RESIDENT R I C H A R D NIXON'S HISTORIC VISITS
H H ^ to China and the Soviet Union begin to ease Cold War hostilities and provide an auspicous start to the year 1972.. In June, however, the arrest of five men inside the Watergate Arms hotel marks the beginning of a new presidential drama that eventually leads to Nixon's resignation. The fall of Saigon in 1 9 7 $ ends the U.S. w a r in Vietnam, but in Cambodia, the Middle East, Northern Ireland, Africa, and parts of South America blood continues to flow as a result of revolution, terrorism, and state-sponsored violence. Despite a worsening U.S. health care crisis and a disastrous national Swine flu vaccination effort, the seventies provide the stage for public health's greatest triumph: the global eradication of smallpox. However, even while the world celebrates this victory, a more sinister infectious disease threat— AIDS—is taking root. At the School of Public Health, H o w a r d Hiatt, the School's fifth dean, harnesses the new molecular research capabilities to solve some of the more intractable public health challenges. Hiatt also positions the School to begin "diagnosing" and "treating" the nation's ailing health-care system. In doing so, he will help redefine the parameters and practice of public health.
% HA H H E R E D I D r r A L L B E G I N ? W W Did it arise out of a deadly London smog that killed 4,000 people in the space of a few days in early December 1952.? Could it have sprung in part from the long-standing interest in pulmonary physiology sparked by polio research? Was it Energy Crisis-induced anxiety over the impact of burning increased amounts of high-sulfur coal in a period of high-priced oil? Or a sense among 1970s scientists and policymakers that the science base for
1972
Harvard President Derek Bok (right) appoints Howard H. Hiatt, professor of medicine at Harvard Medical School, as the fifth dean of the Harvard School of Public Health.
a taie of
six cities
American air pollution standards was insufficient? Whatever the reasons, in late 1 9 7 3 ' Professor Frank Speizer found himself driving to Logan Airport while then-Department of Physiology head James Whittenberger read a proposal so fresh (in that pre-personal computer era) that some reordered paragraphs literally had been cut and pasted together. The proposal Whittenberger conveyed to Washington, composed by Speizer and his colleague, Benjamin Ferris,
Alexander Leighton and Jane Murphy, who hold appointments in the Department of Behavioral Sciences, begin studying the social, cultural, and psychological consequences of the war-time defoliation program using Agent Orange in Viet Nam's Mekong Delta.
described what was to become one of the most influential, innovative, and longest-running experiments concerning the health effects of air pollution in America: the Harvard Six Cities Study. The Six Cities Study was an expansion of Ferris's pioneering effort to bring modern laboratory techniques and tools into people's homes, both for sampling air quality and for monitoring health effects. For the first time in this country, public health researchers directly correlated environmental exposure to toxins with health impacts. The work, which continues today, set a standard for research in air pollution that is emulated throughout public health and around the world. As the study's principal investigator, Ferris was an important part of this hands-on research philosophy. A pediatrician by training, Ferris had been recruited by Whittenberger to what was then the Department of Physiology from Boston Children's Hospital in 1948 because of Ferris's interest in pulmonary function in children with polio. Prior to the invention of the polio vaccine, Ferris had instructed physicians in caring for paralytic polio victims using the iron lung. "He had a very good background," recalls Whittenberger, now at the University of California, Irvine. "And I didn't know how hard a worker he was at that point, but he proved to be a very thorough scientist." When the Salk and Sabin vaccines all but extinguished the polio threat, Ferns expanded his horizons. On a 1 9 5 7 trip with Whittenberger to a
The United States withdraws troops from Vietnam.
coal-mining region of Wales, he saw entirely new techniques being used to study the impact of air quality. "They started out by selecting a probability sample of coal miners, and once they determined the sample size, they made an effort to get everyone in the group examined," Whittenberger recalls. "Previously, this kind of study would have been a matter of examining a number of people at certain exposure levels; that kind of data couldn't be generalized to a larger population. So this was a new concept, and a major methodological improvement." Impressed and energized, Ferris returned home where he immediately began a similar study not far from his wife's summer home, in the New Hampshire paper mill town of Berlin. Initially, the Brown Paper Co. refused Ferris' request for access to systematically sample air quality and monitor worker health in its factory. Ferris, reasoning that pollutants were still coming out of the smokestack, began studying the community surrounding the mill. When he demonstrated the adverse health impact of sulfur dioxide emissions—[including lowered lung function]—the paper company agreed to reduce them. ERRIS H A D BEEN BITTEN BY T H E held epidemiology bug, and he applied his own exacting standards to its execution. But when the Environmental Protection Agency ( E P A ) instituted a large-scale study of air pollution's health effects in the mid-i$6os, Ferris was one of many scientists who was highly critical. The C H E S S (Community Health and Environ-mental Surveillance
Systems) Study was an attempt by E P A to provide scientific justification for the air quality standards set by the 1 9 6 7 Clean Air Act. However, Ferris and other critics in academe and industry charged that the study put the conclusion cart before the raw data horse. Specifically, exposure thresholds that had been set by the E P A for airborne toxins appeared to have limited correlation to the study's observations. "The criticism had to do with data collection problems, machine calibrations, training, and the use of standardized questionnaires," recalls Speizer, now Professor of Environmental Science, Edward H. Kass Professor of Medicine at Harvard Medical School, and Codirector of the Channing Laboratory. "And then, on the analysis side, some very funny things that none of us thought could possibly be there were forced on the data to fit the E P A ' s threshold models. I don't think there was any true malicious intent to defraud, but it was a very difficult problem." Senate hearings followed, and before long the National Institute of Environmental Health Sciences (NiEHs) was founded to assume the EPA's biomedical research burden. While the discredited CHESS study's findings were never released, strong national interest in air pollution persisted. Large amounts of high-sulfur coal were being mined for electric power production, and it appeared that even more coal might be burned in the wake of the Arab-Israeli War of October 1 9 7 3 , which severely damaged US relations with many oilproducing countries in the Middle
Report of President Bok's Committee to Study the Future of the School of Public Health recommends closer cooperation with Harvard Medical School, but calls " w e a k " the case for outright merger. The 12-member committee, chaired by President Bok, includes HSPH faculty members Roger Nichols, Thomas Mack, Jean Mayer, Dade Moeller, Robert Reed, and Alonzo Yerby; Julius Richmond of the medical school; and experts from The Commonwealth Fund, Rockefeller Foundation, Cornell Medical College, and the University of Pittsburgh.
East and played a role in precipitating the late-i970s Energy Crisis. A key research objective was to gain more knowledge about sulfur dioxide; many attributed the deadliness of the London smog and another pollution disaster that occurred in 15)48 in the mill town of Donora, Pennsylvania, to this chemical. "The big thing was to decide whether it was sulfur dioxide or smoke," that had precipitated the deaths, Whittenberger says. "That's basically what the Six Cities Study was supposed to do." T h e n - N i E H S director David Rail believed that such an important study should not be done in a government laboratory, but in a university setting with support, peer review, and funding from N I H . When he asked whether Ferris and Speizer would perform the study, Whittenberger assumed that the answer would be a polite " n o . " " I didn't think they would be interested in such a large undertaking," said Whittenberger. The study as proposed called for at least 1 0 years of
work, and it would be three years until any descriptive data could be published, five years or more before any papers concerning the impact of air pollution would be ready. As a career move, it was a gamble. " I suppose we were a bit naive," says Speizer, "but we assumed it was worth doing, and it never crossed Ben's or my mind that we wouldn't take a shot at it." Speizer and Ferris soon discovered that a national air quality network they had hoped to use had been dismantled. This, however, turned out to be a blessing in disguise, since it allowed them to conceptualize and design their own monitoring systems and measurements, with the help of other faculty from the School. " I was an assistant professor just starting out," says John Spengler, s.M.'73, now Professor of Environmental Health and Director of the Environmental Science and Engineering Program. "I was doing some work on the exposures of commuters in Boston, and Ferris asked if I would play a role."
Fern's f r / g ^ Joseph e^pTweMf /or wieasMn'Mg /Mwg /MMCfWW.
"Iron lung" inventor Philip Drinker, professor of industrial hygiene emeritus, and world-renowned typhus and onchocerciasis investigator George Cheever Shattuck, clinical professor of tropical medicine emeritus, die.
Pro/eMor o/Ewv^rowywewfRf
.Scz'ewce
3peKer.
Working on the 13TH floor of Building 1 , Spengler and his team of doctoral students and young engineers designed and built a variety of personal air monitoring systems and home sampling equipment. A key challenge was keeping the disruption to a minimum, particularly for those subjects who were asked to wear personal air samplers. "Essentially we put the batteries, electronics, and pumping system into a box about the size of a Tupperware container and added some shoulder straps," Spengler says. "It was very quiet, and it had to be because people took them to church, work, their bedrooms, everywhere they went." ^ ^
OON AFTER COMING TO THE School in the Fall of 1 9 7 4 , epidemiologist Douglas Dockery became involved in the study. His days were spent traveling to the study sites—Watertown, Massachusetts; Portage, Wisconsin; Topeka, Kansas; Kingston/Harriman, Tennessee; St. Louis, Missouri; and Steubenville, Ohio—setting up air pollution moni-
HSPH faculty vote to replace the existi ng " Sat Isfactory/U nsatisfactory" grading system with tetter grades, but students balk.
Burglars caught break ing into Democratic Party headquarters in the Watergate office building.
Contributions of the Six Cities Study Particulate M a t t e r and Suifur Dioxides
Acid Aerosols Development of methods for measuring ambient acid aerosol concentrations.
Decline in lung function of children following particulate and sulfur dioxide episodes in Steubenville, Ohio.
Collection of daily concentrations for at least one year in each city. Suggestive evidence that respiratory symptoms my be associated with acid aerosol concentrations.
Respiratory illness reporting among children increased by approximately a factor of two between least polluted and most polluted communities.
Nitrogen Dioxide Respiratory symptoms and lower lung function among children associated with use of gas stove, a source of NO2.
increased incidence of respiratory symptoms associated with daily particulate and sulfur dioxide concentrations. increased daily mortality associated with Particulate air pollution shown in Steubenville, St. Louis, Missouri; and Kingston/Harriman, Tennessee.
Respiratory symptoms seem to increase with measured indoor NO2 concentrations.
indoor Air PoHution a n d Environmenta) Tobacco S m o k e Association between smoking indoors and particulate concentrations, and gas stoves and NO2 concentrations quantified. Effects of passive smoke exposure on respiratory health of children documented. Evaluation of respiratory health effects of indoor pollution quantified with indoor particulate and NO2 measurements. Effects of indoor aero-allergens on respiratory health of children quantified.
Ozone Acute declines in lung function of children observed in low-level ozone exposures in Kingston/Harriman, Tennessee.
tors in people's homes and doing Personal exposure measures. It has always amazed me how 'nterested and cooperative people ^ e r e , " says Dockery, now Associate Professor of Environmental Science and Epidemiology, " W e would go mto people's homes and set up equipment; we would have all "Ms of boxes and noisy pumps, and they were still very happy to Parttcipate. There were people w h o ^ o u l d drill holes m the side of their houses just to make our samPl'ng easier, and they would stay the program for a year or more."
Bangladesh (formerly " S t Pakistan) and Sri Lanka (formerly ^ y l o n ) proclaimed '"dependent r e p u b l i c .
" H e was the calm one," recalls Speizer, "and 1 was the excitable one. 1 would come into his office and yell and scream about problems, and after we talked for a while, everything seemed all right."
him a memorable figure, and an annual report he produced on fatal mountain-climbing incidents contributed greatly to safety in the sport. He frequently combined his climbing ability and respiratory research when he single-handedly carried his 55pound spirometer—an instrument for measuring lung capacity—to the top floor of Watertown tripledeckers in order to test study subjects. His dedication to the study led him to personally interview thousands of the more than 2.0,000 children and adults enrolled in the study.
Ferris's accomplishments as a mountaineer alone would have made
" H e made a point of going to each of the cities once a year to interview
But no researcher or subject was more enthusiastic about the study than the principal investigator himself. Benjamin Ferris—who died in 1 9 9 6 — w a s a man of Renaissance proportions: a physician, a photographer, an enthusiast of food and wines, and, by all accounts, a gentle and caring person.
? '
*
* -T*
? 1*
*
.
'
U.S. Supreme Court declares w a y in which the death penalty is imposed is unconstitutional.
Surgeon General's report w a r n s of dangers of "sidestream s m o k e " to nonsmokers.
U.S. birthrate i s 1 5 . 8 per 1,000 according to t h e National Center for Health Statistics.
8 ^ ^
subjects, working incredibly long hours far into the night for a couple of weeks," says Dockery, who accompanied Ferris on many held trips around the country. "His forte was getting people to participate. First, he would administer the questionnaire and talk with people; then, after he had gained a rapport, he would ask them if they would mind doing one more little test, and bring out the spirometer. Fm sure that if he started out with that huge piece of equipment, many of them never would have participated. He was very gentle and everyone really enjoyed working with him."
all, the study showed that indoor air quality was far more important to overall health than outdoor air; most people simply spend much more of their time indoors, and pollutants often become concentrated inside homes and workplaces. The study also indicated a strong, positive correlation between levels of air pollution and mortality: deaths from lung cancer, pulmonary disease, and heart disease were 2.6 percent higher in Steubenville—a city so polluted that air-born sulfates turned lead-based housepaint black within a year—than in Portage, the cleanest city in the study.
As Whittenberger had predicted, it was years until the Six Cities Study produced data on the health impact of air pollution. When it did, however, the results were different from what anyone had expected. First of
However, rather than indicating sulfur dioxide as the culprit emission, the Six Cities Study directed attention to so-called particulate matter, now recognized as a dangerous form of air pollution. Specifically, the study highlighted the hazards of socalled P M 1 0 particles, which are 1 0 microns in diameter and smaller. This lethal relationship between particulates and cardiovascular mortality has been replicated in studies performed in cities around the world. Following the release of the study's results in 1 9 9 3 , says Dockery, the American Lung Association brought suit against the Environmental Protection Agency to update its standards on particulate matter pollution, which had not been reviewed in accordance with the Clean Air Act in well over five years.
RwggfoM/H^rnTTMM, TewMessee, owe o/^ 53X C?'f!M 27! SfM^y.
1973
Elimination of federal funding for teaching and student aid to schools of public health creates an impending financial crisis at the School. The School stands to lose $2.4 million in federal funds by 1976.
"The quality and quantity of the data were both very impressive," says Mort Lippmann, a New York University Medical Center professor of environmental science who served on the E P A ' s Clean Air Scientific
^MOcMifg Pro/eMor o/^EMtwoMfMgM^ Ep^gw/o/ogy DoMgV^K Dockery Advisory Committee. "This was the largest epidemiologic study of the effect of pollution on individuals that was available. It was done very carefully over a long period of time, and it had to be taken very seriously." ^ ^
IX CITIES S T U D Y D A T A W A S A L S O cited in the E P A ' s standards for nitrous oxide and for ozone. At a recent School of Public Health symposium, current N I E H S director Kenneth Olden praised the study for laying a firm scientific foundation for regulatory policies. Numerous foreign countries have consulted the study when reviewing their limits for particulate matter pollution. The study developed important research tools that went into the hands of public health researchers everywhere. Biostatistical innovations—such as longitudinal data analysis, compensation for missing data and "smoothing" techniques—as well as air sampling techniques that were developed for the Six Cities Study are now used
Sears tower completed in Chicago
in a variety of research settings. In the laboratory of Joseph Brain, s.D.'66, Chair of the Department of Environmental Health and Cecil K. and Philip Drinker Professor of Environmental Physiology, dust from the study's filters has been used in animal models to study pulmonary disease. Conversely, these animal studies have suggested further modifications in sampling and data analysis in the Six Cities Study. At the outset it was expected to be 12. years," says Dockery, "and that we did do. But what was surprising was how many offspring and
"t"re dean Harvey V. Fineberg joins the as assistant professor of wealth services administration
spinoff studies of the Six Cities Study there are." The Five Cities Study and TwentyFour Cities Study have examined the long-term effects of acid aerosols on schoolchildren in the United States and Canada. All three studies continue to yield data that strongly influences the direction and content of American air quality policy, including the possible adoption of standards that may restrict emissions of smaller P M 2 . 5 particles. "The debate on lowering the P M standard is based on this environmental epidemiology program, and
I don't think it's overstating the case to say that the Six Cities Study data has been one of the bedrocks of the Clean Air Act," says Brain. "The research that has been done by the Ferris' disciples has spawned a method and approach that's been used all over the world, and all of us are the beneficiaries."-^
Roger Revetle, Richard Saltonstal) Professor of Population Policy and Director of the Center for Population Studies, becomes president-elect of the American Association for the Advancement of Science.
10
Howard Haym Hiatt ean,
T WASN'T PRESIDENT
1972
KENNEDY'S
1984
sion of the Peter Bent Brigham
speech at Berlin's B r a n d e n b u r g
Hospital and about Harvard's plan to
G a t e s , but history w a s made on a
build a new energy plant on Brookline
local scale on a warm spring day in
Avenue. A lot of folks were worried
1 9 7 9 when H o w a r d Hiatt stood to
about the health implications, and
address a group of Mission Hill resi-
there was a general feeling that
dents inside Boston's Mission Church.
Harvard wasn't listening." In March,
Perched on a low bluff overlooking
community activists had sent Hiatt
Harvard's
and medical school Dean Daniel
sprawling
Longwood
Medical Campus, the Church stands
Tosteson angry letters threatening to
at the foot of the working-class, multi-
disrupt graduation to protest the ener-
ethnic M i s s i o n Hill neighborhood.
gy plant's construction. Hiatt, in char-
Hiatt, a tall, august man then in his
acteristic fashion, responded swiftly,
seventh year as dean of the School of
appointing Smith, then supervisor of
Public Health, spoke about the importance of building
the School's mailroom and a Mission Hill resident, as
partnerships between the School and the Mission Hill
community liaison and authorizing a series of outreach
community. But the substance of his talk was, for the
efforts that brought together faculty, staff, and Mission
most part, eclipsed by the man himself: although
Hill residents. Even after the immediate crisis passed,
Harvard's medical and public health schools had stood
Hiatt continued to push for meetings with community
shoulder to shoulder with Mission Hill for several
representatives, says Smith.
decades, to the best of anyone's memory, Hiatt was the
"Hiatt didn't just talk about it, he got out there and
first dean of either school to venture inside the Mission
got involved," he says.
Church.
The chance to get involved was what had brought
Director of Community Programs Bruce Smith, who
Hiatt to the School of Public Health in the first place.
accompanied Hiatt that day, recalls the importance of the
A brilliant physician and scientist, Hiatt was a professor
visit to the community and the School: "At the time,
at the medical school and physician-in-chief of Beth Israel
Mission Hill residents were up in arms about the expan-
Hospital when new University President Derek Bok
Professor of Engineering in Environmental Health Dade Moeller appointed to the Advisory Committee on Reactor Safeguards of the U.S. Atomic Energy Commission.
H
^ *
P
J y^ ^
.
Martha May Eliot, professor of maternal and child health emerita, receives the American Public Health Association's Centennial Award. William M. Schmidt, professor and chair of the Department of Maternal and Child Health, receives the APHA's Martha May Eliot Award.
HSPH enrollment reaches 258.
offered him the School's deanship in 1972.. It was a bold move for Bok— Hiatt was an outsider to public health—and a risky gambit for Hiatt, who would be giving up a highprohle career in medicine for a much less certain future. In the end, Hiatt says he accepted the deanship because it offered the opportunity not only to shape an institution, but to focus an entire held." During his iz-year tenure, Hiatt went a long way toward realizing these goals. With the help of colleagues from throughout Harvard University, he transformed the School's Departments of Biostatistics and Health Policy and Management and in the process made public health the watchdog and conscience of Medicine. Through a series of brilhant and controversial appointments, he imported the powerful new research tools and methodologies of molecular biology and the quantitative social sciences into the School's traditionally strong research on tropical diseases, cancer, toxicology, and environmental illness. He aggressively broadened the School's training programs in health policy and management by introducing twoyear master's degree programs and executive courses for mid-career Professionals. And he authorized a series of outreach activities that bought the School into closer contact with the community right outside hs front doors.
several scholars Hiatt recruited who have become pillars of the School's present-day research and training mission. Another was a young decision scientist from Harvard's Kennedy School of Government named Harvey Fineberg, who would eventually succeed Hiatt as dean. "One of Howard's most important legacies to the School of Public Health was the quality of appointments he made to this faculty, at every level," says Fineberg, who joined the School's faculty in 1972.. " H e brought leading scientists and scholars into the field, and attracted outstanding young talent to our ranks." Yet in attempting to redraw the boundaries of public health, Hiatt met with resistance from traditional-
ists, including some of the School's most respected faculty members, and found himself at the center of a conflict that to some degree clouded his many achievements as dean. rn rn m H E N H I A T T T O O K O V E R A S W W D E A N in the fall of 1972., the 50-year-old School of Public Health was at a crossroads of sorts. In some respects, the institution had never been stronger, with three new buildings—courtesy of Hiatt's predecessor, John Crayton Snyder—and a distinguished senior faculty and alumni body that had made signal contributions to the understanding and control of disease. Yet public health as a field had, to a great extent, fallen victim to its own success. The remark-
Bosfon's M;'ss:'ow C^Mrc/?, w^gre HMff /or <3 c/oser cooperafzoM C07M7?{K7M'fy /ixcu/fy.
I think Howard was responsible or bringing schools of public health mto the modern era," says Milton ^emstein, Henry J. Kaiser Professor ^ H e a l t h Policy and Management. einstein, an economist, was one of
Supermarket barcodes are introduced.
U.S. Food and Drug Administration issues regulations standardizing nutritional information on food packaging.
U.S. Supreme Court /?oe y. decision establishes a w o m a n ' s right to privacy in seeking an abortion during the first 6 months of pregnancy.
T/?e H<!?-twJ BrgMMaM, HotMrJ
Prac^'ce ^ ^ J y feaw.- N^w LazrJ, /osepA New^oM^e, TroyeM ^wJ LMCMM Le^pe.
able global gains against measles, smallpox, polio, and malaria had fostered a perception that infectious diseases—the traditional locus of public health research—were on the brink of elimination. Federal funding for public health education and research had begun to dry up. Why support more research and programs on problems that would soon be irrelevant? When policymakers and the public at large thought of health care, they thought primarily of doctors and hospitals, not departments and schools of public health. Meanwhile, the revolution in molecular biology unleashed by the discovery of DNA-manipulation techniques was transforming the health sciences. Increasingly, the search for the causes and cures of illness focused on the spiraling genetic matrix that governs human biology and physiology. And, for the most part, this search was being conducted in hospitals, medical schools, and independent laboratories, not schools of
1974
Professor of Nutrition Jean Mayer heads an international task force to evaluate child nutrition in relation to programs sponsored by WHO, UNICEF, UNESCO, FAO, the World Bank, and other international agencies.
public health. Hiatt, a leading proponent of this "new biology," had spent the past decade adapting its tools and techniques to clinical research with great success and felt that public health could reap similar benefits, particularly in combating tropical diseases, environmental toxins, and cancer. But Hiatt was by no means wedded to the bench. Twentyfive years as a practicing physician had made him acutely aware of the shortcomings in American medicine—its penchant for expensive, high-tech treatments; the lack of rigorous evaluation of new clinical practices; the growing numbers of patients excluded from the system; the lack of emphasis on prevention. "I saw that many of my fellow doctors were not thinking about what they did from a broad perspective," he says. "For example cardiac surgeons understood very well what the underlying defect was in the coronary patient, but had little knowledge of the effectiveness of their treatments."
At the annual end-ofthe-year party, students John Boice, Sally Sharpe, and Cheri Papier perform Boice's ballad to epidemiology:
He had recently returned from a one-year sabbatical at London's Imperial Cancer Research Fund, where, while honing his bench skills, he had taken a close look at the British health-care system. What he observed crystallized his belief that doctors alone could not solve America's impending medical crisis, but would need the help of economists, policymakers, statisticians, lawyers, and a variety of other professions. In public health, Hiatt saw the ideal arena in which to achieve this marriage of medicine and social science. And in Derek Bok, he found a colleague who shared his enthusiasm for collaborative, crossdisciplinary research. "Howard reached out and got many people around the university interested in and excited about public health issues as an area of applied scholarship," says Bok. " I think this was exactly the right strategy to employ." Hiatt was certainly not the first person without a degree in public health to hold the office of dean of the School. In fact, of the six permanent deans in the School's 75-year history—David Linn Edsall, Cecil Kent Drinker, James Stevens Simmons, John Crayton Snyder, Hiatt, and Harvey Vernon Fineberg—only Simmons, s.D.'^^, had graduated from a school of public health. Hiatt, however, was unique in never having worked within a traditional public health arena. But throughout his career as a clinician, researcher, and teacher, he had distinguished himself as a man of searching vision who defined health and health care in the broadest possible terms. He
fp/c/em/o/ogy /s AVntfa s/7/y /f don Y mean s%7n d/sease /our co/torfs need confro///ng Suf don 'f af&Aufe fhem fo me fp/dem/o/ogy's not so s/mp/e /Vew tvorc/s are preya/enf affadr, refro^pecf/w or are f/!ey /no'dent?
had also cultivated strong ties with faculty across the university, and he had earned a reputation for making things happen. Bok says Hiatt combined "imagination and high academic standards" with a "capacity to inspirit and inspire young faculty." "Howard is a real bearcat about getting things done," says long-time colleague Frederick Mosteller, who chaired the departments of biostatistics and health policy and management under Hiatt. " H e ' s very decisive about moving forward, and he works hard at the hardest parts of any job." Bearcat" seems an unlikely appellation for the soft-spoken, 72-year°ld former dean. Tall and trim, with handsome, aquiline features and a rehned, almost genteel demeanor, T-f t ^natt is a congenial and charismatic Presence. Interviewed recently in his office at Bngham and Women's Hospital, he hardly looked a day older than when he retired from the School in 1 9 8 4 — a n d even then he ooked more like a man in his forties ^han his hfties. He is variously ^scribed by friends and colleagues as 'hght-hearted," "gentle," an "extraordinarily kind and caring person," and someone w h o "spreads credit around very generously." In conversation he shifts comfortably between ^ c u s s i n g his latest professional °rays—among other things he is heading up an effort to look at the Reality of life of terminally ill patients and an American Academy of Arts arid Sciences task force on problems affecting children—and the achievements of his three children and eight grandchildren. Yet scratch the stately surface, and Hnd a man of formidable intensi-
Cincinnati surgeon Henry Heimlich introduces "Heimlich m a n e u v e r " to clear t h e airways of choking victims.
ty and drive. " H o w a r d ' s very passionate and principled in his beliefs," says long-time friend Barbara Rosenkrantz, professor of the history of sciences emerita at Harvard University. In the late 1 9 7 0 s and early 1 9 8 0 s , Hiatt was one of only a handful of physicians to speak out against the continuing nuclear weapons build-up, which he called, memorably, "the final epidemic." Professor John David, chair of the Department of Tropical Public Health, credits Hiatt with "bringing a moral character to the debate on nuclear arms" in the early 1 9 8 0 s , and says that "one of Hiatt's strengths was his willingness to speak out on controversial issues. I congratulate him on that." O R N I N 192.5 I N P A T C H O G U E , N e w Y o r k , Hiatt grew up in Worcester, Massachusetts, where his father, w h o had immigrated from Lithuania a decade earlier, settled after serving in World War I. He entered Harvard College in 1 9 4 4 , and, after only two years, w o n entry to Harvard Medical School as part of an accelerated program to supply doctors to the armed services. By the time he earned his medical degree, however, World War II was over, so the 2.3-year-oM M . D . embarked on a fairly conventional career path: internship and residency in internal medicine at Boston's Beth Israel Hospital followed by a research fellowship at Cornell Medical College and a faculty appointment at the University of Chicago Hospital. In 1 9 5 0 , however, with the outbreak of the Korean War, he joined the U.S. public health
service and was posted to the National Institutes of Health, where he got his first taste of bench science, studying cellular metabolism in the laboratory of biochemist B.L. Horecker. Energized by the experience, Hiatt returned to Boston and Beth Israel at the invitation of the hospital's legendary physicianin-chief, Herrman L. Blumgart, to set up one of the nation's first medical oncology research and training units. Throughout the 1 9 5 0 s , Hiatt's research focused on endocrinology and neoplastic growth—how normal cells turn cancerous. In particular, Hiatt was studying the synthesis of a sugar molecule called ribose, a building block of ribonucleic acid, or R N A . This work would lead him to France's Pasteur Institute, where he worked with two of the luminaries of modern biology, future Nobel Laureates Jacques Monod and Francois Jacob. As a traveling fellow in M o n o d ' s laboratory in 1 9 6 0 - 6 1 — a period Hiatt describes as the " h e y d a y " of molecular biology— Hiatt was on the research team that discovered messenger R N A . This discovery, which provided a critical link in understanding how information encoded in D N A is used by the cells, has been described as a "monumental scientific event." And, at 35 years old, Hiatt was still a relatively young scientist. "It was very heady stuff," he says. Back at Harvard, Hiatt continued his rise through the medical school's ranks. In 1 9 6 3 he was named Herrman L. Blumgart Professor of Medicine and physician-in-chief at Beth Israel Hospital, where, according to colleagues, he was instrumental
Harvard Six Cities Study of air pollution launched under t h e direction of Professor of Environmental Science Benjamin Ferris. The study will revolutionize understanding of the health impacts of airborne pollutants, indoors and out.
in creating a cutting-edge biomedicai and clinical research program looking at the molecular roots of disease. And yet the higher he rose in medicine, the more troubled he was by what he saw as a system in crisis. Making sense of this system and fixing some of its glaring gaps would become one of the major themes of his deanship at the School of Public Health. U R I N G H I S F I R S T YEAR AS D E A N , Hiatt convened a series of panels to examine the School's research and teaching programs and evaluate their ability to meet the public health challenges facing the nation and world. As a result of this analysis, he says, he came to the somewhat radical conclusion that public health wasn't a discipline per se, but a set of complex problems each of which required a slightly different blend of skills to resolve. "Since many of these problems had not only biological and clinical bases, but political and economic and anthropological and historical underpinnings, it seemed to me that, to address them, you would need input from these other areas," says Hiatt. While many of these disciplines fell outside of the traditional public health canon, the expertise did exist elsewhere at Harvard; the question was how to tap into it. One of Hiatt's first acts as dean was to initiate, with Mosteller, a University-wide Faculty Seminar in Health and Medicine to begin looking at the many problems plaguing the nation's health care system. The seminar, which met bi-weekly, was modeled on an earlier effort by Mosteller and Kennedy School Professor Daniel Patrick Moynihan.
It was an instant hit, drawing more than 1 0 0 participants from Harvard's various faculties and teaching hospitals, including physicians, economists, lawyers, management experts, biologists, and engineers. At the same time, Hiatt launched the interdepartmental Center for the Evaluation of Clinical Procedures (later renamed the Center for the Analysis of Health Practices), which would be the focal point for an innovative health-care policy research and training effort that would be one of Hiatt's primary legacies to the School and the field. (See article, page 2.0). Led by Professor Howard Frazier, the center was a model of interdisciplinary scholarship, bringing together clinicians with decision scientists, economists, statisticians, and policy analysts. "Howard was one of the people who realized early on the importance of the quantitative social sciences to public health," says Rosenkrantz, whom Hiatt brought to the School in 1 9 7 6 to teach the history of public health to health policy students. Rosenkrantz's appointment reflected Hiatt's penchant for pulling in scholars from outside the traditional public health canon to bring new perspective and skills to bear on complex problems. Among the long list of eclectic appointments made by Hiatt were population biologist Richard Levins, now John Rock Professor of Population Sciences (see article, page 64); management expert Nancy Kane, a business school graduate and lecturer in the Department of Health Policy and Management; economist and former
Watergate scandal forces resignation of President Richard Nixon on August 9. Vice President Gerald Ford assumes the presidency.
U S A I D head David Bell, now professor emeritus; and former insurance actuary William Hsiao, now K.T. Li Professor of Economics and Health. (Another Hiatt appointee, the late Herb Sherman, a former M.I.T. engineer with a genius for solving complicated problems, has been described as the "guru" of the clinical practice evaluation group.) "One of Howard's strengths is his ability to appropriate expertise from other disciplines to solve a problem," says Mosteller. "He sees many parallels between fields." Even when he stayed within the traditional bounds of public health, Hiatt often broke fresh ground. Mosteller, whom Hiatt lured from his post as chair of Harvard's statistics department to build up the School's biostatistics department, would later chair the Department of Health Policy and Management (previously the Department of Health Services Administration). In both cases, Mosteller would guide the development of strong research programs focused on improving aspects of health-care delivery. To introduce molecular biology and immunology techniques into the School's tropical disease and toxicology, Hiatt recruited former medical school colleagues John David and Armen Tashjian, both leaders in their respective fields. In a similar vein, Hiatt appointed distinguished biochemist John Cairns, whom he had worked with at the Imperial Cancer Research Fund, to strengthen the School's budding cancer biology effort. To lead an interdisciplinary program in the environmental health sciences, Hiatt secured former Manhattan Project
chemist Donald Hornig, w h o had recently stepped down as president of Brown University. Hiatt also showed a discerning eye for young talent: in addition to Fmeberg and Weinstein, the list of budding scholars that Hiatt brought to the School who have gone on to assume key posts includes N a n Laird, chair of the Department of Biostatistics; Arnie Epstein, chair of the Department of Health Policy and Management; and M a x Essex, chair of the Department of Immunology and Infectious Diseases. Hiatt says his goal was "to bring together the best and brightest minds available to work on major public health challenges." His vision for the School, outlined in his 1 9 7 5 dean's report, was of a flexible, truly interdisciplinary institution that drew outside expertise on an as-needed basis to confront specific problems, ^ o t everyone agreed with this approach, however. A sizeable portion of the faculty, including some of ^ e School's most senior professors, viewed Hiatt's efforts to refashion the School as high-handed and dismissive of past and present achievements. Hns was partly a clash of powerful Personalities, aggravated by severe nnancial stresses that had forced Hiatt o make some unpopular administrat e decisions. (Between 1 9 7 2 and ^977, the School lost an estimated J-5 million in revenue due to the elimination of federal public health training grants.) But at heart, it was a smuggle to define the fundamental ^ s i o n and priorities of the School— ^ e e d of public health as a field, latt's vision was broadly inclusive; ^ to some members of the faculty,
the School's burgeoning work in clinical trials of treatment drugs, assessment of medical procedures, the economics and organization of health-care systems in the United States and abroad, immunology and molecular biology, however impressive, just wasn't public health. Rosenkrantz, who has studied the evolution of public health in the United States, says that the field, by virtue of the diversity of problems and professional and scholarly disciplines it embraces, has always been vulnerable to internal divisions. "Public health is a contentious area," she says. By the middle of the 1 9 7 7 - 7 8 academic year, the debate had turned acrimonious, and in June the undercurrents of dissension spilled over: right after commencement, a group of faculty sent a letter to President Bok demanding Hiatt's removal from office. Within the polite confines of the academy, this was tantamount to a coMp
Af age 73, HMff rewaws acfwe WoweM's
1975
Sebastian S. Kresge Education Building is dedicated, completing the building program initiated by former dean John Snyder.
J ' e f a f . Hiatt, who was vacationing in Europe at the time, was caught off-guard and deeply wounded by this turn of events. H N H I S 1978 D E A N ' S R E P O R T (BY ) tradition submitted at the start of the next academic year), Hiatt made public many of the details of the previous spring's events, in the hope that airing the dispute would speed the healing process and help the School move forward. The report notes that on August 24, after spending the summer reviewing the situation, Bok called a special meeting of the faculty to announce his decision: he was sticking with Hiatt. (According to a faculty member who was present, the announcement was greeted with utter silence.) Hiatt was vindicated, but the faculty remained divided, and Hiatt's dream of a fully integrated institution was cut short. The 1 9 7 8 dean's report begins with
a sew'or cowsM^aw^
a; Bng^aw awe?
As part of Boston's desegregation plan for public schools, faculty at t h e School work with students and teachers at Roxbury High School to provide educational field trips and tours.
the question "What are the boundaries of public health?" and ends with the sober acknowledgement: "a definition of public health that would attract unanimity has not been achieved, nor is it likely to be, for it almost surely must undergo continuing change as contemporaneous health problems change." Hiatt continued as dean for another five years and continued to push forward on a number of important fronts, including sowing the seeds for some of the School's most successful community outreach efforts—Project L I F E and the Longwood Medical Area-Mission Hill Food Drive. He spearheaded the creation of the interdepartmental Division of Biological Sciences, which sought to coordinate and strengthen research and training in the biological sciences at the School. Tashjian, whose work has helped redefine toxicology research, says that Hiatt's commitment to strengthen basic biologic research represents one of his most important legacies to the School and the held of public health. David, whose department is now developing diagnostic tools and vaccines based on immunologic and molecular biologic techniques, agrees: "This has added an important new dimension to tropical disease research. In this respect, Hiatt's vision has absolutely succeeded." Equally noteworthy are the many curriculum reforms Hiatt introduced at the School. Early in his deanship,
Julia Ojiambo, M.P.H.'69,assistant minister of housing and social services in Kenya, is first Kenyan w o m a n appointed to a ministerial post.
he introduced an experimental, university-wide course in health policy and management designed to prepare bachelors-level students for careers in medical management. He also launched the executive programs in health care management and a two-year program in health services administration, both of which sought to provide sound management skills to hospital administrators. In 1 9 8 4 Hiatt stepped down as dean, passing the mantle to his former protege, Fineberg. He remained on the School's faculty until 1 9 9 4 , and, in conjunction with Brigham and Women's Hospital, where he still serves as senior consultant in medicine, he initiated and later led the Harvard Medical Practice Study, which provided some of the first information about the risks of being injured during hospitalization and the inequities in the way malpractice claims were resolved. He also launched the Clinical Effectiveness Fellowships, in an effort, he says, to "push" physicians into the School to learn the basics of medical evaluation. There are few parts of the School today that do not bear some imprint of Hiatt's leadership. Yet Hiatt himself has somehow faded, slipped off the screen. Bok says that Hiatt "showed great courage and perseverance" in leading the School through a difficult but necessary period of transition and "deserves enormous credit" for laying the foundations for the
Saigon falls to North Vietnamese troops, bringing an end to the Vietnam War.
School's present-day research and training. Mosteller says the passage of time has validated Hiatt's longterm vision of pubhc health: "It seems to me now even more farseeing than at the time." Hiatt, however, is circumspect in discussing his long career at the School, treading carefully around sensitive issues, conscious that his opinions are likely to be seen as self-serving or defensive. He is, as Mosteller said, gracious in crediting others for the many successes of his deanship, from Levins ("an extraordinary population biologist who has enriched the held immeasurably") to Tashjian ("he revolutionized the held of toxicology") to Bruce Smith, who accompanied him on that spring day in 1 9 7 9 and whom Hiatt refers to as "one of the School's unsung heroes." As for his own contributions, however, he prefers to let time and others judge. " I consider myself very lucky," he says with a smile. " M a n y of these achievements are just an evolution. It didn't happen because I was there. It was only because I was around at a time when they were in currency that I could take advantage of the widespread interest."
Kevin S o t t a k
Nineteen-year-old Harvard dropout and computer whiz William Gates founds Microsoft, which will grow into the world's largest computer software producer.
N A SHORT, 1981 ESSAY IN THE N E W E N G L A N D J O U R N A L O F M E D I C I N E , THE late William J. Curran weighed in on what was then and still is today one of American medicine's most emotionally and ethically charged debates: the terminally ill patient's "right to die." The issue had been brought to the fore m the late 1970s as a result of several high-profile cases—most notably that of Karen Anne Quinlan—in which families had sought the court's sanction to withhold or remove medical treatment from dying loved ones. The article, one of nearly zoo published between 1964 and 1988 under the heading "Lawmedicine Notes," is vintage Curran: succinct, reasoned, remarkably free of legal and medical jargon, and punctuated with biting irony.
Curran begins by reviewing recent rulings on the right to die, including a lower New York court decision granting a family's petition to remove an 8 3-year-old heart attack victim from a respirator—but only after following an elaborate and arcane set of legal procedures. Curran, who always favored the simplest, most elegant solution, criticizes this decision as a "witches brew of procedural ingredients that would, if ever followed step by step, exhaust
The Father of Heatth Law Witiiam Curran
ah resources and patience committed to individual litigation since the Jarndyce and Jarndyce case." Jarndyce and Jarndyce is, of course, the famously Protracted lawsuit in
HoM^e that is described in the novel as a "scare-
crow of a suit" that has "in the course of time, became so complicated that no man alive knows what it means." In a sardonic aside, Curran suggests that mercifully, perhaps, most of the terminally ill patients would have before these quixotic efforts to protect the patients' dignity and lives "vere completed."
Mozambique, c a p e ^ d e , the People's ^ l i c of Angola, and Papua become ' " ^ p e n d e n t republics
According to an EPA report, 79 U.S. cities have polluted water.
President Ford signs the Toxic Substances Control Act, which phases out the production and sale of PCBs and imposes strict regulations on chemical industry.
The "right to die" debate is one of numerous medico-legal controversies that Curran, who has been cailed the "father of legal medicine," helped inform and ultimately shape through his scholarship and writing during his long career. With a law degree from Boston College, a master's degree from Harvard Law School, and a degree in public health from the School for good measure, Curran was well-qualified to understand the intersection between two fields whose broad areas of overlap include some of the most hotly debated issues of the past 40 years: abortion rights, human subjects research, definition of death, and A I D S discrimination. When Curran began his studies at the School in 1 9 5 7 as the only attorney in his class—and to the best of anyone's knowledge the first lawyer to earn a degree at the School—the medico-legal field existed essentially to support the trial process. "Lawyers and doctors interacted primarily in the courtroom. Medical experts provided forensics testimony at murder trials or testified at malpractice suits," said Curran, in an interview shortly before his death in 1996. "I knew there was room for law and science to work together in more positive ways." It was on the basis of this belief that Curran developed and directed the Law-Medicine Research Institute at Boston University in the early 1960s. According to Professor of Law and Public Health Troyen Brennan, Curran's successor as director of the Law and Public Health Program at the School, the timing was right to broaden the definition of health law. "The research at Tuskegee, which had
Boston ordered to bus 21,000 students, as part of racial integration plan.
followed the course of syphilis in poor, African-American men whose disease went untreated, was beginning to come to light," said Brennan. "This led to an outcry from the public and the scientific community that resulted in regulations concerning the use of informed human subjects in scientific research. Bill Curran nearly single-handedly guided the development of these policies." In 1968, when Curran joined the School's faculty, his appointment was split between the departments of Health Policy and Management and Maternal and Child Health. Five years later, the School's Program in Law and Public Health—a specialized training program for lawyers leading to a master's of public health degree—was incorporated into the Department of Health Policy and Management. Curran directed this program until he retired to emeritus status in 1 9 9 1 . ^ ^ URRAN'S FORMER STUDENTS H remember him as a gentleman^ ^ ^ ly scholar with a personal interest in each of them. "Professor Curran was a friend," explained Joan Rachlin, M . p . H . ' 7 8 , executive director of Public Responsibility in Medicine and Research, a non-profit organization dedicated to educating the medical and legal professions, industry, and the public about the ethical, legal, and policy dimensions of appropriate and ethical research. "The opportunity to study with Professor Curran was actually what attracted me to the program at Harvard, and, apart from the intellectual experience of the program, he went out of his way to make the
Production of first monoclonal antibodies sparks a revolution in diagnostic and therapeutic medicine.
lawyers in his charge, perhaps 1 0 out of the entire student body, feel as though they belonged. I also particularly appreciated and admired the extent to which Professor Curran championed the careers of women lawyers in the health-care field, which had been a traditionally male bastion." Larry Gostin, a long-time colleague of Curran, who now directs the Law and Public Health Program at Georgetown and Johns Hopkins, recalls Curran's Friday afternoon teas. "Every Friday, you could find Bill making tea and offering cookies and conversation to his students in the program," said Gostin. "This kind of personal interaction and commitment is so often lacking in highpowered academic settings, but Bill never succumbed to that mind set." By the late 1980s, concern on the international level about the spread of A I D S led to the enactment of harsh laws in several nations, including the United States, restricting immigration and travel of Hiv-positive individuals. In some instances, legislation was adopted treating the transmission of H i v as a criminal offense. In 1988, the World Health Organization ( W H O ) designed its first international collaborating center for health legislation. With A I D S as it first focus, the Center was placed at the School, largely because of Curran's reputation as a health-law innovator and an expert on individual rights, including the intersection of health and human rights. In the 1960s, Curran designed and taught the School's first course in human rights law as it pertained to health. Curran was selected to serve as the first director of the Harvard
Altair 8800 is the first personal computer on the market. The Apple PC will follow in 1977 and the IBM PC in 1981.
University-WHO International Collaborating Center for Health Legislation, with Gostin as associate director. One of the Center's first accomplishments under Curran was the completion of a worldwide survey of A t D S legislation, undertaken at the request of Jonathan Mann, M . p . H . ' 8 o , Franqois-Xavier Bagnoud Professor of Health and Human Rights, who then served as director of the W H o ' s Global Programme on A I D S and had been a participant in Curran's ground-breaking health and human rights seminar. "To paraphrase Newton, we can see as far as we can because we stand on the shoulders of giants. At this school, Bill Curran is the giant on whose shoulders the Franqois-Xavier Bagnoud Center stands," said Mann. According to Brennan, there is not an aspect of health law on which the Work of Curran or his students has not had an effect. In 1968, Curran served as the legal representative on the Harvard Ad Hoc Committee on Bram Death. The Harvard criteria ecame the basis for the nation's first egislation on brain death in Kansas *n 1970 and subsequently provided the basis for legislation across the country which allowed physicians to etermine death based on a patient's ack of response to external stimuli, spontaneous movement, and respiratory effort in conjunction with an ^ ectroencephaiogram showing no 째rain a c u i t y .
^ ^ ^ URRAN'S WORK ON THE RIGHTS H of the mentally ill produced ^ ^ ^ landmark legislation locally and internationally. In the early 1960s, Curran identified flaws in Massachusetts' laws regarding the rights of the mentally ill as they pertained to the duration of committal, patients' rights to refuse treatment in most circumstances, their rights to hearings to determine the appropriateness of continued in-patient treatment, and the rights of those arrested and awaiting trial who were referred for psychiatric evaluation prior to trial. Curran also wrote regarding the assumed loss of civil rights that at the time accompanied referral for psychiatric treatment, including the automatic revocation of one's drivers license and the barring of a psychiatric patient from making a will or marrying. Curran was appointed to the Legal Studies Unit of the Massachusetts Special Commission on Mental Health. Nearly all of the unit's recommendations, which addressed concerns Curran had identified regarding patient's rights, became law. By the late 1970s, Curran's influence on mental health law had extended to the international front with his co-authoring of the influential Law and Mental Health: Harmonizing Objectives, which reported the results of an international survey of mental health legislation for the W H O and sped worldwide reform of mental health laws. In
1979, Curran was among a group of legal experts drafted by the International Commission of Jurists and the International Institute of Higher Studies in Criminal Science to develop guidelines on the rights of persons with mental illness. Twelve years and numerous re-drafts later, the text was adopted by the United Nations General Assembly as the "Principles for the Protection of Persons with Mental Illness for the Improvement of Mental Health Care." Curran's influence on the Massachusetts laws was considered so great that T^e New Yor^ wrote after his death in September 1996, "In Massachusetts, whose laws became models for national and international legislation, he left his fingerprints on so many statutes dealing with issues like psychiatric commitments, qualifications of physician's assistants, minimum professional standards for medical examiners, patient's rights, and drug addiction rehabilitation, that the state's health and medical laws could be called the Curran code." Brennan agrees: "we take for granted now that there is a legal definition of brain death and regulations regarding psychiatric commitment or the use of human subjects for scientific research. But before Bill Curran, there was no context in which to examine these difficult issues. He gave us that."
Marcetla Bernard
1976 ofltrf chair of the Department Nutrit t ^ faculty. Professor of i<on Jean Mayer leaves to become the 10th P ^ d e n t of Tufts University
China's Chairman Mao Zedong dies.
National Institutes of Health bans some forms of recombinant DNA research for fear of creating virulent, drug-resistant super-pathogens. Cambridge City Council places a three-month moratorium on genetic research at Harvard.
HNBMBH Fearing an epidemic of deadly swine flu, President Ford and CDC head David Sencer, M.P.H.'58, launch an ill-fated national vaccination campaign; 48 million Americans are vaccinated, 535 develop a rare paralytic side-effect, and the epidemic never materializes.
National Academy of Sciences calls for ban on aerosols, a major source of ozone-depleting chlorofluorocarbons.
"fegionnaire's disease -* a rare form of bacterial pneumonia—kills 29 people at an American Legion convention in a Philadelphia hotel.
^
S A N E P H R O L O G I S T , H O W A R D F R A Z I E R H A D SEEN T H E SLOW, W R E N C H I N G
decline of patients with end-stage renal disease many times. First the nausea * ^ and vomiting, then the mental disorientation so distressing to families and loved ones, and then the last breath. Doctors did their best in those days, "tweaking and poking and shifting things around a little bit so people didn't die as fast," says Frazier, an emeritus professor of health policy and management at the School of Public Health. But end-stage renal disease was just that: end-stage. Then the dialysis machine was developed, and in 1 9 5 4 , the first successful kidney transplant was Performed at Peter Bent Brigham Hospital. In the years to come, nephrology would go from being medicine that cared to medicine that cured. Money, equipment, and medical talent flowed into the specialty, ^ h e n there was an outcry over a shortage of dialysis machines and treatment in the early 1970s, Congress responded by setting up a special Medicare-type fund just for end-stage renal disease patients. heady mixture, this combination of money and technology, but for razier it also meant a disturbing Paradox. There I was, enormously relieved y the shifting of an ethical burden— ecause resources were available, and ^ hasn't my responsibility to somew scrounge and come up with t em. On the other hand, it was just a wasteful way of deploying very 'mited resources. To put someone of ° chronic dialysis—which people argued you have to do because the jeatment is there—is just not sensi^ e. You can't even afford three ^cks to provide immunization for e kids across Huntington Avenue
1 ^ ' S . F . . d and Drug
^ , ' ^ t l o n approves use of Inderal ^
beta-blocker, for blood pressure.
Epidemic of a highly fatal infectious disease among Sudanese cotton workers is the first known outbreak of Ebola virus disease.
in the projects, and yet you could afford, $ 3 5 , 0 0 0 to $40,000-a-year to maintain someone symptomatically uremic but not dead." Frazier wasn't the only one troubled by the cognitive dissonance in the American approach to health: the dazzling prowess of curative medicine and the relative neglect of what might be done to keep people from needing that medicine. It was also on the mind of the School's new dean, Howard Hiatt. A top-rank molecular biologist and former chief of medicine at Boston's Beth Israel Hospital, Hiatt was neither ignorant nor dismissive of the post-war accomplishments of American medicine. But he was also aware of the blind spots. Precious little was being done in the way of systematic analysis of medical treatments—what they cost, what the real gains were. And there was the related issue of people who weren't getting this care. "Here we were within the network of Harvard's teaching hospitals, paying extraordinary attention to the patients, but we had very little involvement with people who didn't come to us—especially people who didn't get into the system at all," says Hiatt.
Over the next decade or so, the Harvard School of Public Health became the place where the blind spots, paradoxes, and cross-currents of the American health-care system were put under the bright, searching lights of systematic evaluation and examination. In a research effort unprecedented both in terms of scope and method, faculty at the School studied how decisions were made in American medicine, the motivations behind those decisions, and the consequences both for patients' and the nation's health. To do the job, Hiatt unabashedly imported talent from other parts of Harvard and techniques from other disciplines, most notably from statistics, economics, and decision theory. He galvanized the effort by organizing, with statistician Frederick Mosteller's help, the Seminar in Health and Medicine, a kind of university-wide think-tank of 1 0 0 or so professors and clinicians who met regularly for about three years. The School's Department of Public Health Administration, renamed the Department of Health Policy and Management, was transformed into a hot-bed of original research and scholarship. Members of the seminar
John Crayton Snyder, professor of population sciences and dean of the School from 1954-71, retires. The Kresge Building's main auditorium is named Snyder auditorium.
Nurses' Health Study launched under the direction of Professor Frank Speizer.
the same intensity and scale of effort," he says. Hsiao credits Hiatt and his vision of rigorous study of health care and medicine with "revolutionizing the field of public health." H
As D^ecfor o/t/w Cewfer /or o / H e ^ ^ Prac^'ce, Pro/exsor HoMwJ pMZMr was a Twew^r aw J /F^Mre" fo a sf?*M?7! o/ ^/eM^eJ yoMMg
and department faculty wrote prolifrcally and played a major part in shaping a body of research about the cost-effectiveness of American health-care. Some of the landmark books included Cosfs, BfMe/^s o^M^gery; Hyperfe?!s;'o7!; A Po^cy Perspec^we; and C/w^'c^J Dec/s/ow AM^/y^M. Franz Ingelfinger, the editor of New Ewg/^wJ JoMrw^/ o/^MeJz'cwe was receptive to this new, quantitative approach to medicine and provided Hiatt, Professor Milton Weinstein, and Harvey V. Fineberg, then a young health policy professor, a highprofile forum for their ideas. The School's health policy researchers also made waves outside of academic circles. Professor William Hsiao's Resource-Based Relative Value Scale ( R B R v s ) changed how Medicare pays doctors and underscored the need for more pri-
1977
tn response to a growing world "energy crisis" newly inaugurated president Jimmy Carter proposes a national energy program to reduce U.S. dependence on imported oil.
mary-care physicians. The School's extensive study of medical errors in New York State hospitals made national headlines in 1 9 9 0 and injected reliable data into the nation's fractious debate over medical malpractice. Professor Robert Blendon, the Roger Irving Lee Professor of Health Policy and Management, emerged as the nation's foremost expert on the nuances of American attitudes about health care and medicine during the prolonged debate over health-care reform during the first two years of the Clinton administration. As the Sturm and Drang over the nation's medical costs mounted in the 1970s, other schools and institutions—most notably the Rand Corporation—also started to study and measure the workings of the American health-care system. Frazier says the School set the pace. " I don't think there was a single place with
H tSTORICAL PRECEDENT DID
exist for evaluating medicine. ! Ernest Codman, an iconoclastic surgeon at Massachusetts General Hospital, was ahead of his time in the 1 9 1 0 s when he argued for systematic data collection and analysis on surgeons. About a decade later, the privately-funded Committee on the Costs of Medical Care generated for the first time some statistics now taken for granted: total national expenditure on health-care ($3.6 billion in 192.9); a breakdown of how those expenditures were divided between physicians and hospitals; and some telling numbers on how medical expenditures varied with income. Roger Irving Lee, the Boston physician and Harvard Corporation member so influential in founding the School, was a member of that committee and a prominent advocate of applying economic thinking to health and medicine. In the 1950s, Paul Lembcke, a surgeon at Johns Hopkins, proposed the use of "medical audits" as a way of comparing the performances of physicians and hospitals. At about the same time, Henry K. Beecher, an anesthesiologist at Massachusetts General Hospital, asked a young Harvard statistician named Frederick Mosteller to help him and members of his department design and analyze studies of anesthesia and analgesics. Starting in about 1 9 7 0 , however, several forces came to bear to give
j) World Health Organization records last known case of smallpox in Somalia.
!
!
Elvis Presley dies.
these questions about the cost and quality of medicine a new edge and relevance. The nation's medical bill had skyrocketed, with total health expenditures almost tripling between i960, when $2.7.1 billion was spent, and 1 9 7 0 , when the figure reached $74-4 billion. The creation of the Medicare and Medicaid programs in 1965 meant that taxpayers were footing a growing chunk of that bill. When the Medicare-style program for kidney dialysis patients was created m 1972., Congress was told it would cost $2.00 million. Four years later, the actual costs were double that amount. Dialysis became a case in Point for what might happen to the nation's balance sheet if technologically sophisticated, medically effective, but expensive clinical care became widely available. ^et Americans were in a " l o v e " Phase of the country's love-hate relationship with medical technology. Heart transplants and coronary bypasses were dazzling treatments for the nation's number one killer. President Richard Nixon's 1 9 7 1 announcement of a war against cancer promised to deliver magic bullets to slay number two. If Americans Were enthusiastic about medicine's ^echnical virtuosity, it was partly ecause they weren't seeing the bills, ^ least not directly. World War II^ra tax laws that made insurance Premiums tax-deductible allowed a ^stem of employer-based health msurance to flourish. Fewer and ewer patients had to pay for their th care out of their own pocket. Hiatt was among a relative few o saw a darker side to the medical pending spree on medical care. In
South African political leader Stephen Biko dies while in police custody.
his 1 9 7 5 monograph, "Protecting the Medical Commons: Who is Responsible?" published in The N e w England Journal of Medicine, Hiatt analogized the American appetite for medical care to Garrett Hardin's now-famous parable about herdsmen ruining their common pasture by pursuing their self-interest. "Surely nobody would quarrel with the proposition that there is a limit to the resources any society can devote to medical care," wrote Hiatt, "and few would question the suggestion that we are approaching such a limit." " I honestly think that H o w a r d envisioned that eventually the rise in medical costs and technology would be unsustainable," says Weinstein. "[But] the political and social currents were all going in the opposite direction; that is, more technology is better and medical care is 'free' because someone else pays for it." In taking this somewhat contrarian approach, Hiatt had to basically start from scratch—and without
spending a lot of money. He settled on the idea of an interdisciplinary seminar and selected Mosteller to lead it. A few years earlier, Mosteller had played a key role in a famous Harvard seminar on education. With his experience in medicine and delight in solving statistical research problems, Mosteller was doubly qualified to lead a similar kind of seminar at the School. In the fall of 1972., the Seminar in Health and Medicine held its first meeting. "It wasn't very grand," recalls Hiatt, "because we didn't want people coming for a steak dinner. We wanted them to come to w o r k . " Mosteller says the first couple of meetings there were some grumblings from fellow professors about what the seminar would do exactly. " I said the point was to do what professors do, which is to profess, write papers and books," says Mosteller. When it convened as a whole, the legislaturesized seminar met in Snyder Auditorium, but much of the real work
A/^er aw wfer^Mc/pJ/w^ry seTTMTMr soweJ seeJs /or we&M/ Mre research a? 3c^oo4 FreJen'c^ woM/J go OM fo Departs??? o/^ Po/;'cy ^wJ f^e Dep^rfTMewf o/^
HSPH entomologist Andrew Spielman identifies the G^mmm/tick as the vector of Lyme disease, a parasitic illness first described t w o years earlier in Old Lyme, Connecticut, by researchers at Yale University.
Frazier, who was on Hiatt's staff when he was chief of medicine at Beth Israel Hospital in Boston, was recruited to lead it, a position he held for eight years.
Pro/eMor AMfcw We/Mx^ew, owe o/ ^ e ear/y wew^er^ o^ CAHP, woM/J p;'oweer co^f-e/^ecfwewes^ research OM care.
was done by smaHer groups organized around topics. Formally, the seminar lasted about three years, but some of the smaller groups have kept on meeting. (Mosteller's surgery group still meets on occasion.) Among the slew of papers and books produced by seminar participants that laid the groundwork for what is now called "evidence-based" medicine was the landmark 1 9 7 7 book, Cos?s, Bewe/^s o/ ^Mrgery. Co-edited by Mosteller, John P. Bunker (who chaired the seminar its second year), and Benjamin A. Barnes with chapters written by other members of the surgery group, the book laid out the main ideas of cost-benefit, decision analysis and applied them to a range of surgical interventions, including coronary bypass, cholecystectomy for silent gallstones, radical mastecto my for breast cancer, and hysterectomies.
^ H K S j ^
*^
Space Shuttle makes its first flight atop a Boeing 747.
Frazier credits Mosteller for the seminar's success: " H e is the only person I know who can enter a room on one side and leave it on the other, having gotten commitments to write four chapters of a book and made arrangements for two collaborations!" The other organizational device used by Hiatt was the extra-departmental center. Soon after becoming dean, Hiatt launched the Center for the Evaluation of Clinical Procedures ( C E C U P ) . At least in the beginning, "center" suggested something a good deal more grand than the underlying reality. Weinstein remembers sharing a basement office in the School's old main building at 5 5 Shattuck Street with Peter Braun, now a lecturer at the School. "We were the Center for Evaluation of Clinical Procedures!" he says. C E C L i P was later renamed the Center for the Analysis of Health Practices, and
Weinstein says Frazier was an effective "father figure" to the young investigators at C A H P ; Hiatt provided the intellectual spark. Mosteller says Frazier's practical medical know-how was essential to the successful grant application that kept the C A H P going. He also advised the cadre of young investigators on their research projects and papers, says Mosteller, though on a behind-thescenes basis because he rarely signed on as co-author. " H o w a r d put in a lot of time improving other people's w o r k , " says Mosteller. Fineberg, a member of the Center from 1 9 7 3 1 9 7 8 , says it was an exceptionally close-knit and talented group of researchers who continually batted around new ideas, testing and challenging them. Gradually, the approaches and some of the key personalities involved in these satellite operations were folded into the main organization of the School. Mosteller again was a key figure, serving as chair of the biostatistics department for several years in the late 1 9 7 0 s and recruiting Marvin Zelen from the State University of N e w Y o r k at Buffalo. Zelen would turn the biostat department into a world leader in randomized clinical trials, one of the mainstays of cost-effective, evidencebased medicine. Mosteller chaired the Department of Health Policy and Management from 1 9 8 1 to 1 9 8 7 , steering it toward an emphasis on research and original scholarship.
Lung cancer death rate for U.S. w o m e n reaches 15 per 100,000, a ten-fold increase since 1930. For men, the death rate for lung cancer is approaching 70 per 100,000.
U.S. FDA bans saccharin in food and toothpaste following a Canadian study that links cydamates to bladder cancer.
^ ^ ^ NE OF THE RESPONSES TO THE H H growing sense of an eroding ^ ^ commons and medical spending reaching its limits was the development of cost-effectiveness research. In vastly over-simplified terms, cost effectiveness research was a w a y of Ending the biggest " b a n g " in health gain for each " b u c k " of health expenditure. Weinstein, in a seminal 1 9 7 7 article in the New England Journal of Medicine, co-authored with William Stason, put it this way: "...the underlying premise of cost-effectiveness in health problems is that for any given level of resources available, society wishes to maximize the total aggregate health benefits conferred." A typical problem might be comparing how many years of life are gained by coronary bypass operations to a program aimed at lowering everyone's cholesterol levels. Weinstein says cost-effectiveness health research involves wedding epidemiology to clinical information: Ptdemiology gives researchers a handle on the size of the health problem mey are dealing with, while clinical mformation is used to factor in the effe,ctiveness of the various treatments available. In doing cost-effectiveness analyses, the various nuances of ^ ealth" also have to be considered, s the goal just to reduce mortality and have people live longer? Or does ealth mean being able to run up the stairs? Weinstein and other cost-effect.rveness experts have worked at per^tmg a comprehensive, quantitative ^easurement of health outcomes. E i n s t e i n has also developed elaborate questionnaires to gauge and ^ " l a h z e the trade-offs people make Whe considering quality of life. So, for example, Weinstein might ask,
" H o w much severe nausea are people willing to endure for an extra year of life?" Calculating the costs involved is no less complicated. Tallying up the direct medical costs of the treatment and the costs associated with any side effects is relatively straightforward. But then the costs of treating the more serious illness that was avoided by early treatment has to be subtracted. N o w add back in the costs of treating diseases that wouldn't have had a chance to occur—say cancer—if the patient had died from the earlier condition. Because there is usually a lag between cost and benefit in medicine (especially when chronic illnesses are involved) all these cost calculations must be discounted to take into account the lower value of future dollars. Weinstein's 1 9 7 6 book, Hyperfewszow.- A Po&ry Perspective, co-authored with Stason, was the full-blown debut of cost-effectiveness research. In it, Weinstein and Stason published their findings that community screening programs were not a cost-effective w a y for dealing with hypertension. Instead, their numbers showed that targeted approaches aimed at high-incidence populations were more cost-effective. This was the first of several instances in which Weinstein's research challenged conventional public health wisdom. In 1 9 9 1 , Weinstein published research showing that the most cost-effective cholesterol-lowering strategy should be aimed at treating heart attack victims, not folks with high cholesterol readings who hadn't had a heart attack. His paper induced a government panel to put a new emphasis on so-called secondary prevention. And
Coifs, a n d Benef/fs of W g e r y , edited by Frederick Mosteller, John Bunker, and Benjamin Barnes of the School's Center for t h e Analysis of Health Practice is the first in-depth study of t h e cost and benefits of surgical procedures.
this February, Weinstein was coauthor of a study published in the /oM7*7Mf o / ^ e Awenc^M MeJzcaJ As50CMf;'07? that suggested that the marked decline in heart disease mortality in the 1980s was due in surprisingly small part to healthier lifestyles. Rather, Weinstein and his co-investigators found that the mortality decline was mainly attributable to advances in the medical treatment for heart disease, including drugs and bypass surgery. "That is heresy at a school of public health," says Weinstein, "but that is what's happening, we think, based on the data we have and the model we built." ) H SIAO, A N E W C O M E R TO ACAD^ ^ eme after working in ! Washington, D.C., and in the insurance industry as an actuary, admired the brilliance of the kind of cost-effectiveness studies that Weinstein and Stason were doing. Yet he was troubled by what he saw as the field's underlying idealism. " I gradually appreciated that costeffectiveness analysis has a fundamental underlying presumption, namely, that the truth shall set you free," says Hsiao with a laugh. " M y perception of human beings is that truth matters, but so do incentives—money and risk. That means how you pay doctors and hospitals may have a greater influence on how they practice medicine." And American medicine was full of distorted incentives that, for example, paid doctors handsomely for reading an E K G , which can be done in a couple of minutes, but paid poorly for carefully examining and diagnosing a new patient complaining about a fever and muscle pains.
William Foege, M.P.H/65, succeeds David Sencer as head of the Centers for Disease Control and Prevention.
In 1 9 7 7 , Hsiao co-authored a paper with Stason tided "Rational Price for Physician Services" that sketched out a framework for a more rational schedule for physician payment that Hsiao called a relative value scale. "It was like a pebble dropping into the ocean," Hsiao told Robin Marantz Henig, author of T^g People's He^M?, a book about the recent history of the School. "It was read by my mother and my wife. Neither one understood it." But by 1986, the ripples from Hsiao's had become waves as his system was about to be used to adjust Medicare payment schedules. Almost $7 million in special Congressional funding had turned Hsiao's little-noticed academic efforts into a busy, policy-making enterprise employing 1 0 faculty members (mostly on a part-time basis) and a similar number of full-time researchers. Three years later, Hsiao' brainchild, renamed the Resource-Based Relative Value Scale, or R B R V S , became the system for Medicare payment. The main thrust of Hsiao's
plan was to shift Medicare payments away from specialty services and specialists to primary care and the doctors who provide it. Hsiao says the full effect of his plan was blunted by changes made by Congress under lobbying pressure from medical specialists. Even so, Hsiao figures the annual savings due to R B R V S runs in the range of 1 0 to $0 times the government's $7 million investment in its development. The effect of Hsiao's payment scheme is now being felt throughout the medical system as insurance companies and managed care organizations use R B R V S , or modified versions of it, to set payment schedules for their member physicians. Hsiao also gets credit for being among the first to effectively highlight the surplus of specialists in American medicine. "If you look now, there is no more debate about having too many specialists," notes Hsiao. " The question now is how do we close down the training slots." Hsiao's focus is now overseas as he advises governments in China, "YoM to renw^ p^ysKMws /or Jo;'wg EcOMOTWSt RMOMrce BaseJ Re^fwe ^ca'/e see^s to co77!pe72Mte pw?Mry care doctors.
1978
FoHowing commencement, a group of senior HSPH facutty petition Harvard President Derek Bok to remove Dean Hiatt. After investigating the matter, Bok asks Hiatt to remain as dean and Hiatt accepts.
Taiwan, and several other countries dealing with health-sector reform as booming economic growth and a shift toward market economics erode existing, government-run systems. Cultural values and professional ethics notwithstanding, incentives and risk avoidance have the same pull on doctors and hospitals everywhere, Hsiao says. In China, for example, too many patients are given intravenous fluids for no good medical reason. Why? Because, says Hsiao, doctors there are paid something extra if the patient is hooked up to an IV line. Hsiao rejects the notion that he has a cynical view of doctors. "I wouldn't say it is cynicism. I would say it is realism. By acknowledging that physicians are human, rather than believing that they somehow rise above all temptation, we deal with health care in a much more efficient and rational way," he says " Y o u have to reward physicians for doing the right thing. When you reward them for doing the wrong thing, you are pushing a stone up the hill." INANCIAL INCENTIVES ARE N O T the only reason things sometimes H go awry in health care. As in any endeavor, people make mistakes through inattention, oversight, and outright negligence. In health care, however, the stakes are higher than in most fields. Slip ups can cause serious harm or even death. Studies of mistakes and mishaps in medicine had been done, most notably by Don Harper Mills in California. But in the 1980s, researchers at the School launched an investigation of "adverse events" in
Elkan Rogers Blout, former vice president for research at Polaroid Corporation named dean for academic affairs.
hospitals that set a new, higher standard for malpractice research. A surge m the price of malpractice insurance Premiums paid by doctors was the jumping off point for a more general interest in reforming the malpractice system. Once again taking the broad, university-wide approach he used 'n other areas, Hiatt teamed up with James Vorenberg, then the dean of Harvard L a w School, to form the Harvard Medical Practice Study Group. But the group soon was ensnared in sharp differences of opinion about what exactly the malpractice problem was and how it might be mended. Doctors and other health Professionals saw a need for capping damage awards and alternative, less litigious ways of settling claims. Lawyers wanted stiffer sanctions against bad doctors and easier access to the courts. The division existed, in Part, because neither side had much m the way of hrm facts. "[We] were mired in these controversies because ^e suffered from the same informat'on gap tbat was afflicting legislators and courts," says the preface to A ^easMre o / A M p r a c & r e , a 1 9 9 3 book about the School's malpractice ^search co-authored by Hiatt and sortie of his co-investigators. To RH the gap, Hiatt and others ecided to do a study aimed at mg out how much medical injury Occurred, the seriousness of those mjuries, and who among the injured ^ e d . When they proposed doing eir study in Massachusetts, the esearchers got a frosty response: doers and hospitals were worried the study would waylay pending legisla째n that would cap pain and suffer'ng awards. Then Hiatt met David
^ a n insulin produced by r ^ ' h
is the first
' " " i b i n a n t D N A product.
"We %re ^ere," sgys Pro/eMor LMCMw Leape o/^;s e//orts ewcoMMge % wore coMsfrMCfwe response fo Twe^'cg/ errors.
Axelrod, the N e w York State Health Commissioner. Axelrod, a powerful health official who was pushing for improvements in N e w York hospital care on a number of fronts, embraced the project and persuaded the N e w York state legislature to spend several million dollars on it. "[The] most important resource that N e w Y o r k offered us was David Axelrod," says Besides Hiatt, the Harvard Malpractice Study research team included Professor of Law and Public Health Troy Brennan; Biostatistics Department Chair Nan Laird; Adjunct Professor of Health Policy Lucian Leape; and Howard Frazier. Hsiao assisted during the planning phase. Paul Weiler, a professor at the law school, and Benjamin Barnes, an associate professor of surgery emeritus at Harvard Medical School, also played key roles. The study had the kind of elegant yet sturdy design that pleases epidemiologists at an aesthetic as well as scientific level. The investigators randomly selected the hospitals to be studied. If they had depended
First test t u b e baby is born in London.
on volunteers, the results might have been biased by hospital administrators avoiding the researchers, fearing that they might discover high negligence rates in their institutions. The researchers also went to great lengths to make sure that their review of hospital records was as objective as possible, training a group of medical records analysts especially for their project. Using a set criteria of 1 8 clinical "events," the analysts made an initial determination about whether the hospital record suggested that an "adverse event" might have occurred. Those suspicious records were, in turn, looked at by two physician-reviewers. T o limit the chance of the physician-reviewers' bias creeping into the study, the researchers developed the Adverse Event Analysis Form to lead the doctors on a step-by-step review of the record. Leape says one of the key innovations of the study was to recruit local physicians to review the records, which both saved money and took advantage of physicians' expertise.
First human retroviruses described by National Cancer Institute scientist Robert Gallo, w h o will later be a co-discoverer of the AIDS virus.
28
^ ^
The reviewing of the records began in earnest during the summer of 1988. By the time the study was finished, the researchers had sifted through some 30,000 patient records from hospitals. The dragnet found 1,2.78 "adverse events," about one-fourth of which were identified as injuries caused by provider negligence. Put another way, the study suggested that 4 out of every 100 New Yorkers hospitalized in 1984 were injured during their hospital stay and one-quarter of those injuries was the result of negligence. The researchers then took the next step to see how this epidemiology of medical injury played out in the legal system. What they found was a malpractice system badly out of sync. On the one hand, there were a large number of "false positives"—malpractice claims against innocent doctors. In fact, most of the malpractice claims hied with New York state officials were not based on any real injury. Fewer still involved negligence. On the other hand, the researchers found an even bigger problem with "false negatives"—patients who had been harmed by negligent care who hadn't filed any kind of claim of malpractice. The researchers calculated that just 1 in $0 cases of negligent medical care resulted in a malpractice claim . " [We] found several times as many seriously disabled patients who received no legal redress for their injury as innocent doctors who bore the burden of defending against unwarranted malpractice," they wrote in A Measure When the results of the malpractice study were first published in 1990, they made front page news in T^e New Yor^ T;'?Me5. The study spawned
1978
"The Children of Santa Maria Cauque: A Prospective Field Study of Health and Growth," a landmark study by Leonardo Mata, S.D.'62, describes the impact of diarrhea and dysentery on the health of Costa Rican children. He will later receive the prestigious UNESCO Science Prize for his work.
a new round of debate about the malpractice system, as well as a stream of like-minded research. The School's researchers argued in medical journal editorials and elsewhere that their Endings pointed to the need for a new, no-fault system for dealing with malpractice that would more speedily and reliably compensate victims. But the combination of a leveling off of malpractice premium prices, which cooled physicians' interest in the subject, and Axelrod's disabling stroke in 1 9 9 1 slowed the political momentum for legislated malpractice reform. Even so, Leape says physicians, health-care officials and hospital administrators are beginning to show an interest in reducing medical errors. For one thing, studies like the one Leape published in the /oMHMJ o/ Awen'c^M AssocMff'ow earlier
what he heard there: "We are getting there. People are now saying that this is a problem we have to deal with." ^ ^
VALUATION OF HEALTH CARE now seems as much a part of the ^xn School's mission, and public health more generally, as research on infectious disease and nutrition. It is easy to forget just how novel systematic study of health-care and medicine was 2.5 years ago. Weinstein remembers that shortly after he came to the School in 1 9 7 3 , a prominent member of the powerful epidemiology department sarcastically asked him to "say something to me in policy analysis." Hsiao says the attitude was so chilly when he Arst came to the School that for years he thought he must have been wearing the wrong deodorant.
this year provide evidence that cutting down on errors can save a hospital money. In the J A M A article, Leape calculated that a 700-bed hospital could save $z.8 million a year by setting up systems to avoid preventable adverse drug events. In the JAMA article, Leape explained that the Harvard Medical Practice Study found that drugs were the leading cause of adverse hospitalrelated events. On a national scale, Leape said drug-related morbidity and mortality cost an estimated $76.6 billion. By comparison, he noted in the J A M A paper, the cost of all diabetes care has been estimated at $45.2. billion.
Times have changed. The Department of Health Policy and Management now boasts z6 primary and 1 0 secondary faculty members, and among students, the H P & M classes are consistently the most popular. More fundamentally, the School has helped bring what Dean Fineberg has called an "ethic of e v a l u a tion" to medicine and health-care more generally. In a 1992. Institute of Medicine report, Fineberg defined the ethic of evaluation as "widespread commitment and expectation among physicians, health care institutions, and the public that medical practices must be evaluated for effectiveness, safety and cost."
Last October, Leape was the keynote speaker at a conference on health care error prevention in Rancho Mirage, California, attended by many vips in the health-care and hospital industry. Leape was heartened by
"Adopting a systematic, pervasive strategy for evaluation wilt require public and private resources," F i n e b e f g continued, "but the return in terms of extended lives, reduced suffering and cost savings will be substantial."^
Residents of Love Canal, New York, are evacuated following reports linking birth defects and illnesses to toxic waste exposure. Subsequent studies will call into question these associations, but Love Cana! will become a byword for environmental poisoning.
OXIC C O M E S F R O M T H E LATIN ! word for poison, and toxicology is often described as the study of chemical injury. Over the past two decades, Professor Armen Tashjian, Jr., has deftly steered the School's toxicology program toward research that analyzes "chemical injury" at the most basic level—at the cell membrane, in the cytoplasm, and along the spiral staircase of D N A . His insistence that toxicology needed to peer mto the black boxes of the most fundamental molecular and cellular Processes has required a good deal of Persistence. Skeptics, some of them holding important purse strings, ^ould ask "but is that really toxicology?" Tashjian's research agenda also has meant his program is something of a David among the Goliaths that roam the biomedical research Y°rld of cell and molecular biology. You just have to be a little bit smarter and work a little bit harder," says Tashjian with a smile. Tashjian was born in Cleveland 1 9 3 z and named for his father, an Armenian immigrant who swam across the Bosporus Strait to escape mkish authorities and went on to establish a successful engineering and architectural business. A scholarship ^ Philips Exeter Academy put ashjtan on the road to a blue-ribbon education: after Exeter, he attended a e College for three years and then ^ent to Harvard Medical School. ashman had thoughts of a research ^areer early on, but he really caught research bug while on a postdoctoral fellowship at Harvard Medical oh On the surface, a researcher's ^ork might seem to be a rather Peaceful, if somewhat solitary,
endeavor: it's just you, the lab, and your cells or molecules. But Tashjian points out that research is actually a high-wire act, full of excitement but also anxiety. "Here you are, a young person, entering a world of discovery. And you know the chances of success are 10- or ioo-to-one against you." The key, he said, is to find both a mentor who can help and a problem that can be solved. "If you begin to work on a problem, and it begins to be solved, you get an extraordinary sense of elation that comes with discovery: nobody has ever seen this before, I thought of this, I did it! There is a shiver of excitement. It is almost an orgasmic experience to go through that," he says. Tashjian says he had several mentors, but the key person was Paul Munson, an expert on calcium metabolism on the faculty of Harvard's School of Dental Medicine. Calcium metabolism is heavily influenced by hormones, and the whole held of hormone research and endocrinology was booming in the early 1960s as technological advances in protein chemistry and immunology started to make it much easier to measure and characterize hormones in blood. Munson, Ernest Knobil, Roy Greep (who would go on to hold the John Rock Professorship of Population Sciences from 1967-197Z), and other investigators had turned the dental school into a "mecca of endocrinology," notes Tashjian. Early in his career, Tashjian's niche was the parathyroid hormone. Produced by four small glands in the neck, the parathyroid hormone plays a key role in regulating calcium levels
Twenty-six years after sailing from Wellington, New Zealand, to Boston Harbor to attend the School, alumnus Thomas Davis, M.P.H/53, is elected Prime Minister of the Cook Islands and is made a knight of the British Empire.
in the blood. Tashjian quickly became one of the world's leading authorities on parathyroid hormones as his research yielded novel assays for the hormone and shed new light on its mechanism of action. Lawrence Levine, a biochemistry professor at Brandeis who has collaborated with Tashjian for over 30 years, remembers when Tashjian first approached him about learning some immunology: "He was so damn bright. In five years, he knew more immunology than I did!" says Levine. Tashjian took over Munson's lab in 1965 when he left Harvard. Tashjian's interest soon extended to calcitonin, another calcium-regulating hormone produced by the thyroid gland. And like many others in his held, he was also intrigued by findings that hinted that cancer cells disrupted normal calcium metabolism. In 1 9 7 1 , Tashjian led a research team that discovered in 1 9 7 1 that calcitonin levels could be used to identify a pre-cancerous condition in families at risk of getting a rare, inherited form of thyroid cancer. (The prostate-specific antigen ( P S A ) test for prostate cancer is based on the same general concept.) People with the pre-cancerous condition could have their thyroid glands removed, avoid cancer, and lead normal lives. Though the calcitonin test has now been supplanted by genetic tests, it probably saved several thousand lives while it was still in use. Tashjian's transfer to the School of Public Health came about when he agreed to help his friend and colleague, H S P H Dean Howard Hiatt, build up the School's basic biology research. As a member of the search
1979
Religious fundamentalists depose the Shah of Iran and take hostage 63 Americans in the U.S. embassy in Teheran.
committee to select someone to lead a new Laboratory of Toxicology, Tashjian had argued persuasively that the person chosen shouldn't be a traditional toxicologist, but someone prepared to take advantage of the exciting new developments in molecular and cellular biology. Hiatt, a molecular biologist, agreed wholeheartedly. During his absence from one of the committee meetings, Tashjian's name was added to the list of candidates for the job, and the rest is history. ASHJIAN DESCRIBES HIS FIRST years as head of the School's toxicology lab diplomatically "as an interesting challenge for me." The program had to be built up from scratch, he says. What's more, he says he wanted to build it in an unconventional way, attracting people who were top-shelf molecular and cellular biologists and "not necessarily toxicologists by any formal identification." Government funding agencies looked askance at his approach, however and for a couple of years Tashjian's applications for training grants—the lifeblood of many research labs—were rejected. "The reviewers said, 'None of your people are toxicologists. How can you expect to be training toxicologists?' " says Tashjian. Eventually, Tashjian was rewarded not only with training grants but also with kudos for setting the pace in modern toxicology by emphasizing detailed study of cellular and molecular mechanisms of injury. Under Tashian's direction, the Laboratory of Toxicology evolved into the Department of Molecular and Cellular Toxicology, with a research staff of 55 and an annual sponsored
research budget of almost $ 1 million. Professors Leona Samson and Bruce Demple, experts on D N A damage and repair, are leaders in the held of genetic toxicology. Associate Professor Robert Schiestl has developed the D E L assay, a new genetic test for determining whether a chemical might cause cancer. In September 1 9 9 7 , this department merged with the Laboratory of Radiobiology to create a new, larger Department of Cancer Cell Biology under the direction of Professor Jack Little. Tashjian is once again free to focus on his own research, which is still centered around calcium regulation, but now at the intracellular level. He also sits on a Food and Drug Administration advisory committee in hopes of making new molecular tests the norm in toxicity testing, which still depends on giving high doses to lab animals. Tashjian, a veteran of uphill fights, acknowledges that it is sometimes difficult to compete in the world of high-powered, genome-sequencing basic research. But he says an abiding concern with practical applications and opportunities to work with other public health disciplines creates some special advantages for public healthoriented toxicology. A few years ago, he recalls, a chance lunchtime discussion in the School's cafeteria between a member of his department and a member of the epidemiologic team investigating elevated bladder cancer rates among rubber workers in Akron, Ohio's, tire factories led to the identification of a new mutagen. "I don't think that happens too often elsewhere," Tashjian says with a smile.
Peter Wehrwein
A contingent of Chinese physicians spend a year at the School as part of an exchange program initiated by Dean Hiatt and coordinated by Associate Professor William Hsiao. The following year, four Harvard faculty will travel to China to complete the exchange.
Donald Hornig, science adviser to Presidents Kennedy and Johnson and former president ot Brown University, n a ^ to direct the School's Interdisciplinary P r o g ^ in Health.
^ ^
H E R E IS S E R I O U S Q U E S T I O N AS
black U.S. medical colleges in existence at the time. He graduated in 1946, and the following year enrolled at the Harvard School of Public
^ to whether the best medical care, handsomely delivered to the slumdwellmg indigent, has any meaning in the face of conditions that breed disease and despair far faster than they can be cured or ameliorated." These words, appearing in the August 1965 issue of the /oMrw^/ o/" expressed the passion and frustration of their author, the 'ate Alonzo Smythe Yerby, M.p.H/48. ne timing was significant: a month earlier President Lyndon Johnson had signed the Medicare/Medicaid act— the most sweeping revision to social security since it was installed in 1 9 3 5 . However, Yerby, who had been a consultant to the Johnson Administration in drafting the legislation, Relieved that the hnal act fell short of 'ts original ideals. Although Medicare Was designed to subsidize medical care or elderly Americans, little thought was given to the particular needs of '"digent people who couldn't afford even the low monthly fees required for Participation in the plan. According to a history of Medicare written by the epartment of Health and Human ervices, Medicaid—which appropriates funds specifically for health care the poor—was "almost an aftert J ^ Yerby likened Medicare/ e icaid to the seventeenth century Poor Law, which provided handouts and other alms to the ^ stitute, and criticized the system r reducing something as essential to th as medical care to the status th ^ ^ addition to undermining Recipients' dignity, said Yerby, ^ edicaid's medical "handouts" did ^hing to solve the underlying Problem of poverty.
t t U ^ 'S awarded peace prj^.
Health. As a student, Yerby was a protege of Franz Goldman, associate professor of medical care in the Department of Public Health Practice. At Goldman's suggestion, Yerby went to Germany, first as a held medical officer for the U.N.'s International Refugee Organization, where he supervised the medical services for displaced persons in refugee camps, followed by service as deputy chief of medical affairs of the Office of the U.N. High Commissioner on Refugees.
CHAMPION OF THE POOR Addressing the White House Conference on Health in 1965, Yerby, then Commissioner of Hospitals for New York City, declared: "We can no longer tolerate a two-class system of health care. Let the word go forth...that America is prepared to assure all of its citizens equal access to health services as good as we can make them, and that the poor will no longer be forced to barter their dignity for their health." Born in Chicago, Yerby was the youngest of four children. After finishing high school, he went to the University of Chicago and then to Meharry Medical College in Nashville, Tennessee, one of only two
An accident at Pennsylvania's Three Mile Island nuclear power plant damages the reactor's radioactive core. Little radiation is released, but the accident raises alarms about the safety of nuclear energy.
In 1966, Yerby left public service to return to the School of Public Health as professor and head of the Department of Health Services Administration (forerunner to the Department of Health Policy and Management), a position he held for the next 1 6 years. At the time, H S P H Dean John Snyder told TZ?e New Yor^ TzTwas that Yerby's appointment "...reflects our concern that new and imaginative approaches are needed to establish closer relationships between health professions and hospital administrators on the one hand, and community leaders on the other." Yerby—a man whose professional formality masked a warm sincerity beneath—was the only black tenured faculty member at the School, a distinction noted by minority students at the School and throughout Harvard University, who sought him out as a role model and adviser on career issues. Carolyne Arnold, M . P . H . ' 7 3 , a former student of Yerby's, says she was teaching at
Popu/af/on P/ann/ng, co-authored by alumni Leslie Corsa, Jr., M.P.H.'52, founding chair of the Department of Population Planning at the University of Michigan.
^ ^ ^
32 ^ ^ ^
Howard University when she first began hearing about Yerby, who was making a name for himseif as a leader in public health and as a member of the "small club" of black professionals in academia at the time. Many of the students who sought Yerby's guidance came, in one way or another, from the rising civil rights movement. But while Yerby was deeply troubled by social injustice, particularly in terms of health care and poverty, he steadfastly counseled moderation in achieving the objectives of social justice. "We were all creatures of the 1960s," says Arnold. "The notion of confrontation was part of the way we saw the world. But Professor Yerby wasn't like that. He didn't encourage us to jump up and down." Yerby's eldest son, Mark, says his father's tactics were intended to catalyze rather than polarize the situation. "If the goal is to achieve change and social justice, if you're strident, the opponent becomes defensive, so you can't reach any solution," he says. "That's the lesson I learned. People focus on the advocates, not the thing they're advocating for." Monteal May, Yerby's wife of over $0 years, adds: "The black people we knew were professionals. They weren't suffering," she says. "People were concerned with preparing yourself for the future. We didn't think in terms of skin color. The battles we were fighting were to improve ourselves."
As a teacher, Yerby was known for his vast practical knowledge of health-care systems around the world. He taught a popular course focusing on health systems administration, the highlight of which was an annual held trip to Quebec during intercession. In conjunction with Sidney Seymour Lee, who before leaving to become associate dean for community health at McGill University was clinical professor of hospital and medical care administration at the School, Yerby enabled H S P H students to witness firsthand the evolving Canadian health care system based on universal coverage. "It was really a very broadening and enriching experience," says Arnold. The held trips also spawned a "steady stream" of Quebecois to the School, says Fernand Turcotte, M . p . H . ' y i . "We had come to the States to learn how to do it; we came back to Canada to do it." Turcotte, now a professor of social and preventive medicine at the University of Laval in Quebec, which hosted the American students in the 1970s, says that the training he and his fellow Canadians received at the School enabled them to establish public health programs at medical schools throughout Canada based on what they had learned at the School. Yerby eventually became disillusioned with academic medicine, but he never lost his love for teaching. After resigning from the School in 1982., he
continued teaching at the Uniformed Services University for the Health Sciences in Bethesda, Maryland. "His students were his greatest legacy," says his son Mark. Alonzo Yerby died in February 1994. Reflecting on his father's beliefs and on the Medicare/Medicaid system that his father criticized so passionately, Mark Yerby, who has a private neurology practice in Portland, Oregon, says: "It's not economical to care for people who are poor. You can't have more than 1 0 percent of your patient population be on Medicaid. Do we act differently towards those patients? The answer is, 'yes,' because the clock is always ticking overhead." Moreover, he says, the whole system has become an administrative nightmare. While sitting in his office late one evening, he searches through a book of H C F A codes to locate the required set of numbers and letters that identify a patient's disease— hereditary spastic paresis. He cannot find it. "When Dad was involved, people who went into administration had an M . D . and an interest in how the whole operation should run," he says, hnaliy closing the thick book. "Today, those folks have M B A s . " But despite his frustration, Yerby says he still believes in one major tenet of his father's work: "He believed that public health was not just the purview of public health professionals, but belonged to every physician."
Terr! L. R u t t e r
1980
At graduation, 266 students (124 women) receive degrees, nearly triple the number of degrees awarded in 1960. World Health Organization
declares smallpox officially eradicated. HSPH graduates William Foege, Donald Hopkins, and Ralph Henderson have helped lead the 7-year effort to eliminate the disease, which once claimed 500,000 lives a year, the first (and only) disease to date to be eradicated by human efforts.
^^
O O K , Y O U W A N T T O GET R I G H T T O T H E P O I N T ? " ASKS
Farmer met Gretchen Berggren a dozen years ago
Paul Farmer, pausing only briefly during his rounds
when he was lying on his sick bed in Port au Prince.
at Brigham and Women's Hospital. His words come
" F d heard of them, of course," he says. "Gretchen is
quickly, as if anticipating interruption by his beeper or a
known as the Mother Superior of Public Health in
Page. "Humble service. And, data driven. That's what you
Haiti. But I look up and here's this woman at the end of
want to remember. Gretchen and Warren remind us that
my bed singing in Creole what sounds like a lullaby. It
you can care about the world and still be good scholars."
was a song for mothers of newborns about preventing
For a quarter century, Gretchen Glode Berggren, s . M . H . 66, and Warren Berggren, M . P . H . '63, D . p . H . '67, have
diarrhea." The Berggrens' work and quiet example encouraged
combined their appointments at Harvard with continuous
and guided Farmer in his own efforts to establish new
service across the third world, from Afghanistan to Zaire.
assistance programs. (The recipient of a MacArthur
But their home base, from 1 9 6 7 right up to the present,
Foundation Fellowship, Farmer still spends half his time
has been the Hopital Albert Schweitzer in Deschapelles,
in Haiti.) But Farmer, who was originally trained as a
Haiti. And during their time there, over 2.00 H S P H stu-
medical anthropologist, recalls one bit of direct advice
dents have served at the hospital under their tutelage on
Gretchen Berggren once gave him. "I hope," Gretchen
held projects lasting from several months to several years.
said to him, "we won't lose you to impracticality."
International Physicians for the Prevention of Nuclear War (IPPNW) founded by Professor Bernard Lown and Russian scientist Eugene Chazov.
34
Recew/wg f^e Zw^erwa^'owaf HeaM? A w a r J /row M o ^ e r
healers to use a stethoscope, so they
^
Teresa was owe
hope."
w
o/ ^ e wawy pomts w ^ e
could see for themselves that the heart was still beating and there was In 1962. the Berggrens came to study disease prevention at the
Berggrews' careers.
School. "So much of what we had been working with," says Warren, "was illness that should never have happened." In 1 9 6 7 , with a grant from the N t H and the encouragement of Tom Weller and Hilton Salhanick, heads of the departments of Tropical Public Health and Population
That the Berggrens value practical-
began his medical service at a mission
Sciences, they left for the Hopital
ity perhaps can be attributed to their
in Badja Baya in the north, among
Albert Schweitzer in Deschapelles.
Midwestern upbringing. They come
hills along the great bend of the
Their first year there, Warren says,
from Nebraska, the American heart-
Ubangi River. The two were married
the hospital saw 650 children with
land. Gretchen is from Chadron in
in early 1959 in Brussels, where
tetanus, 550 of them newborns.
the northwest, where the land rolls
Gretchen was studying tropical medi-
"With the hospital doing its best, we
round like great green ocean swells
cine at the Prince Leopold Institute.
were able to save half of them."
into the Black Hills of the Dakotas.
The following year, they began their
Warren comes from Aurora in the
work together in Kimpase, in a Congo
they saw, but it was one that should
Willa Cather country of the south-
shortly to become independent.
have been "easily" prevented simply
east, where, he notes drily, a local saying held that the land was "so flat, you could see so far that you could see the back of your head."
Amidst the turmoil and strife that followed independence—including
Tetanus was not the only illness
by vaccinating mothers. The Berggrens began a vigorous tetanus
once having to be helicoptered away
immunization and education pro-
to safety—Warren and Gretchen per-
gram, reaching out to indigenous
severed in their commitment to heal-
midwives, setting up information and
a - OR BOTH GRETCHEN AND WARREN,
ing: attending to births and injuries,
immunization stations in the market-
the church had been a center of
performing surgery, and serving the
place, going directly to villages.
family and community life as they grew up, and it was from listening to
isolated countryside.
Today, the hospital hasn't seen
"That's when we learned,"
one case of tetanus in nine years,
reports about missionary efforts
Gretchen says, "how important
even though its population area is
abroad at church gatherings that they
getting to the people themselves is.
independently decided to become
over three times larger than the
A family would take their sick child
medical missionaries. They met in
70,000 people it served when the
back home when their indigenous
medical school at the University of
Berggrens started.
healer said it was dead. But the
Nebraska at Omaha. Warren was
child's chances actually might still
three years ahead of Gretchen, and
modern record-keeping and other
be good; we could save it."
practices that facilitate the use of
when he finished his internship he left for the Belgian Congo, where he
Lech Walesa founds Solidarity labor union in Poland.
The Berggrens also introduced
She pauses, then continues. "We
social science measures in evaluating
could save lives simply by teaching
the effects of public health p r o g r a m s .
Mount St. Helen's erupts May 18th in Washington State.
Of the many studies that have resulted, perhaps the most influential was their 1 9 8 1 N e w England Journal
constant inspiration." Warren politet^Br
ly sidesteps the question. " I don't
*
think I'm very effective at preach-
of Medicine article, "Reduction of
ing," he says. Besides, he has work to
Mortality in Rural Haiti Through A
do. He's about to leave for
Primary Health Care Program," co-
Bangladesh to evaluate a program
authored with Douglas Ewbank. It
that attempts to improve nutrition by
demonstrated with acceptable social
bringing mothers of malnourished
science rigor that their interventions
children together with more success-
had had positive effect; and, it estab-
ful mothers in the same village. -A-"/
lished their efforts m Deschapelles as
"Two-thirds of Third-World children are malnourished," says Gretchen.
a model for others.
"All need better nutrition. This is
Today, the people of Deschapelles
where we need to be working."
know the hospital's public health building as " K a y Berggren," Creole
"They don't talk about them-
"the Berggrens' house." Over the
selves," says Dr. Lachlan Forrow,
Past three decades, the Berggrens
Executive V.P. of the Albert
also have raised two daughters;
Schweizer Fellowships. "But on peo-
taught at the School (she was affiliat-
Gretc^ew awgf Warrew Berggw: at ippg HSPH A/MWM; Day, w^ere tAey receweti t^e A/Mww; Awar^ o/MenY.
ples' talk-to-do ratio, they score very
ed with the Harvard Center for Population and Development Studies from 1 9 7 4 - 1 9 8 9 , he was an associate
high." Forrow admires the Berggrens for having "consistantly created a life
Medicine; and, having perhaps the
out of their values," for really living
Professor of tropical public health
greatest personal resonance because
out the Albert Schweitzer admoni-
and population sciences from 1972.
it was presented to them by Mother
tions they'd been inspired by in their
to 1 9 8 1 ) ; guided public health stu-
Theresa, the International Health
youth: "reverence for life," and " m y
dents through held work and special
Award. This spring, the Berggrens
life is my argument."
Projects; and worked with U N t C E F
received the H S P H Alumni A w a r d of
^nd similar organizations, including
Merit—the highest honor bestowed
"Gretchen and Warren are some-
by the School on its graduates.
thing pretty rare in the academic
Years with Save the Children ^deration and, currently, World ehef. Awards have come: a Presidential citation from Bill Cli 'Won; the Donald M c K a y Medal the American Society of Tropical
Pressed to offer insight or lessons
Paul Farmer would agree.
w o r l d , " he says. "They've never lost
about their work, Gretchen remarks:
their commitment to serving the less
" Y o u know, we do laugh and joke a
fortunate—that means the poor.
lot. We've had much joy. And the courage of Third-World mothers is a
That's their commitment: serving."
R o b e r t F. Zatisk
Daniel Botstein and colleagues publish restriction-fragment-length polymorphism paper crucial to mapping disease genes.
Max Essex, chair of the Department of Microbiology, a w a r d e d the National Cancer Society's Bronze Medal, t h e organization's highest honor, for his research on leukemia in animals.
Nantucket
NDY SPIELMAN A D M I T S HE WAS not the obvious candidate for the job. An entomologist and a member of the School's prestigious tropica! public health department for 1 4 years, he had built his career primarily on mosquito research. Babesiosis, it was well known, was spread by ticks. To the casual bug a voider, the difference between insect and a r t h r o p o d might seem slight, but scientifically speaking they are worlds apart. But when Spielman's friend, George Healy, a researcher at the Centers for Disease Control helped diagnose a second case of human babesiosis on
1981
M o r M f y a n d Morfa//fy Wee/;/y Report reports outbreak of rare,tetha! pneumonia among gay men in Los Angeles, California.-The first report on w h a t will eventually be called AIDS.
Ronald Reagan succeeds Jimmy Carter as 40th President of the United States.
Immunologist John David succeeds Nobel Laureate Thomas Weller as chair of the Department of Tropical Public Health. David will hold the chairmanship for 15 years.
Nantucket in 1 9 7 3 , Spielman was intrigued. Although a handful of human cases had been reported worldwide, babesiosis was known, for the most part, as an animal disease. Here was a chance to tackle a Problem that was scientifically entic'ng and perhaps of major public health significance. Over the next several years, Spielman would throw off conventional wisdom and become one of the world's foremost authorities on tickhorne diseases and the environmental forces that shape them. His research solved the puzzle of babesiosis on Nantucket. He identified a new species of tick, J x o J e s &7f7WM7n', which is responsible not only for the emergence of babesiosis in the United States, but for a whole new group of t'ck-borne diseases, the best known which is Lyme disease. Sam Telford III, a young colleague in Spielman's lab, identified a third tickorne pathogen three years ago and as a paper in the works that will hnger a fourth. And Telford and Spielman have recently played a key role m the preliminary testing of a yme disease vaccine. Yet Spielman says to marvel at how chance favored a Harvard mosquito expert with such a Productive career as a tick ^searcher is to misunderstand his Particular brand of research and peraps public health research more Orally. "T am not a mosquito specialist. 1 am not a tick specialist. I am a transf u s i o n specialist," says Spielman. " I ^ interested m the etiology and rnode of transmission of vector-borne A c t i o n s . That is what public health h o m o l o g y is all about."
Profe ^ Director David Bell appointed Gamble H e a l t h ' ' " P o t i o n Sciences and International Sadies? ^ Department of Population ford F ^ ^ d been executive vice-president of the " N a t i o n ' s International Division.
H O O K I N G BACK N O W , SPIELMAN L i says with a broad smile and laugh that " G o d , 1 had no idea what I was doing" as he boarded the ferry for Nantucket one chilly morning in the fall of 1 9 7 3 for the first of many times. But actually, Spielman did know a good deal. For starters, because of Healy's brilliant ant diagnostic skills, he knew he was dealing with a protozoan called Ba^esM, a blobby, single-celled parasite that comes in 70 or so different varieties. It was no coincidence that the Nantucket index case was initially misdiagnosed as malaria. The periodic shaking chills and drenching sweats of malaria are very much the same as in babesiosis. And the underlying parasites of the two diseases have the same nasty habit of destroying red blood-cells. But unlike malaria, babesiosis had been known mainly as a disease of animals, primarily cattle. In fact, almost a century earlier, legendary Harvard researcher Theobald Smith had made the watershed discovery that a protozoan (now known as Babesia bigemina) could cause disease in a warm-blooded animal and be spread by an arthropod (the Boophilus cattle tick) while investigating a cattle disease in Texas. [Smith was a faculty member for about 2.0 years in the Comparative Pathology Department at Harvard Medical School, which later divided into the School's Department of Tropical Public Health and the medical school's Department of Pathology.] Because of Smith's discoveries, and other work that followed, Spielman could be reasonably sure that a tick was the culprit behind on Nantucket.
Another important piece of historical evidence that Spielman had in mind as the ferry churned across Nantucket Sound was that the ticks would probably have a hearty appetite for rodent blood. In 1 9 3 8 , Ernest Tyzzer, who succeeded Smith as Harvard's George Fabyan Professor of Comparative Pathology, published a rather obscure paper in P(?r<3S3Yo/ogy that mentions a B^&esM infection of voles (a mouse-like creature) on Martha's Vineyard, an island near Nantucket and another treasured vacation spot. Moreover, his detailed drawings showed that the kind of that Tyzzer found in the voles on Martha's Vineyard looked to be very similar to the Babesia making people sick on Nantucket. Tyzzer was something of a misanthrope, according to Spielman, but his quirky personality paid scientific dividends as he pursued an interest in animal diseases. Spielman says he knew about Tyzzer's paper " f r o m w a y back." "There was a collection of old departmental papers and reprints in our lunchroom at that time," he explains. "While I was in there having lunch, if there was nobody else around, I would look at those old papers just out of curiosity." So from Smith, Spielman knew he would be dealing with ticks. From Tyzzer, he had the clue that rodents would be involved. Spielman headed out to Nantucket not only with mouse traps, but with bulky raccoon traps that he had cadged from Massachusetts's eastern equine encephalitis research station. His research assistants were not seasoned held biologists but a slightly jit-
Britain's Prince Charles and Lady Diana Spencer are w e d in London's Westminster Abbey.
UMass held station had inadvertently spiders, mites and, of course, tickstery Vietnam veteran (Spielman are the carriers of vector-borne illcreated the "edge" habitat ideal for thinks he may have been suffering nesses. Their biting and blood-suckmice. Ecologically, edge is the boundfrom post-traumatic stress syndrome) ing habits spread the viruses, bacteand his girlfriend. On the island, the ary area between two habitats, which ria, protozoa and other pathogenic trio depended on bicycles for transin this case were meadow and brushy, organisms. In addition to carriers, portation, and when they rode down covered terrain. vector-borne diseases also depend Nantucket's cobblestone streets, the Homing in on the white-footed raccoon traps tied to mouse put Spielman on the b a c k s of their the path to his crownTnp/e ^reat; t^e Ixodes dammini t/c^ carn'es at /east ^ ^MWMM J;se<Me$. bikes came tumbling ing achievement, idendown. And somehow tification of the PxoJes Spielman had gotten tick as the confused about their vector of Nantucket destination. It was the fever. When he returned UMass biological held to Nantucket the next s t a t i o n they w e r e year he began looking looking f o r , not the for the Babesia-carrying M a x Planck field stacreatures in earnest. tion. "We had no idea At this point, if what we were doing!" Spielman had paid too S p i e l m a n says once much attention to what again, for emphasis. other experts were Ba&esM M^'crof!' Borre/M &M7-gJor/i?n' As luck would have saying, he might have Babesiosis Lyme disease Human Granuclocytic it, even w i t h those missed out on the disEhrlichiosis unwieldy raccoon covery. Partly because traps, Spielman w a s the kind of Ixodes ticks able to catch the key he was seeing on animal, the white-footed mouse, that upon reservoir: biological hide-outs Nantucket had not been previously fall. He had also stumbled upon what where the disease-causing microorobserved north of Georgia, Spielman might be one of the best places in the ganisms can prosper and multiply as was told that the ubiquitous world to do held biology research. uninvited, but often harmless, guests. Dermacentor variabilis, or dog tick, The 30-acre, University of Because Tyzzer had found was probably spreading Nantucket Massachusetts held station is on a parasites in voles on Martha's fever. Dog ticks also made sense bluff overlooking a beautiful bay. "It Vineyard, it seemed likely that voles because Rocky Mountain spotted is," says Spielman "the nicest piece of on Nantucket would be providing fever was on the rise at that time on property on Nantucket." For the same safe haven. the East Coast, and dogs ticks spread Spielman, who grew up on Long But Spielman was finding that the Rocky Mountain spotted fever. Island and loves the ocean and outNantucket voles were largely Spielman recalls talking to one doors, this was not a bad job, not free. Instead, it was the red-blood Massachusetts tick expert early in his bad at all. cells of the white-footed mice that investigation: "He kept rattling on were choked with Ba^asM. That about how obvious it was, that it mice, not voles, turned out to be the rn # E C T O R C O M E S F R O M T H E L A T I N wasn't interesting, that it is the dog reservoir for Nantucket fever was a w vehere, which means "to carry." tick and that is all you need to lucky break for Spielman. The mainArthropods-that vast phylum of the know." A group at Ohio State even tenance and mowing schedule of the animal kingdom that includes insects, went as far as to publish a paper
Renowned statistician Frederick Mosteller assumes chairmanship of the Department of Health Policy and Management. He previously served as chair of the Department of Biostatistics and helped found the School's Center for the Analysis of Health Practices.
Sandra Day O'Connor is appointed to the Supreme Court.
Bambi, Babesia, and Bore!ia To be a good botanist, you have to think like a plant, says Wes Tiffney, director of the University of Massachusetts field station on Nantucket and himself a botanist. And he believes the same rule applies to good insect-borne disease research. "Sam [Telford] and Andy [Spielman] can think like a tick." It was thinking like a tick and a pathogen, as well as some careful observations and experiments, that helped Spielman solve one of the big riddles of the epidemic of tick-borne diseases: Why now? Mostly what blood-thirsty deer ticks seem to think about during their brief, two-year life spans is where are they going to get their next meal. In its immature forms, first as a six-legged larva and then as an eight-legged nymph, the deer tick feeds on the white-footed mouse and, occasionally, on people. From the pathogen's point of view, a meal of human blood is a mistake—a "leak," as Spielman calls it—because the tick doesn't pick up a new supply of Ra<bei/3 W o w / , the bacteria that causes babesiosis, or eorre/z'a burpc/or/en; the bacteria that causes Lyme disease. In fact, one reason there is no Lyme disease in the South, says Spielman, is that the deer ticks there feed on lizards, which are not reservoirs of Borrelia burgdorferi. As adults, deer ticks feed on their namesakes. Deer do not function as disease reservoirs. But without deer, adult ticks cannot survive and breed. Spielman started to suspect that the booming Nantucket deer populations played a key role in babesiosis when he couldn't (later retracted) that identified the dog t'ck as the Nantucket fever vector. Yet Spielman kept on seeing the speck-sized deer ticks, not dog ticks. And where he saw them was especially interesting: on the skin of white-footed mice. Pluckmg the ticks off by hand, Spielman counted roughly 1 9 deer ^cks for every dog tick on the mice. That ratio was reversed when it came to the voles. Because vole blood was hardly ever infected with Babesia, and ^ouse blood was, it didn't make sense that the dog tick, which favored voles, ^as the vector. No, though Spielman, the / x o & s ticks found on white-footed m*ce had to be what was spreading babesiosis on Nantucket.
^ ' " n n a Gro Harlem ^ n d t l a n d , M.P.H/65, p o i n t e d to first of j e e terms as Prime d u s t e r of Norway, the 'rst woman to hold the Post.
find any adult ticks on the white-footed mice. "The question was, where the hell are all the adults?" says Spielman. The answer started to surface during deer hunting season, when Spielman saw adults ticks on animals shot by hunters. Several years later, Spielman and colleague Mark Wilson put the deer-tick connection to the test. Over the course of two or three years, they had sharpshooters kill deer on Great Island, Massachusetts, off of Cape Cod, driving the population down to almost one-tenth of its previous level. After the deer were killed, deer tick populations plummeted and have stayed low ever since. Since 1986, only one case each of Lyme disease and babesiosis has been diagnosed among the island's residents. Elsewhere in the eastern United States, deer populations have reached all time highs. Beginning in the 1940s, as farms disappeared and the nation's voracious appetite for timber slackened somewhat, the eastern half of the country started to reforest, explains Spielman. But the reforesting has been patchy, cut up by roads, shopping centers, people living in leafy, distant suburbs and,even further out, vacation homes. The result has been creation of lots of edge habitat, ideally suited to deer and white-footed mice and therefore ticks and the pathogens they spread. "We are living in a very dynamic landscape," Spielman said in a lecture at the School last fall. "The pathogens were always here, but we had no vectors that fit both the reservoir and people. That was what was accomplished when the deer herds came back."
PW
For a century, the standard of proof for causation in infectious disease research has been fulfillment of Robert Koch's famous postulates. First, isolate the organism from an infected animal. Second, reinfect another animal with that organism. And third, recover the original organism from the animal just infected. If Spielman was to nail down the case against the deer ticks, it would mean leaving the lovely Nantucket held station and getting down to work in the lab. Using Ba^asM isolated from a human patient, Spielman infected a hamster with the protozoan. Immature lab-reared deer ticks feast-
Professor of Microbiology John Cairns, one of the world's leading cancer researchers, awarded a MacArthur Fellowship.
ed on the infected hamster. Once they were sated and presumably loaded with carrying Spielman set the ticks loose on 1 1 non-infected hamsters. Spielman waited three weeks and then drew blood from the hamsters. Ten of them were infected with Babesia. Koch himself would have approved. The work was described in November 1 9 7 6 in the American Journal of Tropical Medicine and Hygiene. In that paper and others, Spielman identified the culpable tick as scapM/^n's, a variety of tick that had been identified way back in 1 8 0 5 . Three years later, Spielman officially proclaimed the Nantucket
Alumnus Jim Curran, M.P.H.'74, appointed head of theCDC's AIDS Program.
tick a new variety of arthropod, naming it /xoJes J^rwwnMz after Gustave Dammin, a prominent pathologist at Brigham and Women's Hospital. Naming a disease-spreading tick for someone might seem like a dubious honor, but ever since Carl Linnaeus set up the current taxonomic classification system in the 1 8 T H century, naming a new species for someone has been a way for biologists to immortalize themselves, mentors or loved ones. Spielman chose to honor Dammin because he had helped him with his research and was a property owner on Nantucket (Dammin's wife came from one of Nantucket's most prominent families). Spielman built his case for L J^ww/w/ being a separate species from 7. sc^pM^w on the observations that the two ticks had very distinct ranges (J. &77wwM;' in the Northeast, L sc^pM^ns in the South) and that I. dammini was morphologically different, especially at the nymphal stage. He also marshaled D N A evidence to make his case. Since then, Spielman has been hghting a protracted, but probably losing, battle for L identity as a separate species. Siding with researchers in Georgia, the editors of the Journal of Medical Entomology have officially ruled that, taxonomically speaking, Ixodes is no different from ZxoJes scapM^n's and therefore the two species should be "synonymized" under the ZxoJes sc^pMAgn's name. Spielman disagrees. Aside from any pride and politics (Lyme disease research has become highly politicized in recent years)
1982
Professor Harry Antoniades and colleagues describe part of the genetic sequence of platelet-derived growth factor (PDGF), a blood protein first purified by Antoniades a decade earlier. Subsequent research will reveal that the PDGF sequence is identical to a section of a simian cancer virus, providing the missing link of how viruses can cause cancer.
Spielman says maintaining L &?7M7w'separate identity is key to understanding the ecology and epidemiology of tick-borne diseases. Southerners don't get Lyme disease. And it is immediately clear why that is so, says Spielman, if you understand that the South doesn't have the 7. J ^ w w w ? tick that spreads the disease. ^ ^
^MMfers across JecaJes: Erwesf Tyxxer, AwJy 5p;'e/7?M7!, aw^f T<?//brJ m .
World Health Organization selects the School a s a Collaborating Center for Cancer Biostatistics.
NE H U N D R E D AND TWENTY miles west of Nantucket, in Lyme, Connecticut, just a couple of years after the outbreak of babesiosis, Anne Mensch and Polly Murray were seeing an equally odd, but more alarming, outbreak of disease in their community. The disease was arthritis, and the victims were young children. By 1 9 7 5 , Mensch and Murray had gotten a young rheumatologist at Yale named Allen Steere involved. Steere says he and his colleagues saw the hallmarks of arthropod-transmitted disease nearly from the beginning of his investigation into Lyme arthritis, later named Lyme disease: the cases clustered in a rural area, the hitand-miss pattern, and symptoms generally showing up in summer and fall when arthropods are most active. In fact, one of Steere's brilliant strokes was to focus his epidemiologic investigation not on arthritis, which turned out to be one of the many symptoms of Lyme disease, but on patients' recollections of an unusual reddish, bull's-eye-shaped rash. As it turned out, this condition was reminiscent of erythema migrans, an obscure skin condition seen in Europe that was known to be c a u s e d by a tick bite. In the summer of 1 9 7 7 ' one of Steere's subjects saved a tiny
The Vietnam War Memorial, designed by 21 year old architecture student Maya Lin, is dedicated.
tick that had recently bitten him. Yale researchers identified it as a &W17WM; tick, the same kind of creature Spielman identified on Nantucket. The connection between Lyme disease and babesiosis had been made. It would be, however, another Rve years before Willy Burgdorfer, a researcher at the National Institute of Health's Rocky Mountain Laboratories in Hamilton, Montana, identified exactly what the ticks were spreading that was causing Lyme disease: a squiggly bacterium, or spirochete, that has since been named ^orre/M ^Mrg^or/er;'. In November, 1 9 9 4 , a 68-yearold woman came to the Nantucket Cottage Hospital after five days of fever, mental confusion, and headache. Initially, doctors thought she might be another victim of babesiosis or Lyme disease or both. The woman recalled having been hitten by a tick five days before getting sick. But blood tests showed ^o sign of either Bofre/M &M7*gJo?*/i?n or 7M?'c?*of;. It was Telford, again drawing on Tyzzer's 1 9 3 8 Parasitology paper as a reference, ^ho figured out that the woman was infected with a third pathogen, ^ c f e w . Thus, a third disease, human granulocytic ehrlichiosis
^ e s L. Whittenberger, ^ i r o f t h e Department Physiology and director ^ h e Kresge Center for ^ r o n m e n t a l Health, J t j e s f r o m the faculty, a 36-year affiliat e " with the School.
C. Everett Koop issues Surgeon General's Report calling cigarette smoking t h e chief preventable cause of d e a t h in the U.S.
( H G E ) , was added to the roster of ills wrought by deer ticks. N o w Telford has identified a fourth pathogen, this time a virus, lurking in the guts of deer ticks. So far, he has only isolated it in ticks and deer tick virus (as Telford is calling it) has not yet been linked to any human disease. ] Y M E D I S E A S E IS B Y F A R T H E M O S T Km common of the deer tick diseases with about 1 5 , 0 0 0 cases reported to the Centers for Disease Control and Prevention last year, according to David T. Dennis, M . P . H . ' 7 4 , the coordinator of the C D C ' s Lyme disease program. Those cases were concentrated in 80 counties in 8 states-Connecticut, Rhode Island, N e w Y o r k , N e w Jersey, Pennsylvania, Maryland, Wisconsin and Minnesota. Annual babesiosis and H G E cases number less than 1 0 0 , though lack of reporting and missed diagnosis seriously undermine the reliability of the statistics on all the tick-borne diseases. Though culling the deer herd has worked on an experimental basis in island situations (see sidebar), Dennis says in most situations controlling deer and mouse populations is not a feasible way of controlling Lyme disease. Because most people get bitten by
deer ticks near their homes, simple things like clearing away leaves can help control the disease by making backyards less accommodating to mice. Dennis said one of the most exciting experiments in tick control involves deer feeding stations designed so that when the deer eat, they rub up against some material soaked with insecticide that kills the ticks but doesn't harm the deer. Spielman tested a similar system for mice. Meanwhile, SmithKline Beecham and Connaught are pushing ahead with development of a Lyme disease vaccine. Spielman led the Phase 11 testing of the SmithKline Beecham vaccine among residents of Nantucket, Martha Vineyard, and Block Island. Steere is the investigator in charge of the larger Phase 111 trials. "This is a disease that is likely to be conquered, but we are not exactly there yet," says Steere. Dennis and other public health officials are wary, however, about the eventual marketing of a vaccine. "Selectively used, it could be attractive," he says. "But without real good education, there could be a huge demand for this kind of protection when the cost may exceed the real benefit."*^
Argentine forces invade Britain's Falkland Islands, prompting a month-long war.
First artificial heart is implanted in Barney Clark on December 2.
g y f<?/77 A. / M f e r
IKE T H E M A N W H O W O U L D BE KING, JAMES G O D D A R D , M . P . H . ' 5 5 , H O P E D one day to be surgeon genera}. But he needed a high-powered administra!—— tion job hrst to strengthen his resume. As the nation's hrst Civil Air Surgeon, he was responsible for the medical licensing of some 300,000 pilots a year as well as the investigation of human factors errors in major aircraft acci-
HSPH graduates manned the helm of
dents. After clashing with the F A A ' s top administrator, Goddard was summoned by Surgeon General Luther Terry, who gave him three choices for a placement that would earn him the star he needed to someday put him in line for Terry's job. His last choice was director of the Communicable Disease Center ( C D C ) in Atlanta, Georgia. And that's where Terry sent him. At age 39,
the nation's premier public health agency,
this brash midwesterner was the youngest person to ever hold the job. When Goddard arrived at C D C headquarters at 1600 Clifton Road in Atlanta, Georgia, in 1962., the 16-year-old agency had already gained a reputation for the skill with which its Epidemic Intelligence Service ( E i s ) officers, under the direction of hard-edged Alexander Langmuir, tracked down the cause of outbreaks of infectious disease. The Eis had cut its teeth during the
1983
A series of papers in 5dence, including one by Max Essex, chair of the Department of Microbiology, provides first evidence that a retrovirus may be the cause of AIDS. The AIDS caseload has passed 1,400 according to the Centers for Disease Control and Prevention.
In the first major academic reorganization in a decade, the School's Departments of Microbiology and Physiology are eliminated and the Departments of Cancer Biology and Health Science and Physiology established. Max Essex is named chair of cancer biology, which also incorporates the Laboratory of Radiation Biology. Joseph Harrington (left) is named chair of health science and physiology.
early years of the Cold War by Preparing for the possibility of biological warfare. The anticipated attack never happened, but Eis officers learned much about how to respond to and solve infectious disease outbreaks around the country. ^ 1 9 5 5 , E i s officers tracked a polio outbreak to a vaccine produced at the Cutter Laboratories in California that had been contaminated with live virus. The C D C ' s reputation for expert epidemiology was reinforced two years later when the agency joined an international effort to trace the source of a deadly outbreak of Asian flu. "Our epidemiology was the best in the world," says Goddard today. Established in 1946, the C D C was a direct descendant of the U.S. Public Health Service's Malaria Control in ^ a r Areas ( M W R A ) program. M W R A ^as created during World War H to Protect American troops from the mosquito-borne disease malaria, vvhich was endemic in the southern ^-S. states where some 600 military bases were located. Under the direction of its intrepid leader, Joseph ^ountin, M W R A quickly brought the malaria threat under control by digSmg drainage ditches and spraying generously with the larvicide D D T . By ^943, the anopheline mosquito that Carries malaria had virtually disappeared from the United States, p encouraged by this success, Mountin e x p a n d e d M W R A ' s scope to include battling the louse-borne disease ^phus and the tropical diseases tought home by servicemen returnmg from the war. After the war, Mountin argued successfully for the Creation of a federal agency to moni-
Takemi Program in International Health named for the eminent Japanese physician Taro Takemi, established at the School.
tor and control infectious disease outbreaks nationwide. Congress responded by creating the C D C . Veterinarian James Steele, M . P . H . ' 4 2 , went to the C D C during its first year of operation, as director of the agency's Veterinary Public Health Division. "It was the first of its kind," says Steele of the division, which investigated the transmission of animal diseases to human beings,
around the globe, usually within a day's notice of an outbreak. With the W H O , the C D C was a major player in the eradication of one deadly disease—smallpox—and is participating in the strategic planning for the eradication of two others: polio and Guinea worm disease. In recent years, the C D C has broadened its focus to include chronic diseases and injury control. In 1992., C D C added the word "prevention" to its name to reflect this broader focus. "The C D C is one of the most exciting places that anyone can work," says William Foege, M . p . H . ' 6 $ , who directed the organization from 1 9 7 7 to 1 9 8 3 . "People could do things there that they could never do any place else."
JgTWM G o J J a r J , M . P . H . ' 5 $
including rabies, salmonella and the bird-borne disease psittacosis. Steele's division served as the model for similar efforts at the World Health Organization and the Pan American Health Organization. In the 50 years since its founding, the C D C has grown many times over, in terms of budget, staff, and complexity. What began as a small group of mostly engineers and entomologists has expanded into a complex army of nurses, epidemiologists, biologists, physicians, veterinarians, and behavioral scientists, among others. The C D C has become the world authority on communicable disease— sending teams of Eis microbe hunters
Foege's tenure at C D C falls roughly in the middle of a continuous, 2.3year stretch in which graduates of the Harvard School of Public Health held the post of director. Beginning with Goddard and continuing through Donald Hopkins, M . p . H . ' 7 o , who served as acting director in 1985, the string of alumni directors includes David Sencer, M . p . H . ' 5 8 , Foege, and James Mason, D . P . H . ' 6 y . Much of the C D C ' s growth, and some of its greatest successes, can be traced through the leadership of these five H S P H graduates—the ones Foege calls the "true believers." /
ODDARD BROADENED THE ! **< vision for the C D C , " says ^ ^ Steele of the man who began the legacy. "He was the watchdog for new things on the horizon." Among other achievements, Goddard almost single-handedly introduced the C D C to the age of elec-
Microbiologist Dyann Wirth introduces a rapid new diagnostic test for the parasitic tropical disease leishmaniasis. The technique, which uses a DNA probe, proves highly accurate and Wirth will subsequently develop a similar diagnostic tool for malaria.
tronic computing. The I B M 6 1 0 that Goddard secured for the agency occupied a room 18 feet long and 2.0 feet wide—a true dinosaur compared to modern computers. The E i s officers "grumbled and grumbled" as they were sent to the I B M training courses to learn the language of entering data and outputting results on multivariate outcomes, says Goddard. A year later, however, they were as enthusiastic about the emerging technology as he was.
ing his head into laboratories and offices just to say hello. He also apparently played a mean game of bridge in the dining room during lunchtimes. In i c ) 6 6 , Goddard left the C D C — "the best assignment I had in my career in public health service" he says—to serve as commissioner of the U.S. Food and Drug Administration. Fie left the director's chair open to
Goddard also enlarged the agency's Medical Audiovisual Branch, which produced hundreds of training films for state health departments and public health laboratories and produced informational literature and films for the public, including adult comic books about venereal disease prevention. In her history of the C D C , Sentinel for Health, Elizabeth W. Etheridge illustrates the bold independence for which Goddard was known. Feeling frustrated at how long he had to wait for clearance from Washington for materials produced by the C D C , Goddard asked an assistant to gather and take a picture of all the videos, books, brochures, and other materials produced in a single year; the collected materials covered a long table. He had the picture enlarged to poster size and presented it at the next meeting. When his superiors recognized the amount of time required to review each piece, they resigned their stance on the subject, and Goddard never had to wait for clearance again. Goddard was also a friendly, easygoing man from Ohio who spent every Friday roaming the halls, stick-
Compact disc is invented.
Sewcer, M.p.H.'^S the man he had chosen to be his deputy, fellow H S P H graduate David Sencer, M . p . H . ' ^ 8 . Sencer was "the brightest man I've ever worked with," says Goddard, adding that Sencer wanted the head position at the C D C "so much he could taste it." In /or He^M?, Etheridge notes that the hallmark of David Sencer's 11-year reign as head of the C D C was growth. Sencer took in federal offices whose funds were being cut—such as the Office of Pesticides and the Foreign Quarantine Office— and reorganized them by cutting inefficient and wasteful procedures and making changes in redundant stafhng.
National Center for Health Statistics reports that the nation's infant mortality rate has stopped declining for the first time in two decades.
"Sencer was an organizing, implementing kind of person," says James Curran, M . p . H . ' 7 4 , who went to the C D C in 1 9 7 1 as part of the Sexually Transmitted Disease Division. Sencer was also known for his amazing capacity to remember details and his thorough knowledge of the agency. "That guy knew everything there was to know about the C D C , " says Donald Hopkins. "He knew so many people by name; he has a phenomenal memory." "When he moved to the big corner office on the second floor of 1 6 0 0 Clifton Road, the man and the institution were fortuitously matched at a time when it was possible to get something done," writes Etheridge. In rc)66, Sencer's first year as director, the C D C and W H O launched the global Smallpox Eradication Campaign. Four years later, Sencer put fellow H S P H alumnus William Foege in charge of the campaign. Foege would eventually succeed Sencer in 1 9 7 7 , the same year the last case of small pox was registered. During Sencer's watch, the C D C also implemented the nation's first successful family planning research project, which included the surveillance of birth defects. This eventually grew into the Birth Defects Monitoring Program, which g a r n e r e d support from the March of Dimes. Sencer also scanned the U.S. Public Health Service and decided that sectors such as the National Clearinghouse for Smoking and Health, (which insiders called the "Smokehouse") and the National Institute of Occupational Health and Safety might be more appropriately administered by the C D C . Both were
Pr/nces a n d Peasants—$ma///xw /n M'sKvy, by alumnus and former faculty member Donald R. Hopkins, M.P.H/70, tells the history of smallpox from its probable origins in 10,000 B.C. to its eradication in 1980.
Primarily concerned with prevention and, says Sencer, "the same sorts of skills used in communicable disease control" could be applied to monitor the health effects of tobacco and Workplace safety issues. Thus in 1 9 7 2 , Sencer says he "waged a little campaign" and successfully acquired the two offices. "Sencer had a real grasp of the important public health issues of the time and how they should be dealt With," says Curran. Although Sencer was widely considered " a leader's leader," his tenure ended with controversy, which eventually led to his resignation. In January 1 9 7 6 , four isolates of what turned out to be swine flu—the killer of some zo million people during a worldwide epidemic in 1 9 1 8 — Were discovered among soldiers stationed at Fort Dix, N e w Jersey. One soldier died and 500 others were believed to have been exposed. When Word of the outbreak reached the CDc, Sencer called the first of many high-level meetings; all present agreed something had to be done. Sencer presented a memo to the Ford administration in which he outlined four options for dealing with the potential threat of swine flu: option four, calling for the vaccination of the entire population in time to avert another potentially deadly epidemic of swine flu, was the one he recommended. He gained nearly Unanimous consensus from his Colleagues at the C D C , including the Advisory Committee of immunization Practices and the Public Health Service. The vaccine champions themselves, Jonas Salk and Albert Sabin, conferred with
estimated 35 million ^Tiericans live in ^ n g e r , up from ° million in 1979 f o r d i n g to t h e U.S. Census Bureau.
President Ford and agreed that a widescale vaccination effort was in order. On October 1 , 1 9 7 6 , the first swine flu vaccination shots were given. On December 1 6 , Sencer announced the swine flu vaccination program was being suspended following 54 reported cases of GuillainBarre syndrome, believed to somehow be linked to the vaccine. T w o
sent [the situation] as accurately as we could and say that this was good preventive medicine, and if you believe in good preventive medicine, you sell it." In his introduction to -Swz'ne by Richard Neustadt and Harvey Fineberg, Joseph A. Califano points to the good that was accomplished by the swine flu affair, namely the huge number of people vaccinated, the development of a successful influenza surveillance program, and the ability of that system to track down the negative side-effect of Guillain-Barre. "In these terms, it may go down as a qualified success," wrote Califano, who was then H E W secretary and who commissioned Neustadt and Fineberg to write the book so that the administration could understand the lessons to be learned from it. — H E
Foege, M.p.H.'6y weeks later, Sencer was asked to resign. He also took the brunt of the criticism. "David was the fall-guy on swine flu," says Goddard today. " H e got a bum rap." " I would say over and over again, this was the right thing to do," says Sencer in a video tape produced in 1 9 8 3 by the C D C , part of an oral history of the agency. Critics pointed to Sencer's memo as the incendiary piece of paper that sparked the whole vaccination effort. In the C D C video, Sencer says all he did was present the facts in the name of the public interest: "We didn't pull out people lying in the streets and tear-jerking things. We tried to pre-
Astronaut Sally Ride becomes the first w o m a n in space. "*""" " SM)H DO
„
YEAR WILLIAM FOEGE
assumed the directorship of the C D C , the last case of smallpox had been eradicated from the world. He had been anticipating and planning for this event since he was a student at the School of Public Health. "It's one of those things that is not just a once in a lifetime opportunity," he says, "but it has to be done once in the entire history of the world." And, he adds, "its benefits accrue forever." Foege's involvement in the eradication of smallpox began in a missionary medical center in Nigeria, where he helped devise the "search and containment" strategy that proved so essential to the program's success. Instead of vaccinating every-
President Reagan proposes t h e Strategic Defense Initiative that becomes known as the Star Wars defense.
46
^ ^
body in the world, as was the original plan, limited stocks of vaccine were used to inoculate people living in villages already experiencing a smallpox outbreak, as well as the entire communities of a few surrounding villages. The system was efficient, but most importantly, it was also effective. In 1 9 6 7 Nigeria's six years of postcolonial turmoil finally erupted into civil war, and Foege was evacuated. He returned to the C D C , where in 1962. he began a two-year stint as an Eis officer. When he came back in 1 9 6 7 , he went straight to the Smallpox Eradication/Measles Control Program and in 1 9 7 0 , Sencer named him director of the program. Six years later, Foege replaced Sencer as C D C director. During Foege's hrst year as C D C director, he chose an ambitious project: identify the leading causes of morbidity and mortality in the country and devise means of prevention. He organized what he called the "Red Book Committee," which included, among others James Mason, who would succeed Foege as C D C director. What they found was that injury, including everything from automobile accidents to homicide, was the leading causes of premature morbidity and mortality. The solution, says Foege, was obvious: prevention. Foege called for the C D C to become the "conscience for prevention," and he championed the application of epidemiology to study injury. But he faced strong opposition, particularly from within the department, where it was believed that injury was a problem for law enforcement, not for public health. Publication of the 1983
1984
Harvey V. Fineberg succeeds Howard H. Hiatt as dean of the School of Public Health. The 37-year-old Fineberg is the sixth and youngest man to serve as dean.
Institute of Medicine report "Injury in America: A Continuing Public Health Problem", in which Foege played a key role, began to change minds. T w o years later, the C D C created an injury epidemiology and control division, and in 1 9 9 3 , the National Center for Injury Prevention and Control was developed, thus lending the same legitimacy to injury as communicable disease.
/ a w M Maso?!, D.p.H.'67 "Injury in America really set the stage for the development of injury control as a scientific held," says Mark Rosenberg, director of the C D C ' s National Center for Injury Prevention and Control. Rosenberg credits Foege with unifying the various government agencies into one central agency that would address all phases of injury: prevention, as well as the acute care and rehabilitation of injured people. "He helped to clarify the vision, and he continues to play a critical role in guiding and inspiring workers in this held around the world." On June 5, 1 9 8 1 , two years before Foege left C D C to go to the
Warren Berggren, D.P.H.'67, director of primary health care for Save the Children, heads a relief mission to Ethiopia, where famine threatens an estimated 7 million people.
Carter Center, where he would eventually be named executive director, a report that is now known as "Document Z e r o " appeared in awJ M o r f ^ Y y Wee^Jy Report, the C D C ' s digest of disease outbreaks and trends. Simply titled "Pneumocystis Pneumonia—Los Angeles" this brief article described the deaths of five homosexual men from a rare pneumonia found predominantly in people whose immune systems were severely compromised. " N o one had any idea of how big this problem was going to be," says Foege. It would take two more years for this problem to be given a name—acquired immune deficiency syndrome, A I D S — b y which time it was well on its way to taking an enormous international toll on human life. For many at the C D C , including Foege's successor, Mason, it would become an all-consuming interest. Curran, who would become h e a d of the C D C ' s A I D S program, said e a c h director lent his individual skills a n d strengths to the A I D S issue. "Foege tried to get people to take A I D S seriously," he says. "He was supportive of us at a time when the g o v e r n m e n t was trying to cut funding. When we needed resources, he would find additional resources," says Curran. When Mason came on board, AIDS had been diagnosed in recipients of blood transfusions and hemophiliacs, so there was much more public attention being given to it. " M a s o n , " says Curran, "took responsibility for managing all the attention and making sure people had the right concerns. "What was hidden was so much greater than we could see," says
Toxic gas leak from a Union Carbide p l a n t s Bhopal, India, kills 2,000 people and injures 150,000.
Mason about the emerging A I D S pandemic that was taking so much of the CDc's attention when he assumed the directorship in 1 9 8 3 . "And the C D C ^vas more aware of this than others early in the epidemic." That same year, the C D C ' s National A I D S Hotline was established to handle the growing number of calls for information. Meanwhile reports of heterosexual women who had contracted A I D S from male partners exploded the belief that the disease was strictly conhned to homosexual men. Like his predecessor, Mason spent much of his time hght'ng Congress for more A I D S fund'ng—unfortunately, he says, much of ^ came from the C D C ' s infectious disease budget. "It had to come from somewhere; we couldn't appropriate 't fast enough," he says. He also became involved in writing public Policy on A I D S . Directing the C D C was an event that Mason admits was "not even in his wildest dreams" when he was a student at the School, where he d e c e i v e d his D . p . H . in 1 9 6 7 . In 1 9 5 8 Mason faced two choices to fulfill his military obligation: the navy or the Public health service. lust as he was ah "°out to sign on the dotted line for the former, a position opened up at ^ e C D C . He took it. It was a fantastic two-year period," says Mason about his stint in the E i s , where he rose to the position of chief. "I felt guilty calling it miliary service." In 1962. Mason came to the ^chool a s part of the C D C ' s career evelopment program. He says he ^as so impressed by Professor of topical Public Health Tom Weller
^ approves MRI j S ^ t i c resonance r i s i n g ) scanners for ^ n e r c i a i use
and his department that when Weller asked him if he was interested in working towards a doctoral degree in tropical public health. Mason didn't hesitate. As a student, he co-authored a paper with Weller and Professor Andrew Spielman describing a technique for direct monitoring of natural transmission of mosquito-borne viruses. Over the next five years, Mason shuttled back and forth
"We're helping people become self-reliant," says Mason. When asked why he thought Harvard trained so many directors, Mason says that he and his predecessors share a common thread, which originated at the School: "All of us are really committed to excellence." They also all believe in the importance of being guided by an organized database, and share a commitment to prevention. "We couldn't allow the C D C to get caught up in the treatment paradigm." While Mason says he supported Foege's drive to move the C D C towards understanding the burden of injury and chronic disease, he is concerned that those pursuits not be followed at the expense of the surveillance and prevention of infectious disease. "The C D C ' s future is to maintain its grip on communicable disease," says Mason. " Y o u can't let those go because they're always waiting to bite you."
between the C D C , where he served in different administrative capacities, and the School. E G I N N I N G I N 1968, M A S O N , who is a Mormon, split his time L ^ between the C D C and administrative and clinical duties within the church's health care delivery system— a job he kept, in one capacity 01* another for the next two decades. Today, Mason oversees the church's humanitarian and missionary work throughout sub-Saharan Africa. His organization has bored water holes in the Congo, organized the distribution of clothing throughout the region, and provided food during civil uprisings.
Incidence of suicide among U.S. teenagers reaches 13 per 100,000: a 150 % increase over the past 20 years.
Hopkins, the last in the line of alumni directors, directed the Smallpox Eradication/Measles Control Program of the U.S. Public Health Service in Sierra Leone, West Africa from 1 9 6 7 to 1969, and was a consultant on smallpox eradication programs in Ethiopia and India. Although he went to school at Morehouse College, a black private college located only a few miles from C D C headquarters, Hopkins says he had only "an inkling" of what the C D C was all about before joining the smallpox effort. In 1 9 7 2 , he came to the C D C as a medical officer hoping to work on malaria in Ethiopia. When President Nixon reduced funding for public health work overseas,
Several weeks before classes begin, the School's water main bursts, flooding the lower levels of the Kresge Building and causing an estimated $400,000 in structural damage.
Hopkins left the C D C for a three-year stint as an assistant professor of tropical pubhc health at the School. He was invited back to the C D C in 1 9 7 7 by Foege as assistant director of operations. Three years later he was named assistant director for international health, and in 1984, he became Mason's deputy director. For most of 1 9 8 5 , while Mason served as acting assistant secretary for health in the Department of Health and Human Services, Hopkins assumed the responsibilities of acting director. That year, says Hopkins, was "the grand year of A I D S . " On October 2., Rock Hudson died of the disease. Also that year, the serological test for H i v infection was developed and the C D C cosponsored the first International Conference on A I D S . " T w o thirds of my time as acting director was spent on A I D S , " says Hopkins. Hopkins stayed at the C D C for two more years before leaving for the Carter Center, where he returned to the work he loves—"real" tropical public health, specifically battling Guinea worm disease"—work for which he received a prestigious Mac Arthur Fellowship in 1 9 9 5 . When Hopkins retires at some point
and is "sitting in a rocking chair somewhere" he says he'll reflect with great satisfaction on his work to eradicate two devastating diseases: smallpox and guinea worm disease. As senior consultant since 1 9 8 7 for the Global 2.000 project at the Carter Center, Hopkins is in charge of the guinea worm eradication initiative, which is directly assisting programs in Ethiopia, Ghana, Mali, Niger, Nigeria, Sudan, and Uganda. In June it was announced that yet another H S P H graduate, Jeffrey P. Koplan, M . P . H . ' 78, will take the helm at C D C . A former assistant surgeon general and the first director of the C D C ' s National Center for Chronic Disease Prevention and Health Promotion, Koplan began his career as a foot soldier in the Center's Epidemic Intelligence Service. Even if Koplan's appointment doesn't initiate another 2.3-year stretch of Harvard leadership at the C D C , it does reaffirm the School's continued relevance as a cultivator of professionals who consistently rise to the top of the field.
has worked under—Sencer, Foege, and Mason—he recognizes a consistent quality: "a broad perspective of pubhc health problems throughout the world and an ability to see public health problems as worldwide problems." Perhaps this consciousness was bred at the School, or just as likely, these three and those who have preceded and succeeded them, came to the School because they had that feeling already. "It's not unique to the C D C or H S P H , " says Foege. "There are a large group of people who see public health as more than a vocation; it is a consuming interest of life. " I used to walk down the halls of the C D C and see the campus activists of the '60s," he continues. "People who were concerned about social justice were there. That's the base philosophy of pubhc health."^
"Harvard has always been recognized as one of the premier schools of public health in the country," says Curran. In each of the leaders he
New York State legislature commissions a five-year, $3 million study to provide data on medical malpractice. The Harvard Medical Practice Study, led by former dean Howard Hiatt, finds that 4 % of patients in New York hospitals are injured during their stay, that 2 8 % of medical injuries are due to negligence, and that a no-fault claims system would be no more costly than the existing tort system.
President Reagan halts U.S. funding of international birth control programs.