Global Arena

HSPH alumni and faculty working with the World Health Organiization have been major players in international health

As a rule, death certificates are dreary documents, the grim bureaucratic reminders of human frailty. For health workers, the death certificate too often symbolizes a failure of the core functions of protecting and extending life. Yet on one occasion–May 8, 1980–the signing of a death certificate was a cause for celebration and hope. On that day, the delegates to the 33rd General Assembly of the World Health Organization (WHO) signed their names to the first death certificate for a human disease: smallpox. Few events in the history of public health have had as much symbolic meaning: for the first time, a lethal disease had been permanently uprooted from the planet through a concerted prevention campaign.

Abdul Rahman Al-Awadi, M.P.H.’65, presided over the historic assembly and called the occasion a "personal and professional thrill." At the time the Minister of Health for Kuwait, Al-Awadi had worked with the WHO in a number of capacities since graduating from the School, including twice serving as a member of the WHO Executive Board. Al-Awadi’s presence at the ceremonial signing, coupled with the fact that three HSPH alumni–William Foege, M.P.H.’65; Donald Hopkins, M.P.H.’70; and Ralph Henderson, M.P.H.’70–had played prominent roles in the smallpox campaign, meant that the event also had deep significance for the School of Public Health.

Hopkins had helped lead the eradication campaign in Sierra Leone, Africa, from 1967-68. In his 1983 history of smallpox, Princes and Peasants, Hopkins traces some of the key moments in a struggle between man and disease that had been waged off and on over 3 millenia. The 1966 decision by the World Health Assembly to launch the global eradication campaign–coming precisely 170 years after Jenner’s discovery of vaccination–signaled that the endgame of this struggle had begun in earnest. "One of the most important challenges facing the Smallpox Eradication Program," writes Hopkins, was the need to prove, as quickly as possible, that the disease could be eradicated from poorer countries in spite of their inadequate health services. Many thoughtful public health specialists doubted that could be done to the end of the campaign, but the doubts were especially prevalent during the SEP’s early stages.

It was FOEGE, leading the eradication effort in West and Central Africa, WHO achieved this "crucial psychological victory," writes Hopkins. Foege would go on to lead the successful campaign in India, before departing to join the CDC.

Henderson, WHO was part of the West Africa effort, working in Lagos, Nigeria, says, "the experience of working on this program in West Africa was a career highlight. It was a crash introduction to West African culture, public health, and the constraints of colonialism and socio- economic development. Good tools and good people at all levels made it a spectacular success."

A decade later, Henderson was selected to direct the WHO’s stunningly successful Expanded Programme on Immunization (EPI). He says that his earlier experience with the SEP, along with the support from many national and international "alumni" of the smallpox eradication campaign, were major factors in making the EPI itself such a success.

Since its creation in june 1946 as a special agency of the United Nations, the WHO has been a hotbed of exchange and collaborative activity for faculty and alumni of the School of Public Health. Among the United States’ delegates WHO signed the WHO into existence was Martha May Eliot, then chief of the United States Children’s Bureau and a member of the School’s Visiting Committee. Eliot, WHO would later chair the School’s Department of Maternal and Child Health, was also present the following summer for the first World Health Assembly in Geneva, Switzerland. She was joined there by HSPH Dean James Stevens Simmons, S.D.’39, WHO subsequently reported in the School’s Alumni Bulletin that the School was well-represented with alumni serving as representatives from Japan, Ceylon (now Sri Lanka), and China.

Conceived as part of the post-World War II rebuilding effort with the goal of strengthening national health administrations, the WHO has succeeded where several of its predecessors failed. Nearly a century before, the first International Sanitary Conference (ISC), held in France in 1851, inaugurated an era of inter-national action in public health. Eventually the isc evolved into the Office International d’Hygiene Publique (OIHP), which survived through the end of the First World War, when the League of Nations attempted to establish its own international health agency. World War II, however, brought international health collaboration to a virtual standstill and destroyed or disrupted national health services in many countries. The functions of the OIHP and the League of Nations agency, along with those of the United Nations Relief and Rehabilitation Administration, a temporary organization that assumed OIHP’s responsibilities during the war, were ultimately transferred to the WHO.

Headquartered in Geneva, the WHO receives funding from its 190 member states to confront diseases ranging from malaria to mad cow disease to Dengue Fever to AIDS on every continent and in every corner of the globe. The WHO’s World Health Assembly has quasi-legislative powers, granted by the United Nations, to decide which international health programs should be undertaken. The WHO Executive Board–made up of 32 members, designated by as many states, but serving in their personal capacities–is charged with carrying out the directives of the Assembly. The WHO Secretariat is responsible for providing assistance to individual nations and programs. Much of the WHO’s work is carried out through decentralized regional offices for Europe, the Americas, Africa, the Eastern Mediterranean, Southeast Asia, and the Western Pacific.

Over the past five decades, the School’s faculty and alumni have been active in the WHO as administrators, program officers, collaborators, consultants, and advisers. Henderson, for example, directed the WHO’s Expanded Programme on Immuniza-tion for 13 years before being named assistant director general. When he took over EPI, immunization coverage in developing countries was negligible. By 1990, coverage had increased to some 80 percent of children age one or under. Today, the program prevents an estimated 3 million deaths annually from target diseases. It has also made it possible for the WHO to have the realistic expectation that poliomyelitis will follow smallpox on the path to eradication by the year 2000. Before stepping down as assistant director general, Henderson oversaw six divisions or programs relating to vaccines and immunization, tuberculosis, leprosy, tropical disease control, research and training in tropical disease, and the prevention of blindness and deafness.

The breadth of interactions between the School and the WHO, formal and informal, make it impossible to give a comprehensive list of WHO-HSPH activities over the years. But a sampling shows that the relationship between the two organizations has been both varied and deeply influential to global health. A poll of the School’s graduates taken in 1956 revealed that 26 alumni had worked with the WHO in some capacity. Lawrence Roberts, M.P.H.’55, a regional adviser in tuberculosis for the WHO Regional Office for the Western Pacific, and James S. McKenzie-Pollock, S.M.’52, WHO coordinated communicable-disease services for the WHO’s Regional Office of South East Asia, were typical of the large number of graduates WHO gained hands-on international health experience working out of regional offices of the WHO. In the 1957 Alumni Bulletin, Hans Helweg-Larsen, M.P.H.’51, reported that he had recently been assigned to the position of health statistician for Indonesia after many years at the WHO Tuberculosis Research Office in Copenhagen. In the same report, John A. M. Karefa-Smart, M.P.H.’48, informed his colleagues that he had initiated a malaria and yaws control program in Liberia before being named public health officer for Western Africa. Karefa-Smart credited courses he took in public health practice and Dean Simmons’ seminar on international health for sparking his interest in the work of the WHO.

In 1950, Vlado A. Getting, D.P.H.’40, was named a United States representative to the third World Health Assembly. At the time the Commissioner of Health for Massachusetts, Getting recalls that on his flight to Geneva, he was seated next to J.N. Togba, M.P.H.’49, WHO had just graduated and was serving as Liberia’s representative to the three-week-long meeting. Togba would go on to serve as president of the seventh World Health Assembly, the first of the School’s alumni to be so honored. Eighteen years later, a Canadian alumnus, Basil D.B. Layton, M.P.H. ’52, would also serve as president, as would Al-Awadi in 1980.

Chang Yuo Shu, M.P.H.’47, China’s representative to the first World Health Assembly, joined the WHO Secretariat in 1949. Until her retirement in 1973, Helen Martikainen, S.D.’65, oversaw the WHO’s health education services. Martikainen noted that during her 25-year career at the WHO, her only break from her work was the time she studied at the School. Meropi Violaki-Paraskeva, M.P.H.’50, served the WHO in a variety of capacities over a 35-year period, including serving as president of the 34th World Health Assembly in 1981. She was the fourth graduate of the School to serve in this capacity.

Adetokunbo O. Lucas, S.M.HYG. ’64, believes that the greatest challenge of his three-decade-long career in public health was the establishment of the WHO Special Program for Research and Training in Tropical Diseases, operated in collaboration with the World Bank and the United Nations Development Program. Lucas directed the program from 1976 to 1986, during which time he raised some $30 million annually and conducted training and research in more than 100 countries. For his 10 years of work, Lucas can proudly point to the more than 50 new products–including an effective multiple-drug therapy for leprosy–developed by the program to help combat myriad tropical diseases.

WHO's WHO: Adetokunbo Lucas (top), Gro Harlem Brundtland, and Abdul Rahman Al-Awadi have are amoung the many HSPH alumni WHO have held key positions at the WHO.

In the mid 1980s, with tuberculosis riding the AIDS EPIdemic to renewed prominence in industrialized nations while continuing to hit developing nations hard, Arata Kochi, M.S.’82, assumed leadership of the WHO’s TB program. Kochi was faced with rebuilding a global program that had essentially been neglected for the previous two decades. In an interview for the Harvard Public Health Review in 1993, Kochi said his program’s primary function is "to build coalitions between governments, funding agencies, and other major players" and to provide technical assistance to poor countries in managing TB. Among those WHO have helped Kochi to achieve these goals have been several HSPH alumni, including Peter Eriki, M.P.H.’84, regional adviser for TB and leprosy in Brazzaville; Sergio Spinaci, medical officer for China and India; and WHO scientist Diane Weil, M.S.’88.

For Jonathan Mann, M.P.H.’80, the WHO provided a platform for mobilizing a global response to an Epidemic that would re-invigorate–and ultimately redefine–public health: AIDS. Mann, WHO launched the WHO’s Global Programme on AIDS in 1986, was recruited to the WHO in 1985 by Fakhry Assad, director of the WHO’s Division of Communicable Diseases. When Mann arrived in Geneva, the program’s only other staff member was his secretary. When Mann left, four years later to join the faculty of the School of Public Health, the program was the WHO’s largest, with a staff of over 300 and a budget of more than $100 million. Under Mann, the gpa established 155 national AIDS programs, achieved true global mobilization against the Epidemic, and developed a language and a conceptual framework based on preservation and respect for human rights that Mann believes is critical to help the world address AIDS.

Mann points to the WHO’s ability to utilize the resources and expertise of universities around the world as one of the keys to its success. "With the larger purpose of ensuring global health, it is the WHO’s responsibility to take advantage of the resources available," explained Mann.

The recent appointment of alumna Gro Harlem Brundtland, M.P.H.’65, as director general of the WHO represents a fitting culmination of the productive WHO-HSPH relationship. Brundtland, WHO assumes the post in July 1998, has been one of the world’s most influential advocates for international cooperation on health and environmental issues. She has thrice served as prime minister of her native Norway. As chair of the U.N.’s World Commission on the Environment, she oversaw publication of the report "Our Common Future," which brought the notion of "sustainable development" to the fore of international health efforts. She is the first HSPH graduate–and first woman–to hold the post of director general and those WHO know her expect that she will bring an energetic management and leadership style to the organization that will help it achieve new prominence in international health.

In her presentation to the WHO Executive Board prior to her confirmation, Brundtland proposed a more active role for the WHO as "a catalyst for raising the status of health on the international political agenda. We cannot allow health to remain a secondary dimension as we focus our international resolve into a new century. Health is pivotal. Health is the core of human development."

Complementing the leadership on the ground of the School’s alumni, HSPH faculty have played important collaborative and consulting roles on WHO research and service projects. Collaborative centers, too, have been an important part of the relationship between the WHO and the School. In 1981, the WHO-Harvard University Collaborating Center for Cancer and Biostatistics linked the School’s biostatistical expertise with the WHO’s planning, conduct, and evaluation of cancer control programs. Center faculty provide consultation and evaluation for the activities of the WHO cancer unit based in Lyon, site of the International Agency for Research on Cancer, which was established under the WHO’s auspices, in order to find means of preventing cancer that are effective and accessible to the people of the developing as well as the developed world.

In 1988, the WHO designed its first international collaborating center for health legislation. With AIDS as it’s first focus, the Center was placed at the School, largely because of the reputation of late faculty member William J. Curran, S.M.H.’58, founding director of the School’s health law program. The center conducted the first international survey of AIDS-related legislation and has tackled such topics as international guidelines for dealing with drug and alcohol abuse. The WHO recently established a similar collaborating center with the Department of Nutrition, which seeks to draw on the School’s longstanding strenths in nutritional EPIdemiology and international nutrition.

Perhaps the most important byproduct of HSPH-WHO collaboration is the recently completed Global Burden of Disease study. Led by Professor of International Health Economics Christopher Murray and WHO colleague Alan Lopez, this landmark study is the first attempt to develop a comprehensive set of estimates for patterns of mortality and disability for 107 chronic and infectious diseases ranging from AIDS to heart disease to depression. Originally intended to correct many of the discrepancies and inconsistencies in global reporting of disease prevalence and incidence, the study ultimately revealed some startling insights about global disease trends, including the fact that some non-fatal illnesses, such as depression and diabetes, are a heavier health burden to societies and the world than many fatal illnesses.

To do the study, Murray, Lopez, and more than 100 collaborators around the world analyzed 14 million death certificates and used that information to rectify the often glaring gaps in disease incidence and mortality estimates. The first two of a planned 10 volumes were released in 1996 and include morbidity and mortality projections through the year 2020. Murray’s findings will be critical in planning for national health-care needs in the coming decades.

As the WHO enters its 50th year of protecting and preserving the health of people around the globe, it has more than 150 programs coordinated in Geneva and countless others directed by the regional offices. The WHO employs more than 5,000 scientists, researchers, and administrators in the Secretariat alone. From its headquarters in Geneva, it remains the health consultant to the world. The exchange of personnel, expertise, and resources that has characterized the relationship between the WHO and the School over the last five decades of this century will no doubt continue. Brundtland has emphasized the importance to WHO of partnerships with institutions and agencies at every level dealing with health. For his part, Mann believes that one of the things the School ought to be doing even more of is fostering its relationship with the WHO. "There is no meaningful distinction between the national and international arenas when it comes to health," explained Mann. "It is the School’s responsibility to continue its partnership with the WHO."

- Kevin Sottak