowed

"Gretchen and Warren are some-

by the School on its graduates.

thing pretty rare in the academic

Years with Save the Children ^deration and, currently, World ehef. Awards have come: a Presidential citation from Bill Cli 'Won; the Donald M c K a y Medal the American Society of Tropical

Pressed to offer insight or lessons

Paul Farmer would agree.

w o r l d , " he says. "They've never lost

about their work, Gretchen remarks:

their commitment to serving the less

" Y o u know, we do laugh and joke a

fortunateâ&#x20AC;&#x201D;that means the poor.

lot. We've had much joy. And the courage of Third-World mothers is a

That's their commitment: serving."

R o b e r t F. Zatisk

Daniel Botstein and colleagues publish restriction-fragment-length polymorphism paper crucial to mapping disease genes.

Max Essex, chair of the Department of Microbiology, a w a r d e d the National Cancer Society's Bronze Medal, t h e organization's highest honor, for his research on leukemia in animals.

Nantucket

NDY SPIELMAN A D M I T S HE WAS not the obvious candidate for the job. An entomologist and a member of the School's prestigious tropica! public health department for 1 4 years, he had built his career primarily on mosquito research.

Babesiosis, it was well known, was spread by ticks.

To the casual bug a voider, the difference between insect and a r t h r o p o d might seem slight, but scientifically speaking they are worlds apart.

But when Spielman's friend, George Healy, a researcher at the Centers for Disease Control helped diagnose a second case of human babesiosis on

1981

M o r M f y a n d Morfa//fy Wee/;/y Report reports outbreak of rare,tetha! pneumonia among gay men in Los Angeles, California.-The first report on w h a t will eventually be called AIDS.

Ronald Reagan succeeds Jimmy Carter as 40th President of the United States.

Immunologist John David succeeds Nobel Laureate Thomas Weller as chair of the Department of Tropical Public Health. David will hold the chairmanship for 15 years.

Nantucket in 1 9 7 3 , Spielman was intrigued. Although a handful of human cases had been reported worldwide, babesiosis was known, for the most part, as an animal disease. Here was a chance to tackle a Problem that was scientifically entic'ng and perhaps of major public health significance.

Over the next several years, Spielman would throw off conventional wisdom and become one of the world's foremost authorities on tickhorne diseases and the environmental forces that shape them. His research solved the puzzle of babesiosis on Nantucket. He identified a new species of tick, J x o J e s &7f7WM7n', which is responsible not only for the emergence of babesiosis in the United States, but for a whole new group of t'ck-borne diseases, the best known which is Lyme disease. Sam Telford III, a young colleague in Spielman's lab, identified a third tickorne pathogen three years ago and as a paper in the works that will hnger a fourth. And Telford and Spielman have recently played a key role m the preliminary testing of a yme disease vaccine. Yet Spielman says to marvel at how chance favored a Harvard mosquito expert with such a Productive career as a tick ^searcher is to misunderstand his Particular brand of research and peraps public health research more Orally.

"T am not a mosquito specialist. 1 am not a tick specialist. I am a transf u s i o n specialist," says Spielman. " I ^ interested m the etiology and rnode of transmission of vector-borne A c t i o n s . That is what public health h o m o l o g y is all about."

Profe ^ Director David Bell appointed Gamble H e a l t h ' ' " P o t i o n Sciences and International Sadies? ^ Department of Population ford F ^ ^ d been executive vice-president of the " N a t i o n ' s International Division.

H O O K I N G BACK N O W , SPIELMAN L i says with a broad smile and laugh that " G o d , 1 had no idea what I was doing" as he boarded the ferry for Nantucket one chilly morning in the fall of 1 9 7 3 for the first of many times. But actually, Spielman did know a good deal. For starters, because of Healy's brilliant ant diagnostic skills, he knew he was dealing with a protozoan called Ba^esM, a blobby, single-celled parasite that comes in 70 or so different varieties.

It was no coincidence that the Nantucket index case was initially misdiagnosed as malaria. The periodic shaking chills and drenching sweats of malaria are very much the same as in babesiosis. And the underlying parasites of the two diseases have the same nasty habit of destroying red blood-cells. But unlike malaria, babesiosis had been known mainly as a disease of animals, primarily cattle. In fact, almost a century earlier, legendary Harvard researcher Theobald Smith had made the watershed discovery that a protozoan (now known as Babesia bigemina) could cause disease in a warm-blooded animal and be spread by an arthropod (the Boophilus cattle tick) while investigating a cattle disease in Texas.

[Smith was a faculty member for about 2.0 years in the Comparative Pathology Department at Harvard Medical School, which later divided into the School's Department of Tropical Public Health and the medical school's Department of Pathology.] Because of Smith's discoveries, and other work that followed, Spielman could be reasonably sure that a tick was the culprit behind on Nantucket.

Another important piece of historical evidence that Spielman had in mind as the ferry churned across Nantucket Sound was that the ticks would probably have a hearty appetite for rodent blood. In 1 9 3 8 , Ernest Tyzzer, who succeeded Smith as Harvard's George Fabyan Professor of Comparative Pathology, published a rather obscure paper in P(?r<3S3Yo/ogy that mentions a B^&esM infection of voles (a mouse-like creature) on Martha's Vineyard, an island near Nantucket and another treasured vacation spot. Moreover, his detailed drawings showed that the kind of that Tyzzer found in the voles on Martha's Vineyard looked to be very similar to the Babesia making people sick on Nantucket. Tyzzer was something of a misanthrope, according to Spielman, but his quirky personality paid scientific dividends as he pursued an interest in animal diseases.

Spielman says he knew about Tyzzer's paper " f r o m w a y back."

"There was a collection of old departmental papers and reprints in our lunchroom at that time," he explains. "While I was in there having lunch, if there was nobody else around, I would look at those old papers just out of curiosity." So from Smith, Spielman knew he would be dealing with ticks. From Tyzzer, he had the clue that rodents would be involved.

Spielman headed out to Nantucket not only with mouse traps, but with bulky raccoon traps that he had cadged from Massachusetts's eastern equine encephalitis research station.

His research assistants were not seasoned held biologists but a slightly jit-

Britain's Prince Charles and Lady Diana Spencer are w e d in London's Westminster Abbey.

UMass held station had inadvertently spiders, mites and, of course, tickstery Vietnam veteran (Spielman created the "edge" habitat ideal for are the carriers of vector-borne illthinks he may have been suffering nesses. Their biting and blood-suckmice. Ecologically, edge is the boundfrom post-traumatic stress syndrome) ing habits spread the viruses, bacteand his girlfriend. On the island, the ary area between two habitats, which ria, protozoa and other pathogenic trio depended on bicycles for transin this case were meadow and brushy, organisms.

In addition to carriers, portation, and when they rode down covered terrain. vector-borne diseases also depend Nantucket's cobblestone streets, the Homing in on the white-footed raccoon traps tied to mouse put Spielman on the b a c k s of their the path to his crownTnp/e ^reat; t^e Ixodes dammini t/c^ carn'es at /east ^ ^MWMM J;se<Me$. bikes came tumbling ing achievement, idendown. And somehow tification of the PxoJes Spielman had gotten tick as the confused about their vector of Nantucket destination. It was the fever. When he returned UMass biological held to Nantucket the next s t a t i o n they w e r e year he began looking looking f o r , not the for the Babesia-carrying M a x Planck field stacreatures in earnest. tion. "We had no idea At this point, if what we were doing!"

Spielman had paid too S p i e l m a n says once much attention to what again, for emphasis. other experts were Ba&esM M^'crof!'

Borre/M &M7-gJor/i?n' As luck would have saying, he might have Babesiosis Lyme disease Human Granuclocytic it, even w i t h those missed out on the disEhrlichiosis unwieldy raccoon covery. Partly because traps, Spielman w a s the kind of Ixodes ticks able to catch the key he was seeing on animal, the white-footed mouse, that upon reservoir: biological hide-outs Nantucket had not been previously fall. He had also stumbled upon what where the disease-causing microorobserved north of Georgia, Spielman might be one of the best places in the ganisms can prosper and multiply as was told that the ubiquitous world to do held biology research. uninvited, but often harmless, guests.

Dermacentor variabilis, or dog tick, The 30-acre, University of Because Tyzzer had found was probably spreading Nantucket Massachusetts held station is on a parasites in voles on Martha's fever. Dog ticks also made sense bluff overlooking a beautiful bay. "It Vineyard, it seemed likely that voles because Rocky Mountain spotted is," says Spielman "the nicest piece of on Nantucket would be providing fever was on the rise at that time on property on Nantucket." For the same safe haven. the East Coast, and dogs ticks spread Spielman, who grew up on Long But Spielman was finding that the Rocky Mountain spotted fever.

Island and loves the ocean and outNantucket voles were largely Spielman recalls talking to one doors, this was not a bad job, not free. Instead, it was the red-blood Massachusetts tick expert early in his bad at all. cells of the white-footed mice that investigation: "He kept rattling on were choked with Ba^asM. That about how obvious it was, that it mice, not voles, turned out to be the rn # E C T O R C O M E S F R O M T H E L A T I N wasn't interesting, that it is the dog reservoir for Nantucket fever was a w vehere, which means "to carry." tick and that is all you need to lucky break for Spielman. The mainArthropods-that vast phylum of the know." A group at Ohio State even tenance and mowing schedule of the animal kingdom that includes insects, went as far as to publish a paper

Renowned statistician Frederick Mosteller assumes chairmanship of the Department of Health Policy and Management. He previously served as chair of the Department of Biostatistics and helped found the School's Center for the Analysis of Health Practices.

Sandra Day O'Connor is appointed to the Supreme Court.

Bambi, Babesia, and Bore!ia To be a good botanist, you have to think like a plant, says Wes Tiffney, director of the University of Massachusetts field station on Nantucket and himself a botanist. And he believes the same rule applies to good insect-borne disease research. "Sam [Telford] and Andy [Spielman] can think like a tick."

It was thinking like a tick and a pathogen, as well as some careful observations and experiments, that helped Spielman solve one of the big riddles of the epidemic of tick-borne diseases: Why now?

Mostly what blood-thirsty deer ticks seem to think about during their brief, two-year life spans is where are they going to get their next meal. In its immature forms, first as a six-legged larva and then as an eight-legged nymph, the deer tick feeds on the white-footed mouse and, occasionally, on people. From the pathogen's point of view, a meal of human blood is a mistakeâ&#x20AC;&#x201D;a "leak," as Spielman calls itâ&#x20AC;&#x201D;because the tick doesn't pick up a new supply of Ra<bei/3 W o w / , the bacteria that causes babesiosis, or eorre/z'a burpc/or/en; the bacteria that causes Lyme disease. In fact, one reason there is no Lyme disease in the South, says Spielman, is that the deer ticks there feed on lizards, which are not reservoirs of Borrelia burgdorferi.

As adults, deer ticks feed on their namesakes. Deer do not function as disease reservoirs. But without deer, adult ticks cannot survive and breed. Spielman started to suspect that the booming Nantucket deer populations played a key role in babesiosis when he couldn't (later retracted) that identified the dog t'ck as the Nantucket fever vector.

Yet Spielman kept on seeing the speck-sized deer ticks, not dog ticks.

And where he saw them was especially interesting: on the skin of white-footed mice. Pluckmg the ticks off by hand, Spielman counted roughly 1 9 deer ^cks for every dog tick on the mice.

That ratio was reversed when it came to the voles. Because vole blood was hardly ever infected with Babesia, and ^ouse blood was, it didn't make sense that the dog tick, which favored voles, ^as the vector. No, though Spielman, the / x o & s ticks found on white-footed m*ce had to be what was spreading babesiosis on Nantucket.

^ ' " n n a Gro Harlem ^ n d t l a n d , M.P.H/65, p o i n t e d to first of j e e terms as Prime d u s t e r of Norway, the 'rst woman to hold the Post.

find any adult ticks on the white-footed mice. "The question was, where the hell are all the adults?" says Spielman. The answer started to surface during deer hunting season, when Spielman saw adults ticks on animals shot by hunters. Several years later, Spielman and colleague Mark Wilson put the deer-tick connection to the test. Over the course of two or three years, they had sharpshooters kill deer on Great Island, Massachusetts, off of Cape Cod, driving the population down to almost one-tenth of its previous level. After the deer were killed, deer tick populations plummeted and have stayed low ever since. Since 1986, only one case each of Lyme disease and babesiosis has been diagnosed among the island's residents.

Elsewhere in the eastern United States, deer populations have reached all time highs. Beginning in the 1940s, as farms disappeared and the nation's voracious appetite for timber slackened somewhat, the eastern half of the country started to reforest, explains Spielman.

But the reforesting has been patchy, cut up by roads, shopping centers, people living in leafy, distant suburbs and,even further out, vacation homes. The result has been creation of lots of edge habitat, ideally suited to deer and white-footed mice and therefore ticks and the pathogens they spread.

"We are living in a very dynamic landscape," Spielman said in a lecture at the School last fall. "The pathogens were always here, but we had no vectors that fit both the reservoir and people. That was what was accomplished when the deer herds came back."

PW

For a century, the standard of proof for causation in infectious disease research has been fulfillment of Robert Koch's famous postulates.

First, isolate the organism from an infected animal. Second, reinfect another animal with that organism.

And third, recover the original organism from the animal just infected. If Spielman was to nail down the case against the deer ticks, it would mean leaving the lovely Nantucket held station and getting down to work in the lab.

Using Ba^asM isolated from a human patient, Spielman infected a hamster with the protozoan.

Immature lab-reared deer ticks feast-

Professor of Microbiology John Cairns, one of the world's leading cancer researchers, awarded a MacArthur Fellowship.

ed on the infected hamster. Once they were sated and presumably loaded with carrying Spielman set the ticks loose on 1 1 non-infected hamsters. Spielman waited three weeks and then drew blood from the hamsters. Ten of them were infected with Babesia. Koch himself would have approved.

The work was described in November 1 9 7 6 in the American Journal of Tropical Medicine and Hygiene. In that paper and others, Spielman identified the culpable tick as scapM/^n's, a variety of tick that had been identified way back in 1 8 0 5 . Three years later, Spielman officially proclaimed the Nantucket

Alumnus Jim Curran, M.P.H.'74, appointed head of theCDC's AIDS Program.

tick a new variety of arthropod, naming it /xoJes J^rwwnMz after Gustave Dammin, a prominent pathologist at Brigham and Women's Hospital. Naming a disease-spreading tick for someone might seem like a dubious honor, but ever since Carl Linnaeus set up the current taxonomic classification system in the 1 8 T H century, naming a new species for someone has been a way for biologists to immortalize themselves, mentors or loved ones.

Spielman chose to honor Dammin because he had helped him with his research and was a property owner on Nantucket (Dammin's wife came from one of Nantucket's most prominent families). Spielman built his case for L J^ww/w/ being a separate species from 7. sc^pM^w on the observations that the two ticks had very distinct ranges (J. &77wwM;' in the Northeast, L sc^pM^ns in the South) and that I. dammini was morphologically different, especially at the nymphal stage. He also marshaled D N A evidence to make his case.

Since then, Spielman has been hghting a protracted, but probably losing, battle for L identity as a separate species. Siding with researchers in Georgia, the editors of the Journal of Medical Entomology have officially ruled that, taxonomically speaking, Ixodes is no different from ZxoJes scapM^n's and therefore the two species should be "synonymized" under the ZxoJes sc^pMAgn's name. Spielman disagrees.

Aside from any pride and politics (Lyme disease research has become highly politicized in recent years)

1982

Professor Harry Antoniades and colleagues describe part of the genetic sequence of platelet-derived growth factor (PDGF), a blood protein first purified by Antoniades a decade earlier. Subsequent research will reveal that the PDGF sequence is identical to a section of a simian cancer virus, providing the missing link of how viruses can cause cancer.

Spielman says maintaining L &?7M7w'separate identity is key to understanding the ecology and epidemiology of tick-borne diseases. Southerners don't get Lyme disease. And it is immediately clear why that is so, says Spielman, if you understand that the South doesn't have the 7. J ^ w w w ? tick that spreads the disease. ^ ^

^MMfers across JecaJes: Erwesf Tyxxer, AwJy 5p;'e/7?M7!, aw^f T<?//brJ m .

World Health Organization selects the School a s a Collaborating Center for Cancer Biostatistics.

NE H U N D R E D AND TWENTY miles west of Nantucket, in Lyme, Connecticut, just a couple of years after the outbreak of babesiosis, Anne Mensch and Polly Murray were seeing an equally odd, but more alarming, outbreak of disease in their community. The disease was arthritis, and the victims were young children.

By 1 9 7 5 , Mensch and Murray had gotten a young rheumatologist at Yale named Allen Steere involved.

Steere says he and his colleagues saw the hallmarks of arthropod-transmitted disease nearly from the beginning of his investigation into Lyme arthritis, later named Lyme disease: the cases clustered in a rural area, the hitand-miss pattern, and symptoms generally showing up in summer and fall when arthropods are most active. In fact, one of Steere's brilliant strokes was to focus his epidemiologic investigation not on arthritis, which turned out to be one of the many symptoms of Lyme disease, but on patients' recollections of an unusual reddish, bull's-eye-shaped rash. As it turned out, this condition was reminiscent of erythema migrans, an obscure skin condition seen in Europe that was known to be c a u s e d by a tick bite. In the summer of 1 9 7 7 ' one of Steere's subjects saved a tiny

The Vietnam War Memorial, designed by 21 year old architecture student Maya Lin, is dedicated.

tick that had recently bitten him.

Yale researchers identified it as a &W17WM; tick, the same kind of creature Spielman identified on Nantucket. The connection between Lyme disease and babesiosis had been made. It would be, however, another Rve years before Willy Burgdorfer, a researcher at the National Institute of Health's Rocky Mountain Laboratories in Hamilton, Montana, identified exactly what the ticks were spreading that was causing Lyme disease: a squiggly bacterium, or spirochete, that has since been named ^orre/M ^Mrg^or/er;'.

In November, 1 9 9 4 , a 68-yearold woman came to the Nantucket Cottage Hospital after five days of fever, mental confusion, and headache. Initially, doctors thought she might be another victim of babesiosis or Lyme disease or both.

The woman recalled having been hitten by a tick five days before getting sick. But blood tests showed ^o sign of either Bofre/M &M7*gJo?*/i?n or 7M?'c?*of;. It was Telford, again drawing on Tyzzer's 1 9 3 8 Parasitology paper as a reference, ^ho figured out that the woman was infected with a third pathogen, ^ c f e w . Thus, a third disease, human granulocytic ehrlichiosis

^ e s L. Whittenberger, ^ i r o f t h e Department Physiology and director ^ h e Kresge Center for ^ r o n m e n t a l Health, J t j e s f r o m the faculty, a 36-year affiliat e " with the School.

C. Everett Koop issues Surgeon General's Report calling cigarette smoking t h e chief preventable cause of d e a t h in the U.S.

( H G E ) , was added to the roster of ills wrought by deer ticks. N o w Telford has identified a fourth pathogen, this time a virus, lurking in the guts of deer ticks. So far, he has only isolated it in ticks and deer tick virus (as Telford is calling it) has not yet been linked to any human disease. ] Y M E D I S E A S E IS B Y F A R T H E M O S T Km common of the deer tick diseases with about 1 5 , 0 0 0 cases reported to the Centers for Disease Control and Prevention last year, according to David T. Dennis, M . P . H . ' 7 4 , the coordinator of the C D C ' s Lyme disease program. Those cases were concentrated in 80 counties in 8 states-Connecticut, Rhode Island, N e w Y o r k , N e w Jersey, Pennsylvania, Maryland, Wisconsin and Minnesota. Annual babesiosis and H G E cases number less than 1 0 0 , though lack of reporting and missed diagnosis seriously undermine the reliability of the statistics on all the tick-borne diseases. Though culling the deer herd has worked on an experimental basis in island situations (see sidebar), Dennis says in most situations controlling deer and mouse populations is not a feasible way of controlling Lyme disease.

Because most people get bitten by

deer ticks near their homes, simple things like clearing away leaves can help control the disease by making backyards less accommodating to mice. Dennis said one of the most exciting experiments in tick control involves deer feeding stations designed so that when the deer eat, they rub up against some material soaked with insecticide that kills the ticks but doesn't harm the deer.

Spielman tested a similar system for mice.

Meanwhile, SmithKline Beecham and Connaught are pushing ahead with development of a Lyme disease vaccine. Spielman led the Phase 11 testing of the SmithKline Beecham vaccine among residents of Nantucket, Martha Vineyard, and Block Island. Steere is the investigator in charge of the larger Phase 111 trials.

"This is a disease that is likely to be conquered, but we are not exactly there yet," says Steere. Dennis and other public health officials are wary, however, about the eventual marketing of a vaccine. "Selectively used, it could be attractive," he says. "But without real good education, there could be a huge demand for this kind of protection when the cost may exceed the real benefit."*^

Argentine forces invade Britain's Falkland Islands, prompting a month-long war.

First artificial heart is implanted in Barney Clark on December 2.

g y f<?/77 A. / M f e r

IKE T H E M A N W H O W O U L D BE KING, JAMES G O D D A R D , M . P . H . ' 5 5 , H O P E D one day to be surgeon genera}. But he needed a high-powered administra!â&#x20AC;&#x201D;â&#x20AC;&#x201D; tion job hrst to strengthen his resume. As the nation's hrst Civil Air Surgeon, he was responsible for the medical licensing of some 300,000 pilots a year as well as the investigation of human factors errors in major aircraft acci-

HSPH graduates manned the helm of

dents. After clashing with the F A A ' s top administrator, Goddard was summoned by Surgeon General Luther Terry, who gave him three choices for a placement that would earn him the star he needed to someday put him in line for Terry's job. His last choice was director of the Communicable Disease Center ( C D C ) in Atlanta, Georgia. And that's where Terry sent him. At age 39,

the nation's premier public health agency,

this brash midwesterner was the youngest person to ever hold the job.

When Goddard arrived at C D C headquarters at 1600 Clifton Road in Atlanta, Georgia, in 1962., the 16-year-old agency had already gained a reputation for the skill with which its Epidemic Intelligence Service ( E i s ) officers, under the direction of hard-edged Alexander Langmuir, tracked down the cause of outbreaks of infectious disease. The Eis had cut its teeth during the

1983

A series of papers in 5dence, including one by Max Essex, chair of the Department of Microbiology, provides first evidence that a retrovirus may be the cause of AIDS. The AIDS caseload has passed 1,400 according to the Centers for Disease Control and Prevention.

In the first major academic reorganization in a decade, the School's Departments of Microbiology and Physiology are eliminated and the Departments of Cancer Biology and Health Science and Physiology established. Max Essex is named chair of cancer biology, which also incorporates the Laboratory of Radiation Biology. Joseph Harrington (left) is named chair of health science and physiology.

early years of the Cold War by Preparing for the possibility of biological warfare. The anticipated attack never happened, but Eis officers learned much about how to respond to and solve infectious disease outbreaks around the country. ^ 1 9 5 5 , E i s officers tracked a polio outbreak to a vaccine produced at the Cutter Laboratories in California that had been contaminated with live virus. The C D C ' s reputation for expert epidemiology was reinforced two years later when the agency joined an international effort to trace the source of a deadly outbreak of Asian flu.

"Our epidemiology was the best in the world," says Goddard today.

Established in 1946, the C D C was a direct descendant of the U.S. Public Health Service's Malaria Control in ^ a r Areas ( M W R A ) program. M W R A ^as created during World War H to Protect American troops from the mosquito-borne disease malaria, vvhich was endemic in the southern ^-S. states where some 600 military bases were located. Under the direction of its intrepid leader, Joseph ^ountin, M W R A quickly brought the malaria threat under control by digSmg drainage ditches and spraying generously with the larvicide D D T . By ^943, the anopheline mosquito that Carries malaria had virtually disappeared from the United States, p encouraged by this success, Mountin e x p a n d e d M W R A ' s scope to include battling the louse-borne disease ^phus and the tropical diseases tought home by servicemen returnmg from the war. After the war, Mountin argued successfully for the Creation of a federal agency to moni-

Takemi Program in International Health named for the eminent Japanese physician Taro Takemi, established at the School.

tor and control infectious disease outbreaks nationwide. Congress responded by creating the C D C .

Veterinarian James Steele, M . P . H . ' 4 2 , went to the C D C during its first year of operation, as director of the agency's Veterinary Public Health Division. "It was the first of its kind," says Steele of the division, which investigated the transmission of animal diseases to human beings,

around the globe, usually within a day's notice of an outbreak. With the W H O , the C D C was a major player in the eradication of one deadly disease—smallpox—and is participating in the strategic planning for the eradication of two others: polio and Guinea worm disease. In recent years, the C D C has broadened its focus to include chronic diseases and injury control. In 1992., C D C added the word "prevention" to its name to reflect this broader focus.

"The C D C is one of the most exciting places that anyone can work," says William Foege, M . p . H . ' 6 $ , who directed the organization from 1 9 7 7 to 1 9 8 3 . "People could do things there that they could never do any place else."

JgTWM G o J J a r J , M . P . H . ' 5 $

including rabies, salmonella and the bird-borne disease psittacosis. Steele's division served as the model for similar efforts at the World Health Organization and the Pan American Health Organization.

In the 50 years since its founding, the C D C has grown many times over, in terms of budget, staff, and complexity. What began as a small group of mostly engineers and entomologists has expanded into a complex army of nurses, epidemiologists, biologists, physicians, veterinarians, and behavioral scientists, among others.

The C D C has become the world authority on communicable disease— sending teams of Eis microbe hunters

Foege's tenure at C D C falls roughly in the middle of a continuous, 2.3year stretch in which graduates of the Harvard School of Public Health held the post of director. Beginning with Goddard and continuing through Donald Hopkins, M . p . H . ' 7 o , who served as acting director in 1985, the string of alumni directors includes David Sencer, M . p . H . ' 5 8 , Foege, and James Mason, D . P . H . ' 6 y . Much of the C D C ' s growth, and some of its greatest successes, can be traced through the leadership of these five H S P H graduates—the ones Foege calls the "true believers." /

ODDARD BROADENED THE ! **< vision for the C D C , " says ^ ^ Steele of the man who began the legacy. "He was the watchdog for new things on the horizon."

Among other achievements, Goddard almost single-handedly introduced the C D C to the age of elec-

Microbiologist Dyann Wirth introduces a rapid new diagnostic test for the parasitic tropical disease leishmaniasis. The technique, which uses a DNA probe, proves highly accurate and Wirth will subsequently develop a similar diagnostic tool for malaria.

tronic computing. The I B M 6 1 0 that Goddard secured for the agency occupied a room 18 feet long and 2.0 feet wide—a true dinosaur compared to modern computers. The E i s officers "grumbled and grumbled" as they were sent to the I B M training courses to learn the language of entering data and outputting results on multivariate outcomes, says Goddard.

A year later, however, they were as enthusiastic about the emerging technology as he was.

ing his head into laboratories and offices just to say hello. He also apparently played a mean game of bridge in the dining room during lunchtimes.

In i c ) 6 6 , Goddard left the C D C — "the best assignment I had in my career in public health service" he says—to serve as commissioner of the U.S. Food and Drug Administration.

Fie left the director's chair open to

Goddard also enlarged the agency's Medical Audiovisual Branch, which produced hundreds of training films for state health departments and public health laboratories and produced informational literature and films for the public, including adult comic books about venereal disease prevention. In her history of the C D C , Sentinel for Health, Elizabeth W. Etheridge illustrates the bold independence for which Goddard was known.

Feeling frustrated at how long he had to wait for clearance from Washington for materials produced by the C D C , Goddard asked an assistant to gather and take a picture of all the videos, books, brochures, and other materials produced in a single year; the collected materials covered a long table. He had the picture enlarged to poster size and presented it at the next meeting. When his superiors recognized the amount of time required to review each piece, they resigned their stance on the subject, and Goddard never had to wait for clearance again.

Goddard was also a friendly, easygoing man from Ohio who spent every Friday roaming the halls, stick-

Compact disc is invented.

Sewcer, M.p.H.'^S the man he had chosen to be his deputy, fellow H S P H graduate David Sencer, M . p . H . ' ^ 8 . Sencer was "the brightest man I've ever worked with," says Goddard, adding that Sencer wanted the head position at the C D C "so much he could taste it."

In /or He^M?, Etheridge notes that the hallmark of David Sencer's 11-year reign as head of the C D C was growth. Sencer took in federal offices whose funds were being cut—such as the Office of Pesticides and the Foreign Quarantine Office— and reorganized them by cutting inefficient and wasteful procedures and making changes in redundant stafhng.

National Center for Health Statistics reports that the nation's infant mortality rate has stopped declining for the first time in two decades.

"Sencer was an organizing, implementing kind of person," says James Curran, M . p . H . ' 7 4 , who went to the C D C in 1 9 7 1 as part of the Sexually Transmitted Disease Division.

Sencer was also known for his amazing capacity to remember details and his thorough knowledge of the agency. "That guy knew everything there was to know about the C D C , " says Donald Hopkins. "He knew so many people by name; he has a phenomenal memory."

"When he moved to the big corner office on the second floor of 1 6 0 0 Clifton Road, the man and the institution were fortuitously matched at a time when it was possible to get something done," writes Etheridge.

In rc)66, Sencer's first year as director, the C D C and W H O launched the global Smallpox Eradication Campaign. Four years later, Sencer put fellow H S P H alumnus William Foege in charge of the campaign.

Foege would eventually succeed Sencer in 1 9 7 7 , the same year the last case of small pox was registered.

During Sencer's watch, the C D C also implemented the nation's first successful family planning research project, which included the surveillance of birth defects. This eventually grew into the Birth Defects Monitoring Program, which g a r n e r e d support from the March of Dimes.

Sencer also scanned the U.S. Public Health Service and decided that sectors such as the National Clearinghouse for Smoking and Health, (which insiders called the "Smokehouse") and the National Institute of Occupational Health and Safety might be more appropriately administered by the C D C . Both were

Pr/nces a n d Peasants—$ma///xw /n M'sKvy, by alumnus and former faculty member Donald R. Hopkins, M.P.H/70, tells the history of smallpox from its probable origins in 10,000 B.C. to its eradication in 1980.

Primarily concerned with prevention and, says Sencer, "the same sorts of skills used in communicable disease control" could be applied to monitor the health effects of tobacco and Workplace safety issues. Thus in 1 9 7 2 , Sencer says he "waged a little campaign" and successfully acquired the two offices.

"Sencer had a real grasp of the important public health issues of the time and how they should be dealt With," says Curran.

Although Sencer was widely considered " a leader's leader," his tenure ended with controversy, which eventually led to his resignation.

In January 1 9 7 6 , four isolates of what turned out to be swine flu—the killer of some zo million people during a worldwide epidemic in 1 9 1 8 — Were discovered among soldiers stationed at Fort Dix, N e w Jersey. One soldier died and 500 others were believed to have been exposed. When Word of the outbreak reached the CDc, Sencer called the first of many high-level meetings; all present agreed something had to be done.

Sencer presented a memo to the Ford administration in which he outlined four options for dealing with the potential threat of swine flu: option four, calling for the vaccination of the entire population in time to avert another potentially deadly epidemic of swine flu, was the one he recommended. He gained nearly Unanimous consensus from his Colleagues at the C D C , including the Advisory Committee of immunization Practices and the Public Health Service. The vaccine champions themselves, Jonas Salk and Albert Sabin, conferred with

estimated 35 million ^Tiericans live in ^ n g e r , up from ° million in 1979 f o r d i n g to t h e U.S. Census Bureau.

President Ford and agreed that a widescale vaccination effort was in order.

On October 1 , 1 9 7 6 , the first swine flu vaccination shots were given. On December 1 6 , Sencer announced the swine flu vaccination program was being suspended following 54 reported cases of GuillainBarre syndrome, believed to somehow be linked to the vaccine. T w o

sent [the situation] as accurately as we could and say that this was good preventive medicine, and if you believe in good preventive medicine, you sell it."

In his introduction to -Swz'ne

by Richard Neustadt and Harvey Fineberg, Joseph A. Califano points to the good that was accomplished by the swine flu affair, namely the huge number of people vaccinated, the development of a successful influenza surveillance program, and the ability of that system to track down the negative side-effect of Guillain-Barre. "In these terms, it may go down as a qualified success," wrote Califano, who was then H E W secretary and who commissioned Neustadt and Fineberg to write the book so that the administration could understand the lessons to be learned from it.

— H E

Foege, M.p.H.'6y weeks later, Sencer was asked to resign. He also took the brunt of the criticism. "David was the fall-guy on swine flu," says Goddard today. " H e got a bum rap." " I would say over and over again, this was the right thing to do," says Sencer in a video tape produced in 1 9 8 3 by the C D C , part of an oral history of the agency.

Critics pointed to Sencer's memo as the incendiary piece of paper that sparked the whole vaccination effort.

In the C D C video, Sencer says all he did was present the facts in the name of the public interest: "We didn't pull out people lying in the streets and tear-jerking things. We tried to pre-

Astronaut Sally Ride becomes the first w o m a n in space. "*""" " SM)H DO

„

YEAR WILLIAM FOEGE

assumed the directorship of the C D C , the last case of smallpox had been eradicated from the world.

He had been anticipating and planning for this event since he was a student at the School of Public Health.

"It's one of those things that is not just a once in a lifetime opportunity," he says, "but it has to be done once in the entire history of the world."

And, he adds, "its benefits accrue forever."

Foege's involvement in the eradication of smallpox began in a missionary medical center in Nigeria, where he helped devise the "search and containment" strategy that proved so essential to the program's success. Instead of vaccinating every-

President Reagan proposes t h e Strategic Defense Initiative that becomes known as the Star Wars defense.

46

^ ^

body in the world, as was the original plan, limited stocks of vaccine were used to inoculate people living in villages already experiencing a smallpox outbreak, as well as the entire communities of a few surrounding villages. The system was efficient, but most importantly, it was also effective.

In 1 9 6 7 Nigeria's six years of postcolonial turmoil finally erupted into civil war, and Foege was evacuated.

He returned to the C D C , where in 1962. he began a two-year stint as an Eis officer. When he came back in 1 9 6 7 , he went straight to the Smallpox Eradication/Measles Control Program and in 1 9 7 0 , Sencer named him director of the program.

Six years later, Foege replaced Sencer as C D C director.

During Foege's hrst year as C D C director, he chose an ambitious project: identify the leading causes of morbidity and mortality in the country and devise means of prevention.

He organized what he called the "Red Book Committee," which included, among others James Mason, who would succeed Foege as C D C director.

What they found was that injury, including everything from automobile accidents to homicide, was the leading causes of premature morbidity and mortality. The solution, says Foege, was obvious: prevention.

Foege called for the C D C to become the "conscience for prevention," and he championed the application of epidemiology to study injury. But he faced strong opposition, particularly from within the department, where it was believed that injury was a problem for law enforcement, not for public health. Publication of the 1983

1984

Harvey V. Fineberg succeeds Howard H. Hiatt as dean of the School of Public Health. The 37-year-old Fineberg is the sixth and youngest man to serve as dean.

Institute of Medicine report "Injury in America: A Continuing Public Health Problem", in which Foege played a key role, began to change minds. T w o years later, the C D C created an injury epidemiology and control division, and in 1 9 9 3 , the National Center for Injury Prevention and Control was developed, thus lending the same legitimacy to injury as communicable disease.

/ a w M Maso?!, D.p.H.'67 "Injury in America really set the stage for the development of injury control as a scientific held," says Mark Rosenberg, director of the C D C ' s National Center for Injury Prevention and Control. Rosenberg credits Foege with unifying the various government agencies into one central agency that would address all phases of injury: prevention, as well as the acute care and rehabilitation of injured people. "He helped to clarify the vision, and he continues to play a critical role in guiding and inspiring workers in this held around the world."

On June 5, 1 9 8 1 , two years before Foege left C D C to go to the

Warren Berggren, D.P.H.'67, director of primary health care for Save the Children, heads a relief mission to Ethiopia, where famine threatens an estimated 7 million people.

Carter Center, where he would eventually be named executive director, a report that is now known as "Document Z e r o " appeared in awJ M o r f ^ Y y Wee^Jy Report, the C D C ' s digest of disease outbreaks and trends. Simply titled "Pneumocystis Pneumonia—Los Angeles" this brief article described the deaths of five homosexual men from a rare pneumonia found predominantly in people whose immune systems were severely compromised. " N o one had any idea of how big this problem was going to be," says Foege. It would take two more years for this problem to be given a name—acquired immune deficiency syndrome, A I D S — b y which time it was well on its way to taking an enormous international toll on human life. For many at the C D C , including Foege's successor, Mason, it would become an all-consuming interest.

Curran, who would become h e a d of the C D C ' s A I D S program, said e a c h director lent his individual skills a n d strengths to the A I D S issue. "Foege tried to get people to take A I D S seriously," he says. "He was supportive of us at a time when the g o v e r n m e n t was trying to cut funding. When we needed resources, he would find additional resources," says Curran.

When Mason came on board, AIDS had been diagnosed in recipients of blood transfusions and hemophiliacs, so there was much more public attention being given to it. " M a s o n , " says Curran, "took responsibility for managing all the attention and making sure people had the right concerns.

"What was hidden was so much greater than we could see," says

Toxic gas leak from a Union Carbide p l a n t s Bhopal, India, kills 2,000 people and injures 150,000.

Mason about the emerging A I D S pandemic that was taking so much of the CDc's attention when he assumed the directorship in 1 9 8 3 . "And the C D C ^vas more aware of this than others early in the epidemic."

That same year, the C D C ' s National A I D S Hotline was established to handle the growing number of calls for information. Meanwhile reports of heterosexual women who had contracted A I D S from male partners exploded the belief that the disease was strictly conhned to homosexual men. Like his predecessor, Mason spent much of his time hght'ng Congress for more A I D S fund'ngâ&#x20AC;&#x201D;unfortunately, he says, much of ^ came from the C D C ' s infectious disease budget. "It had to come from somewhere; we couldn't appropriate 't fast enough," he says. He also became involved in writing public Policy on A I D S .

Directing the C D C was an event that Mason admits was "not even in his wildest dreams" when he was a student at the School, where he d e c e i v e d his D . p . H . in 1 9 6 7 . In 1 9 5 8 Mason faced two choices to fulfill his military obligation: the navy or the Public health service. lust as he was ah "°out to sign on the dotted line for the former, a position opened up at ^ e C D C . He took it.

It was a fantastic two-year period," says Mason about his stint in the E i s , where he rose to the position of chief. "I felt guilty calling it miliary service."

In 1962. Mason came to the ^chool a s part of the C D C ' s career evelopment program. He says he ^as so impressed by Professor of topical Public Health Tom Weller

^ approves MRI j S ^ t i c resonance r i s i n g ) scanners for ^ n e r c i a i use

and his department that when Weller asked him if he was interested in working towards a doctoral degree in tropical public health. Mason didn't hesitate. As a student, he co-authored a paper with Weller and Professor Andrew Spielman describing a technique for direct monitoring of natural transmission of mosquito-borne viruses. Over the next five years, Mason shuttled back and forth

"We're helping people become self-reliant," says Mason.

When asked why he thought Harvard trained so many directors, Mason says that he and his predecessors share a common thread, which originated at the School: "All of us are really committed to excellence."

They also all believe in the importance of being guided by an organized database, and share a commitment to prevention. "We couldn't allow the C D C to get caught up in the treatment paradigm."

While Mason says he supported Foege's drive to move the C D C towards understanding the burden of injury and chronic disease, he is concerned that those pursuits not be followed at the expense of the surveillance and prevention of infectious disease. "The C D C ' s future is to maintain its grip on communicable disease," says Mason. " Y o u can't let those go because they're always waiting to bite you."

between the C D C , where he served in different administrative capacities, and the School.

E G I N N I N G I N 1968, M A S O N , who is a Mormon, split his time L ^ between the C D C and administrative and clinical duties within the church's health care delivery systemâ&#x20AC;&#x201D; a job he kept, in one capacity 01* another for the next two decades.

Today, Mason oversees the church's humanitarian and missionary work throughout sub-Saharan Africa. His organization has bored water holes in the Congo, organized the distribution of clothing throughout the region, and provided food during civil uprisings.

Incidence of suicide among U.S. teenagers reaches 13 per 100,000: a 150 % increase over the past 20 years.

Hopkins, the last in the line of alumni directors, directed the Smallpox Eradication/Measles Control Program of the U.S. Public Health Service in Sierra Leone, West Africa from 1 9 6 7 to 1969, and was a consultant on smallpox eradication programs in Ethiopia and India.

Although he went to school at Morehouse College, a black private college located only a few miles from C D C headquarters, Hopkins says he had only "an inkling" of what the C D C was all about before joining the smallpox effort. In 1 9 7 2 , he came to the C D C as a medical officer hoping to work on malaria in Ethiopia.

When President Nixon reduced funding for public health work overseas,

Several weeks before classes begin, the School's water main bursts, flooding the lower levels of the Kresge Building and causing an estimated $400,000 in structural damage.

Hopkins left the C D C for a three-year stint as an assistant professor of tropical pubhc health at the School. He was invited back to the C D C in 1 9 7 7

by Foege as assistant director of operations. Three years later he was named assistant director for international health, and in 1984, he became Mason's deputy director. For most of 1 9 8 5 , while Mason served as acting assistant secretary for health in the Department of Health and Human Services, Hopkins assumed the responsibilities of acting director.

That year, says Hopkins, was "the grand year of A I D S . " On October 2., Rock Hudson died of the disease.

Also that year, the serological test for H i v infection was developed and the C D C cosponsored the first International Conference on A I D S . " T w o thirds of my time as acting director was spent on A I D S , " says Hopkins.

Hopkins stayed at the C D C for two more years before leaving for the Carter Center, where he returned to the work he loves—"real" tropical public health, specifically battling Guinea worm disease"—work for which he received a prestigious Mac Arthur Fellowship in 1 9 9 5 .

When Hopkins retires at some point

and is "sitting in a rocking chair somewhere" he says he'll reflect with great satisfaction on his work to eradicate two devastating diseases: smallpox and guinea worm disease.

As senior consultant since 1 9 8 7 for the Global 2.000 project at the Carter Center, Hopkins is in charge of the guinea worm eradication initiative, which is directly assisting programs in Ethiopia, Ghana, Mali, Niger, Nigeria, Sudan, and Uganda.

In June it was announced that yet another H S P H graduate, Jeffrey P. Koplan, M . P . H . ' 78, will take the helm at C D C . A former assistant surgeon general and the first director of the C D C ' s National Center for Chronic Disease Prevention and Health Promotion, Koplan began his career as a foot soldier in the Center's Epidemic Intelligence Service.

Even if Koplan's appointment doesn't initiate another 2.3-year stretch of Harvard leadership at the C D C , it does reaffirm the School's continued relevance as a cultivator of professionals who consistently rise to the top of the field.

has worked under—Sencer, Foege, and Mason—he recognizes a consistent quality: "a broad perspective of pubhc health problems throughout the world and an ability to see public health problems as worldwide problems."

Perhaps this consciousness was bred at the School, or just as likely, these three and those who have preceded and succeeded them, came to the School because they had that feeling already.

"It's not unique to the C D C or H S P H , " says Foege. "There are a large group of people who see public health as more than a vocation; it is a consuming interest of life. " I used to walk down the halls of the C D C and see the campus activists of the '60s," he continues. "People who were concerned about social justice were there. That's the base philosophy of pubhc health."^

"Harvard has always been recognized as one of the premier schools of public health in the country," says Curran. In each of the leaders he

New York State legislature commissions a five-year, $3 million study to provide data on medical malpractice. The Harvard Medical Practice Study, led by former dean Howard Hiatt, finds that 4 % of patients in New York hospitals are injured during their stay, that 2 8 % of medical injuries are due to negligence, and that a no-fault claims system would be no more costly than the existing tort system.

President Reagan halts U.S. funding of international birth control programs.

^

& RESIDENT RONALD REAGAN'S

economic policies rev up the

f U.S. economy, but his faith in "trickle-down" distribution theories leaves millions out of the money. Internal reforms initiated by Soviet-leader Mikhail Gorbachev in the mid-8os trigger a cascade of events that will lead to the fall of the Berlin wall in 1 9 8 9 and the gradual breakup of the Soviet Union. The new global political order that evolves will be marked by both grisly humanitarian crises and the spread of democratic freedoms to Eastern Europe, southern Africa, and part of Asia and South America Actor Rock Hudson's death from

AIDS

in 1 9 8 5 , combined

with Surgeon General C. Everett Koop's outspoken criticism of government inaction, finally galvanizes a national response to the epidemic, but not in time to stay its course. By the end of 1 9 9 7 , AIDS

has claimed more than 2. million lives worldwide, and 3 1 mil-

lion people carry the Hiv virus. Heart disease remains America's leading killer, but its long decline, coupled with steadily rising cancer mortality, set the stage for a changing of the guard.

At the School of Public Health, 3 8-year-old health policy professor Harvey V. Fineberg succeeds Howard Hiatt as dean.

Fineberg will lead the School through an era of prosperity and growth that coincides with a groundswell of support for public health's fundamental principle prevention.

the gathering storm Harvard scientists confront a threat of

by Sarah

/4brams

bib!ica! dimensions that cha!!enges and transforms the fundamenta! tenets of pubtic heaith.

1985

Cardiologist Bernard Lown and Russian colleague Eugene Chazov accept the Nobel Peace Prize on behalf of the International Physicians for the Prevention of Nuclear War, which the pair co-founded in 1980.

Max Essex and colleague Tun-Hou Lee identify gp-120 and gp-41, t w o structures on t h e surface of HIV-1 t h a t enable the virus to infect cells and are targets for vaccine development.

)

N 1 9 7 8 , AS A T H I R D - Y E A R M E D -

] ical student doing his hrst clinical H rotations at University of N e w Mexico Hospital, Richard Marlink was shown a patient with an extremely rare form of cancer. The attending resident explained that this malignancy, known as Kaposi's sarcoma, typically was found only in older men of Mediterranean descent and was usually quite benign. He ended his talk by telling Marlink and his colleagues that this was probably the only case of Kaposi's sarcoma they would see in their careers. He couldn't have been more wrong.

As an intern at St. Vincent's Hospital in N e w Y o r k City in the early 1 9 8 0 s , Marlink began seeing other patients with the characteristic bruise-like lesions of Kaposi's sarcoma. These cases, however, were different from the one he'd seen as a medical student: the majority were young adults most of whom had other severe symptoms, including Weight loss, swollen lymph nodes, Pneumonia, and diarrhea. Few ever recovered. Marlink, now executive director of the Harvard AIDS Institute, based at the Harvard School of Pubhc Health, recalls the frustration he and his colleagues felt as they saw patient after patient for whom none of the standard explanations applied. " W e knew there was a syndrome," says Marlink today, "but We didn't know what to do about it."

B y the time this m y s t e r i o u s n e w syndrome had a permanent

name—

acquired i m m u n e deficiency syndrome ( A I D S ) — t h o u s a n d s of p e o p l e had already died f r o m the disease a n d millions of a p p a r e n t l y healthy people ^ e r e carrying a n d silently spreading

Hunger in America: The Growing Epidemic", a [sport of the HSPH-based Physician Task Force on ^ n g e r in America h e a d e d by J. Larry Brown, finds at some 20 million Americans go hungry every Honth.

the virus that caused it. Since then, the AIDS epidemic has claimed at least 6 million lives worldwide, and an estimated 25 million people are now living with the virus. Within a decade, according to some estimates, as many as 1 0 0 million people may be infected. In certain areas of the world and certain populations, the epidemic has wreaked particular havoc. Over 90 percent of the world's AIDS cases occur in SubSaharan Africa, North America, and Latin America. In the United States, where the disease hrst devastated the gay community, AIDS is now the leading cause of death for all African Americans under the age of 55. In Uganda, researchers estimate that one-in-four adults is now infected with the virus, perhaps foreshadowing a secondary epidemic of children orphaned by the disease. And in Thailand and India, skyrocketing infection rates portend an Asian epidemic that may exceed in scale and intensity anything seen to date.

Yet mortality and morbidity figures, no matter how staggering, can't fully describe the impact that AIDS has had on the world. N o t since the 1 9 1 8 influenza epidemic has an infectious agent cut such a broad swath of destruction around the planet. But whereas influenza struck hard and fast and then passed on, A I D S has infiltrated the social body, exposing weaknesses and blindspots and challenging long-held beliefs about disease susceptibility and control. At the same time, A I D S has to a large degree revitalized the held of pubhc health, exposing the limits of curative medicine and rejuvenating the search for preventive vaccines and effective

Karen Quinlan, c o m a t o s e since 1976, dies after being removed from her respirator.

behavioral interventions and creating a sense of urgency and global solidarity in the face of a mounting crisis.

Right from the start, faculty and alumni of the Harvard School of Public Health has played a key role in confronting the epidemic. From laboratory discoveries that have set the direction for AIDS vaccine and treatment research to important epidemiologic, data analysis, and human rights work, the School has been a major participant in the fight against A I D S .

H

N M A N Y R E S P E C T S , M A X E S S E X WAS

H an unlikely hero in the A I D S saga.

H A veterinarian and virologist by training, Essex had spent most of his career studying the animal virus FeLV, which causes cancer in cats. In the early 1 9 7 0 s , he had discovered that this virus also severely impaired the cats' immune system.

By 1 9 8 z, Essex, now chair of the School's Department of Cancer Biology, was also researching the human T-cell leukemia virus ( H T L V 1). Like F e L V , H T L V - i caused immune suppression—people infected with H T L V - i had three times the rate of infection with bacteria and other viruses as uninfected people. Essex was struck by the similarities between symptoms of F e L V , H T L V - i , and this new disease, and he was one of the hrst to suggest that the mysterious a g e n t c a u s i n g AIDS w a s , like FeLV a n d

a retrovirus. Essex's insight accelerated the discovery of the AIDS pathogen, now know as the human immunodeficiency virus (Hiv), by the National Cancer Institute's Robert Gallo and the Pasteur Institute's Luc Montagnier the following year. For his role in identifying the cause of

HTLV-i,

British scientists discoveraholeinthe ozone layer.

screening. Working with a young research associate Tun-Hou Lee, s.D.'8z, now professor of virology at the School, Essex discovered glycoprotein 12.0 (gpizo), an envelope protein that plays a key role in HIV transmission and is seen as a promising target for an HIV vaccine.

Mar/w^,

Dz'recfor o/ f^e

A I D S , Essex shared the 1 9 8 6 Albert Lasker Medical Research A w a r d â&#x20AC;&#x201D; the nation's most prestigious medical research awardâ&#x20AC;&#x201D;with Gallo and Montagnier. " M a x catalyzed the notion that retroviruses were something to contend with, that they were diseasecausing agents in animals, and that they could play an important role in humans," said Gallo in a 1 9 8 8 interview in the H S P H Alumni Bulletin. " H e went beyond standard biological thinking about animal models. He looked at the importance of retroviruses broadly and widely."

Other important discoveries followed. In collaboration with scientific colleagues, Essex confirmed that the A I D S virus could be transmitted through blood transfusions. Further studies showed which viral antigens were most useful for blood bank

In 1 9 8 5 , Associate Professor Phyllis Kanki, s . D . ' 8 5 , Francis Barin, then a postdoctoral fellow at H S P H , and Essex uncovered evidence of a second A I D S virus, now known as H i v - 2 . , when they found cross-reactive antibodies in West African sex workers. With Marlink and other French and Senegalese collaborators, a major research and training program was created that continues today. Their work has revealed that Hiv-2. causes disease more slowly and spreads less readily than the more virulent H i v - 1 , and that people with Hiv-z are 70 percent less likely to become infected with H i v - i .

"Once we understand how this happens, we'll know how to manipulate the immune system just as evolution did," Essex says. Because of "the utility of this discovery," Gallo ranked Essex's work on H i v - z among his major achievements.

Essex has said that the emergence of A I D S created a sense of urgency in his research that he still feels today.

"With A I D S , I think we all felt that putting in the extra hours could make a big difference," he told a Boston Phoenix reporter last October. A I D S also awakened him to the global dimensions of infectious disease, and he has spent much of the last decade continent hopping from North America to Africa to Asia in an effort to finally outflank his adversary.

James 0 . Mason M.P.H.'63, D.P.H/67, succeeds William Foege as head of the

rn

HH rn H I L E L A B O R A T O R Y SCIEN-

tists would be instrumen" " tal in identifying the causative agent of A I D S , some of the first clues about the nature of the epidemic were provided by H S P H graduates working on the front lines of the epidemic. Don Francis, s . D / 7 9 , had recently graduated from the School and was working in the Centers for Disease Control's (CDC) hepatitis program when the first reports of gay-related immunodeficiency disease ( G R I D ) began trickling in. The CDC and state public health officials had long been interested in the health problems of gay men because rates of sexually transmitted diseases, primarily gonorrhea, syphilis, and hepatitis B, among this population were so high. T o find out why, CDC enlisted cohorts of gay men throughout the country to answer detailed questionnaires a b o u t their lives and sexual practices.

Because they received treatment free of charge, says Francis, these men were "remarkably willing to answer a bunch of stupid questions from epidemiologists."

The data collected proved invaluable in understanding the transmission patterns of this new disease.

Although no one knew what was causing the disease, once it was e s t a b lished that G R I D , like hepatitis B, was being transmitted through b l o o d and sexual fluids, Francis felt sure it would also begin showing up in o t h e f vulnerable populations: recipients of blood transfusions and injection drug users. (Serum samples g a t h e r e d from these cohorts in the 1 9 7 0 s a n d early 1 9 8 0 s would also shed light on H i v ' s long incubation period.)

Brazil returns to civilian rule after 21 y e a r s of military dictatorship.

It was Francis who called Essex, his former teacher, to alert him to this new disease.

As the epidemic took off, Francis's boss, C D C Director William Foege, M . p . H . ' g j , appointed James Curran, M.p.H.'y^, then head of the agency's venereal diseases research branch, to head a national A I D S initiative.

Curran quickly moved forward on establishing effective data collection and prevention programs. He also set up a national A I D S hotline to provide information to an increasingly alarmed public. Despite these efforts, Curran and other government officials and academics soon came under fire from A I D S activists for responding too slowly to the epidemic. Francis, who eventually resigned hom the C D C in frustration in 1 9 8 5 when Congress rejected his proposal for a comprehensive A I D S prevention Program, says the C D C was continually undercut by the Administration's lack of commitment to fighting A I D S .

"We were told to look pretty and do nothing," he says. "The (Reagan) Administration didn't want to do anything for anybody. It lost all perspective for public health."

Curran has since been recognized

by AIDS activists and medical experts alike for his clear, decisive leadership during a period in which the unknowns far outweighed the ktiowns. In his 1988 chronicle of the epidemic's early years, BawJ ^ a y e j O?!, journalist Randy Shilts Wrote: "Under Curran's leadership, the CDC had done an admirable job of collecting A I D S data. He had guided ^Dc AIDS research on a course that he eh was the best that could be done 'n a conservative administration."

M<2% Essex, Mary Pro/essor o/^Hea/f^ ^cz'ewces J

"Curran pushed the C D C and the public health service hard to recognize the impending epidemic," says the Harvard A I D S Institute's Marlink.

"He organized much of our epidemiologic and prevention response."

Another alumnus who would play a central role in the A I D S struggle on the international front was Jonathan Mann, M . p . H . ' 8 o . Mann was working as an epidemiologist and assistant director of the department of health in New Mexico when Curran tapped him to serve as assistant to the director in charge of international activities in Kinshasa, Zaire. Working with Zairian, Belgian, and American colleagues, Mann established Project S I D A , providing training programs that drew upon the resources and skills of each country and collecting the first and most comprehensive scientific information on A I D S in central Africa. In 1 9 8 5 , Mann organized the first African A I D S Conference in the Central African Republic city of Bangui. The following year he left the C D C to develop and run the Global Programme on A I D S ( G P A ) at the World Health Organization ( W H O ) .

Actor Rock Hudson dies ofAIDS. Since 1981 25,000 Americans have been diagnosed with the disease.

Under his leadership, the C P A ' s staff expanded to over zoo and its budget grew from $2.0 million to over $ 1 0 0 million by 1990, making the G P A the largest single program at W H O .

During his years at both the C D C and W H O , Mann emerged as a preeminent spokesman for international health strategy reform in A I D S control, emphasizing the need for greater government involvement in A I D S research and prevention and increased attention to regional and local needs in establishing programs.

But above all, Mann spoke out for the rights of those infected and against the discrimination to which they were subjected. To combat the disease effectively, he believed, human rights issues must become a priority.

In the fall of 1990, Mann returned to the Harvard School of Public Health as professor of epidemiology and head of the Global A I D S Policy Coalition, established to track the epidemic worldwide. Under the direction today of Daniel Tarantola, the program is at the heart of monitoring the pandemic, circulating information

Institute of Medicine report, "Injury in America," declares injuries the nation's principal public health problem. William H. Foege, M - P H ' 6 5 , chaired the panel that produced the report.

CBAR Takes Center Stage White preventive vaccines are still in the r&d stage, the search for safe, effective AIDS drug treatments to keep the disease at bay has produced some important results. The School's Statistical and Data Analysis Center (SDAC), has been at the heart of this search since 1989, when it was designated to oversee most of the governmentsponsored aids drug trials. Since then, SDAC's group of 150 researchers have followed more then 300 different clinical trials involving 37,500 people. Researchers are involved in each step of the trials process—from the earliest planning stages to the final data analysts.

Among the many important findings to emerge from these trials, according to Center Director Stephen Lagakos, two in particular stand out: ACTG 076, which showed that AZT reduced the chances of HIV transmission from HIV-positive pregnant women to their babies, from one-in-four to one-in-twelve; and ACTG 019, which showed that AZT effectively slows disease progression in asymptomatic adults.

Of all the trials, says Lagakos, ACTG 076 will probably have the the greatest potential for saving lives:" It provides a way to stop the spread of the disease from mothers to their offspring, sparing millions of children from having miserable lives." Because doses are

t h r o u g h articles, AIDS t e x t b o o k s , interviews, a n d participation at conferences.

Y 1987, T H E N U M B E R O F A I D S cases reported to the World t ^ Heath Organization was over 100,000. While experts recognized A I D S as a global phenomenon, tracking the disease was complex, as the pandemic evolved, changed, and rapidly expanded. In countries where infection had once been spread predominantly through homosexual contact, infection rates among heterosexuals were on the rise. Minorities and marginalized populations—such as intravenous drug users—were especially vulnerable. And the disease was making inroads into countries once labeled as low-risk.

1986

Health Professionals Follow-up Study launched under the direction of Professor Frank Speizer. A counter part to the 1976 Nurses' Health Study, the study follows some 50,000 men—mostly doctors—and will provide valuable evidence about the links between lifestyle and cancer, heart disease, and other chronic illnesses.

administered short-term, and are thus less costly, the regimen is employable in places like Sub-Saharan Africa and Asia, where longterm drug regimens would be impossible to implement. Based on the success of the 076 trial, new trials are now under way to determine if lower doses of AZT could provide the same benefits, further lowering the cost of treatments. Scientists and policymakers in Thailand, says Lagakos, are awaiting the results of these trials before establishing a national policy for testing pregnant women.

As for the new combination drug therapies, Lagakos describes recent progress as "mind-boggling." SDAC recently cut short a clinical trial (ACTG 320) of a combination therapy of AZT, 3TC, and the protease inhibitor idinovir, when it became clear that the therapy demonstrated true benefits. Earlier trials by a pharmaceutical company had shown the three-drug combination resulted in improved marker effects, but SDAC's trial revealed an actual delay in disease progression, driving down viral load to undetectable levels. The trials have not yet shown how long the results will last, says Lagakos, but if you can keep viral load undetectable for years, it can buy a patient time until another drug might be available. "It's a big,

Within the A I D S research community, early hopes for a swift solution had given way to the sobering prospect of a long, arduous struggle against a highly adaptable killer.

After the initial, promising burst of discoveries about H i v , the pace of research had inevitably slowed.

With each new finding, the puzzle of H i v / A I D S seemed to grow more complex. Every aspect of this seemingly simple organism—its sugarcoated outer shell, which cloaked it from the body's defenses; its sloppy reproductive apparatus, which generated a continuous series of new mutations; the discovery of different subtypes of the virus—favored its continuing survival and spread.

Frustrated researchers stopped talking cures and vaccines and began

Space shuttle Challenger explodes seconds after launch.

calling for more basic research on the virus itself.

In an effort to spur a new push toward a solution to the crisis, President Derek Bok and Dean Harvey V. Fineberg convened a group of A I D S experts from the School of Public Health, the medical school, and Harvard's afhliated teaching hospitals to discuss how to integrate and advance Harvard's diverse AiDS-related activities. "If we are to meet the challenge of A I D S , " Fineberg said at the time, "we must mobilize all the intellectual and academic resources at Harvard's disposal." The discussions resulted in the creation of the Harvard A I D S Institute, which drew together the University's formidable body of A I D S expertise included leading hguf^ in virology and vaccine research

Working with colleagues in Dakar, Senegal, retrovirus expert Max Essex and colleagues Ric Marlink and Phyllis Kanki discover a second AIDS virus, HIV-2.

(Essex and Lee, the late Bernard Fields of Harvard Medical School), AIDS treatment (Massachusetts General Hospital's Martin Hirsch, the Deaconess Hospital's Jerome Groopman, and others), epidemiology (Professor Nancy Mueller, Marlink, Kanki, and others), molecular biology (William Haseltine and Joseph Sodroski at Dana Farber Cancer Institute), statistical modelling and clinical trials design (Professor Steven Lagakos and Associate Professor Victor De Gruttola, s.D.'86) and AIDS law and policy (Lawrence Gostin, Harvey Fineberg, and the late William Curran).

Officially unveiled in 1 9 8 8 , the Institute, under Essex's direction, has been a catalyst for research and training on AIDS. As hoped, the Institute's creation helped accelerate AIDS research across the university (Harvard ranked hrst among academic institutions in the number of Papers its researchers published on AIDS between 1 9 8 8 and 1992.). The Institute has also succeeded in focusing a t t e n t i o n o n AIDS a n d AIDS

research locally, nationally, and internationally, through Institutesponsored lectures and forums and conferencesâ&#x20AC;&#x201D;including large panel discussions as well as informal, brown-bag lunches. In addition, the Institute has served as a bridge between the academic world and the broader public realm of AIDS activists and advocates.

AIDS Action Committee (Acc),

^

Boston's leading service and advocacy organization for people with A I D S .

Kessler also credits Essex, Groopman, and other Boston-area physicians and researchers with recognizing early on the need to integrate clinical treatment with the services offered through A I D S Action's "social safety net" â&#x20AC;&#x201D;particularly in light of the few treatment options available at that time. As the disease has proliferated, the connection between the advocacy group and the research institution has only become stronger, says Kessler. Each organization had something valuable to teach the other. "While we learned about immunology, the docs learned about the psychosocial issues," says Kessler. It was a relationship that would also prove critical when volunteers were needed for clinical trials of new drugs: Harvard researchers turned immediately to AAC, whose clients trusted the organization to steer them in the right direction.

^ ^ ^ Hiv drug, AZT, was approved ^ ^ by the Food and Drug Administration the demand for safe, effective treatments had reached a fever pitch. Desperate for answers, people with A I D S demanded more attention from government, scientists, and the pharmaceutical industry, clamoring in particular for quicker access to experimental drugs. In 1 9 8 9 , the analysis of AIDS drugs received a big boost when the National Institutes of Health selected Harvard's Statistical and Data Analysis Center ( S D A C ) to analyze and interpret data from most of the federally funded clinical trials of AIDS drugs around the country.

Over the next eight years the center would help analyze over 300 clinical trials involving some 3 7 , 5 0 0 people and provide critical insights about the treatment of AIDS (see sidebar, 54).

"We don't even have to work at it," says Kessler of A I D S Action's continuing "good connection" with the Institute and School. "It's in the fabric of what we do."

^

Y 1 9 8 7 , WHEN THE FIRST ANTI-

By the early 1 9 9 0 s , the emerging picture was that of a relentless epidemic involving shifting demographics. Nearly 2.5 million people had died from the disease, and more than i z million people were now infected with Hiv, a i z o - f o l d increase from a decade earlier.

AssocMfe Pro/essor o/'Pa^o&wfogy, /(g^OMHIV-2., H i v - i ' s /ess w M / e M t

'From the very beginning, Dean Harvey Fineberg saw AIDS as a public health issue and believed that there ^as a role for the public health advocates," says Larry Kessler, executive director and one of the founders of

Center for Health Communication established under the direction of Jay Winsten, to provide reliable health information to the public. The Center will go on to launch the nationwide "Designated Driver" campaign to reduce drunk driving fatalities.

Max Essex, chair of the Department of Cancer Biology, receives the Albert Lasker Clinical Medical Research Award for his pioneering work in understanding the biochemical and genetic characteristics of the AIDS virus.

Women now represented 40 percent of the total A I D S cases. Experts were describing the epidemic as "dynamic, unstable, and volatile." While the great majority of A I D S cases continued to be found in Africa, the United States, and Latin America (90 percent of all adult A I D S deaths to date), the infection rate was rising dramatically in Asia, where the disease had been virtually unknown a decade earlier.

By the end of the century, experts now warned, Asia could become the epicenter of A I D S .

T w o events that took place in 1992. dramatically underscored the need for international collaboration in responding to the pandemic. The first was the Eighth International Conference on A I D S , co-sponsored by the Harvard A I D S Institute. The second was publication of /M WorM, the first effort to define the epidemic's global contours, by the School's Global A I D S Policy Coalition.

The Eighth International A I D S Conference will be remembered as much for the political drama that preceded the conference as for the scientific material presented at the conference. U.S. laws refusing entry to HIV-infected individuals prompted a showdown of sorts between the Bush Administration and conference planners, who threatened to move the conference overseas if the laws were not lifted. T w o years earlier, at the Sixth International Conference on A I D S , the normally soft-spoken and reserved Essex had strongly condemned the government's stand: "This policy...threatens the free and open exchange of information which is critical to international efforts to

conquer the A I D S epidemic. There is no sound public health justification for these restrictions."

Ignoring appeals from activists, academics, and foreign governments, the U.S. government refused to lift the ban, and the Institute, in partnership with the Dutch Foundation, moved the conference to Amsterdam, naming Jonathan Mann as conference chair. A I D S activists and the international scientific community cheered Harvard's principled stand.

A I D S Action's Kessler, whose organization had been involved in planning the conference, says that while his organization was excited to see the world come to Boston for the conference, he supported Essex's decision to move the conference to ensure that people with A I D S would be able to participate. Despite the eleventh hour change of venue, the conference drew more than 1 0 , 0 0 0 scientists, clinicians, and activists, a remarkable show of solidarity in the midst of a mounting global crisis.

The full scope of this crisis was brought into sharp relief with the release of ALD5 w f^e WofM by the School-based Global A I D S Policy Coalition. Edited by Mann, Daniel Tarantola, and Thomas W. Netter, the book detailed, region by region, the status of the pandemic and the global response to it. Describing the epidemic as "spinning out of control" the report's authors predicted major A I D S epidemics in Asia and Oceania and projected that, by century's end, as many as 1 0 0 million people would be carrying the A I D S virus.

The publication, updated and revised in 1 9 9 6 , helped crystallize some of the key principles of

Under an a g r e e m e n t signed by Harvard President Bok and Mexico's Minister of Health, the School trains Mexican physicians to run primary health care hospitals being established in the w a k e of last year's earthquake, which killed 5,000 people in Mexico City.

and related risk behavior to larger societal issues. It also breathed a new sense of urgency and purpose into A I D S research. "We tried to plead for an expansion of the response to A I D S , " said Tarantola, "to define what needed to be done from a societal perspectiveâ&#x20AC;&#x201D;what social interventions needed to take place." The conceptual approach found in both editions, said Tarantola, was employed in two important development efforts. As a result of the publication, the United States Agency for International Development ( U N A I D ) moved from looking at prevention to looking at treatment issues, and the U N A I D S (the Joint United Nations P r o g r a m m e on H i v / A i D s ) strategy broadened from condom distribution and A I D S education and treatment into an expansion of these strategies to look at social issues.

Hiv/AIDS

nt

L M O S T I O Y E A R S A F T E R ITS

# % creation, the Institute contin# ^ ues to bring the research conducted at Harvard and elsewhere to bear on the epidemic and to c r e a t e solutions for ending the epidemic.

Recent research yielded significant information about H i v - i subtypes, of which there are no less than 1 0 .

Essex's laboratory found that subtype E, the cause of an explosive rise in Hiv-infection in Thailand, is spread very efficiently through heterosexual intercourse, unlike subtype B, the subtype found most frequently in the United States and Western E u r o p e .

The Institute's search for a vaccine, under the leadership of P r o f e s s o r Tun-Hou Lee, is also progressing.

Based on a process called " s e l e c t i v e

Harvard University celebrates 350th Anniversary. Ade Lucas.

S.M/64, presented with the Harvard Medal for his lifelong commiitmen* to combatting trop ical diseases.

deglycosylation," in which sugar molecules are selectively deleted from g p i z o ' s surface, this work could lead to vaccine trials within a year.

In editorials, Essex has continued to push for development of a costeffective preventive vaccine that can help relieve the growing AIDS burden in developing countries.

But where the Institute continues to do the most good, says Marlink, is in the role of advocate—influencing and pushing for important AiDS-related issues. A good example, he says, is HAi's Madison Project, which helped Ptopel the government to establish a national AIDS research agenda. Under the auspices of the Harvard AIDS Institute, some of the country's leading AIDS experts, government officials, and activists—including Essex, Larry Messier, Robert Gallo, and National Institute of Allergy and Infectious Diseases head Anthony Fauci—assembled in two separate sessions in 1992. to design a model for establishing a national AIDS research program. The group's work, says Marlink, provided the incentive for federal action in establishing the Office of AIDS Research.

Today, Institute faculty are working to have the same impact on vaccine research and testing in developing countries, one of the Institute's highest priorities. The Institute recently held the fourth of six, three-day long conferences, at which leading ^lDs researchers met to discuss strategies for developing a world-wide AIDS vaccine, a project that Marlink says combines two of the Institute's greatest strengths: its discoveries on the basic mechanisms of the AIDS viruses the different subtypes and types—

^ c ' d population ^aches5billion.

First genetically engineered vaccine, against hepatitis B, approved by FDA.

and its international collaborations.

Institute faculty are also concentrating on ways to curb the epidemic in two of the United States' most vulnerable groups: African Americans and young people. Today, the African American community is losing more of its young members to AIDS than to any other cause of death, before heart disease, cancer, and homicide. With the help of African-American leaders such Henry Louis Gates, Jr., head of Harvard's W.E.B. du Bois Center for African American Studies, medical school psychiatrist Alvin F. Poussaint, and Children's Defense Fund founder Marian Wright Edelman, the Institute recently launched Leading for Life, an educational campaign focused on stopping the epidemic from making further inroads into communities of color.

T o stem the tide of H i v infection in America's youth (one-half of all H i v infections in the United States are in people under age 2.5), the Institute recently teamed with the Center for AIDS Prevention Studies at the University of California at San Francisco to convene a group of youth-focused media and marketing experts to develop new marketing approaches to H i v prevention.

Together they discussed such strategies as condom advertising on cable and network television and incorporating responsible sexual health messages into him, radio, and television programs geared toward young people.

Less than two decades after the hrst cases of A I D S were reported, almost 6 million people have died from the disease, one million of

whom were children. Approximately 2.2. million people are now living with H i v or A I D S , and, last year,

^

over 3 million new Hiv infections

^

occurred. Some recent trends appear encouraging: In some industrialized countries, in parts of Africa, and among some populations in Thailand, Hiv prevalence is either decreasing or stabilizing. AZT has been shown to block a majority of perinatal Hiv transmission. And new combination therapies using powerful protease inhibitors have delayed many deaths from A I D S . But the battle against A I D S is far from over.

More than 90 percent of the people affected by the disease cannot afford existing treatments, and development of vaccines to stop the disease's further spread is still several years away.

^

Until then, the School's researchers, faculty, and alumni will continue their vanguard efforts, tracking the epidemic, devising better prevention strategies, uncovering the most effective drug treatments, searching for a vaccine, and pushing to keep A I D S at the top of national and international policy agendas. As a principal player in the A I D S effort over the last two decades, Jim Curran, now dean of Emory University's Rollins School of Public Health, sees the School's contributions to curbing the epidemic as indispensable.

"From the dean down, the School has provided important leadership in controlling this disease," says Curran. "From its public policy and human rights work to its work in the laboratory and AIDS modelling, its contributions are i r r e f u t a b l e . " ^

Reactor explosion at the Soviet nuclear power plant in Chernobyl,Ukraine, is the worst nuclear accident in history.

World Health Organization launches the Special Programme on AIDS and n a m e s Jonathan Mann, M.P.H.'80, as director.

Harvey Vernon

Fineberg

D e a n ,

1 9 8 4 - 1 9 9 7

] n 1984, while serving out his final months as dean of Harvard's Faculty of Arts ! and Sciences, Professor Emeritus Henry Rosovsky began compiling a crashcourse in university administration for his successor. Later published as the essay "Deanmg," Rosovsky's collection of anecdotes, caveats, and helpful hints offers a witty glimpse into the intricacies of running an academic institution—a "peculiar art," he wrote, for which few presidents, provosts, and deans arrive prepared.

The same year Rosovsky passed the baton of leadership in Cambridge, across the Charles River a 38-year-old health policy professor named Harvey Vernon Fmeberg became the sixth dean of the Harvard School of Public Health. The youngest, by a good decade, of all the School's deans, Fineberg had only recently earned tenure and his only administrative experience to date was a three-year stint directing the School's Graduate Program in Health Policy and Management.

On the other hand, few people could claim as intimate a knowledge of the university as Fineberg. He'd been at Harvard for two decades and held degrees from three different university faculties. Under the tutelage of some of the University's leading lights—including statistician Frederick Mosteller, Kennedy School political scientist Richard Neustadt, business school decision science guru Howard Raiffa, and former H S P H Dean Howard Hiatt— Fineberg had earned a reputation as an enterprising scholar with a particularly wide intellectual bandwidth.

1987

Lincoln Chen picked to direct the 13-nation, independent Commission on Health Research for Development.

"One of the things that's most impressive about Harvey is the breadth of his brilliance. He has a gift for thinking in other arenas," says colleague Milton Weinstein, Henry J. Kaiser Professor of Health Policy and Management, who, as a junior faculty member in the 1970s, co-taught a course with Fineberg and collaborated on several studies.

Among those who recognized Fineberg's intellectual talents was former Harvard President Derek Bok: "Harvey exemplified the kind of bold, energetic, young scholar (former H S P H dean) Howard Hiatt had championed" during his tenure, tn the winter of 1 9 8 3 , shortly after Hiatt announced his decision to step down as dean, Bok asked to meet with Fineberg. Fineberg was expecting to be asked who he thought should lead the School.

Instead, Bok offered Fineberg the deanship.

"In retrospect, one can see that it wasn't totally out of character for him to turn to someone like me, but it still struck me as quite stunning at the time," says Fineberg.

Professors Robert Geyer, Jere Mead, and Frederick Mosteller retire from the faculty of public health. Professor Robert Blendon succeeds Mosteller as chair of the Department of Health Policy and Management.

FDA approves cholesterol lowering drug lovastatm and first AIDS-treatment drug, zidovudine (AZT).

Fineberg, who had seen his friend and mentor Hiatt buffeted by faculty dissension during his tenure, had few illusions about the potential pitfalls of leading the School. While the internal furor had subsided, Fineberg, says that his baseline expectation was that his life as dean would be "filled with noise and thunder." What he got, however, was water—several million gallons of it. Three months into his deanship, and just 1 0 days before the start of the 1 9 8 4 - 8 5 academic year, the School's water main burst, flooding the Kresge Building's lower levels and causing massive damage to Snyder auditorium, the building's mechanical room, and several administrative offices. Photos from the time show wrecked offices, damaged files and equipment, and a patchwork of salvaged carpet remnants laid out to dry in the Kresge courtyard. In weathering this baptism hy water, Fineberg displayed a talent for turning crisis into opportunity that would serve him well throughout his deanship.

"We worked day and night to get the place ready for the students," he recalls. " I remember standing in the Kresge lobby the day before registration as they were repainting the walls and putting on some finishing touches.

Suddenly, the father of a new student came over, shook my hand, and told me how impressed he was with all the Polishing up we did, and the personal attention that I was giving to it."

With equal diligence and aplomb, Fineberg presided over a remarkable Period of prosperity at the School during his 13-year career as dean. By any objective measure—dollars raised, growth in educational and research

^-S. expenditure for health care surpasses ^ 0 0 billion, up from $46 billion in 1966.

programs, expansion of facilities—his tenure has been a spectacular success.

When he took the helm, the School's total budget was $ 3 5 million: in his final year it topped $ 1 3 5 million. He led the School into its first-ever capital campaign, which so far has raised more than $ 1 3 0 million and added 1 0 endowed professorships (bringing the total to 30) and more than 1 5 0 , 0 0 0 square feet of new and renovated laboratory, office, and classroom space.

The centerpiece of this expansion is the seven-story Fran$ois-Xavier Bagnoud Building at 6 5 1 Huntington Avenue, a keel-shaped edifice of polished granite, concrete, and glass that is a fitting monument to Fineberg's deanship: efficient, contemporary, deftly blending form and function.

HE IMPRINT OF FlNEBERG'S

LEAD-

! ership also can be seen in the myriad interdisciplinary centers and programs that have arisen during his watch—including the Harvard A I D S Institute, the Harvard Center for Cancer Prevention, the Center for the Prevention of Cardiovascular Disease, and the Harvard Center for Children's Health—which, collectively, define some of the most critical areas of contemporary public health research. He's been particularly adept at steering the School toward new areas of inquiry— health and human rights, molecular epidemiology, health communications, and public health practice—that seek to stretch the very boundaries of the held.

"Harvey's very good at the 'wheeler-dealer' aspects of public health," says friend and former colleague Barbara Rosenkrantz, professor of the history of sciences emerita at

President Reagan and USSR Party Leader Gorbachev agree to reduce stores of medium-range nuclear missiles.

Harvard. Mark Rosenberg of the Centers for Disease Control and Prevention, w h o has known Fineberg for 2.7 years, says the driving force behind Fineberg's success is his "relentless optimism"and penchant for "new, creative approaches" to age-old problems.

In action, Fineberg projects the unhurried authority of a man who knows precisely where he's going and how long it will take to get there. A methodical and patient planner, he manages to keep a sharp eye on the details without losing sight of the big picture. And while he prefers to leave nothing to chance, he's able to shift gears abruptly without breaking stride when the situation demands it. " Y o u get the impression that Harvey can handle anything. He's equally composed whether the building's on fire or he's getting an award," says Deborah Prothrow-Stith, professor of public health practice.

Fineberg especially excels at the "toastmaster" aspects of deaning, his genial wit and unforced eloquence playing equally well in large lecture halls and intimate dinner parties.

"Harvey's so charming, so erudite," says Weinstein. "He's never at a loss for words, and he rarely makes mistakes." And whether through practice or predilection, he has learned to strike just the right balance of gravity and hopefulness, urgency and assurance to win broad-based support for a held that has traditionally failed to capture the public imagination.

In his rare free moments, Fineberg relaxes by playing the piano and tinkering with computers. A self-confessed "techno-phile," he enjoys taking his laptop out for a spin on the

Harvard Injury Control Center founded to focus on reducing the 150,000 U.S. deaths a year from injury.

^

zp^o's, Fme^erg prac^ceJ pMwo LoweM NoM^e Tower roow.

Internet and has also tried his hand at electronic composing. (Fineberg's wife, Mary Wilson, says that if he could choose any other profession, he'd probably be a composer). And while his professional demeanor is the essence of level-headed discretion, he is not without a waggish side. For his sendoff from the faculty—billed as a celebration of the occasion "Fineberg Crosses the Charles"—Fineberg and Wilson came costumed as George and Martha Washington, powdered wigs and all. And on a recent trip to Japan, Fineberg purportedly sampled the much-prized but occasionally lethal delicacy known as /MgM—but only after doing a quick risk-benefit analysis that took into account the chef's reputation, the number of physicians at the table, and the distance to the nearest emergency room.

1988

Harvard President Derek Bok and Dean Harvey Fineberg a n n o u n c e creation of t h e Harvard AIDS Institute. The Institute, chaired by Professor Max Essex, facilitates university-wide research on AIDS.

I N E B E R G W A S B O R N IN 1 9 4 5 ,

THE

I second of three sons of Saul and Miriam Fineberg, in Pittsburgh, Pennsylvania, in the comfortable, middle class neighborhood known as Squirrel Hill. As a schoolboy, Fineberg participated in the hrst trials of the Salk polio vaccine, an experience he still vividly recalls. He came to Harvard in 1 9 6 3 and has been here ever since. As an undergraduate, he lived in Lowell House, majored in psychology, did thesis research on the sleep habits of birds, practiced piano in the Lowell House tower, and played trumpet in the marching band.

By his junior year he had decided on a career in medicine. (He confesses to being unaware, at the time, that Harvard even had a School of Public Health.) Although by the time he graduated, student protest had reached a fever pitch—the following year Cambridge police officers would be called in to evict student activists from University Hall—Fineberg's politics, in spirit and practice, were shaped more by the constructive "ask what you can do for your country" ethos of the Kennedy era than by the angry, anti-establishment mood of the Vietnam War years. "We looked back at the fifties as a time when students were complacent and just looking to get ahead in life," he says. " B y the mid-sixties, hippie-dom had arrived and people were dropping out. But for my peers, the sense of liberation and possibility was very palpable."

The turning point in Fineberg's education came after his second year at Harvard Medical School, when he took a year off to participate in an experimental public policy training program at Harvard's newly re-chris-

Author Salman Rushdie is c o n d e m n e d by Iran's Ayatollah Khomeini for material perceived as blasphemous in his book 77;e ^ a f a n / c Verses.

tened Kennedy School of Government.

The program was developed and taught by a faculty "dream team" that included Mosteller, Neustadt, Raiffa, game theorist Thomas Schelling, economist Francis Baton, and (as junior course assistants) Graham Allison, Richard Zeckhauser, and Henry Jacoby. The program would introduce Fineberg to many of the academic disciplines—statistics, economics, decision sciences, cost-beneht analysis, and health-care policy—that would underpin his subsequent career. In an era when success in academic medicine was determined primarily by one's laboratory pedigree, Fineberg's request to take a year off to study something as ephemeral as public policy raised eyebrows. He recalls explaining his decision to the dean of students, who sifted through Fineberg's academic hie and said, somewhat perplexedly, "But your record here isn't all that bad!"

(Despite the program's all-star cast, Fineberg says that, at the time, public policy was seen as such a fly-by-night held that initially only students from professional schools " w h o would have a profession to fall back on if the whole thing was a bust" were admitted to the program.)

Fineberg calls his time at the Kennedy School "the most interesting, intellectually stimulating year that I could have dreamed o f . " Although he would go on to earn his medical degree and practice as a primary care physician for 1 0 years in two Boston-area neighborhood health centers, his intellectual center of gravity already had shifted away from treating individual patients to broader questions related to improving the

Professor Tony Earls launches landmark study of aggressive and antisocial behaviors a m o n g children and adults in Chicago neighborhoods. The $20 million study will follow s o m e 11,000 people for more t h a n a decade.

function of the health-care system as a whole. As it happened, these were some of the same questions on the mind of Howard Hiatt, who became dean of the School of Public Health the same year Fineberg began his medical internship at Boston's Beth Israel Hospital. Hiatt recalls running mto Fineberg one afternoon outside of BI and listening as Fineberg described his burgeoning interest in society and health. " I really wanted to work with him," says Hiatt. " A n d I told him, with the things you're interested in, you should be at the School of Public Health." After finishing his residency, Fineberg accepted Hiatt's offer to join the School as an assistant professor in the Department of Health Services Administration (later renamed the Department of Health Policy and Management). Over the next decade, the two worked closely together, coauthoring one article, developing a curriculum for training graduate students in health care policy, and collaborating broadly with colleagues in the landmark Center for the Analysis of Health Practices.

"I learned a great deal from Howard, especially about the value of interdisciplinary w o r k , " says Fineberg today. " I was always inclined to it, hut Howard (Hiatt), Howard Frazier, and Fred (Mosteller) showed me how to make it happen."

ERHAPS THE GREATEST SACRIFICE

* involved in Fineberg's accepting the deanship was putting his scholarly ambitions on the back burner. At the t'me Fineberg was a rising star in the School's Department of Health Policy and Management. His research and

he anti-depressant drug is introduced.

writing on the uses and effectiveness of diagnostic technologies—including the influential 1 9 7 9 N e w Ewgi^wJ /oM7*7M/ article, "Evaluation of medical practices; the case for technology assessment," coauthored with Hiatt—had helped launch the held of medical technology assessment. He was a co-founder and one of the first presidents of the Society for Medical Decision Making and had co-authored, with Weinstein, the textbook Cfw/ca/ D<?c;'s;'o7?

Awfysz's.

Fineberg recently had gained national repute as co-author, with his former Kennedy School mentor Richard Neustadt, of T^e T ^ f Ne^gr a brilliant analysis of the decision-making process behind the government's controversial 1 9 7 6 swine flu vaccination program.

The book was based on a confidential study commissioned in 1 9 7 7 by Secretary of Health, Education, and Welfare Joseph Califano. Along with Neustadt, Fineberg interviewed many of the principals, including poliovaccine pioneers Jonas Salk and Alfred Sabin, both of whom endorsed the swine flu program, and Centers for Disease Control Director David Sencer, M . P . H . ' ^ 8 , who initiated the program and ultimately took the blame for its failure.

The report's initial release in 1 9 7 8 had provoked a squall of controversy within the public health community.

Some influential persons objected to the book's characterizations and conclusions and accused the authors of undermining future preventive vaccine programs. Among the most vocal critics, says Fineberg, were the deans of the nation's schools of public

Former Surgeon Genera! and Project Head Start founder Julius Richmond retires from the Department of Health Policy and M a n a g e m e n t .

health. For his part, Califano says Fineberg and Neustadt did a "fantastic j o b " of maintaining objectivity and drawing critical lessons from the program's failure. "Nothing like it has been done in public health since," he says.

Califano especially praises Fineberg's ability to "instantly grasp the difficulty of making decisions in a political context." (Interestingly, neither the Swine Flu report nor its authors were anti-immunization; indeed Fineberg went on to be something of a champion of immunization.

In 1 9 9 0 - 9 1 he co-chaired an Institute of Medicine panel that studied the safety of pertussis and rubella vaccines and concluded that the slight risk of adverse reactions to the vaccines was outweighed by their broader benefits in preventing childhood disease.)

Fineberg has continued to publish at a prodigious pace since becoming dean—some 30 scholarly articles, 5 books, and more than a dozen editorials and book chapters in all—a truly remarkable output given the hectic schedule a dean must keep.

"Harvey has the ability to block out all distractions and focus completely on what he's doing," says Wilson. "Even on a crowded airplane, he can just sit and work as if nothing else were happening."

N o account of Fineberg's career would be complete without mentioning the special partnership he shares with Wilson, his sometime collaborator and wife of years. A native of Indiana and former graduate student in English literature, Wilson is chief of infectious diseases at Mount Auburn Hospital in Cambridge and a faculty

Following a letter-writing campaign s p e a r h e a d e d

by Paul Wise, M.P.H.'78, alumna Heng Leng Chee, S.M.'79, is released from a Malaysian prison.

Chee w a s arrested and detained for 10 m o n t h s by authorities for advocating for w o m e n ' s rights and welfare for t h e poor.

member in the Departments of Population and International Health and Epidemiology.

They met in 1 9 7 1 while doing their residencies at BI (as a second-year resident, Wilson was his superior) and dated for a couple years before getting engaged. In the spring of 1 9 7 5 , in the midst of planning a wedding on Cape Cod, they were invited to join a medical delegation on a 2.2.-day tour of the People's Republic of China— one of the hrst groups of Westerners allowed into the country since the onset of the Cultural Revolution. On the last leg of the trip, while waiting out a four-hour layover in the Shanghai airport en route to Canton, one of the Chinese guides turned to Fineberg and asked if he were married. (Fineberg says this was the hrst time during the journey that any of the guides had asked any personal question of their guests.) Fineberg replied that he was unmarried, but

engaged to marry the woman sitting next to him. "In fact," Fineberg continued in an uncharacteristically impulsive way, "if we could, we'd love to be married here in China." ("We'd never even discussed it," says Wilson.) A few days later members of the delegation arranged a wedding ceremony at the hotel in Canton.

The Chinese hosts provided a cake and a silk wedding scroll. As part of the celebration, the newlyweds were asked to sing a song to their hosts.

Uncertain what would be appropriate in communist China, the couple serenaded the group with "I've Been Working on the Railroad."

In recent years, Fineberg and Wilson have collaborated on a series of studies of the effectiveness of BCG vaccine in controlling tuberculosis.

They have also co-authored articles on the social dimensions of disease and the risk to travelers of contracting AIDS.

Bt^MOMjBMMw^ owe o/^f^e cap^OMM

France and China authorizeuseof steroid drug RU-486, also known as the "morning after" pill, as an abortifacient.

FTER THE FLOOD THAT CHRIS-

tened his deanship, Fineberg turned his attention to a more subtle challenge facing the School: what marketing consultants would call an identity problem. Both within the faculty and out in the general public, says Fineberg, there was little consensus about what pubhc health was and, by extension, what schools of public health should be doing. "When I hrst became dean, I remember wondering, 'What was the mission?

Where was a succinct statement of what we were all about?'" he says.

Since then, Fineberg has devoted a considerable part of his time and energy to articulating a common mission and set of objectives for the School and, by extension, for public health as a held. It wasn't easy.

Fineberg says that "just getting his arms around everything that was going on at the School" was a challenge. He wisely enlisted the faculty to help define the School's priorities by instituting annual faculty retreats, and he beefed up the School's internal and external communications efforts.

Most importantly, he relentlessly reasserted his message in print, speech, and conversation. " I wanted it so you could take anybody in the School, wake them up in the middle of the night, and they could blurt out the School's mission," he says. This may seem a modest objective, but at an institution where molecular biologists, physicians, economists, and statisticians tended to regard each other with mutual incomprehension, a single, shared phrase—advancing the public's health through learning and discovery—provides a critical thread of cohesion and coherence.

New York state d o s e s 15milesofbeachdue to medical waste,

Of course, mission statements, however apt, are oniy part of the institution-building formuia; equally important is a compelling cause around which to rally. For public health in the past decade and a half, that cause was acquired immune deficiency syndrome ( A I D S ) , whose sudden appearance and rapid spread in the 1980s exposed the limitations of curative medicine, reinvigorated the concept of disease prevention, and brought a flood of attention and funding to schools of public health (see article, page 50). Few scholars have become as involved in the struggle against A I D S on as many fronts as has Fineberg. T o date, he has authored or co-authored 1 1 articles, 3 editorials, one book, and 5 book chapters on diverse aspects of the A I D S epidemic tanging from the ethics of compulsory Hiv testing to the effectiveness of bleach programs in preventing A I D S transmission among iv drug users.

Most of these are polite scholarly tracts written for fellow scientists; but one, a 1 9 9 1 N e w York Times editorial decrying the government's decision to bar Hiv-infected travelers from entering the country, contains what, in academic circles, might be called fighting Words. Dismissing the idea that the Policy had any public health benefit, Fineberg wrote that "the real reasons behind the exclusionary policy are...irrational fear, misunderstanding and prejudice, salted by political opportunism and cowardice."

Fineberg says that any public health dean during the past 1 5 years ^ o u l d have had to contend with A I D S .

It Wasn't exactly a hard call," he says. But few would have taken it up as a personal cause, as he has. He's

been on the board of directors of the American Foundation for A I D S Research since 1 9 8 6 and has served on AiDS-related advisory committees at the Centers for Disease Control and Prevention, the Institute of Medicine, and the U.S. Agency for International Development, among others. He's been especially active in Mexico, where he has worked with H S P H alumnus Jaime Sepulveda, S . D . ' 8 $ , in drafting a national A I D S policy.

Fewer still would have had the insight and influence to mobilize a universitywide response to the disease, as Fineberg did when he launched the Harvard A I D S Institute in 1 9 8 8 (see article, page 50).

At the same time he aggressively confronted A I D S , Fineberg also broadened hisâ&#x20AC;&#x201D;and the School'sâ&#x20AC;&#x201D;horizons on numerous fronts. With the late Sol Levine, former H S P H Professor and current Wellesley College President Diana Chapman Walsh, and new department chair Lisa Berkman, he reinvigorated the School's Department of Health and Social Behavior. He was instrumental in garnering support for the Frangois-Xavier Bagnoud Center for Health and Human Rights, which, under the direction of Professor Jonathan Mann, M.p.H.'8o, has sought to redefine the relationship between human welfare and human rights. His most telling project for the School may be the Division of Public Health Practice. Launched in June during Fineberg's final month as dean, the Division, under the direction of Prothrow-Stith, will promote collaboration between the faculty and students at the School and the many community-level agencies that underpin public health. A fitting capstone

Project LIFE is a collaborative effort b e t w e e n the School and the surrounding Mission Hill community to reduce the community's high infant mortality rates.

to Fineberg's career, this schoolwide effort symbolizes his ideal of an institution dedicated equally to

63

scholarship and service in pursuit of global gains in health.

"In my last year at Harvard, I spent a day meeting with faculty and students at the School of Public Health," says Bok. "It was a very exciting day. I had the impression of a range of problems being addressed with great enthusiasm and vigor.

The feeling of shared commitment was tremendous."

^ y

On April 3, 1 9 9 7 , Harvard President Neil L. Rudenstine announced his selection of Fineberg as University Provost. The appointment, applauded by faculty, graduates, and administrators at the School, marked the end of Fineberg's 13-year term as dean. Fineberg knows enough about "deaning" to give his successor a wide berth in which to develop his own agenda and vision for the School. But one senses that he also is confident that the imprint of his leadership is likely to remain visible for some years to come.

"I've tried to not so much instill as liberate the concept that we're simultaneously doing scholarship and practical work, and to help people understand how what we're doing here at the School makes a difference out in the world," says Fineberg. " A s you look around at all the work being done today, I feel that this faculty is living out its mission."

Kevin S o t t a k

^

H j H Hf H A T H A D S T A R T E D O U T A S A S M A L L D I S C U S S I O N G R O U P T H A T F I T

W

comfortably into the small, iiTH-floor Takemi conference room in

Building i had grown into a standing-room-only crowd. Students and faculty were feeling the intellectual equivalent of an adrenaline rush. The idea under discussion was really quite an old one: that changes in the world's ecology can lead to changes in the diseases that afflict the people who inhabit it. But with Hiv-AiDS,

the Ebola virus and the global rise in tuberculosis all in the news,

there was a new urgency to the subject. Some of the School's most dynamic and accomplished faculty were in attendance. Among the most striking was an older man with a wise mien, snow-white hair and beard, and a weathered face.

When he spoke, recalls Mary Wilson, that Richard Levins was truly impressive. " I would sit there sometimes with my mouth open in awe," says Wilson, an assistant professor in the Departments of Population and International Health and Epidemiology. "He would move so easily, so seamlessly, from economics to molecular genetics to political theory to biology. He pulled it together so effortlessly and then would bring in some very practical observations."

For over two decades, Levins, the John Rock Professor of Population Sciences, has been one of the intellectual giants of the School. A founding theoretician of evolutionary ecology and one of the world's most brilliant

d i a t e c t i c s of d i s e a s e

1989

James 0 . Mason, D.P.H.'67, named assistant secretary for health in the U.S. Department of Health and Human Services. Donald Hopkins appointed acting director of the CDC.

The Exxon Valdez runs aground off Alaskan coast, releasing 240,000 barrels of oil into Prince William Sound.

biomathematicians, Levins has applied ideas from these fields to the problems of disease causation, particularly infectious disease. In over-simplified terms, he is a scholar of, and advocate for, an ecological approach to public health.

The 66-year-old professor says this approach is partly a matter of taste: "There are different aesthetics in science. Physicists have an aesthetic for symmetry and simplicity. M y own aesthetic is for complexity, anomaly and, asymmetry." Levins' scientific views are also guided by a philosophical outlook rooted in Hegel and M a r x that eschews the modern tendency to break systems into their smallest identifiable parts. Instead, Levins sees the world as an evermoving process and looks for patterns in the whole.

"When someone asks me what Richard specializes in, I answer, 'complex systems,' " says Pamela Anderson, s.M/84, s.D.'c<i, a Colombia-based researcher and consultant in the School's Department of International Health and Population Sciences and someone who has prized Levins as a mentor for a decade.

"Problems in health, agriculture, and the environment all span disciplinary boundaries and require the integration of biological and social phenomenon," says Anderson. "Richard applies his integrated, quantitative, and qualitative thinking on complex systems to all these arenas."

Levins grew up in Brooklyn's Manhattan Beach section, a comfortable middle-class neighborhood just ^ast of Coney Island, but he was *nrtbued with a radical socialist outtook at a young age. His great-great

t WUIONAL K iNWfUTE

grandmother rebelled against the orthodox Judaism of her day on the grounds that it was sexist. His father, an attorney, was a member of the Young Communist League. As an eight-year-old, Levins set out to raise money for the Abraham Lincoln Brigade, a contingent of left-wing Americans that fought in the Spanish Civil War. "It was an interesting experience," he says, a smile creeping across his face. "After the hrst meeting or two, we realized that we had no resources for actually contributing to the Abraham Lincoln Brigade and furthermore, we were dependent on our parents for transport." Levins laughs. " S o I decided at that point that a political movement needed a material base!" Levins says he grew up "with the sense of the inseparability of science and politicsâ&#x20AC;&#x201D;that is, trying to understand the world in order to change it."

S AN U N D E R G R A D U A T E AT COR-

^ T ^ nell, Levins split his studies between math and genetics. An active member of the Communist Party, Levins figured opposition to his radical politics would block a career in science. "It was the McCarthy period, and I expected the United States to become more repressive and fascistic," he says. So after he graduated, Levins and his wife, Rosario Morales, moved to her native Puerto Rico to farm and work as labor organizers.

The 90-acre vegetable farm in the midst of coffee plantation country in the island's Central Mountains was "technically innovative, but barely getting by economically," says

National Cancer Institute a w a r d s $3.2 million to Professor of Radiobiology John B. Little to study health effects of ionizing radiation.

Levins. He and his wife had seed sent from all over the world. They used some novel agricultural methods. But two children made the micro-economics of the farm that much more precarious. Sick in bed with hepatitis, Levins began to look over his old math notebooks and decided that maybe he could contribute something to science. In 1 9 5 6 he returned to N e w Y o r k City as a graduate student in Columbia's zoology department.

His family still owns the farm in Puerto Rico, but termites have claimed the farmhouse, and the original 90 acres has shrunk to 35.

Zoology, and the life sciences more generally, was in the throes of a titanic struggle as Levins resumed his studies. After Watson and Crick described DNA's structure in 1 9 5 3 , biology based on held work and observation was being increasingly dismissed as old hatâ&#x20AC;&#x201D;unimaginative "stamp collecting" as Harvard's Edward O. Wilson described it in his 1 9 9 4 autobiography. The way to understand living things, said the upand-comers, was at the molecular level, through genes and biochemistry.

Meanwhile, scientists such as G. Evelyn Hutchinson at Yale and Robert MacArthur at the University of Pennsylvania were headed in the opposite direction. Their biology sought to describe life at the population level, and how those populations compete with and compliment one another in an environment.

Moreover, they wanted to find underlying mathematical patterns to these inter-species and environmental relationships. With his mathematical gifts and knowledge of genetics,

Ebola virus kills 60 monkeys in a Virginia laboratory, the fist known Ebola outbreak in the U.S.

Levins was a weicome addition to this new held, known variously as population biology, population genetics, and evolutionary ecology.

Levins hrst major contribution to this new population-level biology was development of the community matrix, a mathematical model for determining how many overlapping species can co-exist in a shared environment. Levins says he developed the community matrix model after a series of intense scientihc discussions with MacArthur at a meeting on mathematical biology held at Yale in the early 1960s. The community matrix can be thought of as a table in which the rows and columns are species and other elements of an environment and the entries are calculations for describing the interactions among them. It can be used to derive some of the essential ecological features of an environmentâ&#x20AC;&#x201D;its stability, its sensitivity to change, its vulnerability to catastrophe. Levins eventually trumped his own model with loop analysis, which also deals with species interaction in an environment.

More generally, Levins helped change how modern biology views the environment from something that was objective, uniform and largely static to a system that is "selected, transformed, and dehned" by organisms.

Richard Lewontin, the Alexander Agassiz Professor of Zoology at Harvard, who has known Levins for 3 5 years, says Levins has supplied modern biology with the insight that "there is no element of the environment that is not a consequence of the organisms that construct it."

Levins was a professor at the University of Chicago before coming to the School in 1 9 7 5 . Over the years, Levins has challenged his students and his colleagues to view disease in ecological terms rather than settling for standard etiologic explanations.

In a class, he might ask students to calculate how a gene that increases the nitrogen uptake of wheat plants might affect the economic independence of women. His admirers say one of the amazing things about him is that he often has answers to just that kind of question. "He makes connections better than anyone I know," says Lewontin.

H

HILE AT THE SCHOOL, LEVINS

W W has kept his hand in biology, writing articles for QM^r^r/y RsM^w o^B;o/ogy and elsewhere.

Integrated pest management, which seeks to minimize the use of pesticides, has been a practical interest.

He travels frequently to Cuba, where he has taught, conducted research, and advised government officials on agricultural practices. And he still proudly wears the label communist (to show people, he says, that "we are still around and kicking.") "Dick Levins has a very gentle and generous spirit," says Mary Wilson. "I have never seen him be mean or sarcastic."

Pamela Anderson says, "He is a true intellectual; he listens to others and he engages their ideas, irrespective of the source."

That Levins would have interest in new and emerging diseases is only logical. After all, to an evolutionary biologist, a pathogen is just another

species seeking a safe haven for life and reproduction. Levins was a key participant in the pivotal Woods Hole meeting in November 1993 that gave fresh currency to the notion that environmental changes resulted in new opportunities for pathogens. Levins says he is delighted at the public attention that new disease research has gotten as it has put to rest the notion that infectious diseases have been conquered. Working with his close colleague Tamara Awerbuch, a lecturer in the Department of Population and International Health, he is in the midst of a Robert Wood Johnson Foundation-funded study asking why public health was caught off-guard by the emergence of diseases like Lyme disease and A I D S .

Drawn to science by politics and philosophy, Levins has the serenity of someone who has been true to his beliefs. As a young man, he says, he found his "intellectual focus" in dialectics, Marxist philosophy, and "a fascination with complexity." And his most recent causeâ&#x20AC;&#x201D;the need for an "integrated epidemiology" that would take into account the myriad causes and effects that result in diseaseâ&#x20AC;&#x201D;resonates with ideas that a boy from a radical family in Brooklyn was introduced to about a half-century ago.

"Something is not quite right in the way our species' current societies are relating to the rest of nature or in the way we attempt to fix what goes wrong," Levins has written recently"There is a disjunction in science between the exquisite sophistication of the small and the irrationality of the enterprise as a whole."

Peter Wehrwein

Nurses Health Study I! launched under the direction of Professor of Epidemiology and Nutrition Walter Willett. A complement to the original Nurses' Health Study, NHS II enrolls 116,000 young women.

National Institutes of Health selects the Department of Biostatistics as the Statistical and Data Analysis Center (SDAC) for all federally funded clinical trials of AIDS drugs. Directed

by Professor Stephen Lagakos, SDAC will produce some of the most important findings about individual and combination drug treatment.

hea!th numbers

MARViN ZELEN

"

jj '

H E S E D A Y S , E V E R Y T R I A L OF A NEW D R U G OR S U R G I -

erative group studies," says Professor of Biostatistics

cal intervention is closeiy scrutinized by a statistical

Richard Gelber. In doing so, Zelen played a key role in the

"consultant." But before Marvin Zelen came along,

development of cancer treatments that have, just to cite

biostatistics had something of a Rodney Dangerfieid problem: it rarely got the respect it deserved.

"Years ago, clinical trials were often the sole province

one example, vastly increased the chances of surviving leukemia. Many of the lessons learned in cancer clinical trials were subsequently applied to

AIDS

clinical trials,

of surgeons and clinicians," says Professor of Biostatistics

including Gelber and his colleague's landmark study

Stephen Lagakos. " M a n y of them didn't view a clinical

showing that AZT can cut the chances of transmission of

trial as what it is—a scientific investigation—and few

Hiv from an infected mother to her baby by two-thirds.

appreciated the importance of statistics."

Nobody in this country has done more than Zelen, the

Throughout his career, Zelen has been a fighter and defender as well as an intellectual force. "I think I have

69-year-oM former chair of the School's biostatistics

been very determined and very persistent," says Zelen.

department to "elevate the role of the statistician in clini-

"And I never shirk from battle."

cal trials," says Lagakos. Zelen's theoretical work over his

Zelen grew up in the East Bronx during the Depression,

40-plus year career would make any curriculum vitae

and when he wasn't working long hours in his father's

shine. But during the i $ 6 o s and 70s, he also transformed

candy store, he enjoyed doing many of the things that The

clinical trial research into a large, well-managed, and sta-

Music Man's Professor Harold Hill warned were trouble

tistically sophisticated branch of medical research. First in

for River City: playing pool, poker, pinochle, and z i .

Buffalo and then at the School, Zelen created what were

When Zelen stumbled into a probability class as an under-

tn effect large biostatistical laboratories—equipped with

graduate at the City College of New York, he says one

Powerful computers and capable of administering and

reason the subject was so appealing to him was his famil-

keeping tabs on hundreds of clinical trials at a time.

iarity with games of chance.

Randomization techniques, centralized data management,

The post-war years were halcyon days for all kinds of

quality control, and other solutions to the practical prob-

science research in the United States, including math and

lems of running mullet-centered clinical trials were

statistics. Wielding seemingly arcane formulas, the

Worked out by Zelen and his colleagues. "He set the stan-

nation's math and statistical whizzes solved all kinds of

dard for statistical and data management centers in coop-

practical problems during the war, calculating everything

Epidemiology Department Chair Brian MacMahon, S.M.'58, and Professor of Environmental Health and Safety Benjamin Ferris retire from the faculty.

MacMahon is succeeded by Dimitrios Trichopoulos (left).

San Francisco Bay area earthquake causes more than 60 deaths.

68

^ y

from the optimum formation for groups of bomber planes to the best way to search for submarines.

(Another former chairman of the School's biostatistics department, Frederick Mosteller, was a member of an elite group of Princeton mathematicians whose understanding of sampling procedures helped the government answer questions like whether an Army base would overtax a local public transportation system.)

The federal government established two large applied mathematics laboratories after the war, one at the National Bureau of Standards in Washington and the other at U C L A .

After earning a masters degree in statistics from the University of North Carolina (Chapel Hill) in 1952., Zelen was hired by the National Bureau of Standard's Statistical Engineering Laboratory, which was part of the National Applied Mathematics Laboratory.

For Zelen, those 1 0 years at the Bureau are a delightful memory. At age 2.$, he says he was the "baby of the group" and one of the few people without the imprimatur of a PH.D. (which he remedied in 1 9 5 7 by taking evening classes at American University). Zelen thrived in the lively, intellectually rambunctious atmosphere of the Bureau. Zelen says he pursued some theoretical problems, but also gained the invaluable experience of designing research projects up front so that when the results came in they would pass statistical muster.

His first real taste of biostatistics came in the early 1960s when Zelen was a visiting professor at the University of Wisconsin's Mathematics Research Center. Asked to work out a statisti-

1990

The Berlin Wall falls as Germany is reunited and the Soviet Union crumbles.

cal problem related to a trial of a childhood leukemia drug, Zelen and his collaborator George Weiss came up with something called the semi-Markov process (Markov was a Russian mathematician), which now stands as one of Zelen's prime contributions to the biostatistical canon. Essentially, the semi-Markov process is a statistical model used for both calculating "sojourn time," or how long a patient might stay in a certain "phase" of cancer treatment (say remission or relapse) and using that sojourn time to predict the next phase the patient will go through.

N o w dedicated to biostatistics, Zelen was invited to head the National Cancer Institute's Applied Mathematics and Statistical section in 1 9 6 3 , where he immersed himself in cancer and clinical research for the next four years. After a year in London as a Fulbright Scholar, he was lured back to academe and into the arms of the State University of New York at Buffalo. Zeien spent the next decade on the snowy eastern shore of Lake Erie effectively inventing the biostatistics that make possible today's sophisticated clinical testing of cancer, A I D S , and all kinds of other treatment drugs. Zelen says he wasn't happy dispensing advice to his NCI colleagues. " I decided it was important to have some kind of demonstration project to show how things could be done," he says. So he formed the Statistical Laboratory at the University of Buffalo.

<

HE STATISTICAL LABORATORY

was a master stroke. Zelen saw that the statistical aspects of the large, complex trials of treatment

drugs needed to be more centrally administered, particularly when it came to treatment assignments and randomization. Leaving treatment choice to clinicians and treatment centers created too many opportunities for cutting corners, steering certain patients to certain treatments, and robbing randomization of its randomness. "There were a lot of complaints in the beginning," Zelen says. "People would say, 'We used to hold the sealed envelope up to the window to see what the treatment would be, and now we can't do that anymore.' " He also saw that poor record keepingâ&#x20AC;&#x201D; what would be today called data managementâ&#x20AC;&#x201D;was undermining high quality research. Untrained secretaries were often left in charge of reviewing patient records and filling out the forms for a study. Proper training and some "pretty smart people" were needed to do the job right, Zelen believed, so he created a new job and called it "data manager" because managers are paid more. "We made data management into a profession," he says. "There was really no point in applying sophisticated statistical techniques to data that was garbage."

The emergence of the large, multicenter randomized clinical trial also posed some new statistical challenges.

Zelen designed "dynamic randomization" techniques so that a roughly equal number of patients would be allocated to each treatment option under study. He also wrote one of the hrst papers on adaptive design of clinical trials, a novel randomization strategy that would have an investigator stick with a treatment until it fails and then switch over to the alternative. Zelen also did some ground-

Enrollment reaches 530 students, up from 230 in 1970.

breaking work in the heid of survival analysis that preceded Sir David Cox's proportional hazard model, a mainstay of contemporary biostatistics.

Meanwhile, Zelen was building SUNY-Buffalo into a clinical trials juggernaut by getting grants from NCI and attracting young, smart statisticians and mathematicians. For 1 9 years, Zelen was the top statistician in the Eastern Cooperative Oncology Program ( E C O G ) , which becameâ&#x20AC;&#x201D; partly because of Zelenâ&#x20AC;&#x201D;the largest program in the world for testing various cancer treatments.

By the mid-yos, Zelen was prominent enough to capture the attention of Mosteller, who, at Dean Howard Hiatt's request, had come to the School with the express purpose of building up the biostatistics department. In his negotiations with the university and the School, he asked for just a little more than usual. " I said I would like 1 0 faculty appointments in addition to my own. They were used to hiring faculty. They weren't used to hiring a basketball team," says Zelen, adding that he believed bringing the "team" with him to Boston was essential to the viability of ongoing clinical trials. When Zelen came to the School in 1 9 7 7 , he brought with him an entourage that included 1 0 faculty members, 1 7 non-faculty members, a huge DEC 2.0 computer (they had to knock down a wall to ht it into the basement of the DanaFarber's Jimmy Fund building) and 1 5 0 cancer trials involving several thousand patients.

Zelen succeeded Mosteller as chairman of the biostatistics department in 1 9 8 0 and held the post for 1 0 years.

Cancer Causes ancf Confro/, edited by professor of epidemiology emeritus Brian MacMahon, is the first major scientific journal to be published out of the School.

He kept the E C O G trial work going (Professor Dave Harrington has replaced Zelen as the lead statistician) and laid the groundwork for the department's pre-eminence in A I D S clinical trials, now manifest in the Center for Biostatistics in A I D S Research ( C B A R ) . He beefed up the biostatistics curriculum. When one leading professor at the School expressed puzzlement, tinged with disapproval, that there could be that much to teach in biostatistics, Zelen says he answered, "We have only just scratched the surface!" Lagakos says Zelen "really made this department into a wonderful place," fostering creativity and confidence in his colleagues. " H e made you feel like you could do anything." ] N T H E E A R L Y 1980s, T H E W I D E R j world caught a glimpse of Zelen's ' tenacity. Flying in the face of conventional wisdom that such a study could ever produce significant results, Zelen, with Lagakos's help, launched an investigation of the connection between what seemed to be a cluster of childhood leukemia cases in the Boston suburb of Woburn, and the town's contaminated water supply.

Three years later, the Harvard Health Study, as it came to be known, showed for the hrst time a connection between Woburn's contaminated water supply and a variety of adverse health effects, including leukemia. As described in A Cwz'/ AcH'oM, the bestselling account of the lawsuit that grew out the Woburn cancer cluster, when Zelen announced the study's results in the basement of a Woburn church in February 1 9 8 4 , someone in the audience said "Thank God for

Marvin Zelen." The crowd burst into applause. A hero to those Woburn parents, Zelen and his study were

69

attacked elsewhere. In fact, the chair of the School's own epidemiology

^ ^

department, Brian M a c M a h o n , was sharply critical of Zelen and Lagakos for what he said was an over-interpretation of their data. But Zelen didn't waiver. " H e champions the underdog," says Lagakos. " A n d if he feels something is wrong, he doesn't worry about getting in trouble."

In 1 9 9 0 , Zelen stepped down as chairman of the department, but he continues to be a presence at the School, teaching, attending seminars, and supervising post-doctoral students. His fourth-floor office at Dana-Farber overlooking busy Brookline Avenue has the delightful aura of the active, accomplished mind: the haphazard photos of family and colleagues, an eclectic collection of academic journals and textbooks, the desk and tabletop choked by a shifting layer of papers and correspondence. N o longer involved in the day-to-day running of clinical trials of cancer treatments, Zelen has started thinking about how cancer screening studies could be improved, diplomatically describing the current approaches as "suboptimal." And though his back-of-the-candy-shop, card-playing days in the Bronx are long gone, Zelen has given a friend some statistically-based advice on how to play one of the biggest games of chanceâ&#x20AC;&#x201D; mutual fund investment. Zelen's tip is to "play the winner": stick with the biggest gainer until it is surpassed, and then switch to the new leader.

Peter Wehrweirt

South African political resistance leader Nelson Mandela is released from prison after 27 years.

^

prevention as poiitics

by Terri L. Rutter H

O N A T H A N M A N N , M . P . H . ' 8 o , IS R E F L E C T I N G O N A

! crucial time in his life, a time when everything he had believed up to that point suddenly seemed incomplete, even skewed. Speaking quickly, eloquently, he describes events 1 3 years and over 5,000 miles removed

course. In Uganda, for instance, a married woman who refused to have sex with her husband risked divorce and economic disasterâ&#x20AC;&#x201D;even if she knew her husband was infected.

Mann asked himself: "What are the barriers to her

from the present and the frustration of trying to slow

actually carrying out her own choice? To really under-

the spread of

stand this woman is to unveil the factors in her society

AIDS

in East Africa in the mid 1980s.

Guided by the traditional pubhc health paradigm of education begets change in behavior begets disease

that affect her access to employment or to education."

For Mann, women at risk for

AIDS

throughout Africa

prevention, Mann, then assistant to the director of the

became a prototype for a new way of thinking about

Centers for Disease Control's AIDS Program in charge of

healthâ&#x20AC;&#x201D;a so-called "paradigm shift" that seeks to join

international activities in Kinshasa, Zaire, relied primarily

pubhc health theory to political and social realities.

on condom handouts and informational campaigns

Simply stated, he believes that the condition necessary

stressing the importance of using condoms to protect

for every individual to enjoy the highest attainable

against Hiv. But in time he came to realize that no amount

standard of health is a full promotion and protection of

of paper and latex in the world could change the fact

each individual's human rights.

that few of the region's women had the power to say " n o " when faced with unwanted or unprotected sexual inter-

Physiologist Joe Brain, S.D/66, succeeds Donald Hornlg (left) as chair of the Department of Environmental Health.

In 1990, Mann followed this new line of thought back to Harvard, where it eventually culminated in the

Professor of Biostatistics James H. Ware succeeds Elkan Rogers Blout as Dean for Academic Affairs.

creation

the re-awakening of public health's political conscience. of the Frangois-Xavier Bagnoud Center for Health and

disease to recognize and treat the poverty and other social

Human Rights at the School of Public Health. Under

factors that underlay so much human misery. Virchow's

Mann's leadership from 1992. to 1 9 9 7 , the center has been

beliefs were later echoed in the slogans and practices of

the academic focal point for a broad-based movement that

the sanitary reformers w h o gave birth to modern public

seeks to unite two previously distinct enterprises: public

health.

health and human rights. Inherent in this new paradigm is the notion that public health research and practice must

In an interview for T^g People's He^M? a w J f f s Et^ofM^'ow af

A

o/^ Barbara

actively engage political and social injusticeâ&#x20AC;&#x201D;a notion that

Rosenkrantz, professor of the history of science emerita,

many public health traditionalists balk at. And yet, Mann

told author Robin Marantz Henig, that early on "public

and others point out that the roots of this radically " n e w "

health was closely allied to social reform, openly, without

vision for public health are, in fact, more than a century

any apologies." Examples of this alliance between health

old. " W e are heirs to a tradition that goes way back to the

promotion and social activism abound. Legendary Harvard epidemiologist Alice Hamilton was an unabashed

beginning of public health," says Mann.

One of the first to view health through the lens of politics was German pathologist Rudolf Virchow, the popularized patron saint of public health, who in 1 8 4 9 stirred the placid waters of European medicine by challenging his fellow physicians to look beyond clinical manifestations of

Smoking is banned on U.S. domestic airline flights.

socialist who joined in the international protest over the executions of suspected anarchists Sacco and Vanzetti.

Martha M a y Eliot, chair of the Department of Maternal and Child Health and long-time director of the Children's Bureau, was influential in lobbying for federal programs

Jonathan Mann, M.P.H.'80, leaves the WHO's Global AIDS Programme, to join the School as professor of epidemiology and international health.

Harvard Center for Risk Analysis founded under the direction of Professor John Graham.

DMHMg ^/s S years OM ^ e Maww, M.P.H.'8o,

for poor mothers and children. And famed Yale epidemiologist CharlesEdward Amory Winslow called for "the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health."

Yet, notes Rosenkrantz, this activist edge gradually was tempered by the rise of a more empirical brand of public health that viewed social reform as "subjective, politically tainted." By the end of World War II, scientihc advances had given rise to a technology- and biomedicine-based public health paradigm focused more on combating pathogens and vectors than on addressing the broader social context in which they proliferated.

Government funding for basic research on vaccines and antibiotics blossomed. The pesticide DDT was the primary weapon in the international malaria control efforts of the 1950s and 1960s. Medicine, meanwhile, had become big business, and doctors defenders of the status quo.

In 1948, the American Medical Association, exploiting the prevailing

1991

A poll of HSPH students by faculty member David Hemenway reveals that 9 7 % are non-smokers, 9 6 % support legalizing abortion, 8 9 % wear seatbelts, and 75% support national health insurance.

anti-Communist sentiment of the day, helped defeat President Truman's effort to institute a national health insurance program by branding it "socialized medicine."

But even as biology and technology assumed center stage in this brave new era of public health, other forces were paving the way for a new brand of political consciousness. The sheer carnage and suffering unleashed by the Second World War led to the creation of a new global humanitarian doctrine: the Universal Declaration of Human Rights. Adopted by the U.N. General Assembly in 1948, the declaration asserted the "inherent dignity" and "equal and inalienable rights and fundamental freedoms of all members of the human family" and launched an international movement to protect and promote these rights. And the Cold War that followed raised the specter of man-made annihilation that made all previous disease epidemics seem like child's play.

In response to these new realities, the past four decades have seen a rekindling of the political and activist consciousness within the health pro-

fessions, marked by the emergence of international organizations such as Physicians for Social Responsibility ( P S R ) , International Physicians for the Prevention of Nuclear War ( i P P N w ) , and Physicians for Human Rights ( P H R ) . Faculty and graduates of the School have been central figures in the creation and evolution of each of these organizations. Together with Mann's Fran$ois-Xavier Bagnoud Center for Health and Human Rights, which provides a kind of academic counterpart to the advocacy agencies, these organizations embody Virchow's century-old dictum that politics isâ&#x20AC;&#x201D;or should beâ&#x20AC;&#x201D;medicine writ large.

S THE COLD WAR BETWEEN

the United States and the Soviet Union intensified and nuclear weapons stockpiles grew, the prospect of a nuclear war seemed imminent.

By i 9 6 0 the two superpowers had amassed enough nuclear weapons to destroy nearly all life on the planet.

Yet, in America, at least, the national mood was one of "can-do" optimismFamilies built bomb shelters in their basements and backyards, while politicians and military experts openly discussed strategies and contingencies for winning a nuclear war.

At the School, however, a group of students led by George Saxton, M.p.H.'6i, had been meeting and conducting its own study group and had come to a different conclusion.

A Quaker and long-time grassroots activist, Saxton recalls being asked during student orientation what he thought was the most important public health issue facing the world's people.

The first major cholera epidemic in the Americas in a century strikes Lima, Peru, causing 100,000 cases and killing 700.

"Holy smoke, it's nuclear w a r , " he remembers thinking. "We have to do something about this." In an article published in the January 1 9 6 1 Alumni Bulletin, Saxton argued that, given the untold death and destruction that would result from a fullscale nuclear war, prevention was the only rational response to the nuclear threat. Around the same time, Bernard Lown, a cardiologist in the School's Department of Nutrition, was invited by a colleague to a talk in Cambridge. The speaker was the British diplomat Philip John NoelBaker, winner of the 1 9 5 9 Nobel Peace Prize for his role in founding

ed to the United States in 1 9 3 $ , says what moved him most to take action was the disturbing parallel he saw between the proliferation of nuclear weapons and Nazi Germany's orchestrated annihilation of 6 million European Jews: "We destroyed Hitler and we became Hitlerized in our a bility to design mass extermination."

Lown called together a group of colleagues and friends to discuss how they, as physicians and as health professionals, could educate the public about the fallacy of the belief in surviving a nuclear war. Calling itself Physicians for Social Responsibility ( P S R ) , the group undertook an

Arfzc/e

On the basis of its study, PSR produced a series of articles that the group hoped to publish in the New E w g ^ w J /oM?*?Mf o^Me&'cz'we. Lown says that when he approached the journal's editor, Joseph Garland, however, Garland scoffed at the idea.

"We're a medical journal...not a political journal," Lown recalls Garland saying. But the persistent Lown eventually convinced Garland to look at the articles to see if they met the journal's rigorous publication standards.

Lown says Garland called him at the end of the day and agreed to publish the studies, which appeared under the title "The Medical Consequences of

2 J

EVERYONE HAS THE RIGHT TO A STANDARD OF LIVING ADEQUATE FOR THE HEALTH AND WELL-BEING OF HIMSELF AND OF HIS FAMILY, INCLUDING F O O D , CLOTHING, HOUSING AND MEDICAL CARE AND NECESSARY SOCIAL SERVICES, AND THE RIGHT TO SECURITY IN THE EVENT OF UNEMPLOYMENT, SICKNESS, DISABILITY, W I D O W H O O D , OLD AGE OR OTHER LACK OF LIVELIHOOD IN CIRCUMSTANCES BEYOND HIS CONTROL. the League of Nations. Noel-Baker spoke about the impending prospect of a nuclear Armageddon. Lown was transfixed.

"He was like an ancient Hebrew prophet," he recalled. "Here I was concerned with sudden individual death and here's the potential for mass sudden death." Lown, the son of Lithuanian Jews who had emigrat-

exhaustive study of the medical and public health impacts of nuclear war.

Among those present at the founding of PSR was H. Jack Geiger, s.M.'6o, a physician and veteran political activist who would become one of the organizations most active members.

Geiger would go on to co-found the group Physicians for Human Rights (see sidebar, page 74).

Yugoslavia breaks up, precipitating a brutal war between the independent regions of Bosnia, Croatia, and Serbia.

Thermo-nuclear War," in the May 3 1 , 1 9 6 1 , issue of the journal. In an impressive 29 pages, the articles described what would occur if a single nuclear bomb fell on Boston: Nearly three million people in Boston alone would die; over four million in Massachusetts. Some $,000 physicians would perish. Nuclear fallout would poison the air and ground for decades.

Isabelle Valadian, M.P.H/53, retires as professor and chair of the Department of Maternal and Child Health. Marie C. McCormick succeeds Valadian as department chair.

Lown credits the articles in particular with "bursting the bubble" of the idea that, if enough money was invested, everyone could move underground in a massive network of shelters. "The shelter would be the most dangerous place to be because the firestorms would consume the oxygen and you'd be suffocated miserably and incinerated," he says.

Physicians, wrote Garland in his introduction to the articles, should be interested in this problem because "no single group is as deeply involved in and committed to the survival of mankind."

Over the next two decades, PSR continued to work towards the elimination of nuclear weapons and other instruments of mass destruction. It saw some hope in 1968 when the Nuclear Non-Proliferation Treaty was signed by the United States and 1 3 7 other nations. But by the early 1980s, when Ronald Reagan won the U.S. presidency on a strong arms build-up agenda, discussions of the strategic use of nuclear weapons and "Star Wars" defense systems prompted Lown to take a new approach to

his campaign for nuclear disarmament. On travels to the Soviet Union, he had met Yevgeni Chazov, then director general of the Cardiovascular Institute and personal physician to Leonid Brezhnev. In 1980, Lown wrote to Chazov, asking if he would be interested in launching an international collaboration of physicians to prevent nuclear war. Chazov agreed, and the following year the organization International Physicians for the Prevention of Nuclear War ( i P P N w ) was born.

Like P S R , I P P N W sought to draw on the special status of health professionals as impartial arbiters of political and social trends, individuals whose only objective was to protect and preserve health. Unlike P S R , I P P N W was, from the start, an international partnership that set a high-profile example of cooperation between two ideologically opposed adversaries.

Four years later, in 1 9 8 5 , Lown and Chazov traveled together to Oslo to accept the Nobel Peace Prize on behalf of I P P N W . To this day, he is Harvard's only Nobel Laureate for peace. In 1 9 9 3 , to mark Lown's 7PPNW BerwarJ Loww f/e/it) awJ Ywgem C^azcw. Loww, pro/essor ewer^MS

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retirement from the leadership of I P P N W , President Mikhail Gorbachev sent him a note, dated September 6 and written on the back of the INF treaty, the first substantial antinuclear agreement between the two superpowers. Framed and hanging on the wall in Lown's office, it reads, in part, " I want to thank you for your great contribution to preventing nuclear war."

Another faculty member who spoke out against the folly of nuclear war was Dean Howard Hiatt. In 1 9 8 1 , Hiatt joined members of the Pontifical Academy of Sciences to make a personal plea to President Reagan to consider the tremendous medical consequences of a nuclear war. Three years later, in an article in J A M A , Hiatt argued further that, given the incredible need for medical care in this country, and especially in the developing world, the cost of the proliferating arms race was an irresponsible waste of resources. There is a distinctly Vichow-ian echo in Hiatt's call for reapportioning military expenditures toward social programs. In 1869, Virchow presented a motion for disarmament to the Prussian parliament, noting that while funding for weapons was increasing, moneys for education had remained stagnant.

Departwewf

NarMrJ's 072/y No^e/ LaMreafe w peace.

Iraqi generals accept U.N. cease-fire terms, ending the one-month long Persian Gulf War. in the war's aftermath, HSPH researchers will travel to both Iraq and Kuwait to study the effects of environmental and infrastructural devastation caused by the war.

V E N AS F E A R O F " T H E B O M B "

gal'

E vanized one contingent of health professionals to political action, the rise of repressive dictatorships and regional and civil conflicts in Southeast Asia, Africa, and South and Central America sparked a different form of medical activism. Reports of widespread torture, slaughter, and

Soviet Union dissolves.

Activist's Activist: H. Jack Geiger, S.M/60 There are two things any activist worth his or her salt must own: unflinching principles and a police record. Jack Geiger has both. The principtes were acquired while growing up on New York City's Upper West Side. The record came courtesy of police in Nevada, New York, Chicago, and Setma, Alabama. Most of the arrests were of the orderly, round-them-up-then-send-themhome variety in which getting arrested w a s part of the strategy of the protest itself. But in Setma in 1965, Geiger found himself jailed in hostile territory on trumped-up charges by officers willing to use intimidation or violence to derail the accelerating civil rights movement.

Geiger w a s in Selma at the request of Martin Luther King, Jr., as part of a delegation from the Medical Committee for Human Rights (MCHR), an organization Geiger had helped found the previous year. During the voter registration drives of Freedom Summer, MCHR provided a "medical presence" for the thousands of volunteers working throughout Georgia, Alabama, and Mississippi.

Geiger w a s being held on charges of practicing medicine without an Alabama license for assisting in the care of the Reverend James Reeb, a Boston Unitarian minister who had been beaten by local thugs. Reeb would die from his injuries. And while the charges against Geiger were ultimately dropped, the experience itself is indelibly inscribed in his characterâ&#x20AC;&#x201D;one of the many "badges of

displacement of civilians by armed militia and paramilitary groups led to a recrudescence of humanitarian relief efforts. In awJ PzvMc Heaff^, Barry S. Levy, M.p.HL'70, and Victor W. Sidel note that, since the end of World War II, the percentage of civilian casualties during military conflicts has increased from 1 0 to 90 percent of all casualties.

Equally distressing to health-care Professionals was the apparent disregard for medical neutrality in many

honor" that he's earned in a career of social and political activism that spans 5 decades.

Geiger's entree to activism came as a student at the University of Wisconsin in 1943, when he founded one of the first chapters of the Congress of Racial Equality (CORE). He subsequently served as civil liberties chairman of the American Veterans Committee leading campaigns to end racial discrimination in medical school admissions and in hospital careâ&#x20AC;&#x201D;an issue he still pursues with vigor. He would go on to help found Physicians for Social Responsibility and Physicians for Human Rights.

It w a s while working in the poor rural reaches of Mississippi and Alabama that Geiger began hatching the concept of the community health center for which he is now best known. The centers combine clinical medical care and public health interventions into a single program and use both to facilitate social change. The original centers that Geiger helped establish in Mound Bayou, Mississippi, and Columbia Point, Boston, became the models for a national network of urban and rural health centers that now numbers more than 800 and serves more than 10 million low-income and minority individuals across the nation.

Today Geiger, the Arthur Logan Professor of Community Medicine Emeritus at the City University of New York Medical School, regards the community health centers as his greatest contribution to public health. "I think, in terms of the number of people who they've benefited, the community health centers have been enormously successful," he says. That they were inspired by Geiger's experiences as a political organizer suggests a corollary to Virchow's axiom: sometimes health is politics writ small.

areas of conflict, in clear violation of the 1949 Geneva Conventions, which mandate nondiscriminatory access to medical care and protection of hospitals and health-care workers during wartime. In El Salvador, health-care workers were beaten, imprisoned, or killed for providing vaccinations. In Chile, physicians were arrested for providing medical care to people whom the government considered terrorists. And in many war-torn areas, soldiers entered

hospital wards and shot patients lying in beds.

Health professionals had been involved in humanitarian relief missions for over a century, largely under the auspices of the Swiss-based International Committee of the Red Cross ( i C R C ) . Founded on bedrock principles of political neutrality, i C R C volunteers set up held hospitals to care for civilian and military casualties on both sides and ensure that combatants obeyed the rules of war

DEADLY

MtapmcEs!

Pead/y Consequences Mow Wo/ence /s Pesfroy/ng How Violence Our Teenage Popu/af/on, by faculty member Deborah fs Destroying OnrHenage ; Prothrow-Stith, calls for a public health approach to fbpuiationand! a Han to Begin ; halt violence, which has become the second leading SoMngthe ; cause of death for U.S. males a g e s 1 5 - 2 4 .

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FDA approves ddl as an alternative to zidovudine for treating AIDS.

police attacks on blacks protesting apartheid. In 1 9 8 6 , Fine and Schaller called together a number of their professional colleagues, among them the ubiquitous H. Jack Geiger, and launched the organization Physicians for Human Rights (PHR).

Pro/eMor s.M.'yo

listed in the Geneva Convention. In the wake of World War II, however, organizations such as Medecins Sans Frontieres arose that challenged the Red Cross's unswerving commitment to neutrality, especially in civil conflicts in which unarmed civilian populations were targeted by heavily armed militias or government forces.

In 1 9 8 3 representatives from the International League for Human Rights and the AAAS Committee on Scientific Freedom and Responsibility went to Chile, Uruguay, El Salvador, and South Africa to document the effects of abuse on citizens. One of the physicians to go was Jonathan Fine. Upon his return to the United States, Fine, a long-time member of both IPPNW and P S R , met with another Boston physician, Jane Green Schaller, who had just returned from South Africa, where she had witnessed similar evidence of brutal

PHR's mission is to "bear medical witness" to human rights abuses by documenting the physical and psychological evidence of those abuses.

PSR study teams perform autopsies and conduct forensic studies on human remains to determine whether torture, abuse, or murder have occurred; they interview and examine survivors about alleged human rights abuses; and they use the tools of epidemiology to assess the civilian toll of war and armed conflict. The scientific documentation of these abuses, conducted by trained professionals, stands as credible evidence in courtrooms and inter-national tribunals; without such documentation, the stories of beatings and other abuses would only be tales.

PHR physicians are "giving pain a face and death a name," said Jennifer Leaning, s.M.'yo, instructor in health and social behavior, speaking at PHR's tenth anniversary symposium last year in Boston. Leaning is one of many H S P H faculty and alumni who have led fact-finding missions under the auspices of PHR. In 1 9 8 8 , Leaning teamed with fellow graduate H. Jack Geiger, s.M.'6o, to report on the status of medical care in Israel's West Bank and Gaza Strip. T w o years later, at the request of exiled scientist Andrei Sakharov, Leaning traveled to Tbilisi in Soviet Georgia under the auspices of PHR to document the harm caused when Soviet troops broke up a peaceful demonstration using entrenching

MHS

1992

VIII International AIDS Conference, cosponsored by Harvard and scheduled to be held in Boston, is moved to Amsterdam as conference organizers protest federal restrictions on HIV-infected travelers. Despite the c h a n g e in venues, the Conference d r a w s 10,000 participants.

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spades and gas believed to have been toxic. Sixteen people were killed that day, another four died later, and hundreds were injured.

The list of faculty and graduates who have been affiliated with PHR is long and growing. Paul Wise, M.p.H.'y8, assistant professor in the School's Department of Maternal and Child Health, was part of a team that investigated the "human costs" of Operation "Just Cause," the U.S.-led invasion of Panama in 1 9 8 8 . Howard Hu, s.D.'9o, M.p.H.'8o, associate professor of occupational health, has led fact-hnding missions to evaluate the use and effects of tear gas. In 1 9 8 7 he went to Seoul, South Korea, and in 1 9 9 1 to Myanmar, formerly Burma. Paul Epstein, M.p.H.'83, lecturer in the Department of Population and Internationa] Health, went to the Turkey-Iraq border region in 1 9 9 1 to assess the medical condition of over 2 million Kurdish refugees following the Persian Gulf War. Leaning's extensive experience in some of the world's hottest hotspots has led her to try a n d identify societal

elements, especially breakdowns in public health, that prime an area for the type of civil unrest and armed uprisings that have occurred during the past decade in Somalia, Haiti, and the former Yugoslavia. Leaning's work as director of the Program on Complex Humanitarian E m e r g e n c i e s seeks to identify the key characteristics, such as massive population dislocation, extensive e n v i r o n m e n t a l destruction, and high levels of civilian insecurity that render a community vulnerable to disintegration. She hopes that by identifying factors that precipitate these crises, public h e a l t h

/t/DS /n f/;e Wor/d' /S G/oba/ Reporf, edited by Jonathan Mann and Daniel Tarantola of the School s Global AIDS Policy Coalition, is the first comprehensive analysis of the global AIDS epidemic. The book estimates t h a t 13 million people worldwide carry the AIDS virus and predicts that, by the year 2000, up M 110 million people will be infected.

professionals and politicians may begin to be able to anticipate, prepare for, and, ideally, prevent them from occurring. The idea of preventing armed conflict would seem a quaint, post-sixties "save-the-world" notion if it weren't for Leaning's clear-eyed determination and the fact that her beliefs echo the hopes of an earlier HSPH graduate who witnessed firsthand the devastating consequences of war. In a 1 9 4 4 essay in the Alumni Bulletin, Brigadier General James Stevens Simmons, S.D/39, who subsequently became dean of the School, wrote: "One might be allowed to hope that eventually, through the development of preventive medicine, it will be possible to prevent the most pernicious of all diseases, war itself." ^ A !

ANN'S FRAN^OIS-XAVIER

H w ) Bagnoud Center for Health and Human Rights serves as an intellectual bulwark for and collaborator with PSR and other organizations engaged m front-line humanitarian relief and human rights activities. Mann says that the foundation for the center's mission is the $o-year-old Universal Declaration of Human Rights. Perhaps because only one of the declaration's 30 articles deals explicitly with the tight to health, health professionals did not immediately rally behind the declaration, and the human rights movement for much of the past five decades was dominated by legal and political activists.

But Mann, reading the document four decades after it was published, saw it differently: "What struck me Was that reading it from a public health perspective, the whole declaration is about health and the social

conditions people need to be healthy." T o his mind, the right to not be held in slavery or be tortured, the right to privacy and equality before the law, and the right to an education and to practice one's religion—all directly impinged on health.

From this realization, Mann devised a simple but profound equation: for each human right denied to an individual or community, there is a negative impact on health. The strategy that grows from that equation—address the underlying human rights issues, and increased health will follow—is the basis for what he proposes as a new framework for public health. " [The authors of the U.N. Declaration] basically said that if the Universal Declaration is realized, then the societal preconditions for human well-being will be met. There will still be Mozarts and there will be people who can't carry a tune, but the basic fundamental principles for human well-being, that allow the individual to flourish, will be set, and the social conditions for health will be advanced," he says. "This is exactly where I position public health."

In an effort to spread his new gospel of public health, Mann, upon joining the School's faculty in 1 9 9 0 , introduced the practice of handing a copy of the human rights declaration along with the diploma to every graduate. He also began designing courses on health and human rights, both at the School and at the faculty of arts and sciences and Kennedy School of Government.

Mann's pursuit of his new vision got a lift in 1992., when a Swiss countess, Albina du Boisrouvray, gave

AIDS activist and former tennis star Arthur Ashe presented with the Harvard AIDS Institute's first Annual AIDS Leadership Award. Four month later, Ashe dies from the disease.

the School a $2.0 million gift to fund the Frangois-Xavier Bagnoud Center for Health and Human Rights and the Franqois-Xavier Bagnoud Professorship in Health and Human Rights. " T o me, [Jonathan Mann] was a warrior fighting against AIDS at large, standing for health and human rights, committed to rescuing the discriminated, the most destitute, the most vulnerable ones," said du Boisrouvray at the dedication of the Frangois-Xavier Bagnoud Building in October 1 9 9 6 .

Inscribed on the outside wall of the new building, in the six official languages of the World Health Organization, is a phrase from the WHo's Constitution: "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being."

Mann, who last year left the School to become dean of the Allegheny School of Public Health in Philadelphia, believes that the health and human rights movement whose seeds he helped sow is finally beginning to flower. During his keynote speech at the Second International Conference for Health and Human Rights, held at Harvard in October 1 9 9 6 , Mann described this new covenant between public health and human rights in terms that suggested a rebirth: "The tectonic plates are shifting, but it is at the intersection of health and human rights that the most radical transformation is occurring, and it is there that the future will lie. We are in the vanguard of a movement. We have a deeper belief that the world can be changed, and in doing that, we give value to the world.

HSPH nutritionists assert that, contrary to popular belief, margarine is no more healthy for the heart than butter.

S A RULE, DEATH CERTIFICATES

^ ^ ^ are dreary documents, the * ^ grim bureaucratic reminders of human fraiity. For heaith workers, the death certificate too often symbolizes a failure of the core functions of protecting and extending life. Yet on one occasionâ&#x20AC;&#x201D;May 8, 1980â&#x20AC;&#x201D;the signing of a death certificate was a cause for celebration and hope. On that day, the delegates to the 33RD General Assembly of the World

Health Organization (WHO) signed their names to the first death certificate for a human disease: smallpox.

Few events in the history of public health have had as much symbolic meaning: for the first time, a lethal disease had been permanently uprooted from the planet through a concerted prevention campaign.

Abdul Rahman Al-Awadi, M . P . H . ' 6 $ , presided over the historic assembly and called the occasion a

HSPH atumni and facuity working with the Wortd Heaith Organization have been major ptayers in internationai heaith.

Gioba!

Arena Famine exacerbated by civil war kills more than 300,000 people in Somalia. Sudan, Angola, and Mozambique face similar devastation.

The acquittal of white police officers videotaped beating a black man sparks two days of rioting in Los Angeles.

FDA approves the nicotine patch.

"persona! and professional thrill."

At the time the Minister of Heaith for Kuwait, Al-Awadi had worked with the WHO in a number of capacities since graduating from the Schooi, including twice serving as a member of the WHO Executive Board. Al-Awadi's presence at the ceremonial signing, coupled with the fact that three H S P H alumni— William Foege, M.p.H/65; Donald Hopkins, M.P.H/70; and Ralph Henderson, M.P.H.'yo—had played prominent roles in the smallpox campaign, meant that the event also had deep significance for the School of Public Health.

Hopkins had helped lead the eradication campaign in Sierra Leone, Africa, from 1967-68. In his 1983 history of smallpox, P r i c e s awJ Hopkins traces some of the key moments in a struggle between man and disease that had been waged off and on over 3 millenia. The 1 9 6 6 decision by the World Health Assembly to launch the global eradication campaign— coming precisely 1 7 0 years after Jenner's discovery of vaccination— signaled that the endgame of this struggle had begun in earnest. "One of the most important challenges facing the Smallpox Eradication Program," writes Hopkins, was the need to prove, as quickly as possible, that the disease could be eradicated from poorer countries in spite of their inadequate health services.

Many thoughtful public health specialists doubted that could be done to the end of the campaign, but the doubts were especially prevalent during the SEP'S early stages.

]

T WAS F O E G E , L E A D I N G T H E E R A D I -

< cation effort in West and Central Africa, who achieved this "crucial psychological victory," writes Hopkins. Foege would go on to lead the successful campaign in India, before departing to join the CDC. Henderson, who was part of the West Africa effort, working in Lagos, Nigeria, says, "the experience of working on this program in West Africa was a career highlight. It was a crash introduction to West African culture, public health, and the constraints of colonialism and socioeconomic development. Good tools and good people at all levels made it a spectacular success."

A decade later, Henderson was selected to direct the WHO's stunningly successful Expanded Programme on Immunization (EPt). He says that his earlier experience with the SEP, along with the support from many national and international "alumni" of the smallpox eradication campaign, were major factors in making the EPi itself such a success.

was joined there by H S P H Dean James Stevens Simmons, s.D.'39, who subsequently reported in the School's A/M7717?;' that the School was well-represented with alumni serving as representatives from Japan, Ceylon (now Sri Lanka), and China.

Conceived as part of the postWorld War II rebuilding effort with the goal of strengthening national health administrations, the WHO has succeeded where several of its predecessors failed. Nearly a century before, the hrst International Sanitary Conference (isc), held in France in 1 8 5 1 , inaugurated an era of international action in public health.

Eventually the isc evolved into the Ofhce International d'Hygiene Publique (01HP), which survived through the end of the First World War, when the League of Nations attempted to establish its own international health agency. World War II, however, brought international health collaboration to a virtual standstill and destroyed or disrupted national health services in many countries. T h e f u n c t i o n s of the o i H P

^

INCE ITS C R E A T I O N IN J U N E 1 9 4 6

J as a special agency of the United Nations, the WHO has been a hotbed of exchange and collaborative activity for faculty and alumni of the School of Public Health. Among the United States' delegates who signed the WHO into existence was Martha May Eliot, then chief of the United States Children's Bureau and a member of the School's Visiting Committee. Eliot, who would later chair the School's Department of Maternal and Child Health, was also present the following summer for the hrst World Health Assembly in Geneva, Switzerland. She

Swiss Countess Albina du Boisrouvray gives $20 million gift to the School through the Association Fransois-Xavier Bagnoud to create a professorship and center to study health and human rights and to name a new building to house the Center. This is the largest philanthropic gift ever made to the School.

and the League of Nations agency, along with those of the United Nations Relief and Rehabilitation Administration, a temporary organization that assumed oiHP's responsibilities during the war, were ultimately transferred to the WHO. Headquartered in Geneva, the WHO receives funding from its 1 9 0 member states to confront diseases ranging from malaria to mad cow disease to Dengue Fever to AIDS on every continent and in every corner of the globe. The WHO's World Health Assembly has quasi-legislative powers, granted by the United

Resource-based relative value scale (RBRVS), developed over the past four years by Professor William Hsiao and colleague Peter Braun, alters how doctors are reimbursed through Medicare, paying more to primary care physicians and less to specialists.

Nations, to decide which international heaith programs should be undertaken. The WHO Executive Boardâ&#x20AC;&#x201D; made up of 3 2 members, designated by as many states, but serving in their personai capacitiesâ&#x20AC;&#x201D;is charged with carrying out the directives of the Assembly. The WHO Secretariat is responsible for providing assistance to individual nations and programs.

Much of the WHO's work is carried out through decentralized regional offices for Europe, the Americas, Africa, the Eastern Mediterranean, Southeast Asia, and the Western Pacihc.

Over the past five decades, the School's faculty and alumni have been active in the WHO as administrators, program ofhcers, collaborators, consultants, and advisers. Henderson, for example, directed the WHo's Expanded Programme on Immunization for 1 3 years before being named assistant director general. When he took over EPi, immunization coverage in developing countries was negligible. By 1 9 9 0 , coverage had increased to some 80 percent of children age one or under. Today, the program prevents an estimated 3 million deaths annually from target diseases. It has also made it possible for the WHO to have the realistic expectation that poliomyelitis will follow smallpox on the path to eradication by the year 2.000. Before stepping down as assistant director general, Henderson oversaw six divisions or programs relating to vaccines and immunization, tuberculosis, leprosy, tropical disease control, research and training in tropica! disease, and the prevention of blindness and deafness.

1993

As an alternative to the USDA's recently released diet pyramid, the School's nutritionists, led by Department Chair Walter C. Willett, develop the Optimal Traditional Mediterranean Diet pyramid, advocating less red meat, more breads and grains, and daily exercise.

WHO'S

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The breadth of interactions between the School and the WHO, formal and informal, make it impossible to give a comprehensive list of W H O - H S P H activities over the years. But a sampling shows that the relationship between the two organizations has been both varied and deeply influential to global health.

A poll of the School's graduates taken in 1 9 5 6 revealed that 26 alumni had worked with the WHO in some capacity. Lawrence Roberts, M.p.H.'$5, a regional adviser in tuberculosis for the who Regional Ofhce for the Western Pacihc, and James S. McKenzie-Pollock, s.M.'^z, who coordinated communicable-disease services for the WHo's Regional Ofhce of South East Asia, were typical of the large number of graduates who gained hands-on international health experience working out of regional ofhces of the WHO. In the 1 9 5 7 A & w w BM/fe^w, Hans HelwegLarsen, M . p . H . ' $ i , reported that he had recently been assigned to the position of health statistician for Indonesia after many years at the WHO Tuberculosis Research Ofhce in Copenhagen. In the same report, John A. M . Karefa-Smart, M.P.H.'48, informed his colleagues that he had initiated a malaria and yaws control program in Liberia before being named public health officer for Western Africa. Karefa-Smart c r e d i t ed courses he took in public health practice and Dean Simmons' seminar on international health for sparking his interest in the work of the WHO. In 1 9 5 0 , Vlado A. Getting, D.p.H.'^o, was named a United States representative to the third World Health Assembly. At the time

Hantavirus outbreak in the American South-West is traced to a rare virus carried by rodents.

the Commissioner of Health for Massachusetts, Getting recalls that on his flight to Geneva, he was seated next to J . N . Togba, M.p.H.'45), who had just graduated and was serving as Liberia's representative to the three-week-long meeting.

Togba would go on to serve as president of the seventh World Health Assembly, the first of the School's alumni to be so honored.

Eighteen years later, a Canadian alumnus, Basil D.B. Layton, M . p . H .

'52., would also serve as president, as would Al-Awadi in 1 9 8 0 .

Chang Y u o Shu, M.P.H.'47, China's representative to the first World Health Assembly, joined the WHO Secretariat in 1 9 4 9 . Until her retirement in 1 9 7 3 , Helen Martikainen, S.D/65, oversaw the WHo's health education services.

Martikainen noted that during her 2.$-year career at the WHO, her only break from her work was the time she studied at the School. Meropi Violaki-Paraskeva, M.p.H.'50, served the WHO in a variety of capacities over a 3 5-year period, including serving as president of the 34th World Health Assembly in 1 9 8 1 . She was the fourth graduate of the School to serve in this capacity.

Adetokunbo O. Lucas, s.M.HYG. '64, believes that the greatest challenge of his three-decade-long career in public health was the establishment of the WHO Special Program for Research and Training in Tropical Diseases, operated in collaboration with the World Bank and the United Nations Development Program.

Lucas directed the program from 1 9 7 6 to 1 9 8 6 , during which time he raised some $ 3 0 million annually

and conducted training and research in more than 1 0 0 countries. For his 1 0 years of work, Lucas can proudly point to the more than 50 new products—including an effective multipledrug therapy for leprosy—developed by the program to help combat myriad tropical diseases. ] N THE MID 1 9 8 0 s , WITH TUBER-

] culosis riding the AIDS epidemic to renewed prominence in industrialized nations while continuing to hit developing nations hard, Arata Kochi, M.S.'82, assumed leadership of the WHO's TB program. Kochi was faced with rebuilding a global program that had essentially been neglected for the previous two decades. In an interview for the H ^ r M r J H&3M7 ReMgw in 1 9 9 3 , Kochi said his program's primary function is "to build coalitions between governments, funding agencies, and other major players" and to provide technical assistance to poor countries in managing TB. Among those who have helped Kochi to achieve these goals have been several H S P H alumni, including Peter Eriki, M.P.H.'84, regional adviser for TB and leprosy in Brazzaville; Sergio Spinaci, medical officer for China and India; and WHO scientist Diane Weil, M.S.'88.

For Jonathan Mann, M.P.H.'8o, the WHO provided a platform for mobilizing a global response to an epidemic that would re-invigorate— and ultimately redefine—public health: A I D S . Mann, who launched the WHo's G l o b a l P r o g r a m m e on AIDS

in 1 9 8 6 , was recruited to the WHO in 1 9 8 5 by Fakhry Assad, director of the WHO's Division of Communicable Diseases. When Mann arrived in

Newly elected President Bill Clinton appoints a 500-member task force to reform America's health-care system. A poll by Professor Robert Blendon, w h o advises t h e president, reveals that, while public support for health care reform is at a 40-year high, few people are willing to sacrifice their own care or pay more to finance changes.

Geneva, the program's only other staff member was his secretary.

When Mann left, four years later to join the faculty of the School of Public Health, the program was the WHo's largest, with a staff of over 300 and a budget of more than $ 1 0 0 million. Under Mann, the GPA established 1 national AIDS programs, achieved true global mobilization against the epidemic, and developed a language and a conceptual framework based on preservation and respect for human rights that Mann believes is critical to help the world address A I D S .

Mann points to the WHo's ability to utilize the resources and expertise of universities around the world as one of the keys to its success. "With the larger purpose of ensuring global health, it is the WHo's responsibility to take advantage of the resources available," explained Mann.

The recent appointment of alumna Gro Harlem Brundtland, M.p.H.'65, as director general of the WHO represents a fitting culmination of the productive W H O - H S P H relationship.

Brundtland, who assumes the post in July 1 9 9 8 , has been one of the world's most influential advocates for international cooperation on health and environmental issues. She has thrice served as prime minister of her native Norway. As chair of the U.N.'s World Commission on the Environment, she oversaw publication of the report " O u r Common Future," which brought the notion of "sustainable development" to the fore of international health efforts.

She is the first HSPH graduate—and first woman—to hold the post of director general and those who know

A study by Associate Professor Katherine Swartz reveals that, during the course of a year, up to 58 million Americans go without insurance for some period of time.

her expect that she will bring an energetic management and leadership style to the organization that will help it achieve new prominence in international health.

In her presentation to the WHO Executive Board prior to her confirmation, Brundtland proposed a more active role for the WHO as "a catalyst for raising the status of health on the international political agenda. We cannot allow health to remain a secondary dimension as we focus our international resolve into a new century. Health is pivotal.

Health is the core of human development."

COMPLEMENTING T H E L E A D E R S H I P

on the ground of the School's alumni, H S P H faculty have played important collaborative and consulting roles on WHO research and service projects. Collaborative centers, too, have been an important part of the relationship between the WHO and the School. In 1 9 8 1 , the WHOHarvard University Collaborating Center for Cancer and Biostatistics linked the School's biostatistical expertise with the WHo's planning, conduct, and evaluation of cancer control programs. Center faculty provide consultation and evaluation for the activities of the WHO cancer unit based in Lyon, site of the International Agency for Research on Cancer, which was established under the WHo's auspices, in order to hnd means of preventing cancer that are effective and accessible to the people of the developing as well as the developed world.

In 1988, the WHO designed its first international collaborating center for health legislation. With A I D S as it's first focus, the Center was placed at the School, largely because of the reputation of late faculty member William J. Curran, s . M . H . ' $ 8 , founding director of the School's health law program. The center conducted the first international survey of A i D S related legislation and has tackled such topics as international guidelines for dealing with drug and alcohol abuse. The WHO recently established a similar collaborating center with the Department of Nutrition, which seeks to draw on the School's longstanding strenths in nutritional epidemiology and international nutrition.

Perhaps the most important byproduct of H S P H - W H O collaboration is the recently completed G / o ^ / study. Led by Professor of International Health Economics Christopher Murray and WHO colleague Alan Lopez, this landmark study is the first attempt to develop a comprehensive set of estimates for patterns of mortality and disability for 1 0 7 chronic and infectious diseases ranging from A I D S to heart disease to depression.

Originally intended to correct many of the discrepancies and inconsistencies in global reporting of disease prevalence and incidence, the study ultimately revealed some startling insights about global disease trends, including the fact that some non-fatal illnesses, such as depression and diabetes, are a heavier health burden to societies and the world than many fatal illnesses.

To do the study, Murray, Lopez, and more than 1 0 0 collaborators around the world analyzed 1 4 million death certificates and used that information to rectify the often glaring gaps in disease incidence and mortality estimates. The first two of a planned 1 0 volumes were released in 1996 and include morbidity and mortality projections through the year zozo. Murray's findings will be critical in planning for national healthcare needs in the coming decades.

As the W H O enters its 5 0 T H year of protecting and preserving the health of people around the globe, it has more than 1 5 0 programs coordinated in Geneva and countless others directed by the regional offices. The WHO employs more than 5 , 0 0 0 scientists, researchers, and administrators in the Secretariat alone. From its headquarters in Geneva, it remains the health consultant to the world. The exchange of personnel, expertise, and resources that has characterized the relationship between the WHO and the School over the last five decades of this century will no doubt continue. Brundtland has emphasized the importance to WHO of partnerships with institutions and agencies at every level dealing with health. For his part, Mann believes that one of the things the School ought to be doing even more of is fostering its relationship with the WHO. "There is no meaningful distinction between the national and international arenas when it comes to health," explained Mann. "It is the School's responsibility to continue its partnership with the WHO."

Kevin S o t t a k

Serbian nationalists lay siege to Sarajevo and launch a wave of violence that will culminate in genocidal "ethnic cleansing" campaigns against Muslims and

Netherlands legalizes physician-assisted suicide.

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by Harr/et H/a^/i/ngtonr

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H E R E IS C O N V I N C I N G E V I D E N C E , P A R T I C U L A R -

pie, in addition to the 37,000 people killed annually by

LY from the Centers for Disease Control, that

firearms, guns cause 100,000 devastating injuries such as

tells us that the United States may be a more

brain damage or spinal cord injury every year.

violent society than all other industrialized countries,"

Over the past 2.0 years, the violent crime rate has

says Professor Felton Earls, Director of the Project on

decreased slightly, but the rate of violent crimes perpe-

Human Development in Chicago Neighborhoods. T w o million Americans are beaten, knifed, shot, or raped every year. Of the 1 4 5 , 0 0 0 annual Americans deaths due to injury, at least 56,000 are due to violence; 1 9 9 1 , the year the CDC announced that murder was epidemic in this country, saw 1 0 homicides for every 100,000 citizens. Scotland is a distant second with a homicide rate that is only one-fourth of ours.

Not all violence leads to death, of course. Violence destroys lives in a horribly versatile manner: For exam-

Israeli Prime Minister Yitzhak Rabin and Palestinian leader Yasir Arafat sign historic peace agreement.

trated by and upon young people has shot up alarmingly. Injury and violence have replaced infectious diseese as the chief killers of the young during the same period that the young have become responsible for a wildly disproportionate amount of violence and crime. The homicide rate among males 15-2.4 years old in the United States is 1 0 times higher than in Canada, 1 5 times higher than in Australia, and 28 times higher than in France or in Germany. One in hve violent crime arrests in 1994 were of someone under 18 years of age.

WHO declares tuberculosis a "global emergency" and estimates that the disease may claim as many as 30 million lives over the next decade.

"We did have a skyrocketing of adotescent and young adult homicide rates, an epidemic that the biggest cities experienced hrst, in the mid- to late 1 9 8 0 s , " says Earis.

"The second tier followed in the early 1 9 9 0 s . For example, Minneapolis saw its adolescent homicide rate double between 1 9 8 7 and 1 9 9 3 . This is a real increase in adolescent violence, and we have learned to pay more attention to it."

Easily obtained guns are an essential component of America's violent profile, especially for children, say experts. Shooting is now the chief cause of death for black teens and is second only to motor vehicle accidents in killing white teen-agers. Firearms homicide for youths 1 5 - 1 9 years old increased 1 5 5 percent between 1 9 8 7 and 1994.

As a result of the shifting demographics of violence, the focus of research has shifted to the young. At the same time, the nation has fairly recently undergone a paradigm shift that recast violence, formerly within the purview of the criminal justice system, as a public health problem.

In 1 9 7 9 , Surgeon General C. Everett Koop hrst included violence prevention as one of the nation's top 1 5 health priorities. Under the direction of Mark Rosenberg, the Centers For Disease Control and Prevention (CDC) promptly established its Violence Epidemiology Branch. The CDC organized symposia and conferences including the 1 9 8 5 Surgeon General's Conference on Violence as a Public Health Problem.

The story of how violence metamorphosed from a task for jailers

1994

ij^^yj^ / / tIlP SH ? ^ ^ ^ ^

and judges to a challenge for public health and medical professionals is closely intertwined with the efforts of a small group of pioneers on the faculty of the Harvard School of Public Health. They include Earls, whose meticulous, prospective studies ask, "Why do communities and their individual members differ so much in their crime rates?"; Professor Deborah Prothrow-Stith, a charismatic writer who clothes the insights of a clinician with the fervor of a proselyte; Professor David Hemenway, deputy director of the School's Center for Injury Prevention, who applies his expertise in economics to original investigations of firearm injuries; and Jay Winsten, director of the Center For Health Communication, whose "Squash-It" antiviolence campaign employs the same sophisticated social marketing strategies as his highly successful designated driver campaign that helped reduce drunk driving in the 1 9 8 0 s .

Progress toward understanding a problem as complex and elusive as violence has been slow. " A t the end of the zoTH century, we are as close to understanding violence as we were to understanding medicine in the mid-i 8 0 0 s , " observes Earls. But the extent to which we now define violence as a public health problem is illustrated by the fact that the very criminal justice and law enforcement proponents who once owned violence now call for partnerships with public health practitioners. In 1 9 9 0 , Lee Brown, police commissioner of New Y o r k , decried the city's record 1,905 homicides and called upon the medical profession to study the psy-

On the heels of its successful "Designated Driver" media campaign, the Center for Health Communications launches the nationwide "Squash It!" campaign to prevent adolescent violence. A survey conducted by the Center has revealed that 15% of America's sixth through twelfth graders have carried a gun to school.

chological and physiological roots and interventions, schools to educate children to violence prevention and churches to instill moral values that can discourage violent behavior. ^

SINGLE BULLET CHANGED

THE trajectory of Felton * ^ Earls' career, and, not incidentally, the way we view social science research, forever. Earls had graduated from Howard University School of Medicine in the late sixties and in 1968 was a postdoctoral fellow in neurophysiology at the University of Wisconsin at Madison. In April, he withdrew into a soundproof room for an experiment requiring that he remain isolated for several days. He emerged from his research cocoon into a transfigured world: The campus was in chaos because Martin Luther King, Jr., had been shot.

Elegant neurophysiological abstractions were no longer an option, recalls Earls. "King's philosophy of nonviolence crystallized my interest in the issues surrounding violence and crime. M y laboratory had to be the community, and I had to work with children because they represent our best hope.

"I've always been interested in urbanization and health, and I see the planet becoming slowly urbanized in an irreversible way. It is a one-way process, and we're not very skilled yet in knowing how to build a healthy city. Where cities have the biggest social impact is on kids, so that's the reason I'm in public health. " During the early 60s, crime rates had risen dramatically. More police

were hired, more job training materialized, and more interventions and treatments were devised for delinquents and the criminally violent. But, says Earls, "The few intervention programs that looked at the outcomes beyond one year of ending the program have found that the effects wear off. In fact, the boys who received help had somewhat higher recidivism rates than the boys in control groups."

By the late sixties, as crime continued to spiral out of control, researchers undertook retrospective studies, examining people who were

already exhibiting violent behavior in an effort to identify predisposing factors. These retrospective studies fostered a post hoc ergo propter hoc mentality that long informed how policymakers looked at violence: Poverty, drugs, alcohol, associating with gun-toting friends, and even smoking came to be viewed as directly causative agents of violence.

"The limitation of retrospective studies is that you identify people because they're already engaged in the outcomes you are predicting," explains Earls. "It's like loaded dice." Earls believes more subtle

"King's phiiosophy of nonvioience crystahized my interest in the issues surrounding vioience and crime. iV!y iaboratory had to be the community, and t had to work with chiidren because they represent our best hope."

Professor F e / t o n f a r / s

agents of destruction are probably at work, factors that will help explain why, even in the most destitute neighborhoods, only a small fraction of children and adults become violent. "As a scientist I have to say that we are largely ignorant of how and why people become violent. There's been a lot of work on antisocial behavior and violence, but nearly all criminal research to date has studied adults and older teenagers. By these ages, intervention may be too late."

In March 1994, Earls launched a massive study that applies the rigors of prospective epidemiologic research to the multifactorial problems of violence and antisocial behavior. The Project on Human Development in Chicago Neighborhoods, sponsored by the John D. and Catherine T. MacArthur Foundation, the National Institute of Justice, the National Institute of Mental Health and the Department of Education, will track 6000 children in 80 Chicago neighborhoods until 2.003 in an attempt to identify factors that risk violent behaviors. The study encompasses African-American, Latino, white and mixed ethnic neighborhoods and all social classes. " B y a detailed study of Chicago, we sample the whole universe of urban America," he says. " N o other study has attempted to capture in a single design as much of the class and ethnic diversity of urban American. We're looking not just at how individuals shape their environments, but at how changing social and physical environments shape them."

By studying human development in changing urban environments over time, Earls hopes to tease out the

"Haiti: Crisis in Humanitarian Action," a study by the Harvard Center for Population and Development Studies, details widespread health consequences of Haiti's military coup and the subsequent economic sanctions imposed by the international community.

Violence Prevention: Fire With Fire

Television, movies, rap music—even the nightly news—have been blamed for fueling violent impulses among young Americans. Jay Winsten, an associate dean and director of the School's Center for Health Communication, is using some of these same media outlets to send a new message to the nation's youth: keeping control is macho.

Winsten and his colleagues are the creative ^ force behind "Squash It!" a nationwide, multimedia campaign that encourages young Americans to walk away from violent confronta-wag tions. The phrase, "squash it," was drawn from ^ ! focus group research with teenagers from . i Boston and other urban centers conducted by ^ Winsten and center colleagues Susan Moses and & Terri Mendoza in 1994. Later, Moses and Winsten developed a hand signal—a modification of the time out "T" from sports— to accompany the phrase.

Explaining the project, Winsten commented, "Our strategy relies on a critical observation that emerged from our focus groups and was confirmed in our national survey research: although the dominant social norm is that you must stand and fight, a majority of teenagers in our survey (including a majority of urban youth who have been involved in serious violence) secretly believe that it shows strength, not weakness, to walk away. This finding offers a window of opportunity to make public and validate the privately held belief of a majority of teenagers, use this as a wedge to change social norms, and thereby grant social sanction to what most teenagers already w a n t to do—walk away."

Unveiled in 1995, "Squash It!" employs traditional social marketing strategies—public service announcements (PSAs), highprofile celebrity endorsements, and posters—along with tech-

causes of antisocial behaviors such as violence and substance abuse and also to devise interventions and inform policy. Seven age cohorts of from 500 to 1 0 0 0 children are being, followed over an eight-year period; by overlapping the cohorts, the study _

Poputation Poficies Reconsidered

niques that Winsten refined during SPH's Designated Driver campaign, which helped to sharply reduce drunken driving fatalities in the late 1980s and early 1990s. For that effort, Winsten convinced television writers to integrate the designated driver concept into the plot lines of 160 popular prime time shows. This same technique is now being used to promote the central \ message of "Squash It! " — t h a t it's cool to M A walk away. § "Squash It!" PSAs have been broadcast dur^ ^ ing the Grammy Awards, the NCAA men's basketball tournament and on MTV and Black Entertainment Television while subtler anti-violence themes have been incorporated into Fox TV's "Beverly Hilts, 90210" and "New York ^^^ Undercover," ABC's "Dangerous Minds," NBC's "ER," and other prime time episodes.

Winsten may be the only Harvard associate H dean w h o has "juice" with rap stars: performers Coolio, Method Man and KRS One have ^ ^ L employed the "Squash It!" slogan and hand signal.

"This notion—that you can walk away without losing face—is a very important part of what w e need to communicate to our children," says colleague Deborah ProthrowStith, professor of public health practice and head of the School's Violence Prevention Initiative.

For all its visibility, Winsten stresses that "Squash It!" is meant to complement, not replace, other anti-violence efforts. "It's not a panacea," he says. "Violence prevention will take many effective approaches. The totality will make a major difference."An evaluation of the impact of "Squash It!" currently is being conducted by a SPH research team that includes Drs. Steve Buka, Steve Gortmaker, and Penelope Greene.

approximates 2.5 years of research.

The study is unique not just for the number of people enrolled and the period of time of looked at, but for the range of individual, family, and community variables being studied.

"We start in childhood, much earlier than legal interventions, and we look at communities as well as family and individual effects," says Earls. "We plan to identify neighborhood influences that affect children for good or ill as they mature....

— — — — — — Popu/af/on P0//0M /?ecofK/oered, coedited by Lincoln Chen, Gita Sen, and Adrienne Germain, refocuses population control efforts on the health of w o m e n and provides the intellectual foundation for the U.N. Conference on Population and Development in Cairo.

Investigators in the School's Center for the Prevention of Cardiovascular Disease identify the molecular mechanism by which homocysteine, an amino acid found in the blood, promotes atherosclerosis.

in adolescenceâ&#x20AC;&#x201D;by setting curfews and having clubs and athletic facilities, so that adolescents have some positive activities. When a community deteriorates, the loss of supervision and opportunities for constructive activities may result in high levels of violence."

H N LATE J A N U A R Y 1 9 7 8 , A D E C A D E

"Earty on, we saw that bad environments and substance abuse contributed heavity to the viotent behavior we saw."

Many studies don't distinguish between witnessing violence and experiencing violence. They don't include sexual violence. I wanted to get a broad view of violence that could occur in family, home, and school. I think this is important because many studies specialized in one or the other and have not been in a position to answer questions about how they look when you combine factors. " The data gathering is proceeding rapidly, and although it's too early to analyze data, says Earls, "One interesting finding so far is that there are no poor white communities in Chicago. There are many poor white kids, but they're not concentrated in

Deborah Profhrotv-St/th

communities. They are distributed across working-class and mixed-ethnic neighborhoods. That alone tells you that the average poor white kid is growing up in better circumstances than the average poor black kid.

The most common neighborhood in Chicago is a poor black neighborhood. This is a stark reality."

But Earls is cautious about leaping to the conclusion that poverty per se is the root of all violence.

"The fact that violent criminals and victims of crime are disproportionately members of minority groups is not strictly related to poverty," says Earls. "It also has to do with the extent to which families and adults in a community monitor children

"Binge drinking" among college students makes headlines as a study by Henry Wechsler of the Harvard Alcohol Project reveals that nearly half of all undergraduates drink four to five alcoholic beverages in a row.

! after Earls emerged from his ! sound-proof laboratory, a thirdyear medical student at Harvard was coming to terms with the strangely passive mentality toward violence adopted by her colleagues. On a stint in the emergency room during her six-week surgical rotation at Brigham and Women's Hospital, Deborah Prothrow-Stith saw, along with the sore throats, broken bones, and heart attacks, teens who were losing gouts of blood from knife and gun wounds. At 3 a.m. one night, a young man came in with a deep slash across his brow. "If he'd been cut an inch lower, he would have lost an eye," recalls Prothrow-Stith. In the fast-paced milieu of the E R , she concentrated on her training, explaining as she sewed him up that she was suturing patients on her own for the first time. " H e told me he'd been drinking heavily at a party, and he flared into anger at a comment from a guy he barely knew," she recalls.

Insults flew, and an argument erupted, punctuated in blood when the other boy drew his knife.

"After I stitched him up, he told me, 'Don't go to sleep, because the guy who did this to me will be in here in an hour, and you'll get all the practice stitching you need.' He delivered this with humorous brava-

Harvard AIDS Institute scientists led by Max Essex and Phyllis Kanki discover that infection with HIV-2 may protect against infection with the more lethal HIV-1.

8?

^ y

do, and both I and the senior resident laughed. But later, it dawned on me that had he been joking about a suicide attempt, we wouldn't have laughed. In fact we would not have let him leave."

Medicine appropriates everything: Why did doctors shy from treating violence as a medical problem, she wondered? "It's not because it's a complicated behavior: smoking, lead poisoning, tuberculosis are all complicated by social aspects and poverty," she says.

Prothrow-Stith says she felt from the hrst that the same public health strategies that had been so successful in curbing smoking and drunk driving could be employed to prevent violence. For her senior project, she wrote a curriculum for education in violence prevention under the supervision of Sandy Lamb, who went on to become Boston's deputy health commissioner. After she graduated in 1 9 7 9 , she got support from several quarters, including Boston City Hospital Chief of General Internal Medicine John Noble and Mark Rosenberg at the CDC injury center.

Prothrow-Stith's senior project was the precursor to her CMrncM/M??? To Pre^gMf AJo/esceM? that is now used in hundreds of schools internationally. David Nee at the Florence V. Burden Foundation funded writing of the curriculum.

After Prothrow-Stith finished her medical residency at Boston City Hospital, she started a program for high-risk youth that became the Boston Violence Prevention Program. "When we hrst started, people thought we were a little odd because we treated violence in a

health-care context. But early on, we saw that bad environments and substance abuse contributed heavily to the violent behavior we saw." Her anti-violence efforts attained higher visibility when, at 3 3 , she became the youngest personâ&#x20AC;&#x201D;and the hrst womanâ&#x20AC;&#x201D;to serve as Commissioner of Public Health for Massachusetts.

In 1990, she left the post to join the School's faculty, where, as Professor of Public Health Practice, she has continued her crusade to bring violence prevention within the rubric of public health. Her 1 9 9 1 book D e ^ J f y CofMg^MgMces combines anecdote and analysis to support the public health approach to violence.

Prothrow-Stith feels that the efficient way to reduce homicide and assault is to focus on defusing the explosive scenario of two armed acquaintances seized by a sudden anger that is fueled by alcohol or drugs. The youth of those involved in killings, the fact that both the "aggressor" and the "victim" tend to be poor, of the same race, exposed to violence in the past, depressed, and know each other argues for treating both as victims, she says. "Each is likely to feel that hghting is his only choice," says Prothrow-Stith. Parents often abet this reaction by socializing children to feel that it is somehow shameful to walk away from a hght.

"Children are not to be blamed for their inability to handle anger in non-lethal w a y s " , she says. "We as parents, as teachers, as clergy, as health care providers have failed to teach them this basic skill...I think the outcome of violence is determined by environmental, cultural

First International Conference on Health and Human Rights, sponsored by the Fran^is-Xavier Bagnoud Center for Health and Human Rights, is held in Cambridge and draws hundreds of human rights and health professionals from around the world.

and social factors: Kids learn to use violence."

She points to the shocking hgures on gun-toting students as evidence of kids' vulnerability. "Rarely have I heard of an adolescent who is carrying a gun for reasons other than protection. Inside, kids carrying guns do not feel strong: they feel weak and vulnerable. The gun they carry is their compensation."

H o w does she answer those who suggest that violent urges he in the genes and thus are not amenable to social programs or medical intervention? "The problem with such research is that there are such wide discrepancies in the homicide rate from country to country. That makes it hard to ascribe a biologically determined genetic function. If there were a small increase, you might be able to attribute it to some predisposition. But when the U.S. rate is 70 times higher to 1 1 0 times higher, at some point we have to say 'Stop looking for genetic focus and concentrate on social and cultural factors.' We haven't had a homicide in a child under 1 6 in Boston for 1 8 months, and while Boston is an interesting city, we certainly didn't change the gene pool."

Hk

H O W H E R E IS T H E P E C U L I A R L Y

] \ ]

American ambivalence toward violence more evident than in the issue of guns. Estimates place the number of guns now circulating in the United States at over 2.00 millionâ&#x20AC;&#x201D;nearly one for every man, woman, and child. With so many firearms so readily available, it's not surprising that gunshots are the leading cause of death for black

Professor Jonathan Mann leads a threemonth study of health conditions in Bosnia and declares the crisis a "war on public health."

"We're now tooking at a contagion mode in which peopie feei iess safe as their neighbors or ciassmates acquire guns. This causes them to acquire guns in response." Dav/d Hemenway teens—and the second leading cause of death for white teens.

"Day after day, 1 0 0 people die from guns— and half of these are suicides. Clearly it's an American problem. Almost no other countries allow handguns for personal enjoyment," observes David Hemenway, deputy director of the Injury Prevention Center and professor in the Department of Health Policy and Management. Hemenway, an economist, points out that there has been relatively little research on guns given their pubhc health importance.

Accordingly, he has become something of a one-man firearms think tank, investigating who owns and carries guns and why; how to improve storage practices; the costs and benehts of gun ownership; the use of guns in self-defense; gun use among adolescents, on college campuses, and in suicide; and who belongs to the National Rifle Organization.

Hemenway has found, for example, that men are more likely to own guns than women, Republicans are more likely to be armed than Democrats, and whites are more likely to pack hrepower than blacks.

Despite conventional wisdom, gun owners who have had hrearms training are more likely than others to be among the i in 5 who store guns

loaded and unlocked "We've assumed that suicide, homicide and accidental gun injuries were reduced by training," notes Hemenway, "but training seems associated with poor storage habits."

Most recently, Hemenway and Professor Robert Blendon analyzed two decades worth of public opinion polls that suggest the American ardor for hrearms may have cooled: Gun ownership declined from 48 percent of households in 1 9 7 3 to 4 1 percent in 1994. But, says Hemenway, this promising trend is tempered by the finding that even while shotgun and rifle ownership dropped, handgun ownership rose from 1 3 million to 2.4 million households during that same period. Not surprisingly, this increase in handgun ownership has been concomitant with a marked increase in violent crimes. There were 4 1 7 crimes for every 100,000 people in 1 9 7 4 , but this rate leapt to 746 in 1 9 9 3 .

Much of the gun control debate still takes place in the law-enforcement arena, but in 1986 public health physicians declared gun ownership a "public health emergency," and J A M A issued recommendations for stricter gun control measures, citing not only the 38,000 Americans killed by hrearms but the 90,000 gun injuries treated annually in hospital emergency departments.

Phase I! clinical trials o f a Lyme disease vaccine begin on Nantucket and Block Island under the direction of Professor Andrew Spielman.

The rise in handgun ownership may be disquieting, but what does augur well is the discovery that 90 percent of Americans— including gun owners— believe that guns should be withheld from youths under 18 and from those with criminal records. 86 percent of Americans support the Brady Act that includes a 5 day "cooling-off" period and provision for background checks on those who wish to purchase guns.

The pubhc also supports the limit of one handgun purchase per month and a ban on assault weapons.

Hemenway's research supports Prothrow-Stith's claim that children carry guns for defense. He has found that knowing victims of violence, being threatened with a gun, having friends and family who have guns or are involved in drugs are all associated with a child's gun carrying. Yet 87 percent of children surveyed say they want to live in a world with

English Channel tunnel opens.

fewer guns and 76 percent, including more than half of adolescent gun carriers, want it to be impossible to obtain guns. "Currently, it's easy," adds Hemenway.

"We're now looking at a contagion mode in which people feel less safe as their neighbors or classmates acquire guns. This causes them to acquire guns in response," he says.

Everyone falls into a categoryâ&#x20AC;&#x201D; susceptible, infected, or resistant.

Just as with TB, isolating and treating a few "carriers" may have profound health advantages; Hemenway's studies suggest that training in conflict resolution and open family discussions may protect children from catching the handgun "bug".

"This is such a contentious area.

It is hard to research, because the NRA is attacking the CDC for giving money to gun research. Gun-control critics claim guns are more often used in self defense than in crime, but our surveys show this is not even close to the truth." Other studies find it 43 times more likely that a gun in the home will kill someone who lives there than an intruder, and that guns in the home also increase the likelihood of suicide. "The NRA says public health people are opposed to all gun ownership," says Hemenway.

"I'm not. I advocate more rational gun policies."

^ ^ ^

NE OF THE IMPORTANT

H strengths of Harvard's vio^ ^ lence-prevention strategies is the cooperative nature of faculty efforts. Their diverse approaches often converge synergistically. For example, Prothrow- Stith and Earls have taught a course, "Violence in America," for several years. " I am the scientific presenter about causation," says Earls, "and Deborah brings an interventional and therapeutic approach. We constantly have crosstalk about what we know from social and behavioral sciences and how that relates to prevention."

David Hemenway is now collaborating with Earls' study, helping his groups to better assess injuries that stem from violence.

Jay Winsten, director of the Center For Health Communication, also lectures to the violence class.

And he literally got a hand from Earls in designing his nation-wide violence prevention media campaign, (see sidebar) " I was discussing with Jay work on nonhuman primates showing conflict avoidance," recalls Earls.

"Gesture is extremely important in getting a creature to back off.

This got Jay and me to talking about incorporating the .S^M^-?;.' hand signal with his verbal message."

Despite the large gaps that still exist in understanding how and why violence occurs, the School's experts express optimism that a multifaceted approach from publichealth practitioners, schools, parents' groups, the churches and law enforcement will continue to reverse the deadly trends. Prothrow-Stith predicts that parents' groups such as the National Coalition of Survivors for Violence Prevention will have the impact of Mothers Again Drunk Driving. " I find the activism of survivors of violence very exciting," she says.

As of March 1 9 9 7 , Boston had seen no homicide involving a minor child for eighteen months. " I don't think this is an artifact," declares Earls. "It's a real effect that demonstrates something. What happened here is that many parts of the communityâ&#x20AC;&#x201D;police, schools, afterschool programsâ&#x20AC;&#x201D;all combined.

But it's easy to back off. If that happens, I expect violence rates to rise again.

1995

Biostatician Richard Gelber, member of study team that discovers AZT blocks mother-to-infant HIV transmission.

U.S. Postal Service unveils a stamp honoring public health pioneer and former faculty member Alice Hamilton.

E L E V I S I O N V I E W E R S T U N E D INTO

] the A B C News program K H "zo/zo" one Friday night last June were offered a glimpse of what co-anchor Barbara Walters called a "revolutionary" new treatment for heart disease. The segment was narrated by the network's Medical Editor, Timothy Johnson M . P . H . ' y 6 , whose characteristic professional yet compassionate persona has earned the respect and trust of two generations of television-watchers. For the next 1 3 minutes, Johnson guided the program's roughly 1 9 million viewers through a complicated story about a renegade Brazilian cardiac surgeon's new technique to treat an enlarged heart by cutting a chunk of heart muscle away from the lower left ventricle. The fast-paced segment intercut shots of Dr. Randas Batista, the Brazilian cardiologist, in his "jungle" operating room with footage of Batista being interviewed by Johnson, Batista riding a horse on his 300-acre brush ranch, and animated graphics illustrating the procedure.

Much has changed, both in television and in medicine, since Johnson's first 30-minute broadcast aired nearly 2.0 years ago, when he hosted a local program called "Housecalls." In that time, Johnson—"Dr. Tim," as he is known to his colleagues and public— has led the way in the competitive world of broadcast medical journalism. Practically every day, he shifts between reporting on new medical hndings or controversies and providing basic information about the importance of screening for colon cancer and hearing tests for children.

"Some say that I'm providing cheap entertainment for hypochon-

National Center for Health Statistics predicts that by the year 2000, cancer will overtake heart disease as the nation's #1 killer.

driacs, but I like to think it's more than that," says Johnson.

"He has the best public health education job in the country," says colleague Terry Schraeder, who interned with Johnson before becoming a medical reporter at w c v B News (Channel 5) in Boston. Former U.S. Surgeon General C. Everett Koop, a friend and colleague of Johnson, agrees. "When you educate patients the way Timothy Johnson is doing, you empower them to take a larger role in their health care," he says. "It changes the paradigm of passive patient and active physician."

A graduate of Albany Medical College, Johnson was practicing emergency medicine in Lynn, Massachusetts, when he was recruited to host the local television venture "Housecalls." The half-hour show's low-key format consisted primarily of Johnson and a guest discussing a single health topic, such as cataracts or chest pain. The few graphics employed were decidedly low tech. In the early 1980s, Johnson hosted a half-hour-long newsmagazine called "Healthbeat"—a precursor to his current Channel 5 News segment of the same name—that included five or six short segments. In 1984, Johnson went national when he joined the ABC News organization as medical editor.

CAMERA

tagaw Timothy Johnson, MPH '76

During this time, Johnson's on-air patter has quickened a few beats to keep time with the new demands of the mediuim. But while the pace of broadcasting has changed, Johnson has earned respect for not abandoning his unique, physician cum journalist style, which integrates the perspectives of the patient wanting infor-

Ebola outbreak in Zaire

^ ^ ^ ^

mation, the physician concerned that his patient get the right information, and the reporter asking the tough questions to get it.

"He is enough of an expert that he rises above the daiiy grind of news stories and becomes an educator, an on-air adviser to the pubiic on health matters," says Phil Hilts, medical writer for T/?e New Yor^ T;'we.s.

Johnson came to the School in 1 9 7 5 specifically to learn to evaluate studies more rapidly and accurately and to hone up on statistics. He credits Professor Marge Drolette with providing an "excellent" instruction in biostatistics. Drolette, who earned her M.p.H. from the School in 1 9 5 4 and taught most of the required biostatistics courses, was known for her unbridled enthusiasm towards both her students and her subject. In a memoriam that appeared in the Alumni Bulletin in 1 9 8 7 , she was called the "best-loved teacher in the history of the Harvard School of Public Health." (She also served as chief coordinator for the M.P.H. program from 1 9 7 7 to 1 9 8 5 , and every year at commencement, to show their appreciation, graduating students kissed her as she handed out diplomas. This tradition led former Dean for Academic Affairs Elkan Blout to call Drolette "the most kissed faculty member" he had ever known.)

While at the School, Johnson also collaborated with Steven Goldhnger, dean for continuing education at

Alumnus Donald Hopkins, M.P.H.'65, named a MacArthur Fellow for his efforts to eliminate guinea worm disease.

Harvard Medical School, to create the Harvard Health Letter, a lay person's newsletter on medicine and health.

"Tim was a man full of ideas that were well thought-out and creative," says Goldhnger, who now heads the Harvard Health Publications Group, the umbrella organization that publishes the Harvard Health Letter as well as five additional letters dedicated to specific health topics, such as women's, digestive, mental, and cardiovascular health.

Johnson was also having a great time, says William Ira Bennett, who replaced Johnson as editor-in-chief in 1 9 7 9 . Headlines from the hrst few issues of the Letter reflect Johnson's sense of humor toward his subject: "What You Should Know about Heart Attacks Before You Die from One," and "What You Always Wanted to Know about Colds and Flu, but Felt too Rotten to Ask." But the Harvard Health Letter also sought to provide useful information to people, especially about preventive measures such as tests ad screening, and to do so in a way that was informative and respectful. "The basic decision not to talk down to people was something I really respected," says Bennett.

Today the health letter started by Johnson and Goldhnger reaches some 2.50,000 people every month.

Through his new medium, however, Johnson numbers his audience in the

tens of millions. During any given week, Johnson appears several times on ABC's news programs " 2 0 / 1 0 " , "Nightlme", "ABC N e w s " , " G o o d Morning America", and "World News Tonight". He also continues to do spots called "HealthBeat" on the local ABC news afhliate.

"He's always on the go," says Judy Burke, who has been his assistant for 1 0 years and who produced some of his earlier programs.

Johnson has won two Emmy Awards from the Boston/New England Chapter of the National Academy of Television Arts and Sciences, and the Lewis Thomas Award for Communications from the American College of Physicians. And in a 1995 T V Guide poll of the most trusted television news personalities in America, he ranked second, behind Walter Cronkite.

"What is so good about what Tim does," says Marcia Angell, executive editor of the New England Journal of Medicine, "is his ability to put science into language the public can understand." Angell describes Johnson as an essential "link" in the chain of health information. " A link to people being healthier and receiving better health care is good accurate information," says Johnson. "I like to see myself as a public heaith teacher, albeit in a different way than many."

Terri L. R u t t e r

Tropical disease specialist Sam Telford III identifies a new disease, HGE, that resembles Lyme disease and is carried by the same tick.

HE FIRST-EVER HSPH A L U M N I D A Y

H was scheduled to coincide with commencement in 1 9 6 3 . Unfortunately, scheduling conflicts resulted in the event being postponedâ&#x20AC;&#x201D;for 34 years. It wasn't until April 2.6, 1 9 9 7 , that the School would finally host returning graduates as part of the 75th Anniversary Celebration. But few of the more than 350 alumni who attended the event complained about the delay. Most were too busy reminiscing, socializing, and enjoying the day's activities, which included roundtable discussions, a panel presentation, and a reception.

The event was organized by the School's Alumni Association, now in its 61st year of existence. Officially formed by a vote of the class of 1 9 3 7 , the Association held its first meeting in New York in October of that year. Ninety-five of the School's approximately 1,000 alumni attended-an auspicious start to an organization that has evolved over time to meet the changing needs of the School's graduates.

of the American Pubhc Health Assoc-

For the first several years, the association limited itself to organizing and hosting an annual meeting in conjunction with the annual meeting

Vlado A. Getting, D.p.H/40, who served as the HM/fe^'s editor from 1944 until 1 9 4 9 , recalls that the early days of the Alumni Association were

i a t i o n (APHA). A t t h e 1 9 4 4

however, members of the association unveiled plans to publish the hrst H^r^rJ^c/yooJo^PMMzcHeaM? BM^efz'M. The magazine, written and edited by alumni, would be the primary link to the School and each other for a majority of graduates for the next 45 years. (In 1 9 8 9 , the BM/Jefz'w was re-christened the H a r f a r J PM^/z'c HeaM? ReMew.)

Six Decades of the HSPH Alumni Association

U.N. holds Fourth World Conference on Women in Beijing.

93

meeting,

g^ ^ ^

o\ ^ ^

oriented toward socializing and professional networking. "There weren't that many schools of public health at the time, and the Harvard graduates were always out in fullforce for the APHA meetings. It was fun to get together with one another during the meeting and catch up."

involved in the day-to-day life of the School. Dumbaugh had served first on the Student Coordinating Council, from which she was directly recruited to serve on the Alumni Council, the 8- to 10-member committee that helps determine the course of the association's activities throughout the year.

Thomas F. Whayne, Sr., D.P.H.'$o, became president of the association in 1 9 5 8 and, working with then-Dean James Stevens Simmons, s.D/39, began a more concerted outreach effort to alumni. "Dean Simmons was anxious to keep alumni connected to the School," explained Whayne.

In addition to helping with the formation of regional alumni associations in the Philippines, Ceylon—now Sri Lanka—and Japan, Simmons also introduced fund-raising to the association's agenda. By the 1960s, alumni were being asked by Association President Edmund G. Zimmerer, D.P.H.'4i, to help underwrite the costs of the BM/fefv! and provide students with much-needed scholarship funds. Zimmerer also pointed to the challenge of keeping the School's large percentage of international alumni connected to the School.

"When the association first started, its focus was completely on communication among alumni, and it received a lot of administrative support from the School, like in maintaining address lists," said Dumbaugh.

"But by the time I got involved, the Alumni Association had become more peripheral to the School. The Bulletin wasn't supporting itself, Alumni Day had not gotten off the ground, and the mailing list was woefully out of date."

T w o years later, under the leadership of Zimmerer's successor, Fred Mayes, M.p.H.'^i, the association voted to establish a standing committee on the Alumni Fund and Service Program. The committee was responsible for securing, on a continual basis, the resources for an active alumni program that included a revolving emergency student loan fund. The association also began exploring the possibility of increasing its fundraising activities to support

1996

"Harvard Report on Cancer Prevention," prepared by faculty in t h e Harvard Center for Cancer Prevention, is a comprehensive, cause-by-cause u p d a t e on w h a t is known about preventing cancer.

W a J o GeHMg, D.p.H/40, /row 1944 ^roMg^ student fellowships, the newly established Henry Lee Shattuck International House, and scholarships for foreign students. ^

R A N K L. B A B B O T T , J R . , S . M L ' 5 4 ,

who served as president of the association in 1968 and 1 9 6 9 , noted that, "The Alumni Association for the School, by its nature, was different than that of a college. Graduates of the School may share a class year, but are different ages and have different professions. Yet we have the bond of being alumni, and we bump heads professionally. The Alumni Association faced the continual challenge of finding ways to keep in touch with graduates living around the globe pursuing vastly different interests."

By the time Karin A. Dumbaugh, M.H.s.'72, s . D / 7 7 , became a member of the Alumni Council in 1 9 7 2 , students at the School—like those at other institutions around the country —were becoming more vocal and

Dedication of the Fran^ois-Xavier Bagnoud Building.

One of the first tasks Dumbaugh and her colleagues tackled was the creation of the School's first Alumni Directory. "For many years, alumni records were kept at the School by staff who helped out with the association's activities, like Margaret Penrose (the long-time director of Shattuck International House) who had done a wonderful job. But over the years, addresses were lost or not updated, and the alumni list was in bad shape," said Dumbaugh.

The Alumni Association also began to focus more intensively on fundraising for student aid. One of its early fund-raising efforts relied heavily on support and assistance of the faculty. The association planned an auction to add funds to a revolving loan fund for students, particularly international students who sometimes wound up strapped for cash while awaiting funding from their home country.

Former HSPH Journalism Fellow Laurie Garrett wins t h e Pulitzer Prize for her book 7?]e Com/Tip P/apue.

"Faculty really rallied around the idea for the auction," reported Dumbaugh, "and were instrumental in its success." Dumbaugh recalls that Dean Howard Hiatt auctioned off a baking lesson, which included dinner at his house as well. Alonzo Yerby, M.p.H/48, chair of the Department of Public Health Service Administration, auctioned off a loaf of bread, a jug of wine, and a copy of the Rubaiyat, and Margaret Penrose auctioned off her famous cheesecake recipe. The auction raised enough money to keep the revolving loan program operational.

The U.S. FDA approves use of the fat-substitute Olestra, despite opposition by Nutrition Department Chair Walter Willett, who believes that the synthetic fat robs the body of essential nutrients and may increase rates of cancer.

ITU ^

ENDORSEMENT FROM

WW Dean Hiatt and the support of a significantly larger and increasingly enthusiastic alumni body, the association also completed a successful fundraising drive in 1 9 7 9 to establish a scholarship in honor of Penrose. The following year, the association organized a trip for 2.0 alumni to visit the People's Republic of China. Alumni came from across the United States and from as far away as England, Barbados, and Haiti for a tour that also included stops in Egypt, Pakistan, and Hong Kong. Proceeds from the tour benefited the council.

President Clinton signs the welfare reform bill, which effectively cuts funding to millions of impoverished mothers and children.

When Dumbaugh hnished her term as president of the association in 1 9 8 5 , the association was able to award two scholarships annually.

Moreover, regional alumni associationsâ&#x20AC;&#x201D;which held meetings and were involved in recruitment of students as well as some fundraisingâ&#x20AC;&#x201D;were in place in many parts of the United States, Australia, Asia, and Europe.

Stephen C. Schoenbaum, M.p.H.'74, got involved in fundraising activities at a phonathon, and was then recruited directly to the Alumni Council. Schoenbaum served as president from 1993 to 1 9 9 $ .

"The Global Burden of Disease" is a landmark report on the world's leading causes of death and disability cosponsored by the HSPH, WHO, and the World Bank. The 10-volume report, edited by Professor Christopher Murray, left, and Alan Lopez, analyzes the health impact of 107 major diseases and injuries in 9 different global regions.

During his tenure, the association began to explore an area of special interest for him, student diversity.

"If you look at which schools of public health are most likely to attract students from diverse racial and ethnic backgrounds from within the United States, you will see that they are the public institutions with lower costs," said Schoenbaum. To help Harvard reach a more diverse population, the association raised enough funds to establish the School's hrst minority student scholarship in 1 9 9 5 .

NE OF THE MOST NOTEWORTHY

^ ^ recent efforts of the association was the creation and annual awarding of the Alumni Award of Merit.

First bestowed in 1992., the Award of Merit recognizes graduates whose accomplishments in public health set them apart, even from the many distinguished leaders produced by the School. As a council member, Myron Allukian, Jr., M.P.H.'67, helped spearhead the creation of the award of merit. Allukian would go on to serve as association president from 1995 to 1 9 9 7 .

Responding to requests from recent graduates for help in finding jobs, the association has also worked with the School's Career Services to create the Alumni Career Advisory Network. The network now includes some 1,000 alumni, which represents

about a quarter of the alumni body.

Also under Allukian's leadership, the election of class ofhcersâ&#x20AC;&#x201D;president, vice-president, and secretaryâ&#x20AC;&#x201D;was reinstated in 1995 for each graduating class.

The success of the first two Alumni Day programs in 1 9 9 7 and 1998 confirms the fact that, while you can take the alumni out of the School, you never really take the School out of the alumni. "It's obvious that the School's graduates want to stay connected to the School.

The challenge for the association is to continue to make it easier to do so," said Allukian.

"The primary role of the Alumni Association has been, and always will be, connection and communication," adds current President Joel Finlay, M . P . H . ' 9 1 . " N e w a d v a n c e s in

communication, like e-mail and the World Wide Web, are helping us keep in touch with the School's far-flung alumni. But it is really up to the alumni to keep the momentum going, to send information in for the Class Notes section of the H a r t w J PMM;c HeaM? ReM'ew, to return to the School on alumni day, to visit or become active in regional alumni associations, and to attend the School's alumni reception at the a n n u a l APHA m e e t i n g . W e a r e

the School's best spokespeople."

MarceHa Bernard

The A!umni Award of Merit S/nce 7992, 27 gracfuafes Aat/e rece/yecf tbe /t/umn/ /) ward of Mer/f, f/re A/gAesf Aonor fAe 5c/!oo/ of Wea/fA bestows on graduates.

1998

Gretchen G. Berggren, S.M.'66 Warren L. Berggren, M.P.H.'63, D.P.H/67 Frederick T. Sai, M.P.H.'60 James Steele, M.P.H/42

1997

Paul R. Torrens, M.P.H.'62 Joan M. Altekruse, M.P.H.'65 Jaime Sepulveda, S.D.'85

1996

Abdul Rahman Al-Awadi, M.P.H/65 William J. Curran, S.M.'58 Samuel Ofosu-Amaah, M.P.H/70

1995

Dorleena A. Sammons-Posey, S.M.'59 Nevin S. Scrimshaw, M.P.H.'59 John B. Wyon, M.P.H/53

1994

Gro Harlem Brundtland, M.P.H/65 William H. Foege, M.P.H.'65 Alonzo S. Yerby, M.P.H/48

1993

James W. Curran, M.P.H/74 Jack Ditlenberg, M.P.H/78 Joseph F. Fraumeni, Jr., S.M.'65

1992

H.Jack Geiger, S.M/60 Carl E. Taylor, D.P.H.'53

1997

"Gateway to World Health: New Sciences and Strategies in Public Health," a three-day symposium staged in honor of the School's 75th Anniversary, draws key faculty, alumni, and public health experts from around the world.

Dean Harvey V. Fineberg announces that he will step down at the end of the academic year to become Provost of Harvard University. James H. Ware, Frederick Mosteller Professor of Biostatistics and Dean of Academic Affairs] is named Acting Dean of the School.

Time-line Photo Credits AP/Wide World: pages 8, 22, 30, 31, 34, 46, 53, 57, 59, 64, 72, 74, 77, 85, 91 Courtesy of Brigham and Women's Hospital, Boston: page 47.

Corbis/Bettmann: page 93 The Francis A. Countway Library of Medicine, Boston: pages 10,16,21,33,90 @1998, Betsy Cullen: page 58

Kent Dayton, HSPH: pages 43, 67A, 71 A, 87, 94, 95, 96 Harris & Ewing, Collection of the Supreme Court of the United States: page 7 Courtesy of the Harvard University Archives: page 4 Sarah Hood: page 35 NASA: pages 24, 45, 54

01998, Photodisc, Inc.: pages 17, 20, 80 Owen Franken, Stock Boston: page18 Reuters/Corbis Bettmann: pages 60, 68, 69, 78, 82 UPl/Corbis Bettmann: pages 6 , 1 3 , 1 4 , 1 9 , 23, 28,37, 38, 40,41,56A,67B, World Health Organization: page 32, 56B

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