The Crystal Ball Project
Welcome to the history of the future of public health.
Words by Karen Kruse Thomas • Illustration by Oivind Hovland
In 1954, the School convened a Crystal Ball Committee. Its mission: Identify the top public health problems on the horizon and help the School prepare accordingly. The committee turned in a spot-on report. They named aging, chronic diseases, mental health and health care administration as challenges that would “loom large in the future both from the administrative and scientific point of view.” In the 1960s, the School would establish departments of Chronic Disease, Mental Hygiene, and Medical Care and Hospitals. (A center devoted to aging would follow in 1995.)
Prognostication is an essential skill for public health professionals seeking maximum future returns from today’s finite resources. For decades, School faculty have peered into the future—that unknown country—and bravely shared predictions. Sometimes their accuracy was astounding. Sometimes their crystal ball was a bit opaque. Read on to see how the past predicted the future of public health.
Essential To Public Health: Hospitals And Medical Care
William Henry Welch, MD
In 1915, Welch had a radical vision: Link hospitals to all the agencies connected with public health. Impressed by Welch, his idea and the Johns Hopkins Hospital, the Rockefeller Foundation located the first independent graduate school of public health at Johns Hopkins in 1916.
The medical community was not similarly impressed. Doctors continued to forbid public health officers from any involvement in treating illness so Welch’s vision remained unrealized for decades. Then, with the postwar growth of government-funded medical care programs, the School teamed with Johns Hopkins Hospital in 1947 to create a specialized MPH program to prepare physicians for “the role of the future, the public health officer-hospital administrator.” A scathing accreditation report later pooh-poohed the need for the program.
Undeterred, the School founded the General Preventive Medicine Residency in 1963, which trained physicians in clinical and population-based approaches to disease prevention and health promotion. In 1987, the Department of Health Policy and Management established what would become the Master of Health Administration degree. Many GPMR and MHA graduates have held top leadership positions in hospitals and health systems.
Welch’s vision was most fully realized in the field of health services research, pioneered by Charles Flagle, DrEng, Kerr White, MD, Barbara Starfield, MD, MPH ’63, and others.
The Epidemiological Transition: From Infectious To Noncommunicable
Wade Hampton Frost, MD
Frost, the first professor of Epidemiology in the School and the nation, was among the earliest to recognize that morbidity and mortality from infectious diseases was declining. In 1927, he was the first to apply the term “epidemiology” to the study of noninfectious conditions such as nutritional deficiency. A decade later, he declared to the American Public Health Association’s Epidemiology Section that the methods of epidemiology applied to all diseases and health hazards.
The advent of new methods for studying chronic disease did not immediately yield effective prevention methods, however. As late as 1960, cancer and heart disease—the top two killers of Americans—accounted for only 6 percent of U.S. Public Health Service grants to state and local health departments. Chronic disease would not become a major focus of national public health efforts until 1964, with the release of the Surgeon General’s Report on Smoking and Health. With the arrival of Abraham Lilienfeld, MD, MPH ’49, in 1959, and George W. Comstock, MD, DrPH ’56, in 1962, the School would begin building its world-renowned program in the epidemiology of genetic and chronic disease.
A Scientific Approach To Global
Lowell J. Reed, PhD
The biological sciences at Johns Hopkins should devise an approach to the population problem, with particular emphasis on those forces that influence human reproduction,” declared Reed, chair of Biostatistics and dean from 1937 to 1946. Reed was voicing contemporary concerns about the economic and environmental consequences of population growth and distribution in the U.S., but he was also instrumental in guiding the Rockefeller Foundation’s shift in 1950 to focus on global population growth.
In 1964, Paul Harper, MD, MPH ’47, established the Division of Population Dynamics, which would provide crucial research that addressed the complex linkages among high fertility, malnutrition, infectious disease and lack of access to primary care.
Reed’s emphasis on biology was realized two years later when John D. Biggers, ScD, PhD, founded the Laboratory of Reproductive Biology in the Department of Population and Family Health. After the lab became a full division in 1972, director Barry Zirkin, PhD, established the Core Electron Microscopy Lab, where he studies mammalian spermatogenesis in relation to male infertility and contraception, including the molecular regulation of Leydig cell function in producing testosterone.
Aviation Medicine: A New Public Health Field
Ernest Stebbins, MD, MPH '32
Dean Stebbins observed that “the extremely rapid development of air transportation has created new and fascinating problems.” Pilots had to be certified as physically fit to fly, and then had to be monitored for the physiological effects of speed, G-force, temperature and altitude. The School was among the first three schools of public health to host first-year students for a three-year aviation medicine residency program established in 1952 by the U.S. Air Force and American Board of Preventive Medicine.
Stebbins and Joseph Lilienthal, MD, chair of Environmental Medicine, founded an MPH specialization in aviation medicine that prepared physicians to manage “the medical, environmental, and operational problems involved with high speed, high altitude flight aboard jet aircraft, [such as] heart and lung function, high altitude and hyperbaric physiology, [and] accident investigation and crash safety.”
After the space race began, aviation medicine evolved into aerospace medicine, and Environmental Medicine chair Richard L. Riley, MD, would apply his air hygiene research to develop air purification systems for NASA’s space capsules.
The Modern Importance Of Injury Prevention
Abel Wolman and Cornelius Krusé, DrPH, MENG
In 1957, Wolman and Krusé warned that home accidents killed “more American children than all the communicable diseases put together.” The School, they argued, should engage in an inter-departmental attack on injuries, including those caused by automobile crashes.
In 1968, Susan P. Baker, MPH ’68, launched the first in-depth investigations of the epidemiology of injury—especially the risk of death posed by unrestrained infants in car crashes. In 1987, she founded the Center for Injury Research and Policy. From 1980 to 2010, the rate of crash deaths per 100,000 U.S. population declined by more than half. During the same period, the rate of crash deaths among children under 13 declined by two thirds, largely as a result of safety belt and car seat use.
Strengthening Mental Health And Behavioral Approaches
Ernest L. Stebbins
In his 1960 long-range plan for the School, Stebbins wrote that “no single problem in public health is more pressing” than mental illness. He urged earlier diagnoses of mental illness, discovery of its causes and the development of effective interventions that would prevent the “massive drain” on society of harmful social behaviors. Stebbins pursued these goals by granting departmental status to the Division of Mental Hygiene in 1961, chaired by Paul V. Lemkau, MD, and then establishing a new Department of Behavioral Sciences in 1967. Mental Hygiene, renamed Mental Health in 2004, has developed strengths in drug and alcohol addiction; psychiatric epidemiology; school-based early interventions to prevent violence, suicide, substance abuse, poor school performance and other negative outcomes; well as autism and developmental disabilities, and global mental health.
In contrast with Mental Health’s steady growth, Behavioral Sciences enjoyed a brief but meteoric rise under founding chair Sol Levine, PhD, a pioneer in understanding the physiological effects of emotional stress. In 1968, the School opened a new $4.5 million eight-story Behavioral Sciences Wing (now the Stebbins Wing), and proposed creating 22 faculty positions by 1979. Yet after Levine departed for Harvard in 1972 and federal funding for behavioral sciences dried up, the department’s prospects dwindled and it became a division of Health Policy and Management in 1987.
The School’s interest in behavioral sciences reawakened in the 21st century with the creation of the Department of Health, Behavior and Society in 2005. Under founding chair David Holtgrave, PhD, the department has done path-breaking work on interventions to address a spectrum of high-risk behaviors, from alcohol, tobacco and drug addiction, to unprotected sex and dangerous driving. Reaching 50 full-time primary faculty in only a decade, HBS has become one of the largest and most influential departments of its kind.
Computing And Record-Matching As Critical Epidemiologic Tools
Alan Gittelsohn, PhD
In a 1964 NIH grant proposal, Gittelsohn diagnosed the public health system as having “significant deficiencies in the areas of information quality, trained personnel, and capabilities for mass data processing, data reduction and data analysis.” He pointed to the recent thalidomide tragedy as an example. Computer-assisted examination of the incidence data could have revealed sooner the link between the drug (which had been prescribed off-label for morning sickness) and severe birth defects.
He urged state health departments to link marriage, birth and childhood death records in order to provide deeper analyses of risk factors for death, disability and premature birth. Gittelsohn went on to play a fundamental role in establishing the computerized National Death Index within the National Vital Statistics System.
Today, the School’s expertise in “big data” is a pillar of the University’s unmatched reputation in biostatistics and epidemiology. Faculty are merging multiple sources of data and analyzing mass-scale data sets to unravel the etiology of complex conditions, using gene sequencing and biomarkers. They are also charting the population health impact of changes in risk factors such as air pollution and climate.
The Rise Of Academic Research Centers
John C. Hume, MD, DrPH '51
Hume, dean from 1967 to 1977, presided over one of the greatest periods of growth in the history of the School. Yet he feared that federal categorical grants were causing the traditional disciplinary departments to suffer in favor of problem-oriented departments that focused on “the issue of the moment as perceived by public and private funding agencies.”
Instead of the School splitting into “a series of minischools with limited interests,” Hume wanted it to remain a united institution where each department made distinctive contributions to the educational programs. Stressing the need for interdepartmental communication, collaborative research and joint planning for education programs, Hume foresaw that “such a structure would require a capacity to rapidly develop interdisciplinary groups—called centers, institutes, clones, or clusters—and to react quickly and flexibly in order to grasp new opportunities and address [significant] problems.”
Hume’s vision for the best of both worlds—stable, collaborative, discipline-based departments coupled with responsive, problem-solving centers—anticipated the Bloomberg School’s modern structure. In 1974, the School had three domestic and three international centers. Today, the School houses 82centers and institutes.
The Impending Epidemic Of Chronic Kidney Disease
Michael J. Klag, MPH '87
In a 1989 article in Hypertension, Klag and Paul K. Whelton, MD, MSc, provided the first estimate of the incidence of end-stage renal disease (ESRD: loss of kidney function to where dialysis or transplant is needed to maintain life) and pointed out that the U.S. was in the midst of an ESRD epidemic. In a 1996 New England Journal of Medicine article, Klag identified blood pressure as a strong independent risk factor, based on a study of 332,544 men from the mid-1970s through 1990. Patients with stage 4 hypertension had a 22-fold higher relative risk of developing ESRD than those with normal blood pressure. Warning that ESRD would create “a large burdenfor both individuals and society as a whole,” Klag and co-authors alerted colleagues to the problem’s scope and possible solution: Emphasize the need for the prevention and control of both high-normal and high blood pressure. Using the same data, Klag also determined that black men, who were more likely to have both higher systolic blood pressure and lower income, had a four-fold higher incidence of treated ESRD compared with white men. In the Family Investigation of Nephropathy in Diabetes Study, Klag and coinvestigators Linda Kao and Rulan Parekh found a genetic locus that explained 60 percent of the excess risk of nondiabetic ESRD in black compared to white Americans.
In the 27 years since Klag and Whelton sounded the alarm, the rate of chronic kidney disease overall has continued upward, more than doubling in people over 65 between 2000 and 2008, but the rate of ESRD leveled off—thanks to the interventions to prevent and treat hypertension. Although more work must be done to narrow racial disparities in rates of ESRD, which increased dramatically from 1980 to 2000, the incident rates for all races have since stabilized and the rates for African Americans and Native Americans have recently shown a decline.
What We Got Wrong
The Imminent Disappearance Of Maleria
Enamored with the power of DDT, Fred Soper, MD, DrPH '25, director of the Pan American Sanitary Bureau, predicted in 1948 that 90 percent of malaria worldwide could be eliminated within 10 years, at a cost of $280 million (about $3 billion today).
By 1958, so much progress had been made that entomologist Lloyd Rozeboom, ScD '34, predicted that DDT would eliminate malaria and most other insectborne diseases in a matter of years.
Although WHO's malaria eradication campaign dramatically reduced mortality in India and much of Asia, it failed to consolidate initial gains. Difficulty reaching isolated areas, substandard living conditions, malnutrition and inadequate or nonexistent local health services perpetuated malaria transmission. In 1969, WHO formally abandoned the global malaria eradication campaign first proposed by Soper.
What Else We Got Wrong
The Downfall Of Tuberculosis
In 1937, Wade Hampton Frost predicted the downfall of tuberculosis in the wake of public health measures and rapidly improving living standards: “The tubercle bacillus is losing ground, and the eventual eradication of tuberculosis requires only that the present balance against it be maintained.” Between 1900 and 1955, mortality fell tenfold in the U.S. with improved case finding and treatment, such as the introduction of streptomycin in 1944, yet TB morbidity lingered on. Well into the 1950s, the School’s Statistical Methods in Epidemiology course used tuberculosis as “the principal illustrative chronic disease.”
Today, 2–3 million people die from TB and 9 million people contract it annually, WHO reports.