Courtesy of the Harvard School of Public Health
Julio Frenk
The
launch of the Harvard School of Public Health (HSPH) capital campaign coincides
with the school’s centennial celebration. Since opening in September 1913 as
the Harvard-MIT School for Health Officers, the school has influenced many
major public-health initiatives of the twentieth century, from the development
of a polio vaccine to the passage of the Clean Air Act. Harvard Magazine spoke with several current HSPH professors about
achievements of the past and directions for the future: combating malaria,
stopping pandemic flus, improving humanitarian aid, and more.
Dean Julio Frenk is quick to put the
school’s centennial and campaign into historical context. “The field of public
health already has made some of the largest contributions to society of any
human endeavor,” says the Angelopoulos professor of public health and
international development, who has been dean since January 2009 (see “A Global Health View”). In the past
century, public health has “completely [changed] the character of disease and
death among humans” and succeeded in developing a “set of specialized
institutions and dedicated professionals devoted exclusively to taking care of
health.” Average life expectancy in the United States increased more than 30
years in the twentieth century—“a larger gain in life expectancy than in all of
previously accumulated history”—and 25 of those years, he says, are
attributable to public-health interventions: vaccines, sanitation, clean air,
seat belts, tobacco control. “We’ve been able to move the average age of death
closer and closer to the biological limit.”
He highlights several continuing
changes in how researchers and practitioners think about the field. A
revolution in big data is transforming basic research, allowing access to
enormous amounts of information about the human body. The first human genome,
for instance, was sequenced through a national effort spanning more than a
decade; now, billions of base pairs of information are available for a few
thousand dollars, and with the influx of data has come a change in systems
thinking and the ability to “understand and harness complexity.” Closely
related is a revolution in communications that now connects the world through
mobile phones and the Internet; Frenk points to mHealth, a movement that uses
mobile health platforms to increase the reach of aid workers and empower
citizens, particularly in poor nations. Another shift is a revolution in
rights, closely tied to healthcare—“the awareness that access to the benefits
of the other revolutions is a fundamental right of people.”
At the same time, public-health
progress faces major threats, the dean says, encapsulated in the four HSPH
campaign themes:
old and new pandemics;
harmful physical and social environments;
poverty and humanitarian crises; and
failing health systems
Across
fields, HSPH is also adapting its curriculum and pedagogy for the new century. “Our
mission in life and our value to society is to create the knowledge and educate
the leaders that will be able to protect us all from these four threats,” Frenk
says. “That’s the key message for the campaign, and that’s the key priority for
the next hundred years for this school.”
Kris Snibbe/Harvard Public Affairs and Communications
Dyann Wirth
Old and new pandemics: Developing tools to
reverse killer diseases
Something old. “The landscape of infectious diseases has changed significantly in
the past century,” says Dyann Wirth, Strong professor of infectious disease and
chair of the department of immunology and infectious diseases (see “Evolving Foe”), and
HSPH has played an important role. The school’s Thomas Weller was one of three
researchers awarded the 1954 Nobel Prize in physiology or medicine for
culturing poliovirus (the iron lung for polio treatment was likewise developed
at HSPH, in 1928), paving the way for development of a vaccine; his student
William Foege, M.P.H. ’65, S.D. ’97, led the worldwide effort for smallpox
eradication. “The theme there,” says Wirth, “is that fundamental knowledge has
changed infectious disease outcomes in a dramatic way.”
Smallpox has been defeated, and both
polio and guinea worm are on their way out, but old diseases like tuberculosis
and malaria remain major public-health problems today. Wirth, who leads the
Harvard Malaria Initiative, believes that innovation in both medical treatment
and in public-health intervention require the unraveling of biological secrets.
The malaria parasite, for instance, is capable of antigenic variation—changing
surface proteins to evade immune recognition. “The pathogens we encounter
today,” she says, “are the survivors who have undergone the ultimate test.” She
therefore emphasizes a new, holistic research mindset that focuses on
investigating systems rather than individual genes. “The malaria parasite has a
complex life cycle,” she explains, “and studying parts in isolation may not
reveal what aspects are most important.”
The fight against disease must also go beyond basic research.
A new, cross-school initiative—“Defeating Malaria: From the Genes to the
Globe”—emphasizes the role that business and government must play in
eradicating the disease. “The world had two of the best tools for combating
malaria in the 1950s,” she says, with the simultaneous development of the
cheap, effective drug chloroquine and the insecticide DDT. Indeed, the disease
was successfully eliminated from the United States and southern Europe. But
problems arose. As the disease petered out, so did government commitment to its
control; at the same time, the efficacy of both treatments declined as resistance
emerged in the parasite and mosquitos. Add in environmental concerns about DDT,
and malaria surged back. To sum up, Wirth says, “Many pieces are needed to
craft an effective solution.”
Stephanie Mitchell/Harvard Public Affairs and Communications
Marc Lipsitch
Something new. A new
infectious disease begins with just a few cases, and it is up to researchers
like Marc Lipsitch, professor of epidemiology, to squeeze as much information
as possible from initial reports and draw a portrait of a possible pandemic in
the making. As director of the Center for Communicable Disease Dynamics at
HSPH, Lipsitch uses population genomic techniques and mathematical models to study
disease transmission and recommend public responses to emerging infectious-disease
threats.
One example is the 2009 H1N1 swine
flu pandemic. Lipsitch, working closely with the U.S. Centers for Disease
Control and Prevention, examined available public-health data—“line lists” of
patients, their locations, and the course of the disease—to infer
epidemiological metrics like incubation time and transmissibility that would
describe how an epidemic might unfold—and what response measures were likely to
succeed.
For instance, a pandemic flu patient
generates, on average, about two more flu cases, compared to a basic
reproduction number (BRN) of more than 10 for measles. School closings have
much more impact on the less-contagious flu, says Lipsitch, and similar models
of disease spread may also influence decisions about quarantine and vaccination
strategy. For SARS, isolation and quarantine were enough to prevent a possible
pandemic; Lipsitch’s team calculated that the disease’s BRN was 3, but the main
factor aiding public-health officials was the lengthy eight-day incubation
period following exposure before the disease became transmissible (see “The SARS Scare”).
“Control measures like closing
schools and ‘social distancing’ provide only a temporary delay in the
transmission of a pandemic infection,” says Lipsitch. When these measures are
eventually relaxed, the outbreak may resume with its former intensity. Nonetheless,
“such measures can ‘buy time’ until vaccines are available, and can reduce the
number of people sick at any given time.” In the public-health community,
Lipsitch observes, “people are stretched at the local, and increasingly, the
federal level.”
Meanwhile, new diseases will continue to emerge, and their
exact nature can be hard to predict. Genetic tests give researchers more power
to identify new pathogen strains and to track their spread and evolution, but
developing successful tests—and eventually, vaccines—requires investigators
with strong foundations in basic research. Research on coronaviruses, for
example, was a “backwater” before the SARS epidemic, Lipsitch says. “We need more
people working on diseases that aren’t fashionable, and it’s the role of
government to maintain the diversity of research programs.”
Courtesy of the Harvard School of Public Health
Douglas Dockery
Harmful physical and social environments:
Preventing pollution, promoting healthy communities
The
air we breathe. From his office on the thirteenth floor, Douglas
Dockery can see well into downtown Boston—and he has helped make the view
possible. In the 1970s and 1980s, the professor of environmental epidemiology
led the longitudinal Six Cities Study, published in 1993 as the first
definitive evidence linking air pollution to respiratory and cardiovascular
illness and even premature death (see “Clearing the
Air”). The findings, which now seem self-evident, would form the basis for
Clean Air Act regulations on fine particulate matter in 1997. Today, Dockery
notes that the air in Boston is remarkably clean despite arriving from
America’s heartland and industrial region, and the city has had great success
cleaning its rivers and waterfront as well—in large part thanks to the
influence of public-health practitioners (see “Clean Air,
Longer Life”).
The department of environmental
health, which Dockery now chairs, studies “the environment, broadly defined as everything
outside our genes and our behavior”; that is, not the act of smoking, but the
effect of secondhand smoke; not food, but the pesticides on food; not only the
quality of water, but also the plastic containers from which we drink. The work
is by nature interdisciplinary, he says, drawing from fields as disparate as microbiology,
genetics, epidemiology, meteorology, engineering, and public policy.
Researchers often focus on chronic diseases, conceiving of them as products of
a lifetime of exposures that encompass anything from chemicals like lead in the
physical sphere, to subtle influences in the social and built environments.
Rapid increases in the prevalence of diseases like asthma and autism “cannot be
entirely due to genes.” Any time such shifts in disease patterns occur, says
Dockery, there’s a clue that changes in the environment might be of interest.
New scientific advances change how
we view our environment, he says. The field of epigenetics has emerged from the
finding that environmental influences like famine can alter gene expression for
many generations to come. Meanwhile, studies of the human microbiome, the
ecosystem of bacteria within the gut, show that microorganisms link our insides
with the world around us. And, as Dockery says, “We are the environment for
other organisms.”
In many areas, as with the Six Cities Study, research
dovetails with issues of public policy, and Dockery believes his department’s
role is to provide sound science to inform and evaluate policy decisions.
Whether the concern has been air pollution, toxic metals, or synthetic
chemicals, he says public health has managed to win major victories.
Nevertheless, he points out, environmental health almost always studies past
events, and researchers still struggle to predict the effects of new chemicals.
As a society, he emphasizes, “we will need to be vigilant, as our actions can
often have unexpected consequences.”
Stephanie Mitchell/Harvard Public Affairs and Communications
Walter Willett
The food we eat. “It’s hard to imagine what life was like a hundred years ago,”
says Walter Willett, Stare professor of epidemiology and nutrition (see
“The Way
We Eat Now”). Infectious
diseases dominated the public-health sphere; the concept of nutrition was
barely on the horizon. The HSPH department of nutrition, which Willett chairs,
was founded in 1942 by Frederick Stare. Until that time, nutrition research had
mainly focused on micronutrients; by studying diseases like scurvy, rickets,
and beriberi, researchers identified the minerals and vitamins essential for
health. Stare recognized that cardiovascular disease was becoming more common
in the United States and initiated research into the epidemic’s origins. The
department’s Irish Brothers Study, which examined diet and heart disease in
pairs of siblings on opposite sides of the Atlantic, as well as several studies
of diet and cholesterol, were early landmarks.
Willett pioneered
the field of nutritional epidemiology, overseeing this research in three large
cohort studies—the two Nurses Health Studies begun in 1976 and expanded in
1989, and the Health Professionals Follow-Up Study in 1986—that have together
tracked the diets of nearly 300,000 people for more than two decades. “Many
hypotheses existed about the relation of diet to cardiovascular disease,
cancer, and other diseases, but what was missing was a large a body of
empirical evidence,” he says. His research has found connections between
nutrition and health that, though often vigorously debated at the time, are now
conventional wisdom—the link between trans fats and heart disease, for
instance, and the health risks of being overweight. Willett has engaged with
businesses and chefs through initiatives like Menus of Change and fought for
bans on trans fats. The department now hosts NutritionSource, a website dedicated
to making the best available evidence accessible to the public. “I think of
nutrition as an orchestra,” says Willett. “You can’t just focus on one piece.”
Advances in research are bringing
new factors to light, he says. Nutritionists are returning to archived blood
samples to study DNA and metabolomics, the chemical processes inside cells, and
the gut microbiome is thought to have an important health effect as well. Childhood
diet seems increasingly connected with later-life events like breast cancer and
cardiovascular disease. “These conditions that develop in old age are the
result of what happens over the whole lifespan,” he says. And even as obesity
is on the rise in developed nations, the developing world still suffers from
malnutrition; in conjunction with the department of global health and
population, Harvard nutritionists also study maternal-child health. Though
nutrition has come a long way, says Willett, “there is still lots of scientific
work that needs to be done.”
Poverty and humanitarian crises: Advancing
health as a human right
Jon Chase/Harvard Public Affairs and Communications
Michael VanRooyen
A
disaster strikes, and aid pours in—donations of clothing, for instance, are a
common response. Following the disaster, local markets are flooded with cheap
or free clothing, much of it often culturally inappropriate, putting merchants
out of work and undermining the existing economic infrastructure. The donation,
though well intentioned, has had unforeseen consequences.
“Non-governmental organizations are
great at field operations,” says Michael VanRooyen, director of the Harvard
Humanitarian Initiative (HHI) and professor in the department of global health
and population, “but not as good at analysis, research, and reflection.” The
goal of the initiative, founded in 2005, is to draw upon expertise from all of
Harvard’s schools—public health, medicine, business, law, government—to
implement strategic approaches to humanitarian aid. VanRooyen makes a
comparison to how medical schools support hospitals: academic programs provide
elements of training, research, and education that contribute to more effective
practice. A major emphasis, he says, is to “help people acknowledge that humanitarian
assistance is its own discipline” (see “Think
Tank for Aid Workers”).
Take the 2010 earthquake in Haiti,
he says. Though many aid organizations were on the ground, the crisis response
suffered from lack of coordination. Assessment of conditions was hampered by
the different data, methods, and questions that each agency had. “Big crises
often force reflection in the humanitarian community,” VanRooyen reports.
Following the Haiti response, the UN made revisions to the organizational “cluster
system” put in place after the 2004 Indonesian tsunami and instituted a
“transformative agenda” to further streamline its response. Harvard researchers
are developing a mobile platform, KoBo, that integrates all data collected in a
humanitarian crisis, making it available to UN and international organizations so
that they can share information on health, logistics, human rights, and
protection. Continuing- and professional-education initiatives by the
Humanitarian Academy at Harvard train and retrain emergency field workers, and
each spring, VanRooyen leads an intensive, simulation-based course that touches
on issues from sanitation to international humanitarian law.
Beyond addressing the immediate demands of humanitarian
crises, promoting “health as a fundamentally human right” has been a priority
of Frenk’s deanship. Millions of people still die every year from preventable
causes, from childbirth to malnutrition, he says. “This is not a failure to
know. This is a failure to act.” He launched the HSPH Women and Health
Initiative in 2010, drawing on his previous experiences combatting maternal
mortality and increasing access to contraception as Mexico’s minister of health
(see “Labor,
Interrupted”); the school’s François-Xavier
Bagnoud Center for Health and Human Rights also conducts research and makes
policy recommendations on conditions of extreme poverty. “In addition to being
a violation of human rights, [such poverty is] a threat to our common
security,” Frenk explains, “because it’s exactly those injustices that generate
civil strife and create a mindset of extremism and fundamentalism.”
Failing health systems: Leading change,
changing leaders
Courtesy of the Harvard School of Public Health
John McDonough
“When
public health is working,” says John McDonough, professor of the practice of
public health, “no one notices it.” The discipline’s reach is broad, and as
director of the Center for Public Health Leadership, McDonough trains leaders
for the varied roles that public health demands.
HSPH has trained several ranking
officials in the World Health Organization and six directors of the U.S.
Centers for Disease Control and Prevention, whose combined tenure of more than three
decades constitutes nearly half the organization’s 67-year history. Now,
McDonough hopes to create a more systematic basis for leadership training. In the
fall of 2012, the school launched an interdisciplinary concentration in public-health
leadership. Coursework addresses topics like health-sector reform and social
entrepreneurship, while encouraging students, he says, to embrace a “broader
definition of leadership” in both their careers and everyday lives.
The school has also sought voices
from outside academia, bringing in current leaders like U.S. secretary of
health and human services Kathleen Sebelius and Massachusetts governor Deval
Patrick to discuss policy choices and scientific controversies. The Ministerial
Leadership in Health Program, meanwhile, invites current ministers of health
and finance to create what McDonough calls a learning community of academics
and political leaders. McDonough also directs the school’s program for
executive and continuing professional education; a new initiative brings together
global corporate medical directors who oversee everything from employee
benefits to occupational health and safety. Their role, he says, is
diversifying and increasing in sophistication; they are “people who daily use
the tools of population and public health in corporate practice.”
Frenk warns that current health-care
systems around the globe are failing to meet societal demands: medical errors
threaten patient well-being, and “unproductive costs” are a drag on the world economy.
As for this nation: “The U.S. is the industrialized country that spends the
most on health, yet it is also the industrialized country that has the worst health
outcomes,” he says. This summer, HSPH launched an effort with Brigham and
Women’s Hospital called Ariadne Labs; led by Atul Gawande, professor in the
department of health policy and management, it is developing “safe surgery” and
“safe childbirth” checklists to reduce complications and deaths from medical
procedures (see “The
Unlikely Writer”).
Frenk acknowledges that educational initiatives like those
led by McDonough represent a major component of the school’s impact. “Leading
change, changing leaders—that’s what we do,” says Frenk. “We lead change by
providing knowledge and translating it into relevant policy. We also change the
leaders—we educate both the current and future generation.” In his 2013
Commencement address, the dean emphasized the need for interdisciplinary
solutions to public-health problems. “What we need are T-shaped leaders,” he
said, “leaders with knowledge that is not only deep in a few areas but also
extends to many.”
Transforming public health education for
the twenty-first century
Kris Snibbe/Harvard Public Affairs and Communications
David Hunter
Though
not an official campaign theme, education is central to the school’s second
century. When HSPH opened in 1913, it was the nation’s first graduate training
program in public health; that year, it also became the first Harvard school to
open admissions to women on the same basis as men.
In 2010, the school began a
multiyear curricular review. Its conclusions have pushed the adoption of a more
competency-based curriculum, says dean of academic affairs David Hunter, and the
addition of more practical, immersive elements (see “Talking About
Teaching”). HSPH designed one of the first two HarvardX courses last year,
“Health in Numbers: Quantitative Methods in Clinical and Public Health
Research,” and some professors are experimenting with a “flipped classroom”
approach, in which students watch recorded lectures before the course meets,
and engage in discussion during class time. “HarvardX came along at the right
time for us because our faculty were very, very interested in digital learning,”
says Hunter. “We have essentially a global mission…and we see [digital
learning] as an important part of our spectrum of activities.”
The structure of the school’s degree
programs is undergoing revision as well, spurred by the centennial review. A
new Dr.P.H. in public-health leadership will launch next fall, underwritten by
$5 million from anonymous donors. Existing doctorates, says Hunter, are
oriented toward research; this professional degree will train students to be
public-health practitioners and
policymakers. Similar research and professional tracks will be implemented
among the master’s degree programs, and a prospective interdisciplinary Ph.D.
in population sciences is in development. These new educational initiatives,
says Frenk, will train a new generation of researchers and leaders to bring
HSPH into its second century.