Prevention as Politics
the re-awakening of public health's political conscience

Jonathan Mann, M.P.H.’80, is reflecting on a crucial time in his life, a time when everything he had believed up to that point suddenly seemed incomplete, even skewed. Speaking quickly, eloquently, he describes events 13 years and over 5,000 miles removed from the present and the frustration of trying to slow the spread of AIDS in East Africa in the mid 1980s.

Guided by the traditional public health paradigm of education begets change in behavior begets disease prevention, Mann, then assistant to the director of the Centers for Disease Control’s AIDS Program in charge of international activities in Kinshasa, Zaire, relied primarily on condom handouts and informational campaigns stressing the importance of using condoms to protect against HIV. But in time he came to realize that no amount of paper and latex in the world could change the fact that few of the region’s women had the power to say "no" when faced with unwanted or unprotected sexual intercourse. In Uganda, for instance, a married woman who refused to have sex with her husband risked divorce and economic disaster–even if she knew her husband was infected.

Mann asked himself: "What are the barriers to her actually carrying out her own choice? To really understand this woman is to unveil the factors in her society that affect her access to employment or to education."

For Mann, women at risk for AIDS throughout Africa became a prototype for a new way of thinking about health–a so-called "paradigm shift" that seeks to join public health theory to political and social realities. Simply stated, he believes that the condition necessary for every individual to enjoy the highest attainable standard of health is a full promotion and protection of each individual’s human rights.

In 1990, Mann followed this new line of thought back to Harvard, where it eventually culminated in the creation of the François-Xavier Bagnoud Center for Health and Human Rights at the School of Public Health. Under Mann’s leadership from 1992 to 1997, the center has been the academic focal point for a broad-based movement that seeks to unite two previously distinct enterprises: public health and human rights. Inherent in this new paradigm is the notion that public health research and practice must actively engage political and social injustice–a notion that many public health traditionalists balk at. And yet, Mann and others point out that the roots of this radically "new" vision for public health are, in fact, more than a century old. "We are heirs to a tradition that goes way back to the beginning of public health," says Mann.

One of the first to view health through the lens of politics was German pathologist Rudolf Virchow, the popularized patron saint of public health, who in 1849 stirred the placid waters of European medicine by challenging his fellow physicians to look beyond clinical manifestations of disease to recognize and treat the poverty and other social factors that underlay so much human misery. Virchow’s beliefs were later echoed in the slogans and practices of the sanitary reformers who gave birth to modern public health.

In an interview for The People’s Health: A Memoir of Public Health and Its Evolution at Harvard, Barbara Rosenkrantz, professor of the history of science emerita, told author Robin Marantz Henig, that early on "public health was closely allied to social reform, openly, without any apologies." Examples of this alliance between health promotion and social activism abound. Legendary Harvard epidemiologist Alice Hamilton was an unabashed socialist who joined in the international protest over the executions of suspected anarchists Sacco and Vanzetti. Martha May Eliot, chair of the Department of Maternal and Child Health and long-time director of the Children’s Bureau, was influential in lobbying for federal programs for poor mothers and children. And famed Yale epidemiologist Charles-Edward Amory Winslow called for "the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health."

Yet, notes Rosenkrantz, this activist edge gradually was tempered by the rise of a more empirical brand of public health that viewed social reform as "subjective, politically tainted." By the end of World War II, scientific advances had given rise to a technology- and biomedicine-based public health paradigm focused more on combating pathogens and vectors than on addressing the broader social context in which they proliferated. Government funding for basic research on vaccines and antibiotics blossomed. The pesticide DDT was the primary weapon in the international malaria control efforts of the 1950s and 1960s. Medicine, meanwhile, had become big business, and doctors defenders of the status quo. In 1948, the American Medical Association, exploiting the prevailing anti-Communist sentiment of the day, helped defeat President Truman’s effort to institute a national health insurance program by branding it "socialized medicine."

During his 8 years on the School's faculty, Jonathan Mann, M.P.H. '80, launched the global health and human rights movement.

But even as biology and technology assumed center stage in this brave new era of public health, other forces were paving the way for a new brand of political consciousness. The sheer carnage and suffering unleashed by the Second World War led to the creation of a new global humanitarian doctrine: the Universal Declaration of Human Rights. Adopted by the U.N. General Assembly in 1948, the declaration asserted the "inherent dignity" and "equal and inalienable rights and fundamental freedoms of all members of the human family" and launched an international movement to protect and promote these rights. And the Cold War that followed raised the specter of man-made annihilation that made all previous disease epidemics seem like child’s play.

In response to these new realities, the past four decades have seen a rekindling of the political and activist consciousness within the health professions, marked by the emergence of international organizations such as Physicians for Social Responsibility (PSR), International Physicians for the Prevention of Nuclear War (IPPNW), and Physicians for Human Rights (PHR). Faculty and graduates of the School have been central figures in the creation and evolution of each of these organizations. Together with Mann’s François-Xavier Bagnoud Center for Health and Human Rights, which provides a kind of academic counterpart to the advocacy agencies, these organizations embody Virchow’s century-old dictum that politics is–or should be–medicine writ large.

As the cold war between the United States and the Soviet Union intensified and nuclear weapons stockpiles grew, the prospect of a nuclear war seemed imminent. By 1960 the two superpowers had amassed enough nuclear weapons to destroy nearly all life on the planet. Yet, in America, at least, the national mood was one of "can-do" optimism. Families built bomb shelters in their basements and backyards, while politicians and military experts openly discussed strategies and contingencies for winning a nuclear war.

At the School, however, a group of students led by George Saxton, M.P.H.’61, had been meeting and conducting its own study group and had come to a different conclusion. A Quaker and long-time grassroots activist, Saxton recalls being asked during student orientation what he thought was the most important public health issue facing the world’s people.

"Holy smoke, it’s nuclear war," he remembers thinking. "We have to do something about this." In an article published in the January 1961 Alumni Bulletin, Saxton argued that, given the untold death and destruction that would result from a full-scale nuclear war, prevention was the only rational response to the nuclear threat. Around the same time, Bernard Lown, a cardiologist in the School’s Department of Nutrition, was invited by a colleague to a talk in Cambridge. The speaker was the British diplomat Philip John Noel-Baker, winner of the 1959 Nobel Peace Prize for his role in founding the League of Nations. Noel-Baker spoke about the impending prospect of a nuclear Armageddon. Lown was transfixed.

"He was like an ancient Hebrew prophet," he recalled. "Here I was concerned with sudden individual death and here’s the potential for mass sudden death." Lown, the son of Lithuanian Jews who had emigrated to the United States in 1935, says what moved him most to take action was the disturbing parallel he saw between the proliferation of nuclear weapons and Nazi Germany’s orchestrated annihilation of 6 million European Jews: "We destroyed Hitler and we became Hitlerized in our a bility to design mass extermination."

Lown called together a group of colleagues and friends to discuss how they, as physicians and as health professionals, could educate the public about the fallacy of the belief in surviving a nuclear war. Calling itself Physicians for Social Responsibility (PSR), the group undertook an exhaustive study of the medical and public health impacts of nuclear war. Among those present at the founding of PSR was H. Jack Geiger, S.M.’60, a physician and veteran political activist who would become one of the organizations most active members. Geiger would go on to co-found the group Physicians for Human Rights.

On the basis of its study, PSR produced a series of articles that the group hoped to publish in the New England Journal of Medicine. Lown says that when he approached the journal’s editor, Joseph Garland, however, Garland scoffed at the idea. "We’re a medical journal…not a political journal," Lown recalls Garland saying. But the persistent Lown eventually convinced Garland to look at the articles to see if they met the journal’s rigorous publication standards. Lown says Garland called him at the end of the day and agreed to publish the studies, which appeared under the title "The Medical Consequences of Thermo-nuclear War," in the May 31, 1962, issue of the journal. In an impressive 29 pages, the articles described what would occur if a single nuclear bomb fell on Boston: Nearly three million people in Boston alone would die; over four million in Massachusetts. Some 5,000 physicians would perish. Nuclear fallout would poison the air and ground for decades.

Lown credits the articles in particular with "bursting the bubble" of the idea that, if enough money was invested, everyone could move underground in a massive network of shelters. "The shelter would be the most dangerous place to be because the firestorms would consume the oxygen and you’d be suffocated miserably and incinerated," he says. Physicians, wrote Garland in his introduction to the articles, should be interested in this problem because "no single group is as deeply involved in and committed to the survival of mankind."

Over the next two decades, PSR continued to work towards the elimination of nuclear weapons and other instruments of mass destruction. It saw some hope in 1968 when the Nuclear Non-Proliferation Treaty was signed by the United States and 137 other nations. But by the early 1980s, when Ronald Reagan won the U.S. presidency on a strong arms build-up agenda, discussions of the strategic use of nuclear weapons and "Star Wars" defense systems prompted Lown to take a new approach to his campaign for nuclear disarmament. On travels to the Soviet Union, he had met Yevgeni Chazov, then director general of the Cardiovascular Institute and personal physician to Leonid Brezhnev. In 1980, Lown wrote to Chazov, asking if he would be interested in launching an international collaboration of physicians to prevent nuclear war. Chazov agreed, and the following year the organization International Physicians for the Prevention of Nuclear War (IPPNW) was born.

Like PSR, IPPNW sought to draw on the special status of health professionals as impartial arbiters of political and social trends, individuals whose only objective was to protect and preserve health. Unlike PSR, IPPNW was, from the start, an international partnership that set a high-profile example of cooperation between two ideologically opposed adversaries.

IPPNW co-founders Bernard Lown (left) and Yevgeni Chazov.

Four years later, in 1985, Lown and Chazov traveled together to Oslo to accept the Nobel Peace Prize on behalf of IPPNW. To this day, he is Harvard’s only Nobel Laureate for peace. In 1993, to mark Lown’s retirement from the leadership of IPPNW, President Mikhail Gorbachev sent him a note, dated September 6 and written on the back of the inf treaty, the first substantial anti-nuclear agreement between the two superpowers. Framed and hanging on the wall in Lown’s office, it reads, in part, "I want to thank you for your great contribution to preventing nuclear war."

Another faculty member who spoke out against the folly of nuclear war was Dean Howard Hiatt. In 1981, Hiatt joined members of the Pontifical Academy of Sciences to make a personal plea to President Reagan to consider the tremendous medical consequences of a nuclear war. Three years later, in an article in JAMA, Hiatt argued further that, given the incredible need for medical care in this country, and especially in the developing world, the cost of the proliferating arms race was an irresponsible waste of resources. There is a distinctly Vichowian echo in Hiatt’s call for reapportioning military expenditures toward social programs. In 1869, Virchow presented a motion for disarmament to the Prussian parliament, noting that while funding for weapons was increasing, moneys for education had remained stagnant.

Even as fear of "the bomb" galvanized one contingent of health professionals to political action, the rise of repressive dictatorships and regional and civil conflicts in South-east Asia, Africa, and South and Central America sparked a different form of medical activism. Reports of widespread torture, slaughter, and displacement of civilians by armed militia and paramilitary groups led to a recrudescence of humanitarian relief efforts. In War and Public Health, Barry S. Levy, M.P.H.’70, and Victor W. Sidel note that, since the end of World War II, the percentage of civilian casualties during military conflicts has increased from 10 to 90 percent of all casualties.

Equally distressing to health-care professionals was the apparent disregard for medical neutrality in many areas of conflict, in clear violation of the 1949 Geneva Conventions, which mandate nondiscriminatory access to medical care and protection of hospitals and health-care workers during wartime. In El Salvador, health-care workers were beaten, imprisoned, or killed for providing vaccinations. In Chile, physicians were arrested for providing medical care to people whom the government considered terrorists. And in many war-torn areas, soldiers entered hospital wards and shot patients lying in beds.

Health professionals had been involved in humanitarian relief missions for over a century, largely under the auspices of the Swiss-based International Committee of the Red Cross (ICRC). Founded on bedrock principles of political neutrality, ICRC volunteers set up field hospitals to care for civilian and military casualties on both sides and ensure that combatants obeyed the rules of war listed in the Geneva Convention. In the wake of World War II, however, organizations such as Medecins Sans Frontieres arose that challenged the Red Cross’s unswerving commitment to neutrality, especially in civil conflicts in which unarmed civilian populations were targeted by heavily armed militias or government forces.

Assistant Professor Jennifer Learning, S.M. '70

In 1983 representatives from the International League for Human Rights and the aaas Committee on Scientific Freedom and Responsibility went to Chile, Uruguay, El Salvador, and South Africa to document the effects of abuse on citizens. One of the physicians to go was Jonathan Fine. Upon his return to the United States, Fine, a long-time member of both IPPNW and PSR, met with another Boston physician, Jane Green Schaller, who had just returned from South Africa, where she had witnessed similar evidence of brutal police attacks on blacks protesting apartheid. In 1986, Fine and Schaller called together a number of their professional colleagues, among them the ubiquitous H. Jack Geiger, and launched the organization Physicians for Human Rights (PHR).

PHR’s mission is to "bear medical witness" to human rights abuses by documenting the physical and psychological evidence of those abuses. PSR study teams perform autopsies and conduct forensic studies on human remains to determine whether torture, abuse, or murder have occurred; they interview and examine survivors about alleged human rights abuses; and they use the tools of epidemiology to assess the civilian toll of war and armed conflict. The scientific documentation of these abuses, conducted by trained professionals, stands as credible evidence in courtrooms and inter-national tribunals; without such documentation, the stories of beatings and other abuses would only be tales.

PHR physicians are "giving pain a face and death a name," said Jennifer Leaning, S.M.’70, instructor in health and social behavior, speaking at PHR’s tenth anniversary symposium last year in Boston. Leaning is one of many hsph faculty and alumni who have led fact-finding missions under the auspices of PHR. In 1988, Leaning teamed with fellow graduate H. Jack Geiger, S.M.’60, to report on the status of medical care in Israel’s West Bank and Gaza Strip. Two years later, at the request of exiled scientist Andrei Sakharov, Leaning traveled to Tbilisi in Soviet Georgia under the auspices of PHR to document the harm caused when Soviet troops broke up a peaceful demonstration using entrenching spades and gas believed to have been toxic. Sixteen people were killed that day, another four died later, and hundreds were injured.

The list of faculty and graduates who have been affiliated with PHR is long and growing. Paul Wise, M.P.H.’78, assistant professor in the School’s Department of Maternal and Child Health, was part of a team that investigated the "human costs" of Operation "Just Cause," the U.S.-led invasion of Panama in 1988. Howard Hu, S.D.’90, M.P.H.’80, associate professor of occupational health, has led fact-finding missions to evaluate the use and effects of tear gas. In 1987 he went to Seoul, South Korea, and in 1991 to Myanmar, formerly Burma. Paul Epstein, M.P.H.’83, lecturer in the Department of Population and International Health, went to the Turkey-Iraq border region in 1991 to assess the medical condition of over 2 million Kurdish refugees following the Persian Gulf War.

Leaning’s extensive experience in some of the world’s hottest hotspots has led her to try and identify societal elements, especially breakdowns in public health, that prime an area for the type of civil unrest and armed uprisings that have occurred during the past decade in Somalia, Haiti, and the former Yugoslavia. Leaning’s work as director of the Program on Complex Humanitarian Emergencies seeks to identify the key characteristics, such as massive population dislocation, extensive environmental destruction, and high levels of civilian insecurity that render a community vulnerable to disintegration. She hopes that by identifying factors that precipitate these crises, public health professionals and politicians may begin to be able to anticipate, prepare for, and, ideally, prevent them from occurring. The idea of preventing armed conflict would seem a quaint, post-sixties "save-the-world" notion if it weren’t for Leaning’s clear-eyed determination and the fact that her beliefs echo the hopes of an earlier hsph graduate who witnessed first-hand the devastating consequences of war. In a 1944 essay in the Alumni Bulletin, Brigadier General James Stevens Simmons, S.D.’39, who subsequently became dean of the School, wrote: "One might be allowed to hope that eventually, through the development of preventive medicine, it will be possible to prevent the most pernicious of all diseases, war itself."

Mann’s François-Xavier Bagnoud Center for Health and Human Rights serves as an intellectual bulwark for and collaborator with PSR and other organizations engaged in front-line humanitarian relief and human rights activities. Mann says that the foundation for the center’s mission is the 50-year-old Universal Declaration of Human Rights. Perhaps because only one of the declaration’s 30 articles deals explicitly with the right to health, health professionals did not immediately rally behind the declaration, and the human rights movement for much of the past five decades was dominated by legal and political activists.

But Mann, reading the document four decades after it was published, saw it differently: "What struck me was that reading it from a public health perspective, the whole declaration is about health and the social conditions people need to be healthy." To his mind, the right to not be held in slavery or be tortured, the right to privacy and equality before the law, and the right to an education and to practice one’s religion–all directly impinged on health. From this realization, Mann devised a simple but profound equation: for each human right denied to an individual or community, there is a negative impact on health. The strategy that grows from that equation–address the underlying human rights issues, and increased health will follow–is the basis for what he proposes as a new framework for public health.

"[The authors of the U.N. Declaration] basically said that if the Universal Declaration is realized, then the societal preconditions for human well-being will be met. There will still be Mozarts and there will be people who can’t carry a tune, but the basic fundamental principles for human well-being, that allow the individual to flourish, will be set, and the social conditions for health will be advanced," he says. "This is exactly where I position public health."

In an effort to spread his new gospel of public health, Mann, upon joining the School’s faculty in 1990, introduced the practice of handing a copy of the human rights declaration along with the diploma to every graduate. He also began designing courses on health and human rights, both at the School and at the faculty of arts and sciences and Kennedy School of Government.

Mann’s pursuit of his new vision got a lift in 1992, when a Swiss countess, Albina du Boisrouvray, gave the School a $20 million gift to fund the François-Xavier Bagnoud Center for Health and Human Rights and the François-Xavier Bagnoud Professorship in Health and Human Rights. "To me, [Jonathan Mann] was a warrior fighting against AIDS at large, standing for health and human rights, committed to rescuing the discriminated, the most destitute, the most vulnerable ones," said du Boisrouvray at the dedication of the François-Xavier Bagnoud Building in October 1996.

Inscribed on the outside wall of the new building, in the six official languages of the World Health Organization, is a PHRase from the who’s Constitution: "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being."

Mann, who last year left the School to become dean of the Allegheny School of Public Health in Philadelphia, believes that the health and human rights movement whose seeds he helped sow is finally beginning to flower. During his keynote speech at the Second International Conference for Health and Human Rights, held at Harvard in October 1996, Mann described this new covenant between public health and human rights in terms that suggested a rebirth: "The tectonic plates are shifting, but it is at the intersection of health and human rights that the most radical transformation is occurring, and it is there that the future will lie. We are in the vanguard of a movement. We have a deeper belief that the world can be changed, and in doing that, we give value to the world."

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