Special Report

by Madeline Drexler, Editor, Harvard Public Health

There’s a gas station maybe a five-minute drive away from us, and the gas station sells guns. I didn’t realize places like that existed. Ryan just walked in and bought a handgun. We had gotten into an argument—which we hardly ever did—and he left. The next morning, the police knocked on my door. A construction crew had found him dead in his car at an abandoned railroad station.
— Emily Frazier, 27, widow of Ryan Frazier, who shot himself with a semiautomatic in 2008.

In the national debate over gun violence—a debate stoked by mass murders such as last December’s tragedy in a Newtown, Connecticut, elementary school—a glaring fact gets obscured: Far more people kill themselves with a firearm each year than are murdered with one. In 2010 in the U.S., 19,392 people committed suicide with guns, compared with 11,078 who were killed by others. According to Matthew Miller, associate director of the Harvard Injury Control Research Center (HICRC) at Harvard School of Public Health, “If every life is important, and if you’re trying to save people from dying by gunfire, then you can’t ignore nearly two-thirds of the people who are dying.”

Suicide is the 10th-leading cause of death in the U.S.; in 2010, 38,364 people killed themselves. In more than half of these cases, they used firearms. Indeed, more people in this country kill themselves with guns than with all other intentional means combined, including hanging, poisoning or overdose, jumping, or cutting.

Though guns are not the most common method by which people attempt suicide, they are the most lethal. About 85 percent of suicide attempts with a firearm end in death. (Drug overdose, the most widely used method in suicide attempts, is fatal in less than 3 percent of cases.) Moreover, guns are an irreversible solution to what is often a passing crisis. Suicidal individuals who take pills or inhale car exhaust or use razors have time to reconsider their actions or summon help. With a firearm, once the trigger is pulled, there’s no turning back.

Not “Why?” but “How?”
When we think of suicide, we usually think of a desperate act capping years of torment. According to the National Institute of Mental Health, complex and deep-rooted problems—such as depression and other mental disorders, drug and alcohol abuse, family violence, and a family history of suicide—often shadow victims. Suicide among males is four times higher than among females. In adults, separation or divorce raises the risk of suicide attempts. In young people, physical or sexual abuse and disruptive behavior increase vulnerability.

The harrowing fact of suicide demands a story: “Why?” But from a public health perspective, an equally illuminating question is “How?”

Intent matters, but so does method, because the method by which one attempts suicide has a great deal to do with whether one lives or dies. What makes guns the most common mode of suicide in this country? The answer: They are both lethal and accessible. About one in three American households contains a gun.

The price of this easy access is high. Gun owners and their families are much more likely to kill themselves than are non-gun-owners. A 2008 study by Miller and David Hemenway, HICRC director and author of the book Private Guns, Public Health, found that rates of firearm suicides in states with the highest rates of gun ownership are 3.7 times higher for men and 7.9 times higher for women, compared with states with the lowest gun ownership—though the rates of non-firearm suicides are about the same. A gun in the home raises the suicide risk for everyone: gun owner, spouse and children alike.

This stark connection holds true even when other factors are taken into account. “It was a reasonable hypothesis to think that the type of person who chooses to own a gun is different from the type of person who chooses not to. Maybe there’s a ‘go-it-alone’ attitude that leads to less help seeking. Or maybe gun owners are more likely to live in rural areas, and rural locales are associated with greater suicidality,” explains Catherine Barber, director of HICRC’s Means Matter campaign, a suicide prevention effort that focuses on the ways people attempt to take their own lives.

“But when we compared people in gun-owning households to people not in gun-owning households, there was no difference in terms of rates of mental illness or in terms of the proportion saying that they had seriously considered suicide,” Barber says. “Actually, among gun owners, a smaller proportion say that they had attempted suicide. So it’s not that gun owners are more suicidal. It’s that they’re more likely to die in the event that they become suicidal, because they are using a gun.”

While gun-suicide rates are higher in rural states, which have proportionally more gun owners, the gun-suicide link plays out in urban areas, too. “In the early 1990s, the dramatic rise in young black male suicides was in lock step with the homicide epidemic of those years,” says HSPH’s Deborah Azrael, associate director of the Harvard Youth Violence Prevention Center. “Young black male suicide rates approached those of young white males—though black suicide rates had always been much lower than white suicide rates. It was entirely attributable to an increase in suicide by firearms.”

Put simply, the fatal link applies across the board. “It’s true of men, it’s true of women, it’s true of kids. It’s true of blacks, it’s true of whites,” says Azrael. “Cut it however you want: In places where exposure to guns is higher, more people die of suicide.”

Impulsive acts
The scientific study of suicide has partly been an effort to erase myths. Perhaps the biggest fallacy is that suicides are typically long-planned deeds. While this can be true—people who attempt suicide often face a cascade of problems—empirical evidence suggests that they act in a moment of brief but heightened vulnerability.

“One of the things that got me interested in launching the Means Matter campaign was that I had been reading through thousands of thumbnail sketches of suicide deaths, to see if a reporting system we were testing was catching the feel for the case,” says Barber. “I started noticing that, jeez, this death happened the same day that the kid was arguing with his parents, or that the young man had just broken up with his girlfriend, or that the middle-aged guy had gotten word that the divorce papers had come through. That reactivity surprised me, because I’d always pictured suicide as being a painful, deliberative process, something that was getting worse and worse, escalating until finally you’ve got it all planned out and you do it. It hadn’t occurred to me that it could be a cop arguing with his wife, and in the midst of the argument, pulling out his gun and killing himself.”

This impulsivity was underscored in a 2001 study in Houston of people ages 13 to 34 who had survived a near-lethal suicide attempt. Asked how much time had passed between when they decided to take their lives and when they actually made the attempt, a startling 24 percent said less than 5 minutes; 48 percent said less than 20 minutes; 70 percent said less than one hour; and 86 percent said less than eight hours.

The episodic nature of suicidal feelings is also borne out in the aftermath: 9 out of 10 people who attempt suicide and survive do not go on to die by suicide later. As Miller puts it, “If you save a life in the short run, you likely save a life in the long run.”

Lethal environments
A central tenet of public health is that environment shapes individual behavior. In the realm of suicide, this truth has played out dramatically in recent history. When widely used lethal means are made less available or less deadly, suicide rates by that method decline, as do suicide rates overall. In Sri Lanka, for example, where pesticides are the leading suicide method, the suicide rate fell by half between 1995 and 2005, after the most highly human-toxic pesticides were restricted.

Similarly, in the United Kingdom before the 1950s, domestic gas derived from coal contained 10 to 20 percent carbon monoxide, and poisoning by gas inhalation was the leading means of suicide. A source of natural gas virtually free of carbon monoxide was introduced in 1958; over time, as carbon monoxide in gas decreased, so did the number of suicides overall—driven by a drop in carbon monoxide suicides, even as other methods increased somewhat.

Changing the means by which people try to kill themselves doesn’t necessarily ease the suicidal impulse or even the rate of attempts. But it does save lives by reducing the deadliness of those attempts.

Dearth of data

Though these basic facts are known, there is a striking dearth of research on guns and suicide. In the U.S., government officials don’t even have current data on where household gun ownership rates are higher or lower. The only survey large enough to produce state-level estimates of gun ownership was conducted by the federal Behavioral Risk Factor Surveillance System, the world’s largest ongoing telephone health survey. The survey asked questions about gun ownership in 2001, 2002 and, for the last time, in 2004. It was HICRC investigators who analyzed this state-level data to show that suicide rates run in tandem with gun ownership rates.

Today, the U.S. Centers for Disease Control and Prevention’s National Violent Death Reporting System, which collects data from police and coroners’ reports and death certificates on every suicide and homicide, covers only 18 states. Compare this with the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System, which amasses extensive details within 30 days of every fatal car crash on public roads, from the time and location of the accident to weather conditions to the role of alcohol and drugs. Partly as a result of this bureaucratic diligence, the fatality rate from car crashes has dropped by about a third over the last two decades. Could the same dedication bring down suicides?

Matthew Miller thinks it can. “Better data is a good place to start. That way, discussions are grounded in facts rather than distorted by ideology. It can only help foster social-norm-shifting conversations similar to those that took place around cigarette smoking, safety belt use and driving drunk,” he says. “I’d like physicians to feel it’s their responsibility to tell people about the risks. There’s no reason that you should have a conversation about a bike helmet or a seat belt, but not firearms.”

But change also takes time. “With public health, when you don’t have the one-size-fits-all solution, you chip away at the problem,” says Barber. Preventing suicides will likely require many approaches, from education and media campaigns to skilled treatment and community support. Ultimately, the goal is to transcend politics—which is why those who have lost loved ones to gun suicide should have the last word:
Ryan is my baby. I remember once telling him, “If anything happens to you, I would cease to exist.” And that’s what it feels like. It’s a pain like no other. I would encourage open conversation—actually talking about it. Preventing just one person from going through what I went through and will go through for the rest of my life—that would be enough for me.
— Wendy Tapp, mother of 19-year-old Ryan Tapp, who shot himself with a handgun in 2011

Part 2: Starting a Conversation

Part 3: The Gun Shop Project

Part 4: Politics & Beyond

Survivor Profiles

“He was struggling with nightmares.”

“I couldn’t tell people that my father had died of suicide.”

“A club I never wanted to join.”

Download a PDF of Guns & Suicide: The Hidden Toll here

Quick updates about the latest public health news from across the School and beyond.

HSPH cracks secrets of the malaria parasite
HSPH researchers, led by Manoj Duraisingh, HSPH associate professor of immunology and infectious diseases, have discovered the mechanism by which the malaria parasite, Plasmodium falciparum, evades detection by the human immune system.  The parasite changes a critical protein on its surface, which it uses as one of several molecular “keys” to enter a new red blood cell. With 1.2 million malaria deaths each year worldwide—mainly children in sub-Saharan Africa—these findings could help in developing drug therapies.

Workplace wellness: HSPH leads by example
The CEO Roundtable on Cancer recently accredited HSPH with the CEO Cancer Gold Standard™, recognizing the School’s efforts to reduce cancer risk for employees and family members by promoting healthy lifestyle choices, cancer screenings and access to quality treatment.

SNAP diets fall short on nutrition
The federal Supplemental Nutrition Assistance Program (SNAP) is “a vital program with the potential to influence the diets of millions of vulnerable Americans,” said Cindy Leung, SD ’12. But Leung and other School researchers have found that SNAP participants’ diets are actually worse than those of low-income adults not participating in the program, with significantly lower intakes of whole grains and higher intakes of fruit juice, white potatoes and red meat, and too many sugary beverages, particularly among women. Researchers speculate that SNAP beneficiaries may be spending their allotments on cheaper, nutrient-poor foods. Leung and her colleagues conclude that “further consideration needs to be given to creating incentives for SNAP participants to access healthier foods, and to limit the purchase of unhealthy food with SNAP benefits.”

Dean Frenk Strengthens Collaborations During China Trip
In a week long trip to China in January 2013, HSPH Dean Julio Frenk brought an important message about public health: It’s essential to continued human progress.

Frenk’s trip, which took him to Shanghai, Beijing and Hong Kong, was aimed at strengthening the School’s existing ties in China, connecting with health sector leaders and meeting with some 150 alumni and other supporters of the School.

At a speech to the Asia Society in Hong Kong, Frenk spoke of the “profoundly important connection” between public health and economic growth, and of ways that HSPH can work with the government, organizations, businesses, and individuals to help promote both health and prosperity in China.

Frenk also signed a renewed memorandum of understanding with the University of Hong Kong School of Public Health, which is led by HSPH alumnus Gabriel Leung, MPH ’99, PDS ’05. The two schools have collaborated since the 1990s on public health research relevant to China and the Asia-Pacific region.

Is it ADHD, or is he just young for his grade?
Being younger than one’s classmates may lower a child’s academic performance throughout childhood and increase the likelihood of being prescribed medication for attention-deficit/hyperactivity disorder (ADHD), according to a study from HSPH and the University of Iceland. Of nearly 12,000 Icelandic students ages 9 to 12, students in the youngest one-third of their class were 50 percent more likely than older peers to be prescribed ADHD medications. “Kids may just be acting their age if they’re nearly a year younger than some of their peers and are struggling a bit emotionally and academically,” said senior author Sonia Hernández-Díaz, HSPH associate professor of epidemiology.

Air pollution down, life expectancy up
A new HSPH study—the largest of its kind to date—has documented continued reductions in air pollution and improved life expectancy in 545 U.S. counties between 2000 and 2007. Air pollution has been declining steadily in the U.S. since 1980, but at a slower rate since 2000. HSPH researchers set out to ascertain whether even these relatively smaller decreases in particulate levels are still improving life expectancy. Lead study author Andrew Correia, HSPH PhD candidate in the Department of Biostatistics, concluded, “Despite the fact that the U.S. population is exposed to much lower levels of air pollution than 30 years ago, it appears that further reductions in air pollution levels would continue to benefit public health.”

Lowering women’s heart attack risk: Berry good news
Women who eat three or more half-cup servings of blueberries and strawberries each week may lower their risk of heart attack, the leading cause of death for women. A recent study led by researchers from HSPH and the University of East Anglia found that the dietary flavonoid anthocyanin in these berries may improve blood flow and counteract plaque buildup. “Blueberries and strawberries can easily be incorporated into what women eat,” said HSPH senior author Eric Rimm, associate professor of nutrition and epidemiology. “This simple dietary change could have a significant impact on prevention efforts.”

Documenting public health concerns at world’s largest gathering
Every 12 years, a massive temporary city is created in Allahabad, India, to accommodate the tens of millions of Hindu worshippers gathered to bathe in the sacred waters of the Ganga, Yamuna and Saraswati rivers during the Kumbh Mela festival. It is the largest human gathering on earth.

This year, a team of HSPH faculty members and students, coordinated and funded by the School’s FXB Center for Health and Human Rights, implemented a real-time disease surveillance system at the Mela— the first of its kind in a transient mass gathering. The project was part of a larger qualitative study that focused on health care delivery, water distribution, sanitation systems, and stampede mitigation strategies at this year’s festival, which was held from January 12 to March 10 and drew an estimated 80 million pilgrims.
The team’s innovative surveillance tool, the goal of which was to bolster understanding of public health concerns during mass gatherings and migrations, was noted in the February 8, 2013 New York Times.

Cigarette warnings: The power of pictures
New research from HSPH and Legacy®, a national public health foundation devoted to reducing tobacco use in the U.S., suggests that graphic cigarette warning labels may help smokers quit—including those who are poor and belong to racial/ethnic minorities, who often struggle harder to quit than others. The new study—among the first to compare pictorial labels with text-only labels across diverse racial/ethnic and socioeconomic groups—shows that powerful pictorial warning labels (mandated by the 2009 Family Smoking Prevention and Tobacco Control Act) play a lifesaving role in motivating smokers to quit. Despite this evidence, a U.S. appeals court in August 2012 ruled that cigarette companies do not need to comply with federal rules requiring their products to show graphic warning images. In March 2013, while defending the constitutionality of graphic warnings, the government dropped its push for such images on cigarette labels and said it would craft new anti-smoking ads. Senior author Vish Viswanath, HSPH associate professor of society, human development and health, said, “Given the disproportionate burden of tobacco-related disease faced by the poor and minorities, mandating strong pictorial warnings is an effective way to communicate the risk of tobacco use.”

Off the Cuff

Ten years ago, President George W. Bush launched a $15 billion international program to fight AIDS—the largest public health initiative in history dedicated to a single disease. The School’s Phyllis Kanki spearheaded HSPH’s application to the President’s Emergency Plan for AIDS Relief (PEPFAR) and served as principal investigator on the grant. Kanki talks about how history will look back on this effort.

PEPFAR was a turning point in public health. If you roll back the clock to the 1990s, the developed world was benefiting from new drugs to combat AIDS—the disease no longer had to be a death sentence. But in Africa and Asia, where the burden of AIDS was—and still is—greatest, treatment was not widely available or affordable. How could we consider we were making progress in combating the AIDS epidemic if we weren’t helping the most resource-limited nations?

The PEPFAR program’s goals were huge: treat 2 million people, prevent 7 million new infections, provide supportive care for 10 million people. And with AIDS patients, you can’t just deliver therapies and walk away—it’s lifelong. When PEPFAR was launched, drugs were relatively expensive, but over time the costs went down. This meant that long-term treatment in even the poorest nations could enter the realm of the possible.

The School’s program, like PEPFAR overall, surpassed all goals. Through our work in Botswana, Tanzania and Nigeria, we enabled 160,000 patients to receive lifesaving drugs.  We trained thousands of health care workers, set up systems to deliver treatments and refurbished and equipped clinics and labs. And we learned lessons through research that can guide prevention and treatment for other common and deadly diseases, such as tuberculosis or malaria. PEPFAR proved that even the most resource-deprived clinics and hospitals in Africa can deliver and sustain the highest quality of care.

Download a PDF of Frontlines here and Off the cuff here

As this issue of Harvard Public Health confirms, public health rings loud and clear in the daily news. And virtually every story that is printed, podcast, browsed, blogged, streamed, tweeted—and even just talked about—circles around ideas that inform our purpose and mission at the School.

Against the backdrop of a broad national discussion on gun violence, our cover article delves into the hidden toll of gun suicide—a problem on which the School’s Matthew Miller, Catherine Barber and Deborah Azrael have conducted groundbreaking studies that have shaped the debate. Indeed, the Harvard Injury Control Research Center, directed by David Hemenway, has been at the forefront of separating facts from fiction in the contentious discussion around the U.S. gun violence crisis.

Also in this issue, the profile of Siddharth Kara reminds us that the quest for health and well-being is inextricable from the quest for universal human rights. Curtis Huttenhower’s creative work on the human microbiome is setting the stage for what may be the next revolution in public health and medicine. Raul Ruiz’s inspiring journey from California’s Coachella Valley to Capitol Hill brings a sharp public health focus to federal lawmaking. And a lively conversation with Ichiro Kawachi reveals how the burgeoning science of behavioral economics can be applied in public health.

The public health mission is timely, because so much human suffering—from infectious diseases to unhealthy lifestyles to the afflictions of poverty and unequal access to care—can be prevented with evidence-based policies. But public health is also timeless, because it depends on vigilance and a longterm vision that transcends the accelerating news cycle.

As the School prepares to celebrate its centennial, the vital role of public health will continue to find its way into the headlines. And many of those headlines will reflect the work of the School, which accounts for more media mentions than any other school of public health. As this issue of Harvard Public Health shows, HSPH researchers will be there with the high-impact data and perspective needed to make sense of our rapidly changing world.

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

Download a PDF of Health and headlines here

Why we act against our own best interests

Human beings act irrationally. This long-established observation, corroborated now by the burgeoning field of behavioral economics—which studies the influence of social, cognitive and emotional forces on our choices and decisions—holds great potential to transform both personal habits and public health. Ichiro Kawachi, chair of the Department of Social and Behavioral Sciences, talks with Harvard Public Health writer Amy Gutman about why all of us (himself included) so often fail to act in our own best interests and how we can change.

Q: Public health often starts out with good intentions but fails to change people’s behavior. Why?

A: Because many public health theories assume that humans are rational, and we’re not. Our thought processes are automatic. And our behaviors are ruled by emotions, including the emotional states that advertisements create.

Q: Can you give me some examples of wrongheaded public health interventions?

A: Take smoking. Public health tries to dissuade people from smoking by using surgeon generals’ messages that smoking will cause lung cancer 20 years down the line—as if, at the moment of lighting up, someone is thinking about what will happen 20 years from now. It’s what behavioral economists call “the problem of intertemporal choice”: The costs and benefits of many behaviors fall in different time periods.

Nearly all of the lifestyle choices that we in public health lecture people about fall into this category. For example, there are “investment behaviors,” such as going to the gym today to prevent heart attack 10 years from now, or flossing your teeth so that you can avoid dental bills six months later. There are also “sinful goods,” where the pleasure comes now and the cost comes later: Krispy Kremes, risky sex, smoking.

If we were perfectly rational beings, we would be able to factor all this in and make the right decision. But we’re not coldly calculating machines. We are motivated by the part of the human brain that is heavily present-focused.

Q: So what can public health do to overcome this irrationality?

A: We can be the architects of people’s decisions, so that the natural choice tends to be the healthier one. One trick from behavioral economics is default options. At McDonald’s, make the default option for kids’ meals an apple instead of a bag of french fries. Or instead of asking people if they want to supersize their meal, ask if they want to downsize it. A third default option is to make serving containers smaller; one reason why Europe has less obesity than the U.S. is that their cups and saucers and plates are much smaller than ours.

Even public transportation is a default option. In Japan, in spite of the fact that virtually nobody works out in their leisure time, they have managed to remain lean and slim. It’s because of the investments their society has made in public transportation and the resulting exercise involved in walking between their homes and train stations, and walking up and down stairs and platforms at those stations.

Q: Any other lessons from behavioral economics?

A: It’s taught us that if you give people a good feeling about a product, your assessment of the benefits goes up and your assessment of the risks goes down. Cigarette ads play up positive emotions—“alive with pleasure,” how much fun you’re going to have by smoking this product. Often, these ads don’t even show people smoking.

Until recently, the public health message about smoking was totally unemotional: You’ll get cancer in 20 years. With the proposed Food and Drug Administration warnings, we are finally combatting fire with fire by showing images that are equally vivid and emotion-laden. But fear also tends to put people in a state of denial. I happen to think there’s a vast palette of subtler emotions, such as pride or anger or sadness, which we could use to instill healthier choices.

Q: What’s at stake if we don’t take these ideas into account?

A: Ralph Keeney, who is emeritus professor at Duke, has said we should stop thinking about the major health problems in America as being cancer and cardiovascular disease. But smoking, a sedentary lifestyle and overeating represent the lion’s share of preventable causes of illness. It’s personal decisions that are the major cause of our health problems.

A: The food and tobacco industries are well aware of the insights from behavioral economics. They liberally use these techniques in their advertising and persuasion. So why don’t we?

Q: Do you ever find yourself making the sort of irrational health choices that you’ve just described?

A: When I go to Logan Airport, specifically Terminal C, there’s a Burger King. Even though I tell myself that I’m falling prey to this pattern—even though I tell myself the night before that I’m not going to do it this time—the moment I’m there, I smell the french fries and find myself making a beeline.

Download a PDF of Q&A: The science of irrationality here

“Do I look like a man with a plan?”

The slender young man with the radiant smile is mimicking a line from the villainous Joker in the second Batman movie.

At first glance, the answer to his mischievous question is, “Yes.” The youngest of six children in a hardworking Indonesian family, Panji Hadisoemarto, now 33, earned a medical degree before embarking on a public health research and teaching career that has taken him from his hometown of Bandung to Boston, where he is currently a doctoral student at Harvard School of Public Health.

But appearances can be deceiving. In fact, this seamless list of accomplishments began as a Plan B. Medical school was a distant second choice for Hadisoemarto when he failed to get into a top informatics program to prepare for a career creating computer games, the passion of his teen years. Two older siblings already owned the pricey medical textbooks, and he didn’t really see another option. “My dad always told us, ‘You don’t have any choice but to pass the college entrance exam. If you don’t, I will just buy you a pair of goats.’ I didn’t want to be a goatherd—not that there’s anything bad about it.”

Soon, however, his ambivalence faded, and he found himself engrossed in his medical studies, especially classes in public health, where he quickly saw the potential for vastly expanding his impact. “With medicine, you’re most likely doing good just one person at a time. With public health, you have the opportunity to do good for many people at a time.”

Bird flu to breakbone fever
Shortly after completing his medical degree, Hadisoemarto landed a plum job with a U.S. Naval Medical Research Unit in Jakarta, embarking on an exhilarating if often unnerving stint on the front lines of Indonesian public health. He was on the ground in a disaster area the week after the 2004 tsunami that killed more than 200,000 people, helping with an epidemiologic assessment for his office. The following year, he found himself in the historic position of collecting the sample of what turned out to be Indonesia’s first-ever human case of avian flu (H5N1). Alone in his office one day, he was called out on a two-hour road trip to take a nasal swab from a patient with a mysterious illness—an experience he describes as “very, very exciting and a little bit scary.”

This was also when Hadisoemarto’s interests coalesced around infectious-disease epidemiology, including dengue fever, now the focus of his dissertation. A mosquito-borne virus, dengue has been spreading rapidly since World War II and is now endemic in half the world’s nations. “The mosquito is very smart,” Hadisoemarto notes. “Controlling them is difficult, as if they were created to adapt to whatever we do. Perhaps, as one of my Indonesian professors says, ‘The world was created for insects.’”

While some 80 percent of those infected with dengue show either no or very mild symptoms, in a small portion of cases, the disease can be life-threatening and extremely painful, earning it the moniker “breakbone fever”—as Hadisoemarto knows firsthand from his own two bouts with the disease, the first quite serious. “I was hospitalized for a week, and I felt very, very weak for a month after that,” he recalls.

Two years into his research job, Hadisoemarto got an offer he couldn’t refuse: an invitation to teach at his Indonesian alma mater. He had grown increasingly uneasy with the aura of political intrigue that surrounded the Navy lab—to his mind, a reflection of larger tensions between Islamic countries and the U.S. And he had fallen in love with teaching classical guitar.

Thriving in the least developed place
Hadisoemarto quickly took to the academic environment. After a Fulbright Scholarship and an MPH at Georgia State, he applied to the HSPH doctoral program in Global Health and Population, drawn by the focus on world health issues. (In the meantime, he also married and had a child.)

Today, he is using mathematical modeling to explore how a dengue vaccine—now in Phase III clinical trials and widely predicted to be available in the next decade—could be deployed most economically and effectively in Indonesia. Looking ahead, he envisions using similar methods to fight other infections, including, perhaps, HIV/AIDS.

Hadisoemarto’s vision for his own future is even more expansive. On returning to Indonesia, he plans to let his public health career take him where the need is greatest in a country that is moving forward (universal health insurance is slated to begin in 2014) but still suffers from “a double burden of disease”: deadly infections such as dengue, malaria and TB, alongside the cardiovascular and other chronic afflictions now skyrocketing around the world.

“In my opinion, the best place to thrive is the place that is least developed,” he says. “I want to involve the Indonesian communities in my research and improve whatever health condition needs to be improved there. I’m not going to limit myself to dengue, because, I think, there aren’t enough people to do other things. I like research, but I don’t want to do research for itself. I want to see change.”

Hadisoemarto may not be a man with a plan, but he’s clearly a man with a mission.

Amy Gutman is a senior writer at HSPH.

Download a PDF of A man with a plan here

Our work is working…

The past two decades have seen major progress in global health, according to the latest Global Burden of Disease study–an ambitious worldwide project involving Harvard School of Public Health faculty and many others. But as life expectancy has risen, the burden of disease has shifted–people are living both longer and sicker.


Download a PDF of the Global burden of disease infographic here

Microbes in and on our bodies outnumber human cells 10 to 1—and may determine how we get sick and stay well.

The story of public health has largely been a story of conquering infections, from smallpox to syphilis to scarlet fever. Since the late 19th century, the War on Germs has boosted life expectancy and eased incalculable suffering.

But today, scientists are realizing that the unseen bacteria, viruses and other microorganisms that pervade our world are not necessarily our foes. While our bodies contain some 10 trillion human cells, there are more than 100 trillion microbial cells in and on every exposed surface of our bodies—a resident menagerie collectively known as the human microbiome. (Because of their small size, microorganisms make up only 1 to 3 percent of the body’s mass.) And while we sport about 23,000 human genes, our microbiome contains some 8 million, making them a far more capable force than we had ever reckoned.

Put simply, our bugs are us. And according to Curtis Huttenhower, assistant professor of computational biology and bioinformatics in the Department of Biostatistics, that insight may transform our understanding of how healthy bodies become diseased, how aging leads to infirmity and especially how we might tinker with our internal ecosystems to prevent and treat a vast range of conditions, from diabetes to asthma to obesity.

“Our relationship with our microbes is not a war; it’s a well-defined truce, a balance. It’s a system that natural selection has worked on for millions and millions of years,” he says. “We get one genome and that’s what we’re stuck with for our life. But our bugs can change and adapt much faster than we can. And our immune system, our metabolism and many other systems in our bodies evolved specifically to engage in this rapid conversation with our bugs, and vice versa.”

Now, for the first time, scientists are listening in.

Power in numbers

In the long genealogy of life on Earth, single-celled microbes preceded multicellular creatures by a billion years. According to Huttenhower, “You could say that humans and other multicellular organisms evolved as robots to carry around microbes.”

And microbes can boast power in numbers. “If you go to Africa and count the large mammalian species, it’s in the double digits, but their interactions and ecology are still complex,” he explains. “If you examine a particular skin location or a microbial biofilm in the mouth, you’ve got ten or a hundred times that many different kinds of bacteria, all interacting, and each with its own niche and genome and priorities.” The human gastrointestinal tract is the most microbially diverse part of our bodies, exposed to an onslaught of foods, drugs and other disturbances that exert strong and constant selection pressures.

In 2007, the National Institutes of Health launched a massive five-year consortium to map our microbial complexity. The agency’s Human Microbiome Project (HMP) created a base line portrait of a healthy human microbiome. By sequencing more than 5,000 samples from 242 healthy volunteers in two U.S. cities, it revealed the contours of microbial diversity in disease-free individuals. Researchers sampled and analyzed the genomes of microbes from five areas on the human body: nasal passages, oral cavities, skin, the gastrointestinal tract, and the urogenital tract.

The project found that more than 1,000 microbial species occupy our internal ecosystems. And while our human genomes are more than 99 percent identical genetically, our microbial communities are typically only about 50 percent the same. That suggests that different species of bugs are doing the same jobs in our bodies—in a sense, pinch-hitting for one another.

The HMP also found that while the worst bad guys—microbial pathogens—aren’t present in healthy individuals, all of us carry organisms that can cause disease under the wrong circumstances. Most of the time, these “opportunistic” pathogens live in harmony with their human hosts, providing the vital functions necessary for their and our survival. How and why these microbes become renegades rather than team players is an important scientific question.

New tools and technologies
These insights were made possible by new tools, both in the lab and on the computer. Traditionally, microbiology has focused on single species, often isolating each by itself in a petri dish for examination. But the vast majority of microbes that thrive in and on us have never been cultured in this way, in part because their growth depends on a particular microenvironment that had not been, or could not be, replicated at the bench.

Modern advances in DNA sequencing technology changed all that. Today, scientists can parse not just the genome of a single bacterial strain, but the genetic material from whole microbial communities. They first purify the human and microbial DNA in a sample straight from the environment, sequence it and then use computers to sort through the resulting genomic fragments and identify the genetic signals found only in bacteria and other microbes. This cheap, high-volume technology can create an instant catalog of organisms, genes and genomes from a microbial community sample. “From literally billions and billions of microbial DNA sequences,” says Huttenhower, “we’re beginning to interpret these complex mixtures of nucleic acids—the A’s, C’s, G’s, and T’s—in terms of how they affect our ecosystems and our health.”

A lead author for one of the HMP papers published in Nature, Huttenhower likens the possibilities to those that suddenly opened when astronomers began using radio telescopes. “The data that you obtain from a radio telescope aren’t something you can see with the eye, but abstract values read out of an instrument and converted into a pattern by a computer. Likewise, in biology, we’ve gone from optical microscopes—our equivalent of telescopes—to instruments that rely on DNA sequencing and use a computer to tease out signals from the data.” Using these high-throughput sequencing technologies, researchers have uncovered an infinitesimal universe.

Unique microbial profiles
Each of us has a unique microbial profile—in some ways, our bugs are as much a biological signature as our genomes. Our unique sets of microbial passengers are forged by genetics, early life events, diet, and a lifetime of exposures to infections, pharmaceuticals and other aspects of our physical environment.

Even within each of us, individual body sites harbor unique microbial ecologies. “To the microbes living on our bodies,” says Huttenhower, “our skin and our mouth and our gut are as different as a desert and a prairie and a rainforest.”

Where do these organisms come from? Until birth, humans are virtually sterile, consisting of only our own somatic cells. But during the first few years of life, we are bathed in microbes we pick up from our mothers, the hospitals where we’re born, our homes, our families, food, clothing, trees, dirt, pets, playgrounds, the air we breathe. Some of these organisms stick with us all our lives, while others are transient.

Just as these microbes need us to survive, we rely on them as well. Among other things, they train our immune systems from an early age to discern healthy flora from disease-causing invaders, break down our food into nutrients that we can absorb, manufacture essential compounds such as vitamins and anti-inflammatory signals, and crowd out dangerous pathogens, such as disease-causing strains of Clostridium difficile in our intestines or Staphylococcus on our skin.

From health to disease
And when this ecosystem, finely tuned by evolution, slips out of balance, we get sick.

Inflammatory bowel disease (IBD), for example—a group of conditions that includes Crohn’s disease and ulcerative colitis, both painful and relapsing conditions—seems to be triggered when normal gut bacteria become less diverse and shift in their proportions of various species. Huttenhower is working on a study that may illuminate whether the typical high-fat, low-fiber Western diet correlates with the microbiome profile found in IBD patients. To help answer that question, he is drawing on data from the Health Professionals Follow-Up Study, which for a quarter-century has collected detailed information on volunteers’ diets and lifestyles. Using oral and fecal samples from the study’s volunteers, Huttenhower hopes to learn how IBD, a disease with both genetic and environmental components, interacts with microbial influences in the environment.

Other autoimmune conditions, such as type 1 diabetes, rheumatoid arthritis and asthma, may also arise from changes in the microbiome. Long before researchers began investigating the microbiome, they knew that allergies and asthma were tied to early-life environments. Children who are more exposed to dirt and animals are less likely to develop allergies and asthma. The so-called hygiene hypothesis suggests that childhood exposure to germs and certain infections trains the immune system to be robust later in life, and that, conversely, relatively clean environments in early life prod the immune system to overreact to harmless substances such as pollen.

Microbiome studies may uncover the mechanisms behind the hygiene hypothesis. Today, researchers are comparing the microbiomes of children raised on farms and exposed to livestock with those of kids who grow up in cities. According to Huttenhower, “If you’re a child in an urban area that’s all steel and concrete, with no trees and no parks, that increases your risk of allergy or asthma later on, relative to growing up in open areas with more natural microbial communities.”

Microbes and mass transit
In 2012, Huttenhower received a grant from the Alfred P. Sloan Foundation to study how our normal microbial communities are transmitted during our everyday lives, such as in Boston’s crowded MBTA subway system. Swabbing samples from subway cars and touch screens on three different lines, his team will try to find out how or if bugs are transferred between people, becoming permanent denizens of other riders’ microbiomes.

“What happens when I shake somebody’s hand?” he ponders. “Do their skin microbes get beaten out, in some sense, by my skin microbes, because my microbes have evolved to be with me? Or do our microbial communities combine? Or do they stably transfer some of their community to me? And do those same patterns of transmission hold true for surfaces and airways? That’s why I’m interested in looking at the MBTA: How do our bugs get to our environment and back, if at all?”

Given the intimate connection between our microbiome and our own cells, other conditions, from obesity to mental illness to the frailty of old age, are also ripe for exploration. Huttenhower cites several recent studies indicating that the microbiome in older people, for example, is less diverse than in the young. As in several other conditions, this raises the question of whether changing microbial communities are a cause or a result of declining health during aging and disease.

Into the clinic?
Microbiome studies may someday pay off in methods to alter the course of disease. According to Huttenhower, “An important difference between our microbial genes and our own genes is that our microbes are plastic and modifiable. Every time we eat something or take antibiotics, we change our microbial communities. This means that they have the potential to be an effective point of prevention and disease treatment.”

Take the painful and seemingly random flare-ups of Crohn’s disease. “If we could determine from changes in bugs—say, from a stool sample or, in an optimistic world, a saliva sample—that there’s a microbial or immunological change before the flare begins, then we could treat the problem before it starts,” says Huttenhower. That treatment could consist of standard medications, or perhaps even of tailored doses of bacteria that would restore the gut microbiome to a healthy state. (Think of it as a research-based version of consuming large quantities of live-culture yogurt to keep the digestive system functioning smoothly.)

Deploying bacteria as drugs isn’t new. Earlier this year, studies showed that transplanting fecal specimens from healthy individuals cured Clostridium difficile infections—an agonizing and sometimes deadly infection in the intestine, usually in the elderly, that typically follows a regimen of broad-spectrum antibiotics. Indeed, antibiotics—the lifesaving medications behind many of public health’s 20th-century triumphs—may turn out to have unintended consequences beyond the well-documented problem of drug-resistant pathogens.

If our bodies are composed of delicately balanced microbial environments, then antibiotics are like a “wildfire,” says Huttenhower. “They burn down everything.” Even interventions like fecal transplants “are a big hammer,” he conceded. “A question many of us are interested in is: What’s the smallest, most targeted, most nuanced intervention to treat not only C. diff infections or IBD, but also other inflammatory conditions such as diabetes or rheumatoid arthritis? Could we introduce a single species of bacteria, or just a few species, to restore a healthy, diverse ecology? Could we target specific molecules or a specific chain of events in microbial communities, the way we’ve begun to do in cancer?”

The microbiome even offers possibilities for early diagnosis. “We should be able to learn to read our bugs to tell us about our future health, just like we’ve done with the human genome in the past 10 or 15 years,” says Huttenhower. Microbial profiles are potential clues to whether patients will respond to drug treatment, need surgery or stand the risk of ever developing certain diseases.

But it’s important to temper the enthusiasm of the moment against the daunting challenge such research presents. “Think about how long it’s taken us to find molecular treatments for cancer or genetic treatments based on the human genome, both of which have been more studied by more people for a lot more time,” he warns. “All translational science underestimates two things. One is the difficulty of reliably picking a signal out of big data. The second is the difficulty of going from that signal to the clinic.” Both steps are possible in the human microbiome, but neither will be easy.

High stakes
But the stakes for such research are high, and the potential payoff dramatic. “The microbiome is one part of the environment that might help explain the rapid increase in the last 50 or so years of chronic, nongenetic disease. Obesity, types 1 and 2 diabetes, inflammatory diseases like inflammatory bowel disease, and autoimmune diseases like rheumatoid arthritis have all have gone up at a rate that cannot be explained by human genetics, and therefore must be caused by changes in our environment,” Huttenhower says. “Changes in that time have included diet, our stress levels, our indoor and outdoor environments, and our use of antibiotics and other pharmaceuticals. All of those factors also affect our microbiomes, which have evolved over hundreds of millions of years to train our immune systems and keep us healthy. The last few decades have seen changes at a rate faster than anything else during those millennia, and our microbes might be having trouble adapting—putting our health at risk in the meantime.”

If those connections prove true, he adds, “That’s a huge motivation to do this work. We need to focus on this now, as quickly as possible.”

Madeline Drexler is editor of Harvard Public Health.

Download a PDF of Our bugs, ourselves here

The medieval system of bonded labor traps millions of workers worldwide for life.

In a thatched hut in Bihar, India, amid agricultural fields and brick kilns where his children and grandchildren toiled away, an elderly man with shaking hands prepared tea. The “frayed skin scarcely covered the crumbling bones beneath,” later wrote his guest, Siddharth Kara, who recently became a fellow at the François-Xavier Bagnoud (FXB) Center for Health and Human Rights. The man’s name is Ajay, and he is a modern-day slave. He has spent more than five decades, his entire adult life, in so-called bonded labor, forced to work to pay off debts to a local landowner.

The original loan, incurred when Ajay was 17 years old, totaled 800 rupees—about $18—to pay for his marriage. After decades of work, he still had not paid off the debt, which eventually consumed him and his family. When his wife became chronically ill, Ajay was too poor to afford medicine, and his wife died. Ajay suffers even more because he knows his two sons and grandchildren will inherit his financial obligation. “No one in this country cares about people like us,” he told Kara. “We live and die, and no one but ourselves knows we have drawn breath.”

Frozen fish to fine marble
The story of Ajay, and hundreds more in similar situations, is recounted in Kara’s new book, Bonded Labor: Tackling the System of Slavery in South Asia. The deeply researched exposé examines this cruel system of exploitation, sometimes called debt bondage. Kara, who is also a fellow at the Carr Center for Human Rights Policy at the Harvard Kennedy School, estimates that there are 18 to 20.5 million bonded laborers in the world, more than 84 percent of whom reside in just four nations: Bangladesh, Nepal, Pakistan, and most of all, India, Kara’s native country.

Although the practice of debt bondage largely takes place in South Asia, the products of this institutionalized system of exploitation are consumed worldwide in everyday life. Kara found that bonded labor is used in a vast range of commodities and consumer goods, including frozen fish, tea, coffee, rice, wheat, diamonds, sporting goods, apparel, and marble. Nearly three-quarters of the frozen shrimp exported from Bangladesh, for example, is produced by bonded labor or child labor.

Stemming from a medieval system of labor, debt bondage is today an integral part of globalization, as transnational companies scour the world for cheaper labor and higher profits. As Kara writes, “[T]he persistence of bonded labor in South Asia is driven by the ability to generate substantial profits at almost no real risk, through the exploitation of an immense underclass of systemically impoverished and vulnerable people.”

Treated like “dirt and chattel”
Though a 1976 law banned the practice of bonded labor, it has gone largely unenforced. In a later Indian Supreme Court decision upholding the law, Chief Justice P. N. Bhagwati decried the hypocrisy of a society that “treats large masses of people belonging to the lower rungs of the social ladder or economically impoverished segments of society as dirt and chattel.” According to FXB Director Jennifer Leaning, the problem “is cyclical, it’s chronic and it’s deeply entrenched in the economic system of the state. It is fundamentally a problem of corruption and poor regulation.”

Kara’s unusual method of investigation, euphemistically known in academia as “active research,” is highly immersive. He spends countless hours with his subjects and their families, getting to know them and sharing in their work and lives. He makes it a practice to engage for up to a day in the grueling tasks he is writing about, so that he knows the experience firsthand. He has plowed fields, broken stones, tended a kiln, harvested shrimp, planted rice paddies, hand-rolled cigarettes, polished gems, and woven carpets.

“Simple scientific research is not adequate for this kind of project—it’s an intensive human engagement, trying to appreciate the predicaments of another human’s existence,” Kara says. “I wanted to make sure that I knew what their lives were like.” Forging a personal connection with his subjects is integral to telling their stories of hardship, he adds. “When anybody shares an intense pain, there’s a bond of trust.” A more traditional research approach—using a questionnaire, for example—can’t capture the real-life complexities.

“Is this how I want to spend my time on the planet?”

Although Kara had witnessed forced labor as a child in India, he didn’t fully understand the issue until he was an undergraduate at Duke University, in the early 1990s. Volunteering at a Bosnian refugee camp, he heard disturbing stories about sex trafficking and rape camps, where Serbs reportedly systematically raped Bosnian women. Continuing his studies back in the U.S., he never forgot the experience.

In 2000, after several years as an investment banker, Kara asked himself, “Is this how I want to spend my time on the planet?” Contemplating his next move, he recalled his college experience in Bosnia and started to look into the issue of sex trafficking. Surprised to find a dearth of research on the problem, he decided to do the research himself. In the beginning, “I was just some investment banker who hopped on a plane,” he says. But after nine years, that work became his first book, Sex Trafficking: Inside the Business of Modern Slavery (published in January 2009), which received Yale University’s Frederick Douglass Book Prize in 2010. His new book fills out what he learned with a wider-ranging look at human servitude.

Kara says his work would not have been possible under traditional academic constraints. “You would probably never get institutional review board approval for a lot of the research I did, especially for Sex Trafficking. It’s too risky in most cases.” When encountering horrific situations where someone was being abused, for example, Kara resisted the reflex to rescue them. To do so could cause more harm than good, he explains, because the victims or their families could face violent retribution. Instead, he alerted trustworthy local NGOs or law enforcement officials, who could take effective action. Kara also protected the anonymity of his subjects by using pseudonyms and withholding identifying details.

These days, Kara sees his role as multifaceted: academic researcher, policy adviser and human rights activist, yet not fully any one of these. His investigations, which have taken him to 31 countries across six continents since 2000, have been almost totally self-funded, using his banking earnings and funds from further finance advisory assignments.

“A common and pervasive assault”

For many, the system of bonded labor unfolds in a hellish perpetuity, passed on generation to generation. A man named Gaurav, toiling at a brick kiln, recounts to Kara how he inherited his debt from his father. “No matter how hard I work, I am always in debt. I have taken so many loans through the years … I take loans for food and water and cooking oil.” Finally, he tried to escape with his family, but was captured by the landowner’s men, who electrocuted him and then sold off his daughter to a trafficker. “I never saw my daughter again,” Gaurav tells Kara.

Young children are frequent victims of this exploitative system. Pratima was 14 when her parents sent her to work for a wealthy family in Kolkata (Calcutta). In exchange, they were given an advance of 3,000 rupees, or about $67. For three years, Pratima dusted, cleaned, washed, and cooked, without a day off, with only a mat to sleep on and leftovers for her meals, while being shouted at and demeaned by her employers. All the time, she was supposedly working off the advance that had been given to her family, but Pratima never saw a penny. While Pratima was never physically abused, other girls Kara encountered were not so lucky, regularly suffering rapes and beatings at the hands of their employers.

Jennifer Leaning explains that human trafficking and debt bondage are classic public health issues, because they are “a common and pervasive assault on the life chances of children and adolescents.” Kara’s work, she says, is in keeping with the evolving mission of public health over the last 50 years, from a narrow focus on disease to a broader range of issues that includes psychological well-being and interventions that bolster an individual’s ability to live life to a full capacity.

Stopping servitude
Kara envisions both demand-side and supply-side solutions to the complex problem of bonded labor. On the demand side, Kara argues for several legal reforms, including laws in every country in South Asia that mandate a national minimum wage of at least $5 per eight-hour day for unskilled labor and higher for more skilled positions, and stricter laws so that commercial employers can be held liable if local subcontractors violate humane labor practices, as well as greater economic penalties for the offense of bonded labor. He would create rapid-response teams to identify and rehabilitate bonded laborers. Kara has also called for land reform: “Landlessness is a key driver of vulnerability to debt bondage,” he writes in his book, “and fear of eviction for landless tenants ensnares countless millions in years of slavelike exploitation.”

Among his proposals on the supply side: a comprehensive program that reduces extreme poverty, expands access to formal credit markets to the poor, improves infrastructure, and opens new markets to laborers. Kara also calls for national awareness campaigns for the general public, as well as educational programs for law enforcement, judicial and government officials focused on promoting the equality of minority castes and ethnicities across South Asia and on raising awareness of bonded and child labor.

“I hope that the analysis in this book, the voices of the bonded laborers that I share and the elevated awareness in media, policy and government circles will lead to more resources, more research and more efforts to tackle this issue,” he says. Kara’s book on debt bondage is the second in a planned series of three or four that will focus on forced labor. His next volume will cover such issues as organ trafficking and labor trafficking.

As Kara sees it, the biggest factor keeping people in bondage is lack of economic alternatives. “The duress is the force of grinding destitution. It is a colossal failure of society, of civilization, that millions of people have to face that devil’s bargain every day: Either I die or I accept servitude,” he says. “It is exceedingly painful to encounter hundreds of cases of extreme human barbarism and exploitation—particularly when you come from a world where people have so much. It is hard to comprehend that we all live on the same planet.”

Sam Loewenberg is a Boston-based journalist specializing in global health.

Download a PDF of Globalization’s permanent underclass here

From California’s impoverished Coachella Valley to HSPH to Capitol Hill

When Raul Ruiz was growing up in California’s Coachella Valley, his parents—both migrant farm workers—couldn’t afford health insurance, so they relied on home remedies and nutritious meals to stay healthy. His mother served herbal teas and lentil soup fortified with vitamin-rich onions and bell peppers, a dish Ruiz would eat to gather his strength before college exams.

“She taught us to appreciate food as a vehicle for feeling better and promoting a happier life,” says Ruiz, MPH ’07. “More important than the science of the food was the motivation and the inspiration and the worldview of nutrition as remedy, food as medicine.”

That experience of material deprivation and common-sense care helped shape Ruiz’s thinking about public health and medicine in the years that followed. Now 40, he plans to put those insights to work as a newly elected U.S. congressman representing California’s 36th District, the same area where he grew up. Ruiz, a Democrat, won the seat that Mary Bono Mack had held for 14 years.

9,000 residents, 1 doctor
Ringed by mountains and known for its grape, date and alfalfa crops, Coachella Valley has long faced a shortage of doctors in poorer areas. Even if more physicians practiced in the area, some residents would still be unable to afford a visit to the doctor. “That’s one of the main reasons I decided to become a physician,” explains Ruiz, who returned to the valley to work in emergency medicine after earning three degrees from Harvard, including medical and public policy degrees in 2001.

Coachella Valley faces “one of the worst health care crises in the state of California, possibly in the country,” he says, “not only in the lack of health care access but also in disparities to access.” Low-income areas have just one doctor for every 9,000 residents, while more affluent areas have one per 300 people. The national standard is one doctor per 2,000 people. “We’re way below that target.”

In 2010, Ruiz founded the Coachella Valley Healthcare Initiative, an organization dedicated to expanding access to health care for disadvantaged residents. For Ruiz, widening access to health care also means offering education that will help people “make the right decisions to live a healthier life, not only for themselves but for the entire community.” He cites childhood obesity as one of the valley’s most urgent public health challenges.

A pledge to return home
This concern for community has been a recurring theme in Ruiz’s life. Born in Mexico and adopted as a baby by his aunt and uncle in California following the death of his biological mother, he credits much of his success to his upbringing in the Coachella Valley. He raised funds for school by soliciting money from local businesses and pledging that he would return to the area as a doctor—a profession he had chosen at age 4.

After graduating magna cum laude from UCLA, Ruiz went on to Harvard, where he worked on public health projects in Mexico, El Salvador and Serbia. At HSPH, he focused on humanitarian and disaster aid, assisting in the aftermath of the 2010 earthquake in Haiti. “I always knew, even when I was in medical school, that in order to make a larger impact in a community I would have to leave the exam room.”

Ron Walls, chair of the emergency medicine department at Brigham and Women’s Hospital in Boston, knew Ruiz when he was an international emergency medicine fellow at the hospital in 2006 and 2007. “Raul saw the little things we do as part of bigger things and was always thinking of those bigger things. He’d try to figure out the context of the problem,” Walls says, adding that Ruiz was an exceptionally compassionate doctor who was also “very charismatic” and “instantly likable.”

Curing a sick health system
Now that he’s embarked on a career in politics, Ruiz says he will miss being an emergency medicine doctor and shaping students into a new kind of physician focused on community wellness and advocacy. “But policy is a toolbox where I can fix and build the pillars of the American dream.”

As part of his agenda, Ruiz wants to preserve the Medicare benefits and services that many of his constituents depend on. At the same time, he wants to streamline the system by “cutting off the fat.” He supports allowing Medicare to negotiate drug prices with pharmaceutical companies, as the U.S. Department of Veterans Affairs does, and eliminating unnecessary lab procedures by improving the sharing of medical information.

In the Coachella Valley, Ruiz plans to work with the public health and medical communities to boost the number of doctors serving the area. Already, he’s collaborating with the University of California, Riverside, School of Medicine on residency programs that encourage students from disadvantaged parts of the valley to return and serve there as doctors. He has also launched a mentorship program for pre-med students who want to work in the valley.

Congress Resembles the ER 
Ruiz expects that working in Congress will resemble working in an emergency room, with its urgent and sometimes conflicting demands. In a sense, he plans to treat constituents as patients. “I will always put people before politics,” he says. He likens policy development to a medical work-up, explaining that both require a diagnosis, an evidence-based treatment plan and—what lawmakers often overlook—a measurement of the outcome.

His path through the worlds of public health, medicine and now politics seems as clear to Ruiz as his mother’s formative advice on good nutrition. “This is a dream come true for me: to incorporate the best public health school in our country into the farmworker trailer parks and in the poorest areas of our district, where I grew up,” he says.

“I feel comfortable working in the barrios of the eastern Coachella Valley. I feel comfortable in the jungles of Chiapas or Port-au-Prince in Haiti. I feel comfortable in the halls of Congress. It’s just a matter of being true to my values and understanding that we’re all fundamentally humans, made up of the same fabric of life.”

Daniel Lovering is a Cambridge-based journalist who has reported on public health issues and other subjects from nearly a dozen countries.

Download a PDF of Dr. Ruiz goes to Washington here