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Public Health & the Future of Medicine
The spring of 1972 found the SS Hope, a floating hospital ship, anchored in the harbor of Natal, an impoverished town on the northeast coast of Brazil. On board was Michael H. Merson, a medical resident at Johns Hopkins with a deepening interest in the health-care issues of the developing world. “I wanted to know more about diseases you didn’t see at Hopkins, and I wasn’t disappointed,” says Merson, who last April was named Yale’s first dean of public health and director of the medical school’s department of epidemiology and public health (EPH). “I dealt with all sorts of ailments: malaria, schistosomiasis, typhoid, leprosy—Natal was a museum of tropical illnesses.”
And then some. Infant mortality was appallingly high. Family income was low. Each day’s roster of the infirm conveyed an unavoidable message. “The society these people lived in was making them sick,” recalls Merson. “In Brazil, I got to see first-hand the relationship between health, social, and economic problems. That experience made me want to go into public health.”
Twenty-three years later, and after stints at the U.S. Centers for Disease Control in Atlanta and at the World Health Organization in Geneva, Merson, 50, comes to Yale to direct an institution that, like healthcare itself, is undergoing a period of rapid change, not to mention soul-searching. “Mike’s an outstanding public health activist and a real leader who can help EPH develop a consensus about its direction,” says Gerald Burrow, dean of the Medical School. “The program here can’t be all things to all people.”
Burrow’s statement reflects a problem that goes back to the very beginnings of the discipline, which traces its origins at Yale to 1915. In that year, Charles-Edward Amory Winslow became the Anna M. R. Lauder Professor of Public Health. (Winslow, incidentally, had studied with, and worked for, William Sedgwick, Class of 1877S, who had taught at the Medical School before starting the nation’s first public health school at M.I.T., in 1906.) In establishing Winslow’s department, the University bucked both a trend and the recommendation of the Rockefeller Commission. Schools of public health, said those who had inaugurated them and those who were evaluating the enterprises, should remain separate institutions. Such was the case at M.I.T., Harvard, Johns Hopkins, and elsewhere, but at Yale (and also at George Washington University), public health was made a department of the medical school—precisely the situation the Rockefeller Commission sought to avoid for fear that the discipline—which deals with the health of populations—would be overshadowed by medicine, which is concerned primarily with the health of individuals. (Epidemiology, the study of the factors that affect the occurrence of a disease in any population, was added to the department’s name in 1960.)
While this unusual arrangement worked well for decades, the occasion of a major—though routine, say officials—review of the program in the late 1980s had many in the department uncertain about EPH’s future. However, the work of a study group headed by then-provost Frank Turner in 1989 resulted in the University’s reaffirming its commitment to the discipline. Six years after the Turner Commission issued its report, the school has revamped its curriculum, tightened admissions standards, and begun to overhaul its Philip Johnson-designed headquarters on College Street. The most conspicuous sign of Yale’s renewed faith in the future of EPH is not only that it has hired someone of Merson’s stature to run the program, but that it has granted him the title of dean, which (except for engineering) is reserved for heads of free-standing schools rather than departments.
At the moment, Merson’s department has more than four dozen full-time faculty members and nearly 200 graduate students who work and train in six distinct areas—chronic disease epidemiology; health policy, resources, and administration; environmental health sciences; international health; the microbiology and epidemiology of infectious diseases; and biostatistics. Where the new dean intends to lead his organization, however, is currently under debate.
“This is an exciting and challenging time to be in public health,” says Merson. Indeed, the entire health-care delivery system of the United States is undergoing revolutionary change, so there is health-care policy to effect and analyze. The recent outbreaks of Ebola in Africa and plague in India, as well as the reemergence of tuberculosis in American cities and the continuation of the AIDS epidemic, are reminders of the urgency of the need.
That public health in general and EPH in particular have important roles to play in dealing with these and related issues has never been more obvious, says Henry Chauncey Jr., who joined the EPH faculty as director of its program in health policy administration after serving as president of the Gaylord Hospital, a Wallingford, Connecticut, facility that specializes in rehabilitation. “It’s axiomatic that if you want to cut the costs of health care, you need to have less illness and increase the quality and availability of care,” notes Chauncey. “Public health holds the answers.”
To determine which answers EPH is in the best position to provide, Merson has instituted a top-to-bottom review by faculty and administrators of everything the school does. “We’ve always provided a solid education in public health that focused on epidemiological methods, and since we started, we’ve been on the cutting edge of research. This will certainly continue,” he says. But to take advantage of new opportunities, a certain amount of change is also necessary, and while it is too early in the review process to know precisely where the institution is headed, its new dean has singled out a number of areas to explore.
“Last year, the federal government made an effort to draft a national health care plan, which, as we all know, wasn’t accepted,” says Merson. “In its absence, market, social, and political forces have moved forward to quickly bring more and more people under a managed care framework. Trying to figure out whether or not these rapidly evolving systems of managed care are cost-effective and efficient is now becoming a public health responsibility. We need to be involved.”
The prevention of disease has been a key part of the discipline since its inception, and here too, managed care systems have to be watched carefully to ensure that they don’t stint on this critical function. “We’re now reaping the benefits of prevention research of the past 30 years, research that has shown that 70 percent of mortality can be viewed as premature,” says Merson. “So another challenge is determining how we should organize our approach to prevention in a managed care context.”
Then there is the aging U.S. population to consider. “How do we best care for the aged?” asks the dean. “How do we prevent diseases and age-related ailments like broken bones due to falls? How do we deal with the dying? These are certainly issues public health needs to deal with.”
EPH researchers are already working in this area, as they are in another topic on the dean’s agenda: emerging and re-emerging infectious diseases, as well as noninfectious ailments like asthma and Alzheimer’s disease. “For reasons we don’t always understand, we’re getting new problems, old ones are resurfacing, and uncommon illnesses are becoming more common,” Merson notes. “We in public health need to figure out why.”
Figuring that out falls within the traditional domain of epidemiology; understanding how to prevent the ailments they cause is a key part of the public health discipline. Merson would like to bring both parts of the EPH arsenal to bear on a problem Yale is already involved in: eradicating urban decay. “A challenge for us is how to help get healthy cities,” he notes. “It’s not enough to ensure that there’s access to good health-care systems and preventive services. We also have to play a role in designing interventions that deal with the major social factors that affect the population. Why are people violent? Why is there drug abuse? These are not just medical questions, and if we’re ever going to solve them, we need to adopt a broader view of health.”
In the current health-care climate, the fact that EPH is part of the Medical School, rather than in competition with it, is a major advantage, says William Kissick '53, '57MD, '61DPH, the George Seckel Pepper Professor of Public Health and Preventive Medicine at the University of Pennsylvania. Kissick, one of the fathers of Medicare, is a strong proponent of linkage. “No society in the world has sufficient resources to provide all the health services its population could utilize, so real health-care reform will require the application of public health principles to medical practice,” he explains. “Each discipline desperately requires the other.”
Such a synthesis already has a long, if sometimes strained, working history at Yale, but the strains seem to be easing in an era when, according to Merson, “the line between medicine and public health is becoming less and less clear.” There is, for example, a Clinical Scholars Program in the Medical School in which physicians are studying how to provide better treatment by understanding epidemiology and policy issues. Another example of the advantages of togetherness occurred during the curricular changes inaugurated in the early 1990s. At that time, faculty members decided that it was critical for students in the two-year master of public health degree program to understand the basics of molecular biology. “At the very least, they should be able to distinguish a bacterium from a virus,” said Michael Bracken, a professor of epidemiology and public health who was instrumental in putting together the new curriculum. (Unlike many schools, Yale requires both a thesis and a community project.) Because of Yale’s “extraordinary strengths in molecular medicine,” developing such a course was relatively easy, says Bracken.
More such “bridge-building” efforts will, Merson predicts, enable EPH researchers to move quickly into new areas by drawing on the existing resources of other graduate and professional schools, as well as on those of Yale College. The advantages of this integrated approach appealed to the Pew Charitable Trusts, which recently awarded EPH a $300,000 grant to develop a course being offered this semester on urban health. The program is designed to bring together medical, public health, and nursing students to work on problems that might best be solved by combining the strengths of both groups. Similar initiatives are underway between EPH and the School of Forestry and Environmental Studies, with the Child Study Center, with the John B. Pierce Laboratory, and with the School of Management. The collaboration with SOM involves the development of a new health-care management track for master’s degree students. “We’ve been very strong in hospital management training,” says Merson, “but managed care will require professionals who can deal with much more than just hospitals.”
Clearly, the discipline is changing, but in deciding how to respond, Theodore R. Marmor, a professor at the School of Management, offers words of caution. “I hope Merson won’t get so caught up in trying to do the highly desirable that he pays no attention to the doable and to the legacy of public health,” says Marmor.
There is probably little likelihood of that happening, for Merson is nothing if not well-grounded in the basics of the discipline (even though, ironically enough, he has no degrees in public health). Growing up in Brooklyn, the dean was heavily influenced in his career path by his grandfather, a cardiologist who had the boy drawing blood while still in high school. At Amherst College, Merson majored in biology, but he also pursued studies in political science and government. “I’ve long been interested in a broader view of health—in issues of social justice and equity, as well as in medicine,” says Merson.
These dual concerns came together for the first time in 1969 when, after his junior year at the State University of New York’s medical school in Brooklyn, he landed in New Delhi en route to a summer of family-planning work in Nepal. “I’ll never forget the smells of the Indian food or the beautiful colors of the saris,” Merson recalls, adding that in and around Katmandu, “I did vasectomies, inserted IUDs, and conducted a survey on what services were available. It was in the Himalayas that I got bitten by the international health bug.”
That experience, and his service on the SS Hope, showed Merson that while advances in medical research were able to provide treatments for many diseases, medicine, by itself, could not cure what ailed the developing world. Poverty, environmental degradation, development, and a simple lack of information—all of these had to be dealt with as well.
Merson’s opportunity to tackle the “broad spectrum of public health issues” came in 1977 when he became the chief medical epidemiologist at the Cholera Research Laboratory in Dhaka, Bangladesh. After finishing his residency, the physician had been working under the auspices of the U.S. Centers for Disease Control and had, in the course of publishing numerous papers on such topics as “gastrointestinal illness on passenger cruise ships” and “toxic turista,” become one of the leading experts in diarrheal diseases. In this country such ailments often fall under the category of nuisances—unpleasant but rarely life-threatening—but in Third World nations like Bangladesh, says Merson, these diseases were, when he began his work, “the major killer of young people.”
Two breakthroughs began to change that. In the early 1970s, microbiologists were finally able to identify many of the organisms that caused the various forms of diarrhea. This development allowed researchers like Merson to begin to understand the epidemiology of the ailment and thus to craft prevention strategies. At about the same time, a team of investigators and physicians (some of them from Yale) were perfecting oral rehydration therapy (ORT), a relatively cheap and easy way to prevent the dehydration and malnutrition that together cost the lives of many diarrhea victims.
In Bangladesh, Merson helped bring both innovations to bear on the health of a beleaguered population, and the results were quickly apparent. “We demonstrated that most cases of diarrhea were infectious in origin—believe it or not, that was controversial back then—and that they were treatable with ORT and antibiotics,” he said.
The World Health Organization at the United Nations took notice, and in 1978, Merson was invited to join WHO’s Diarrheal Diseases Control Programme, which was based in Geneva, and whose scope was world-wide. “We developed a very comprehensive approach,” Merson says, noting that in addition to pushing for advances in basic science and in the availability of ORT, the organization had a wide range of other items on its agenda: pure water, improved hygiene, vaccine development, and encouraging mothers to breast-feed their children for at least the first two years of life.
“As a result of what we did, at least a million childhood deaths a year were averted,” says Merson, who became the program’s director in 1984 and was asked in 1987 to tackle another major child-killer, pneumonia.
“In this country, when you want to diagnose the disease, you listen with a stethoscope and take an X-ray,” said the physician. In much of the developing world, however, even the most basic medical equipment is frequently unavailable. But research done in the 1980s showed that a reasonably correct diagnosis could still be arrived at by the most low-tech of means: counting the number of breaths a child took and watching the way he or she breathed. “With two simple observations, you could determine which kid needed antibiotics and which kid didn’t,” says Merson. “True, there was a tendency to overtreat, but with this approach, we estimated that deaths from pneumonia could be reduced by two-thirds.”
Flush with similar successes around the world, medical optimists had begun speculating that it would soon be possible to declare a victory over infectious diseases. Then came AIDS.
WHO responded to the epidemic with its Global Programme on AIDS, and in 1990, Merson was asked to head what was then a $100 million effort that employed 450 people. “This terrible disease poses the greatest threat to health on the planet, and for me, all the reasons I went into public health came together in running the program,” says the physician. “I was involved in setting policy, long-range planning, supporting research, and evaluation. The job challenged my total public health self, and we had some real successes. In five years, we achieved a worldwide consensus that AIDS is truly a global health problem, and that it can affect every segment of society. We’ve shown that we can control the incidence of AIDS by teaching people to make changes in their behavior.”
Despite such efforts, however, the number of people infected with the virus that causes AIDS continues to grow, and by this year, it had become clear at WHO that “the epidemic had become too big for any one UN agency to handle alone,” says Merson, who, after 17 years in Geneva running three global health programs, was also contemplating a change. “I’d traveled to more than 100 countries, and I’d seen their problems first hand. I wanted to play a role in getting people to come into public health—in training and educating future leaders, in influencing the field’s research agenda, and in being an advocate.”
Yale, it turned out, had an opening. The chemistry was good. The University was close to the home base of Merson’s favorite basketball team, the New York Knicks (the dean, captain of his college basketball team, also played soccer and baseball, and is now a swimmer). Merson, his wife Claudia—a bilingual curriculum development specialist who is working at the new Career High School—and his son Jonathan, now a freshman at the College, moved from Geneva to New Haven.
With his family well ensconced in the Elm City and his office looking a little less spare, Merson reflected on a remark he'd made last spring when he addressed his constituency for the first time. “I firmly believe that EPH is a hidden treasure in this University and this country,” the dean had said.
Merson, particularly after his tenure in the WHO AIDS “hot seat,” is nothing if not expert at getting the print and broadcast world to take notice of “hidden treasure.” (Indeed, he has been to school to learn the art of getting his point across in the media, where he’s been interviewed everywhere from the New York Times to Good Morning America.) So after the soul-searching effort Merson began is complete—sometime this winter, he estimates—and the department begins implementing the resulting changes, don’t expect EPH to remain hidden much longer. “There has never been a time when the challenges for public health are as great as they are today,” says the dean. “Yale has a tremendous amount to offer toward solving these problems.”
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