SPH Anniversary Book is Released

By Bunmi Fatoye-Matory

Special to the Gazette

In turn-of-the-century America, the life expectancy of a newborn baby girl was 44 years. Today, that baby is expected to live to 78, thanks in large part to the many and varied advances which have taken place in the relatively new field of public health.

In a richly documented book on the contributions of the School of Public Health, The People's Health: A Memoir of Public Health and Its Evolution at Harvard (Joseph Henry Press, 1997), Robin Marantz Henig traces the development of public health in America with its stunning successes and many challenges. The book concentrates specifically on Harvard's School of Public Health, which has been at the forefront of many of these developments since its inception 75 years ago.

Henig begins her story in the early part of the century, when the main focus of public health was sewerage development, sanitation, and purification of food. This emphasis shifted by the middle of the century to effective disease prevention techniques, pasteurization of milk, control of cholera, yellow fever, and vaccinations against diseases like tetanus, whooping cough, and smallpox.

From quiet detective work locating the hidden causes of ill health to dramatically successful efforts to prevent disease, from painstaking solitary research to collaboration with Hollywood to combat the epidemic of drunk driving, Henig brings to life 75 years of this dynamic and public-spirited field.

Mission

The School of Public Health became a free-standing faculty in the University (separate from the medical school) 50 years ago. From the beginning its goal has been as simple to formulate as it is difficult to achieve: to make possible the optimum state of health for the greatest number of people. Some of the more newsworthy achievements of the School documented in Henig's history include the development of an effective method to grow the polio virus in the laboratory, a pivotal advance in the ultimate production of a polio vaccine, and discovery of the relationship between many aspects of diet and chronic diseases. Today, the School conducts ongoing research on heart disease, breast cancer, and other illnesses using large-scale population-based studies. One example is the Harvard Nurses' Health Study.

As the School recognizes, public health faces some of its greatest challenges yet at the end of this century. Many of the most severe threats to our collective health now come from the choices that we all make. What we choose to eat, drink, and inhale can constitute far more serious hazards to our health than landfills, for example, or naturally occurring radon.

In a recent interview, Henig and the Dean of the School of Public Health, Harvey V. Fineberg, talked about some of the issues that face public health as we enter the 21st century.

Q: What is the relation between medicine and public health?

Fineberg: While medicine focuses on treatment of the individual, public health concentrates on the health of populations and emphasizes the prevention of disease. Beyond medical care, public health considers other powerful tools like behavior, environmental influences, social forces, and public policy. A large number of our students are physicians, engineers, lawyers, nurses, and managers who have all come together to solve health problems from the population point of view.

Q: What kind of physician chooses to go into public health?

Fineberg: Thinking physicians. All our students made deliberate choices that are not motivated by financial rewards. There is a standing joke that I'm the one dean in Harvard who lowers the lifetime earnings of his graduates. Our graduates are people committed to quality and equity in health, they are internationally minded, and they believe in our common humanity. The average age of our students is 31. So their motivation is borne out of experience which they bring to the field.

Henig: Some of them discovered that you can't solve the problem one patient at a time. They see the wisdom of prevention as social policy.

Q: One criticism of Western biomedicine is that it is ill-equipped to address many dimensions of illness. How does the SPH address cultural diversity in its mission?

Fineberg: Public health is concerned with cultural diversity, evaluating how culture influences or determines health. In the case of AIDS, for example, prevention strategies need to take into account the values of those who are at risk of this disease, their world views, behavior patterns, and cultural beliefs.

Henig: People learn unhealthy messages from the media, unfortunately. Take for example, the sitcoms. People are having sex with each other without ever acknowledging the risk. They don't talk about the real world. They don't use condoms. I'm struck by how irresponsible some of those scripts are.

Fineberg: As a society, we put a lot of resources into commercial advertising, but we are fiscally timid when it comes to investing in public health messages. I would like to see AIDS addressed like drunk driving. There ought to be peer education, young people as role models, not just talking heads on television giving advice.

Q: What is the relationship of SPH with the other bodies concerned with public health, e.g., the government and watchdog groups?

Fineberg: There are two sides to public health -- the research or learning side and the action side. The ultimate goal of research is to solve practical problems. Interactions with government and nongovernmental organizations provide public benefit and augment core academic programs. The practical side feeds back into research. Conferences, seminars, and public talks provide meeting places for different public health professionals. We like to think of the School as a kind of crossroads where people can meet and exchange ideas, using scholarship and action, to advance the public's health.

Q: Are there many women and minorities going into public health?

Fineberg: Actually we have more women than men in our student body. Approximately 20 percent of our U.S. citizens are members of minority groups. It is important to bring more minorities into public health because the minority population bears a disproportionate burden of illness in our society.

Q: In your book you mentioned a new science of quality measurement used by public health professionals as a way of evaluating how much a doctor should be paid. Could this really affect health care reform?

Henig: It will control one aspect, which is reimbursement. In theory, it will remove the incentive for doctors to do too much.

Q: The desire to find a cure for polio intensified after middle-class children became victims of the disease. Could health care reform in America eventually be made possible by a disaffected middle class?

Henig: Yes. Polio did not come to national attention until the children of middle-class families were getting sick. It may take the mobilization of a vocal middle class for any major health reform to be made. Right now, most middle-class people are content with their coverage.

Q: You address health and human rights in your book.

Henig: Yes. The Harvard School of Public Health is the only one I know with a program like this. It's not a connection that people easily make. As an example, the greatest determinant of progress in a society is the educational attainment of women. Significantly, when students graduate from the School of Public Health, they receive the United Nations Universal Declaration of Human Rights, a reinforcement of the importance of freedom and individual rights to health worldwide.

Q: How about violence?

Henig: Public health looked at the causes of premature death and found that one of the major causes is violence, so the public health professionals consider it their responsibility. Public health focuses on getting to adolescents before they are harmed by violence -- for example, curricula in the schools and the "Squash It!" campaign. Public health efforts aim to make confrontation unfashionable.

Gun control has been a major concern. I mentioned the cases in Vancouver in Canada and Seattle in the United States, two cities with similar statistics except that the murder rate in Seattle is much higher than Vancouver's because guns are allowed in the U.S. and they are restricted in Canada. I hope public health professionals will be able to muster a lot of data as they did with smoking.

Q: What is your vision of SPH for the next century?

Fineberg: The overarching goal of advancing health has been a constant in our field. What makes public health dynamic are demographic shifts, changes in the burdens of disease, technological and scientific advances, changing socioeconomic conditions, and rising public expectations. In the decades ahead, public health will advance at both micro- and macro-frontiers, gaining new insights from genetic epidemiology as well as new understanding of the social determinants of health. The twentieth century has witnessed unprecedented progress in longevity. Perhaps the next century can do as much for our quality of life.