Friday, April 30, 1999
Dean Barry Bloom, a world-class immunologist with a passionate commitment
to understanding and combating global infectious diseases, joined the
Harvard School of Public Health in January 1999. Prior to coming to Harvard
in January, Bloom was an investigator of the Howard Hughes Medical Institute
and Weinstock Professor of Microbiology and Immunology at Albert Einstein
College of Medicine in New York, an institution with which he was affiliated
for 34 years. In his inaugural speech, which was given at a dinner in
his honor at the Charles Hotel in Cambridge, Mass., Bloom conveys his
tremendous enthusiasm for the public health research at the School and
offers a glimpse of his hopes and plans to make it the “Public Health
School for the Nation and the World” under his administration.
I feel not unlike the junior scientist of ancient Rome at Circus Maximus
University who regrettably failed to get his SPQR grants that year and
was banned from the school. It was worse in those days, and he was sent
to the Coliseum to be fed to the lions. After several non-academics were
polished off, a very fierce lion came into the room, and this poor fellow
was introduced. It looked pretty grim for the assistant professor, and
he went up to the lion and whispered in the lion’s ear. The lion
looked puzzled and then went back to his corner. The emperor was astonished.
He spared the life of this assistant professor and put him on the tenure
track once again, but had to ask him, “What did you say to the lion?”
And he said, “I simply said, ‘After dinner, there are speeches.’”
So I am sorry, after dinner there is a speech, and I truly hope you will
bear with me.
One of the themes of this speech is that people have trouble understanding
what public health is, partly because it’s so diverse, partly because
we don’t do a good job of communicating. Let me just summarize some
of the achievements that I think will be obvious to all of you, but I
still find astonishing. One of them is that life expectancy has increased
by 50 percent in this century over the earliest recorded life expectancies
in history. That is, of all the increases in life expectancies, most have
occurred within this century, and most have occurred before the middle
of the century with the introduction of great drugs, surgical procedures,
and vaccines. That’s public health. We heard today that in 1854
one of the first pioneers in public health, John Snow, found out that
there was a whole slew of people in London who died of cholera because
they got their water from a common pump. What’s interesting is if
you have traveled around the rest of the world, it is not to be taken
for granted that the water we drink does not cause cholera or diarrhea
or other illnesses. Yet we take it for granted here (except for occasional
outbreaks as in Milwaukee, where when the water wasn’t pure and
440,000 people got cryptosporidiosis).
We perhaps haven’t appreciated that there has been a decline from
1979 to 1990 of about 30 percent of deaths from heart attacks in the United
States. That’s an enormous contribution to health by both medical
and public health intervention. There’s been a drop of smoking from
1965 to 1990 from 42 percent to 25 percent. It’s not good enough,
but there has been some progress—and there’s a desperate need
for more progress since smoking is the cause of about 30 percent of premature
death and mortality around the world. This is the one avertable cause
of death we can make an impact on.
This year was the first time a drug, which is usually used for treatment,
can prevent cancer. The drug is tamoxifen. The impact on people at high
risk for breast cancer was prevention of about 45 percent: a spectacular
new advance in public health. We know that the population in the United
States and most of the industrialized world has reached almost steady-state
levels, and we know that infant mortality is down in the United States
by 26 percent in the last decade. There’s nothing more dramatic,
however, that I can convey to you about the power of public health than
the success of child immunization. The last case of smallpox in the world
was October 26, 1977. It cost $32 million for the entire 10 or 15 years
of the March of Dimes research effort to create a vaccine for smallpox.
Yet smallpox has been eradicated, and we save about $32 million every
20 days in not having to immunize people. So I relate for the first time
health benefits with economic benefits, and we’ll have more to say
Nine diseases have essentially disappeared in the United States, from
polio to diphtheria to whooping cough. One has only to look at Eastern
Europe to know what happens when you stop vaccinating. In 1974, 5 percent
of the world’s children had their childhood vaccines. In 1990, that
number was 80 percent. That is a spectacular achievement, but one about
which we can’t be sanguine because the rate hasn’t improved
in the eight years that have succeeded 1990.
The most spectacular event in public health—in a way not fully
accomplished—is the attempt to get rid of polio. I’ve spent
most of my life working on vaccines and being told you can’t do
it. You can’t do it in developing countries, because they just can’t
get it done. On December 6th and 7th of 1997, 121 million Indian children
received vaccines against polio in two days, administered by 2.4 million
volunteers. What this says is: if you want to do it, it can be done. And
if it can be done for polio, it will ultimately be possible to do it for
AIDS. That was possible, not in small part, because of Tom Weller at the
Harvard School of Public Health. With John Enders and Fred Robbins, he
created the possibility of growing the virus to make the vaccine—getting
it out of mice and into cells in a test tube that allowed it to be possible.
He has been an inspiring and encouraging mentor of mine. I’m thrilled
to be in the same institution as he, and I want to acknowledge that gift.
He created with his colleagues the knowledge that enabled the vaccine
to be developed. And when Nobel Prizes were given out, they were given
to him and his colleagues, not to Salk and not to Sabin. Not that they’re
not worthy scientists, but the value at that time was on the knowledge.
I think we all have to be enormously indebted and are privileged to be
associated with Tom.
My perception is that there are two big crosscutting issues in public
health. One is an unfinished agenda. We have wiped out many major infectious
diseases of children in the United States, but we have not done so in
the rest of the world. Polio is now a major push; measles will come next.
But there is a big unfinished agenda of new vaccines coming down the line.
Will the international community make the resources available so that
while our kids are protected, children in the rest of the world have a
chance to have a life? I like an American Indian proverb that says, “The
world is not left to us by our parents; it is lent to us by our children.”
We have an obligation to keep those kids alive and let them steward this
The other major issue is what we called in a report written by WHO, the
coming epidemic. And the coming epidemic is what happens when kids don’t
die before the age of five. The demography changes and people live full
lives but ultimately develop chronic debilitating diseases such as heart
disease, psychiatric disease, and cancer. The questions then are how to
deal with those problems. We need to have knowledge of the biological
basis for those diseases. We also need to know the social and environmental
factors that cause or predispose people to suffer from those diseases.
The aim of this business is ultimately to keep people alive, well, and
functioning to the very last possible time. Hopefully, they will die peacefully
in their sleep and not suffer immensely. That goal is not so hard to imagine
My goal is a bit arrogant, but clear. I believe the Harvard School of
Public Health has to be the “Public Health School for the Nation and the
World.” It has to become a think tank where leaders within this country
and around the world will choose to come. It has to be a center for public
discussion of issues. And most importantly, it has to create data that
people can trust and believe in, that are scientifically valid, and that
become data for decision making. That’s the vision that I have for
the School. I think the School is up to it. There are a lot of other schools
of public health, but the unique strength of the Harvard School of Public
Health is its analytical capabilities. We have ten departments; we have
15 cross-departmental centers; we have about 170 full-time faculty and
300 when you take people that come from the medical school and other schools
in the University. It has a diversity of interests in its mission: from
AIDS vaccines to the practice of public health in the Boston communities;
from children’s health to HMO’s health care management and
financing; from nutrition to the analysis of risks; from environmental
health and occupational health problems to parasitology; from the lifestyle
of insects, if you will, to the social determinants of health and illness
of humans. There is no place in the world that has the analytical skills
and capability of this institution, and the issue then is how to get that
recognized in a way that people can relate to.
The public health paradigm—and there is a paradigm—can be
summarized in three simple statements. The first is to define the problem,
the second is to identify the risks, and the third is to design interventions
to prevent the disease or the problem. The key step is defining the problem,
and the scientists at the Harvard School of Public Health have carried
out that data for decision making in ways that have impacted everybody’s
life. The Center for Risk Analysis has done a study of the injuries caused
by air bags and has caused the regulations in companies to completely
change air bags so more kids aren’t killed with air bags than are
killed in automobile accidents. Environmental Health has changed the EPA
standards for the tolerance and the impact of small air particle hazards
and has had a huge impact on the environment that we live in. Nutrition
has demonstrated the benefits of olive oil and broccoli, but also the
hazards of transfatty acids. And Population and International Health,
as I understood last week, is restructuring the entire health care systems
of countries. Last Thursday, the entire health care bureaucracy of Poland
was at the School of Public Health, deciding how to go from a socialist
system to a different system. In a year’s worth of work, with our
population and international health and health policy and management people,
they have developed a system that is not irrational. It’s a Canadian
system with regional payers, and everybody has health care coverage. We
contributed to that, and we should be very proud.
But perhaps no aspect of the data for decision making is more tangible,
in a way, than the studies of my long-time friend, Christopher Murray,
and his group on the global burden of disease. To go back to the paradigm,
the first step is do we know what the problem is—and we didn’t.
There are 209 disease categories listed by WHO, and we had not a clue
of what people died of or lost productive years of life from in developing
countries around the world. Chris undertook a heroic study, originally
for the World Bank, to find out the major burdens of diseases, causes
of premature death and disability, if you lumped them into 96 categories.
The work resulted in a list, and on the list in 1990 for developing countries,
perhaps not unexpectedly, is that communicable diseases are the major
cause of death. Not cancer; not heart disease. Infectious diseases. And
we see that we’ve wiped those out in the industrialized world. We
have to ask ourselves why we haven’t wiped them out in developing
Next on the list comes heart disease. Then comes cancer. Then injuries.
But Chris is also a modeler, and he’s projected a secular trend.
What is the world going to look like in 2020? It’s going to be a
very interesting place because the #1 developing country problem is going
to be heart disease, the same as we have in the industrialized world.
Depression will be the #2 cause of disability in the world, and injuries
will be #3. That is, the Third World will become, in health problem terms,
the First World. So we will have a common set of problems. We will need
a common set of strategies.
Chris has pointed out that if you look at the crudest measure of health,
which is life expectancy, no good health economist would say you could
learn very much from that. I would challenge that, but these are the numbers.
If you take the country in the world that has the highest life expectancy,
it’s Japan. Life expectancy is about 80 years. That with the poorest
life expectancy is Sierra Leone with about 43 years in 1990. (Now it’s
almost certainly less than 40 years because of the civil war.) When we
say there’s a 35-year or 40-year gap, it’s not a big deal
because this is a comparison of a really poor country and a really rich
country. Chris is now working for the World Health Organization, setting
up a burden of disease unit there to refine those numbers, to find out
the costs that are entailed, and to develop cost effective solutions appropriate
to the economics of each country. Before he did that, he decided to do
it in a very peculiar country called the United States of America, and
anybody could have done the same study. The data had been at CDC in Atlanta
since 1900, and only Chris Murray at the Harvard School of Public Health
was clever enough to get it out. The data that are available are life
expectancy in the United States by county, and the data are shocking.
They say that if you’re born in a rural county of Minnesota, you
will live on average 25 years longer than if you’re born in four
counties in South Dakota. You will live 23 years longer in a slew of counties
in Mississippi and Alabama. You will live 22 years longer than if you
were born in Washington, D.C., or Baltimore, Maryland. The disparity in
life expectancy between Japanese American women in Bergen County, New
Jersey, and people who grew up in South Dakota or the southern counties
is a 41-year disparity or variance in life expectancy. We don’t
know why. We assume the differences in disease would be very different
in different places. That strikes me as a public health agenda.
Public health is a challenge, partly because people don’t understand
it and partly because it’s intrinsically complicated to relate to.
For example, we understand our relationship with the physician, and we
understand curative medicine. But the main objective of public health
is not to treat people; it’s to prevent disease. That’s not
where the money is. That’s not where the glory is. Yet with managed
care now, and resources being scarcer, preventing disease makes a lot
more sense than spending a lot of money on treating people who are ill
and unable to function.
We are concerned not about individuals, but with populations and communities.
We don’t have a grateful patient. We are concerned, in biostatistics
and epidemiology, with processes that people cannot understand. What you
can understand is the great moments in medicine: the picture in the newspaper
of the doctor in the white coat with the bald kid who is going to make
it through his leukemia because he got an injection from the doctor in
the white coat. And that’s not unimportant. But who designed the
trials that made it possible to know whether that injection was going
to work? And who did the statistical analyses to know, with all the variables
in human frailties, whether that drug made a significant impact? I point
out to you that the biostatistics of the Dana Farber Cancer Institute
is manned by the faculty of the Harvard School of Public Health in a wonderful
and important collaboration. It’s hard for people to relate to that.
We work on medically unfashionable diseases, but crucial issues: radiation
effects, insect-borne tropical diseases, occupational and environmental
health, human behavior, risks for health injury, and violence. That’s
the Harvard School of Public Health. Not everybody wants to work on those
problems. Congress doesn’t want to fund all of those. But those
are the health problems that can be prevented if we do our job well.
You all know Tip O’Neill who had this wonderful line that says
all politics is local. You now know Barry Bloom, and Barry Bloom says
that all health is global. We have a major mission at the Harvard School
of Public Health to do this for the world. I would point out that the
Harvard AIDS Institute that comes out of the Harvard School of Public
Health has the longest acting program in AIDS in all of Africa. The Center
for Population Genetics at the School of Public Health has a potential
to do genetics, human genetics, on risks for disease, environmental risks,
and interaction with the genome on about two to three million people in
China. A third of our students come from abroad and make an enormous,
enriching contribution to the School, and a major challenge is to link
the expertise in health care policy and management, the hard sciences,
and the international program.
It’s a privilege to be here because the School, whether it knows
it or not, is engaged in some of the great debates in health of our time.
There’s a demographic transition that I pointed out where people
are living longer in some places, and there’s a tendency now to
shift resources in all of health away from children and into the chronic
diseases of adults. But I would point out to you that if you look at equity
issues, as David Gwatkin has done at the World Bank, that while infectious
diseases are only about a third of the cause of death in the world, in
the poorest 20 countries, infectious diseases are responsible for 79 percent
of premature death and mortality. There’s a reason to believe that
we owe it to those countries to target their needs in a way different
than those adult diseases, and we need to do that in a thoughtful way.
There’s a major issue in the School, a debate between the cost of
health care and the quality of care, and that will permeate the entire
debate on what is appropriate in medicine. We collect the data on both
the quality and the cost to try to make that assessment. There’s
a debate about what’s important, whether it’s really important
to provide access to the poor to health, whether that will do it. There
are studies that show, for example, that if you look at health outcomes
of the poorest segments of society, either in Chicago in the United States,
or in England in the ’70s, they are about the same. The extraordinary
thing is that the British have a universal national health care system
and we have not. Yet, the outcomes are the same. So is access sufficient
to guarantee that everybody will have health? Or is it more complicated?
Is it working the system, or other things? Those are big issues that are
being explored within the School of Public Health.
There is also the debate of nature versus nurture. Where are the susceptibilities
to risks and health? Are they in our genes, or are they in our environment?
Can we control our genes? Not well, but we can find out about those risks.
Can we control our environment? You bet, particularly if we know enough
about our genetic risks.
There’s a big debate, and I’m pleased that Sudhir Anand is
here. He is a major player in that debate with Amartya Sen. What is the
role of health and economic development? Is health an important instrument
in increasing economic development? Healthy people make better producers,
better workers. Or is health an intrinsic value in itself, not just a
tool to be measured by economic productivity?
And finally, is health a human right? Or do we get concerned only about
humanitarian activities, that we do the best we can in the worst of circumstances?
Let me dwell on that a moment. The School of Public Health has a unique
center that exists nowhere in the world. It’s called the François-Xavier
Bagnoud Center for Health and Human Rights. Its first chair was well known
to everyone here: Jonathan Mann, who was tragically killed in the Swiss
Air 111 crash. I would remind you that the preamble of the charter of
the World Health Organization states in its very first paragraph that
the enjoyment of the highest attainable standard of health is a fundamental
right of every human being.
We have an enormous responsibility in creating a field and a discipline
that relate health and human rights, and we are actively searching for
a director for that program. But, in my judgment, there is a vision that
we could create that would be absolutely unique in the world. And the
question is: How do you measure human rights? In most cases, for civil
and political rights, they are measured by violations. You count skulls.
You count people behind bars. You count scars in people who have been
tortured. If we want to make health a human right, it’s too late.
People will be injured and maimed and destroyed. Whether that right is
the right of a nine-year-old girl to read at third-grade level, or the
right for every child in the world to be vaccinated. We have the tools
of epidemiology and biostatistics to go into any country and say if it
is a right that kids should be vaccinated, in a very quick time, we can
say whether Burkino Faso or the United States is fulfilling that right.
I believe we ought to do that. With that, and the way the world is changing,
we need to link humanitarian assistance, and humanitarian assistance and
rights are sometimes at conflict. Looking at the problem of women in Afghanistan,
the human rights people say there’s a limit below which we can’t
stay. We need a symbolic gesture to say this cannot go on. The humanitarians
will stay until the last woman in that country is destroyed. That’s
a debate that occurs at the Harvard School of Public Health.
Finally, there’s an increasingly urgent need to look at all aspects
of the ethical issues of health and medicine. And again, most ethical
concerns have been the transactions between the individual doctor and
the individual patient, the issue of pulling the plug or not. And the
challenge is to look at ethics of populations. Look at ethics of gender
and ask the question: Can we contribute something novel and unique? For
example, the economics of cervical cancer is very interesting. It is not
considered by WHO to be a best buy, although it’s the largest cause
of death in the world of women in developing countries from cancer. Is
there not an ethical and an equity need to create a special equity bonus
saying women have been left out of so many things? We can afford a little
extra to get rid of this cancer which is done simply by pap smears. It’s
an ethical concern of populations we should think about.
My favorite line in the Book of Proverbs is Verse 29:18. It goes very
simply: Where there is no vision, the people perish. The judgment on whether
this dean or any dean is a good dean should depend on how well they fulfill
that requirement. I’m not sure that I’m up to it, but I can
outline, at least at the first cut, my vision for some short-term strategies
that I think could make a difference in the School and elsewhere. The
first is to point out, as many of you have heard from me before, that
in 1996, Research America, an NGO concerned about health and biomedical
science, took a poll. They found out that in the United States, 77 percent
of people who were asked if they would pay a dollar a week for biomedical
research said they would. In that same year, Harris polls asked people
if they knew what public health was: 7 percent said yes, but nobody quizzed
them to know if they knew what they were talking about. That’s where
we start from. If people don’t understand what public health is,
it is partly our problem. That reminds me of the wonderful story of the
Oxford don who was seen with his robes and his bicycle, which unfortunately
had a flat tire. The flat tire was on the front wheel. An undergraduate
was peddling by and saw this poor don pumping like mad into the back tire.
The undergraduate came up to the poor, befuddled don and said, “Why, if
your front tire is out, are you pumping the back tire?” And his response
was, “I say, I always thought they were communicating.” That’s the
problem in public health. I think that we have to have a major undertaking
to improve communications about the Harvard School of Public Health, and
about public health in general. A couple of brilliant ideas have been
suggested by Jay Winsten and Bob Blendon. I’ll share a couple with
One is what we call the “public health minute,” which would simply be
to say, “44,000 people die every year of colon cancer. Did you know that
broccoli can prevent colon cancer to an extent? This is a public health
minute brought to you by the Harvard School of Public Health.” We could
do that every day for years and not run out of messages or a plug for
the Harvard School of Public Health. I would like to see that done. Bob
Blendon believes the public is interested in health only when there’s
a crisis; for example, Kosovo, and for the moment the interest in humanitarian
relief. We need to have a response to hot button issues and be able to
provide the expertise to inform the public, excite the public, and get
them engaged in thinking through those problems.
Finally, 750 students can come each year to the Harvard School of Public
Health, and there are vast numbers of young people desperate for the kind
of knowledge and expertise that we have. A major goal of mine would be
to set up distance learning programs so that we can reach first the policymakers
and the leaders in the ministries and universities and schools of public
health and medical schools, and ultimately students all around the world.
The Internet should be making that possible. We’re in the Stone
Age in that respect, and we have to move forward. I would point out that
the power of this kind of learning and communications is not to be underestimated.
The designated driver program was introduced in Sweden originally, then
was brought to the United States by Jay Winsten, dean of communication
at the School of Public Health. Within three years, 80 percent of all
high schools in America had a designated driver on weekends to keep kids
from getting killed by drunken drivers. And we have now a new reproductive
health Web page with regional sites all over the world, which is getting
400,000 hits a month, all set up by a very small dedicated team of wonderful
young people led by Orit Halpern. So we have a lot that we can do in the
way of communication.
The second goal or aim that I would love to be able to realize, many
of you heard about today. The School has a unique asset through the Channing
Laboratories, home to several great cohort studies of healthy people who’ve
been studied, some for 23 years. By looking back at the behaviors of these
people, Frank Speizer and his colleagues at the Channing Laboratories
have been able to establish whether broccoli is good for colon cancer,
or hormones are bad for breast cancer. It is a unique resource for the
assessment of extrinsic factors that are risks for disease. What the genetics
would add are the intrinsic factors that would enable us to define individual
risks and which would allow you, or me, to reduce risk for disease, based
on our genetic risks, by making lifestyle or environmental changes.
The third goal, and I would put it in my highest priority, is very simple.
It comes from another proverb, an African proverb that many of you know,
which is: If you give a man a fish, you will feed him for a day. If you
train a man to fish, you will feed him for a lifetime. We’re in
the business of training people in public health, and we need help. There
is a desperate need for support for fellowships to get the best students,
and my simple view is Harvard has got to get the best students if it wants
to keep the best faculty. As you know Jack Kennedy’s great line,
“Why not the best?” And that’s the question that I ask here. We’re
not competitive. We lose money on every training grant slot that we get
from the NIH because they don’t cover all the costs of a student.
I’ve been through every department now in the School, and number
one on the list of faculty is that we must make it possible for the best
students to afford to come and get the best education at Harvard. All
I can say is I have a very limited amount of funds at my discretion, and
I’m prepared to commit those into that program and would welcome
anyone who wishes to join me.
Let me end finally on an issue that permeates every aspect of what we
do, and the issue is the value of health. And the question is: What is
the ultimate value of health? We know health is expensive. It’s
14 percent of GDP. We know that there is great concern that health costs
are increasing too much. I’m going to ask you to walk through with
me the figure that you have at your place, and see if you can share with
me my interpretation of the value of health. What you see on this table
is a figure made by Sam Preston, a demographer at the University of Pennsylvania.
Every dot is a country where there are data, and it was published by the
World Bank in 1993. What it’s got on the up-and-down axis is life
expectancy and on the sideways axis, is normalized dollars, which converts
all the years into 1991 dollars. And as you look across, I would draw
two interpretations. The first is, if you’re really poor on the
income scale, you die early. That’s not news. But if you have minuscule
increases in disposable income, there is a significant increase that with
minimal resources—one can take people from very low probabilities
of survival and get them to survive. We’re talking about 4 to 5,000
1991 dollars, which can keep a whole lot of people from dying. It’s
not news to you that being poor gives you very high risks for early death.
But I think what’s news to me is that if you follow my dotted line
and ask what could you buy in 1900 if you had all the money in the world,
you could buy a lot of cars and I’m sure a lot of houses. But you
could not buy 20 years of health that with $5,000 per capita income you
could buy in 1990. What is it that you could not buy in 1900 with all
the money in the world? I would argue, in the broad sense, what you couldn’t
buy was knowledge, knowledge of public health. That’s why we need
schools of public health.
So, when everybody tells you that health is too expensive, I would ask
you, “How much is 20 years of life worth?” If it’s too expensive,
you win. I hate to use the economic arguments only, but they are major
arguments and they are highly determinative. But I would caution you about
linking the value of health only to economics. The simplest case is being
made now for AIDS, but it was made by historians and economists for the
Black Death in 1348. The argument is to take the AIDS case, that AIDS
is a good thing for developing countries. It kills off marginal labor,
stabilizes wage prices, increases wages, gets the people who survive to
be more productive. It’s exactly the same arguments that were made
for the Black Death in Europe that killed 30 to 70 percent of the population.
I find that argument absolutely morally obscene. It says that there may
be circumstances, which are not the best in macro-economic terms—but
life has a value, and we must value health as part of that. And I am privileged
to be able to know Amartya Sen, who won the Nobel Prize in economics this
year and who is an adjunct professor in the Center for Population and
Development Studies. He made the extraordinary case that if you want ultimate
moral and practical values, it’s not money, as the monitor said.
It’s not satisfaction or happiness or pleasure, as the utilitarians
said. It’s the capability to fulfill one’s functions, one’s
potential. If you’re sick, you don’t have that potential,
no matter how much money you have.
I guess my sense is it is hard for a dean as enthusiastic as I, looking
at the broad spectrum of problems, to have any kind of a perspective.
And so I would end with a wonderful perspective from Margaret Catley-Carlson,
who headed the Population Council and was head of the Canadian International
Development Agency, and it goes simply as follows: “The GNP of a country
tells you everything about a country that is not important. It doesn’t
inform you about the beauty of the countryside, the joy and the value
of its music, or the health of its children.” Public health has a great
agenda. I will need your help, advice, and support. I thank you enormously
for coming tonight and listening. Thank you.