100 Years of HSPH

The launch of the Harvard School of Public Health (HSPH) capital campaign coincides with the school’s centennial celebration. Since opening in September 1913 as the Harvard-MIT School for Health Officers, the school has influenced many major public-health initiatives of the twentieth century, from the development of a polio vaccine to the passage of the Clean Air Act. Harvard Magazine spoke with several current HSPH professors about achievements of the past and directions for the future: combating malaria, stopping pandemic flus, improving humanitarian aid, and more.

Dean Julio Frenk is quick to put the school’s centennial and campaign into historical context. “The field of public health already has made some of the largest contributions to society of any human endeavor,” says the Angelopoulos professor of public health and international development, who has been dean since January 2009 (see “A Global Health View”). In the past century, public health has “completely [changed] the character of disease and death among humans” and succeeded in developing a “set of specialized institutions and dedicated professionals devoted exclusively to taking care of health.” Average life expectancy in the United States increased more than 30 years in the twentieth century—“a larger gain in life expectancy than in all of previously accumulated history”—and 25 of those years, he says, are attributable to public-health interventions: vaccines, sanitation, clean air, seat belts, tobacco control. “We’ve been able to move the average age of death closer and closer to the biological limit.”

He highlights several continuing changes in how researchers and practitioners think about the field. A revolution in big data is transforming basic research, allowing access to enormous amounts of information about the human body. The first human genome, for instance, was sequenced through a national effort spanning more than a decade; now, billions of base pairs of information are available for a few thousand dollars, and with the influx of data has come a change in systems thinking and the ability to “understand and harness complexity.” Closely related is a revolution in communications that now connects the world through mobile phones and the Internet; Frenk points to mHealth, a movement that uses mobile health platforms to increase the reach of aid workers and empower citizens, particularly in poor nations. Another shift is a revolution in rights, closely tied to healthcare—“the awareness that access to the benefits of the other revolutions is a fundamental right of people.”

At the same time, public-health progress faces major threats, the dean says, encapsulated in the four HSPH campaign themes:

• old and new pandemics;
• harmful physical and social environments;
• poverty and humanitarian crises; and
• failing health systems

Across fields, HSPH is also adapting its curriculum and pedagogy for the new century. “Our mission in life and our value to society is to create the knowledge and educate the leaders that will be able to protect us all from these four threats,” Frenk says. “That’s the key message for the campaign, and that’s the key priority for the next hundred years for this school.”

Old and new pandemics: Developing tools to reverse killer diseases

Something old. “The landscape of infectious diseases has changed significantly in the past century,” says Dyann Wirth, Strong professor of infectious disease and chair of the department of immunology and infectious diseases (see “Evolving Foe”), and HSPH has played an important role. The school’s Thomas Weller was one of three researchers awarded the 1954 Nobel Prize in physiology or medicine for culturing poliovirus (the iron lung for polio treatment was likewise developed at HSPH, in 1928), paving the way for development of a vaccine; his student William Foege, M.P.H. ’65, S.D. ’97, led the worldwide effort for smallpox eradication. “The theme there,” says Wirth, “is that fundamental knowledge has changed infectious disease outcomes in a dramatic way.”

Smallpox has been defeated, and both polio and guinea worm are on their way out, but old diseases like tuberculosis and malaria remain major public-health problems today. Wirth, who leads the Harvard Malaria Initiative, believes that innovation in both medical treatment and in public-health intervention require the unraveling of biological secrets. The malaria parasite, for instance, is capable of antigenic variation—changing surface proteins to evade immune recognition. “The pathogens we encounter today,” she says, “are the survivors who have undergone the ultimate test.” She therefore emphasizes a new, holistic research mindset that focuses on investigating systems rather than individual genes. “The malaria parasite has a complex life cycle,” she explains, “and studying parts in isolation may not reveal what aspects are most important.”

The fight against disease must also go beyond basic research. A new, cross-school initiative—“Defeating Malaria: From the Genes to the Globe”—emphasizes the role that business and government must play in eradicating the disease. “The world had two of the best tools for combating malaria in the 1950s,” she says, with the simultaneous development of the cheap, effective drug chloroquine and the insecticide DDT. Indeed, the disease was successfully eliminated from the United States and southern Europe. But problems arose. As the disease petered out, so did government commitment to its control; at the same time, the efficacy of both treatments declined as resistance emerged in the parasite and mosquitos. Add in environmental concerns about DDT, and malaria surged back. To sum up, Wirth says, “Many pieces are needed to craft an effective solution.”

Something new. A new infectious disease begins with just a few cases, and it is up to researchers like Marc Lipsitch, professor of epidemiology, to squeeze as much information as possible from initial reports and draw a portrait of a possible pandemic in the making. As director of the Center for Communicable Disease Dynamics at HSPH, Lipsitch uses population genomic techniques and mathematical models to study disease transmission and recommend public responses to emerging infectious-disease threats.

One example is the 2009 H1N1 swine flu pandemic. Lipsitch, working closely with the U.S. Centers for Disease Control and Prevention, examined available public-health data—“line lists” of patients, their locations, and the course of the disease—to infer epidemiological metrics like incubation time and transmissibility that would describe how an epidemic might unfold—and what response measures were likely to succeed.

For instance, a pandemic flu patient generates, on average, about two more flu cases, compared to a basic reproduction number (BRN) of more than 10 for measles. School closings have much more impact on the less-contagious flu, says Lipsitch, and similar models of disease spread may also influence decisions about quarantine and vaccination strategy. For SARS, isolation and quarantine were enough to prevent a possible pandemic; Lipsitch’s team calculated that the disease’s BRN was 3, but the main factor aiding public-health officials was the lengthy eight-day incubation period following exposure before the disease became transmissible (see “The SARS Scare”).

“Control measures like closing schools and ‘social distancing’ provide only a temporary delay in the transmission of a pandemic infection,” says Lipsitch. When these measures are eventually relaxed, the outbreak may resume with its former intensity. Nonetheless, “such measures can ‘buy time’ until vaccines are available, and can reduce the number of people sick at any given time.” In the public-health community, Lipsitch observes, “people are stretched at the local, and increasingly, the federal level.”

Meanwhile, new diseases will continue to emerge, and their exact nature can be hard to predict. Genetic tests give researchers more power to identify new pathogen strains and to track their spread and evolution, but developing successful tests—and eventually, vaccines—requires investigators with strong foundations in basic research. Research on coronaviruses, for example, was a “backwater” before the SARS epidemic, Lipsitch says. “We need more people working on diseases that aren’t fashionable, and it’s the role of government to maintain the diversity of research programs.”

Harmful physical and social environments: Preventing pollution, promoting healthy communities 

The air we breathe. From his office on the thirteenth floor, Douglas Dockery can see well into downtown Boston—and he has helped make the view possible. In the 1970s and 1980s, the professor of environmental epidemiology led the longitudinal Six Cities Study, published in 1993 as the first definitive evidence linking air pollution to respiratory and cardiovascular illness and even premature death (see “Clearing the Air”). The findings, which now seem self-evident, would form the basis for Clean Air Act regulations on fine particulate matter in 1997. Today, Dockery notes that the air in Boston is remarkably clean despite arriving from America’s heartland and industrial region, and the city has had great success cleaning its rivers and waterfront as well—in large part thanks to the influence of public-health practitioners (see “Clean Air, Longer Life”).

The department of environmental health, which Dockery now chairs, studies “the environment, broadly defined as everything outside our genes and our behavior”; that is, not the act of smoking, but the effect of secondhand smoke; not food, but the pesticides on food; not only the quality of water, but also the plastic containers from which we drink. The work is by nature interdisciplinary, he says, drawing from fields as disparate as microbiology, genetics, epidemiology, meteorology, engineering, and public policy. Researchers often focus on chronic diseases, conceiving of them as products of a lifetime of exposures that encompass anything from chemicals like lead in the physical sphere, to subtle influences in the social and built environments. Rapid increases in the prevalence of diseases like asthma and autism “cannot be entirely due to genes.” Any time such shifts in disease patterns occur, says Dockery, there’s a clue that changes in the environment might be of interest.

New scientific advances change how we view our environment, he says. The field of epigenetics has emerged from the finding that environmental influences like famine can alter gene expression for many generations to come. Meanwhile, studies of the human microbiome, the ecosystem of bacteria within the gut, show that microorganisms link our insides with the world around us. And, as Dockery says, “We are the environment for other organisms.”

In many areas, as with the Six Cities Study, research dovetails with issues of public policy, and Dockery believes his department’s role is to provide sound science to inform and evaluate policy decisions. Whether the concern has been air pollution, toxic metals, or synthetic chemicals, he says public health has managed to win major victories. Nevertheless, he points out, environmental health almost always studies past events, and researchers still struggle to predict the effects of new chemicals. As a society, he emphasizes, “we will need to be vigilant, as our actions can often have unexpected consequences.”

The food we eat. “It’s hard to imagine what life was like a hundred years ago,” says Walter Willett, Stare professor of epidemiology and nutrition (see “The Way We Eat Now”). Infectious diseases dominated the public-health sphere; the concept of nutrition was barely on the horizon. The HSPH department of nutrition, which Willett chairs, was founded in 1942 by Frederick Stare. Until that time, nutrition research had mainly focused on micronutrients; by studying diseases like scurvy, rickets, and beriberi, researchers identified the minerals and vitamins essential for health. Stare recognized that cardiovascular disease was becoming more common in the United States and initiated research into the epidemic’s origins. The department’s Irish Brothers Study, which examined diet and heart disease in pairs of siblings on opposite sides of the Atlantic, as well as several studies of diet and cholesterol, were early landmarks.

Willett pioneered the field of nutritional epidemiology, overseeing this research in three large cohort studies—the two Nurses Health Studies begun in 1976 and expanded in 1989, and the Health Professionals Follow-Up Study in 1986—that have together tracked the diets of nearly 300,000 people for more than two decades. “Many hypotheses existed about the relation of diet to cardiovascular disease, cancer, and other diseases, but what was missing was a large a body of empirical evidence,” he says. His research has found connections between nutrition and health that, though often vigorously debated at the time, are now conventional wisdom—the link between trans fats and heart disease, for instance, and the health risks of being overweight. Willett has engaged with businesses and chefs through initiatives like Menus of Change and fought for bans on trans fats. The department now hosts NutritionSource, a website dedicated to making the best available evidence accessible to the public. “I think of nutrition as an orchestra,” says Willett. “You can’t just focus on one piece.”

Advances in research are bringing new factors to light, he says. Nutritionists are returning to archived blood samples to study DNA and metabolomics, the chemical processes inside cells, and the gut microbiome is thought to have an important health effect as well. Childhood diet seems increasingly connected with later-life events like breast cancer and cardiovascular disease. “These conditions that develop in old age are the result of what happens over the whole lifespan,” he says. And even as obesity is on the rise in developed nations, the developing world still suffers from malnutrition; in conjunction with the department of global health and population, Harvard nutritionists also study maternal-child health. Though nutrition has come a long way, says Willett, “there is still lots of scientific work that needs to be done.” 

Poverty and humanitarian crises: Advancing health as a human right

A disaster strikes, and aid pours in—donations of clothing, for instance, are a common response. Following the disaster, local markets are flooded with cheap or free clothing, much of it often culturally inappropriate, putting merchants out of work and undermining the existing economic infrastructure. The donation, though well intentioned, has had unforeseen consequences.

“Non-governmental organizations are great at field operations,” says Michael VanRooyen, director of the Harvard Humanitarian Initiative (HHI) and professor in the department of global health and population, “but not as good at analysis, research, and reflection.” The goal of the initiative, founded in 2005, is to draw upon expertise from all of Harvard’s schools—public health, medicine, business, law, government—to implement strategic approaches to humanitarian aid. VanRooyen makes a comparison to how medical schools support hospitals: academic programs provide elements of training, research, and education that contribute to more effective practice. A major emphasis, he says, is to “help people acknowledge that humanitarian assistance is its own discipline” (see “Think Tank for Aid Workers”).

Take the 2010 earthquake in Haiti, he says. Though many aid organizations were on the ground, the crisis response suffered from lack of coordination. Assessment of conditions was hampered by the different data, methods, and questions that each agency had. “Big crises often force reflection in the humanitarian community,” VanRooyen reports. Following the Haiti response, the UN made revisions to the organizational “cluster system” put in place after the 2004 Indonesian tsunami and instituted a “transformative agenda” to further streamline its response. Harvard researchers are developing a mobile platform, KoBo, that integrates all data collected in a humanitarian crisis, making it available to UN and international organizations so that they can share information on health, logistics, human rights, and protection. Continuing- and professional-education initiatives by the Humanitarian Academy at Harvard train and retrain emergency field workers, and each spring, VanRooyen leads an intensive, simulation-based course that touches on issues from sanitation to international humanitarian law.

Beyond addressing the immediate demands of humanitarian crises, promoting “health as a fundamentally human right” has been a priority of Frenk’s deanship. Millions of people still die every year from preventable causes, from childbirth to malnutrition, he says. “This is not a failure to know. This is a failure to act.” He launched the HSPH Women and Health Initiative in 2010, drawing on his previous experiences combatting maternal mortality and increasing access to contraception as Mexico’s minister of health (see “Labor, Interrupted”); the school’s François-Xavier Bagnoud Center for Health and Human Rights also conducts research and makes policy recommendations on conditions of extreme poverty. “In addition to being a violation of human rights, [such poverty is] a threat to our common security,” Frenk explains, “because it’s exactly those injustices that generate civil strife and create a mindset of extremism and fundamentalism.”

Failing health systems: Leading change, changing leaders

“When public health is working,” says John McDonough, professor of the practice of public health, “no one notices it.” The discipline’s reach is broad, and as director of the Center for Public Health Leadership, McDonough trains leaders for the varied roles that public health demands.

HSPH has trained several ranking officials in the World Health Organization and six directors of the U.S. Centers for Disease Control and Prevention, whose combined tenure of more than three decades constitutes nearly half the organization’s 67-year history. Now, McDonough hopes to create a more systematic basis for leadership training. In the fall of 2012, the school launched an interdisciplinary concentration in public-health leadership. Coursework addresses topics like health-sector reform and social entrepreneurship, while encouraging students, he says, to embrace a “broader definition of leadership” in both their careers and everyday lives.

The school has also sought voices from outside academia, bringing in current leaders like U.S. secretary of health and human services Kathleen Sebelius and Massachusetts governor Deval Patrick to discuss policy choices and scientific controversies. The Ministerial Leadership in Health Program, meanwhile, invites current ministers of health and finance to create what McDonough calls a learning community of academics and political leaders. McDonough also directs the school’s program for executive and continuing professional education; a new initiative brings together global corporate medical directors who oversee everything from employee benefits to occupational health and safety. Their role, he says, is diversifying and increasing in sophistication; they are “people who daily use the tools of population and public health in corporate practice.”

Frenk warns that current health-care systems around the globe are failing to meet societal demands: medical errors threaten patient well-being, and “unproductive costs” are a drag on the world economy. As for this nation: “The U.S. is the industrialized country that spends the most on health, yet it is also the industrialized country that has the worst health outcomes,” he says. This summer, HSPH launched an effort with Brigham and Women’s Hospital called Ariadne Labs; led by Atul Gawande, professor in the department of health policy and management, it is developing “safe surgery” and “safe childbirth” checklists to reduce complications and deaths from medical procedures (see “The Unlikely Writer”).

Frenk acknowledges that educational initiatives like those led by McDonough represent a major component of the school’s impact. “Leading change, changing leaders—that’s what we do,” says Frenk. “We lead change by providing knowledge and translating it into relevant policy. We also change the leaders—we educate both the current and future generation.” In his 2013 Commencement address, the dean emphasized the need for interdisciplinary solutions to public-health problems. “What we need are T-shaped leaders,” he said, “leaders with knowledge that is not only deep in a few areas but also extends to many.”

Transforming public health education for the twenty-first century

Though not an official campaign theme, education is central to the school’s second century. When HSPH opened in 1913, it was the nation’s first graduate training program in public health; that year, it also became the first Harvard school to open admissions to women on the same basis as men.

In 2010, the school began a multiyear curricular review. Its conclusions have pushed the adoption of a more competency-based curriculum, says dean of academic affairs David Hunter, and the addition of more practical, immersive elements (see “Talking About Teaching”). HSPH designed one of the first two HarvardX courses last year, “Health in Numbers: Quantitative Methods in Clinical and Public Health Research,” and some professors are experimenting with a “flipped classroom” approach, in which students watch recorded lectures before the course meets, and engage in discussion during class time. “HarvardX came along at the right time for us because our faculty were very, very interested in digital learning,” says Hunter. “We have essentially a global mission…and we see [digital learning] as an important part of our spectrum of activities.”

The structure of the school’s degree programs is undergoing revision as well, spurred by the centennial review. A new Dr.P.H. in public-health leadership will launch next fall, underwritten by $5 million from anonymous donors. Existing doctorates, says Hunter, are oriented toward research; this professional degree will train students to be public-health practitioners and policymakers. Similar research and professional tracks will be implemented among the master’s degree programs, and a prospective interdisciplinary Ph.D. in population sciences is in development. These new educational initiatives, says Frenk, will train a new generation of researchers and leaders to bring HSPH into its second century.