Harvard Public Health, Fall 2012

HSPH.HARVARD.EDU

Six Cities: A Decades-Long Fight for Clean Air

Making the Case for Public Health

Why Do We Age? Surprising Revelations from a Worm

HARVARD PUBLIC HEALTH Fall 2012

The Dollars & Sense of Public Health

DEAN’S MESSAGE

Health & Wealth

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he cover story in this issue of Harvard Public Health

of life expectancy on average in the United States.

explores one of the most complicated intersections

According to the federal Centers for Disease Control and

in policymaking: the nexus of public health and the

Prevention, these advances included: the eradication of

economy. With the November U.S. elections just two

smallpox and control of other infectious diseases through

months away, voters can consider what we have learned

vaccination; improved sanitation and access to clean

about these closely linked issues.

water; improvements in food safety and nutrition; safer

One thing we know for sure: A nation’s health

workplaces; family planning; and a drop in smoking rates.

performance and economic performance can’t be

Today, different public health problems threaten

separated. On the most fundamental level, wealthier

economic gains, both in affluent and developing

nations tend to have better health conditions and

countries. Of particular concern are rising levels of

therefore healthier people. And as HSPH’s David Bloom

noncommunicable diseases, such as obesity, diabetes,

has shown, healthier people likewise promote economic

high blood pressure, heart disease, cancer, and mental

growth, in part because they are more productive and

disorders. In the U.S., three-quarters of health care dollars go to treating these chronic—and often preventable—

A nation’s health performance and economic performance can’t be separated.

diseases.

Health, of course, is an intrinsic value—an end in itself. But it is no contradiction to add that healthy people make for a healthier economy. In the U.S. and around the world, a strong and sustained investment in public health is the best policy bargain of all.

less likely to cost health care dollars. In developing countries, a 10 percent increase in life expectancy at birth is associated with a rise in economic growth of 0.3–0.4 percent a year, according to a 2001 report by the World Health Organization’s Commission on Macroeconomics and Health. Recent events in the news confirm that as countries around the world advance, they realize that creating universal health care systems nourishes long-term economic growth.

Public health, which focuses on disease prevention and health promotion, is central to an economyboosting healthy population. In the 20th century, public health advances accounted for 25 more years 2 Harvard Public Health

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

HARVARD PUBLIC HEALTH Fall 2012

COVER STORY 16 The Economy and Public Health As the election season heats up, seven HSPH experts draw surprising connections between public health and the U.S. economy.

FEATURES

DEPARTMENTS

2 Dean’s Message: Health and Wealth

Healthy people make for a healthier economy.

12 HSPH 2012 Commencement 14 Making the Case for Public Health

Q&A with HSPH professor Robert Blendon.

38 Why Do We Age? Surprising Revelations from a Worm

The School’s William Mair explores why we get frail as we get older.

25 Working the System

HSPH alumnus Anthony Chen tackles the big issues in Washington State.

4 Frontlines 9 Philanthropic Impact

28 Infographic: The Dollars and Sense of Chronic Disease

45 Continuing Professional Education Calendar 46 Alumni News 48 Faculty News

42 Arku’s Journey 30 Prevailing Winds

The Six Cities air pollution study showed that when science triumphs, the public wins.

Back Cover HSPH and the Affordable Care Act

Student Raphael Arku traded a lucrative job for a career cleaning up air and water in Ghana.

Image Credits: main image, HSPH; all others clockwise from top, William Mair; Shaw Nielsen; courtesy of Jack Spengler; Jones Adam/Photo Researchers.

FRONT LINES High Cost, Low Quality of U.S. Health Care Add to Woes of the Sick

HSPH RAISES A HEALTHY CUP TO CHEF JAMIE OLIVER Jamie Oliver—celebrity chef, TV personality, and “food revolution” activist—accepted HSPH’s Healthy Cup Award in May before an enthusiastic audience of more than 500 at the Joseph B. Martin Conference Center in Boston. “Jamie Oliver has changed the way millions of people think about the importance of healthy eating and healthy cooking,” HSPH Dean Julio Frenk said at the ceremony. “He … continues to be tremendously influential in the battle against childhood obesity, which is of critical importance to the “We need a food revolution,” Oliver told the audience. “Imagine a world where children are fed real food and educated about it. Where I knew where my meat came from and animals were treated with respect. Where children and their parents eat and garden together. Where children get clean water.

Where the biggest cause of death was not self-inflicted by food.”

world’s present and future health.”

A poll released jointly by the Robert Wood Johnson Foundation, National Public Radio, and HSPH revealed that a large majority of the U.S. general public (87 percent) considers the cost of health care to be a serious problem for the country.

The poll, entitled “Sick in America,” found that more than 40 percent of sick Americans (those requiring considerable medical care or overnight hospitalization within the past 12 months) experienced the cost of their care as a serious problem for their family’s finances. And one in six sick Americans reported that there was a time in the past 12 months when they could not get the care they needed—most often because they couldn’t afford it or because their insurers would not pay for it. In the poll, which was released in May, many sick respondents also reported problems with the quality of their care, with one in eight believing that they were given the wrong diagnosis, test, or treatment, and 26 percent feeling that their condition was not well managed.

New Study of Bee Colony Collapse Causes Buzz

LEARN MORE ONLINE Visit Harvard Public Health online at http://hsph.me/frontlines for links to press releases, news reports, videos, and the original research studies behind Frontlines stories.

4 Harvard Public Health

From top, ©Tony Rinaldo; Don Farrall/Digital Vision

One of the most widely used pesticides in agriculture and the residential environment—imidacloprid—is the likely culprit behind the sharp decline in honeybee colonies worldwide since 2006, according to a new HSPH study, led by Chensheng (Alex) Lu, HSPH associate professor of environmental exposure biology. Lu has found “convincing evidence” of the link between the pervasive pesticide and colony collapse disorder, a mysterious phenomenon in which adult bees abandon their hives. Full study results are in the Bulletin of Insectology, June 2012.

Arctic Mercury Rising as the Mercury Rises

Researchers have known that climate change and other atmospheric forces are causing dramatic increases in levels of mercury—a potent neurotoxin—in the Arctic. But now, a joint study by Harvard School of Engineering and Applied Sciences and Harvard School of Public Health (HSPH) has found that much of the mercury accumulation in the Arctic actually comes from three huge Siberian rivers— the Lena, the Ob, and the Yenisei—that flow into the Arctic Ocean. The study suggests that mercury levels in the rivers may be rising because of permafrost melting and other climate-driven changes in the landscape. Co-principal investigator Elsie Sunderland, Mark and Catherine Winkler Assistant Professor of Aquatic Science at HSPH, said, “Understanding the sources of [the potent neurotoxin] mercury to the Arctic Ocean … is key to protecting the health of northern populations.” The bad news: Global warming may prolong the problem. Full study results are in Nature Geoscience, May 20, 2012.

HIV/AIDS Patients Living Longer, Presenting New Challenges as They Age Health and social systems must better plan for the aging of the HIV epidemic, says Till Bäernighausen, HSPH associate professor of global health. That’s because antiretroviral drugs have changed the face of HIV/AIDS treatment and care: No longer an automatic death sentence, HIV/AIDS can now be managed as a chronic condition. The good news is that worldwide, “People infected with HIV … live to old ages,” says Bäernighausen. He led a team of researchers who ran national microsimulation models for the 43 countries in sub-Saharan Africa. The team found that with the scale-up of antiretroviral treatment, the number of HIVinfected people older than 50 in the region will nearly triple over the next three decades, from about 3 million in 2011 to 9 million in 2040.

HPH Editor Receives National Journalism Award Madeline Drexler, editor of Harvard Public Health, won a prestigious Sigma Delta Chi Award from the Society of Professional Journalists for an article she had published in the October 2011 issue of Good Housekeeping, entitled “Why Your Food Isn’t Safe.” The story detailed flaws in the federal food safety system. The same week the story was published, the United States Department of Agriculture announced tough new rules to prevent E. coli contamination in the meat supply—one of the measures strongly recommended in the article. Drexler received the award for Public Service in Magazine Journalism (National Circulation) at a ceremony in July at the National Press Club, in Washington, DC.

HSPH Alum William Foege Honored with Presidential Medal of Freedom Legendary public health epidemiologist William Foege, MPH ’65, has received the nation’s highest civilian honor—the 2012 Presidential Medal of Freedom. Foege’s Bob Strong/REUTERS; Leigh Vogel/WireImage

distinguished public health career has been highlighted by groundbreaking work in the 1970s to eradicate smallpox; Foege developed the vaccination strategy that ultimately broke the transmission cycle of deadly infection. Foege served as director of the U.S. Centers for Disease Control and Prevention from 1977 to 1983. As director of the Carter Center, he has worked for universal basic immunization for children and for the elimination of river blindness and Guinea worm, two diseases that plague Africa. He is a senior fellow at the Bill & Melinda Gates Foundation, a professor emeritus at the Rollins School of Public Health at Emory University, and an affiliated professor of epidemiology at the University of Washington School of Public Health.

5 Fall 2012

William Foege receives a Presidential Medal of Freedom from President Barack Obama in the East Room of the White House on May 29, 2012 in Washington, DC.

FRONT LINES

HSPH Gathers World Health Ministers

URBAN ENVIRONMENTS DEPRESSING? JUST ADD TREES

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ixteen of the world’s ministers of health gath-

It’s common wisdom that block after block of unrelieved streetscape can be oppressive. With backgrounds in architecture, HSPH visiting scientist Morteza Asgarzadeh and research scientist Anne Lusk, both from the Department of Nutrition, teamed up with architectural researchers from the University of Tokyo to explore the psychological effects of high-rise urban environments. Studying the influences of trees, buildings, and sky on emotions, they found that the distance between a viewer and high-rise buildings, as well as how large a solid object appears, influence stress and depression in street observers. They also showed that trees have a measurable mitigating effect on urban “oppressiveness.” The scientists went on to develop a mathematical tool for urban planners that gauges environmental cheerlessness. Full study results appear in “Measuring Oppressiveness of Streetscapes,” Landscape and Urban Planning, July 2012.

ered at the Harvard Kennedy School (HKS) in June for the Harvard Ministerial Health Lead-

ers’ Forum, sponsored by the Ministerial Leadership in Health Program, an initiative launched by HSPH and HKS in collaboration with the Children’s Investment Fund Foundation. With the forum focused on improving the health, growth, and development of the world’s children, HSPH Dean Julio Frenk—Mexico’s health minister from 2000 to 2006—told participants that this is a time of opportunity to make gains in child and maternal health. Frenk emphasized that the 2015 deadline for achieving the United Nations’ Millennium Development Goals is fast approaching, and that many nations not currently on track to reach their goals could be encouraged to renew their efforts.

Frenk advocated focusing on health priorities—smallpox eradication being the greatest historical example of international coordination—to drive future improvements in the health care system.

OUR BODIES, OUR BUGS:

Microbial Genes Outnumber Human Genes 100 to 1

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6 Harvard Public Health

D-BASE/Getty Images; Illustration, Shaw Nielsen

ew studies led by HSPH researchers in the Human Microbiome Project (HMP) have helped identify and analyze the vast human “microbiome”—the trillions of single-celled microbes and millions of microbial genes that exist inside the human body. Researchers are studying the role that these microbes—bacteria, viruses, and fungi that live in the gut, mouth, skin, and elsewhere—play in normal bodily functions, such as development or immunity, as well as in disease. In a healthy individual, the microbial metagenome, or total complement of genes, can carry about 100 times as many genes as does our own human genome. The HMP, a consortium of 250 members from 80 research institutions, estimates that more than 10,000 microbial species live in humans, including several opportunistic pathogens—microorganisms that typically coexist harmlessly with the rest of the microbiome and their human hosts, but can trigger disease under the wrong conditions. HMP research appears in Nature, Nature Methods, and several Public Library of Science (PLoS) publications.

Offthe Starting a Revolution CUFF

WINSTON HIDE ASSOCIATE PROFESSOR OF BIOINFORMATICS AND COMPUTATIONAL BIOLOGY

Q. “

Last May, you resigned from the editorial board of Genomics, protesting the exorbitant subscription fees that scientific journals charge. Researchers and institutions in poor nations often cannot afford to pay and are effectively shut out of new science. You called for a system of open-access scientific publications. What’s been the fallout since your resignation?

For one thing, I was ranked in the top thousand tweets in Twitter for a couple of days, based upon this

A.

announcement. Why did it go viral? Because my resignation got to the basic issue: Why must scientists, by virtue of the fact that they were born in the wrong place, be excluded from doing science the way that

colleagues in the West do it? Why must they put out their hats and beg by email to get PDFs from authors?

They will never be able to compete intellectually if they are artificially excluded.

I didn’t resign with a marketing strategy or a political agenda in mind. I resigned because my heart told me this practice was wrong. The only way we’re going to change the system is through the people who supply the publishers: the researchers who submit papers, the reviewers, the journal editors. We also need to say to governments in the West, which are funding access to these journals: You are perpetuating the scientific

”

divide between rich and not-rich nations. ©Tony Rinaldo

LEARN MORE ONLINE Visit Harvard Public Health online at http://hsph.me/frontlines for links to press releases, news reports, videos, and the original research studies behind Frontlines stories.

7 Fall 2012

FRONT LINES

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LEARNING TO LEAD

aking a difference in public health requires more than knowledge and idealism. It also requires finesse in communication, conflict resolution, negotiation, and mobilizing strangers. In short, it takes an expertise not widely recognized in public health education: leadership.

“If we want people to be agents of change, we have to invest in making them so,” says Jack Spengler, Akira Yamaguchi Professor of Environmental Health and Human Habitation at Harvard School of Public Health. “We don’t do this in public health—instead, we teach students to be statisticians, epidemiologists, lab analysts, exposure scientists. Look at how we failed in climate change, where the message is one of fear. Look at the message we constantly

the capacity to be a leader? And what holds you back?’”

Students are immersed in theory through the center’s new 10-credit interdisciplinary concentration in Public Health Leadership. They are also learning from experienced leaders in the division’s “Decision-Making: Voices from the Field” seminar series, now in its third year.

STANDING UP TO AUTHORITIES

Meanwhile, a series of noncredit seminars and workshops piloted by the center last year and officially launched this fall is aimed at the subjective and reflective side of leadership development—a critical component of training, says McDonough. “When you have to stand up and disagree

“If we want people to be agents of change, we have to invest in making them so.”

Jack Spengler, Akira Yamaguchi Professor of Environmental Health and Human Habitation deliver about food, carcinogens, lifestyle: it’s all negative.

We can do better.”

This fall, new and expanded efforts at the School are filling that gap.

AN INNER JOURNEY

Amy Roeder is assistant editor of Harvard Public Health.

8 Harvard Public Health

Aubrey LaMedica/HSPH

“There are three main approaches to teaching leadership,” says John McDonough, professor of the practice of public health and director of the Center for Public Health Leadership, part of the School’s Division of Policy Translation and Leadership Development. “One way is to teach theory.

Another is to expose students to leaders. And the third way is to help students figure out their inner journey, to ask them, ‘What is it in you that strengthens you and gives you

with someone, maybe someone who has more authority than you, how do you respond both intellectually and emotionally to that kind of challenge?” he asks. “We give students the opportunity to try out difficult situations and gain instantaneous and long-term self-reflection.”

“Students want to make a difference,” says Martin Reidy, SM ’13, co-chair of the division’s student committee on leadership development. “But there are skills they might not have, like learning how to bring people with different beliefs than yours over to your side. Most people don’t understand what public health is. You have to figure out how to communicate in a way that helps people grasp how what we’re trying to do will benefit them.”

PHILANTHROPIC IMPACT

LIVES TRANSFORMED On May 1, 2012, Harvard School of Public Health launched the Harvard Humanitarian Academy.

From left to right: Professor Michael VanRooyen, Jonathan Lavine and Jeannie Lavine, and

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Dean Julio Frenk.

his month, as in every September for nearly the last century, a new group of students walks through the doors of Harvard School of Public Health. Like the generations before them, they enter with hope, excitement, maybe a touch of fear—and with plans to change the world.

There’s no better place for them to do so than at HSPH. From the classroom studies on Huntington Avenue to hands-on lessons in developing countries, our students transform the health of millions. And when people’s health improves through disease prevention and health promotion, so, too, do the economies of their countries. As Dean Julio Frenk says, “Investing in health is not only the right thing to do on ethical grounds, but it is also the smart thing to do in order to achieve economic prosperity.” As our cover story, “The Dollars and Sense of Public Health,” shows, public health is a critical economic engine.

Here at HSPH, philanthropy is the financial fuel that powers everything HSPH accomplishes. Without the generosity of all of our donors—from the 1,400-plus alumni who supported us this year to the largest of foundations—our work simply could not happen. One case in point: With their gift of $5 million, Jonathan and Jeannie Lavine have established the Lavine Family Humanitarian Studies Initiative, as part of the new Humanitarian Academy within the Harvard Humanitarian Initiative (HHI).

Directed by HSPH professor of global health and population Michael VanRooyen, HHI advances the science and practice of humanitarian response worldwide. The Lavines’ transformative gift has enabled the creation of a first-of-its-kind global resource for educating and training leaders to respond to crises caused by war, genocide, and natural disasters.

I am delighted to report that this year, our contributors have been more generous than ever, supporting the School with a landmark total of $63.7 million. To all of you who have given your time, talent, and treasure, know that you are making an extraordinary difference in people’s lives—here on campus and throughout the world. I cannot thank you enough.

Ellie Starr, Vice Dean for External Relations

9 Fall 2012

Kent Dayton/HSPH

PHILANTHROPIC IMPACT

New Scholarship Supports Doctoral Students in Nutrition, Honors Willett

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rajna—a Sanskrit word that conveys ultimate wisdom—is the name of a new scholarship for doctoral students in the HSPH Department of Nutrition that was established to recognize the leadership and distinction of the department’s chair, Walter Willett. The first Prajna Scholar— Neha Khandpur of India—envisions a career focused on obesity prevention in disadvantaged population groups.

The new Prajna Chair’s Scholarship in Public Health Nutrition, created through an anonymous gift of $1.75 million, will provide opportunities for highly accomplished and motivated but financially underprivileged students to study at HSPH. The donors hope that, in particular, the scholarship benefits students from economically challenged countries.

“This scholarship will afford me the academic freedom to really think about my education and career in

Neha Khandpur, of India, HSPH’s first Prajna Scholar

public health nutrition and to really find my calling,” said Khandpur, who has worked in India as a nutrition and

tions to public health nutrition. Likewise, the donors hope

fitness consultant and for the Public Health Foundation

that the scholarship will encourage its recipients to merge

of India, which propelled her desire to influence nutri-

intellect and practice together to compassionately advance

tion not just one-on-one but in populations. “It’s really

the welfare of humanity, and to become leaders in the field

exciting.”

of public health nutrition, like Willett. They also hope their gift will inspire others to support both students and

“Neha is a very good fit for this scholarship,” said Willett. “She already has quite a bit of experience working in India on nutrition programs and she’s planning to return

faculty at HSPH. Willett said that now, more than ever, support of stu-

to India to work in this area. The scholarship underscores

dents and faculty is critical because of cutbacks in HSPH’s

what our department is all about—working at the very cut-

major funding source, the National Institutes of Health.

ting edge of science, but also applying this knowledge to

“If someone wants to give to a worthy cause, supporting

solve real problems of real people in the real world.”

a doctoral student is probably one of the very best things

The word Prajna (pronounced Pra´-gyia) refers to

they can do,” Willett said. “It’s investing in people who, for decades in the future, will make a real difference in the

alone, but includes insight from experience and under-

world. The multiplication effect is huge.”

standing gained through engagement with the world. The donors chose this word because it aptly describes Willett, whose wisdom and insight has fueled his major contribu-

10 Harvard Public Health

Aubrey LaMedica/HSPH

wisdom that cannot be reached by developing intellect

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Transformative Education for Public Health Leaders

iller infections. A dramatic rise in

toward competencies in high-level

third-year internship experience that

chronic diseases. Environmental

policy analysis and problem-solving

serves as the capstone to the degree.

emergencies. Unequal access to medi-

leadership,” he said. “This gift will

cal care. These problems—just a few of

enable us to continue as the leading

expected to sustain already estab-

the daunting public health issues facing

school of public health—first in quality

lished leaders at various points in their

the world today—demand not only

as well as first in our capacity to shape

careers. For current leaders, HSPH has

wide-ranging expertise, but also in-

the future.”

already initiated a Ministerial Leadership

spired leadership. To help future public

“We have followed with admira-

The Leadership Incubator is also

in Health Program, an intensive five-day

health leaders meet this challenge,

tion the work of the School for more

campus-based program for ministers of

a $5 million gift has been made to

than two decades, and this initiative

health, which is followed by year-long

Harvard School of Public Health to fund

is one of the most exciting things that

support from experienced public health

a “Leadership Incubator for Strengthen-

we have seen during this period,” the

experts and HSPH faculty. Meanwhile,

ing Health Systems.” The gift is a key

donors said. “It speaks to our deep

leaders who have recently held high-

component of the “Roadmap to 2013,”

belief in the power of young people—

level public health positions can spend

a comprehensive review of HSPH’s

in particular, this generation of young

time on campus as “Senior Leadership

educational strategy, which is being

people—to change the world.”

Fellows,” sharing expertise with students

undertaken as the School approaches its centennial in fall 2013.

The Leadership Incubator for

and project work with faculty members.

IMMERSIVE EDUCATION

And a new joint initiative with Harvard

A key component of the gift supports

Business School will give advanced

Strengthening Health Systems is ex-

students at all levels of experience

leaders the chance to study major social

pected to be supported by an anony-

and creates opportunities for them to

problems that shape health.

mous gift of $5 million—the largest

learn from each other. Another unique

gift ever made to HSPH in support of

and important part of the gift supports

PRIMED TO MAKE AN IMPACT

education.

faculty members’ efforts to work with

“HSPH’s new Leadership Incubator will

alumni and other public health leaders

provide the impetus for a paradigm

BREAKING THE MOLD

to create state-of-the-art curricula, new

shift in educating entrepreneurial public

According to Dean Julio Frenk, the

teaching methods, technology en-

health students—both young and old,

incubator will foster changes in educa-

hanced learning, and an immersive and

less experienced and more—who will

tion that will “break the mold,” push-

life-changing educational experience

be primed to make the greatest pos-

ing the traditional discipline-based

for professional degree students.

sible impact on the health challenges of

boundaries of academia, research,

Under a proposal to redesign the

the 21st century,” said Ian Lapp, associ-

and public health. It will encourage a

DrPH degree, for example, 25 out-

ate dean for strategic educational initia-

greater focus in coursework on the

standing students, beginning in 2014,

tives. “We are extremely grateful for this

importance of leadership and on the

will be named each year as “Centenni-

historic gift, which will enable us to live

complexities—political, economic, and

al Fellows”; 10 will be supported by the

out the spirit of our centennial celebra-

social—of achieving global improve-

new gift. Students will complete two

tion by beginning our second century

ments in public health. “A new doctor

years of coursework, bolstered by case

with innovations in the education of

of public health (DrPH) degree that we

studies, crisis simulations, and field

today’s and tomorrow’s leaders.”

envision, for example, will be oriented

experience, followed by an innovative

11 Fall 2012

HSPH Commencement speaker alumnus Gerald Chan, SM ’75, SD ’79

Commencement FUTURE PUBLIC HEALTH LEADERS WILL “MOVE BETWEEN WORLDS,” GRADUATES TOLD Harvard School of Public Health Dean Julio Frenk encouraged this year’s graduates to look beyond “tightly defined career paths” as “the only routes to personal and professional achievement.” “It is vital,” he said, “that we have people educated in science and public health who see opportunities where others see barriers—who are comfortable moving easily between the worlds of government, business, civil society, and academia, to improve people’s health.”

Frenk noted that the day’s Commencement speaker, HSPH alumnus Gerald Chan, SM ’75, SD ’79, went on to a “bold, nontraditional career path” as an entrepreneur and innovator, but has continued to work on improving people’s health. Chan founded Morningside Group, which has provided support for companies and technologies that benefit the public’s health. Chan studied medical radiological physics and radiation biology while at HSPH. Opposite are some of the remarks Chan offered at Commencement on May 24. Full coverage of the day, including photo slide shows and complete transcripts of remarks by Chan, student speaker Kevin Koo, AB’ 07, and HSPH Dean Julio Frenk, can be found at http://hsph.me/commencement2012.

12 Harvard Public Health

HSPH 2012 COMMENCEMENT

BY THE NUMBERS

Highlights from the remarks of Gerald Chan at the School’s 2012 Commencement A BEAUTIFUL MIND New knowledge is now being produced at a breakneck speed and is readily accessible to anyone with connection to the Internet. A learned person can no longer be defined merely as one who is in possession of knowledge, or perhaps more accurately, and somewhat derogatorily, one who is in possession of information. Today, whether a person can be considered a learned person hinges on what he does with the knowledge he has. A beautiful mind is not beautiful by virtue of its storage capacity, nor even what has been stored in it. A beautiful mind is a mind with beautiful ideas.

A SOUND BITE SOCIETY I see in the communications of today’s society … an impoverishment of ideas. Politicians are known by their sound bites. Messages with 140 characters or less encourage the communication of the trivial. Tweets are great for knowing where your friends are having dinner tonight, but they are not conducive to the generation nor to the communication of ideas … Being flooded with minutiae of everyday life subverts our intellectual life by luring us into, and holding us captive in, the present, in what is, such that we have no time and no energy left to consider what might be, or what can be, or what should be. The peril we face in today’s society is that we unwittingly become mere pragmatists, and soon, exhausted realists.

THE (NEW) THREE Rs Enrich your lives with ideas, even big ideas. Read, reflect, and ruminate (the new Three Rs). Observe and deduce, postulate and verify, look for connections. Be curious, be open-minded, reframe problems rather than just looking for answers, have the courage to differ from conventional wisdom, do not dismiss your intuition. Discuss, debate, and discourse with others. Look into history, watch current affairs; study the sacred texts, observe humanity. These are the mental habits conducive to the spontaneous generation of ideas. A life is rich when it is rich with ideas.

Students from 57 countries, 34 U.S. states, and the District of Columbia received degrees at Harvard School of Public Health’s 2012 Commencement ceremonies on May 24. Six out of every 10 members of the Class of 2012 were women.

A TOTAL OF 515 DEGREES WERE AWARDED:

25 Doctors of Philosophy 1 Doctor of Public Health 53 Doctors of Science 11 Masters of Arts 272 Masters of Public Health 153 Masters of Science AWARDS

At a reception the evening before Commencement, students, faculty members, and staff members were selected for special recognition.

STUDENT AWARDS Albert Schweitzer Award Monica Bharel, MPH ’12 Dr. Fang-Ching Sun Award Joshua Lee Glasser, SM ’12 Edgar Haber Award In Biological Sciences Jessica Lucas Yecies, PhD ’12 Gareth M. Green Award Jessica Terese Celentano, SM ’12; Alex Urban Cox, SM ’12; Joseph David Lippi, SM ’12 James H. Ware Award For Achievement In The Practice Of Public Health Atena Asiaii, MPH ’12 Robert B. Reed Prize For Excellence In Biostatistical Science Matey Neykov Neykov, MA ’12, PhD ’16 HSPH Student Recognition Award Rosemary Wyber, MPH ’12 Teaching Assistant Award Caitlin Eicher Caspi, SM ’08, SD ’12; Ankur Pandya, PhD ’12; Pamela Marie Rist, SM ’09, SD ’12; Kristin Woody Scott, PhD ’16 Uwe Brinkman Memorial Travel Award Ca Eul Lim, PhD ’16

Suzanne Camarata

To watch all of the commencement speeches, go to: www.hsph.harvard.edu/multimedia/video/2012/ commencement.

13 Fall 2012

The Dollars & Sense of Public Health | SPECIAL REPORT

Making the Case for Public Health Robert Blendon rewrites the political script.

Q&A

Q: Y ou published a fascinating paper in 2010, “Americans’

For nearly 30 years, Robert

Conflicting Views of the Public Health System.” One

Blendon, Senior Associate Dean for

of your findings was that while most Americans favor

Policy Translation and Leadership

public health saves money in the long run, they oppose

spending more on public health in general, and believe specific interventions and programs. What’s behind that

Development, has been polling

contradiction?

Americans about their views of

A: O ur polling suggests that people have a great deal of re-

public health, health care, and

spect and support for what we think of as “traditional public

other related hot-button issues.

ing people during disasters and emergencies, basic educa-

Polls on the eve of the 2004 and

diabetes, even conditions such as obesity. Americans aren’t

health”: communicable diseases, foodborne outbreaks, helption. The conflict is around chronic illnesses—heart disease, convinced that public health measures alter those.

2008 presidential elections found Americans deeply divided on these

Q: B ut chronic diseases are the top cause of death and disability in the United States. Three-quarters of the health care budget goes toward treating those conditions.

issues. Today, with an uncertain

Maybe people don’t understand the logic of prevention?

economy the most pressing concern

A: I f you want to convince the public, you can’t just cite some

in voters’ minds, Blendon spoke

gross economic number: If I invest $8 now, I’ll get $12 later.

with Harvard Public Health

credible. You have to say: Studies show that if we do this in-

editor Madeline Drexler about the

of cases within this time frame. Or: If we launch this program,

current politics of public health in

cancer in Kentucky.

America.

You have to be very specific before anybody sees it as tervention, then type 2 diabetes will go down by this number there will be this many fewer women diagnosed with breast The more specific you get, the more the public support goes up. But people in public health are generalists. They talk about abstract things like “prevention” and “education.”

Those are not budgetary winners.

14 Harvard Public Health

Q: I n politics, the timeline is short. In public health, the timeline is usually long. Does that also work against public health in our polarized, individualized, attention-deficit culture?

A: I n public health, we talk about society. But actually, I’ve never interviewed a voter who has talked about society. Voters talk about the federal government, state government, local government, their insurance plan, their Medicare. But society? Never.

“ After the big hurricanes in 2005, a lot of government agencies were roaming around. Only one group did not have rain slickers with the name of their agency on them: the Centers for Disease Control and Prevention (CDC).

The CDC was not interested in seeking attention for itself, but the fact is you have to do that if you want the appropriation.”

Q: S o how should public health professionals make their case?

A: Y ou get long-term confidence from the public if you do things for people in the short term. Every time there’s an outbreak, you’re there. If people say, “Who are you?,” you say, “I’m the Commissioner of Public Health.” With that one line, you show that you were there to save people’s lives and that you give really solid advice. Plant that idea in people’s heads: “Public health. Working to save your life. Gave sensible advice.”

Q: I sn’t that the message that’s conveyed today?

A: N o. I’ve done many briefings for public health officials. They say, ‘Wow, you’re right. I get it.’ They understand the concept—but their training is such they cannot stop talking in abstract terms. So they testify before lawmakers: ‘We’re launching a new education initiative around noncommunicable diseases.’ Later, they call me and complain, ‘The state legislature cut our budget by one-half.’”

Q: A re you saying that public health has a marketing problem?

A: A bsolutely. We’re living in a world where people believe in smaller government and lower taxes.

So you have to convince people that there are interventions that can actually save their lives.

After the big hurricanes in 2005, a lot of government agencies were roaming around. Only

one group did not have rain slickers with the name of their agency on them: the Centers for Disease Control and Prevention (CDC). Their jackets and hats were blank. Everybody else’s said Coast Guard, State Police, this and that. A CDC employee told me, ‘We were there just to help the state officials. No point seeking any attention for ourselves.’ I said, ‘Well, do you want the appropriation?’ In this world, you have to be targeted and directive.”

15 Fall 2012

—Robert Blendon

The Dollars & Sense of Public Health | SPECIAL REPORT

W

ith the November 2012 elections on the horizon, Americans surveyed in national polls consistently rank the economy as their number one concern. Public health professionals can have a big impact on this ballot-box issue. More than 17 percent of the U.S. Gross Domestic Product is spent on health care—in many cases, for conditions that could be prevented or better managed with public health interventions. Yet only 3 percent of the government’s health budget is spent on public health measures. A 2012 study in Health Affairs notes that since 1960, U.S. health care spending has grown five times faster than GDP. Why do these numbers matter?

First, a healthier workforce is a more productive workforce. According to an April 2012 report from the Institute of Medicine (IOM), the indirect costs associated with preventable chronic diseases—costs related to worker productivity as well as the resulting fiscal drag on the nation’s economic output—may exceed $1 trillion per year.

A 2007 study from the Milken Institute found that when unhealthy workers show up on the job, as many must to survive financially, the effects of their lower productivity on the nation’s economic health are immense: in dollar value, several times greater than the business losses accrued when employees take actual sick days. Avoidable illness also diverts the economic productivity of parents and other caregivers.

Public Health & the U.S. Economy

Second, the costs of health care are built into the price of every American-built product and service. And the per capita cost of health care in the U.S. is higher than in any nation in the world. If the U.S. can reduce the costs of health care over the long term—by preventing diseases that require costly medical procedures to treat and by making our existing health systems more efficient—the costs of American products can become more competitive in a global marketplace.

Today, U.S. per capita health expenditures are more than twice the average of other countries in the Organization of Economic Cooperation and Development. The IOM estimates that cutting the prevalence of adult obesity by 50 percent—roughly the same reduction across the population as was achieved through public health’s multipronged attack on smoking in the late 20th century—could cut annual U.S. medical care expenditures by $58 billion.

Put simply, effective public health measures, including those aimed at improving health systems, have the potential to be economic engines. But these engines have been chronically underfunded and have received too little attention from lawmakers and voters. Michael Blanding, a Boston-based journalist and author, asked seven Harvard School of Public Health experts, from widely ranging fields, to assess public health’s vital but often overlooked role in the American economy. Here’s what they told him.

continued

How the next U.S. president can stack the deck in favor of people’s health and wealth in 2013 17 Fall 2012

The Dollars & Sense of Public Health | SPECIAL REPORT

STOP SPENDING Government Funds to Promote Obesity

All we have to do to fix this is apply the same criteria, or similar criteria, to SNAP purchases that we already WALT WILLETT Chair, Department of Nutrition

have for the federal WIC program (Women, Infants and Children program), which essentially allows purchases

The obesity epidemic has huge economic consequences,

only for healthy foods. That policy would cost virtu-

and we have not even begun to pay the full cost. There

ally nothing, but it would transform the food supply and

is a generation of children today who have diabetes or

dramatically improve the health and wellbeing of SNAP

prediabetes, and they are just coming to the age when they

recipients. Little stores and bodegas that only stock junk

will start developing heart disease and kidney failure, and

now would start carrying healthy foods, the cost would

need amputations as well as treatment for sight loss. These

come down because of the greater volume of healthy alter-

conditions will cause enormous costs in the future, even if

natives, and these foods would also become available for

we arrest obesity at the present levels.

those not receiving SNAP benefits.

The federal SNAP program (Supplemental Nutrition

We are talking about doing something that is cost

Assistance Program, formerly called “food stamps”) allows

neutral but would produce not just better health, but also

recipients to use SNAP dollars for any kind of food. As a

economic benefits in the medium and long term. How? If

result, SNAP serves as a funnel for nearly $80 billion a year

you change what people eat—and perhaps return physical

of taxpayer money to the junk food industry. This industry

education to our nation’s schools at the same time—within

produces the foods most readily available in low-income

months, children’s weight and incidence of diabetes will go

neighborhoods—a lot of soda and lower-cost foods loaded

down. Their parents’ weight will decline as well. Within a

with calories and refined starches. People on the SNAP

year or two, there will be important medical cost savings.

program are more obese, have more metabolic syndrome,

Long-term health costs will decline as fewer people

and have more cardiac risk factors than people not on

develop diabetes, and the cost of healthy food will drop for

SNAP, adjusted for income. And their health care costs will

all of us.

be higher, which ends up costing taxpayers even more.

18 Harvard Public Health

PREVENT Duplication, COORDINATE Care “ Concepts like the patientcentered medical home have the potential to reduce waste from overuse and duplication of medical tests and services, and also increase the delivery of high-value preventive care.”

MEREDITH ROSENTHAL Professor of Health Economics and Policy

What really matters to health economists is value.

Health care is a huge part of our national economy, and our Medicare and Medicaid programs represent the most important spending categories in the national budget. But our health care system is subject to market failures, so some of that spending does not generate improved health.

We are wasting money in health care that we could be spending on education, roads, and other goods and services

able for coordinating any care that may be needed across

that we value as private citizens.

specialists, hospitals, home health agencies, and nursing

So improvements in this area, particularly reforms to

homes, as well as care provided by community-based

health insurance and delivery systems, have an important

services and the patient’s loved ones.

role to play in balancing the federal budget and in fixing

Concepts like the patient-centered medical home have

the economy as a whole.

the potential to reduce waste from overuse and duplication

One critical area for reform is primary care. Without

of medical tests and services, and also increase the delivery

robust primary care, lots of people—especially patients

of high-value preventive care. The result is a more efficient

with complex needs—are getting poorly coordinated care.

and effective, and less costly, system designed to keep patients healthy, rather than respond to illness. continued

The health care delivery system has been ineffective at managing these patients, because as soon as they leave the doctor’s office, the medical system disengages.

That’s why the concept of patient-centered medical Kent Dayton/HSPH

homes that we are studying is so important. In this model, insurers pay primary care providers a fixed amount for each patient every month, whether the patient sees the doctor once a year or every week. The provider is account-

19 Fall 2012

The Dollars & Sense of Public Health | SPECIAL REPORT

SPEND MORE to Reduce Risk NORMAN DANIELS Mary B. Saltonstall Professor of Population Ethics and Professor of Ethics and Population Health

There is vast evidence suggesting that as important as medical care may be, risk reduction—particularly public health measures that reduce the chances people will suffer adverse health conditions—has the greatest impact on people’s health. The return on investment from these

When legislators look for something to cut in the

measures is not always economic, but if we look carefully at

budget, they cut something that has no visible effects.

what improves the health of large numbers of people, we’re

If you stop investing in anti-tobacco campaigns, you don’t

going to place considerable value on public health initiatives.

necessarily see more illness right away—it might take a

A well-known Centers for Disease Control and Prevention

long time to appear. But private markets don’t produce

(CDC) report noted that people in the U.S. increased their

public goods like clean water or clean air, which everybody

average life expectancy by 30 years in the 20th century.

draws on. If you don’t believe that, just look at the rates

When the CDC listed the major drivers of that increase,

of diarrheal disease in countries that don’t have sanitary

most of them were public health initiatives: clean water,

conditions.

motor vehicle safety, vaccine programs, occupational safety programs, smoking cessation programs, and the like.

Because the benefits of risk reduction programs like these are often invisible, there is an obstacle to investment

“ Private markets don’t produce public goods like clean water or clean air, which everybody draws on.” in public health. When people are healthy, they rarely attribute their health to a specific action taken by government. They view it as their constitution or their lifestyle or But if they’re sick, it’s highly visible and they demand to be treated. The visibility of that need creates enormous pressure to heavily invest in medicine, rather than in public health.

20 Harvard Public Health

Kent Dayton/HSPH

their luck.

virus that causes cervical cancer, human papillomavirus, then guidelines may well shift toward even less frequent screening.

Intensive care unit treatment for patients with certain fatal conditions, or extra diagnostic tests such as MRI, CT scans, and PET scans, are expensive; for many patients who don’t have clear indications of a disease, you often get very small gains. In these scenarios, you’re talking about cost-effectiveness ratios of hundreds of thousands of dollars per quality-adjusted life-year gained.

Identify What is COST EFFECTIVE MILTON WEINSTEIN Henry J. Kaiser Professor of Health Policy and Management

We’re spending more than one-sixth of our national income on medical care. We’ve already reached the point of diminishing returns in some areas of medical care, but we can still see very good returns for many medical and public health interventions that are currently underutilized.

If you want to get more health for the money, then reallocate resources from some of the things that are done in medical care that are not cost effective and use that money for underutilized, cost-effective programs, including both

How do we persuade the American people that more

medical and public health programs that aren’t being done

care isn’t necessarily better care? It’s hard. People view

enough.

medical care as an entitlement: If I’m sick, I should get the

What does this mean on a practical level? We need to

best available medical technology. A first step is to show

convince doctors and patients that women don’t need a

that we can get more value for the money we’re already

Kent Dayton/HSPH

Pap smear every year if they have had three normal Pap

spending—but that will mean doing more of some things

smear tests. Doing a Pap smear once every three years is extremely cost effective, but doing it every year adds about

and less of others.

continued

$800,000 per life-year gained across the population. If most girls and young women are vaccinated against the

“ We can get more value for the money we’re already spending—but that will mean doing more of some things and less of others.”

21 Fall 2012

The Dollars & Sense of Public Health | SPECIAL REPORT

FOCUS ON VALUE not just price KATE BAICKER Professor of Health Economics

The key is not spending less, but improving the value delivered through our health care system. Lots of interventions that are cost effective don’t actually save money. For example: smoking cessation programs might be costly, because smokers who die before the age of 65 then don’t collect Social Security benefits and Medicare. If we just want to save money, we could hand out cigarettes. But that’s wildly inconsistent with public health goals.

Our focus should be on producing health at a reasonable price, understanding that only a very small subset of things actually improve health and are cheaper than free.

The relationship between health insurance and the labor market is important because the vast majority

of post–World War II wage controls that limited increases in wages but not in benefits, and the fact that employer contributions to health insurance aren’t taxed. This tax treatment of health insurance favors those who get health insurance through an employer instead of buying it on their own, and favors more generous health insurance relative to wages and other benefits.

There is thus a direct connection between health insurance premiums and wages: When the cost of providing health insurance to workers goes up, that leaves less money for things like wages and other benefits that come with employment. When health insurance premiums rise more

of private insurance in the U.S. is delivered through employer-sponsored insurance plans. That is largely a relic

quickly, workers’ wages rise more slowly and some workers are at higher risk of being laid off.

And what drives health insurance premiums? In large part, it’s the cost of health care.

So it’s clearly good for the economy when we can improve the productivity of the health care sector—or any other sector. But it is also important to remember that any effects improving health care delivery may have on economic growth are second-order relative to the effect on improving health itself.

22 Harvard Public Health

Kent Dayton/HSPH

“ The key is not spending less, but improving the value delivered through our health care system.

If we want to save money, we could hand out cigarettes.”

INVEST NOW … or pay later “ The payoff for public health investments is extraordinary in terms of lifetime health status and averting the need for costly interventions at the later stages of life. But it is difficult to persuade governments or individuals to pay for something when the payoff is not immmediate.”

DEBORAH ALLEN, SM ’80, SM ’86, SD ’98 Director, Child, Adolescent and Family Health Boston Public Health Commission

In our economic system, payback comes when you sell something expensive to a captive market. You have that in health care, when you sell high-cost drugs, medical services, and equipment.

But public health promotes the opposite: Let’s invest now for a benefit that may not emerge for many years. Let’s create the conditions for healthy birth, healthy infancy, and healthy childhood. The payoff is extraordinary in terms of lifetime health status and averting the need for extraordinarily costly, often ineffective intervention at the later stages of life. It also creates a population that has a much higher quality of life. But it is more difficult to persuade governments or individuals to pay for something for which the payoff is not immediate.

Adverse health exposures for fetuses in utero or children in the early years of life can cause lifelong problems.

It could be a mother inhaling toxic chemicals where she works. It could be maternal stress associated with poverty and racism, which causes her fetus to be exposed to toxic levels of the stress hormone cortisol. Exposures like these lead to disproportionate levels of preterm birth and low birth weight. And even if there is no visible impairment, We have to ensure that families have the internal

the child is invisibly vulnerable and will have an elevated Aubrey LaMedica/HSPH

lifetime risk of asthma, cardiovascular disease, diabetes,

resources to raise kids, but also that families live in

and hypertension.

communities where there’s access to exercise and good

When you invest early in prevention, and a healthy

food. These are not what people traditionally think of as

full-term baby grows into a healthy child, then you prevent

health interventions—but they are the things that shape

not only chronic medical problems, but also cognitive and

lifetime health.

behavioral impacts.

23 Fall 2012

continued

The Dollars & Sense of Public Health | SPECIAL REPORT

Treat HEALTH as the Nation’s number one ASSET DAVID BLOOM Clarence James Gamble Professor of Economics and Demography

Another bridge between health and the economy is education. Unhealthy children may enter school with physical and cognitive disadvantages, miss more days of school, attend school for fewer years, and learn less when they’re in school. By contrast, healthy children are more likely to be able to take advantage of whatever education is available to them—and a good education has profound economic consequences throughout an individual’s life. These consequences include a higher starting wage and larger salary increases over the course of one’s working life—earnings that ripple out into the larger economy.

Human health is fundamentally a national asset, which means that spending on the promotion and protection of There are many links between health and the economy.

We’ve known for a long time that richer nations generally have better overall health conditions than do poorer nations—and that, within a country, more affluent individuals have, on average, better health than do poorer individuals. This association has long been thought to reflect a causal link running from income to health—which makes sense for a variety of reasons, including simply that richer countries can afford to spend more on health care.

But new thinking and evidence—much of it pioneered at HSPH—shows that cause and effect also flow in the other direction: A healthy population spurs economic

health is more like a fruitful investment than a consumption expenditure. A 2011 study on the global economic burden of noncommunicable diseases estimated that the five most serious conditions will cost $47 trillion in lost output worldwide over the next two decades. In the U.S., reducing heart disease and cancer alone could save trillions of dollars over that time frame. Investments in public health measures that can avert these diseases (and frequently cost less than treatment) or measures that can better manage these diseases if they do strike, are an essential and highly justifiable way to enhance the value of America’s most important asset: its people.

growth. First, healthier people are more economically productive. Better health also leads to an increase in savings rates—because healthier people expect to live longer and are naturally more concerned with their future financial needs.

©Robert Scoble

24 Harvard Public Health

The Dollars & Sense of Public Health | SPECIAL REPORT

As director of the secondlargest health department in Washington State, Anthony Chen, MPH ’06, tackles all the issues—from infections to inequities— that shape people’s health.

Working the System

T

he elderly Taiwanese man had been Anthony Chen’s patient for years. When the patient developed liver cancer, Chen worked closely with him, his wife, and his son to address their concerns and calm their fears. Often, he made home visits as the man became sicker. He’d do a physical exam. He’d ask if any help was needed in the household. And

he’d talk with the family about how they were coping with a husband and father’s decline.

©Brian Smale

It was heartbreaking for Chen to watch a longtime patient struggle with his disease. It

was even tougher to realize that his death from liver cancer could have been avoided—if he’d simply been vaccinated for hepatitis B. continued

25 Fall 2012

The Dollars & Sense of Public Health | SPECIAL REPORT

This was one of many frustrations that propelled Chen, MPH ’06—after 16 years in family practice—into the public health profession. Chen, 51, is now Director of Health for TacomaPierce County Health Department, the second-largest health department in the state of Washington, with 270

B all the time, because the disease is endemic in their countries of origin and gets passed down from mothers to children,” says Chen. “You look at how much time and energy you’re spending taking care of patients with liver cancer—and it all could have been avoided with a vaccine.”

Democratically controlled state legislature passed a law requiring that all Washingtonians have access to private insurance, regardless of their health status, and mandating that they purchase coverage.

Two years later, Republicans took control of the legislature, repealed

“Seeing health care reform come to fruition was a powerful experience.”

—Anthony Chen, MPH ’06 employees and an annual budget of about $36 million. As director, he works on the full gamut of public health issues: obesity, air and water quality, sexually transmitted diseases, pertussis, flu, oral health—and hepatitis B. A PREVENTABLE CANCER

After working in a number of underserved communities—in Boston, Chicago, and Seattle, as well as in rural North Carolina—Chen came to see that a broad systems approach and population-based public health focus visibly improved the lives of his individual patients. This fact was brought into stark relief through his work since the early 1990s with the Asian American and Pacific Islander (AAPI) community in the Seattle area.

According to recent statistics, AAPIs account for half of the estimated 1.4 million people infected with hepatitis B in the U.S., even though they make up only 5 percent of the population. “When you work with any sizable Asian or Pacific Islander community, you see patients with chronic hepatitis

CITY WITHIN A CITY

In 1996, Chen took a job as lead family physician at a medical and dental clinic in Holly Park, a heavily Asian and African American section of Seattle, where roughly 25 percent of residents live below the poverty line. His nine years at the clinic, he says, sometimes felt like toiling in an isolated Third World medical outpost.

“We were only six miles from the nearest hospital, but many people living there were poor or working and didn’t want to travel to the hospital,” Chen recalls. “We gave shots, drew blood, orally rehydrated kids with high fevers in the back room. In Seattle, people don’t think there’s an ‘inner city’—but there is.”

Chen saw how political realities were hurting his patients. After national welfare reform went into effect in 1996, for instance, even legal immigrants face new restrictions on benefits and could not receive public assistance until they’d lived in the U.S. for five years. It was also sobering for him to witness the fallout from Washington State’s failed health reform effort. In 1993, the 26 Harvard Public Health

most unimplemented provisions of the law—including the individual mandate—but left intact the guaranteed issue provision. The result?

Enrollment in health insurance dropped, many bought insurance only when faced with large expenditures, insurers lost money, premiums rose, and a number of insurers left the state.

MEDICINE AND MARKETING

Chen headed to HSPH so that he’d have more tools to deal with such challenges. In 2006, he earned a master’s of public health with a concentration in health care management and completed the Commonwealth Fund Harvard University Fellowship in Minority Health Policy. In classes with Robert Blendon, senior associate dean for policy translation and leadership development, and Howard Koh, then Harvey V. Fineberg Professor of the Practice of Public Health, Chen learned about the importance of shaping one’s message and providing compelling arguments. “I knew that medicine was important,” he says. “I learned that communication was, too.”

After HSPH, as medical director at several Boston-area health centers, Chen witnessed the launch of health care reform in Massachusetts. “I saw patients come in after not seeing doctors for years,” he says. “Seeing health care reform come to fruition, after seeing it falter in Washington State, was a powerful experience.”

DOING MORE WITH LESS

In October 2008, as the U.S. economy began to plummet, Chen became Tacoma-Pierce County’s Director of Health. Immediately, he put together a new strategic plan. “Too often, public health is reactive to the economy,” he says. “When I got here, the budget was $40 million with 300 employees. Now it’s $36 million with 270 employees. Instead of just shrinking our programs, we needed objectives and strategies.”

Compared with the state overall, Pierce County residents have worse health, more heart disease, and higher death rates, and breathe more contaminated air. The poorest residents have high rates of obesity and tobacco use. There are disturbing health disparities between African Americans and whites.

Under Chen’s leadership, the Tacoma-Pierce Health Department has tackled these problems head-on, encouraging landlords and property owners to develop smoke-free rental housing, for instance, and working to deliver vaccines to children who need them. ©Brian Smale

THE BIG PICTURE

Anthoy Chen, at the wheel of a “hand washing truck” that travels to schools, public events, and other venues to promote hand washing to children.

for example, about the impact of the recession on children. “People lose their jobs and their kids might not get fed,” he says. “They lose the roof over their heads, and then their kids can’t concentrate at school. They lose their health insurance, and then the kids get sick.” He pauses. “It gets very frustrating when you have to deal with people who don’t see the connection between all of these things.”

In 2011, Chen coauthored a study examining how public health departments in the state of Washington were dealing with budget cuts. The researchers found that there was often no systematic process for prioritizing or cutting programs in response to tight budgets. Because of a state mandate to investigate dog bites and rabies cases, for example, some counties were cutting crucial programs like epidemiology or chronic disease

In public health, says Chen, it’s crucial to look at the big picture. He thinks,

prevention. As Chen sees it, “People end up doing things that may not be evidence-based—instead, it’s just what some lawmaker thinks.”

“Most people don’t understand public health,” he concedes. “They also don’t understand the difference between health care and public health.

So funding for public health—which has ‘health’ in its name—may be neglected or may get cut because of political opposition to health care reform.”

“I know public health people are stressed out right now, with their budgets cut down to survival level.

They feel they don’t have the bandwidth to think about policy on the national level,” he says. “But we have to get engaged in the debate. We need to be on the phone and travel to our state capitals and DC. We can’t do things the same old way.”

Karen Feldscher is a senior writer at HSPH.

27 Fall 2012

No

THE DOLLARS AND SENSE OF CHRONIC DISEASE According to the Centers for Disease Control and Prevention, nearly 1 out of every 2 Americans suffers from a chronic disease, defined as a noncommunicable disease (NCD) prolonged in duration, including cancer, heart disease, stroke, and diabetes. Chronic diseases are the number one cause of death in the U.S.

$8

$2

Ho

Unhealthy Habits

Life Ex

The most common behaviors that lead to chronic diseases are: Insufficient Physical Activity

Tobacco

The p and c

85

Poor Eating Habits

Excessive Alcohol

The World Health Organization estimates that 80 percent of all heart disease, stroke, and type 2 diabetes, as well as more than 40 percent of cancer, would be prevented if Americans would stop using tobacco, eat healthy, and exercise.

Causes of Death Worldwide

80

75

U.S. Health Care Costs 70

25% 39% 61%

75%

Do

In the cance Noncommunicable Diseases

Noncommunicable Diseases

Injuries, Infections, and Other Conditions

Other

The U

(includes communicable diseases, maternal and perinatal conditions, and nutritional deficiencies)

Investing in health is not only the right thing to do on ethical grounds but it is also the smart thing to do in order to achieve economic prosperity...

Good health is not only a consequence of, but a condition for, sustained and sustainable economic growth. —Julio Frenk, Dean, Harvard School of Public Health

28 Harvard Public Health

$

is sp pe

The projected global economic toll of noncommunicable diseases—chiefly cancer, mental health disorders, and cardiovascular and chronic respiratory diseases—over the next two decades is $47 trillion.

$47 TRILLION $15 TRILLION

U.S. national debt (as of July 1, 2012).

$800 BILLION Cost of the U.S. war in Iraq. $250 BILLION Economic losses from Hurricane Katrina.

How Much Health Do We Get for Our Money?

Life Expectancy, by Country

H

ZL

R O

U

SW

Z

SA

N

EN A CA U N T N ED LU X

D

N

FR IR G A L ER

ZE SL PO O R

U N SV

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PO TU

R

M

EX

75

70

L

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H

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2 op

C

KO

R

80

G G RE J BR ES ITA PN SW FI P N IS E BE L AU L S

IS

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85

ES T

ffers ing U.S.

Noncommunicable Diseases: Comparing the Economic Toll

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

Total Health Expenditures per Capita Spending in U.S. Dollars and PPP Adjusted

According to General Motors, employee health care costs add between $1,500 and $2,000 to the sticker price of every car the company makes.

Dollars and Diseases In the U.S. alone, a 10% reduction in mortality from heart disease, cancer, and diabetes would have an annual socioeconomic value of The U.S. spends $2.5 trillion on health care every year.

$8,086

is spent on medical care per person per year.

Only $251 is spent per person on public health measures that prevent medical conditions before they occur.

29 Fall 2012

$10.9 TRILLION Sources include: “The Global Economic Burden of Noncommunicable Diseases” World Economic Forum, 2011; “Health Care Costs & U.S. Competitiveness” Council on Foreign Relations, 2012; “An Unhealthy Truth: Rising Rates of Chronic Disease and the Future of Health in America” Partnership to Fight Chronic Disease, 2007; and “Chronic Diseases: The Power to Prevent, The Call to Control” Centers for Disease Control and Prevention website, 2009. For a complete list of sources, please visit: hsph.me/infosources

O

n a raw January day in Washington, DC, Doug Dockery climbed Capitol Hill on his

way to testify to Congress about the Harvard School of Public Health study he’d been running. He would have preferred to be anywhere else. It jarred Dockery— today, chair of the Department of Environmental Health—to confront people wearing white lab coats, holding signs that read, “Harvard, release the data!”

Employed by an industry-backed group called Citizens for a Sound Economy, the protesters pressed on passersby fliers claiming that Harvard was hiding “secret” data. Their message was aimed directly at Dockery.

continued

PREVAILING 30 Harvard Public Health Review

Jones Adam/Photo Researchers

A decades-long fight to bring clean air standards in line with environmental health science offers lessons for today.

WINDS 31 Fall 2012

T

he year was 1997, and Dockery had arrived in

were conclusive evidence that soot produced by fossil fuel

Washington to tell Congress that because it had promised

combustion kills.

study participants confidentiality, Harvard couldn’t share

That evidence was also enough for the U.S.

the raw data from its federally funded Six Cities study.

Environmental Protection Agency (EPA), which in 1997

The landmark research—one of the single most influen-

used the science, along with many other studies, as the

tial public health studies ever conducted—examined over

foundation for the first-ever Clean Air Act regulations on

14 to 16 years the health effects of air pollution on more

particulate matter smaller than 2.5 microns in diameter.

than 8,000 adults and 14,000 children in six U.S. cities.

The EPA claimed the new PM2.5 rules would prevent

During that time, HSPH scientists published more than

15,000 premature deaths annually and produce other

100 peer-reviewed papers detailing their findings.

huge benefits, among them preventing 250,000 inci-

The blockbuster paper came in 1993, when Dockery’s team described what he now calls amazing results.

dences of aggravated asthma, 60,000 cases of bronchitis, and 9,000 hospital admissions every year.

Residents of Steubenville, Ohio—the city with the dirt-

But meeting the new standards would be far from

iest air—were 26 percent more likely to die prematurely

simple or cheap. Manufacturing, power, steel, auto and

than were citizens of Portage, Wisconsin, the city with

other industries spent untold millions trying to disprove

the cleanest air. The primary culprit: fine particulates, up

the science, discredit the EPA, and defeat the new regula-

to hundreds of times narrower than a human hair, which

tions. The New York Times dubbed the clash “the environ-

were associated with increased incidence of lung cancer

mental fight of the decade.” It embroiled the Six Cities

and cardiopulmonary disease. “The effects of air pollu-

study in a years-long controversy—one that holds lessons

tion were about two years’ reduction in life expectancy,”

for public health professionals working on issues critical

Dockery says. “It was much, much higher than we had

in this year’s election cycle, from new Clean Air Act rules

expected.” To Dockery and his colleagues, the results

“ The effects of air pollution were about two years’ reduction in life expectancy. It was much, much higher than we had expected.”

—Douglas Dockery

32 Harvard Public Health

WHY SIX CITIES MATTERS TODAY The clash between industry, politics, and science over the Six Cities study remains relevant today.

Consider just a small sampling of contemporary public health controversies:

and oil drilling to natural gas fracking and the ubiquitous

Global Warming:

pesticides and chemicals in our food, homes, and bodies.

A U.S. federal appeals court in June agreed with the EPA that auto and power plant emissions endanger the public health. Opponents had filed more than 60

A DEADLY CLOUD

lawsuits to block the EPA from regulating greenhouse

Ever since a toxic black cloud dubbed the “Great Smog”—

gas emissions. As Matthew Wald of The New York

made up primarily of coal-burning emissions and diesel

Times wrote, “The judges unanimously dismissed

exhaust—hovered over London in 1952 and killed more

arguments from industry that the science of global

than 4,000 people within days, environmental scientists

warming was not well supported and that the agency

had worried about the mysterious ingredients composing

had based its judgment on unreliable studies.”

industrial haze. In the U.S., that concern intensified in

Natural Gas Fracking:

1973 following the Arab oil embargo, when power plants

Public health studies show the hydrofracturing, or

were expected to substitute cheap, high-sulfur coal for

fracking, process of drilling fouls the air and water and

expensive oil. What could the nasty emissions from

may contribute to earthquakes. Industry advocates question the certainty of that science and say the

dirtier fuel do to people?

country needs cheap, “clean” fuel.

HSPH’s Ben Ferris, a legendary public health

Mining and Cancer:

professor who died in 1996, and Frank Speizer, professor

The Mining Awareness Resource Group, a mining-

of environmental science, proposed to find out: They

industry-funded organization, spent years going

would sample the air quality in six Eastern cities with

to the courts and to Congress for assistance in

varying degrees of pollution while simultaneously moni-

accessing data from, and delaying publication of, a

toring the health of thousands of those cities’ residents.

study showing that miners exposed to diesel exhaust

Among their team were the wiry, intense Jack Spengler,

underground were at high risk of developing lung

now the Akira Yamaguchi Professor of Environmental

cancer. Twenty years after the study was launched,

Health and Human Habitation, who built personal air

the Journal of the National Cancer Institute finally published the results.

quality monitoring equipment that participants wore; and the tall, reserved Dockery, who traveled from city to city, setting up air pollution monitors in residents’ homes. Jim Ware, professor of biostatistics, joined the team in 1979.

In the mid–1970s, no one had yet conducted a

Later, Joel Schwartz, professor of environmental epidemiology, would join the team and become one of its most prolific authors.

comprehensive study of particulates’ effects on human health. Dockery and his colleagues expected to learn that the true threat of industrial haze would stem from sulfur

Their goal was simple: to identify links between

dioxide. But it was the fine particles that were the biggest

illness and death rates and air pollution levels. They

dangers (although the study did not show how these

sampled the air for toxic emissions, including sulfur

particles created illness, a missing link critics would

Kent Dayton/HSPH

dioxide and particulate matter, a brew of acids, metals, petroleum byproducts, diesel soot, and other potentially

highlight). Another surprise: indoor air pollution was continued

harmful substances that readily deposit deep in the lungs.

33 Fall 2012

hundreds of billions of dollars. The EPA put the final tab at $6 to $8 billion.

As the debate grew more contentious, many experts— including Philip H. Abelson, former editor of Science magazine—pushed the EPA to delay regulations until the

“ To have a hostile group combing through your data looking for anything to attack you about was not something any of us relished.”

—James Ware

science was more certain. Abelson maintained that the makeup of particulate matter differed greatly from place to place. In an editorial, he queried, “How can the EPA minimize the effects of particulates if it does not know what they are or which, if any, have deleterious physiological effects?”

Others, like fellow HSPH faculty member John D. Graham, professor of policy and decision sciences at HSPH, were also critical of the EPA, arguing that the

more harmful than outdoor toxins, setting the stage for

Clean Air Act’s legal framework for rule making does not

years of important research.

allow the agency to consider costs, just health outcomes.

Today, because of Six Cities, it is conventional wisdom

Graham had pioneered the study of risk analysis at

that particulate matter contributes significantly to a

HSPH, having founded and, from 1990 to 2001, directed

wide variety of illnesses across the spectrum of life, from

the Harvard Center for Risk Analysis. From 2001 to

asthma and bronchitis to sudden infant death syndrome

2006, he led the White House’s Office of Information

and lung cancer.

and Regulatory Affairs, making him what the Natural Resources Defense Council called “the second most

INDUSTRY RESPONDS

powerful environmental official in the nation after

Public health considerations aside, the new standards

George W. Bush.” Today, he serves as Dean of Indiana

forced dramatic changes on industry. The New York Times

University’s School of Public and Environmental Affairs.

reported that old Midwestern power plants would have

Over the years, Graham testified at many congres-

to install expensive pollution control equipment; states

sional hearings that there should be an opportunity for

would need to invest in mass transit and other initia-

cost/benefit analysis during EPA rule making. “One of my

tives designed to reduce auto pollution; and factories

key arguments is that practical people are going to do it

that burned mountains of coal would have to switch to

anyway,” he says. “We shouldn’t make them do it behind

cleaner-burning fuels. How much those changes would

closed doors. That’s not good, because their arguments

cost depended upon who was doing the estimating:

are then not open to public scrutiny.”

industry spokesmen said the bill would reach into the 34 Harvard Public Health

THE BATTLE LINES HARDEN

Still, the scientists held their ground. “We knew that

Opposite, Kent Dayton/HSPH; below, Francis Miller/Time Life Pictures/Getty Images.

Citizens for a Sound Economy blanketed the country

if we released the data, it would be endless aggravation

with ads designed to influence public opinion. The group,

and defending against attacks,” says Ware. “To have a

which the Washington Post called the “pro-industry alli-

hostile group combing through your data looking for

ance at the center of an extraordinary, multimillion-

anything to attack you about was not something any of

dollar campaign to turn back EPA regulations for smog

us relished.” Furthermore, Frank Speizer told Dockery, to

and soot,” attracted grassroots supporters by contending

release the raw data would be to allow “biased groups” to

the new rules would force bans on such American icons

manipulate it and to set a precedent that “will undermine

as backyard barbecues, farm tractors, and wood stoves.

future research by academic institutions.”

In addition, critics from industry, members of Congress, and some governors demanded that Harvard release the

EPA UNDER SIEGE

raw data. “We declined,” says Jim Ware, then HSPH acting

But the EPA, too, was under siege—from lobbyists and

dean and now Frederick Mosteller Professor of Biostatistics.

from Congress, which demanded the agency produce

The team had promised participants that their personal

so-called “secret data” on which the new rules rested.

data would never be released. When Harvard refused,

In February 1997, EPA bowed to the pressure and urged

critics accused the researchers of conspiracy and pres-

Harvard to do so. As a compromise, the team came up

sured Congress to hold hearings. “The issue is the quality

with the idea of asking an independent scientific panel

of the science,” said National Association of Manufacturers

to audit the researchers’ findings. They gave a warehouse

spokesman Richard Siebert. “In order for people to ascertain

full of data to the Cambridge, Massachusetts–based

the science they need to understand the background data …

Health Effects Institute (HEI), which was funded by both

What are they hiding?”

the automotive industry and the EPA. It took HEI three years to reanalyze the data—an

“It was a painful time,” says Dockery. “You’d get up in the morning and look in the paper and there you’d be again.”

agonizing period of limbo for the scientists. But it was continued

The Clean Air Act and the policies triggered by HSPH’s Six Cities study are classic examples of how public health should work: good science shapes public policy, and policy, in turn, saves people’s lives.

Aerial view of Steubenville, Ohio in 1958.

35 Fall 2012

worth the wait. In 2000, HEI scientists confirmed the original Six Cities findings. It was a huge win for the School.

In 1997, while HEI was auditing the data, President Bill Clinton approved the new Clean Air Act’s PM2.5 regulations and tightened ozone standards.

In 1999, Alabama Republican Senator Richard Shelby, still simmering about Harvard’s “hidden” data, inserted a single sentence into a 4,000-page budget bill that would change everything for future researchers. The still-controversial Shelby Amendment calls for those university scientists working on federally funded projects to share their data with anyone who requests it via the Freedom of Information Act. When the issue of sharing primary data first arose, critics like HSPH’s Frank Speizer feared such a rule would dampen future research by dissuading potential participants whose confidentiality could no longer be protected.

Today, the issue is so fraught that, even within HSPH, scientists find themselves on opposing sides. Doug Dockery calls the Shelby Amendment “a direct

—Jack Spengler

studies aren’t subject to the same rules. In contrast, Jim Ware says, “As a matter of principle, the Shelby Amendment is right: When the federal government pays for research … that research ought to be made available for scrutiny by others and for debate and examination.”

THE LONG VIEW

Today, Dockery looks out his 13th-floor window across the Charles River at the Cambridge skyline, a view that, decades earlier, had often been obscured

“UNCERTAIN SCIENCE” A COMMON CLAIM When public health and industry collide, foes of regulation often claim that epidemiology is an uncertain science, says Sheila Jasanoff, Pforzheimer Professor of Science and Technology Studies at Harvard Kennedy School of Government.

“The most favored method is to ‘deconstruct’ agency scientific claims, on grounds of methodological inadequacy,” she says. “The problem is that public health research often operates in zones of ignorance and uncertainty; it is relatively easy to find, or at least claim to find, ‘problems in the science.’”

The inherent uncertainty of emerging science leads to fiery rhetoric on both sides—which is unfortunate, Jasanoff adds. “The constant debates about ‘good science’ and repeated charges of overregulation undermine trust in government and hinder a mature understanding of how to live prudently in complex industrial societies that will never be risk-free and where full scientific certainty on many issues will likely take very long to achieve.”

Even today, the Six Cities debates linger. John Graham applauded HSPH’s decision to give its data to the nonpartisan organization Health Effects Institute for analysis. But 15 years later, he remains frustrated that Harvard didn’t share the original data earlier. “These findings are still utilized around the world,” Graham says. “They sit as a foundation for multibillion-dollar decisions in China, Brazil, and elsewhere. I would still like to see the data be made publicly available. It’s the basic principle of transparency in science.”

36 Harvard Public Health

Kent Dayton/HSPH

“ We teach people to be statisticians, epidemiologists, lab analysts, exposure scientists, but we must also equip them for the big fights.”

assault on research conducted by universities,” because privately funded

THE DEBATE GOES ON The controversy over standards for fine particulate matter

by urban haze. “I can see a long way,” he says. “That’s

air pollution continues today. In June 2012, a federal court

gratifying.”

order forced the EPA to propose new, tighter standards; the agency settled on reducing the allowed annual level

Over the last 30 years, air quality nationwide has

from 15 micrograms per cubic meter to a range between 13

improved dramatically, due to Clean Air Act rules

and 12.

based in part on Six Cities research. In 2009, Dockery

But a 2011 report by the American Lung Association,

and colleagues Arden Pope (now at Brigham Young

Clean Air Task Force, and Earthjustice claims that this

University) and Majid Ezzati (now at Imperial College

reduction doesn’t go far enough. Their analysis, which

London) demonstrated that from 1980 to 2000, reduc-

cites Six Cities findings, argues that at those levels, a

tions in exposure to fine particulate matter had increased

maximum of 15,000 premature deaths would be averted

average American life spans by 1.6 years. “That’s huge,”

annually. The coalition argues that the EPA should adopt a more stringent annual limit of 11 micrograms per cubic

Dockery says. “If you got rid of all cancers, the net effect

meter, which its analysis shows would prevent nearly

on average life expectancy would be two years.”

36,000 premature deaths yearly.

The Clean Air Act and the policies triggered by

The EPA is expected to issue final standards in

HSPH’s Six Cities study are classic examples of how

December 2012.

public health should work: good science shapes public policy, and policy, in turn, saves people’s lives.

“ Of [EPA’s] 20 air rules, the rule with the highest estimated benefits is the Clean Air Fine Particle Implementation Rule, with benefits estimated at a minimum of $19 billion per year. While the benefits of this rule far exceed the costs, the cost estimate for the Clean Air Fine Particle Implementation Rule is also the highest at $7.3 billion per year.”

—Office of Management and Budget Analysis A STEEL BACKBONE

“We provided the basis for quantifying how many hospital

On a crowded shelf in his office, Dockery keeps two six-

visits, how many asthma attacks, how many COPD [chronic

inch-thick binders of correspondence and media clippings

obstructive pulmonary disease] cases, how many heart

from the Six Cities fight. Buried in them are memories—

attacks, and how many deaths were associated with these air

many painful—but also lessons for today’s public health

pollutants,” he says. “It completely changed the discussion.

professionals.

When you actually used those numbers, suddenly the cost/

For Dockery, two stand out. First, “Solid, quality

benefit analysis became very clear—and suddenly, the benefits

science does stand up over time.” Second: “How you

were found to far outweigh the cost of controls.”

present the information—how you translate the data—is extremely important.”

Years later, Office of Management and Budget (OMB) analysis confirmed Dockery’s claims: in a 2011 report, the

He believes the PM2.5 standards survived because,

OMB stated, “Of [EPA’s] 20 air rules, the rule with the

for the first time, the science made it possible to calculate

highest estimated benefits is the Clean Air Fine Particle

the costs and finger the sources of air-pollution-related disease.

continued page 45

37 Fall 2012

HSPH’S WILL MAIR HOPES HIS WORK IN WORMS WILL IDENTIFY MOLECULES THAT HAVE AN EFFECT ON AGING-RELATED DISEASES—AND WHICH COULD ULTIMATELY BE TESTED AS TREATMENTS FOR HUMANS.

38 Harvard Public Health Review

Why do we

AGE? Surprising revelations

Worm from a

“How old you are is immutable—you can’t change how old an animal is,” says William Mair, assistant professor of genetics and complex diseases at HSPH. “But you can change how it ages.”

That observation points to a new way of thinking about aging: not as a preordained decline, but as a malleable function of the body. And viewed in this way, aging belongs at the center of public health research. Rather than just treating endpoints—such as cardiovascular disease, metabolic disorders, cancer, and neurodegeneration—could researchers improve population health by targeting the aging process itself?

Mair’s young lab, launched last November, is trying to answer that question. “It’s not enough to say it’s inevitable that we get more frail,” says Mair. “There’s something that happens that makes an old animal more susceptible to getting these disease states. For example, if you look at cancer, one of the most common age-related diseases, it’s clearly not one pathology. Similar tumors can result from very different mutations in different individuals. Trying to find those specific mutations is one way to do research. But if you could make the environment more resistant to developing tumors in the first place, you can try to reduce the chances of getting cancer with age.”

William Mair

continued 39 Fall 2012

M

air first became intrigued with aging as an evolutionary question: If infirmity isn’t just a product of wear and tear, why do we age at all? His research began with an observation known since the 1930s: A diet severely restricted in calories (about 30 percent below normal, but above starvation levels)

reproduce less, and have dampened immune systems. More than just cutting calories, dietary restriction seems to switch the body into a survival mode in which growth and energy consumption are suppressed.

Today, stalwart human volunteers are testing whether dietary restriction

restriction without the negative side effects. “We want to try to uncouple the good from the bad,” he says. “And to do that, you need a system that you can play around with genetically.”

A FAST-FORWARD VIEW OF AGING His subject of choice: Caenorhabditis

“ Everybody knows someone who’s had cancer or type 2 diabetes or Alzheimer’s disease.

They see how it destroys people’s lives.”

— William Mair, assistant professor of genetics and complex diseases works in humans, both on their own and as part of studies like the ongoing federally funded clinical CALERIE trial (for Comprehensive Assessment of the Long-term Effects of Reducing Intake of Energy). “It’s not something I would advocate doing,” Mair says, not only because food deprivation is unpleasant, but also because it could produce similar negative side effects in humans, such as fertility problems or susceptibility to infections.

Mair wants to see if there’s a way to tap into the health benefits of dietary

40 Harvard Public Health

elegans, the classic laboratory nematode used across a wide field of research. These tiny, transparent worms have played a central role in aging research. Though just a millimeter long and composed of barely a thousand cells, they show visible signs of aging: they slow down, stop reproducing, and even develop wrinkled skin. Easy to manipulate genetically, and with a life span of just two weeks, C. elegans provides a quick time-lapse view of the aging process. That speed suits Mair,

Kent Dayton/HSPH

can increase lifespan, lower rates of cancer, and slow declines in memory and movement. This effect, first seen in laboratory rats, has been replicated in species as diverse as yeast, fruit flies, worms, and even rhesus monkeys. Further research has uncovered genetic mutations in animals that can mimic the effects of dietary restriction, and some of these same mutations are found in people who live into their 90s.

But laboratory-manipulated longevity also comes with a price. Restricted-diet animals grow more slowly,

whose rapid speech bears inflections from his native Suffolk, England.

“What on earth can we learn about humans from studying a worm? One answer is that the worm is a way to investigate causality. You can learn a lot of stuff by doing an epidemiological study to find out what’s changing in population—but it’s very hard to find causality in those changes. With this simple worm, in a cheap and quick way, we can tweak things and find causality.

And if we do that, coupled with what

at energy sensing and how that affects stress resistance and healthy aging. But it involves exactly the same molecules.”

For example, some of the patients taking the widely prescribed diabetes drug metformin appear to be resistant to certain cancers—an outcome unrelated to the protective effect that the drug has on diabetes. Mair’s lab has shown that activating one of the key molecular targets of metformin in worms makes them age more slowly. Seeing the same disease pathways turn up in research

WITH THIS SIMPLE WORM, IN A CHEAP AND QUICK WAY, WE CAN TWEAK THINGS AND FIND CAUSALITY. we know from colleagues who are working on how these genes are linked to different pathologies, then it can be a very powerful model.”

JOINING FORCES: AGING AND DISEASE After completing a postdoctoral fellowship at the Salk Institute for Biological Studies in La Jolla, California, Mair moved to the School to collaborate with scientists studying the chronic diseases he believes his research can help alleviate. There’s reason to join forces: Many of the same genes and cellular processes involved in aging also play a role in diabetes, obesity, and cancer. Mair, for instance, recently received an award for a pilot project through HSPH’s Transdisciplinary Research on Energetics and Cancer (TREC), a program funded by the National Cancer Institute to promote research on links between obesity and cancer.

“I’m not looking at cancer or obesity in the worm,” he says. “I’m looking

across widely separated disciplines argues for a more integrated research approach.

Mair hopes that his work in the worm will identify molecules that have an effect on aging-related disease, which could then be tested in mice and eventually in humans as possible therapies. But for now, he’s focused on making basic discoveries rather than hunting for drugs. He sets himself apart from scientists who explicitly want to boost lifespan in humans, which he says has given studies on aging a Frankensteinlike reputation among the public.

“You have to walk a fine line in the field,” he says. “There are certainly members of it who don’t. Their motivation is that they want a pill to make themselves live a long time,” he says. “Some people—and it’s a very small minority who are not well-credited in the aging field—have said that the first human to live to 500 is alive right now. There’s no scientific basis for that. It’s so detached from my reason for working on these questions, it’s sci-fi rather than natural science. We have a long way to go.”

41 Fall 2012

FRESH PERSPECTIVES, ETHICAL QUESTIONS At the same time, tinkering with the aging process could have huge public health repercussions. “Everybody knows someone who’s had cancer or type 2 diabetes or Alzheimer’s disease. They see how it destroys people’s lives and they’re scared of it,” says Mair. As for the argument that research on prolonging a healthy life is unethical, because the planet is already too crowded: Mair doesn’t buy it. “Everything that alleviates suffering is unethical not to do,” he says. “All public health strategies, if successful, will help more people survive to older ages—and hopefully, succumb less to chronic diseases. How we cope as a species with the effect that might have on the age structure of our population is a separate issue.”

Though he explores the fundamentals of aging, Mair, who is 33, cultivates a decidedly fresh presence on his HSPH website. One link features a ticking digital clock showing the exact age of the lab, down to the second.

Another tracks the music playing in the lab (from Esperanza Spalding to Sigur Rós to Radiohead). The lab also posts Twitter messages.

“Being a young lab is a difficult thing. You’re trying to get things off the ground,” says Mair. “The ticking clock is meant to reflect a certain level of honesty about how long we’ve been here. The more transparency you have—showing what’s going on, that we’re progressing and moving—the better. We want people to feel excited about our work. It’s also very important to make a lab a community. If you can give the lab a personality, it helps you recruit. This lab website has a face—it’s not just an entry on the faculty page.”

Courtney Humphries is a Boston-based science journalist and author.

R

aphael Arku should have been on top of the world. There he was, in his early 20s, a geologist for a gold mining company, a job with prestige and money—neither of which he’d ever had before.

The second of seven siblings, Arku had been raised by his single mother in a rural village in Ghana. At school, with his fellow students, he would forage for firewood and carry water in from a nearby stream. He always had a candle in his pocket. “The lights can go off anytime, and we don’t have generators,” Arku recalls.

“But you have to study because you’re competing with other students for the same national exams to enter the university. So the best you can do is have candles, and you light them up to study. That was my high school.”

ARKU’S JOURNEY

Arku won a slot at the University of Ghana and then se-

Raphael Arku

cured his lucrative job. To everyone who knew him, it made

working in the Nima

sense that after those years of grinding work, Arku should

neighborhood of Accra, Ghana. He is

be happy.

doing fieldwork at a

But he wasn’t.

rooftop site set up to

Exploring for gold in Ghana came with ugly surprises.

measure ambient air

“We caused a lot of damage to villagers’ water resources, to

pollution.

their farm fields,” Arku says. One day, working in a remote village, the team dynamited a huge boulder. “It was right on top of the water head,” Arku says. “Everything fell into the water and it became muddy. We were washing the alluvial gold right into the river.”

WATER FOULED Villagers soon came to fetch drinking water. Before using it, they simply let the toxic sediment settle to the bottom.

globe’s most polluted. “If you go out in the morning,” says

But the water was now fouled with contaminants from the

Arku, “over the course of the day, you can actually see the

blasting, including arsenic and other toxic heavy metals,

color of your shirt darken.”

and with gas and diesel from the miners’ leaky equipment.

He had begun his quest to understand how the tainted

“They didn’t even know they could boil it,” Arku says. After

environment affects the health of Accra’s residents, especial-

only a year on the job, he quit. “I had a conflict between my

ly the poor, as an undergraduate at the University of Ghana

personal beliefs and what was happening in the field.”

in 2003. There, he worked for Allan Hill, today HSPH’s An-

Arku replaced his high-paying career with something far

delot Professor of Demography. Hill was on leave, setting up

more valuable: a commitment to improving the environment

the Women’s Health Survey of Accra with the University of

for his fellow Ghanaians. Once again poor, the quiet, slender

Ghana. He needed skilled interviewers—and people capable

student began a long, difficult journey toward a public health

of persuading female participants to provide blood samples

career—one that had him earning two master’s degrees

and submit to medical exams. “Raphael quickly distinguished

before starting his doctorate at Harvard School of Public

himself as by far the most able of my new recruits,” Hill says.

Health in 2010.

Now 31, Arku has traded his interest in water for a pas-

MISTAKEN IDENTITY

sion to clean up Ghanaians’ foul air. The need, he implies, is

One big problem: mistaken identities could easily foul up

obvious. “Have you ever been to Accra?” he asks, eyebrows

the research sample. “In Ghana, people have family names,

raised. With some 4 million residents, Accra is the country’s

‘days’ names, nicknames, and so on,” Hill says. “Raphael

largest city and one of the fastest-growing urban areas in

would doggedly approach the women in turn and, by sys-

the world. A stew of ingredients in the air—exhaust from the

tematic inquiry and cajoling, ensure the right women were

city’s fleet of old imported cars, dust from unpaved roads,

recruited for the study.”

Arku’s day started at dawn, when he would hop a

and especially toxic emissions from the coal and firewood most people use as cooking fuel—makes it one of the

minibus or ride a motorbike to the neighborhood they had

continued

Justin Ide

Raphael Arku was able to attend HSPH with the help of financial aid.

He won a Thorley D. Briggs Scholarship, which is given to African students to attend the School.

He was also awarded a Mitchell L. Dong and Robin LaFoley Dong Scholarship, which is provided to students on the basis of need and academic excellence.

43 Fall 2012

targeted. Often, he made several trips to catch the women

infrastructure—and exploring technology and policy innova-

at home. “The work continued to late in the evening,” Hill

tions (further electrifying the city, for example, or introducing

recalls. “But Raphael’s work rate was relentless.”

clean-burning, affordable stoves) that could help reduce both

When he pursued his first master’s degree in 2006,

household and neighborhood air pollution exposures.

Arku helped another HSPH professor, Majid Ezzati (now an adjunct professor at HSPH and chair in Global Environmental

WRESTLING WITH BUREAUCRATS

Health at Imperial College London), who was equally im-

Last summer, Arku returned to Ghana to collect more data—

pressed. Their work, also with the University of Ghana, was

this time trying to link illness to air pollution sources. In the

groundbreaking. With pockets of wealth, a sizable middle

smoggy heat, he walked from one doctor’s office and clinic

class, and millions living in poverty, Accra is notable for its

to another, trying to find administrators willing to share

striking economic inequality—inequality that, Ezzati theo-

information. “It takes several hours or days to find the right

rized, reaches all the way down into the air and water.

person,” Arku says. “Think of this as ‘wrestling with bureau-

With the help of Arku and other students, Ezzati pinpointed the sources of air pollution in four neighborhoods,

crats’ to get the data you need.”

Arku wants to return home, Ph.D. in hand (expected

Arku discovered that a job exploring for gold had ugly—and toxic—surprises.

He replaced his high-paying career with a commitment to improve the environment in Ghana. from high-income areas to slums. “You’re trying to do really

in 2015), to set up a world-class research program at the

good science in a place where everything from the elec-

University of Ghana. “If you ever lived in Accra and you have

tricity supply to the social conditions are unstable,” Ezzati

a passion for the environment, I think you would be mad

says. Trudging from place to place, the researchers learned

enough so that you would like to do something,” he says.

that in the densely populated slums, almost everyone uses

But given his experience of growing up without a stable

firewood; cheap, dirty coal; and dung for cooking, typically in

source of energy, Arku has an extremely practical side.

makeshift kitchens set up in bedrooms or on front porches.

“There is an urgent need for regular, community-level access

In contrast, Arku says, about 80 percent of people living in

to cleaner fuel,” he says. The recent discovery of crude oil off

high-income neighborhoods use liquid propane gas (LPG),

Ghana’s shores, along with the expectation of new produc-

with biomass fuels as a backup due to an unstable LPG

tion of natural gas, could help alter the future for Accra’s

delivery system. Not surprisingly, “The lowest-income neigh-

people, depending upon how new resources are expended.

borhoods had the highest air pollution,” Ezzati reports.

According to Arku, “We need a relevant policy debate that

Poor residents cook with these low-quality fuels be-

would focus on whether a portion of the proceeds and sup-

cause it’s all they can afford. From previous studies else-

ply from these projects should be used to develop energy

where—including HSPH’s Six Cities study (see page 30)—it’s

infrastructure in low- and middle-income Accra neighbor-

clear that high levels of particulate matter produced by fossil

hoods.”

fuels cause health problems ranging from low birth weights

Such fundamental changes could vastly improve resi-

to asthma, bronchitis, lung cancer, cardiovascular disease,

dents’ health. Arku’s research will be central to building the

and premature death.

case for such changes, not just in Accra, but also in scores of

Intending to learn more about the link between Accra’s dirty air and the health of its residents, Arku applied to HSPH to do his doctorate. “My dream was to be at Harvard,” he says. Although he hasn’t yet settled on a dissertation,

cities across Africa.

Elaine Appleton Grant is assistant director of development communications and marketing at HSPH and a former public radio reporter.

he is deeply interested in analyzing urban energy use and

44 Harvard Public Health Review

PREVAILING WINDS continued from page 37 Implementation Rule, with benefits estimated at a minimum of $19 billion per year. While the benefits of this rule far exceed the costs, the cost estimate for the Clean Air Fine Particle Implementation Rule is also the highest at $7.3 billion per year.”

Although not everyone agrees with OMB’s assessment or even with the legitimacy of assigning a price tag to health outcomes (what is the monetary value of a human life saved?), many believe such data are more important than ever. The industry lobby has gained strength in the 15 years since the Six Cities brouhaha. In 2011, a hearing before the Republican-led House of Representatives subcommittee on new Clean Air Act rules was entitled, “Lights Out: How EPA Regulations Threaten Affordable Power and Job Creation.”

CHALLENGES IN TODAY’S POLITICS

Seen through a 2012 lens, it may be surprising that the Six Cities imbro-

glio wasn’t a strictly partisan fight.

Unlike today, earlier environmental battles didn’t erupt along party lines.

It was President Richard Nixon who established the EPA in 1970, setting the stage for a string of Republican environmental accomplishments, including the first major reauthorization of the Clean Air Act in 1990 under George H. W. Bush. “When you look at the record,” says Dockery, “the Republican administrations have been better for environmental controls than the Democratic administrations.”

Dockery believes today’s political environment is actually far more difficult for science than it was in 1997.

“Before, there was the cry that we wanted the best science for defining the regulation,” he says. Now, he adds, referring to debates like those over global warming and certain childhood vaccinations, “What we’re seeing is a total rejection of science as the basis for making regulatory decisions.”

HSPH’s Jack Spengler has become convinced that scientists studying today’s environmental problems need both new communication skills and a steel backbone. “You really have to know you’ve got the personality to do this,” he says. “If you choose a public health career and you believe in it, and if you have an urgent public health message that needs to be delivered, this is part of the territory.”

To Spengler, that means public health educators have a new job to do: teaching scientists how to lead and how to deliver their messages to policymakers. “We teach people to be statisticians, epidemiologists, lab analysts, exposure scientists,” he says.

“But we must also equip them for the big fights.”

Elaine Appleton Grant is assistant director of development communications and marketing at HSPH and a former public radio reporter.

EXECUTIVE AND CONTINUING PROFESSIONAL EDUCATION PROGRAMS 2012–2013 SEPTEMBER 2012 September 17–20 Work, Health, and WellBeing: Strategic Solutions for Integrating Wellness and Occupational Safety and Health in the Workplace September 27–28 Sleep and Shift Work: Optimizing Productivity and Health Management in the 24/7 Global Economy OCTOBER 2012 October 1–5 Ergonomics and Human Factors: Strategic Solutions for Workplace Safety and Health

October 14–26 Leadership Development for Physicians in Academic Health Centers

Customized programs are also available. Foster the growth of your executives and your organization as a whole by developing a custom program that will address the specific challenges you face in today’s marketplace. CCPE brings custom programs to organizations around the globe.

October 28–November 2 Leadership Strategies for Evolving Health Care Executives JANUARY 2013 January 13–25 Program for Chiefs of Clinical Services FEBRUARY 2013

All programs are held in Boston unless otherwise noted.

For a complete list of topics and faculty, or to register, visit: https://ccpe.sph.harvard.edu email: contedu@hsph.harvard.edu call: 617-384-8692 Harvard School of Public Health Center for Continuing Education 677 Huntington Ave. CCPE-Dept. A Boston, MA 02115

February 13 and May 17 Leadership Strategies for Information Technology in Health Care

45 Fall 2012

ALUMNI NEWS 1973 Frank M. Torti, MPH, became vice president for health affairs at the University of Connecticut Health Center, and the eighth dean of the UConn School of Medicine in May. Torti holds a Board of Trustees professorship in the Department of Medicine. Torti previously served as vice president for strategic programs, director of the Comprehensive Cancer Center, and chair of the Department of Cancer Biology at Wake Forest University School of Medicine in Winston-Salem, North Carolina.

connections between the built environment and public health. Frumkin is dean and professor of environmental and occupational health sciences at the University of Washington School of Public Health. Frumkin recently married Joanne Silberner, a former National Public Radio health reporter now teaching at the University of Washington.

1983

Jacques Carter, MPH, received a certificate of appreciation from the Mashpee Alma Foggo York, MPH, passed away on Wampanoag Tribe for his dedication February 9 after being struck by a car to providing health care services to the near her Huntsville, Alabama home. A tribal nation. The Mashpee Wampanoag native of Bermuda, she was a mentor and Tribe is connected to Harvard University, educator who served as dean of women both historically and currently, through and chair of the Department of Nursing at the University Charter of 1650, which Oakwood University in Huntsville. describes Harvard’s pledge to educate the tribe’s youth.

1976

1977

Dr. Lonnie Norris, MPH, received the American Dental Education Association (ADEA) Distinguished Service Award during the 2012 ADEA Annual Session & Exhibition in March. He was honored for his significant contributions to education and research, and to the ADEA. Norris has been a faculty member at Tufts University School of Dental Medicine since 1980 and is a tenured professor of oral and maxillofacial surgery. He was appointed interim dean at Tufts University School of Dental Medicine in July 1995 and dean in February 1996. He retired as dean in 2011 and was named dean and professor emeritus.

1982

Dr. Robert Travnicek, MPH, received the Mississippi State Medical Association’s prestigious Community Service Award in June. He was cited for his more than two decades of service as district director of Coastal Plains Public Health District IX. During the aftermath of Hurricane Katrina in 2005, Travnicek “worked tirelessly for two consecutive months without a break,” according to the award citation.

1994 Dr. Gina Solomon, MPH, was appointed deputy secretary for science and health at the California Environmental Protection Agency in April by Governor Jerry Brown. Solomon previously served as a senior scientist for the Natural Resources Defense Council and as clinical professor of health sciences at the University of California, San Francisco.

1997 Brian Jung, MPH, performed with the San Francisco Gay Men’s Chorus in a music video posted online as part of the It Gets Better Project, which aims to inspire LGBT youth who are facing harassment and contemplating suicide. Jung appears in the video, viewable on YouTube at www.youtu.be/-XZRNL9ZnyM.

1998

Swati Piramal, MPH, director of Piramal Healthcare, was elected in May to serve a six-year term on Harvard’s Board of Overseers.

Dr. Roderick King, MPH, was named deputy director of the Florida Public Health Institute in May. King previously was president of Next Generation Consulting Group, a health care organization. He is an instructor in the Department of Global Health and Social Medicine at Harvard Medical School, a senior faculty member at the Massachusetts General Hospital Disparities Solutions Center, and a former director of the Program on Cultural Competence in Research in Harvard Clinical and Translational Science Center at Harvard Catalyst.

Endang Sedyaningsih, MPH, SD ’97, passed away on May 1 from lung cancer.

In 2009, she was appointed minister of health in her native Indonesia. Minister Endang returned to HSPH in May 2011 to deliver a Dean’s Distinguished

Dr. Martin Makary, MPH, published the book Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care (Bloomsbury Press) in September. The book received favorable notice from a Publishers Weekly

1992

46 Harvard Public Health

Kent Dayton/HSPH

Howard Frumkin, MPH, DPH ’93, coedited the book Making Healthy Places: Designing and Building for Health, Wellbeing, and Sustainability (Island Press, August 2011). The book analyzes the

1990

Lecture on “Efforts in Materializing Health Care Equity in Indonesia.”

ALUMNI NEWS Meet Your Alumni Association Representatives Harvard Public Health runs an ongoing series of bios introducing elected representatives on the HSPH Alumni Council. If you would like to get more involved as a representative, committee member, volunteer, donor, or mentor, contact the alumni office at alumni@hsph.harvard.edu.

Teresa Chahine, SD ’10

Sameh El-Saharty, MD, MPH ’91

Teresa Chahine graduated in 2010

Sameh El-Saharty works as senior health policy spe-

with an ScD in environmental health,

cialist in the South Asia region at the World Bank in

and stayed on as a research fellow at

Washington, DC. Before joining the bank, he held sev-

HSPH, while exploring entrepreneurial

eral positions with international or-

approaches to solving global health and

ganizations, academic institutions,

international development challenges

and consulting firms, including the

through MIT’s Legatum Center for

United States Agency for International

Development and Entrepreneurship. Prior to HSPH, Chahine

Development, UNFPA, Harvard

worked as a reproductive health coordinator with the Ministry

University, the American University in

of Social Affairs and UNFPA (the United Nations Population

Cairo, and Pathfinder International. El-

Fund) in Lebanon. Currently, she divides her time between

Saharty has extensive experience for

Boston and Beirut, where she joined the Systems Reform

more than 25 years as a researcher,

Group, a consulting network dedicated to strengthening health

technical adviser, and international consultant on public

and education systems in Arab countries and other transi-

health, health policy and management, health insur-

tional regions in Asia. Chahine conducts urban sustainability

ance, and health sector reform programs in more than

research at HSPH in collaboration with the Harvard Graduate

18 countries in the Middle East and North Africa region,

School of Design and Qatar Foundation, and teaches sustain-

Africa, South Asia, and in the United States. El-Saharty, an

able development practice at Harvard Extension School.

Egyptian national, is married with two children.

reviewer, who wrote, “This thoughtprovoking guide from a leader in the field is a must-read for MDs, and an eyeopener for the rest of us.” Makary is codeveloper of the lifesaving checklist outlined in HSPH Professor Atul Gawande’s best-selling book The Checklist Manifesto: How to Get Things Right. Learn more at UnaccountableBook.com.

1999 Dr. Nawal Nour, MPH, is the 2012 recipient of the Lila A. Wallis Women’s Health Award, presented by the American Medical Women’s Association at their annual meeting in April. Nour was honored for her work establishing and directing the African Women’s Health Center at Boston’s Brigham and Women’s Hospital. The center is devoted to the medical needs of African

women who have undergone female genital cutting (FGC), also known as female circumcision. Nour, who also directs the hospital’s Division of Global Obstetrics and Gynecology, helped develop a surgical procedure that can alleviate some of the negative effects of FGC, such as urinary tract infections, painful menstrual periods, painful sexual intercourse, and difficulty conceiving and giving birth.

Dr. Kelly Moore, MPH, medical director of the Tennessee Immunization Program, was awarded the national Association of Immunization Managers 2012 Natalie J. Smith, MD, Memorial Award at the Centers for Disease Control and Prevention in February. The award recognizes her achieving national vaccine preventable disease goals, visionary leadership, service as a role model, and 47 Fall 2012

advancement of the mission of AIM. It is the highest form of recognition for an immunization program manager.

2000 Jeffrey Blander, SM ’04, SD ’08, and his wife, Michelle, are celebrating the birth of daughter Rose Maisha Blander in May. The family relocated to Washington, DC, in the spring after Blander joined the U.S. Department of State as senior adviser for private sector engagement, Office of the Global AIDS Coordinator, The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).

2007 Raul Ruiz, MPH, is running for Congress in California’s 36th District, where he works as a physician in the Coachella Valley. continued

2011 Oliver Mytton, MPH, who has conducted research on the health effects of taxing unhealthy foods, was cited in a May 16 article in The Guardian.

Mytton and his colleagues found that the price of unhealthy food and drinks would need to increase by 20 percent to cut consumption by enough to reduce obesity and other diet-related diseases.

They recommended that such taxes be accompanied by subsidies on healthy foods such as fruit and vegetables to help encourage a significant shift in dietary habits. Mytton is an academic clinical fellow in public health at Oxford University.

2012 Jason Rafferty, MPH, recently completed his doctorate in medicine at Harvard Medical School, along with his degree in maternal and child health from HSPH. He is continuing his training at Brown University in a residency program combining pediatrics, adult psychiatry, and child/adolescent psychiatry.

Harvard Public Health is interested in hearing from you. Please send comments or class notes to: Amy Roeder, Assistant Editor Harvard Public Health 90 Smith Street Boston, MA 02120 Phone: (617) 432-8440

Fax: (617) 432-8077 Email: magazine@hsph.harvard.edu

AWARDS AND HONORS

May 23 in London. Lown is renowned for his groundbreaking work on the causes and treatment of heart disease and cardiac arrhythmias and his dedication to the prevention of nuclear war.

During the Cold War, he co-founded International Physicians for the Prevention of Nuclear War. The organization won a Nobel Peace Prize in 1985.

Associate professor Sarah Fortune received an award from the Burroughs Wellcome Fund’s Investigators in the Pathogenesis of Infectious Disease program in May. The awards are intended to give recipients the freedom to pursue high-risk projects and new avenues of inquiry. Fortune was recognized for her work on the diversity and virulence of the tuberculosis bacterium.

John McDonough, professor of the practice of public health and director of the Center for Public Health Leadership, received the 2012 Schweitzer Leadership Award in May from the Boston Schweitzer Fellows Program. The award recognizes an individual in Greater Boston or Central Massachusetts “whose life example has significantly mitigated the social determinants of health, and whose commitment to service has influenced and inspired others.”

Atul Gawande, professor in the Department of Health Policy and Management, received a prestigious National Committee for Quality Assurance Health Quality Award in March for contributing to the public’s understanding through his writing and research. Gawande is a staff writer for The New Yorker and has written three best-selling books.

Assistant Professor Maria Glymour was promoted to associate site director of the Robert Wood Johnson Foundation Health & Society Scholars Program at Harvard in May. This interdisciplinary initiative has the goal of building the nation’s capacity for research, leadership, and policy change to address the multiple determinants of health and supports postdoctoral researchers with activities integrated across HSPH, Harvard Kennedy School, Harvard Medical School, and the Faculty of Arts and Sciences.

Bernard Lown, HSPH professor emeritus, received a Lifetime Achievement Award at the British Medical Journal Group’s Improving Health Awards on 48 Harvard Public Health

Franziska Michor, associate professor of computational biology, received HSPH’s second annual Alice Hamilton Award in April. She was honored for her pathbreaking work applying evolutionary theory to cancer. The award is named in honor of Harvard’s first female faculty member, who was appointed assistant professor of industrial medicine in 1919 in what ultimately became the Department of Environmental Health at HSPH.

Eric Rimm, associate professor in the Departments of Epidemiology and Nutrition, received the 2012 General Mills Bell Institute of Health and Nutrition–Innovation Award from the

From top, ©Tony Rinaldo, Aubrey LaMedica/HSPH

Xuehong Zhang, SD, received the American Society of Preventive Oncology’s inaugural Electra Paskett Annual Scholarship at the Society’s conference in March. Zhang, an instructor in medicine at Harvard Medical School, earned the scholarship for his abstract, “Prospective Cohort Studies of Vitamin B6 Intake and Colorectal Cancer Incidence: Modification by Time?” The award recognizes Zhang as an outstanding scientist in cancer research.

FACULTY NEWS

American Society for Nutrition (ASN).

This award is given to an investigator whose scientific contributions advance the understanding of the health benefits of whole grains. Rimm was honored during the ASN Awards Ceremony in April.

K. “Vish” Viswanath, associate professor of society, human development, and health, became a member of the National Vaccine Advisory Committee of the U.S. Department of Health and Human Services in February. The committee recommends ways to achieve optimal prevention of infectious diseases through vaccine development and provides guidance on preventing adverse reactions to vaccines.

APPOINTMENTS & PROMOTIONS Xiaole Shirley Liu professor of biostatistics and computational biology at HSPH and the DanaFarber Cancer Institute Sarah Fortune Melvin J. and Geraldine L. Glimcher Associate Professor of Immunology and Infectious Diseases Josiemer Mattei assistant professor of nutrition Joshua Salomon professor of global health George Seage professor of epidemiology Zhi-Min Yuan professor of radiobiology and director of the John B. Little Center for Radiation Sciences and Environmental Health

IN MEMORIAM Hilton Salhanick Hilton Salhanick, professor emeritus and a former chair of the Department of Population Sciences, died on June 20 at the age of 87.

Salhanick served as Frederick Lee Hisaw Professor of Reproductive Physiology at HSPH from 1971 through 1996. He was also a professor of obstetrics, gynecology,

BOOKSHELF Renegotiating Health Care: Resolving Conflict to Build Collaboration Leonard J. Marcus, Barry C. Dorn, and Eric J. McNulty

Marianne Wessling-Resnick, professor of nutritional biochemistry in the Department of Genetics and Complex Diseases, became the director of the Division of Biological Sciences at HSPH in May. She continues in her role as the director of the PhD Program in Biological Sciences in Public Health.

Kent Dayton/HSPH

Marvin Zelen, Lemuel Shattuck Research Professor of Statistical Science and member of the Faculty of Arts and Sciences, was one of two awardees for the inaugural Karl E. Peace Award, established by the American Statistical Association to recognize “outstanding statistical contributions for the betterment of society.” Zelen was honored at this year’s Joint Statistical Meetings, held in San Diego from July 28 to August 2.

Jossey-Bass 512 pages

Health care today is a complex field, rapidly evolving in ways that can spur divisive conflict or new opportunities for collaboration and innovation. The authors, all part of HSPH’s Program on Health Care Negotiation and Conflict Resolution, tackle the field’s critical issues with practical, proven techniques for navigating turbulent situations and achieving positive outcomes. This thoroughly revised and updated edition focuses on the complex interactions among those who deliver, receive, administer, and oversee health care. It outlines negotiation techniques and conflict resolution approaches that can improve efficiency, quality of care, and patient safety. The book also explores why unresolved conflict can hamper an organization’s ability to make timely, cost-effective decisions and implement new strategies.

49 Fall 2012

and reproductive biology at Harvard Medical School for many years.

Salhanick was instrumental in the design and development of many improvements in contraceptive devices, particularly oral contraceptives. He was the first to purify human progesterone, in 1960, and to show that it had biological activity. He was also among the first to identify some of the side effects of first-generation oral contraceptives, such as liver toxicity and stroke.

HARVARD PUBLIC HEALTH DEAN OF THE FACULTY Julio Frenk

VISITING COMMITTEE Jeffrey P. Koplan, MPH ’78 Chair

ALUMNI COUNCIL As of November 2011

Nancy E. Adler Anita Berlin Joshua Boger Lincoln Chen Walter Clair Lawrence O. Gostin Anne Mills Kenneth Olden Barbara Rimer Mark Lewis Rosenberg John W. Rowe Bernard Salick Edward M. Scolnick Burton Singer Kenneth E. Warner

Officers Elsbeth Kalenderian, MPH ’89 President Anthony Dias, MPH ’04 President Elect Ramon Sanchez, SM ’07, SD ’11 Secretary Royce Moser, MPH ’65 Immediate Past President Alumni Councilors 2009-2012 Marina Anderson, MPH ’03 Rey de Castro, SD ’00 Cecilia Gerard, SM ’09* 2010-2013 Teresa Chahine, SD ’10* Sameh El-Saharty, MPH ’91 Chandak Ghosh, MPH ’00

BOARD OF DEAN’S ADVISORS Jeanne B. Ackman Theodore Angelopoulos George D. Behrakis Katherine S. Burke Christy Turlington Burns Gerald L. Chan Lee M. Chin Jack Connors, Jr. Jamie A. Cooper-Hohn Mala Gaonkar Antonio O. Garza C. Boyden Gray Jeanne Lavine Jonathan Lavine Richard L. Menschel* Roslyn B. Payne Swati A. Piramal Alejandro Ramirez Carlos E. Represas Richard W. Smith Howard Stevenson Samuel O. Thier Katherine Vogelheim

*emeritus

2011-2014 Haleh Armian, SM ’93 Michael Olugbile, MPH ’11* Alison Williams, PD ’10

Harvard Public Health is published three times a year for supporters and alumni of the Harvard School of Public Health. Its readers share a commitment to protecting the health and improving the quality of life of all people.

Harvard Public Health Harvard School of Public Health Office for External Relations 90 Smith Street Fourth Floor Boston, Massachusetts 02120 (617) 432-8470 Please visit http://www.hsph.harvard.edu/ news/magazine/ and email comments and suggestions to magazine@hsph.harvard.edu.

Dean of the Faculty Julio Frenk T & G Angelopoulos Professor of Public Health and International Development Vice Dean for External Relations Ellie Starr Associate Vice Dean for Communications Julie Fitzpatrick Rafferty Director, Strategic Communications and Marketing Samuel Harp Editor Madeline Drexler Assistant Editor Amy Roeder Senior Art Director Anne Hubbard

*Class Representative

Assistant Director for Development Communications and Marketing Elaine Appleton Grant

For information about making a gift to the Harvard School of Public Health, please contact:

Principal Photographer Kent Dayton

Ellie Starr Vice Dean for External Relations Office for External Relations Harvard School of Public Health 90 Smith Street Fourth Floor Boston, Massachusetts 02120 (617) 432-8448 or estarr@hsph.harvard.edu

Contributing Photographers Aubrey LaMedica, Brian Smale Contributing Illustrators Shaw Nielsen Marketing and Communications Coordinator Rachel Johnson

For information regarding alumni relations and programs, please contact, at the above address:

Contributing Writers Michael Blanding, Luisa Cahill, Karen Feldscher, Courtney Humphries © 2012 President and Fellows of Harvard College

Jim Smith, Assistant Dean for Alumni Affairs (617) 432-8446 or jsmith@hsph.harvard.edu www.hsph.harvard.edu/give

50 Harvard Public Health

“ There is something better than science …

That is science with a moral compass, science that contributes to social equity, science in the service of humanity.”

William Foege MPH ’65

Epidemiologist William Foege’s interest in global health began in his teen years, when he read about Albert Schweitzer’s work in Gabon. His fascination took him first to medical school and then to Harvard School of Public Health, where the shy six-foot-seven doctor earned his master’s degree in 1965.

His studies set the stage for a 50-year career that made him a public health hero.

Foege is credited with helping implement the vaccination strategy that eradicated smallpox, one of the deadliest human scourges in history. He led the CDC from 1977 to 1983. In 1984, he created a task force on global childhood immunization, and in six years the proportion of children who had received at least one immunization rose from 20 to 80 percent. Foege led the Carter Center and is a senior fellow at the Bill & Melinda Gates Foundation. In May 2012, President Barack Obama awarded him the nation’s highest civilian honor—the Presidential Medal of Freedom.

“I’ve been so lucky in my life,” Foege told The Lancet. “I’ve worked on everything I’ve been interested in for half a century.”

With your help, HSPH can train a new generation of global health leaders who one day can have an impact as great as or greater than Foege.

Please give to support financial aid today.

To find out how, visit http://hsph.harvard.edu/give or call Morgan Pendergast at 617-432-8436.

Nonprofit Org. U.S. Postage PD Burlington, VT Permit No. 586

Harvard University Office for External Relations 90 Smith Street Boston, Massachusetts 02120

Change Service Requested

As National Elections Near, HSPH Experts Weigh In On Affordable Care Act The U.S. Supreme Court ruled on June 28, 2012 to uphold most of the Obama administration’s health care law. But the fate of the Affordable Care Act remains a hotly contested issue in the upcoming presidential and congressional elections.

Throughout the debate, Harvard School of Public Health researchers have been part of the national conversation, contributing innovative research and expert commentary on the issues.

For the latest polling on health care, analysis of the Supreme Court’s ruling, and coverage of HSPH research on health policy topics ranging TV networks report live on the sidewalk during the third and final day of legal arguments over the Patient Protection and Affordable Care Act at the Supreme Court in Washington Jonathan Ernst/REUTERS

from cost control to electronic medical records, visit hsph.me/election2012healthcare.