International Health at 50
In 1961, the School’s Division of International Health debuted as the world’s first academic program to address public health at the international level. The occasion marks the birth of international health as a distinct discipline of public health.
Founded by Professor Timothy Baker and then Dean Ernest Stebbins, the division became a department in 1967 with public health visionary Carl Taylor as its chair. “Trying to define a new field, I guess, is what we really were trying to do,” Taylor recalled in an interview for the Bloomberg School’s oral history project.
Taylor, who died in 2010, rejected the idea of merely importing the best Western medicine to impoverished countries. He wanted to train leaders to view international health as a complex mix of health problems, politics, economics, culture and environment. His vision expanded international health beyond its roots in tropical medicine, a disease-specific field typically spread among different departments, says Robert Black, MD, MPH, Department chair since 1985 and one of the world’s leading experts on child health.
“The challenges are still there, and the solutions are getting better every day.” —Robert Black
“I think what was important about the start of the Department was looking much more broadly not just at particular diseases that occur in different places but at health systems and how services could be delivered in very resource-constrained environments—how social conventions interacted with environmental risk and medical problems, how infectious disease was related to nutrition,” Black says. “It was really looking at the health problems in low-income countries in a much more holistic way.”
The following pages highlight the Department’s contributions in its first half century.
Community–Based Research and Health Care
The Department’s approach to community-based public health centers on collaboration with local populations. Together, they first identify health problems and then test intervention strategies under realistic conditions. The goal is developing inexpensive, evidence-based health programs. This strategy began with Carl Taylor’s signature field study—the Narangwal Rural Health Research Project—which lasted from 1965 to 1974. The project demonstrated that community health workers (CHWs) could deliver quality health care. Among its seminal findings: CHWs can cheaply and effectively treat pneumonia cases by administering antibiotics themselves.
1978: Carl Taylor is the top consultant to WHO in drafting the historic Alma Alta Declaration, which advocates an integrated primary care approach to public health over the traditional disease-control model. Signed by representatives from 134 countries, the document states that primary care brings “health care as close as possible to where people live and work and constitutes the first elements of a continuing health care process.”
1980: To curb a childhood diarrhea epidemic that was killing infants at seven times the national average on the Fort Apache Indian Reservation in Arizona, Mathuram Santosham partners with tribal leadership to train parents in oral rehydration therapy (ORT). Further studies help make ORT the first-line therapy for diarrhea treatment.
2008: Abdullah Baqui and researchers in Bangladesh develop a package of maternal and newborn care services. Relying on local women to provide care, the initiative reduces neonatal mortality by 34 percent in 30 months. The research—recognized by The Lancet as a 2008 paper of the year—encourages WHO-UNICEF to recommend postnatal home visits to improve newborn survival.
2009: Prenatal and newborn care and maternal life skills delivered by lay health workers to American Indian teen mothers significantly improve infants’ social, behavioral and emotional development. The study, led by John Walkup and Allison Barlow, is recognized by the Journal of the American Academy of Child & Adolescent Psychiatryas a 2009 paper of the year.
“If you’re interested in disadvantaged or vulnerable populations, you need to get them engaged in ways that are meaningful. Community empowerment approaches have long been a part of our work.” —David Peters
The Department’s revolutionary research in public health nutrition continues a tradition of pioneering work in the field. Department nutrition researchers have made lifesaving discoveries demonstrating the importance of vitamin A, zinc and other nutrients in child and maternal health, disease prevention and survival. The findings, in many cases, have served as the impetus for national and international policy changes that have saved and improved the lives of millions.
1968: Carl Taylor coauthors the now-iconic WHO monograph, “Interactions of Nutrition and Infection” and subsequently demonstrates, in the Narangwal project, the cost-effectiveness of integrating nutrition services with maternal and child health care.
1968–76: George G. Graham’s Peru research establishes effective dietary approaches to treat and prevent infant malnutrition, as well as the link between copper deficiency and malnutrition. Graham founds the Division of Human Nutrition (now an academic program area within the Department).
1982–86: In the world’s first large field trial on vitamin A and child survival, Alfred Sommer and Keith West lead research in Aceh, Indonesia, showing that vitamin A reduces child mortality by 34 percent. The work spurs subsequent vitamin A trials that confirm the vitamin’s global impact on child survival.
1988–92: The Nepal Nutrition Intervention Project–Sarlahi (NNIPS) is established by Keith West, Joanne Katz, Steven LeClerq and colleagues in the Terai of Nepal. In the first trial of more than two decades of field research at this site, they show that vitamin A can reduce child mortality by 30 percent, stimulating a nationwide program and affirming the magnitude of its impact on child survival.
1990: Benjamin Caballero founds the Department’s Center for Human Nutrition as a home for multidisciplinary research to address and solve nutritional problems.
Early 1990s: Zinc trials in Bangladesh, India, Peru, Nepal and Zanzibar led by Robert Black show that zinc supplementation can both treat and prevent diarrhea, prevent pneumonia and reduce child mortality. In 2004, WHO and UNICEF recommend zinc for treatment of diarrhea.
2000–present: West, Alain Labrique, Parul Christian and Rolf Klemm set up the JiVitA nutrition and health research site in Bangladesh. A study among 16,000 infants finds that a single dose of vitamin A at birth reduces neonatal mortality by 15 percent.
2001–2011: Joel Gittelsohn and colleagues begin a series of trials—mainly in the U.S.—to improve the food environment and reduce risk for chronic disease by working with food stores and local institutions to offer healthier foods.
2006–2008: West, Christian, Katz and Tielsch lead follow-up trials with three NNIPS cohorts of children to reveal long-term effects of antenatal and childhood micronutrient supplements on early biomarkers of chronic disease risk, child cognition, hearing loss, and lung and immune function.
2010: Anna Durbin begins work with colleagues in Brazil to test the safety and efficacy of a tetravalent vaccine—the product of 10 years of clinical development at the CIR—against dengue.
Maternal and Child Health
Well past the 20th century’s midpoint, the worldwide health agenda had yet to focus on the needs of mothers, infants and children, resulting in millions of needless deaths, illness and suffering. For more than three decades, the Department has made the well-being of these vulnerable populations a top priority and documented the costs of neglecting them. In recent years, faculty have developed simple interventions that can improve a child’s chances for survival in the critical first weeks after birth.
1996–present: Jean Humphrey’s research in Zimbabwe demonstrates the overriding importance of exclusive breastfeeding in minimizing mother-to-child transmission of HIV and in increasing the likelihood of infant survival.
2002: James Tielsch and Luke Mullany lead a community-based intervention in Nepal that shows using the antiseptic chlorhexidine to cleanse the umbilical cord reduces neonatal deaths by a third. Nepal adds the practice to its national health policy.
2008: In Bangladesh, Mark Steinhoff documents a 63 percent reduction in influenza illness in newborns whose mothers received the flu vaccine, as well as a 36 percent drop in serious respiratory illnesses in both mothers and infants.
2008: Preventive newborn care delivered by community health workers in Uttar Pradesh, India, reduces a baby’s risk of death within the first month of life by up to 54 percent. Researchers, led by Gary Darmstadt, and the community develop the program of umbilical cord cleaning, mother-to-baby skin contact (to keep the baby warm) and breastfeeding.
To strengthen the Department’s work in vaccines and infectious diseases, chair Robert Black and Mary Lou Clements-Mann established the Center for Immunization Research (CIR) in 1985. The Department now houses three other centers with work focused on vaccine research, and is a recognized leader in the evaluation of new vaccine candidates, early phase clinical trials and licensure trials, training in vaccine trials, and vaccine safety and policy, as well as accelerating vaccine access in developing countries.
1990: In a landmark trial of a vaccine for Haemophilus influenzaetype b (Hib)—the bacterium that causes meningitis—Santosham demonstrates that giving two shots to children before age 2 nearly eradicates the disease in the Navajo Nation in Arizona. Today, almost every developed country uses the Hib vaccine.
1997: At CIR, Clayton Harro begins the first human trials of a human papillomavirus (HPV) virus-like particle (VLP) vaccine, the progenitor of the Gardasil and Cervarix vaccines.
2000: At the Navajo and White Mountain Apache reservations, Mathuram Santosham and Katherine O’Brien show that a new vaccine against pneumococcus (PCV) is effective against pneumococcal disease not only among vaccinated infants, but also in adults and the elderly in the community not vaccinated with PCV. WHO recommends PCV as a routine vaccine.
2003: Orin Levine, Kate O’Brien and colleagues launch the PneumoADIP project to accelerate the introduction of PCV vaccines for children in the world’s poorest countries. With support from the GAVI Alliance, and based on PneumoADIP’s work, PCV vaccines are expected to prevent more than 5 million child deaths by 2030.
Without well-functioning health systems with efficient care delivery mechanisms and trained staff, the most transformative public health discoveries may never reach their intended populations. The Department has a history of leadership in health systems, including Timothy Baker, Carl Taylor and William Reinke’s early health manpower planning work and the Narangwal Project’s innovative research that supported the integration of health care services—like primary care and family planning—at the community level.
1960–1970s: William Reinke directs a certificate training program in health planning for public health officials from developing countries. Over two decades, several hundred senior planners take part in the program.
1961: Major health manpower assessments are carried out in Turkey, Nigeria, Taiwan, Peru and Chile. They reveal vast country-specific differences in the roles of the various health services personnel.
1985: The Institute for International Programs (IIP), currently directed by Robert Black, becomes a leader in generating sound evidence used by governments and donor agencies worldwide to assess maternal and child health programs.
2003–present: Hired by the Afghanistan government, David Peters, Gilbert Burnham and colleagues lead the largest annual survey of health facilities and patient care, resulting in policy and program changes that address quality and access, hospital reform, HIV prevention and water protection.
2005: A PEPFAR initiative in Ethiopia led by Andrea Ruff provides technical assistance and capacity building in HIV/AIDS and TB treatment, care and research. Accomplishments include a new regional testing lab, the training of hundreds of researchers and lab technicians, and a telemedicine program.
2009: The Department leads an innovative collaboration with the newly formed Makerere University College of Health Sciences in Uganda to help it become a leading and transformational institution in Africa.
2010: The International Injury Research Unit (IIRU), led by Adnan Hyder, is named a collaborating center by the World Health Organization, joining centers in 80 countries. The IIRU leads the Road Safety in 10 Countries Project, the largest international research collaboration on traffic injury prevention.