A Day in the Life of Hopkins Public Health
Profiles by Mike Field
8:30 a.m. the small window unit air conditioner in Nimesh Desai's
office is already running full blast. Summers in Delhi can be brutally
hot, and even here, in the midst of a 110-acre oasis of low-slung
buildings and green open spaces at the northeast tip of the city,
the noisy compressor's stream of cool air comes as a welcome relief.
Gazing out the windows from his office, Desai, MPH '01, sees an
expanse of green lawn punctuated by the Eastwhile Mental Hospital,
built in the 1960s. Under Desai's supervision, the grounds of the
former psychiatric hospital are being transformed into the Institute
of Human Behavior and Allied Sciences, a planned 500-bed teaching
hospital providing services in psychiatry, neurology, and clinical
As chair of the Institute's Department of Psychiatry and medical
superintendent of the Hospital, Desai sees patients and manages
campus academic and business affairs, as well as conducts research
in psychiatry and in his own subspecialty of substance abuse. Although
India has what Desai terms only "moderate addiction rates,"
heroin filters into the cities from Myanmar and the other Southeast
Asian nations, and the synthetic opiate buprenorphine is sold on
the streets in the form of tablets or powder.
aims to educate the health establishment and the public toward understanding
the "importance of social and behavioral sciences through programs
focused on the issues of health and behavior. Specifically,"
he says, "I want to focus on problems like drug abuse, HIV
transmission, and suicidal behavior."
Mental health programs face considerable challenges in India, a
nation where, according to Desai, there are only about 3,500 practicing
psychiatrists in a population of more than 1 billion. "The
number of trained clinicians will never be adequate in the next
20 years," he says. "A large part of society still doesn't
recognize psychiatry as a specialty. One of the things we strive
for is to get mental health issues addressed as part of our national
With need far surpassing available resources, Desai has turned
to his training in public health to help develop new ways of addressing
critical social problems. Shortly after a devastating earthquake
left thousands dead in the western state of Gujarat earlier this
year, Desai's team organized a project to bring mental health caregivers
together with grieving families. Another research project under
way involves studying suicidal behavior to learn how to predict
when troubled people will make an actual suicide attempt. Bit by
bit, Desai is helping forge a mental health infrastructure in the
world's second most populous nation — an effort he finds most satisfying.
"There is the old story about going into the quarry and asking
the workers what they're doing," he says of his 16-hour days.
"The first man says 'I'm breaking rocks.' The second says,
'I'm earning a living to support my wife and children.' Then the
third says, 'I'm cutting these stones that will go into a temple
that will provide solace to millions over thousands of years.'"
Desai pauses to consider his story. "That's what I like to
think I'm doing in helping develop these hospitals in India's public
service sector: building temples for humanity. I wouldn't trade
this for anything else."
At 9 a.m. Halida Akhter, MPH '79, DrPH '82, is in her office at
her desk, trying to reach government officials on the telephone.
Home pregnancy test kits — thousands of them — are en route to Dhaka
from a neighboring country. Since the kits are critical to her complex
maternal health study that will identify and track 54,000 pregnant
women over a three-year period, Akhter wants to make certain they
will make it safely into the country, intact and on time.
study in North Bengal will attempt to confirm previous findings
that have shown vitamin A supplementation at normal dietary levels
can significantly reduce maternal morbidity and mortality. Akhter
serves as co-principal investigator on the study with Keith West,
DrPH '87, MPH '79, professor, International Health. Two decades
ago, the two were classmates at Hopkins. Since then, Akhter has
become a respected Bangladeshi scientist, serving as director of
the Bangladesh Institute of Research for Promotion of Essential
& Reproductive Health and Technologies, which she founded more
than a decade ago.
"One of my major goals has been to develop a major research
environment in this country, particularly in the area of reproductive
health," says Akhter, who modeled her fledgling effort on the
U.S. Centers for Disease Control and Prevention where she worked
as a visiting scientist in the early 1980s.
She counts as one of the greatest successes of the Institute the
gradual shift in government emphasis from family planning to the
broader scope of reproductive health. "For many years the model
was the mother and child. But that didn't include adolescent health,
unmarried women, or young girls in puberty. We pointed out that
it's important to take a life cycle approach, and now the country's
health program is based on the reproductive health model."
research training and expertise will be critically important in
the months ahead as the micronutrient supplementation study gets
under way. The effort, funded largely by USAID, the Bill and Melinda
Gates Foundation, and the Canadian government, presents a daunting
task. In a remote district of 900 square kilometers traversed mainly
by paths and primitive country roads, she will induct a platoon
of 800 health care workers (most of them local women) in 56 teams.
Each month they will go house to house throughout the region's 600
villages offering free pregnancy tests to women who have missed
a menstrual period.
The goal is to enroll at least 18,000 newly pregnant women per
year in the study. Those who enroll will be supplemented with vitamin
A every week for the duration of their pregnancy and three months
postpartum. If the study results duplicate a similar investigation
completed recently in Nepal, the vitamin A supplementation will
lead to significantly better health outcomes among the pregnant
"I have an advocacy role not only for women's health, but
also for being a woman scientist. I am always keenly aware of my
obligations as a role model in this country," she says.
Hamburgers. These days in the go-go international city of Seoul
many workers spend their lunch breaks munching that quintessential
American fast food — along with fries and a soda — much like their
counterparts in the U.S. Strolling through the campus of Seoul's
prestigious Yonsei University, Seung-Hum Yu, DrPH '82, observes
student infatuation with the increasingly common convenience foods
of Western industrialized nations. And this worries the professor
of Preventive Medicine and Public Health.
A specialist in Health Policy and Management who serves as director
of the university's Institute of Health Services Research, Yu has
focused much of his career on studying the South Korean system of
health care as his country rebuilt from a devastating war and emerged
as a major world economy. Much of the research originating at Yonsei
University has focused on comparing the Korean health care system
with those of neighboring countries. Yu is one of the country's
leading experts at finding ways to improve it.
South Korea, national health insurance was introduced in the late
1970s, and universal coverage was achieved by the end of the 1980s.
Today, many of the challenges facing the system are similar to those
in other developed nations: Soaring medical costs led by advances
in medical technology and pharmaceuticals have created fiscal deficits,
unhappy providers, dissatisfied patients, and emotionally charged
issues of health care rationing. But as intractable as many of these
problems seem, there is a larger issue confronting professor Yu
"My new project is to help Koreans improve their quality of
life," Yu says. In a highly urbanized environment like South
Korea (which has a higher population density than Japan), quality
of life issues involve more than simple access to reliable health
care. "It's not only medicine, it's social services and the
environment and lifestyles," Yu says. The rapid inroads made
by the Western fast food diet among Korea's young are just one example.
"In recent years the average income level has been quite increased.
The per capita income now exceeds $10,000 and many younger people
eat a Western diet with a lot of meat." The results, he says,
are predictable: "Twenty years ago, myocardial infarction was
quite rare. Today, it's common."
Alumni Benefit: Lifelong Continuing Public Health Education
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Nationally, the Korean government has engaged in a vigorous anti-smoking
campaign for several years that has curtailed smoking in public
places, raised tobacco prices, and had some success in reducing
numbers of smokers. But despite the program's achievements, the
government has been slow to initiate similar efforts in diet, exercise,
and healthy lifestyle choices. Yu hopes to initiate a quality of
life movement that will encourage more people to move in that direction.
"Korean people spend their money on travel, on dining out,
on entertainment, but comparatively little on their health,"
Yu says. "This is common in newly industrialized countries,
so we will have to work hard to improve the health aspects of life."
After a long day spent battling infectious disease, Duane Gubler,
ScD '69, enjoys nothing more than a quiet dinner at home with his
wife. But during a chaotic period not so long ago, those dinners
were few and far between.
In the autumn of 1999, the news hit that a cluster of human encephalitis
cases in New York City was caused by the West Nile virus — a potentially
life-threatening disease new to American shores. The carrier was
apparently the tiny and somewhat reclusive mosquito Culex pipiens.
Gubler still sits in on weekly conference calls monitoring the
relentless spread of West Nile across the eastern United States.
As director of the Division of Vector-Borne Infectious Diseases
at the Centers for Disease Control and Prevention, he leads the
agency's efforts at surveillance, prevention, and control of the
virus. In 1999 he spent many long nights huddled with his staff,
coordinating the first public response to the outbreak. During that
time, the shortcomings of local public health infrastructure in
the U.S. became rapidly evident.
Nile was a wake-up call to a lot of people," says Gubler. "People
have forgotten that in the past we've had major epidemics of vector-borne
diseases in this country."
He worries that some of the conditions that have made disease outbreaks
so virulent in the past — such as high population density and poor
mosquito control — are all too common today. "One of our biggest
challenges right now is to rejuvenate our public health infrastructure.
We have to revive the research programs that were allowed to lapse,
and train the human resources we desperately need in state health
departments. And we need mosquito control programs and labs for
diagnostic support," he says, noting "the symptoms for
vector-borne diseases are often non-specific, so rapid identification
of diseases is imperative."
Ironically, it was the very success of public health efforts in
the United States during the 20th century that led to dangerous
complacency by the start of the 21st. "By the 1970s, we had
diseases like plague, dengue, yellow fever, and malaria pretty well
under control, which created a mind-set that these diseases were
a thing of the past. So resources were redirected," says Gubler.
"As a consequence, today we're unprepared. But with huge new
urban populations and the rapid intercontinental movements of people
and materials we've created ideal conditions for the dramatic resurgence
In New York, at the height of the West Nile hysteria, Mayor Rudolph
Giuliani ordered the spraying of pesticides from helicopters and
trucks. Though reassuring to many, Gubler observes that, in fact,
widespread spraying isn't the best way to fight a mosquito. Insecticide-spraying
trucks are usually a last-ditch effort. "What we need more
of in this country are effective mosquito abatement programs that
monitor the mosquito species present, observe where they breed,
and map their habitats," he says. "What you want is an
integrated type of approach that emphasizes larval control, water
management, and biological control. That's the best way to prevent
the risk to humans. We need to get away from this emergency response
the red-eye flight to a conference in Sri Lanka may not be everyone's
idea of fun. For orthopedic surgeon James Cobey, however, the late-night
flight out of Washington's Dulles airport is a labor of love. "I
practice orthopedics part time — about 60 to 80 hours a week,"
is how he describes his often frenetic schedule, "and do the
other stuff instead of playing golf."
What Cobey, MPH '71, calls the "other stuff" is his decades-long
commitment to international social activism. In the 1970s he helped
coordinate the Red Cross disaster relief effort in refugee camps
on Thailand's Cambodian border. In the 1980s he founded Health Volunteers
Overseas, which annually sends hundreds of doctors, nurses, dentists,
and therapists to help developing nations create sustainable local
medical programs. Then, in 1991, Physicians for Human Rights invited
Cobey to conduct the first epidemiological study of landmine injuries
among Cambodia's civilian population. That effort became a book,
Landmines in Cambodia: A Coward's War, which among other
findings asserted that as a result of landmines, 1 in 236 Cambodians
is an amputee (compared with 1 in 22,000 in the United States).
War quickly became one of the fundamental charters — and Cobey
an early member — of the nascent International Campaign to Ban Landmines.
In 1997 he joined several dozen other members of the organization
in Stockholm, where the ICBL campaign and campaign coordinator Jody
Williams were jointly awarded the Nobel Peace Prize.
Since then, Cobey's efforts to help bring about a complete ban
on anti-personnel mines have continued. On this night he is traveling
to Sri Lanka to make a presentation on getting each of the 140 signatory
nations to ratify the landmine treaty; 117 have done so thus far.
And of course, the greatest challenge is yet remaining — convincing
the United States, which declined to sign the treaty, to agree to
stop manufacturing, selling, and using landmines.
To date, the George W. Bush administration has shown little interest
in joining the international ban on landmines. "And that stops
other countries from signing on," Cobey says. "Their military
leaders say, 'The U.S. has the best military in the world. If they
need landmines, then we need them too.'"
Cobey, it's a matter of standing up to the military. "Historically,
the American military has never liked civilians telling it what
to do," he says. "But when you talk to retired members
of the U.S. military — none of the current brass will discuss this
on the record — you find out that a lot of them hate landmines.
Thirty percent of American casualties in Vietnam were from landmines.
Half of those were from our own mines - the Viet Cong would dig
them up and move them."
Cobey hopes to harness some of that hidden antipathy and apply
it where it matters most. To that end, he retains his faith in the
powers of personal persuasion. "I'm lobbying the White House
on landmines," he says. "I had a brief encounter with
[Secretary of State] Powell, and I'm trying to get in to see [Vice
President] Cheney. I believe I can help them appreciate the public
health approach to this issue - to think in terms of populations
and the overall needs of the country. That's what a degree in public
health does for you."