In 1906, six people in one household came down with typhoid. George Soper, a recent engineering graduate from the Columbia University School of Mining, set about to track the cause of the infection. Soper eventually connected Mallon to the outbreak.
Dr. David Rosner, professor of sociomedical sciences and history and director of the Center for the History and Ethics of Public Health at the Mailman School of Public Health, has studied public health in this period. He describes Sopers methods as unique. He used civil engineering techniques to eliminate water-borne contaminants as the possible source and medical science to verify that Mallon was the immediate source of the typhoid infections. He demonstrated the value of deploying together two fields that were generally considered separate.
In 1908, at an extensive lecture series on public health held at Columbia University, some of the best-known experts in the emerging discipline held up the Typhoid Mary case as one of the best examples of the potential of the field of public health.
And as Dr. Rosner has documented in his research, one of the results was a drive to create a permanent school of public health at Columbia. It is sincerely to be hoped that this [series of lectures] will lead to some permanent organization, a lecturer said at the time. A special committee has outlined the possibilities for funding such a permanent department in connection with Columbia University.
Competing for Funding
It took 14 years, but in 1922, Columbia officially opened the Institute of Public Health, under the directorship of Dr. Haven Emerson, an 1899 graduate of the College of Physicians & Surgeons and a great-nephew of philosopher Ralph Waldo Emerson.
Although todays school is a world-renowned institution, its founding was something less than auspicious. In 1913, the philanthropic Rockefeller Foundation decided to promote the promising area of public health by financially supporting the nations first school dedicated to the field. The three finalists, from among several universities, were Columbia, Harvard, and the ultimate winner, Johns Hopkins.
Dr. Allan Rosenfield, the DeLamar Professor of Public Health, professor of obstetrics and gynecology at P&S, and current dean of the Mailman School, said the Rockefeller Foundation made the correct choice at the time. Harvard and Johns Hopkins wanted to create separate and independent schools of public health, and Johns Hopkins in particular had outlined an ambitious blueprint for an independent institution focused on the discipline. In contrast, the president of Columbia rejected the idea of setting up a separate school of public health.
Although Columbia missed out on the Rockefeller donation, the school received a second chance in 1918, when the estate of Joseph DeLamar provided an endowment of $3 million to the College of Physicians & Surgeons and other universities to establish educational programs in public health.
Placing the Institute of Public Health within P&S was not the best organizational structure, says Dr. Rosenfield. The school was founded in an atmosphere when there was little understanding of the field of public health, and neither the University generally, nor P&S, was particularly supportive, he says. Today, the school is recognized as one of the best in the country, but the University pretty much ignored it for the first 50 years of its existence.
Shifting to Chronic Illness
New York City in the first several decades of the 20th century was ripe for epidemics, with bacteria spreading like wildfire through the crowded tenements and bustling city streets. However, the era of infectious diseases was coming to a close. Dr. Jack Elinson, professor emeritus of sociomedical sciences and founder of the Department of Sociomedical Sciences at the Mailman School, said that by the 1930s and 1940s, illnesses borne of squalor and transmitted by ignorance had been brought significantly under control through a vastly improved public health infrastructure, successful public health campaigns to educate the citys population, and development of effective vaccines and antibiotics. Cholera, typhoid, tuberculosis, smallpox all of these had once ravaged the population but now were considered under control.
By the 1950s, infectious diseases were under control, or at least were thought to be, and the major causes of death were chronic illnesses, says Dr. Elinson.
In this era, the school moved toward more independence. In 1945, under the leadership of Dr. Emersons successor, Dr. Harry Mustard, the institute became the Columbia School of Public Health and Administrative Medicine, although it was still administered as a department of P&S.
Public Health Embraces Social Sciences
With the transition toward chronic illness, civil engineering and sanitation became less important to public health, while social sciences became increasingly important. Dr. Elinson joined the faculty as an associate professor in 1956, with a joint appointment in sociology. As a mere social scientist, Dr. Elinson would not have qualified for admission as a student. At that time schools of public health admitted only physicians, nurses, sanitary engineers, veterinarians, hospital administrators, and others with specific backgrounds as health professionals.
Dr. Elinson partnered with Dr. Ray Trussell, who had been named director of the school in 1955, to produce a landmark study on chronic illness in a rural area. What made the study unique was the first use of clinical examinations in a probability sample of a geographically defined population Hunterdon County, N.J. We found much more chronic illness than anyone had expected, Dr. Elinson says. The results of the study and those of a parallel study carried out at the Johns Hopkins School of Hygiene in an urban area Baltimore led to the adoption by the National Center for Health Statistics of the U.S. Public Health Service of a periodic national Health Examination Survey to assess the health status of the U.S. population.
This was one of the earliest examples of the two disciplines being used together so effectively in a public health project, and Dr. Elinson says it demonstrated that public health is the field that links social sciences and medical sciences.
Social science research methods were included in Columbias public health studies, Dr. Elinson says, because Dr. Trussell recognized the value of the social science disciplines in quantifying and evaluating public health issues. He made it particularly easy for social scientists to work in public health, Dr. Elinson says. He saw that social science could contribute to the understanding of public health problems.
Dr. Mervyn Susser, the Gertrude Sergievsky Professor Emeritus and former head of the schools epidemiology program, continued to advance the merger of these two disciplines when he joined the faculty in 1966. One of Dr. Sussers early works was the highly influential book, Sociology in Medicine. Public health is an important bridge between social science and medicine, he says. I had a strong interest in the application of social sciences to medicine.
Not everyone at the School of Public Health shared that vision, however. Many faculty members in that period were more focused on traditional medical approaches, a legacy of the politics that continued to place the school under the aegis of P&S. As head of epidemiology, Dr. Susser incorporated social science practices into the course work and ongoing research.
I wanted to change the structure of education in the school. I was open about what I was trying to do, and the dean knew we needed change, he recalls. But the faculty I took over was generally not appreciative. Fortunately, Dr. Susser had Dr. Trussell in his corner, and these innovative practices eventually found their way into the school, which was renamed the School of Public Health in 1972.
Examining the Environment
In the late 1960s, researchers began to look at a new threat to public health: pollution and industrial waste. In 1970, the school opened a new division, the Division of Environmental Health Sciences. Initially, it was a very small unit, with just a few faculty members, remembers Dr. Joseph Graziano, associate dean for research and former head of the department.
Although the most important early research focused on mercury exposure, led by Dr. Leonard Goldwater, for many years to follow, under the leadership of Dr. I. Bernard Weinstein, the main scientific thrust was on cancer and carcinogenesis. When Dr. Graziano took the reins in 1991, he was in the middle of a 15-year study of lead poisoning in Eastern Europe, and he was determined to diversify the department.
Although his background is in pharmacology and he has developed drugs to treat lead poisoning, he eventually came to see that public health and environmental science were better ways to address the issue. Drug treatment can work, but its too late, he says. Prevention is far more powerful than drugs. I became a real believer in public health.
Throughout the 1990s, he made sure that Columbia researchers addressed the links between environmental contaminants and other diseases, studying connections between lead, pesticides, and neurological disorders, between air quality, allergens, and asthma, and other important areas.
His focus has been rewarded, with the National Institutes of Health, among others, awarding Columbia several of its most prestigious and lucrative grants. The department has morphed into a very large research program, Dr. Graziano says.
Infectious Diseases Reappear
By the mid-1980s, it was clear that public health had a new crisis, an epidemic of an entirely new infectious disease: HIV/AIDS. This marked a return to the earliest forms of public health, with a focus on prevention instead of treatment and on caring for a sick population. Its quite evident that we were premature in redirecting our focus and de-emphasizing infectious disease, says Dr. Susser. However, in the early 1980s in New York City, with the advent of AIDS and the HIV virus and soon after the recrudescence of resistant tuberculosis, it at once became evident to several of us in epidemiology that we had a major new problem on our hands.
The health field confined the outbreak as an affliction of the gay community, but Zena Stein, professor of epidemiology and psychiatry, voiced an early concern that women as the sexual partners of affected men were bound to be at risk, Dr. Susser says. Dr. Stein prepared the ground with field studies of sex workers, but NIH epidemiology study sections could not be convinced at that early stage that the risk to women was of any consequence. This was an inauspicious beginning, but she together with her colleagues has since vigorously prosecuted research and intervention among women, especially in the United States and Southern Africa. She is now internationally acknowledged as a founder in those research areas, says Dr. Susser, her husband and collaborator.
Confronting HIV/AIDS, which initially had no treatment and now entails expensive drug treatment, has created an entirely new school of thought, the ethics of public health. Dr. Ronald Bayer, professor of sociomedical sciences, was recruited by Dr. Rosenfield to join the school in 1988, and he designed the curriculum and taught one of the first classes in the United States on the ethics of public health. Other schools have been catching up on ethical issues, but it was a pretty lonely field in those days, says Dr. Bayer.
HIV and AIDS led to some significant changes in public health. Economic issues led to questions about which patients, and which nations, would have access to critical drugs. The private nature of a disease that is transmitted often through sexual contact can place the doctor-patient relationship at odds with the overall public health issues. This also can put clinical perspective in conflict with the social outlook of public health. Public health is about enhancing the health of the overall population, of doing the greatest good for the greatest number of people, Dr. Bayer says. With the HIV/AIDS epidemic, those goals may not always be consistent with the needs of an individual patient.
The Issue of Access
Although preventing illness remains the main focus of the school, its researchers have in the past few decades begun to study another important aspect of public health: the increasingly important issue of who has access to care. We know that people without health insurance are substantially more likely to die, so this is very much in line with the schools focus on improving health, says Dr. Sherry Glied, chairwoman of the Department of Health Policy and Management. Right now, health insurance and how to expand coverage to more people is a huge issue.
This problem came to the fore in the early 1990s, especially in the early days of President Bill Clintons administration, and Dr. Glied took a year away from Columbia in 1993 to work on the governments health care reform policies. Since taking the top spot in her department, Dr. Glied has made it a priority to promote better distribution of health insurance, including mental health benefits and prescription medicines, to the population.
Medical care has been getting more expensive, she says, and that makes access more important. It means not having insurance is becoming more expensive.
In 1975, the Mailman School launched a new center to focus on the unique needs of women and children. The Harriet and Robert Heilbrunn Department of Population and Family Health is now considered one of the leading centers for studies of reproductive, maternal, and childrens health, including teen pregnancy, maternal mortality, and the impact of AIDS on women and children in developing nations. Dr. Rosenfield, whose work before joining Columbia included studies on population, family planning, and other reproductive health topics in Thailand, was recruited to the school to help start the center, which soon became the largest program in the school. Later, he was instrumental in the centers transition into full department status.
The Mailman Gift
In 1998 the Mailman Foundation donated $33 million to the school, the largest single capital and endowment gift to any school of public health at that time, and the school was renamed the Mailman School of Public Health. In 1999, the school received a $50 million, five-year grant from the Bill & Melinda Gates Foundation, the largest single foundation grant in Columbia history.
Through the Mailman gift, the DeLamar legacy, and other more recent gifts, the endowment at the school increased from $2 million in 1985 to $51 million in 2003. The Mailman School is in the process of moving into its own building, the former New York State Psychiatric Institute, providing the school with more than 200,000 square feet of space, a far cry from its original 12,000 square feet of space in a building shared with the New York City Department of Health, space it will continue to use. Its the first time in the schools history that it has had its own space.
As the school evolved into the Mailman School, it also gained its independence from P&S. In 2000, the school became a Faculty of Public Health, one of the four faculties within Health Sciences. With funding and a new facility, the Mailman School is prepared to meet the public health challenges of the future.
Looking Toward the Future
Dr. Gerald Fischbach, executive vice president for health and biomedical sciences, oversees the four Health Sciences schools. He repeatedly calls attention to the Mailman School, calling it the Universitys success story of the past decade. As a school, it has become one of the leading public health institutions in the country, measured both in the quality of its research and its size, Dr. Rosenfield says.
And thats important, because public health in the 21st century is going to be as big a challenge as it was in the 20th century. Dr. Rosenfield points to several issues that must be seen as the future of public health. An aging population means chronic health issues will continue to be important, but the HIV/AIDS pandemic and the recent emergence of SARS demonstrate that infectious diseases will still need the attention of well-trained public health experts.
And unlike a century ago, when the nascent Institute of Public Health was focused mainly on issues within New York City, the world of medicine today is focused on global issues. Along with medical challenges, this will lead to important ethical questions, especially surrounding economic problems and access issues.
The events of Sept. 11, 2001, highlight the role public health plays in disaster preparedness and recovery efforts. The potential for bioterrorism and warfare will provide a new type of challenge to public health.
The Mailman School has evolved from a small institute, lacking in funding and prestige, to one of the most highly respected schools of public health in the country. Once a subset of P&S, it has become an independent faculty in its own right, with six departments and 17 centers, and has grown into Columbias second largest school in terms of sponsored research support. Most of that growth has come in the past 15 to 20 years, says Dr. Rosenfield. We are seeing the school become a leading school of public health in this country. Our mission now is to become a global school, with an emphasis on understanding international issues and especially questions of access.
Will Wade is a New York City-based free-lance writer.