Harvard Public Health, Fall 2012

Six Cities: A Decades-Long Fight for Clean Air

Making the Case for Public Health

Why Do We Age? Surprising Revelations from a Worm

HSPH.HARVARD.EDU

HEALTHHARVARD

PUBLIC

The Dollars & Sense of Public Health

Fall 2012

T of life expectancy on average in the United States.

According to the federal Centers for Disease Control and

Prevention, these advances included: the eradication of

smallpox and control of other infectious diseases through

vaccination; improved sanitation and access to clean

water; improvements in food safety and nutrition; safer

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

Today, different public health problems threaten

economic gains, both in affluent and developing

countries. Of particular concern are rising levels of

noncommunicable diseases, such as obesity, diabetes,

high blood pressure, heart disease, cancer, and mental

disorders. In the U.S., three-quarters of health care dollars

go to treating these chronic—and often preventable—

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.

he cover story in this issue of Harvard Public Health

explores one of the most complicated intersections

in policymaking: the nexus of public health and the

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

months away, voters can consider what we have learned

about these closely linked issues.

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

performance and economic performance can’t be

separated. On the most fundamental level, wealthier

nations tend to have better health conditions and

therefore healthier people. And as HSPH’s David Bloom

has shown, healthier people likewise promote economic

growth, in part because they are more productive and

Health & Wealth

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

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 economy-

boosting healthy population. In the 20th century,

public health advances accounted for 25 more years

DEAN’S MESSAGE

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

2Harvard Public Health

HARVARD HEALTHPUBLIC

Fall 2012

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

COVER STORY16 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.

38 Why Do We Age? Surprising Revelations from a Worm

The School’s William Mair explores

why we get frail as we get older.

FEATURES

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.

25 Working the System

HSPH alumnus Anthony Chen tackles

the big issues in Washington State.

28 Infographic: The Dollars and Sense of Chronic Disease

DEPARTMENTS

42 Arku’s Journey

Student Raphael Arku traded a

lucrative job for a career cleaning up

air and water in Ghana.

30 Prevailing Winds

The Six Cities air pollution study

showed that when science triumphs,

the public wins.

4 Frontlines

9 Philanthropic Impact

45 Continuing Professional Education Calendar

46 Alumni News

48 Faculty News

Back Cover HSPH and the Affordable

Care Act


From

top, ©Tony R

inaldo; Don Farrall/D

igital Vision

HSPH RAISES A HEALTHY CUP TO CHEF JAMIE OLIVERJamie Oliver—celebrity chef, TV personality, and “food revolution” activ-

ist—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

world’s present and future health.”

“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.”

FRONT LINES

High Cost, Low Quality of U.S. Health Care Add to Woes of the SickA 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) consid-ers 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 requir-ing considerable medical care or overnight hospitalization within the past 12 months) experienced the cost of their care as a serious prob-lem 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 qual-ity 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 BuzzOne of the most widely used pesticides in agriculture and the residential environ-ment—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.

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.

5Fall 2012

Researchers have known that climate change and other atmospheric forces are causing dramatic increases in levels of mercury—a potent neurotox-in—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 Arc-tic 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 per-mafrost 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, “Un-derstanding 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 HIV-

infected 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.

Bob Strong/REU

TERS; Leigh Vogel/W

ireImage

HSPH Alum William Foege Honored with Presidential Medal of FreedomLegendary public health epidemiologist William Foege, MPH ’65, has received the

nation’s highest civilian honor—the 2012 Presidential Medal of Freedom. Foege’s

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 Rol-

lins School of Public Health at Emory University, and an affiliated professor of epidemi-

ology at the University of Washington School of Public Health.

Arctic Mercury Rising as the Mercury Rises

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.

HPH Editor Receives National Journalism AwardMadeline 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.


FRONT LINES

D-BASE/G

etty Images; Illustration, Shaw

Nielsen

OUR BODIES, OUR BUGS: Microbial Genes Outnumber Human Genes 100 to 1

URBAN ENVIRONMENTS DEPRESSING? JUST ADD TREES

It’s common wisdom that

block after block of un-

relieved streetscape can

be oppressive. With back-

grounds 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, build-

ings, 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,” Land-

scape and Urban Planning, July 2012.

ew studies led by HSPH researchers in the Human Microbiome Project (HMP) have helped identify and analyze the vast human “microbi-ome”—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 immu-nity, 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.

HSPH Gathers World Health Ministers

Sixteen of the world’s ministers of health gath-

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 Invest-

ment 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—small-

pox eradication being the greatest historical example

of international coordination—to drive future im-

provements in the health care system.

N

A.Q.

7Fall 2012

WINSTON HIDE ASSOCIATE PROFESSOR OF BIOINFORMATICS AND COMPUTATIONAL BIOLOGY

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

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.

OfftheCUFF

©Tony R

inaldo

LEARN MORE ONLINEVisit 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.

“

”

Starting a Revolution

M


FRONT LINES

Aubrey LaMedica/H

SPH

LEARNING TO LEADaking a difference in public health requires more than knowledge and idealism. It also requires finesse in commu-nication, conflict resolution, negotiation, and mobilizing strangers. In short, it takes an expertise not widely recog-nized 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 scien-tists. Look at how we failed in climate change, where the message is one of fear. Look at the message we constantly

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

“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 Leader-ship, 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

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 experi-enced 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 leader-ship development—a critical component of training, says McDonough. “When you have to stand up and disagree

with someone, maybe someone who has more author-ity 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 commit-tee 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.”

Amy Roeder is assistant editor of Harvard Public Health.

“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

T

9Fall 2012

LIVES TRANSFORMED

Kent D

ayton/HSPH

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.

PHILANTHROPIC IMPACT

Ellie Starr, Vice Dean for External Relations

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

Dean Julio Frenk.

P


PHILANTHROPIC IMPACT

New Scholarship Supports Doctoral Students in Nutrition, Honors Willett

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 depart-

ment’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 accom-

plished and motivated but financially underprivileged

students to study at HSPH. The donors hope that, in par-

ticular, the scholarship benefits students from economi-

cally challenged countries.

“This scholarship will afford me the academic free-

dom to really think about my education and career in

public health nutrition and to really find my calling,” said

Khandpur, who has worked in India as a nutrition and

fitness consultant and for the Public Health Foundation

of India, which propelled her desire to influence nutri-

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

exciting.”

“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

to India to work in this area. The scholarship underscores

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

ting edge of science, but also applying this knowledge to

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

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

wisdom that cannot be reached by developing intellect

alone, but includes insight from experience and under-

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-

tions to public health nutrition. Likewise, the donors hope

that the scholarship will encourage its recipients to merge

intellect and practice together to compassionately advance

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

of public health nutrition, like Willett. They also hope

their gift will inspire others to support both students and

faculty at HSPH.

Willett said that now, more than ever, support of stu-

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

major funding source, the National Institutes of Health.

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

a doctoral student is probably one of the very best things

they can do,” Willett said. “It’s investing in people who, for

decades in the future, will make a real difference in the

world. The multiplication effect is huge.”

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

Aubrey LaMedica/H

SPH

Transformative Education for Public Health Leaders

Killer infections. A dramatic rise in

chronic diseases. Environmental

emergencies. Unequal access to medi-

cal care. These problems—just a few of

the daunting public health issues facing

the world today—demand not only

wide-ranging expertise, but also in-

spired leadership. To help future public

health leaders meet this challenge,

a $5 million gift has been made to

Harvard School of Public Health to fund

a “Leadership Incubator for Strengthen-

ing Health Systems.” The gift is a key

component of the “Roadmap to 2013,”

a comprehensive review of HSPH’s

educational strategy, which is being

undertaken as the School approaches

its centennial in fall 2013.

The Leadership Incubator for

Strengthening Health Systems is ex-

pected to be supported by an anony-

mous gift of $5 million—the largest

gift ever made to HSPH in support of

education.

BREAKING THE MOLD

According to Dean Julio Frenk, the

incubator will foster changes in educa-

tion that will “break the mold,” push-

ing the traditional discipline-based

boundaries of academia, research,

and public health. It will encourage a

greater focus in coursework on the

importance of leadership and on the

complexities—political, economic, and

social—of achieving global improve-

ments in public health. “A new doctor

of public health (DrPH) degree that we

envision, for example, will be oriented

toward competencies in high-level

policy analysis and problem-solving

leadership,” he said. “This gift will

enable us to continue as the leading

school of public health—first in quality

as well as first in our capacity to shape

the future.”

“We have followed with admira-

tion the work of the School for more

than two decades, and this initiative

is one of the most exciting things that

we have seen during this period,” the

donors said. “It speaks to our deep

belief in the power of young people—

in particular, this generation of young

people—to change the world.”

IMMERSIVE EDUCATION

A key component of the gift supports

students at all levels of experience

and creates opportunities for them to

learn from each other. Another unique

and important part of the gift supports

faculty members’ efforts to work with

alumni and other public health leaders

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

teaching methods, technology en-

hanced learning, and an immersive and

life-changing educational experience

for professional degree students.

Under a proposal to redesign the

DrPH degree, for example, 25 out-

standing students, beginning in 2014,

will be named each year as “Centenni-

al Fellows”; 10 will be supported by the

new gift. Students will complete two

years of coursework, bolstered by case

studies, crisis simulations, and field

experience, followed by an innovative

third-year internship experience that

serves as the capstone to the degree.

The Leadership Incubator is also

expected to sustain already estab-

lished leaders at various points in their

careers. For current leaders, HSPH has

already initiated a Ministerial Leadership

in Health Program, an intensive five-day

campus-based program for ministers of

health, which is followed by year-long

support from experienced public health

experts and HSPH faculty. Meanwhile,

leaders who have recently held high-

level public health positions can spend

time on campus as “Senior Leadership

Fellows,” sharing expertise with students

and project work with faculty members.

And a new joint initiative with Harvard

Business School will give advanced

leaders the chance to study major social

problems that shape health.

PRIMED TO MAKE AN IMPACT

“HSPH’s new Leadership Incubator will

provide the impetus for a paradigm

shift in educating entrepreneurial public

health students—both young and old,

less experienced and more—who will

be primed to make the greatest pos-

sible impact on the health challenges of

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

ate dean for strategic educational initia-

tives. “We are extremely grateful for this

historic gift, which will enable us to live

out the spirit of our centennial celebra-

tion by beginning our second century

with innovations in the education of

today’s and tomorrow’s leaders.”

11Fall 2012

Harvard School of Public Health Dean Julio Frenk encour-aged this year’s graduates to look beyond “tightly defined career paths” as “the only routes to personal and profes-sional 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 eas-ily 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 pro-vided 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, includ-ing 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.


Commencement

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

FUTURE PUBLIC HEALTH LEADERS WILL “MOVE BETWEEN WORLDS,” GRADUATES TOLD

Highlights from the remarks of Gerald Chan at the School’s 2012 Commencement

A BEAUTIFUL MINDNew 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 derogato-rily, 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 stor-age capacity, nor even what has been stored in it. A beautiful mind is a mind with beautiful ideas.

A SOUND BITE SOCIETYI 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 RsEnrich 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.

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

13Fall 2012

Suzanne Camarata

HSPH 2012 COMMENCEMENT BY THE NUMBERS

Students from 57 countries, 34 U.S. states, and the District of Columbia received degrees at Harvard School of Public Health’s 2012 Com-mencement 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 Philosophy1 Doctor of Public Health53 Doctors of Science11 Masters of Arts272 Masters of Public Health153 Masters of Science

AWARDSAt 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 AwardJoshua 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 HealthAtena 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


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

For nearly 30 years, Robert

Blendon, Senior Associate Dean for

Policy Translation and Leadership

Development, has been polling

Americans about their views of

public health, health care, and

other related hot-button issues.

Polls on the eve of the 2004 and

2008 presidential elections found

Americans deeply divided on these

issues. Today, with an uncertain

economy the most pressing concern

in voters’ minds, Blendon spoke

with Harvard Public Health

editor Madeline Drexler about the

current politics of public health in

America.

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

Conflicting Views of the Public Health System.” One

of your findings was that while most Americans favor

spending more on public health in general, and believe

public health saves money in the long run, they oppose

specific interventions and programs. What’s behind that

contradiction?

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

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

health”: communicable diseases, foodborne outbreaks, help-

ing people during disasters and emergencies, basic educa-

tion. The conflict is around chronic illnesses—heart disease,

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

convinced that public health measures alter those.

Q: But chronic diseases are the top cause of death and dis-

ability in the United States. Three-quarters of the health

care budget goes toward treating those conditions.

Maybe people don’t understand the logic of prevention?

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

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

You have to be very specific before anybody sees it as

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

tervention, then type 2 diabetes will go down by this number

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

there will be this many fewer women diagnosed with breast

cancer in Kentucky.

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.

Q&A

The Dollars & Sense of Public Health | SPECIAL REPORT

15Fall 2012

Q: In 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: In 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.

Q: So how should public health professionals make their case?

A: You 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 Commis-

sioner 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: Isn’t that the message that’s conveyed today?

A: No. 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 noncommunica-

ble diseases.’ Later, they call me and complain, ‘The state legislature cut our budget by one-half.’”

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

A: Absolutely. 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 appro-

priation?’ In this world, you have to be targeted and directive.”

“ 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.”—Robert Blendon


Public Health & the U.S. Economy

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 Insti-

tute 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.

W

17Fall 2012

continued

Second, the costs of health care are built into the price of every American-built product and service. And the per cap-

ita 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 per-

cent—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 Ameri-

can economy. Here’s what they told him.

How the next U.S. president can stack the deck in favor of people’s health and wealthin 2013



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

have for the federal WIC program (Women, Infants and

Children program), which essentially allows purchases

only for healthy foods. That policy would cost virtu-

ally nothing, but it would transform the food supply and

dramatically improve the health and wellbeing of SNAP

recipients. Little stores and bodegas that only stock junk

now would start carrying healthy foods, the cost would

come down because of the greater volume of healthy alter-

natives, and these foods would also become available for

those not receiving SNAP benefits.

We are talking about doing something that is cost

neutral but would produce not just better health, but also

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

you change what people eat—and perhaps return physical

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

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

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

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

Long-term health costs will decline as fewer people

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

all of us.

WALT WILLETTChair, Department of Nutrition

The obesity epidemic has huge economic consequences,

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

is a generation of children today who have diabetes or

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

will start developing heart disease and kidney failure, and

need amputations as well as treatment for sight loss. These

conditions will cause enormous costs in the future, even if

we arrest obesity at the present levels.

The federal SNAP program (Supplemental Nutrition

Assistance Program, formerly called “food stamps”) allows

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

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

of taxpayer money to the junk food industry. This industry

produces the foods most readily available in low-income

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

with calories and refined starches. People on the SNAP

program are more obese, have more metabolic syndrome,

and have more cardiac risk factors than people not on

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

be higher, which ends up costing taxpayers even more.

19Fall 2012

“ Concepts like the patient-centered 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.”

PREVENT Duplication, COORDINATE Care

Kent D

ayton/HSPH

MEREDITH ROSENTHALProfessor 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

that we value as private citizens.

So improvements in this area, particularly reforms to

health insurance and delivery systems, have an important

role to play in balancing the federal budget and in fixing

the economy as a whole.

One critical area for reform is primary care. Without

robust primary care, lots of people—especially patients

with complex needs—are getting poorly coordinated care.

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

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-

able for coordinating any care that may be needed across

specialists, hospitals, home health agencies, and nursing

homes, as well as care provided by community-based

services and the patient’s loved ones.

Concepts like the patient-centered 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. The result is a more efficient

and effective, and less costly, system designed to keep

patients healthy, rather than respond to illness.

continued


“ 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 govern-

ment. They view it as their constitution or their lifestyle or

their luck.

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.

When legislators look for something to cut in the

budget, they cut something that has no visible effects.

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

necessarily see more illness right away—it might take a

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

public goods like clean water or clean air, which everybody

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

of diarrheal disease in countries that don’t have sanitary

conditions.

NORMAN DANIELSMary 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

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

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

going to place considerable value on public health initiatives.

A well-known Centers for Disease Control and Prevention

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

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

When the CDC listed the major drivers of that increase,

most of them were public health initiatives: clean water,

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

SPEND MORE to Reduce Risk

Kent D

ayton/HSPH


21Fall 2012

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.

continued

Kent D

ayton/HSPH

MILTON WEINSTEINHenry 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 dimin-

ishing 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 real-

locate 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

medical and public health programs that aren’t being done

enough.

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

convince doctors and patients that women don’t need a

Pap smear every year if they have had three normal Pap

smear tests. Doing a Pap smear once every three years is

extremely cost effective, but doing it every year adds about

$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.”

Identify What is COST EFFECTIVE

How do we persuade the American people that more

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

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

best available medical technology. A first step is to show

that 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.


KATE BAICKERProfessor of Health Economics

The key is not spending less, but improving the value

delivered through our health care system. Lots of interven-

tions 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 reason-

able 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 private insurance in the U.S. is delivered through

employer-sponsored insurance plans. That is largely a relic

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 rela-

tive to wages and other benefits.

There is thus a direct connection between health insur-

ance 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

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.

FOCUS ON VALUE not just price

“ 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.” K

ent Dayton/H

SPHThe Dollars & Sense of Public Health | SPECIAL REPORT

23Fall 2012

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 chil-

dren 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,

the child is invisibly vulnerable and will have an elevated

lifetime risk of asthma, cardiovascular disease, diabetes,

and hypertension.

When you invest early in prevention, and a healthy

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

not only chronic medical problems, but also cognitive and

behavioral impacts.

We have to ensure that families have the internal

resources to raise kids, but also that families live in

communities where there’s access to exercise and good

food. These are not what people traditionally think of as

health interventions—but they are the things that shape

lifetime health.

Aubrey LaMedica/H

SPH

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.”

continued


Treat HEALTH as the Nation’s number one ASSET

DAVID BLOOMClarence James Gamble Professor of Economics and

Demography

Another bridge between health and the economy is

education. Unhealthy children may enter school with phys-

ical 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 conse-

quences 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

health is more like a fruitful investment than a consump-

tion 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.

©R

obert ScobleThe Dollars & Sense of Public Health | SPECIAL REPORT

There are many links between health and the economy.

We’ve known for a long time that richer nations gener-

ally have better overall health conditions than do poorer

nations—and that, within a country, more affluent indi-

viduals have, on average, better health than do poorer indi-

viduals. 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

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.

T25

Fall 2012

Working the Systemhe 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.

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.

As director of the second-

largest health department in

Washington State,

Anthony Chen, MPH ’06,

tackles all the issues—from

infections to inequities—

that shape people’s health.

continued

©Brian Sm

ale



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 Tacoma-

Pierce 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 legis-

lature 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

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 under-

served 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 indi-

vidual 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 hepa-

titis B in the U.S., even though they

make up only 5 percent of the popula-

tion. “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 reali-

ties were hurting his patients. After

national welfare reform went into

effect in 1996, for instance, even

legal immigrants face new restric-

tions 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

most unimplemented provisions of

the law—including the individual

mandate—but left intact the guar-

anteed 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 chal-

lenges. In 2006, he earned a master’s

of public health with a concentra-

tion 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 leader-

ship 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.”

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

—Anthony Chen, MPH ’06


27Fall 2012

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 resi-

dents 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, encour-

aging landlords and property owners

to develop smoke-free rental housing,

for instance, and working to deliver

vaccines to children who need them.

THE BIG PICTURE

In public health, says Chen, it’s crucial

to look at the big picture. He thinks,

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 depart-

ments 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 coun-

ties were cutting crucial programs

like epidemiology or chronic disease

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 band-

width 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.

©Brian Sm

ale

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.


AUTCAN

FRA

GER

ESP

IRL

DENLU

X

NED NOR

USASW

ZCZE

POL

HUN SVKBEL

FIN

GBR

NZL

PORSLO

CHIKOR

ESTMEX

TUR

AUS

ISLSW

E

ISR ITA

JPN

GRE

THE DOLLARS AND SENSEOF CHRONIC DISEASE

The most common behaviors that lead to chronic diseases are:

According to the Centers for Disease Control and Prevention, nearly 1 out of every 2 Americans su�ers 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.

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.

Tobacco InsufficientPhysical Activity

Poor Eating Habits

Excessive Alcohol

The U.S. spends $2.5 trillion on health care every year.

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

In the U.S. alone, a 10% reduction in mortality from heart disease, cancer, and diabetes would have an annual socioeconomic value of

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.

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.

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.

Noncommunicable Diseases

Injuries, Infections, and Other Conditions (includes communicable diseases, maternal and perinatal conditions, and nutritional deficiencies)

Unhealthy Habits

Noncommunicable Diseases: Comparing the Economic Toll

How Much Health Do We Get for Our Money?

Dollars and Diseases

Cost of the U.S. war in Iraq.

Economic losses from Hurricane Katrina.

$47 TRILLION

$800 BILLION

$250 BILLION

$10.9 TRILLIONNoncommunicable Diseases

Other

61%

39%

Life Expectancy, by Country

$8,000 $9,000$7,000$6,000$5,000$4,000$3,000$2,000$1,000

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

85

80

75

70

U.S. Health Care CostsCauses of Death Worldwide

U.S. national debt (as of July 1, 2012).$15 TRILLION

is spent on medical care per person per year.

$8,086

—Julio Frenk, Dean, Harvard School of Public Health

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

75%

25%

29Fall 2012

AUTCAN

FRA

GER

ESP

IRL

DENLU

X

NED NOR

USASW

ZCZE

POL

HUN SVKBEL

FIN

GBR

NZL

PORSLO

CHIKOR

ESTMEX

TUR

AUS

ISLSW

E

ISR ITA

JPN

GRE

THE DOLLARS AND SENSEOF CHRONIC DISEASE

The most common behaviors that lead to chronic diseases are:

According to the Centers for Disease Control and Prevention, nearly 1 out of every 2 Americans su�ers 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.

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.

Tobacco InsufficientPhysical Activity

Poor Eating Habits

Excessive Alcohol

The U.S. spends $2.5 trillion on health care every year.

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

In the U.S. alone, a 10% reduction in mortality from heart disease, cancer, and diabetes would have an annual socioeconomic value of

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.

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.

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.

Noncommunicable Diseases

Injuries, Infections, and Other Conditions (includes communicable diseases, maternal and perinatal conditions, and nutritional deficiencies)

Unhealthy Habits

Noncommunicable Diseases: Comparing the Economic Toll

How Much Health Do We Get for Our Money?

Dollars and Diseases

Cost of the U.S. war in Iraq.

Economic losses from Hurricane Katrina.

$47 TRILLION

$800 BILLION

$250 BILLION

$10.9 TRILLIONNoncommunicable Diseases

Other

61%

39%

Life Expectancy, by Country

$8,000 $9,000$7,000$6,000$5,000$4,000$3,000$2,000$1,000

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

85

80

75

70

U.S. Health Care CostsCauses of Death Worldwide

U.S. national debt (as of July 1, 2012).$15 TRILLION

is spent on medical care per person per year.

$8,086

—Julio Frenk, Dean, Harvard School of Public Health

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

75%

25%

O

PREVAILING WINDS

Jones Adam/Photo R

esearchers

30Harvard Public Health Review

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.

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

continued

PREVAILING WINDS

31Fall 2012

T


he year was 1997, and Dockery had arrived in

Washington to tell Congress that because it had promised

study participants confidentiality, Harvard couldn’t share

the raw data from its federally funded Six Cities study.

The landmark research—one of the single most influen-

tial public health studies ever conducted—examined over

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

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

During that time, HSPH scientists published more than

100 peer-reviewed papers detailing their findings.

The blockbuster paper came in 1993, when Dockery’s

team described what he now calls amazing results.

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

iest air—were 26 percent more likely to die prematurely

than were citizens of Portage, Wisconsin, the city with

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

to hundreds of times narrower than a human hair, which

were associated with increased incidence of lung cancer

and cardiopulmonary disease. “The effects of air pollu-

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

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

expected.” To Dockery and his colleagues, the results

were conclusive evidence that soot produced by fossil fuel

combustion kills.

That evidence was also enough for the U.S.

Environmental Protection Agency (EPA), which in 1997

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

foundation for the first-ever Clean Air Act regulations on

particulate matter smaller than 2.5 microns in diameter.

The EPA claimed the new PM2.5 rules would prevent

15,000 premature deaths annually and produce other

huge benefits, among them preventing 250,000 inci-

dences of aggravated asthma, 60,000 cases of bronchitis,

and 9,000 hospital admissions every year.

But meeting the new standards would be far from

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

other industries spent untold millions trying to disprove

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

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

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

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

for public health professionals working on issues critical

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

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

—Douglas Dockery

33Fall 2012

and oil drilling to natural gas fracking and the ubiquitous

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

A DEADLY CLOUD

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

made up primarily of coal-burning emissions and diesel

exhaust—hovered over London in 1952 and killed more

than 4,000 people within days, environmental scientists

had worried about the mysterious ingredients composing

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

1973 following the Arab oil embargo, when power plants

were expected to substitute cheap, high-sulfur coal for

expensive oil. What could the nasty emissions from

dirtier fuel do to people?

HSPH’s Ben Ferris, a legendary public health

professor who died in 1996, and Frank Speizer, professor

of environmental science, proposed to find out: They

would sample the air quality in six Eastern cities with

varying degrees of pollution while simultaneously moni-

toring the health of thousands of those cities’ residents.

Among their team were the wiry, intense Jack Spengler,

now the Akira Yamaguchi Professor of Environmental

Health and Human Habitation, who built personal air

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.

Later, Joel Schwartz, professor of environmental epide-

miology, would join the team and become one of its most

prolific authors.

Their goal was simple: to identify links between

illness and death rates and air pollution levels. They

sampled the air for toxic emissions, including sulfur

dioxide and particulate matter, a brew of acids, metals,

petroleum byproducts, diesel soot, and other potentially

harmful substances that readily deposit deep in the lungs.

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

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

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

dangers (although the study did not show how these

particles created illness, a missing link critics would

highlight). Another surprise: indoor air pollution was continued

Kent D

ayton/HSPH

WHY SIX CITIES MATTERS TODAYThe clash between industry, politics, and science over the Six Cities study remains relevant today. Consider just a small sampling of contemporary public health controversies:

Global Warming:

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

lawsuits to block the EPA from regulating greenhouse

gas emissions. As Matthew Wald of The New York

Times wrote, “The judges unanimously dismissed

arguments from industry that the science of global

warming was not well supported and that the agency

had based its judgment on unreliable studies.”

Natural Gas Fracking:

Public health studies show the hydrofracturing, or

fracking, process of drilling fouls the air and water and

may contribute to earthquakes. Industry advocates

question the certainty of that science and say the

country needs cheap, “clean” fuel.

Mining and Cancer:

The Mining Awareness Resource Group, a mining-

industry-funded organization, spent years going

to the courts and to Congress for assistance in

accessing data from, and delaying publication of, a

study showing that miners exposed to diesel exhaust

underground were at high risk of developing lung

cancer. Twenty years after the study was launched,

the Journal of the National Cancer Institute finally

published the results.


more harmful than outdoor toxins, setting the stage for

years of important research.

Today, because of Six Cities, it is conventional wisdom

that particulate matter contributes significantly to a

wide variety of illnesses across the spectrum of life, from

asthma and bronchitis to sudden infant death syndrome

and lung cancer.

INDUSTRY RESPONDS

Public health considerations aside, the new standards

forced dramatic changes on industry. The New York Times

reported that old Midwestern power plants would have

to install expensive pollution control equipment; states

would need to invest in mass transit and other initia-

tives designed to reduce auto pollution; and factories

that burned mountains of coal would have to switch to

cleaner-burning fuels. How much those changes would

cost depended upon who was doing the estimating:

industry spokesmen said the bill would reach into the

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

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 mini-

mize 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

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

allow the agency to consider costs, just health outcomes.

Graham had pioneered the study of risk analysis at

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

the Harvard Center for Risk Analysis. From 2001 to

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

and Regulatory Affairs, making him what the Natural

Resources Defense Council called “the second most

powerful environmental official in the nation after

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

University’s School of Public and Environmental Affairs.

Over the years, Graham testified at many congres-

sional hearings that there should be an opportunity for

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

key arguments is that practical people are going to do it

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

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

are then not open to public scrutiny.”

“ 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

35Fall 2012

THE BATTLE LINES HARDEN

Citizens for a Sound Economy blanketed the country

with ads designed to influence public opinion. The group,

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

ance at the center of an extraordinary, multimillion-

dollar campaign to turn back EPA regulations for smog

and soot,” attracted grassroots supporters by contending

the new rules would force bans on such American icons

as backyard barbecues, farm tractors, and wood stoves.

In addition, critics from industry, members of Congress,

and some governors demanded that Harvard release the

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

dean and now Frederick Mosteller Professor of Biostatistics.

The team had promised participants that their personal

data would never be released. When Harvard refused,

critics accused the researchers of conspiracy and pres-

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

of the science,” said National Association of Manufacturers

spokesman Richard Siebert. “In order for people to ascertain

the science they need to understand the background data …

What are they hiding?”

“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.”

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

if we released the data, it would be endless aggravation

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

hostile group combing through your data looking for

anything to attack you about was not something any of

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

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

manipulate it and to set a precedent that “will undermine

future research by academic institutions.”

EPA UNDER SIEGE

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

from Congress, which demanded the agency produce

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

In February 1997, EPA bowed to the pressure and urged

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

with the idea of asking an independent scientific panel

to audit the researchers’ findings. They gave a warehouse

full of data to the Cambridge, Massachusetts–based

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

the automotive industry and the EPA.

It took HEI three years to reanalyze the data—an

agonizing period of limbo for the scientists. But it was

continued

Aerial view of Steubenville, Ohio in 1958.

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.

Opposite, K

ent Dayton/H

SPH; below

, Francis Miller/Tim

e Life Pictures/Getty Im

ages.


worth the wait. In 2000, HEI scientists confirmed the original Six Cities find-

ings. 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-controver-

sial Shelby Amendment calls for those university scientists working on feder-

ally 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 them-

selves on opposing sides. Doug Dockery calls the Shelby Amendment “a direct

assault on research conducted by universities,” because privately funded

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 govern-

ment pays for research … that research ought to be made available for scru-

tiny 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.”

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

—Jack Spengler

Kent D

ayton/HSPH

37Fall 2012

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

gratifying.”

Over the last 30 years, air quality nationwide has

improved dramatically, due to Clean Air Act rules

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

and colleagues Arden Pope (now at Brigham Young

University) and Majid Ezzati (now at Imperial College

London) demonstrated that from 1980 to 2000, reduc-

tions in exposure to fine particulate matter had increased

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

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

on average life expectancy would be two years.”

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.

“We provided the basis for quantifying how many hospital

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

obstructive pulmonary disease] cases, how many heart

attacks, and how many deaths were associated with these air

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

When you actually used those numbers, suddenly the cost/

benefit analysis became very clear—and suddenly, the benefits

were found to far outweigh the cost of controls.”

Years later, Office of Management and Budget (OMB)

analysis confirmed Dockery’s claims: in a 2011 report, the

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

highest estimated benefits is the Clean Air Fine Particle

THE DEBATE GOES ONThe controversy over standards for fine particulate matter

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

order forced the EPA to propose new, tighter standards;

the agency settled on reducing the allowed annual level

from 15 micrograms per cubic meter to a range between 13

and 12.

But a 2011 report by the American Lung Association,

Clean Air Task Force, and Earthjustice claims that this

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

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

maximum of 15,000 premature deaths would be averted

annually. The coalition argues that the EPA should adopt

a more stringent annual limit of 11 micrograms per cubic

meter, which its analysis shows would prevent nearly

36,000 premature deaths yearly.

The EPA is expected to issue final standards in

December 2012.

A STEEL BACKBONE

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

inch-thick binders of correspondence and media clippings

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

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

professionals.

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

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

present the information—how you translate the data—is

extremely important.”

He believes the PM2.5 standards survived because,

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

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

disease. continued page 45

“ 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


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.

Why do we AGE?

Surprising revelations

Wormfrom a

39Fall 2012

“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 hap-

pens 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 pa-

thology. 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 environ-

ment more resistant to developing tumors in the first place, you can try to reduce the chances

of getting cancer with age.”

continued

William

Mair

Kent D

ayton/HSPH

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)

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

elegans, the classic laboratory nema-

tode used across a wide field of re-

search. 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,

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. Fur-

ther 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. Re-

stricted-diet animals grow more slowly,

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

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 unpleas-

ant, but also because it could produce

similar negative side effects in humans,

such as fertility problems or susceptibil-

ity to infections.

Mair wants to see if there’s a way

to tap into the health benefits of dietary

“ 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

41Fall 2012

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 epidemiologi-

cal 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 tak-

ing 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

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 funda-

mentals 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.

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 fellow-

ship 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 can-

cer. 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 obe-

sity 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 thera-

pies. But for now, he’s focused on mak-

ing 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 Frankenstein-

like reputation among the public.

“You have to walk a fine line in the

field,” he says. “There are certainly mem-

bers of it who don’t. Their motivation

is that they want a pill to make them-

selves 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.”

WITH THIS SIMPLE WORM, IN A CHEAP

AND QUICK WAY, WE CAN TWEAK THINGS

AND FIND CAUSALITY.

R

ARKU’S JOURNEY

aphael Arku should have been on top of the

world. There he was, in his early 20s, a ge-

ologist 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 compet-

ing 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.”

Justin Ide

43Fall 2012

ARKU’S JOURNEY

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

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

sense that after those years of grinding work, Arku should

be happy.

But he wasn’t.

Exploring for gold in Ghana came with ugly surprises.

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

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.

But the water was now fouled with contaminants from the

blasting, including arsenic and other toxic heavy metals,

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

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

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

personal beliefs and what was happening in the field.”

Arku replaced his high-paying career with something far

more valuable: a commitment to improving the environment

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

student began a long, difficult journey toward a public health

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

before starting his doctorate at Harvard School of Public

Health in 2010.

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

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

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

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

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

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

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

and especially toxic emissions from the coal and firewood

most people use as cooking fuel—makes it one of the

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

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

color of your shirt darken.”

He had begun his quest to understand how the tainted

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

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

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

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

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

Ghana. He needed skilled interviewers—and people capable

of persuading female participants to provide blood samples

and submit to medical exams. “Raphael quickly distinguished

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

MISTAKEN IDENTITY

One big problem: mistaken identities could easily foul up

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

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

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

tematic inquiry and cajoling, ensure the right women were

recruited for the study.”

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

minibus or ride a motorbike to the neighborhood they had

Raphael Arku

working in the Nima

neighborhood of

Accra, Ghana. He is

doing fieldwork at a

rooftop site set up to

measure ambient air

pollution.

continued

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.


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

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

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

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

Arku helped another HSPH professor, Majid Ezzati (now an

adjunct professor at HSPH and chair in Global Environmental

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

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

groundbreaking. With pockets of wealth, a sizable middle

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

striking economic inequality—inequality that, Ezzati theo-

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

With the help of Arku and other students, Ezzati pin-

pointed the sources of air pollution in four neighborhoods,

from high-income areas to slums. “You’re trying to do really

good science in a place where everything from the elec-

tricity supply to the social conditions are unstable,” Ezzati

says. Trudging from place to place, the researchers learned

that in the densely populated slums, almost everyone uses

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

makeshift kitchens set up in bedrooms or on front porches.

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

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

with biomass fuels as a backup due to an unstable LPG

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

borhoods had the highest air pollution,” Ezzati reports.

Poor residents cook with these low-quality fuels be-

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

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

clear that high levels of particulate matter produced by fossil

fuels cause health problems ranging from low birth weights

to asthma, bronchitis, lung cancer, cardiovascular disease,

and premature death.

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,

he is deeply interested in analyzing urban energy use and

infrastructure—and exploring technology and policy innova-

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

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

household and neighborhood air pollution exposures.

WRESTLING WITH BUREAUCRATS

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

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

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

to another, trying to find administrators willing to share

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

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

crats’ to get the data you need.”

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

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

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

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

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

But given his experience of growing up without a stable

source of energy, Arku has an extremely practical side.

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

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

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

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

people, depending upon how new resources are expended.

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

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

ply from these projects should be used to develop energy

infrastructure in low- and middle-income Accra neighbor-

hoods.”

Such fundamental changes could vastly improve resi-

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

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

cities across Africa.

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

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.

45Fall 2012

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 esti-

mate 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 envi-

ronmental 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 diffi-

cult 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

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.

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.eduemail: [email protected]: 617-384-8692

Harvard School of Public HealthCenter for Continuing Education677 Huntington Ave. CCPE-Dept. ABoston, MA 02115

SEPTEMBER 2012

September 17–20Work, Health, and Well-Being: Strategic Solutions for Integrating Wellness and Occupational Safety and Health in the Workplace

September 27–28Sleep and Shift Work: Optimizing Productivity and Health Management in the 24/7 Global Economy

OCTOBER 2012

October 1–5Ergonomics and Human Factors: Strategic Solutions for Workplace Safety and Health

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

October 28–November 2Leadership Strategies for Evolving Health Care Executives

JANUARY 2013

January 13–25Program for Chiefs of Clinical Services

FEBRUARY 2013

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

PREVAILING WINDS continued from page 37

45Fall 2012


1973Frank M. Torti, MPH, became vice presi-dent 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 previous-ly 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.

1976 Alma Foggo York, MPH, passed away on February 9 after being struck by a car near her Huntsville, Alabama home. A native of Bermuda, she was a mentor and educator who served as dean of women and chair of the Department of Nursing at Oakwood University in Huntsville.

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.

1982Howard Frumkin, MPH, DPH ’93, co-edited the book Making Healthy Places: Designing and Building for Health, Well-being, and Sustainability (Island Press, August 2011). The book analyzes the

connections between the built environ-ment 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 mar-ried Joanne Silberner, a former National Public Radio health reporter now teach-ing at the University of Washington.

1983 Jacques Carter, MPH, received a certifi-cate of appreciation from the Mashpee Wampanoag Tribe for his dedication to providing health care services to the tribal nation. The Mashpee Wampanoag Tribe is connected to Harvard University, both historically and currently, through the University Charter of 1650, which describes Harvard’s pledge to educate the tribe’s youth.

1990Dr. Robert Travnicek, MPH, re-ceived 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.

1992Swati Piramal, MPH, director of Piramal Healthcare, was elected in May to serve a six-year term on Harvard’s Board of Overseers.

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

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

1994 Dr. Gina Solomon, MPH, was ap-pointed 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 clini-cal 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 Dr. Roderick King, MPH, was named deputy director of the Florida Public Health Institute in May. King previ-ously was president of Next Generation Consulting Group, a health care or-ganization. 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 for-mer director of the Program on Cultural Competence in Research in Harvard Clinical and Translational Science Center at Harvard Catalyst.

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

ALUMNI NEWS

Kent D

ayton/HSPH

47Fall 2012

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 [email protected].

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

1999Dr. Nawal Nour, MPH, is the 2012 re-cipient 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 de-voted to the medical needs of African

Teresa Chahine, SD ’10

Teresa Chahine graduated in 2010

with an ScD in environmental health,

and stayed on as a research fellow at

HSPH, while exploring entrepreneurial

approaches to solving global health and

international development challenges

through MIT’s Legatum Center for

Development and Entrepreneurship. Prior to HSPH, Chahine

worked as a reproductive health coordinator with the Ministry

of Social Affairs and UNFPA (the United Nations Population

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

Boston and Beirut, where she joined the Systems Reform

Group, a consulting network dedicated to strengthening health

and education systems in Arab countries and other transi-

tional regions in Asia. Chahine conducts urban sustainability

research at HSPH in collaboration with the Harvard Graduate

School of Design and Qatar Foundation, and teaches sustain-

able development practice at Harvard Extension School.

Sameh El-Saharty, MD, MPH ’91

Sameh El-Saharty works as senior health policy spe-

cialist in the South Asia region at the World Bank in

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

eral positions with international or-

ganizations, academic institutions,

and consulting firms, including the

United States Agency for International

Development, UNFPA, Harvard

University, the American University in

Cairo, and Pathfinder International. El-

Saharty has extensive experience for

more than 25 years as a researcher,

technical adviser, and international consultant on public

health, health policy and management, health insur-

ance, and health sector reform programs in more than

18 countries in the Middle East and North Africa region,

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

Egyptian national, is married with two children.

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 con-ceiving and giving birth.

Dr. Kelly Moore, MPH, medical direc-tor 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 vac-cine preventable disease goals, visionary leadership, service as a role model, and

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

2000Jeffrey 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 sec-tor engagement, Office of the Global AIDS Coordinator, The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).

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

Harvard Public Health is interested in hearing from you. Please send comments or class notes to: Amy Roeder, Assistant EditorHarvard Public Health90 Smith Street Boston, MA 02120

Phone: (617) 432-8440 Fax: (617) 432-8077Email: [email protected]


Associate professor Sarah Fortune re-ceived an award from the Burroughs Wellcome Fund’s Investigators in the Pathogenesis of Infectious Disease pro-gram 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.

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 ca-pacity for research, leadership, and policy change to address the multiple determi-nants 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 emeri-tus, received a Lifetime Achievement Award at the British Medical Journal Group’s Improving Health Awards on

May 23 in London. Lown is renowned for his groundbreaking work on the causes and treatment of heart disease and cardiac arrhythmias and his dedica-tion to the prevention of nuclear war. During the Cold War, he co-founded International Physicians for the Prevention of Nuclear War. The organi-zation won a Nobel Peace Prize in 1985.

John McDonough, professor of the prac-tice 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 influ-enced and inspired others.”

Franziska Michor, associate professor of computational biology, received HSPH’s second annual Alice Hamilton Award in April. She was honored for her path-breaking 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

AWARDS AND HONORS

FACULTY NEWS

2011Oliver Mytton, MPH, who has con-ducted 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 aca-demic clinical fellow in public health at Oxford University.

2012 Jason Rafferty, MPH, recently complet-ed 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 com-bining pediatrics, adult psychiatry, and child/adolescent psychiatry.

Xuehong Zhang, SD, received the American Society of Preventive Oncology’s inaugural Electra Paskett Annual Scholarship at the Society’s con-ference 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 outstand-ing scientist in cancer research.

From top, ©

Tony Rinaldo, Aubrey LaM

edica/HSPH

49Fall 2012

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 dur-ing the ASN Awards Ceremony in April.

K. “Vish” Viswanath, associate profes-sor 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 com-mittee recommends ways to achieve optimal prevention of infectious dis-eases through vaccine development and provides guidance on preventing adverse reactions to vaccines.

IN MEMORIAM

Hilton Salhanick

Hilton Salhanick, profes-

sor 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 profes-

sor of obstetrics, gynecology,

and reproductive biology at

Harvard Medical School for

many years.

Salhanick was instrumental

in the design and develop-

ment of many improvements in

contraceptive devices, partic-

ularly 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.

Marianne Wessling-Resnick, profes-sor 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.

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 better-ment of society.” Zelen was honored at this year’s Joint Statistical Meetings, held in San Diego from July 28 to August 2.

APPOINTMENTS & PROMOTIONSXiaole Shirley Liu professor of biostatistics and computa-tional biology at HSPH and the Dana-Farber 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

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

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 is-sues with practical, proven techniques for navigating turbulent situations and achieving positive outcomes. This thor-oughly revised and updated edition fo-cuses on the complex interactions among those who deliver, receive, administer, and oversee health care. It outlines nego-tiation techniques and conflict resolution approaches that can improve efficiency, quality of care, and patient safety. The book also explores why unresolved con-flict can hamper an organization’s ability to make timely, cost-effective decisions and implement new strategies.

Kent D

ayton/HSPH


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 HealthHarvard School of Public HealthOffice for External Relations90 Smith StreetFourth FloorBoston, Massachusetts 02120(617) 432-8470

Please visit http://www.hsph.harvard.edu/news/magazine/ and email comments and suggestions to [email protected].

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

Vice Dean for External RelationsEllie Starr

Associate Vice Dean for CommunicationsJulie Fitzpatrick Rafferty

Director, Strategic Communications and MarketingSamuel Harp

EditorMadeline Drexler

Assistant EditorAmy Roeder

Senior Art DirectorAnne Hubbard

Assistant Director for Development Communications and MarketingElaine Appleton Grant

Principal Photographer Kent Dayton

Contributing Photographers Aubrey LaMedica, Brian Smale

Contributing IllustratorsShaw Nielsen

Marketing and Communications CoordinatorRachel Johnson

Contributing WritersMichael Blanding, Luisa Cahill, Karen Feldscher, Courtney Humphries

© 2012 President and Fellows of Harvard College

DEAN OF THE FACULTYJulio Frenk

ALUMNI COUNCIL As of November 2011

Officers Elsbeth Kalenderian, MPH ’89 President

Anthony Dias, MPH ’04President Elect

Ramon Sanchez, SM ’07, SD ’11Secretary

Royce Moser, MPH ’65Immediate Past President

Alumni Councilors

2009-2012Marina Anderson, MPH ’03Rey de Castro, SD ’00Cecilia Gerard, SM ’09*

2010-2013Teresa Chahine, SD ’10*Sameh El-Saharty, MPH ’91 Chandak Ghosh, MPH ’00

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

*Class Representative

VISITING COMMITTEE Jeffrey P. Koplan, MPH ’78Chair

Nancy E. AdlerAnita BerlinJoshua BogerLincoln ChenWalter ClairLawrence O. GostinAnne MillsKenneth OldenBarbara RimerMark Lewis RosenbergJohn W. RoweBernard SalickEdward M. ScolnickBurton SingerKenneth E. Warner

BOARD OF DEAN’S ADVISORS Jeanne B. AckmanTheodore AngelopoulosGeorge D. BehrakisKatherine S. BurkeChristy Turlington BurnsGerald L. ChanLee M. ChinJack Connors, Jr.Jamie A. Cooper-HohnMala GaonkarAntonio O. GarzaC. Boyden GrayJeanne LavineJonathan LavineRichard L. Menschel* Roslyn B. PayneSwati A. PiramalAlejandro Ramirez Carlos E. RepresasRichard W. SmithHoward StevensonSamuel O. ThierKatherine Vogelheim

*emeritus

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

Ellie StarrVice Dean for External RelationsOffice for External RelationsHarvard School of Public Health90 Smith StreetFourth FloorBoston, Massachusetts 02120(617) 432-8448 or [email protected]

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

Jim Smith, Assistant Dean for Alumni Affairs(617) 432-8446 or [email protected]

www.hsph.harvard.edu/give

HARVARD HEALTHPUBLIC

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.”

“ 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.”

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 PDBurlington, VTPermit No. 586Harvard University

Office for External Relations90 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

from cost control to electronic medical records,

visit hsph.me/election2012healthcare.

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

Documents

Harvard Public Health, Fall 2012