Public health is more than the water we drink and the quality of the food that we eat. It is also about wearing seatbelts and not smoking, about practicing safe sex and and exercising regularly, notes Dr. Michael Merson, chair of the Department of Epidemiology and Public Health (EPH) at the School of Medicine.
Merson, who describes EPH as the "best kept secret on campus," brought a decidedly global perspective when he became the first dean of public health at Yale in 1995. He previously spent 17 years with the World Health Organization, most recently as executive director of the WHO Global Program on AIDS.
Under his tenure, enrollment and applicants to EPH's master's and doctoral programs have increased 30%; the number of full-time faculty has grown 40% from 50 to 70; and grant income has almost doubled from $10.5 million to $19 million. Interest among undergraduates is growing, too. There recently were 150 applicants for 18 spots in EPH's evening college seminar, "Public Health at Yale College."
EPH's curriculum is evolving to reflect current demands. For example, it has a new Health Management Program undertaken with the School of Management that is training future leaders in the field, and a Regulatory Affairs Program for students interested in working at agencies such as the U.S. Food and Drug Administration. EPH now offers a Master of Science in Biostatistics, and it is developing a new program in the social and behavioral sciences in recognition of the importance of behavioral and social factors in health promotion and disease prevention. EPH also is strengthening its public health practice courses for those students who plan to work in local health departments.
Merson spoke recently with the Yale Bulletin & Calendar about public health here and abroad. The following are excerpts from that interview.
You have said in the past that increasing minority representation in public health education, research and practice is a priority. What is the situation now?
Among the industrialized countries, the United States has the greatest gap in economic and social conditions between the richest and the poorest in society. Unfortunately, many of our public health problems are more serious among our poorest and most underserved communities, which are often communities of color. There are not enough minority graduates pursuing careers in medicine, and even fewer opt for careers in public health. We want to train more leaders from these communities to play a prominent role in public health, be it in public health practice, education or in research.
We recently cosponsored "Partners in Health and Sickness, New Haven and Yale," an event which highlighted the need to better integrate research, diagnoses, treatment and prevention efforts in addressing health disparities in New Haven and nationwide.
What is being done to increase minority enrollment at EPH?
We are working with the Office of Multicultural Affairs in the medical school to attract minority students. Last year we received a grant from the Robert Wood Johnson Foundation that allows us to bring high school students to campus during the summer in hopes of getting them interested in public health before they make career decisions. We try to be sure that we have courses in our curriculum that address public health issues that are of importance to these students. We are also mobilizing our alumni to help in our recruitment efforts and we are offering more scholarships, many to students from communities of color.
You also have said that more attention must be paid to health and disease prevention, and population-based health. What is "population-based health?"
There is much confusion among the public about what the term "public health" means. Some people think that it means just providing health care to the poor. In fact, public health, more than anything else, means prevention -- preventing illness, preventing premature death, preventing absenteeism from work or school, preventing the high cost of health care. That is the heart and soul of public health.
When we think about prevention, we are concerned with individuals, but even more so about how we can prevent disease in the population as a whole; how we can address specific health problems in communities and the factors that contribute to them. School-based programs that educate kids about the risks of tobacco, and needle exchange programs that prevent HIV and hepatitis infection are examples of population-based health programs that EPH faculty have been evaluating.
Since 1900 the average life span has been lengthened by 30 years. Twenty-five of these years are due to advances in public health. What advances were responsible for this increase?
We are a very treatment-oriented society. We believe that by taking drugs we can cure almost any illness. And we are fascinated by high technology -- CAT scans, bypass surgery, new gene therapy. While these are wonderful advances, our greatest advances in public health in the last century have been in prevention. These include vaccinations against common childhood diseases, motor vehicle safety, safer workplaces and fluoridation of drinking water. Some of our major achievements in prevention have been in what is often called lifestyle behaviors. We know that by not smoking or taking illicit drugs and by eating a healthy diet, exercising regularly and practicing safe sex, we can reduce current premature mortality rates in half.
Will advances in public health help us add another 25 years to our life expectancy in this millennium?
I think that we can achieve a longer life span for the rapidly growing aging population by promoting the right lifelong dietary and physical activity habits. Other future priorities must include the reduction of violence in society, better recognition, prevention and treatment of mental disorders, and cleaning up and protecting the environment.
We also need to be able to respond to the threat of new diseases, such as mad cow disease, which may turn out to be our next global pandemic. The application of what we have learned through our understanding of the human genome to advance prevention is one of our greatest challenges. We need to apply this new knowledge ethically, equitably and responsibly. We are hoping to join hands with the medical school to explore ways to apply the new genetics to prevention.
Is there a lot of collaboration between EPH researchers and other Yale departments on prevention strategies?
Effective public health practice programs or research often requires the skills of many disciplines. This certainly includes the behavioral and social sciences like psychology, sociology and anthropology. We also collaborate with experts in the biological sciences, the management sciences -- since so much of our concern today is about the organization of health systems -- and the environmental sciences like toxicology. Ethical and legal issues today are major concerns in public health so we also collaborate with lawyers, political scientists, and historians. It is because of the multidisciplinary nature of public health that EPH faculty work closely with faculty throughout the University.
One of your areas of expertise as an epidemiologist is AIDS. What are your thoughts on the AIDS drugs being offered by pharmaceutical companies for reduced cost in Brazil and other developing countries?
The Brazil experience raises the question as to whether it is ethical, in the face of such a devastating, tragic epidemic, to deny populations of the world access to these drugs which can prolong life. By making anti-retroviral drugs available, one not only keeps HIV-infected persons alive longer, but also prevents new infections from occurring.
Africa, where the epidemic is clearly the most severe, is another example. Only 1.5 percent of the entire pharmaceutical market is in Africa. For the pharmaceutical companies to make these drugs available to African nations at a very reduced price, say one to two dollars a day for triple therapy, or $350 a year compared to $15,000 a year, is not going to hurt the profits of these companies. I would like to think the pharmaceutical industry could work cooperatively with governments and international agencies
to find a way to provide these drugs, especially when you realize the gravity of this epidemic.
I recently visited medical wards in Pre-toria and found that 95% of patients there were HIV-positive. In many countries, one-third of young people are dying from this disease.
I should say that there is a risk in all this and that is that it will divert countries from prevention programs. In San Francisco we are seeing an increase in new HIV infections for the first time in years. That's because people think that if they get infected they can just take the drugs and everything will be fine.
(Editor's Note: Bristol-Myers Squibb recently announced that it was making its AIDS drugs available in Africa below cost. One of the drugs, Zerit, is a Yale research discovery that Yale licenses to Bristol-Myers Squibb. Yale holds the patent to Zerit in South Africa, and Yale amended its licensing agreement with Bristol-Myers Squibb so that generic versions of the drug could be made available in Africa.)
It has been reported that vector-borne diseases are on the rise. What is a vector-borne disease and what is the reason for the increase?
In public health we have air-borne, food-borne, water-borne, and vector-borne diseases. A vector-borne disease is one which is transmitted by a living organism. The most common one worldwide is malaria, which is transmitted by the Anopheles mosquito. The tsetse fly is the vector for trypanosomiasis or African Sleeping Sickness. A number of our faculty are involved in the study of malaria, Lyme disease, leishmaniasis, trypanosomiasis, Chagas disease and West Nile Virus.
One main reason for the increase in vector-borne diseases is the changing world environment. Deforestation and land use changes expose people to vectors carrying new pathogens. We know, for example, that when there is an increase in temperature -- and this is where global warming becomes a concern -- you can create an environment where the mosquito is more likely to breed. Or if you put in a dam and change the flow of water, you might create ideal conditions for vectors that live in water. Global transport of vectors and pathogens is another cause of new epidemics, as we have seen with the introduction of West Nile Virus into this country.
What is the role of EPH's insectary in research?
We are one of the few public health schools that has an insectary for rearing mosquitoes, sand flies and ticks. We also have the only tsetse colony in North America. One cannot have a vector biology program without having a facility that can house the vectors with the right temperature, humidity and climate for them to live so that their role in disease transmission can be studied.
Does much of the research being done at EPH have a global impact?
EPH has traditionally had a large global health perspective. The majority of our students are planning careers in domestic health, but about a quarter to one-third are interested in global health issues. Many of them enroll in our Global Health division, which is mostly concerned with global health policy and governance, international health promotion and community development.
Last summer, EPH held its first Seminar on Global Health Governance which analyzed and debated the implications of globalization for health governance. We also have faculty undertaking research in infectious or chronic diseases that are global health problems, whether it be AIDS, vector-borne diseases, perinatal infections or asthma. In fact, one of our researchers recently conducted a study in China where he found that breast-feeding for two or more years reduced a woman's risk of developing breast cancer by 50%.
Other ongoing research here focuses on gender differences in health. Is this a promising direction to take?
Traditionally. there has been more health research undertaken in men than in women. There is a recognition today that there are health problems unique to women and that women may respond to disease-producing organisms in different ways than men. One of our faculty members was among the first to call attention to the acceleration of HIV and AIDS rates among women and is now studying the importance of sexually transmitted diseases and HIV infection in young pregnant adolescents in Connecticut.
There are also significant social disparities that need to be addressed for certain diseases. Another member of our faculty found that the diagnosis of breast cancer is made later in African American women than in Caucasian women, which means we have to increase our screening programs for breast cancer in African-American women. Gender inequality is part of our general concern in public health for social justice, which means making available to all populations -- no matter their gender, race, ethnicity or economic status -- the benefits of existing and new knowledge in prevention and care.
You have said that everyone has a right to health and longevity. Could you expand on that statement?
I would even go further and say that health is a human right. Shouldn't adequate health services be provided to our population just like clean water, safe food and housing? Shouldn't every person have a right to know how to live a long and healthy life and have the ability to do so?
-- By Jacqueline Weaver
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