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International Health

The Third Annual George G. Graham Lecture
Interactions of Nutrition and Infection

The program for this year’s George G. Graham’s Lecture was one of the most noteworthy events of the academic calendar. While honoring its namesake and advancing the work Graham devoted his life to, the proceedings also celebrated the 40th anniversary of one of human nutrition’s most seminal works: the World Health Organization’s 1968 monograph, Interactions of Nutrition and Infection, by Nevin Scrimshaw, Carl Taylor and John Gordon. And through a generous grant from the Middendorf Foundation, the Third Annual George G. Graham Lecture also marked the inaugural endowed Graham Lectureship, the first endowed lectureship in the Department.

Prof. West

Professor George G. Graham

The origins of the Lectureship can be traced back to the beginning of Professor Graham’s career at Hopkins as he transitioned from the School of Medicine to International Health. Graham had worked for years in Peru treating severely malnourished children, and his work there led to groundbreaking recovery treatments that are still in practice today. His commitment to improving infant and child nutrition in some of the most remote and neediest places in the world, as well as his conviction that infection control and fighting malnutrition must go hand in hand, led to the founding of the Department’s Division of Human Nutrition in 1976, with Graham as its founding director and first professor.

In 2005, in honor of his work, the George G. Graham Professorship in Infant and Child Nutrition was established by family, friends and protégés, with Professor Keith West installed as the first Graham Professor. In May 2006, Professor Kenneth Brown, a protégé of Dr. Graham’s and director of the Division in the mid-eighties, gave the first Graham lecture, which seeks to highlight challenges and advances in child and public health nutrition. Dr. William McLean, a long-time colleague of Graham’s, gave the lecture in 2007.

The Endowed Lectureship and the 40th Anniversary of the WHO Monograph

The Middendorf Foundation, a Baltimore-based organization, honored both Graham’s work and the Human Nutrition Program by endowing the Graham Lectureship so it can continue regardless of the overall financial climate. To celebrate such generosity, Professor West was pleased to realize that an important anniversary in human nutrition was upon us: the 40th anniversary of the WHO monograph Interactions of Nutrition and Infection, a groundbreaking work by pioneers in the field of nutrition and public health, Nevin Scrimshaw, the Department’s founding chair Carl Taylor, and John Gordon. In this monograph, the authors were the first to thoroughly conceptualize what would become widely known as the Vicious Cycle of Malnutrition and Infection, which was little understood or accepted at the time of publication. An impressive line of speakers agreed to participate, including the two lead authors of the monograph, who, now in their 90s, are still actively contributing to international nutrition and health.

The Vicious Cycle of Malnutrition and Infection

Since the celebrated work’s concept of the interaction between infection and malnutrition is still operational today, Dr. West organized the lecture to parallel that concept. Charles Stephensen, PhD, presented one side of the cycle: the effects of malnutrition on the risk of infection. Dr. Stephensen is a research scientist at the U.S. Department of Agriculture’s Western Human Nutrition Research Center at the University of California, Davis. He focused on the immune response to infection and the effects of malnutrition on the resistance to infection.

Claudio Lanata, MD, MPH, is a senior researcher at the Instituto de Investigacion Nutricional, Lima, Peru, where Professor Graham did some of his groundbreaking work in the 1960s and ‘70s. Moreover, Dr. Lanata received his MPH from Hopkins and was a student of Graham’s. He is an Associate faculty member of the Department and an honorary professor at the London School of Hygiene and Tropical Medicine. He examined the progress made in understanding the other side of the cycle: infection’s effect on nutritional status.

Department Chair Robert Black brought the two sides of the cycle together to look at the way forward in studying nutrition-infection relationships. He first outlined some of the questions that have been resolved over the past 40 or 50 years. For example, the evidence overwhelmingly shows that infectious diseases have a causal role in undernutrition. He also presented some new questions that have arisen, such as what role nutritional deficiencies have in microbial evolution, and whether nutrition-infection interactions factor into vascular disease, as some studies have suggested.

Scrimshaw and Taylor

Reflections by Taylor and Scrimshaw

The evening concluded with a discussion between Drs. Scrimshaw and Taylor about how, with John Gordon, the historic monograph came to be. Scrimshaw, emeritus professor at the Massachusetts Institute of Technology, compared it to navigating in the night without instruments. He described how in 1949 there was no accepted link between nutrition and infection, except for possibly TB. While there were some observational studies that pointed to nutrition’s role, the leading researchers at the time told him that he was completely off course.

Both Taylor and Scrimshaw pointed to Gordon’s Philosophy of Epidemiology class at Harvard as the event that made their work possible. Not only did it bring the three together, but work begun there led to a journal article in 1959 entitled, Interactions of Nutrition and Infection. Nearly 10 years later that article served as the basis for their celebrated monograph of the same name. While difficult to get admitted to Gordon’s class, Taylor acknowledged that it was certainly worth the trouble. During this course in 1953, the three began conceptualizing this vicious cycle, which Taylor eventually conceived of as synergisms and antagonisms, but which Gordon insisted on calling concatenations. Taylor’s nomenclature eventually prevailed.

Taylor and Scrimshaw humbly acknowledged the contributions of others who were working in the field. One researcher they singled out was Cicely Williams who in Ghana first described kwashiorkor, a severe form of malnutrition with symptoms such as hair loss and edema. Her findings from careful and thorough observation were also questioned by the status quo because malnutrition, rather than infection, appeared to cause the symptoms. As the evidence began to build, Scrimshaw, Taylor and Gordon became more convinced of the infection-nutrition interaction, and so set out to fully document the evidence and develop this unifying system that is still relevant today.

In a bow to the Lecture’s namesake, Dr. Taylor brought the discussion around to Graham and his contributions to the field and to the School. He recollected how Graham used the monograph to convince Dean Hume that Nutrition should be a Division within the School, an argument he finally won. Moreover, he used the evidence presented in the monograph to help move from the School of Medicine to Public Health. Dr. Taylor also praised current Chair Robert Black for successfully merging infection control and nutrition within the Department. 

Graham Speakers

Interactions of Nutrition and Infection: 40 Years Later

To commemo rate this momentous evening, each speaker was presented with a brass plaque fashioned in a Bangladesh village and engraved with a tribute to their contributions to the evening and the field of human nutrition. To mark the evening, the publisher Site and Life is also planning the future release of a book that will commemorate the original monograph and capture advances in the field of interactions of nutrition and infection over the past forty years. Stephensen, Lanata, and Black will contribute chapters that expand on their presentations. And, in perhaps the highest honor of all, the book will open with the first chapter and early forwards from the monograph, which unaltered 40 years later still describe the seminal concepts that guide researchers in the field of human nutrition today.

 --Brandon Howard, May 2009