FOOD FRIGHT Targeting Sugar & Salt

Harvard Public Health Review Fall 2009

ALSO INSIDE John Briscoe’s “waterspace” Health inequality on the Internet Social and environmental pollution: a toxic mix Tracking urban air pollution Tapping into stimulus funds Cancer looms in the developing world

HARVA RD School of Pu blic Health Dean of the Faculty Alumni Councilors Visiting Committee Julio Frenk 2006-2009 Jeffrey P. Koplan Anthony Dias, mph ’04 Chair Alumni Council Harvard Ramona Lunt, mph ’74 Ruth L. Berkelman The Harvard Public Health Review Biba Nijjar, mph ’06** Nils Daulaire Officers is published three times a year for Nicholas N. Eberstadt Mark S. Clanton, mph ’90 2007-2010 supporters and alumni of the Harvard Roderick King, mph ’98 Tore Godal President School of Public Health. Its readers share Monisha Machado, SM ’07** Jo Handelsman a commitment to the School’s mission: Royce Moser, Jr., mph ’65 Gloria Rudisch, MPH ‘70 Risa Lavizzo-Mourey President-Elect advancing the public’s health through 2008-2011 Bancroft Littlefield learning, discovery, and communication. Elsbeth Kalenderian, mph ’89 G. Rita Dudley-Grant, Nancy T. Lukitsh Vickie M. Mays Secretary MPH ‘84 Harvard Public Health Review J. Jacques Carter, mph ’83* Sean Dunbar, SM ‘08** Michael H. Merson Harvard School of Public Health Immediate Past President Maxine Whittaker, MPH ‘86 Anne Mills Office for External Relations Kenneth Olden Third Floor, East Atrium Regional Representative John W. Rowe 401 Park Drive Myron Allukian, Jr., mph ’67* Bernard Salick Boston, Massachusetts 02215 Burton Singer (617) 384-8991 **Class Representative *Harvard Alumni Please visit www.hsph.harvard.edu/review Association-appointed and email comments and suggestions to director [email protected]. Dean of the Faculty Julio Frenk T & G Angelopoulos Professor of Public Health and International Development Vice Dean for External Relations The Association of Schools of Public Health recently embarked on a campaign entitled Ellie Starr “This Is Public Health,” because many people outside the profession don’t understand Sr. Director of Development Marketing what public health is and how it affects their daily lives. In this issue of the Review, we and Planning use the campaign logo and accompanying text so readers can easily share with friends Julie Fitzpatrick Rafferty what public health’s mission is and how HSPH contributes to the field. To learn more Guest Editor about the “This Is Public Health” campaign, go to www.thisispublichealth.org/. Madeline Drexler Associate Editor Larry Hand For information about making a gift to the Harvard School of Public Health, Art Director please contact: Anne Hubbard Ellie Starr Development Communications Vice Dean for External Relations Coordinator Office for External Relations Amy Roeder Harvard School of Public Health Third Floor, East Atrium Principal Photographer 401 Park Drive Kent Dayton Boston, Massachusetts 02215 Cover: Kent Dayton/HSPH (617) 384-8970 or [email protected]

For information regarding alumni relations and programs, please contact, at the © 2009 President and Fellows of above address: Harvard College James Smith, Assistant Dean for Alumni Affairs (617) 998-8813 or [email protected] www.hsph.harvard.edu/give Public Health Review Fall 2009

14 Food Fright 8 Mr. Water in His Element Public health takes aim at sugar and salt. John Briscoe offers bold, unorthodox ideas for managing scarce water in the developing world.

4 The Shadow Epidemic Also in this Issue 24 Cancer is on the rise in developing nations. 38 In Memoriam 21 Navigating Health on the 40 Alumni News Information Superhighway Researcher removes roadblocks HSPH in Brief for people with limited income and literacy. 42 Research 24 The Wrights’ Stuff 44 Philanthropic Impact Couple’s combined expertise forges new directions for treating 46 New Initiatives asthma and lead poisoning. 47 Faculty News 28 Stimulating Ideas 48 Bookshelf Researchers tap into a new 32 source of government dollars. 49 Continuing Professional 30 Catching the Flu Before It Education Calendar Catches the World 52 HSPH Commencement 2009 HSPH investigators help lead H1N1 research and response. 32 Clearing the Air Students target air pollution, from Boston to Sub-Saharan Africa. 34 2009 Alumni Award Winners Are Scientific Pioneers, Inspirational Teachers

Image credits: top left, Sean McCabe; top right, Tony Rinaldo; all others, Kent Dayton/HSPH Cancer Prevention

Malignancies are on the rise in developing nations. by Julio Frenk, MD, MPH, PhD Dean, Harvard School of Public Health

hile it’s well known that cancer According to the most recent In low- and middle-income Wis a leading cause of death World Health Organization (WHO) countries, the high incidence of and disability worldwide, what is less estimates, in 2004 there were malignant tumors related to commu- recognized and understood is the 7.4 million cancer deaths worldwide, nicable diseases, such as the human significant growth of cancer in the representing around 13 percent of papilloma virus (HPV), reflects a developing world. Only two decades total deaths. More than 70 percent dearth of reliable systems for disease ago, the percentage of new cases was of those deaths occurred in low- and control and screening services. By similar for developed and developing middle-income countries. contrast, the increasing incidence of regions. Today, 55 percent of new lung, breast, and colorectal cancer is cases arise in developing nations—a Public health successes set stage largely the result of demographic and figure that could reach 60 percent by Why is cancer increasing in the devel- lifestyle changes, including longer life 2020 and 70 percent by 2050. oping world? expectancy and accelerated urbaniza- Unless a shift in mindset Ironically, successes in other tion, which in turn leads to repro- occurs—with those committed to realms of public health are partly ductive patterns (pregnancy at older global health investing more in cancer behind this shift. Gains made against ages, low prevalence of breastfeeding) information, prevention, screening, infectious diseases and increases in and lifestyles (tobacco consumption, and treatment—the number of new child survival beyond age 5 now make high calorie intake, alcohol abuse) cancer cases worldwide will grow from it possible for people in developing associated with several forms of around 12 million today to 15 million countries to live long enough to suffer cancer. in 2020, with much of that growth the noncommunicable diseases associ- occurring in developing nations. ated with age. Yet infectious diseases remain serious threats, creating a double burden of ill health.

4 Harvard Public Health Review a comprehensive view of by agents such as HIV, HPV, hepatitis Hemisphere outside of sub-Saharan Global health B virus, and Helicobacter pylori. Africa are more alike than different,” says The global health agenda remains In addition, noncommunicable Barry R. Bloom, former Harvard School focused primarily on communicable diseases and injuries are increasingly of Public Health dean. diseases and the traditional identifi- prevalent in the developing world. cation of international health with Problems only of the poor—such False dilemma creates barriers infectious disease control. We need, as common infections, undernutri- Today’s alarming cancer statistics stand however, to adopt a more comprehen- tion, and maternal deaths—are no in stark contrast to an equally alarming sive view. First, the separation between longer the only problems of the poor. lack of awareness, both locally and glob- communicable and noncommunicable Impoverished groups also suffer the ally. Sadly, a false dilemma has created diseases is not as clear-cut as it was highest rates of many chronic ailments, barriers to action. Screening procedures once thought. According to WHO, such as cardiovascular diseases, cancer, for cancer are considered too difficult one-fifth of all cancers worldwide are and mental disorders. “Healthwise, the and costly to implement. Some experts caused by chronic infections produced Northern Hemisphere and the Southern continued

Statistics paint a changing cancer picture

Women Men • Breast, cervical, stomach, lung, and colorectal • Lung, stomach, liver, esophageal, and colorectal cancers are the most common cancers among cancers are the most common cancers in men in women in developing nations. developing nations. • Breast cancer now surpasses cervical cancer as • While rich countries are witnessing a decline the number one cause of cancer-related deaths in new cases of lung cancer (a result of broad in all but the poorest nations of the world. antismoking campaigns), low- and middle- Developing countries account for 45 percent income nations—the focus of billion-dollar of the 1 million new cases of breast cancer tobacco industry publicity campaigns—are diagnosed each year, and 55 percent of deaths. experiencing the opposite trend. • In Latin America, two countries, Uruguay (83 • Developing countries’ share of new lung cancer per 100,000 women) and Argentina (75 per cases increased from around 30 percent in 1980 100,000 women), have already reached breast to more than 50 percent in 2007. cancer incidence rates similar to those of Canada (96 per 100,000 women), which are among the • In China alone, smoking prevalence in the highest in the world. general population is 31 percent. In adult Chinese men, smoking prevalence may be • Cervical cancer, now a rare disease in rich reaching 70 percent. nations, causes more than 200,000 deaths annually in developing countries. • Liver cancer is also increasing among men in poor countries. More than 80 percent of the new cases of this disease occur in developing nations, with sub-Saharan Africa and Southeast Asia showing the highest rates worldwide. It comes as no surprise to learn that in these same regions, hepatitis B virus infection, which affects the liver, is endemic.

Statistics: From Disease Control Priorities Project (DCPP), the American Cancer Society and the World Health Organization. Latin America breast cancer statistics from paper entitled “Tendencias del cáncer de mama en América Latina y el Caribe” by Rafael Lozano and colleagues [Salud Publica de México 2009;51(supplement 2):S147-S156]. Tobacco consumption in China prevalence statistics from paper entitled “Chinese physicians and their smoking knowledge, attitudes, and practices” by Yuan Jiang and colleagues [American Journal of Preventive Medicine 2007;33(1):15-22]. Breast cancer in developing countries statistic from Porter P. “Westernizing Women’s Risk? Breast Cancer in Lower-Income Countries” [The New England Journal of Medicine, 2008: 358;213-216].

Fall 2009 5 argue that it is unethical to screen, because treatment is unaffordable for the Breast cancer: vast majority of the population. Finally, A personal story observers ask: Why tackle cancer when so many are ill and dying from commu- The recent recognition of breast nicable diseases and the backlog associ- cancer as an “unforeseen public ated with underdevelopment? health priority” in Mexico and In middle-income countries, access many parts of the less-developed to screening and treatment for cancer world formed the basis of an tends to be limited to affluent popula- April 14 event hosted by Dean tions and to the minority of insured Julio Frenk and his wife, Dr. Felicia persons. Even in upper-middle-income Marie Knaul, a Harvard-trained countries, where noncommunicable economist who was diagnosed diseases now account for the largest with breast cancer in 2007 in Mexico. proportion of the burden of disease, One way in which she has cancer rarely appears at the top of the coped with her diagnosis, Dr. Knaul says, has been by plunging into health agenda. research and advocacy on breast cancer, with the active support Why is cancer absent from the of her husband, who is the former minister of health in Mexico. global public health agenda? Together, they have helped shed new light on the previously unrec- To address the health needs of ognized toll of breast cancer among the poor in Mexico and other the developing world, we need health less-developed countries. reforms that take into account the reality Knaul, born in Canada, said that she and Frenk had believed of the disease burden these nations the common public health myth that breast cancer is primarily a face. In the case of the recent Mexican disease of wealthy women and developed countries. In the devel- health reform, for example, two separate oping world, cervical cancer has garnered much more attention financial funds were created—one to because of a long history of causing death and disability, particu- address catastrophic health problems, larly among the poor. including cancer in children and cervical But this assumption was shattered when Knaul and others and breast cancer in adults, and another dug into the statistics and found that cervical cancer mortality had for community health encompassing peaked in 1990, declining rapidly thereafter due in large part to prevention and screening procedures for improved screening and treatment, while deaths from breast can- noncommunicable diseases, including cer have steadily risen. “In fact, breast cancer is striking women at all socioeco- several forms of cancer. Globe/Landov Rizer/Boston George nomic levels in all developing and, especially, middle-income Spreading information, countries,” said Knaul, senior economist at the Mexican Health changing attitudes Foundation and founder of “Cáncer de mama: Tómatelo a Pecho” Information will play a key role—in (Breast Cancer: Take it to Heart). Dr. Knaul was named Director risk assessment, provision of services, of the Harvard Global Equity Initiative and Associate Professor training, academic research, and of Medicine and Social Medicine at Harvard Medical School this policy implementation. Information spring. will also be critical to confront the See the webcast of the April event at: cultural resistance that stymies the www.hsph.harvard.edu/administrative-offices/deans-office/panels-on- fight against cancer. In many devel- public-health-priorities/ oping countries, it is not uncommon for women with breast cancer to be considered diminished in their femi- ninity. Concerned about the possi- bility of being abandoned by their

6 Harvard Public Health Review spouses when discovered ill, many of the Breast Health Global Initiative In this spirit, it would be decide not to look for care—or, if in 2002. Working with Dana-Farber useful to invoke the words of the they do, to reject proper treatment. and Brigham and Women’s Hospital, Nobel laureate Amartya Sen at the Fortunately, governments in devel- HSPH is also highlighting breast cancer International Symposium on Human oping nations are becoming more aware in developing countries as a challenge to Security, held in Tokyo in 2000: of the cancer threat. In 2005, the 58th women’s health and global equity. “We live in a world that is not World Health Assembly passed a resolu- only full of dangers and threats, but

Problems only of the poor—such as common infections, undernutrition, and maternal deaths—are no longer the only problems of the poor. tion calling on member states to inten- Cancer belongs in the global also one where the nature of the sify action against the disease by devel- health agenda adversities is better understood, the oping and reinforcing cancer control To place cancer on the global health scientific advances are more firm, programs. Efforts to support research agenda, we must expand the United and economic and social assets that on cancer in developing countries, Nations’ Millennium Development can counter these menaces are more though still meager, are also increasing. Goals to include health targets extensive. Not only do we have more A major breakthrough was the approval related to noncommunicable diseases problems to face, we also have more of a $50 million grant from the Bill & common in low- and middle-income opportunities to deal with them.”1 Melinda Gates Foundation to create the countries, such as hypertension, Let this keen awareness of the Alliance for Cervical Cancer Prevention. diabetes, and the most prevalent challenges, tempered by the realistic Breast cancer is also being recog- malignancies. We also have unprec- optimism offered by current opportu- nized as a major public health chal- edented opportunities in today’s five nities, inspire the crucial work needed lenge. Recent efforts include the revolutions in health: life sciences, to face the global epidemic of cancer. creation, by the Fred Hutchinson telecommunications, systems This article is based on remarks made Cancer Research Center with support thinking, knowledge management, by Dean Frenk at the Dana-Farber/ from Susan G. Komen for the Cure, and human rights. Harvard Cancer Center on April 7, 2009. Octavio Gómez-Dantés provided valuable input.

IN THE DEV ER EL Special November event on NC O A PI C N T G breast cancer S W A E O A special three-day program entitled “Breast Cancer in the R R

B L

D Developing World: Meeting the Unforeseen Challenge to

M :

E Women, Health, and Equity”—sponsored by the Harvard

T T

I Global Equity Initiative, Dana-Farber Cancer Institute, and

N U

G Q HSPH, among others—will be held November 3–5 at Dana-

H Farber’s Jimmy Fund Auditorium and Harvard Medical D

E N

U A School’s Joseph B. Martin Conference Center. Please visit

N H F T the conference website for complete venue and registration O L R A E E information. This event is free and open to the public. S E H E , N N E C H M A W O www.hsph.harvard.edu/breastandhealth/ L L E N G E T O

1 Amartya Sen. “Why human security.” Unpublished text presented at the International Symposium on Human Security in Tokyo, July 28, 2000.

Fall 2009 7 Environmental Health

Mr. Water in His Element Tony Rinaldo for HSPH for Tony Rinaldo john briscoe offers bold, unorthodox ideas for managing scarce water in the developing world.

hat do people in developing nations understand about water that people in wealthy W nations do not? “They understand the absence of it,” says John Briscoe, newly appointed Professor of the Practice of Environmental Health at HSPH. If it doesn’t rain, women who haul water for their families must walk vast distances to fetch it. Without rain, the lights go out in hydropowered locales. Lack of sani- tary facilities in schools deters girls from an education. Indian farmers unable to drill into dwindling aquifers even commit suicide. “Water is not taken for granted,” Briscoe says. “People live with insecurity at every turn.” That insecurity has preoccupied him for nearly four decades—first in his native South Africa, then in a remote village in Bangladesh and in newly independent Mozambique, then as a teacher at the University of North Carolina and as a policymaker and practitioner at the World Bank, and now at Clean water is a timeless Harvard (where he holds a joint appointment with the School defense against death of Engineering and Applied Sciences, as the Gordon McKay and disease. As safe and reliable water runs out Professor of Environmental Engineering). Briscoe has studied in impoverished nations, water from every conceivable angle: how it’s captured, con- experts must find ways taminated, diverted, dammed, piped, poeticized, regulated, to reverse the trend. ritualized, squandered, sanitized, fished, and fought over.

continued

Fall 2009 9 The Itaipu hydroelectric power station in Brazil is the largest in the world.

Over a long career focused on There is a “profound thoughtful, deeply thinking person the developing world, he has taken in the field,” says former HSPH stands that are politically unfashion- moral hazard,” Briscoe Dean Barry R. Bloom, who brought able. Pointing out, for example, that says, when rich Briscoe to the School from the World the United States and Europe have countries dictate to Bank in Brazil this past January. “You developed 80 percent of their hydro- can make energy, though it may not power potential, but Africa only 2 developing nations always be economical. But you can’t percent, he has strongly defended the what services they can make water—you either have water Images Getty opposite, Chen; Lincoln bottom, Etchart/PANOS; Top, ©Julio need for large dams in poor coun- or you don’t. Bringing someone here tries. And while elected leaders have and cannot have. who is not only knowledgeable theo- praised his support for these investments, critics in nongovernmental John Briscoe (right) with organizations (NGOs) in the West Roger Revelle, counter that such projects wreak co-founder of the both environmental and human Harvard Center devastation. Despite such sharp for Population and Development disagreements, Briscoe has gained Studies. Both the reputation of being one of the Revelle and world’s most knowledgeable experts Briscoe worked on water management. on water issues in Pakistan, India, “To a lot of economists, he’s and Bangladesh Mr. Water: the most far-sighted, during their careers.

10 Harvard Public Health Review retically, but also about managing description, a “self-righteous young true revolutionary change—was water resources, was the best bargain socialist-ecologist,” radicalized by a reality. Far from being harmed, I could imagine.” having grown up under apartheid. poor residents were better off in Briscoe’s experience in every way. The steady water supply From Radical to Insider Fatepur—a village perched on an had spurred a growing market for Briscoe’s conversation dashes in one island where the braided branches agricultural labor, which in turn direction, then another—a cascade of of the world’s second-largest river lifted people out of destitution. The words, befitting his specialty. He went system merge—altered his life better-off villages could now buy to school in Kimberley, South Africa, course. Malnutrition and disease hand pumps for drinking water and a diamond-mining city in the arid were rife. Life expectancy was less eat more nutritious food and install center of the country. Drought was a than 50 years. Briscoe, trained as an latrines. Women’s life expectancy perpetual worry. engineer, had been inexplicably hired had increased by two decades in just After earning his doctorate as an epidemiologist. 20 years. in environmental engineering at Twenty-one years after Briscoe’s “They got three crops a year Harvard, Briscoe in 1976 found first stay in Fatepur, he returned to instead of one,” says Briscoe. “They himself at the Cholera Research the village. The flood control and became better off—and lo and behold, Laboratory in Fatepur, Bangladesh, irrigation infrastructure that he they didn’t die so often.” The dramatic doing field work in water demand, had emphatically opposed in the progress vividly confirmed the view the health impact of water use on late 1970s—on the grounds that he had acquired after decades on cholera, and the political economy it would harm poor people and development issues, namely that the of rural energy. He was, by his own the environment, and fell short of continued

Harvard Water Security Initiative

ith grow- Engineering and Applied Sciences (SEAS), the University ing threats is initially forging collaborations among Harvard and Wto their Massachusetts Institute of Technology scientists and re- water security, many searchers in six countries: Australia, Brazil, Mexico, Pakistan, nations are exploring South Africa, and the United States. The Initiative is also new ways to safeguard engaging with a growing number of private companies drinking water and involved with water issues. And partnerships are being food, generate energy, established on specific water security issues with nations and sustain economic in which Harvard faculty and students are engaged. The growth. As part of this Initiative’s mission is to build knowledge and train a new effort, the Harvard generation of scholars—undergraduates, doctoral students, Water Security Initiative is stimulating world-class research post-docs, and young faculty—to address this looming by faculty and students across many disciplines—including global crisis. To aid this effort, HSPH and SEAS will be rais- history, anthropology, climate change studies, environmen- ing funds to support faculty, research, and scholarships for tal research, biology, business, government, engineering, undergraduates and graduate students. and public health. Their goal: to enable policymakers to better understand today’s water threats and to mobilize a For more information, contact Monique Bertic full range of tools for countering them. Under the leader- in the HSPH Office for External Relations at ship of Professor John Briscoe of HSPH and the School of [email protected] or (617) 384 -8987.

Fall 2009 11 basics—economic growth, infrastruc- has strong professional and personal will happen when Himalayan glaciers ture, and agriculture, with water critical ties—starting with Pakistan, South recede and potentially disappear, to all—are incalculably important to Africa, Brazil, and Australia. feeding less water to the Indus River, people who are poor. He will also open a “waterspace” the nation’s lifeline. In 1988, Briscoe joined the World in which faculty and students will bring A third avenue will explore how Bank. By 1996, he had risen to senior various tools to the water security chal- to mitigate risk. It will include biolo- water advisor, responsible for over- lenge. As he sees it, the expertise will gists (to propagate new varieties of seeing a multibillion-dollar portfolio of flow in both directions—with politicians crops more resistant to water stress), water resources, irrigation, hydropower, and policymakers from abroad teaching financiers (to craft better crop and sanitation, and environmental projects. Harvard faculty about the political rainfall insurance mechanisms), insti- Ironically, his appointment came at a realities of change, and Harvard and its tutionalists (to study how institutions time when the Bank had been scaling partner researchers boring down into influence how water is shared and back large infrastructure investments. knotty research questions. utilities regulated), and public health A strong proponent of such projects in The partnerships will focus specialists (to protect populations as 4Countries, 4Water Challenges India Sacred Ganges River, severely polluted, needs cleanup Brazil Amazon deforestation threatens farming, hydropower Pakistan Receding Himalayan glacier cuts meltwater to vital Indus River Yemen Unregulated extraction has depleted groundwater in this arid nation poor nations, Briscoe cut a controver- on a handful of themes. One is environmental conditions change). sial but successful path, culminating “context”—the history, anthropology A fourth avenue will look at in what he terms “the best job in the and religion of a region—and how how water shortages will affect public Bank”: country director for Brazil. it shapes the way governments deal health, the economy, the environment, “There were many things I did not with water. India’s Ganges River, for and migration. agree with in the Bank. But it was an example—repulsively polluted, despite Briscoe foresees “general principles” environment in which you could argue its sacred status—has recently been arising from these research collabora- for change, and sometimes achieve it. targeted for clean-up by holy men in tions—widely applicable ideas such as For me to be at that table with our the pilgrimage site of Varanasi. “In a how nations can provide incentives for partners in developing countries, rather country where Ganga is a sacred river,” people, farmers, and industry to use than writing an article for a journal, Briscoe says, “it turns out to be a very water more efficiently, or which crops was a tremendous privilege.” important mobilizing force.” work best in differing water conditions. A second avenue of research will The partnerships could also generate Harvard’s Water Mission ask about external threats to a nation’s knowledge to help resolve international What lured Briscoe to Harvard was water supplies. Brazil’s leaders, for water issues—such as the threatened the chance to translate his frontline example, must understand how defor- 1960 water-sharing treaty between India experience into useful interdisciplinary estation in the Amazon rainforest will and Pakistan, which currently divides research and training. He plans to forge alter the rains in the plains, which may up between the two nations exclusive partnerships with countries where he in turn undercut farming and threaten use of the western and eastern waters in the nation’s hydropower capacity. Pakistan’s leaders must anticipate what

12 Harvard Public Health Review the Indus system of rivers. “Harvard has their own imagined idea of how they them,” says Cash. “John comes out enormous brand recognition in those would have developed if they hadn’t of the world of trying to make some- countries,” he says. “We could act as a developed the way they had developed, thing work. That involves not just neutral party, bringing ideas to the table, but with the models that they now engineering, but anthropology and helping stimulate debate.” have. So California should never have economics and political science. Yes, had dams? It’s nonsense. And it’s saying he’s probably going to shake things up. Valuing Water to other countries: ‘We’re going to deny Good. My guess is that, in the process To all these activities, Briscoe carries you exactly what we used to develop.’ of doing it, he will also have to defend the conviction that management and That’s deeply resented and quite intel- his own positions.” infrastructure are equally essential. lectually suspect.” Briscoe relishes the intellectual “Once you have something, you don’t Early this year, Briscoe discussed give-and-take. Quoting the Harvard value it,” he laments. “Nobody in the water issues with administrators at a historian David Blackbourn’s recent United States likes a dam, for example. large philanthropic foundation: “They book on land and water in Germany, But every one of us has 6,000 cubic said, ‘Two billion people don’t have he noted, “In water, any solutions are meters of water in storage because of sanitation. This is a failure of the sani- always provisional. There is no point

“They said, ‘Two billion people don’t have sanitation. This is a failure of the sanitation sector.’ I said, ‘Not really. To me, it’s a failure of economic prosperity.’” —John Briscoe dams. People here are worried that tation sector.’ I said, ‘Not really. To me, at which the United States or Pakistan infrastructure in developing nations will it’s a failure of economic prosperity. or any country is going to have defini- have a negative impact on the environ- Because those two billion people also tively solved its water problems.” ment. But try a blackout for a day. Try don’t have energy, transport, jobs, With that long view, Briscoe a couple weeks of blackout, and then education. I mean, they’re poor. We remains both an optimist and a realist. see how you think about major power have to address their problems of “In some places, the glass is almost infrastructure.” poverty and their demands and prior- full. In other places, it’s five minutes to He concedes that apprehen- ities—not impose what we think they midnight. Or five minutes past.” sions about environmental and social should and should not have.” Madeline Drexler is a visiting scientist effects of dams “are valid and have to Richard Cash, Senior Lecturer at HSPH and guest editor of this issue be addressed, mainly because affected on International Health at HSPH, of the Harvard Public Health Review. people should be the first beneficiaries and a colleague of Briscoe’s back in of any dam.” But there is a “profound Bangladesh in the 1970s, sees Briscoe Her work has appeared in the New Conceicao Andrade Conceicao moral hazard,” he adds, when rich fitting in well at the School and York Times, Boston Globe, and many countries dictate to developing nations Harvard, although his views at times national publications. She is the author what services they can and cannot have. may seem impolitic. “At a university, of Secret Agents: The Menace of The U.S. and Europe “are looking to we have the luxury of not having to Emerging Infections. solve problems—but rather to analyze

Fall 2009 13

Nutrition

Public health takes aim at sugar and salt Food Fright

he war on obesity and other lifestyle ills has opened a new battlefront: the fight against sugar and salt. TIt may be a fight for our lives. In the last few years, evidence has mounted that too much of these appealing ingredients—often invisibly insinuated into beverages, processed foods, and restaurant fare—harms health. Research at the Harvard School of Public Health and elsewhere, for example, has tied sugary drinks to an epidemic of obesity in the United States. The average 12-ounce can of soda contains 10 teaspoons of sugar, and the average teenage boy consumes nearly three cans of sugary drinks a day. Is it any wonder that about two- thirds of Americans are now overweight or obese? Obesity, in turn, raises the risk of type 2 diabetes, heart disease, arthritis, and certain cancers. Meanwhile, studies have linked salty diets to high blood pressure, which increases the risk of heart attacks and strokes, the first and third leading causes of death in the United States. At HSPH, the Department of Nutrition is helping to lead the charge for healthier consumer fare. In April, at a widely covered video press conference, the department’s faculty publicly challenged beverage makers to create a class of drinks with 70 percent less sugar—a partial reduction that could lower obesity and diabetes rates within a year, they believe. On the salt side, experts estimate that cutting average sodium consumption by one-half could prevent at least 150,000 With rates of obesity and other deaths annually in the United States. chronic illnesses skyrocketing, Bolstering this two-pronged public health campaign public health experts are has been a shift in national political philosophy. “The exploring new ways to promote Sean McCabe Sean previous administration believed that market forces food industry change. Their solved everything and that regulation was off the table. strategies range from refining But market forces, left alone, damaged the economy,” our taste buds to imposing taxes on soft drinks. continued

Fall 2009 15 says Walter Willett, Chair of the Disease Control and Prevention (CDC), 17 teaspoons of sugar, they’d become Department of Nutrition and Fredrick installing a fierce advocate for lowering nauseated,” Willett says. “But they are John Stare Professor of Epidemiology salt and taxing sugary beverages in a able to drink it right down and go for and Nutrition. “That also applies to the position to bring about change. another.” While we normally balance food supply and health. Market forces a big meal by taking in fewer calories don’t promote a healthy diet—in fact, Spoonfuls of Sugar later, that compensation doesn’t they do exactly the opposite. We made In the School’s current battle plan, seem to occur after guzzling soft a lot of progress on trans fat. Now the the prime target is sugar in sodas, drinks—possibly because fluids are not biggest issue, outside of too many calo- fruit juices and other cloying drinks. as satiating as solid foods, or because ries, is the huge amount of sugar and Here’s why: sweet-tasting soft drinks whet the salt.” appetite for high-carbohydrate foods. • Downing just one 12-ounce can of As in many recent public health Willett and Lilian Cheung, a typical sweetened beverage daily campaigns, New York City has lecturer in the Department of can add 15 pounds in a year. been ahead of the pack. Its “Healthy Nutrition and editorial director of Heart—Cut the Salt” program, now • In children, one sweetened beverage The Nutrition Source website (www. a nationwide effort by a coalition of a day fuels a 60 percent increase in thenutritionsource.org), urge people health organizations and public agen- the risk of obesity—and American to choose drinks far lower in sugar cies, works with food industry leaders teenaged boys drink almost three and calories: options such as water, on a voluntary framework to cut salt in times that much. tea, seltzer with a splash of juice, their products. “New York City created • This April, an HSPH study linked coffee with one lump of sugar. a market for trans-fat-free foods, and it sugary drinks to increased risk of “If we can shift the present will create a market for lower-sodium heart disease in adults. Scientists American norm back to a lower foods,” Willett predicts. In May, Presi- have long known that sugar expectation of sweetness, people will dent Barack Obama picked Thomas R. reduces the “good” HDL cholesterol adjust their palates, particularly the Frieden, New York City’s health com- in the blood. Consistent with this younger population,” says Cheung. missioner, to direct the U.S. Centers for effect, the April study showed that it wasn’t just weight gain that Pass (Up) the Salt raised heart disease risk, but sugar Almost 80 percent of the salt in the itself—eating an otherwise healthy American diet comes not from the salt diet or being at a healthy weight shaker, but from processed or restau- only slightly diminished the risk. rant foods. According to the U.S. Department of Agriculture, in 2005 • In 2004, the Nurses’ Health and 2006, the average American on a Study found that women who had 2,000-calorie-per-day diet devoured one or more servings a day of a more than 3,400 mg of salt per day sugar-sweetened soft drink or fruit (mg/d). That’s substantially more punch were nearly twice as likely than current dietary guidelines, which The Congressional Budget Office to develop type 2 diabetes as those recommend that adults in general estimates that a three-cent tax on who rarely imbibed these beverages. consume no more than 2,300 mg/d— every 12-ounce soft drink could about a teaspoon. yield $24 billion over the next four As a dietary enemy, sugar is years—money that could help pay for cleverly camouflaged, because it is Several years ago, the National overhauling the nation’s health care dissolved in liquid. A typical 20- Institutes of Health’s Dietary system, according to The Wall Street Approaches to Stop Hypertension- Journal. ounce soda contains 17 teaspoons of sugar. “If people thought about eating

16 Harvard Public Health Review Sodium clinical trial (DASH- Most Americans should Sodium), led by HSPH’s Frank Sacks, eat no more than 1,500 mg of sodium per day. professor of cardiovascular disease That goal would require prevention, found that the biggest removing 80 percent of blood-pressure-lowering benefits came sodium from processed to those eating at the lowest sodium and restaurant foods. level tested, 1,500 mg/d. For those prone to high blood pressure, people over 40 and African Americans— groups that together represent nearly 70 percent of the population—the CDC likewise advises no more than 1,500 mg/d. In 1982, the U.S. Food and Drug did in the early 1970s, and women 69 That 1,500 mg/d threshold would Administration (FDA) called on the percent more. require cutting sodium in processed food industry to voluntarily reduce and restaurant foods by about 80 sodium levels in processed foods—yet Refining the American Palate percent. Though it may sound drastic, sodium consumption has steadily To wean ourselves from excess sugar, the the goal is more urgent than ever. drifted upward. By 2000, men were Department of Nutrition’s challenge uses eating 48 percent more salt than they continued on page 20

What Other Countries Have Done

W.H.O.

Over the past three decades in From 1998 to 1999, food In its “traffic-light” label- In 2007, the World Health Finland, deaths from heart dis- processors in New Zealand ing program, the United Organization, citing conclu- ease and stroke have both fallen reduced sodium content Kingdom designates foods sive evidence that excess 75 to 80 percent. As sodium in breakfast cereals by 61 as high (red), medium (yel- sodium causes hyperten- intake has dropped 42 percent, percent, in bread by 26 perlow) and low (green) in fat, sion, called for worldwide and the Finnish population has cent, and in margarine by 11 saturated fat, sugar, and reformulation of processed made other healthy changes, percent—eliminating about salt. The country’s Food and prepared foods with life expectancy has risen more 33 tons of salt from these Standards Agency published the lowest possible sodium than 10 percent. By contrast, in products. Foods that meet a set of voluntary salt re- content. the 1960s, Finland suffered the government standards can duction targets in 2006 for highest heart disease rates in the use a check-mark label that 85 categories of food. The world. To grapple with the prob- makes it easier for consum- U.K. program has begun to lem, its government launched ers to choose healthier fare. reduce average adult salt

Illustrations, Sean McCabe Sean Illustrations, measures to improve the pro- consumption. duction and marketing of health foods, passed salt labeling laws, held mass-media campaigns, and conducted school programs and worksite interventions.

Fall 2009 17 Fast Facts on Sugar and Salt

Sugar in Hiding As a dietary enemy, sugar is cleverly camouflaged because it is dissolved in liquid. A 20-ounce bottle of a sugary soft drink contains 17 teaspoons of sugar. In August 2009, the American Heart Association recommended that women consume no more than six teaspoons of added sugar a day, and men no more than nine teaspoons.

TEN COMMONLY EATEN FOODS: HOW SALTY ARE THEY?

SIZE TOTAL SODIUM

Submarine sandwich, with cold cuts 1 sandwich, 6” roll 1,651 mg

Fast-food taco 1 large 1,233

Spaghetti sauce, marinara, ready-to-serve 1 cup 1,203

Soup, chicken noodle, canned, prepared with water 1 cup 1,106

Croissant 1 croissant 424

Bagel, plain 3 and 1/2” bagel 379

Corn flakes 1 cup 298

Cashew nuts, dry roasted, with salt added 1 oz. 181

Potato chips, plain, salted 1 oz. 168

Tofu, firm 1/4 block 6

Source: USDA, University of Maine Cooperative Extension

Most Americans should consume no more than 1,500 mg of sodium per day. Eating just one or two high-sodium items can far exceed this amount.

18 Harvard Public Health Review Interpreting the Label HOW SWEET IS IT?

SPOONS OF SUGAR The HSPH Department of Nutrition has devel- t t oped a chart to illustrate the sugar content of

t common beverages. Healthy alternatives are shown in green, less healthy alternatives to be consumed in moderation in yellow, and those to be avoided in red. Find the complete list and The highlighted The number Consumers often see how your favorite beverage compares at areas illustrate in the % Daily overlook the www.hsph.harvard.edu/nutritionsource/files/ the serving size, Value column fact that one sodium content, is based on a package may how-sweet-is-it-color.pdf. and amount of 2000-calorie contain multiple sugar. diet. servings. Welch’s 100% Grape Juice THE SALT PIE Red Light Snapple Iced 77 percent of the average person’s sodium intake Peach Tea comes from processed or restaurant foods. Coca-Cola Classic

6% Added at table Low Sodium V8 Vegetable Juice 5% Added during Yellow Light Snapple Earl Grey cooking Black Tea

12% Berry Box Naturally Fortified Water occurs

Iced coffee with 77% 1 tsp. sugar

FROM PROCESSED Tea with no sugar OR RESTAURANT Green Light FOODS Seltzer with a splash of juice

Source: CDC

“Market forces don’t promote a healthy diet—in fact, they do the opposite.” —Walter Willett

Fall 2009 19 continued from page 17 a benchmark of one gram of sugar per processed foods as “serious concerns” he adds. “Public education is central ounce, which equates to a 12-ounce soda for the Obama administration. The to this effort, and talking to journalists that contains three teaspoons of sugar Washington, D.C.-based Center for is a great multiplier of information.” A and 50 calories. “We’ve suggested that Science in the Public Interest (CSPI) has Reuters news service story on the depart- manufacturers provide an option in also pressed Congress and the adminis- ment’s industry challenge was picked up between high-sugar and sugar-free tration to act. from Canada to China, and in June USA drinks,” Willett says, “to help people step Looking to economic levers to Today ran a major story on the topic. Nu- down if they can’t go cold turkey from cut consumption, Willett proposes a trition department investigators are also full sugar to no sugar.” The department national sales or excise tax of up to 18 preparing a scientific review article for a is currently discussing the challenge percent on sodas and candy. Along leading medical journal about the delete- with Obama administration officials. with CSPI, the Department of Nutri- rious consequences of high-sugar drinks. While Willett and others are not tion submitted a letter to Congress in The HSPH Department of Nutri- directly in contact with manufacturers, June supporting a tax on full-sugar tion is raising funds to set up a research the challenge’s press coverage has beverages; Willett has also testified and information center that would stirred debate within the beverage before the Massachusetts Legislature in conduct, compile, and disseminate industry, and several small start-ups are support of such a bill. Some of this tax studies on the health implications of introducing low-sugar drinks. could be used to subsidize healthy but sugar-sweetened beverages. The center’s The HSPH challenge further relatively expensive alternatives, such mission: to educate policy makers and proposes that the FDA require manu- as fresh fruits and vegetables. Willett the public. facturers to label the fronts of their cans would also rewrite government procure- So far, food manufacturers have and bottles with information on total ment policies to help set new industry not widely reformulated their products, contents rather than per-serving quanti- standards. In his view, food services at for fear of losing customers and get- ties. Currently, most consumers assume military facilities, hospitals, government ting ahead of taste trends. But other that a single package of chips or bottle organizations, and schools should all nations, such as Finland, have proven of soda is a single serving. Only upon phase out highly sweetened beverages not only that palates can grow more close inspection do they discover that in favor of low-sugar options. refined when governments embark on there are two or more “servings” in the And Willett has called for a ban full-scale efforts steering people toward package. Willett has called for an initial on child-focused marketing for sweet- more wholesome fare, but that popu- reduction of salt in processed foods of ened drinks—since children and teens lation health dramatically improves up to 20 percent—a change that studies drink most of their sugary calories at when they do. (See: What Other show does not perceptibly affect taste. home. “There should be strong regula- Countries Have Done on page 17.) tions, with real teeth in them, against For now, Willett intends to point Launching a National Campaign advertising to children. It’s immoral— public health’s artillery toward sodas and In its forceful call to action, HSPH criminal, even—to have children’s other sweetened drinks. “Going for the joins a growing chorus of health experts health undermined for the sake of low-hanging fruit is the first step, and the demanding change. “New Horizons for profit,” he says. To this end, Willett has sugared beverage area is the place,” he a Healthy America: Recommendations also contemplated lawsuits on behalf says. “These products are in a class with to the New Administration,” a report of children: “If a child is encouraged to tobacco. There’s only harm, no benefit.” issued in April by the Commission on consume these beverages by a fast-food U.S. Federal Leadership in Health and chain, without being warned of the Larry Hand is associate editor of the Review. Medicine: Charting Future Directions, consequences, and they develop diabe- describes sugary beverages and salty tes, is there not some liability? Madeline Drexler is guest editor of this issue of the Review. “We will use all levers possible, as we have done for trans fat elimination,”

20 Harvard Public Health Review Health Communication with debate over unequal access to health care raging in the U.S., one Complexly designed place where the racial and economic divide in health is greatest is websites, pop-ups, slow getting scant attention: the Internet. Health websites number in the tens of millions, but most are connections, and text written at a level only high school or college graduates can understand. written at grade levels As a result, their use by those with limited education or income is low. difficult to understand Among the poorest Americans, broadband Internet access has actually declined in the past year. can disenfranchise people “You or I will go online to research a disease we’ve just been from getting the health diagnosed with or check on the latest health claims regarding a favorite food. That’s just not a realistic option for the poor, many information they need. minorities, and those with limited education,” says Kasisomayajula “Vish” Viswanath, HSPH associate professor of society, human development, and health. “I’m interested in trying to understand how inequalities in communication result in inequalities in health. In terms of access to information, there are profound differences between the haves and the have-nots.” continued

Navigating Health on the Information Superhighway

Fall 2009 21 wrong turns on the internet Viswanath believes that such access can improve health THE DIGITAL DIVIDE outcomes. Cancer prevention and treatment, diabetes management, tobacco control, and stress levels could all be improved by knowledge gained from the Internet. “These are conditions Seventy percent of the U.S. adult population that, in many cases, are preventable—or, if you have them, in 2007 was online and 80 percent of them say you can do something about them to reduce their effects on they have searched for health information. your health. But if you don’t have the information, or can’t But data from two studies—the Pew Internet understand the information, you can’t benefit from it to & American Life Project in 2008 and HINTS, a improve your chances to lead a healthier life.” 2005 NIH research project focused on use of the Some of the Internet stumbling blocks encountered by Internet for cancer information—paint a radi- those with lower incomes and literacy levels are the same as cally different story of Internet health informa- those that everyone experiences from time to time: annoying tion access among the haves and have-nots. pop-ups, too many choices, slow connections. “People with • Twenty-five percent of Americans whose house- adequate education and resources can overcome these frus- hold incomes are $20,000 a year or less had broadband at home in 2008—down from 28 “In terms of access to percent in 2007. information, there are • Forty-three percent of African Americans re- ported having home broadband, compared profound differences between with 57 percent of whites and 56 percent of the haves and have-nots.” English-speaking Hispanics.

—”Vish” Viswanath • Of those whose income was below the federal poverty level (which was $19,349.99 for a family trations,” says Viswanath. They buy a faster computer or of four in 2005 when the study was completed), get broadband at home. They turn on the pop-up blocker only about 30 percent were using the Internet or pay someone to remove a virus that is causing problems. for health information. By contrast, more than They can read quickly enough to pick out the best website 70 percent of those whose household income choices from the millions Google serves up. “But for the was three times the poverty level or higher poor and those with limited literacy, these problems are over- (income over $58,050 for a family of four) were going to the Internet for health information. whelming,” he observes. At a gathering sponsored by Discovery Communications • While 30 percent of high school graduates use and hosted by HSPH alumnus John Whyte, MD, MPH ’93, the Internet for health information, that figure rises to 75 percent among those with at least a at Discovery in Silver Spring, MD, recently, Viswanath told a bachelor’s degree. group of HSPH alumni and friends that as part of one study he is conducting, free Internet training is being provided to • The most popular health website on the Internet, WebMD.com, is written at the 13th- help the underserved obtain health information. He is also grade level. Breastcancer.org is written at grade developing a simple health Web portal that enables those with level 12. The National Institutes of Health’s web- limited literacy to get on the health information superhighway. site is written at grade level 9. As a first step in the research study, Viswanath conducted • Television remains the great health care infor- focus groups among adults with low income and low education mation equalizer. Irrespective of income, about levels, and among minorities. He did separate usability testing 75 percent of all individuals say they watch of a Web portal with individual volunteers—similar to that health news on TV. done by sophisticated website designers for multimillion- 000111001010010001010111110101111010111010010100101001010101001000101000101010101010000110111101101010101001101100111111100101001010010101010010001010001010101010100001101111011010101010011011001111111110 0000101000001111100101001010010100101010100100010100010101010101000011011110110101010100110110011111111100000101000001001010101001000101000101010101010000110111101101010111000010101011101101101010000110

101100010100000111110010001000001111101010101000100101010111101010101110111011 00011100101001000101011111010111101011101001010010100101010100100010100010101010101000011011110110101010100110110011111111100 000101000001111100100010000011111010101010001001010 0001110010100100010101111101011110101110100101001010010101010010001010001010101010100001101111011010101010011011001111111001010010100101010100100010100 22 Harvard Public Health Review Viswanath acknowledges that, for now, training programs in Internet use will need to be offered by nonprofit groups with a commitment to the underserved. Ideally, he would like to see broader measures that guarantee equal access to Web-based health resources. Among these: subsidized cable and broadband Internet access for the poor; websites that are easily navigable by people with low literacy; consistent health information across official websites produced by government agencies and non-governmental health organizations; and widespread training on how to use the Web to acquire health information—including training offered at work. “In the end, communications inequalities are more Dr. Viswanath recently talked to HSPH alumni and friends about the disparities in digital health access at a forum addressable than most of the other social factors that deter- sponsored by Discovery Communicatons at their global mine how healthy or unhealthy you will be,” Viswanath headquarters outside Washington, D.C. says. “Social determinants that influence health—such as dollar clients. Input from the usability testing led him to social class, discrimination and violent neighborhoods—are design the next iteration of the health Internet portal (see vitally important problems, but difficult to address when it at www.clicktoconnect.org). compared to communication inequalities. As a society, “As a media company with more than 1.7 billion subscribers in 170 countries, we’re deeply committed to finding new ways to empower people to lead healthier lives. The issues Dr. Viswanath talked about are important to us as a company and to me personally. ” John Whyte, MD, MPH ’93 Discovery Health Vice President for Continuing Medical Education Discovery Communications Discovery Most focus group members were using computers at we should be able to develop health websites that people school or a library, and were exploring the Web for school with limited literacy skills can use. And we should be able work or resume writing. They often relied on younger to find ways to provide subsidized broadband access and family members for help with the Internet. inexpensive computers for the poor.” As Viswanath sees it, such equitable access to health Building a better information highway information is rooted in democracy itself: “I think of this With the input from the focus groups, Viswanath designed a in terms of the Jeffersonian notion of an informed citi- new health Internet portal with simpler language, a two-column zenry. If you don’t have information, you are acting on a layout rather than three or more columns, a simple naviga- lack of information or misinformation, which means you tion system, technology that would load quickly onto older are unable to act in your own best interest.” computers, and no distracting pop-ups. The website is written Julie Rafferty is senior director of development marketing at grade levels 6-8. The website includes content on a wide and planning at the Harvard School of Public Health. range of health related topics, both as text and, in some cases, with access to video. The trial is currently in its fourth year. 000111001010010001010111110101111010111010010100101001010101001000101000101010101010000110111101101010101001101100111111100101001010010101010010001010001010101010100001101111011010101010011011001111111110 0000101000001111100101001010010100101010100100010100010101010101000011011110110101010100110110011111111100000101000001001010101001000101000101010101010000110111101101010111000010101011101101101010000110

n their way to school one morning, two middle-school boys skirted a crime Oscene where a high-schooler lay dead, shot just a few minutes earlier while waiting at a bus stop. By the time they got to their classroom about two blocks away, both boys started wheezing and coughing and used their asthma inhalers to regain control of their breathing. This hypothetical scenario is a realistic example, say Harvard School of Public Health faculty members Rosalind and Robert Wright, of how stress in impoverished neighborhoods affects health. And it will take more than prescription inhalers to solve the problem.

The Wrights, who are HSPH alumni, are using their Poor neighborhoods typically have more old and combined expertise in toxicology, genetics, pulmonary peeling lead-based paint than do more affluent locales. medicine, and the effects of physical and social environ- Already, the Wrights’ research suggests that when children ments on health to change how medicine is practiced. are exposed to significant and persistent emotional stress, Their goals are three-fold. First, they intend to docu- the added exposure to environmental lead results in brain ment scientifically the role stressful environments play in damage at lower thresholds than previously suspected. creating medical problems that range from asthma to lead Their research also provides a bright counterpoint: that poisoning. Second, they want to get physicians talking the complications of lead poisoning might actually be with patients and their families about how these stressors mitigated if life stresses are reduced. cause and exacerbate disease. Finally, they hope to iden- The Wrights and their colleagues first proposed this tify ways to intervene in the lives of children and adults effect in humans in a paper based on the study of mother- who face the double burden of being poor and of being child pairs in Mexico City, published in the March 2008 exposed to daily emotional distress—to help them live issue of Neurotoxicology. Animal studies had previously healthier lives. made the association. “As a pediatrician, it has always bothered me that the literature cites the permanency of lead poisoning,” says Robert, MPH ’00, an associate professor of environmental

24 Harvard Public Health Review Couple’s combined expertise forges new directions for treating asthma and lead poisoning.

health. “It makes no sense to me. Children’s brains are be doing anything comparable to our public health malleable. Why would lead cause permanent damage? work,” says Rosalind, MPH ’96, an assistant professor My belief is that it doesn’t. We just don’t have the right of environmental health. “But listening to our patients, intervention yet.” it was quite clear that the numerous social stressors they were dealing with affected our ability to provide good care collaborators in work and life continued As researchers, the Wrights often appear as co-authors on papers that break new ground. Common phrases in their

published work include “no previous study” and “has not Some diseases attack certain groups more been studied among children.” than others. The Wrights are deciphering Kent Dayton/HSPH Kent They met while both were attending medical school the complex roots of asthma and lead at the University of Michigan. Both plunged into clinical poisoning, which disproportionately strike practice—Robert in pediatrics and Rosalind in pulmonary the urban poor. medicine. “We never went into medicine thinking we’d

Fall 2009 25 Vaughn Wascovich —Rosalind Wright Investigators have already linked physical factors such into treatment diseasesinto of and conditions. If scientific progress could be measured a scale Robert on 100, 1 to of says,12. the to 10 field Researchis currentlyat on asthma and lead poisoning have made the most headway. as air allergens, pollution, tobacco dust smoke, mites, and cockroaches a greater to risk asthma of severe and more to asthma. that But research, Rosalind says, only partially explains asthma why is concentrated in high-risk groups such as the urban In a paper published in poor. Clinics Chestin Medicine in 2006, proposed that she a “violence and urban asthma paradigm” exists in “socially toxic neighborhoods.” Psychological stress disrupts the disrupts the Psychological stress as same biological pathways in air pollution or does breathing tobacco smoke.” “ Harvard Public Health Review Harvard Health Public

The professional collaboration developed gradually, ASTHMA-violence link 26 the areThe Wrights part a small of growing but movement physiciansof incorporating environmental considerations and improve theirand improve health. That is what drew us public to Bothhealth.” taught the at Harvard Medical School before coming the to Public Health, School over of and appointments. joint hold now conversations aroundas the house kept work-related revealing common threads. was “I studying the impact of metals says such Robert. as lead child on development,” “Roz had all these articles around the stress house on and brain The biological development. similarities between the two mechanisms studying were we striking, were and When just seemed thereit me to had be to a relationship.” a medical literature search turned nothing, up inspired it mission health. ina joint public Both still see patients on a part-time basis, applying the results their of research directly in the clinic—Robert Hospital and Children’s at Rosalind Beth at Israel Deaconess Medical Center. The Tar Creek Superfund site in northeast Oklahoma is a public health nightmare. Between 1891 and the 1970s, Creek Superfund site in northeast The Tar tons of lead and zinc from below its surface. Robert and Rosalind Wright mining companies extracted millions of iron High area. the in living children in exposures metal toxic of effects the reduce could that interventions design orange.levels from mining wastes turn the water An earlier paper she coauthored, in Environmental specific metabolic pathways linked to asthma, colleagues in Health Perspectives in 2001, described four cases of Boston the medical community started listening,” says Rosalind. children in whom severe asthma attacks appeared to be trig- Indeed, physicians are beginning to view the myriad stressors gered after they witnessed violence or were victims them- in underprivileged neighborhoods as “social pollution” that selves. In a 2007 study published in the same journal, Rosa- affects risk for a wide range of diseases. lind and colleagues linked increased asthma risk to traffic-related air pollution and to exposure to violence. “Psychological Social toxins behind disease stress disrupts the same biological pathways as does breathing The couple’s research into lead poisoning shows that the in air pollution or tobacco smoke,” she says. combination of poverty and lead actually increases the According to Rosalind, the couple’s physician colleagues toxicity in children. Traditionally, Robert says, physicians were reluctant at first to start asking asthma patients and have considered lead poisoning untreatable; children with their parents about the stress in their lives. “I think the fear lead poisoning, who are usually poor, were believed destined was that patients and families would consider the probing to intellectual impairments that would prevent them from a violation of privacy,” she says. But once she and her fellow leading normal lives. Does exposure to violence worsen childhood asthma in “socially toxic” neighborhoods?

doctors started asking the questions, it became clear that “In our approach, we’re hoping to show that patients appreciated someone talking with them about how interventions in the social environment may be a treatment community and domestic violence affects their asthma and for lead poisoning,” says Robert. “We’re saying these kids may health in general. As she explains, “It validated something the be able to overcome their lead poisoning and enjoy productive patients already knew was important.” lives.” And, he adds, “If we are right that social interventions Today, physicians more frequently screen patients for work, the applications wouldn’t be limited to lead poisoning. exposure to violence, both inside and outside the home. Other toxicants could also be treated this way.” “Once we more directly connected exposure to domestic The Wrights’ approaches have earned them respect violence to asthma risk in children, and emotional stress to among other researchers conducting similar studies. Rosalind “has pioneered the concept that, in addition to physical environment pollutants affecting asthma, there is a parallel construct of social pollutants,” says Edith Chen, associate professor in the department of psychology at the University of British Columbia in Vancouver and an asthma researcher. And the application of Rosalind’s research in the clinic, Chen says, “is happening even now. She’s raising levels of awareness among physicians about social contributors to childhood asthma.” The same is true for Robert’s innovative studies, notes Phillip Landrigan, director of the Children’s Environmental Health Center and professor of pediatrics and community and preventive medicine at Mount Sinai School of Medicine Exposure to lead in older urban homes still ranks as a public health threat in the U.S. The Wrights’ research continued on page 50 may point to ways to mitigate neurological damage in children.

Fall 2009 27 Research Funding

Researchers tap into a

new source of Source © Image government dollars. Stimulating Ideas

cientists at the Harvard part of the $787 billion package, but not funded due to budget School of Public Health passed by Congress and signed constraints, and supplements to Sand around the country are into law by President Barack grants already under way. Funds hoping that a busy spring will pay Obama on February 17. Of that, were being awarded as the Review off in an ample fall harvest of new $8.2 billion will flow to scientific went to press. research funding. The bounty could research. Faculty members from Funding in all of the NIH’s come courtesy of the American every department at HSPH quickly stimulus grant programs comes Recovery and Reinvestment Act pulled together proposals this spring with more stringent reporting re- (ARRA), more commonly known totaling more than $72 million. quirements than usual. As with all as the federal stimulus package. Under the stimulus package’s ARRA funds, there will be height- Flat funded for the past five years, mandate, the NIH’s 27 centers and ened scrutiny from public and gov- the National Institutes of Health institutes can distribute the money ernment auditors. Researchers will (NIH) received $10.4 billion as through an array of grant pro- be required to submit financial and grams, but will collectively support scientific progress reports quarterly, projects that stimulate the econo- rather than annually. And the gov- my, create or retain jobs, and have ernment reserves the right to re- The National the potential for making scientific scind funding if it’s not being spent Institutes of Health’s progress in two years. The fund- quickly enough. Scientific progress one-time funding ing is divided between promising reports will be posted to ARRA’s boost is expected to new projects, previously submit- website. support promising or ted grants that were well reviewed underfinanced research.

28 Harvard Public Health Review Among the first faculty mem- $19 billion for health I.T. bers at the School to receive ARRA The stimulus package also seeks to promote the adoption of electronic medical funding is I-Min Lee, associate pro- records through the Health Information Technology for Economic and Clinical fessor of epidemiology. Her study Health (HITECH) Act. Under the act, $19 billion will be distributed through examining the effects of physical Medicare and Medicaid payment incentives to physicians and hospitals using certified electronic health information systems in a “meaningful”—but as yet activity on cancer patients originally undefined—way beginning in 2011 and continuing for the next five years. fell below the NIH funding cut-off, “This mechanism is smart,” says Ashish Jha, associate professor of health but was given new life when more policy and management, who published a study in March on the slow adop- resources became available. tion of electronic health records. “If Congress had created a grant mechanism, Like many other researchers, adoption would be slower. No one is going to want to buy a system now if the Lee wonders what will happen to government is going to pay for it later. And this way it doesn’t penalize those the research generated by ARRA who have already purchased systems.” The program will provide enough money to cover the systems used in most when the funding runs out in two doctors’ offices, although probably not enough for most hospitals, Jha says. years. “Everything goes through He is optimistic that the program will spawn adoption of electronic health re- a cycle so we just keep our fingers cords, which will eventually lead to health care quality improvements and cost crossed.” reductions. Stimulating Ideas Amy Roeder is the development For more on electronic health records, read the Harvard Public Health communications coordinator in the Review’s “Doctoring in a Digital World”: www.hsph.harvard.edu/news/hphr/ Office for External Relations at fall-2008/fall08ehealth.html. Learn more about Jha’s study at: www.hsph. HSPH. harvard.edu/news/press-releases/2009-releases/us-hospitals-extremely-slow-to- adopt-electronic-health-records.html

$1.1 billion for comparative effectiveness research

With health care costs now exceeding 15 percent of Gross particular medical condition is often the more expensive one, Domestic Product (GDP), the Obama administration and which means that it is possible to contain costs only by allo- Congress are taking another look at comparative effective- cating resources more wisely.” For example, spending money ness research, which weighs the medical benefits, harms, on treating high blood pressure in a large number of patients and costs of treatment alternatives—such as watchful wait- would yield greater health improvement—gains in life expec- ing, surgery, or radiation for prostate cancer. tancy and quality of life—than spending the same amount of ARRA funds totaling $1.1 billion will be distributed money on lung transplants for only a few people. between several government agencies, including the Weinstein does not believe that the new legislation will Department of Health and Human Services, which will re- result in mandates for doctors and rationing of care, as some ceive recommendations on setting research priorities from opponents fear. But it remains to be seen, he says, whether a new 15-member council. Researchers will then be able to Medicare and private insurers will take comparative effective- apply for funding, which will carry ARRA’s stringent reporting ness research findings into account in their coverage and requirements. reimbursement decisions. Milton Weinstein, Henry J. Kaiser Professor of Health What is now known as comparative effectiveness research Policy and Management, is cautiously optimistic that this was developed at HSPH’s Center for the Analysis of Health new effort will produce results. But he’s concerned that the Practices in the 1970s, under the leadership of former dean funding effort does not explicitly mention cost-effectiveness Howard Hiatt. To learn more, read the Review’s “Protecting analysis, a component of the field’s research agenda used to the Medical Commons”: www.hsph.harvard.edu/review/ ©Magictorch measure the value of medical treatment. “It will be necessary protecting_the.shtml. for public and private payers to address cost-effectiveness to contain costs,” he says. “The more effective treatment for a

Fall 2009 29 Influenza virus, ©CDC/Photoresearchers, Inc. hes c hing c the Flu Cat t It before Cat Coincidentally, just before the before just Coincidentally, the World Modeling an epidemic Modeling was in Mexico, Frenk While Dean Lipsitch lent his infectious-disease modeling skills to the CDC in with agency worked He Atlanta. scientists to judge the severity and transmission rate of the virus. collaborators included faculty His and colleagues and students at HSPH, University, Kong colleagues at Hong for Institute National the Netherlands and the Environment, Health Public College London. and Imperial epidemic emerged, Lipsitch had completed a paper that described how dipping into small reserves of second- Relenza could line flu drugs such as to stockpiled hedge against resistance Tamiflu. such as first-line treatments published the paper PLoS Medicine a separate May 19. In online May of Medicine Journal England 27 New article, Lipsitch and colleagues described steps needed to prepare for the upcoming flu season in the Frenk—Mexico’s former minister Frenk—Mexico’s of health—praised Mexico’s initial of health—praised Mexico’s to the epidemic. After response disease surveillance system Mexico’s picked up a minor but troubling “An imme- April, in flu cases in trend within a few led, diate investigation and full genetic to the isolation weeks, causing sequencing of the microbe the Times in the illness,” he wrote 1, May Diagnosis,” Fast (“Mexico’s - The charge that the govern 2009). enough, he acted quickly ment hadn’t to take into account the added, “fails and complexity of recognizing real-life to an unexpected public responding consulted Frenk health emergency.” April as the Mexico in with officials in conti- began to jump across outbreak Mexican how by nents. Impressed scientists had quickly spotted H1N1 of standard against a background alertedseasonal flu and had promptly “Theirglobal authorities, he wrote, other countries the fast action gave for the warning they needed to screen new virus.” —backed by

a new influenza pandemic a new influenza pandemic

s this spring set off alarms in the global health community, Harvard Public Health Review Harvard Health Public

30 A Harvard School of Public Health Health School of Public Harvard scholars helped illuminate the crisis and lead a practical response. In a op-ed Times York New widely read described Frenk article, Julio Dean sharp government’s Mexican the how surveillance system prompt government interventions— government prompt alerted the world to the novel H1N1 virus and contained its initial spread. Professor of Epidemiology Marc Lipsitch lent his epidemic modeling skills to the U.S. Centers for Disease (CDC) and Prevention Control and published two timely scientific papers on the topic. And Associate Professor Atul Gawande teamed up Organization Health World with the (WHO) a concise influenza to create checklist for beleaguered patient-care hospitals. Infectious Diseases HSPH investigators help lead H1N1 research and response

Northern Hemisphere—from capital- lists recommended medical proce- When the H1N1 (swine) izing on university and private-sector dures from the time a patient arrives influenza virus surfaced in expertise to amping up government at a clinic until the discharge and Mexico this spring, HSPH surveillance. after. For medical personnel, the first faculty and Dean Frenk were in two procedures are “put on medical/ the thick of the public health helping hospitals prepare surgical mask” and “clean hands” response, offering expertise Gawande, who led a team that —commonsensical actions that are ranging from statistical developed a surgical checklist now shockingly ignored in modern health modeling to cell phone surveys to checklists for beleaguered used in operating rooms world- care, according to a 2006 study in hospital staffs. wide (“A Simple Checklist that Michigan on which Gawande had Saves Lives,” Harvard Public Health based part of his research. Review, Fall 2008), responded to a cell phone surveys WHO request for similar influenza Media avalanche Collaborating with a major cell H1N1 guidelines. Twelve hospitals Doctoral student Lajous also helped phone company in Mexico, Lajous around the world, including one in Assistant Dean for Communications helped draft a survey to pinpoint the Mexico, joined in reaching clinical Robin Herman in working with outbreak’s earliest cases. The company, consensus on the checklist and in Spanish-language media as an Telefonica, then sent to its customers quickly bringing the guidelines into avalanche of media requests from both the survey and a message from the operation. HSPH doctoral student around the world hit the HSPH Mexican minister of health. Lajous and Martin Lajous, a medical doctor from Office of Communications. Reporters colleagues are now analyzing the data, Mexico, acted as a go-between with were most eager for Dean Frenk’s which could offer insights into how cell Mexican hospitals. perspective on the epidemic as the phones might enhance public health By May 15—barely five weeks former Mexican health minister, and surveillance and response—not only for after Mexican authorities started the dean participated in dozens of pandemic flu, but for any fast-spreading investigating the first wave of cases interviews in the first few weeks after emerging disease. —the WHO published the checklist. the outbreak became known. Larry Hand is associate editor of the The two-page swine flu document Review.

Fall 2009 31 Students

Students target air pollution, from Boston to sub-Saharan Africa. clearing the air

A pair of HSPH doctoral students look at air pollution in new ways. For one, the goal is to describe unique air pollution challenges in the developing world. For the other, the aim is to measure more precisely the effects of air pollution on the heart, to understand how it causes damage.

Kathie Dionisio tery backup system to keeping the Kathie Dionisio has the mind of an equipment running on an unreliable engineer but a heart devoted to global power supply,” Dionisio says. Now a health. The graduate student’s tech- doctoral candidate in the departments nical know-how and problem-solving of Global Health and Population and drive came in handy when she arrived Environmental Health, she spent a year in Accra, Ghana, in 2006, charged with in Accra as a research assistant before Clouds, Getty Images; Students, Kent Dayton/HSPH Kent Students, Images; Getty Clouds, launching research with her HSPH beginning her studies at HSPH, and faculty adviser Majid Ezzati. The goal: returned periodically during the fol- to understand the detailed patterns lowing year to manage data collection. of air pollution throughout the city “I had to solve problems without the and its neighborhoods—one of the benefit of overnight delivery for the first such studies in urban areas of the parts I needed—just whatever I could developing world. get from the local market,” she says. “We had to do everything from Dionisio studied biomedical engi- making personal connections in the neering as an undergraduate at Colum- neighborhoods to building a bat- bia University, and earned a master’s degree in mechanical engineering Kathie Dionisio at the Massachusetts Institute of

32 Harvard Public Health Review Technology. Eager for an interna- The key may prove to be in the tional experience and curious about measurement of the heart’s electrical exploring research with a more direct cycle known as the QT interval, says application to health, Dionisio pur- environmental health doctoral student sued an MIT-funded service project Emmanuel Baja, who is advised by with a community-based health care Suh. Exposure to traffic pollution organization in Zambia following has been associated with longer QT graduation. The experience stoked intervals in the elderly. Abnormally her interest in public health, and the long or short QT intervals suggest a data-driven Accra project seemed like risk of developing abnormal electrical an ideal next step. activity (arrhythmias) in the heart. Baja Currently, Dionisio is analyz- hypothesizes that pollution may trigger ing reams of measurements from the arrhythmias, leading to heart attack or stationary and mobile monitors she even sudden death. and other student-researchers carried To explore this idea, he set up a around Accra. The devices captured study drawing on pollution data he airborne particulate matter, registering gathered from monitoring devices lo- differences between neighborhoods cated on the roof of Harvard Medical caused by traffic patterns, widespread School’s Countway Library, as well as burning of charcoal or wood for fuel, air quality data from Massachusetts’ and other factors. Department of Environmental “Kathie is tremendously moti- Protection and health data from a long- vated, with great scientific and per- running cohort of elderly veterans. His sonal judgment,” says Ezzati, associate study garnered top honors in HSPH’s professor of international health at student research poster competition in Emmanuel Baja HSPH. “We spoke regularly about April. The judges praised Baja’s “novel research and the project’s operation approach,” but he is reluctant to take sole during Kathie’s field research in Ac- credit. “Studies are always a collabora- cra. It was clear her decisions were the What is tion,” he says. right ones for both the scientific and particulate matter? When pressed, Baja will admit social aspects of our work.” he was determined to help develop a Dionisio and her colleagues Now recognized as a dangerous form computer program that more accurately aim to create a detailed profile of the of air pollution, particulate matter measures the QT interval than the con- unique air pollution challenges faced is the complex mixture of extremely ventional method—measuring by hand by cities in developing countries, laying small particles and liquid droplets the distance between blips on a paper the groundwork for future monitoring suspended in air. It includes dust and chart. Baja collaborated with colleagues efforts and interventions. pollen, as well as diesel soot and to supply the statistical model used to other potentially harmful substances analyze the study’s data. Dipping into emmanuel baja produced by fires and fossil fuel com- applied mathematics skills acquired ear- “It’s fairly well accepted that air pollu- bustion. Current air pollution stan- lier in his academic career, Baja realized tion is bad for your heart,” says Helen dards regulate particles as small as that a model from economics could be Suh, associate professor of environ- 2.5 microns in diameter—hundreds a good fit for measuring cumulative mental chemistry at HSPH. “But what of times smaller than the width of exposures over a period of time. is not as well understood is how it a human hair. These particles, called “It’s fascinating to me that certain causes damage.” PM2.5 for short, easily deposit deep theories cut across disciplines,” Baja in the lungs. says. “I can take models from economics continued on page 49

Fall 2009 33 Alumni 2009 Alumni Award Winners

Scientific Pioneers, Inspirational Teachers

Call them pioneers for delving into unexplored research areas. Call them conventional-wisdom busters for proving that common health risks can be limited or eliminated. Or call them mentors who challenge students and guide them to be the future leaders in public health. This year, call them winners of the Harvard School of Public Health Alumni Award of Merit, presented annually to alumni who make exceptional contributions to public health. Meet the four 2009 winners honored at a special dinner in June.

Graham Colditz o Graham Colditz, preventing most cancers is MPH ‘82, Dr.PH ‘86 Tsimple: quit smoking, eat a healthy diet, and lose Niess-Gain Professor of Surgery those extra pounds. The American population, however, Associate Director of Prevention finds it difficult to get beyond the relentless marketing and Control, Alvin J. Siteman by tobacco companies, sugary beverage makers, and Cancer Center manufacturers of processed food. “The consumer focus of Washington University our culture leads us down the path of unhealthy lifestyle in St. Louis without any countermanding force saying we need to be more physically active and eat healthier foods,” he says. Graham Colditz has focused his career on the relation- So he has developed tools that people can use to ship between lifestyle, obesity, and cancer. His research assess their risks for disease and set themselves on a on breast cancer made the epidemiology professor, a healthy path. While at HSPH, he and his colleagues principal investigator for HSPH’s Nurses’ Health Study, designed what became a website called “Your Disease and director of the former Harvard Center for Cancer Risk” (now at www.yourdiseaserisk.wustl.edu/). Prevention, a world authority on the risk factors of “The prevailing view was that nothing could be done exogenous hormones such as oral contraceptives and to avoid cancer,” he says, “yet scientific evidence by the estrogen. At HSPH and now at Washington University mid-1990s revealed that 50 percent of cancer could be in St. Louis, he has pursued a course of translating his avoided if we acted on what we knew. research into changes in society and individual behavior.

34 Harvard Public Health Review “We spent several years developing tools that might and broadened the range of diseases as a way to engage a be readily accessible to the general public. We launched broader sector of society.” the project with cancer in 2000 and suddenly realized that Colditz is now developing a shorter, second-genera- the prevention messages of not smoking, being physically tion website (“Your Health Snapshot”) that patients can active, eating a healthy diet, and avoiding weight gain were access in doctors’ waiting rooms—with the idea that, going to prevent diabetes, stroke, heart disease, and in during the appointment, physicians could immediately large part, osteoporosis,” he explains. “We went back and reinforce the online prevention messages. put together the materials supporting the other diseases

Dimitrios Trichopoulos, SM ‘68 Dimitrios Trichopoulos has continually staked out Vincent L. Gregory Professor scientific frontiers—from seminal research linking of Cancer Prevention and hepatitis B virus and tobacco smoking to liver cancer, Professor of Epidemiology to documenting that surgically induced and early Past Chair, Department of Epidemiology natural menopause reduce breast cancer risk, to writing one of the two original papers associating Harvard School of Public Health secondhand smoke from cigarettes with an increased risk of lung cancer. And he’s not finished. His current work points to intrauterine and perinatal factors that affect risk of breast cancer in adulthood.

ome significant “firsts” highlight the career of breast cancer, we have not been equally successful, and SDimitrios Trichopoulos. He was first, with a 1990 it is intriguing to keep working in areas where there has paper in The Lancet, to propose that in utero exposures not been much success and the potential to contribute is play a major role in breast cancer causation. He also was greater.” first in 1981, along with an independent paper published a Though he is proud to have published extensively in few days later, to report that secondhand smoke increases the scientific literature, he gets enormous satisfaction from the risk of lung cancer. In 1997, the editor of The Lancet mentoring younger colleagues to become leaders in public included a paper Trichopoulos and colleagues had written health. “The most gratifying feeling of all,” he says, “is in a list of 27 papers deserving to form a core canon of to see students you have mentored become major stars in medical literature that every health professional should their own right.” read. The paper linked psychological stress after a 1981 The Harvard Public Health Review published earthquake in Athens to risk of cardiac death. a profile of Trichopoulos in its Fall 2004 issue (see Chalk it up to a pioneering spirit, which has www.hsph.harvard.edu/review/review_fall_04/rvw_ prompted Trichopoulos to continually explore new trichopoulos.html). scientific questions. “When you are relatively successful in continued one area of research, you can move to a different area,” he explains. “For liver cancer, in theory, we have the resources to prevent two-thirds of it. For lung cancer, when you consider active and passive smoke, we have the resources and knowledge to prevent more than two-thirds of it. For

Fall 2009 35 Isabelle Valadian, MPH ‘53 Professor, Emerita, Maternal and Child Health Past Chair, Department of Maternal and Child Health Harvard School of Public Health

Isabelle Valadian always made hen Isabelle Valadian’s grade-school teacher asked her to write an herself available as a teacher and Wessay on what she wanted to do when she grew up, she described “a mentor to her students throughout fantastic trip around the world.” The teacher gave it a poor grade, asserting that her career at HSPH. As a result, it was “a dream, not a future.” During her 50-year association with HSPH, Valadian—who speaks six languages—mentored countless international her legacy is present throughout students, many of whom invited her to visit after graduation. Although she the world as international students hasn’t circled the globe in one fell swoop, she has crossed the Mediterranean Sea have returned home to become seven times, been to Taiwan three times, visited China and Greece twice, and public health leaders themselves. popped in on a number of other student stomping grounds. Her career-long research with After growing up and attending schools in Iran (then known as Persia), the Longitudinal Study of Child Lebanon, and France, Valadian was already a world citizen when she arrived Health and Development helped in Boston in 1949. “I believed from the very beginning that a school should to establish that obesity and put emphasis on teaching,” Valadian explains. “Research can support what blood-pressure patterns persist you are teaching, but students should come first.” from youth to adulthood and that She knew she would work in public health when she was in medical adolescents have “growth spurts” school at the French University in Beirut. “Every fall, there was an epidemic at various ages; the finding helped of typhoid fever. One year, some of the students and I went into the fields refine the idea of chronological age, when the vegetables were ripening. They took vegetables from the ground with the coining of the term “age and started eating them. I said, ‘You cannot do that. Don’t you know there’s of maturation.” an epidemic?’ They laughed at me, but two of them fell ill and one died. That was my first attempt at prevention. And so prevention became my goal from then on.” “Dr. Valadian helped to create the conditions for people like me to thrive at the Harvard School of Public Health,” says Magda Peck, MPH ’83, ScD ’86, professor of pediatrics and public health at the University of Nebraska Medi- cal Center and founding CEO of CityMatCH, a national organization of city and county maternal and child health leaders. “She promoted research but also understood that people in the field needed to know how to translate that research into action to get lasting results. She made it possible for us to do what we needed to do.”

36 Harvard Public Health Review John Peters has a habit of upending conventional wisdom. His doctoral thesis on college students who smoked pointed out subtle damage that showed up in just a few years rather than decades. His study of Boston fire- John Peters, MPH ‘64, SD ‘66 fighters, who did not wear face- Hastings Professor of Environmental Health masks at the time, provided the Director, Division of Environmental evidence behind development of Health in the Department of new safety equipment for Boston Preventive Medicine and elsewhere. His studies of the Keck School of Medicine Vermont granite industry proved University of Southern California that “allowable” exposure levels to respiratory silica still posed risks for chronic lung disease.

efore the Army drafted him, That approach exemplified his BJohn Peters had set out to be work at HSPH. “Team efforts have a surgeon. Sent to care for military gone into everything I’ve done,” he workers in the North and South poles says. “I don’t take credit for anything and other remote locales, he imme- other than trying to get smart people diately recognized that workplaces together to work on problems.” themselves could pose health risks, In 1991, he launched the and found himself delving into what Children’s Health Study, which would become occupational and envi- evaluates the chronic health effects ronmental health research. of air pollution on elementary school In studies documenting risks children in and around Los Angeles. to workers in the rubber industry, “It used to be that air pollution including the first epidemiological was thought to exacerbate but not evidence associating vinyl chloride cause asthma,” he says. “Our study exposure to a rare liver cancer, turned up some good evidence that it Peters is most proud of having causes it. That changed conventional helped develop at HSPH a new wisdom.” type of research collaboration. “The Larry Hand is associate editor opportunity to work in the first of the Review. agreement between a company, a union, and a university was unique and gratifying—a new and better way of doing things,” he says.

Fall 2009 37 In Memoriam d. mark hegsted

D. Mark Hegsted, who was instrumental in the development of the federal “Dietary Guidelines for Americans,” died on June 16 at age 95. Hegsted was a founding member of the Department of Nutrition at the Harvard School of Public Health, among the first such departments in a medical or public health school in the world. His research demonstrated the effects of specific dietary fats and cholesterol on blood cholesterol levels. Many of his more than 400 papers also dealt with protein, responses to malnutrition, and the effects of calcium intake on osteoporosis. Hegsted joined HSPH in the newly established nutrition department in 1942. In 1978, he was named administrator of human nutrition in the U.S. Department of Agriculture. In this role, Hegsted helped map out seminal nutrition guidelines that included recommendations to reduce meat consumption and increase intake of fruits and vegetables. His work helped inform the current guidelines, which are Hegsted’s work helped map published by the U.S. departments of Health and Human Services and Agriculture out fundamental nutritional and serve as the foundation of federal food and nutrition education programs. guidelines to reduce Editor of Nutrition Reviews from 1968 to 1978, Hegsted remained actively meat consumption and engaged in nutrition research after his official retirement in 1980. He was president increase intake of fruits and of the American Institute of Nutrition and served on advisory committees for the vegetables. World Health Organization, Food and Agriculture Organization of the United Nations, National Institutes of Health, and the National Research Council. He was a member of the National Academy of Sciences and a fellow of the American Institute of Nutrition and of the American College of Nutrition. An annual lecture at the School—the Stare-Hegsted Lecture—is named after him and after Fredrick Stare, the founding chair of the HSPH Department of Nutrition. jeremiah “jere” mead

Dr. Jeremiah (Jere) Mead, professor emeritus in the Department of Environmental Health, died on July 4 at age 88. A beloved figure in the department, Mead had a 37-year career at HSPH, retiring in 1987. “He shaped the culture and science of lung biology in a way that endures,” says HSPH Dean Julio Frenk. “How we measure pulmonary function in humans is dominated by his ideas and technology.” Mead began his career at the School as an associate professor in physiology in 1950 and was appointed professor of physiology in 1965. He made major scientific contributions to the control, prevention, and treatment of lung diseases, and was instrumental in developing the present field of respiratory mechanics. Working with researcher Mary Ellen Avery, Mead showed that fatal respiratory distress syndrome in newborns was

38 Harvard Public Health Review How scientists measure caused by abnormal surface tension in the lungs. The discovery led to a treatment pulmonary function in that continues to save lives. humans is dominated Mead’s achievements in the study of respiratory biology led the School to appoint him as the first Cecil K. and Philip Drinker Professor of Environmental by Mead’s ideas and Physiology in 1975. In 1990, he received the Edward Livingston Trudeau Medal technology. from the American Lung Association, in recognition of his career accomplishments. In 1996, he received the HSPH Faculty Emeritus Award of Merit. His colleagues described Mead as a generous spirit who actively encouraged challenge and debate among junior investigators, for whom he was an influential mentor. His research was driven by curiosity and animated by strong collaboration with scientists in other disciplines. The Mead Fellowship was formed on the occasion of his retirement by his trainees, colleagues, and friends, and is awarded each year to an outstanding postdoctoral fellow training in respiratory biology. armen h. tashjian

Dr. Armen H. Tashjian, Jr., professor of toxicology emeritus and former chair of what was previously called the Department of Molecular and Cellular Toxicology at HSPH, died on July 3 at age 77. Tashjian was celebrated for his neuroendocrine research, which contributed to a life-saving test for a precancerous condition associated with inherited thyroid cancer and played a key role in the development of two osteoporosis drugs. He was also professor of biological chemistry and molecular pharmacology emeritus at Harvard Medical School (HMS). In June, Tashjian received the HSPH Faculty Emeritus Award of Merit for his contributions to the field of pharmacology. Tashjian led the School’s toxicology program for nearly three decades. As founding chair of the School’s Department of Molecular and Cellular Toxicology, he pioneered research into the molecular mechanisms behind the toxicity of environmental chemicals and therapeutic agents. He also made seminal contributions Tashjian’s research to the field of endocrinology. contributed to a Tashjian graduated from Yale University in 1953, and earned his MD from life-saving test for a Harvard Medical School in 1957. After working at the National Institutes of Health precancerous condition (NIH), he returned to HMS in 1961 and to the Harvard School of Dental Medicine, associated with thyroid where he became an expert in parathyroid hormone and calcium metabolism. In later years, he was involved in the creation of the drug raloxifene, which is used to cancer. help prevent and treat osteoporosis and, more recently, to prevent breast cancer. He further contributed to the development of a separate drug for severe osteoporosis. Tashjian was an officer in numerous scientific societies. He served on NIH study sections and government advisory panels, and on the editorial boards of numerous scientific publications, including the New England Journal of Medicine. Throughout his career, he was a devoted teacher, mentoring nearly 100 graduate students and postdoctoral fellows. Fall 2009 39 Alumni News

1955 Law, Bioethics, and Human Rights Dr. Joyce Wilson Hopp, MPH, in BU’s School of Public Health. The a distinguished emeritus profes- author or editor of 17 books, in- sor in the Department of Health cluding American Bioethics, Annas Promotion and Education, has is the cofounder of Global Lawyers been teaching at Loma Linda and Physicians, a transnational University School of Public Health nongovernmental organization in California since it began in 1967. dedicated to promoting health and She served as dean of the School human rights. of Allied Health Professions from 1986 to 2002. 1979 Lorna Scott McBarnette, Alumni Weekend 2009: faculty member Nancy Kane 1960 SM, died on March 17. She was takes questions from the audience. Judith S. Stern, SM, ScD ‘70, was 69. McBarnette had a long and who was born in Grenada, advised at Jefferson Medical College in elected a Fellow of the American distinguished career in govern- Caribbean government leaders on Philadelphia, where she continues Association for the Advancement ment, health, and education. Most public health policy. to see patients. Widely respected of Science in February. Stern is recently, she was vice president for in the field of medical journalism, a distinguished professor in the institutional development and vice Laine has authored articles on departments of Nutrition and provost for health professions at 1985 many subjects, including patient- Internal Medicine at the University American International University Dr. Sylvie Stachenko, SM, be- centered communication, preven- of California, Davis. of Antigua School of Nursing. came dean of the School of Public Previously, she was deputy com- Health at the University of Alberta, tive care, women in medicine, and HIV/AIDS care. 1972 missioner of health of New York in Canada, in January. Most re- state. She also served as professor cently, Stachenko served as Deputy George Annas, MPH, was ap- and dean of the School of Health, Chief Public Health Officer at the 1993 pointed the first William Fairfield Technology and Management at Public Health Agency of Canada. Dr. Bhaswati Bhattacharya, Warren Distinguished Professor at the State University of New York at From 2002 to 2004, she was the MPH, is now a holistic and pre- Boston University in May. Annas is Stony Brook. Among her many oth- director general in the Centre for ventive medical doctor in New the Edward R. Utley Professor and er accomplishments, McBarnette, Chronic Disease Prevention and York City. For the past two years, Chair of the Department of Health Control at the Public Health Agency Bhattacharya has been working of Canada. From 1997 to 2002, with the Dinacharya Institute, Stachenko worked with the World which hosts classes in holistic Health Organization Regional medicine and ayurveda for health Office for Europe as the director of professionals, and convenes health policy and services. groups of scientists, ayurvedic doctors, and mainstream physicians 1992 to develop dialogue for collabora- Dr. Christine Laine, MPH, was tion in education and research. named editor of the journal Annals Bhattacharya also earned the 2008 of Internal Medicine in April. She is international award for outstand- Dayton/HSPH Kent ing service to Global Ayurveda by Alumni Weekend 2009: Alumni Award of Merit winner the youngest editor in the journal’s Dimitrios Trichopoulos (center) with colleagues and 82-year history. Laine is a clinical the Arogyadham Centre in India. former students. associate professor of medicine in the Division of Internal Medicine

40 Harvard Public Health Review 1994 2006 Osei B. Acheampong, SM, is describes the role technological Audrey Perlow, MS, graduated doctoral research in Harvard School the director of research and de- advances in instant messaging from the Northeastern University of Public Health’s Department velopment at the National Health and surveillance software are School of Law in May. She joined of Nutrition, as well as his more Insurance Authority in Ghana. He playing in helping public health Health Law Advocates as a Parmet than 12 years of experience help- is responsible for developing and officials share new information Fellow in September, and will be ing people lose weight. Halton monitoring systems for implement- critical for safeguarding the public’s assisting low- and middle-income has published in leading journals, ing the country’s national health health. Read the piece at: Massachusetts residents in obtain- including the New England Journal insurance scheme, in addition to www.newsday.com/news/ ing health care coverage and ac- of Medicine and The American initiating policies to improve access opinion/ny-opcha2112788251 cess to benefits. Journal of Clinical Nutrition. His and quality of care. may20,0,118342.story. research has also been featured in Dr. Thomas Halton, SD, dozens of media outlets, including published The Weight Loss Triad CNN, The Wall Street Journal, and 1997 2003 in February. The book presents Newsweek. Dr. Yvette Roubideaux, MPH, Dr. John D. Bullock, MPH, pre- a comprehensive weight-loss was unanimously confirmed by sented a paper to the American strategy, broken down into three the United States Senate as Indian Ophthalmological Society in May areas: diet, cardiovascular exer- Health Service Director on May 6. titled “Root Cause Analysis of cise, and resistance training. The She served most recently as an as- the Fusarium Keratitis Epidemic program is based on Halton’s sistant professor in the Department of 2004-2006 and Prescriptions of Family and Community Medicine for Preventing Future Epidemics.” at the University of Arizona College Bullock was the second person to of Medicine. She has conducted report U.S. cases to the Food and extensive research on American Drug Administration (FDA) and Alumni Affairs Goes Green Indian health issues, with a focus the Centers for Disease Control on diabetes. Roubideaux previously and Prevention. The paper, his Update your e-mail address worked in the Indian Health Service fourth on the outbreak, traces the To reduce costs and help safeguard the environment, as a medical officer and clinical epidemic to temperature instability HSPH’s Office forA lumni Affairs is moving from paper mailings to director on the San Carlos Indian of the antimicrobial agent in the electronic invitations and other information whenever possible. Be Reservation and in the Gila River commercial contact lens solu- sure to stay abreast of upcoming events, timely news, and alumni Indian Community. Roubideaux is a tion cited by the FDA, which had council elections by updating your e-mail address at www.post. member of the Rosebud Sioux tribe. noted the failure of the company harvard.edu or contact Daphne Mazuz in the Office forA lumni Affairs to regulate storage and transport at [email protected] or 617-998-8814. 1998 temperatures of their product.

Kathleen O’Loughlin, MPH, Bullock teaches infectious disease epidemiology and is a clinical became the American Dental The Harvard Public Health Review is interested in professor of community health Association’s first female executive hearing from you. director in May. Previously, she and professor of mathematics and was chief dental officer at United statistics at Wright State University Please send comments or class notes to: in Dayton, Ohio. Healthcare and a consultant to Amy Roeder, Development Communications Tufts University School of Dental Jennifer Weuve, SD, became as- Coordinator Medicine and the Forsyth School of sistant professor of medicine at the Harvard Public Health Review Dental Hygiene. Rush Institute for Healthy Aging at East Atrium, Third Floor Rush University in Chicago in July 401 Park Drive 2001 2008. At Rush, Weuve is continu- Boston, MA 02215 Humayun J. Chaudhry, SM, ing to pursue research in environ- Phone: (617) 384-8991 Fax: (617) 384-8990 health commissioner of Suffolk mental health and cognitive aging. Email: [email protected] County, New York, had an op-ed published in Newsday on May 21. Titled “Flu tracking meets the ‘tweet,’” Chaudhry’s piece

Fall 2009 41 HSPH In Brief For more information about these topics and other breaking news, visit the HSPH website at http://www.hsph.harvard.edu/news. Use the search function to locate detailed press releases and articles. [Research]

BPA QUICKLY LEACHES FROM BOTTLES TO HUMANS Drinking cold liquids from polycarbonate, hard-plastic bottles for just one week can elevate the level of bisphenol A (BPA) in human urine substantially, according to a study by Harvard School of Public Health researchers published May 12 in Environmental Health Perspectives. “If you heat those bottles, as is the case with baby bottles, we would expect the levels to be considerably higher,” says senior author Karin Michels, associate professor of epidemiology. Monitoring 77 Harvard College students, the researchers compared urine samples taken after a one-week “washout” period, during which the students drank cold beverages from stainless steel bottles, with samples taken after a week during which the students drank cold beverages from polycarbonate drinking bottles—the popular, hard-plastic bottles identified by the recycling code 7, sometimes with the letters PC, although 7 is also used for other types of plastics. Previous research has linked exposure to BPA to problems in reproductive development in animals and to heart disease and diabetes in humans. This is the first study to connect the plastic bottles to BPA levels in human urine. For more information, see www.hsph.harvard.edu/news/press-releases/2009-releases/ bpa-chemical-plastics-leach-polycarbonate-drinking-bottles-humans.html.

DIABETES STRIKES YOUNGER, THINNER ASIANS Type 2 diabetes strikes at a younger age and lower body weight in Asian populations than in Westerners, according to a review of more than 200 studies of the disease in Asia between January 1980 and March 2009. In the United States, diabetes onset often occurs at ages 60 and over in people who are overweight or obese. In Asia, by contrast, the rate is increasing in young and middle-aged DIABETES HIGHLY PREVENTABLE FOR OLDER AMERICANS people who carry excess abdominal fat. The review’s authors, led Most new cases of diabetes in older Americans could be prevented, by HSPH Professor of Nutrition and Epidemiology Frank Hu, link according to a study published in the April 27 issue of Archives of rapid economic development, eating more Western-style foods, and Internal Medicine. All it takes is healthy lifestyle choices, including increasingly sedentary lifestyles to an escalating diabetes epidemic physical activity, a nutritious diet, no tobacco use, and maintaining in Asia. The review, published May 27 in the Journal of the American a lower weight, researchers report. Led by HSPH Assistant Professor Medical Association, concludes that earlier diabetes onset and of Epidemiology Dariush Mozaffarian, the scientists tracked almost longer disease duration places Asians at high risk of developing

4,900 men and women over age 65 over a 10-year period. They found heart and kidney disease and cancer. Diabetes prevention and © M that lifestyle factors contributed to 90 percent of new cases of type control, they write, should be a top public health priority. For more M arcy information, see: “Obesity in China Portends Diabetes Disaster,”

2 diabetes. Learn more at www.hsph.harvard.edu/news/press- olloy/ releases/2009-releases/majority-of-new-cases-of-diabetes- Harvard Public Health Review, Spring 2009, www.hsph.harvard. G in-older-us-adults-could-be-prevented-by-following-modest- edu/news/hphr/chronic-disease-prevention/spr09brown- I etty ly-healthier-lifestyles.html. rice/. mages

42 Harvard Public Health Review [Research]

A CALL FOR FULL AGE OF MENSTRUATION, MENOPAUSE DISCLOSURE linked to GENE VARIANTS ON CIGARETTE HSPH researchers and colleagues have identified INGREDIENTS gene variants associated with the age at which Tobacco companies have con- females first menstruate and with the onset of tinually changed the design of menopause. Because early menstruation and later cigarettes over time—sometimes menopause are associated with breast and endo- departing from even the indus- metrial cancer, and early menopause increases risk try’s own guidelines—without of osteoporosis and heart disease, studying these advising consumers of the chang- genetic variants could help identify ways to prevent es, new research at HSPH has shown. Now that President Barack Obama has signed into these diseases, the authors write. The researchers law legislation authorizing the U.S. Food and Drug Administration (FDA) to oversee tobacco were led by Chunyan He, now an assistant profes- products, the researchers are calling on the FDA to require full disclosure on all product sor at Indiana University School of Medicine and a changes and to disallow changes that would make products even more harmful. doctoral student at HSPH while the research was For a study published online June 19 in Tobacco Control, Greg Connolly, director conducted. They identified 10 genetic variants as- of the HSPH Tobacco Control Research Program, and HSPH researcher Geoffrey Ferris sociated with age of menstruation and 13 genetic Wayne analyzed tobacco companies’ internal documents released after the 1998 Master variants associated with age of menopause. The Settlement Agreement. The documents described such changes as altering the smoke study appeared on May 17 in Nature Genetics. chemistry to enhance nicotine delivery, and modifying the levels of processed tobacco in Learn more at www.hsph.harvard.edu/news/ products, which increases the delivery of harmful chemicals. Learn more at www.hsph. press-releases/2009-releases/genetic-links- harvard.edu/news/press-releases/2009-releases/tobacco-control-fda- to-age-of-first-menstrual-period-and- complete-disclosure-tobacco-companies-changes-cigarettes.html. menopause.html.

STUDY LINKS MOTHER’S SMOKING, HIGH BLOOD PRESSURE CAUSE HEIGHT TO CHILD’S MOST EARLY DEATHS HEALTH IN INDIA Smoking causes about one in five premature or preventable deaths The state of a mother’s own in American adults. High blood pressure leads to about one in six childhood health could have deaths. Other diet or lifestyle factors result in a smaller—but none- an impact on children she may theless significant—proportion of deaths. The data come from an C igarettes, © igarettes, bear years later, according HSPH study published April 28 in PLoS Medicine. Doctoral student to a study by HSPH research- Goodarz Danaei, senior author Majid Ezzati, HSPH associate profes- ers published April 22 in sor of international health, and colleagues analyzed risk factors REU the Journal of the American involved in about 2.5 million U.S. deaths in 2005. Other top causes of T ER

S; mother and child, © R child, and mother S; Medical Association. Led by early death included over- Associate Professor of Society, Human Development and Health S.V. weight/obesity, inadequate Subramanian, researchers studied data on more than 50,000 children physical activity, high blood under age 5 included in India’s 2005–06 National Family Health sugar and cholesterol, and Survey. They concluded that children whose mothers were shorter than high dietary salt. Learn 4 feet 9 inches were more likely to die than children whose mothers more at www.hsph.har- upak De C De upak were at least 5 feet 3 inches tall. The study viewed maternal height as vard.edu/news/press- an indicator of the mother’s childhood health environment and sug- releases/2009-releases/ howdhuri/ gested that shorter mothers were effectively passing their own poor smoking-high-blood- childhood health on to their children. Learn more at www.hsph. pressure-overweight- R eu t er harvard.edu/news/press-releases/2009-releases/transfer- preventable-causes-

s poor-health-mortality-mother-child-india-height.html. death-us.html.

Fall 2009 43 [Philanthropic Impact]

Taplin Gift Expands Fellowship Fund

Mrs. Virginia Taplin—who together with her late husband, John, has her lifetime. At the been a longtime Harvard School of Public Health benefactor—has beneficiary’s death, made a significant new gift to the Taplin Family Fellowship Fund at the funds contributed the School. are either spent down Established in 1995, the fellowship fund has supported nearly 40 for the originally in- doctoral students at HSPH. Students helped through the fund have tended purpose—in gone on to major achievements, including becoming a world-famous this case, fellowship virologist and a senior health economist at the World Bank. Several funding—or are used now serve as faculty members at HSPH. Each year, members of the to create a permanent Taplin family gather to meet the students being currently supported, endowment that gen- an exchange deeply enjoyed by both students and the Taplins. John erates income for the Taplin, an accomplished inventor and entrepreneur, died in 2008 at intended purpose in John and Virginia Taplin the age of 94. perpetuity. In addition to the fellowship fund, the Taplins over the years have “John and I have had a long and enjoyable relationship with funded equipment purchases that have moved the School’s research HSPH. John was always fascinated and encouraged by the School’s agenda to a new level and have also established gift annuities dedi- focus on preventative actions,” says Mrs. Taplin. “It has been a cated to benefiting the HSPH Department of Biostatistics. tremendous joy to see the impact of the Taplin Family Fellowships The new fellowship funding is also in the form of a charitable and to meet the fellows each year. After John’s death, it was an easy gift annuity—a simple arrangement under which a donor makes a decision to increase our commitment to the Taplin Fellowship Fund gift to Harvard and Harvard guarantees that income generated by through another charitable gift annuity.” the gift will be given to the donor or other beneficiary during his or

Rose Gift Supports Traveling Fellowships

The Rose Traveling Fellowship health have been strongest in Students in turn will share their Program in Chronic Disease the areas of family planning and experiences with the larger Epidemiology and Biostatistics infectious disease, mainly in School community upon their has been established with a developing countries. Yet chronic return. $250,000 gift by HSPH alumna non-communicable diseases “The goal of this initiative Deborah Rose, SM ‘75. Each year, such as heart disease, obesity, is to broaden the range of inter- the program will give up to seven and diabetes now account for ests, programs, and countries R Deborah of courtesy Bottom, Dayton/HSPH; Top, Kent students or postdoctoral fellows more than 60 percent of deaths that students in these two dean opportunity to travel to a coun- worldwide, four-fifths of those partments can be exposed to,” try outside the United States for fatalities being citizens of low- says Rose. “I hope it will also academic projects. and middle-income countries. serve to expand the opportuni- Deborah Rose, SM ’75 Public health exists in a mul- Thanks to the new fel- ties for enrichment that inter- tinational, multicultural world, lowship program, students in national travel and professional and with the speed of travel and biostatistics and epidemiology involvement afford, at any stage information networks, opportuni- will have funds to pursue intern- of one’s career.” ties for cross-cultural exchange ships, research work, or other are widespread. Traditionally, academic endeavors related to opportunities in international chronic diseases, in either a de- ose veloping or developed country.

44 Harvard Public Health Review [Philanthropic Impact]

Donatelli Gift to Finance Scholarships While HSPH strives to enroll the best, most motivated students regard- and those from families hurt by the current economic downturn. less of their financial circumstances, currently the School simply does Donatelli says that he is making the gift to HSPH because he wants not have as much financial-aid money as students need. Thanks to a to help relieve students of the pressure to pay back student loans, and gift of $500,000 from Harvard College and Harvard Law School alum enable them to pursue the types of jobs that will benefit the public’s Mike M. Donatelli, AB ‘79, JD ‘81, to establish the Mike M. and Evelyn health most—but that may not be as remunerative as other jobs an B. Donatelli Fellowship Fund at HSPH, the School will have new re- HSPH grad would be qualified to take. sources for students pursuing masters or doctoral-level degrees. “It’s our hope that by helping more students graduate debt-free Roughly half of HSPH’s 400-plus graduates each year leave the or with only a small amount of debt,” he says, “these students will feel School with significant student-loan debt. The average debt for a free to pursue jobs such as directing a rural health clinic or researching master’s student, for example, is $44,000. And the demand for more the causes of childhood asthma in the inner city.” scholarship aid is growing, particularly among international students

LOWN SCHOLARS PROGRAM TO TRAIN MID-CAREER PROFESSIONALS Anonymous Donor makes $500,000 unrestricted A scholarship program to honor HSPH Professor Pledge Emeritus Bernard Lown has been established An anonymous donor has made a to train mid-career clinicians, scientists, nurses, $500,000 unrestricted pledge to the and other health professionals in strategies to School to ensure that HSPH faculty and prevent heart disease in developing countries. new Dean Julio Frenk have additional The Bernard Lown Cardiovascular Scholars resources to pursue whatever areas they Program will select individuals from candidates believe are most important in public meeting criteria for admission to HSPH, with health in the next few years. the goal of creating an international community Unrestricted gifts—contributions of Lown Scholars who will continue to interact made without limitation on their use— throughout their careers. help support the School’s most pressing Bernard Lown is acclaimed for his ground- needs in critical areas such as faculty breaking work on the causes and treatment of research, student financial aid, post- heart disease and cardiac arrhythmias, and for de- Bernard Lown doctoral fellowships, and technology veloping the direct current defibrillator. He is also investment. They also provide the Dean renowned for his efforts to prevent nuclear war. Jacobson Professor of Public Health. “This is an with latitude to take advantage of un- He and a Russian colleague accepted the Nobel excellent way to honor the highly distinguished anticipated opportunities and to address Peace Prize in 1985 on behalf of the organization career and extraordinary contributions of Bernard unforeseen challenges. that they co-founded, the International Physicians Lown to global health and security.” “Unrestricted gifts are particularly for the Prevention of Nuclear War. As part of the program, Lown Scholars may appreciated in challenging financial Heart disease is reaching epidemic propor- periodically return to Harvard for stays of one L

ane Turner/ ane times like these,” says HSPH Dean Julio tions in middle-income and poorer nations due to week to several months, strengthening their Frenk. “It gives me the opportunity to diet changes, high smoking rates, psychosocial collaborations. support a student who may not have the

G stress, and sedentary lifestyles. “The Lown lobe N lobe The Bernard Lown Fund in Cardiovascular money he or she needs to come here, Scholars Program will help to train a new genera- Health, which underwrites the scholars program, or to fund a faculty member’s new or ewspaper C ewspaper tion of public health leaders focused not just in will also support a professorship at HSPH focused groundbreaking idea for which govern- treating heart disease but also in preventing the on teaching and research about heart disease ment funding may not be available. I am coming epidemic of cardiovascular disease,” says ompany prevention in the developing world. very grateful to this donor for his gener- Barry R. Bloom, Harvard University Distinguished osity and foresight in making this gift.” Service Professor and the Joan L. and Julius H.

Fall 2009 45 [Philanthropic Impact] continued Starr To Head Fundraising Effort

Ellie Starr joined HSPH in late planned and major gifts. June as the School’s new Vice HSPH’s fundraising and alumni relations efforts will report to Starr. Dean for External Relations. “The School’s mission to translate knowledge into programs and policies Starr comes from the Perkins that improve the health of millions of people is extremely compelling. That School for the Blind, where she mission and the multidisciplinary way the School approaches its work are served as executive director of what draw me here,” says Starr, “I am honored to have the opportunity to the Perkins Trust. lead a team of fundraising professionals and work with Dean Frenk and all During her tenure at the talented HSPH faculty, alumni, students, and donors to promote that Perkins, Starr restructured mission.” Perkins’ development office, built and led a team of development profes- “Ellie joins HSPH with a wealth of fundraising experience, a lifelong sionals to increase fundraising by 40 percent, and launched the largest passion for issues of public health, and solid experience in building and fundraising campaign in Perkins’ 180-year history. growing successful development teams,” says HSPH Dean Julio Frenk. A 17-year veteran of the development field, Starr spent eight years at “I see her work, and the efforts of those working with her, as the es- Dana-Farber Cancer Institute (DFCI) prior to her time at Perkins. At DFCI, sential bridge between our academic community and the business and Starr built the highly successful principal and major gifts efforts and devel- philanthropic communities.” To reflect that dual function, Dean Frenk has oped fundraising strategies and plans for the $1 billion Mission Possible chosen to rename the Office for Resource Development the Office for Campaign, the largest in DFCI history. She led teams that raised hundreds External Relations. of millions of dollars. “I know our donors and friends will enjoy working with her and the Starr began her development career at Brandeis University, where entire external relations team as we endeavor to attract funds to support she planned and implemented strategy to develop and cultivate our vital mission,” says Dean Frenk.

[New Initiatives]

BANGALORE BOSTON NUTRITION HHI ESTABLISHES TRAINING COLLABORATIVE TO FOCUS ON TRAINING PROGRAM IN INDIA To address the emerging burden of preventable chronic The Harvard Humanitarian Initiative (HHI) and the disease in India, HSPH teamed up with Tufts University Public Health Foundation of India (PHFI) launched a and the St. John’s Research Institute in Bangalore, India, five-year program in April 2009 to train public health to establish the Bangalore Boston Nutrition Collaborative. professionals to respond to monsoons, potential ter- Headed by Program Manager Christopher Duggan, MPH rorist attacks, or other man-made or natural disasters. ‘94, HSPH associate professor of nutrition, the collab- Headed by HHI Co-Director Jennifer Leaning, the orative will develop and deliver Web-based courses in collaboration will develop a state-of-the-art, globally Wafaie Fawzi, HSPH professor epidemiology, biostatistics, nutritional epidemiology, and influenced curriculum designed to build India’s capac- of nutrition and nutritional biochemistry for students at St. John’s. In ad- ity to respond to public health emergencies. epidemiology dition, promising students will come to Boston for further Among the collaborative’s objectives: to create graduate training. HSPH, Tufts, and St. John’s faculty members will lead seminars and a new cadre of public health professionals skilled in

mentor students in Bangalore. managing emergencies, and to build a research base Dayton/HSPH Kent Funding from a private foundation will sustain the collaborative for two years, on disasters and humanitarian crises in India that will during which time collaborative members will evaluate its performance and apply for shape the teaching curriculum and inform policy rec- additional funding. Wafaie Fawzi, HSPH professor of nutrition and epidemiology, will ommendations. Collaboration funding will come from serve as co-investigator with the collaborative. Anura Kurpad, dean of St. John’s and joint fundraising efforts and existing resources. head of its nutrition department, will direct the project in Bangalore.

46 Harvard Public Health Review [Faculty News] New Academic Deans Named

Longtime HSPH faculty For the past three years, Grusby has served as the director of the member David Hunter PhD in Biological Sciences in Public Health Program within the Division became dean for academic of Biological Sciences at HSPH. His research focuses on the role of a affairs on August 1. He class of transcription factors called signal transducer and activator of is the Vincent L. Gregory transcription (STATs), which Professor of Cancer operate in the differentia- Prevention, and profes- tion and function of T help- sor of epidemiology and er cell subsets. Studies from nutrition. In recent years, his lab have shown how Hunter has led teams that manipulating STAT activity co-discovered the most can alter the function of T common genetic variants helper cells and therefore David Hunter associated with breast and change the outcome of Dean for Academic Affairs prostate cancer risk. diseases such as asthma “It is with great enthu- and diabetes. siasm that I welcome Professor Hunter to lead the expanded academic In her new role, executive team at the School,” Dean Julio Frenk says. “I look forward Michael Grusby Emmons works with Hunter to working with him to maintain and strengthen the School’s excel- Senior Associate Dean for and the School’s financial lence and leadership position among schools of public health.” Academic Affairs and research administra- Hunter’s principal research focuses on the origins of cancer, tion, while continuing to do particularly breast and prostate cancer. He has analyzed inherited research half-time. In addition to being a professor at HSPH, Emmons susceptibility to cancer and other chronic diseases and established has been based at the Dana-Farber Cancer Institute, where since the Dana-Farber/Harvard Cancer Center Core Laboratory for High- 1999 she has served as deputy director of the Center for Community- Throughput Genotyping at the School. He is co-chair of the National Based Research. She has held leadership roles within the Dana-Farber/ Cancer Institute’s (NCI) Breast and Prostate Cancer Cohort Consortium, Harvard Cancer Center,

Top left and right,Kent Dayton/HSPH; bottom right, courtesy of Karen E Karen of courtesy right, bottom Dayton/HSPH; right,Kent and Top left and a co-director of the NCI Cancer Genetic Markers of Susceptibility including director of the Initiative. Earlier in his career, Hunter helped develop HSPH’s collabo- Health Communications rations with colleagues in Tanzania studying interventions to reduce Core and associate di- HIV incidence and disease progression. He has taught a variety of rector for the Initiative courses ranging from HIV Epidemiology and Field Methods to Genetic to Eliminate Health Epidemiology. Disparities. Emmons’ research focuses on New positions created to strengthen behavior change and academic administration policy interventions for Dean Frenk also created two new positions within the School’s academic behavioral risk factors in administration. Michael Grusby, professor of molecular immunology, cancer, particularly for became senior associate dean for academic affairs. Karen Emmons, low-income communi- professor of society, human development, and health, became associ- ties. She also specializes Karen Emmons Associate Dean for Research ate dean for research, on July 1. These positions, says Frenk, will allow in cancer disparities re- Hunter to focus on strategy around academic planning and improve search, and in efforts to increase the dissemination and translation of mmons service to the HSPH community on issues related to research and edu- health research in low-resource settings. cation, students, and faculty.

Fall 2009 47 [Faculty News] continued

Other Faculty News

studies to identify the best means disorders of iron metabolism Biotechnology Study Center at an of providing such therapy. He also at the molecular level and their awards ceremony in April. He was has served on National Institutes implications in complex disease. cited for the discovery and clon- of Health (NIH) study sections, Her laboratory was the first to ing of the first cytokine—a small Food and Drug Administration define transferrin receptor-2 protein molecule involved in the advisory panels, and on Institute as the critical “iron sensor” of immune response—and for his of Medicine committees. circulating serum iron levels. work applying modern immunology More recently, her work has to the study of global disease. focused on the influence of iron Victor De Gruttola, professor deficiency and overload in the of biostatistics, was named chair absorption of inhaled metals. of the Department of Biostatistics Wessling-Resnick will become in June. He had served as acting chair of the National Institutes of chair since January. De Gruttola Health Integrative Nutrition and has spent most of the past 23 years Metabolic Processes Scientific teaching and conducting research Review Committee next fall. in the department. He has helped Marianne Wessling-Resnick, develop statistical methods re- professor of nutritional biochemis- Rima Rudd, a senior lecturer in quired for appropriate public health try in the Department of Genetics the Department of Society, Human response to the AIDS epidemic, and Complex Diseases, became Development, and Health, was both within the U.S. and interna- the director of the Biological honored by the Partnership for tionally. His focus has been on the Sciences in Public Health Program Clear Health Communication at the transmission and natural history of at HSPH on July 1. Wessling- National Patient Safety Foundation infection with the human immuno- Resnick has played an important with a prestigious Pfizer Health deficiency virus (HIV) as well as the role in the School’s educational Literacy in Advancing Patient development and consequences of programs for many years and is John David, Richard Pearson Safety Award. The Partnership F Jelena left, from Photos, HIV drug resistance. program director for three major Strong Professor of Tropical Public cited her work as a pioneer in De Gruttola served as the training grants that have contrib- Health Emeritus, HSPH, and chief, the field of health literacy, which director of the Statistics and Data uted to shaping interdisciplinary Division of Tropical Medicine, aims to help low-literacy popula- Analysis Center of the Adult Project interactions between various Department of Medicine, Harvard tions better navigate the health of the AIDS Clinical Trials Group departments at the School. Medical School, was recognized care system.

during the period in which highly C Suzanne Dayton/HSPH; Kent Dayton/HSPH; Kent ollweiler; As a researcher, Wessling- as an outstanding pioneer in the active antiretroviral treatments were Resnick focuses on genetic field of biotechnology by the New developed. He was also instru- York University School of Medicine mental in designing and analyzing bookshelf Public health has made our lives safer, but it often works behind the While We Were Sleeping: scenes, without our knowledge—that is, “while we were sleeping.” This Success Stories in Injury book powerfully illuminates how public health works, with more than 60 and Violence Prevention success stories drawn from the field of injury and violence prevention. It also profiles dozens of individuals who have made important contribu- David Hemenway University of California Press tions to safety and health. Highlighting examples from the United States 248 pages and other countries, While We Were Sleeping will inform a wide audience of readers about what public health actually does, and at the same time inspire a new generation to make the world a safer place. amarata

48 Harvard Public Health Review Clearing The Air continued from 33 Landmark HSPH study sets the standard in air pollution research and psychology and apply them to epidemiology to create Launched by faculty members in HSPH’s Department of Envi- something different.” ronmental Health 35 years ago, the Harvard Six Cities Study Baja’s passion for math has taken him down several evaluated the effects of air pollution on the respiratory different paths, including jobs in banking and consulting. But health of thousands of Americans and found a strong link while earning his master’s degree in applied mathematics from to premature death. Its findings, released in 1993, led to the the University of the Philippines, he worked on an analysis revision of air quality standards by the U.S. Environmental of the toxicity of pesticides and discovered that his skills Protection Agency (EPA). Data produced by the study and its could be put to use in making the world a healthier place. many spin-offs continue to strongly influence American air After he graduates, Baja hopes to continue working in quality policy, including further strengthening particulate air pollution research, perhaps for a nongovernmental orga- emissions standards by the EPA in 2006 and recognizing in- nization in Southeast Asia where he sees a strong need for door air pollution as a significant contributor to health prob- data collection. Or, he says, he may find another way to pull lems. Follow-up studies have shown that people are now together his wide-ranging background. “I’d love to create living longer in cities where fine airborne particulate matter public service campaigns for public health issues.” has been reduced. Read more about the original study in “A Tale of Six Amy Roeder is the development communications coordinator Cities” at in the Office for External Relations at HSPH. www.hsph.harvard.edu/review/a_tale.shtml.

Continuing Professional Education Programs, 2009–2010 Where theory informs practice and practice informs theory 2009 2010 April 20–23 For additional information or to Forces of Change: Executive September 21–24 January 10–22 register, contact: (617) 384-8692 Education Program Ergonomics and Human Factors: Program for Chiefs of Clinical [email protected] Strategic Solutions for Workplace Services April 26–29 www.hsph.harvard.edu/ccpe Safety and Health Occupational and Environmental January 25–29 Harvard School of Public Health Radiation Protection: Principles and October 13–16 Leadership Strategies for Center for Continuing Professional Practices of Radiation Safety Managing Ambulatory Information Technology in Health Education Health Care I: Care: A Certificate Program 677 Huntington Ave. Introductory Course for Physicians February 22–26 CCPE-Dept. A in Community Health Centers Safety in Design and Construction: Customized programs are also Boston, MA 02115 October 18–30 A Lifecycle Approach available. Leadership Development for March 1–4 Physicians in Academic Health All programs are held in Boston Managing Ambulatory Centers unless otherwise noted. Health Care II: November 1–6 Advanced Course for Physicians in Contact: Leadership Strategies for Evolving Community Health Centers Deputy Director Paul Tumolo Health Care Executives (617) 384-8675 March 15–17 [email protected] November 30–December 4 Basic Hands-On CAMEO Training or Lynn Fitzgerald Guidelines for Laboratory Design: March 16–19 Health and Safety Considerations (617) 384-8677 Analyzing Risk: Science, [email protected] Assessment, and Management March 29–31 Management Skills for Emerging Leaders in Environmental Health and Safety

Fall 2009 49 The Wrights’ Stuff continued from 27 in New York. “He’s at the forefront of looking at children’s Hospital, Boston Medical Center, and urban health health and at the toxicity of exposure to low levels of centers in Boston, in addition to women participating in metals which five years ago were thought to be safe.” federal Women, Infants, and Children programs in Boston Further research into the effects of lead, iron, manganese, and suburbs. and other metals, Landrigan added, could likewise usher Both Wrights are working on a Mexico City study of in changes in the way medicine is practiced. social stressors, iron deficiency anemia, and lead exposure as environmental risk factors for poor neurodevelopment Bridging society and environment in children. Robert was senior author on an April 2008 The Wrights are part of a new breed of so-called “transdis- Environmental Health Perspectives study showing that iron ciplinary” researchers at leading academic institutions such metabolism gene variants can modify lead metabolism as Harvard. Although it is common for researchers from and boost blood lead levels in young children in Mexico

Can the complications of lead poisoning in children be eased if life stressors are reduced? different fields to collaborate on studies in which each through gene-environment interactions. Their current person brings his or her own special expertise to the table, study will lay the groundwork for development of social the National Institutes of Health is increasingly funding interventions based on scientific evidence. studies in which a single researcher develops expertise Their work, says HSPH Department of across multiple disciplines. Environmental Health Chair Douglas Dockery, “is a Robert, first a pediatric toxicologist, expanded his microcosm of what we do here at the School. The Wrights expertise into genetics. Rosalind, first an adult pulmonary are bridging the physical environment and the social specialist, took on social and environmental determinants environment and the genetics, bringing together social of health. They work separately on individual efforts and sciences and biological sciences that were previously together as principal investigator and co-investigator in separated.” other studies. “What we’re trying to do is stop looking at silos Currently, Robert is leading an investigation, and of disease causation—how much is due to genetics, Rosalind is one of the co-investigators, of children’s chemicals, exposure to metals, or nutrition—and, instead, exposures to toxic metals at the Tar Creek Superfund look at them all at once, to see how they interact,” says site in Oklahoma. More than 40,000 people live in this Robert. “That’s what happens in real life.” 50-square-mile area where mining waste has left lead, Admittedly, their decades of collaborative work manganese, cadmium, and other potentially harmful on such a complex public health topic won’t lead to a metals in the ground and water. Theirs is the first large- profitable “magic bullet” for medicine. “What we’re scale study into how exposure to manganese and arsenic at studying probably won’t make a lot of money for a early ages may cause harm later in life. company. And I can’t imagine a firm selling social and Rosalind is also leading a major effort, and Robert is a behavioral interventions,” Robert says. “But when you co-investigator, for the Asthma Coalition on Community, invest in children, it is better for society—and not just Environment, and Social Stress, a study of how early life because they can contribute and pay taxes and bring in stressors, starting in pregnancy, affect the future risk of revenue. They also lead more meaningful lives.” asthma in urban children. Study subjects include mothers Larry Hand is associate editor of the Review and their children receiving care at Brigham and Women’s

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Hsph Faces of the Future

At its 2009 commencement, HSPH awarded degrees to 491 students in the School’s 86th graduating class:

278 master of public health degrees 128 master of science degrees 54 doctor of science degrees 16 PhDs 13 master of arts degrees 2 doctor of public health degrees

Graduates came from 60 countries,39 U.S. states and Puerto Rico.

More than half were women. Our commencement speaker was acclaimed author Atul Gawande, associate professor of health policy and management at HSPH and surgeon at Brigham and Women’s Hospital. Our student speaker was MPH Graduate Hope O’Brien. View photos and videos of the day’s ceremonies and celebrations at www.hsph.harvard.edu/news/ commencement-2009.