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February 22, 2010

Deans Past and Present on Public Health's Future
The Annual 'We Three Deans' Lecture

Public health is all about looking forward—preparing for the next pandemic, developing a new vaccine or a more effective intervention.

In the area of family planning, however, Bloomberg School dean emeritus D.A. Henderson, MD, MPH ’60, proposes that it would be instructive to look back to a time of illegal abortions, lack of access to contraceptives and no sex education as a reminder of what life was like for women in the not-too-distant past.

Speaking at the third annual We Three Deans lecture on January 27 at the Bloomberg School, he said that too often during the past decade—a time Henderson refers to as “the dark ages of family planning”—he found himself thinking that he had actually lived through a period when women were essentially powerless over their reproductive health.

“There are those who would have us return to a late Victorian-type era when sex education was unknown and contraception and abortion were illegal under any circumstances,” said Henderson who  joined dean emeritus Alfred Sommer, MD, MHS ’73, and dean Michael J. Klag, MD, MPH ’87, to discuss “The Next Big Thing in Public Health.”

He stressed that government support and expansion of family planning services must be in public health’s future, following a decade of what he described as politically driven cutbacks and, in some cases, outright elimination of family planning and women’s reproductive health services.

Henderson saw firsthand the consequences of a lack of such services during his medical residency in upstate New York. His patients included unmarried, pregnant woman who were often cut off by their family and who sometimes viewed illegal abortion as their only choice.

“We forget this was a reality in our own country and not that many years ago,” he said.

Henderson said he’s encouraged so far by the Obama administration’s stance on family planning and reproductive health, noting that the president last month repealed rules that restricted federal money for international organizations that promote—defined as offering advice and counseling—or provide abortions overseas.

Klag echoed Henderson’s concerns, citing the related problem of population growth and its consequences.

“Climate change, what’s driving that is population growth,” he said. “Access to safe water and the problem of emerging contaminants, population growth is driving that.”
 
Klag also called attention to the alarming growth of chronic disease in developing countries, noting that 20 percent of the Indian population has diabetes, as well as high malnutrition rates in the country.

“People think of chronic disease as a condition in America and the developed world, but rates are very high in the developing world,” Klag said of the world’s leading cause of death.

For Sommer, the assignment to predict the next big thing in public health is, by definition, unknowable, he said. However, he exhorted students to create their own game-changing public health innovations, and recalled some examples from his own career.
 
“These examples were the products of unique opportunities provided by unique circumstances at a specific moment in time,” he said.
   
In the aftermath of a 1970 cyclone in East Pakistan that killed more than 200,000, Sommer needed a method of identifying populations of children most in need of emergency food supplies. He and his colleagues learned of a practice employed in emergency Quaker Service Teams in Nigeria in the early 1960s that involved measuring arm circumference as a way to gauge nutritional status.

They refined the technique for use in Pakistan, and found that children in the bottom eighth percentile accounted for 56 percent of all deaths and had 20 times the mortality rate of children in the upper half of the percentile. 

 “Now arm circumference is the standard used in anthropomorphic measurements around the world,” said Sommer, who recalled that the paper on diagnosing malnutrition in the field was “almost impossible to get published.”

Sommer also recounted his efforts, during his residency in ophthalmology at the Wilmer Eye Institute, to identify a reliable way of diagnosing glaucoma at an earlier stage than other diagnostic methods, in the hopes of slowing vision loss with early treatment. Using existing data, he found thinning of the retinal nerve fiber layer to be an accurate predictor of a later diagnosis of glaucoma. Now, Sommer noted, there are three machines on the market for measuring nerve fiber layer loss.

Despite his reluctance to peer into the crystal ball of public health, Sommer offered this prediction:  “One next big thing comes straight out of the mess that is health care reform,” he said. “It’s huge and is right on top of us.”—Jackie Powder


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