INDIA

8:30 a.m.

By 8:30 a.m. the small window unit air conditioner in Nimesh Desai's office is already running full blast. Summers in Delhi can be brutally hot, and even here, in the midst of a 110-acre oasis of low-slung buildings and green open spaces at the northeast tip of the city, the noisy compressor's stream of cool air comes as a welcome relief. Gazing out the windows from his office, Desai, MPH '01, sees an expanse of green lawn punctuated by the Eastwhile Mental Hospital, built in the 1960s. Under Desai's supervision, the grounds of the former psychiatric hospital are being transformed into the Institute of Human Behavior and Allied Sciences, a planned 500-bed teaching hospital providing services in psychiatry, neurology, and clinical psychology.

As chair of the Institute's Department of Psychiatry and medical superintendent of the Hospital, Desai sees patients and manages campus academic and business affairs, as well as conducts research in psychiatry and in his own subspecialty of substance abuse. Although India has what Desai terms only "moderate addiction rates," heroin filters into the cities from Myanmar and the other Southeast Asian nations, and the synthetic opiate buprenorphine is sold on the streets in the form of tablets or powder. 

Desai aims to educate the health establishment and the public toward understanding the "importance of social and behavioral sciences through programs focused on the issues of health and behavior. Specifically," he says, "I want to focus on problems like drug abuse, HIV transmission, and suicidal behavior." 

Mental health programs face considerable challenges in India, a nation where, according to Desai, there are only about 3,500 practicing psychiatrists in a population of more than 1 billion. "The number of trained clinicians will never be adequate in the next 20 years," he says. "A large part of society still doesn't recognize psychiatry as a specialty. One of the things we strive for is to get mental health issues addressed as part of our national medical needs." 

With need far surpassing available resources, Desai has turned to his training in public health to help develop new ways of addressing critical social problems. Shortly after a devastating earthquake left thousands dead in the western state of Gujarat earlier this year, Desai's team organized a project to bring mental health caregivers together with grieving families. Another research project under way involves studying suicidal behavior to learn how to predict when troubled people will make an actual suicide attempt. Bit by bit, Desai is helping forge a mental health infrastructure in the world's second most populous nation — an effort he finds most satisfying.

"There is the old story about going into the quarry and asking the workers what they're doing," he says of his 16-hour days. "The first man says 'I'm breaking rocks.' The second says, 'I'm earning a living to support my wife and children.' Then the third says, 'I'm cutting these stones that will go into a temple that will provide solace to millions over thousands of years.'" Desai pauses to consider his story. "That's what I like to think I'm doing in helping develop these hospitals in India's public service sector: building temples for humanity. I wouldn't trade this for anything else."

BANGLADESH

9:00 a.m.

At 9 a.m. Halida Akhter, MPH '79, DrPH '82, is in her office at her desk, trying to reach government officials on the telephone. Home pregnancy test kits — thousands of them — are en route to Dhaka from a neighboring country. Since the kits are critical to her complex maternal health study that will identify and track 54,000 pregnant women over a three-year period, Akhter wants to make certain they will make it safely into the country, intact and on time.

The study in North Bengal will attempt to confirm previous findings that have shown vitamin A supplementation at normal dietary levels can significantly reduce maternal morbidity and mortality. Akhter serves as co-principal investigator on the study with Keith West, DrPH '87, MPH '79, professor, International Health. Two decades ago, the two were classmates at Hopkins. Since then, Akhter has become a respected Bangladeshi scientist, serving as director of the Bangladesh Institute of Research for Promotion of Essential & Reproductive Health and Technologies, which she founded more than a decade ago.

"One of my major goals has been to develop a major research environment in this country, particularly in the area of reproductive health," says Akhter, who modeled her fledgling effort on the U.S. Centers for Disease Control and Prevention where she worked as a visiting scientist in the early 1980s. 

She counts as one of the greatest successes of the Institute the gradual shift in government emphasis from family planning to the broader scope of reproductive health. "For many years the model was the mother and child. But that didn't include adolescent health, unmarried women, or young girls in puberty. We pointed out that it's important to take a life cycle approach, and now the country's health program is based on the reproductive health model."

Akhter's research training and expertise will be critically important in the months ahead as the micronutrient supplementation study gets under way. The effort, funded largely by USAID, the Bill and Melinda Gates Foundation, and the Canadian government, presents a daunting task. In a remote district of 900 square kilometers traversed mainly by paths and primitive country roads, she will induct a platoon of 800 health care workers (most of them local women) in 56 teams. Each month they will go house to house throughout the region's 600 villages offering free pregnancy tests to women who have missed a menstrual period.

The goal is to enroll at least 18,000 newly pregnant women per year in the study. Those who enroll will be supplemented with vitamin A every week for the duration of their pregnancy and three months postpartum. If the study results duplicate a similar investigation completed recently in Nepal, the vitamin A supplementation will lead to significantly better health outcomes among the pregnant women.

"I have an advocacy role not only for women's health, but also for being a woman scientist. I am always keenly aware of my obligations as a role model in this country," she says.

SOUTH KOREA

Noon

Hamburgers. These days in the go-go international city of Seoul many workers spend their lunch breaks munching that quintessential American fast food — along with fries and a soda — much like their counterparts in the U.S. Strolling through the campus of Seoul's prestigious Yonsei University, Seung-Hum Yu, DrPH '82, observes student infatuation with the increasingly common convenience foods of Western industrialized nations. And this worries the professor of Preventive Medicine and Public Health. 

A specialist in Health Policy and Management who serves as director of the university's Institute of Health Services Research, Yu has focused much of his career on studying the South Korean system of health care as his country rebuilt from a devastating war and emerged as a major world economy. Much of the research originating at Yonsei University has focused on comparing the Korean health care system with those of neighboring countries. Yu is one of the country's leading experts at finding ways to improve it.

In South Korea, national health insurance was introduced in the late 1970s, and universal coverage was achieved by the end of the 1980s. Today, many of the challenges facing the system are similar to those in other developed nations: Soaring medical costs led by advances in medical technology and pharmaceuticals have created fiscal deficits, unhappy providers, dissatisfied patients, and emotionally charged issues of health care rationing. But as intractable as many of these problems seem, there is a larger issue confronting professor Yu this afternoon.

"My new project is to help Koreans improve their quality of life," Yu says. In a highly urbanized environment like South Korea (which has a higher population density than Japan), quality of life issues involve more than simple access to reliable health care. "It's not only medicine, it's social services and the environment and lifestyles," Yu says. The rapid inroads made by the Western fast food diet among Korea's young are just one example. "In recent years the average income level has been quite increased. The per capita income now exceeds $10,000 and many younger people eat a Western diet with a lot of meat." The results, he says, are predictable: "Twenty years ago, myocardial infarction was quite rare. Today, it's common."

Nationally, the Korean government has engaged in a vigorous anti-smoking campaign for several years that has curtailed smoking in public places, raised tobacco prices, and had some success in reducing numbers of smokers. But despite the program's achievements, the government has been slow to initiate similar efforts in diet, exercise, and healthy lifestyle choices. Yu hopes to initiate a quality of life movement that will encourage more people to move in that direction. "Korean people spend their money on travel, on dining out, on entertainment, but comparatively little on their health," Yu says. "This is common in newly industrialized countries, so we will have to work hard to improve the health aspects of life."

COLORADO

8:00 p.m.

After a long day spent battling infectious disease, Duane Gubler, ScD '69, enjoys nothing more than a quiet dinner at home with his wife. But during a chaotic period not so long ago, those dinners were few and far between.

In the autumn of 1999, the news hit that a cluster of human encephalitis cases in New York City was caused by the West Nile virus — a potentially life-threatening disease new to American shores. The carrier was apparently the tiny and somewhat reclusive mosquito Culex pipiens.

Gubler still sits in on weekly conference calls monitoring the relentless spread of West Nile across the eastern United States. As director of the Division of Vector-Borne Infectious Diseases at the Centers for Disease Control and Prevention, he leads the agency's efforts at surveillance, prevention, and control of the virus. In 1999 he spent many long nights huddled with his staff, coordinating the first public response to the outbreak. During that time, the shortcomings of local public health infrastructure in the U.S. became rapidly evident.

"West Nile was a wake-up call to a lot of people," says Gubler. "People have forgotten that in the past we've had major epidemics of vector-borne diseases in this country."

He worries that some of the conditions that have made disease outbreaks so virulent in the past — such as high population density and poor mosquito control — are all too common today. "One of our biggest challenges right now is to rejuvenate our public health infrastructure. We have to revive the research programs that were allowed to lapse, and train the human resources we desperately need in state health departments. And we need mosquito control programs and labs for diagnostic support," he says, noting "the symptoms for vector-borne diseases are often non-specific, so rapid identification of diseases is imperative."

Ironically, it was the very success of public health efforts in the United States during the 20th century that led to dangerous complacency by the start of the 21st. "By the 1970s, we had diseases like plague, dengue, yellow fever, and malaria pretty well under control, which created a mind-set that these diseases were a thing of the past. So resources were redirected," says Gubler. "As a consequence, today we're unprepared. But with huge new urban populations and the rapid intercontinental movements of people and materials we've created ideal conditions for the dramatic resurgence of disease."

In New York, at the height of the West Nile hysteria, Mayor Rudolph Giuliani ordered the spraying of pesticides from helicopters and trucks. Though reassuring to many, Gubler observes that, in fact, widespread spraying isn't the best way to fight a mosquito. Insecticide-spraying trucks are usually a last-ditch effort. "What we need more of in this country are effective mosquito abatement programs that monitor the mosquito species present, observe where they breed, and map their habitats," he says. "What you want is an integrated type of approach that emphasizes larval control, water management, and biological control. That's the best way to prevent the risk to humans. We need to get away from this emergency response mentality."

WASHINGTON, D.C

10:00 p.m.

Catching the red-eye flight to a conference in Sri Lanka may not be everyone's idea of fun. For orthopedic surgeon James Cobey, however, the late-night flight out of Washington's Dulles airport is a labor of love. "I practice orthopedics part time — about 60 to 80 hours a week," is how he describes his often frenetic schedule, "and do the other stuff instead of playing golf." 

What Cobey, MPH '71, calls the "other stuff" is his decades-long commitment to international social activism. In the 1970s he helped coordinate the Red Cross disaster relief effort in refugee camps on Thailand's Cambodian border. In the 1980s he founded Health Volunteers Overseas, which annually sends hundreds of doctors, nurses, dentists, and therapists to help developing nations create sustainable local medical programs. Then, in 1991, Physicians for Human Rights invited Cobey to conduct the first epidemiological study of landmine injuries among Cambodia's civilian population. That effort became a book, Landmines in Cambodia: A Coward's War, which among other findings asserted that as a result of landmines, 1 in 236 Cambodians is an amputee (compared with 1 in 22,000 in the United States).

Coward's War quickly became one of the fundamental charters — and Cobey an early member — of the nascent International Campaign to Ban Landmines. In 1997 he joined several dozen other members of the organization in Stockholm, where the ICBL campaign and campaign coordinator Jody Williams were jointly awarded the Nobel Peace Prize.

Since then, Cobey's efforts to help bring about a complete ban on anti-personnel mines have continued. On this night he is traveling to Sri Lanka to make a presentation on getting each of the 140 signatory nations to ratify the landmine treaty; 117 have done so thus far. And of course, the greatest challenge is yet remaining — convincing the United States, which declined to sign the treaty, to agree to stop manufacturing, selling, and using landmines.

To date, the George W. Bush administration has shown little interest in joining the international ban on landmines. "And that stops other countries from signing on," Cobey says. "Their military leaders say, 'The U.S. has the best military in the world. If they need landmines, then we need them too.'" 

To Cobey, it's a matter of standing up to the military. "Historically, the American military has never liked civilians telling it what to do," he says. "But when you talk to retired members of the U.S. military — none of the current brass will discuss this on the record — you find out that a lot of them hate landmines. Thirty percent of American casualties in Vietnam were from landmines. Half of those were from our own mines - the Viet Cong would dig them up and move them."

Cobey hopes to harness some of that hidden antipathy and apply it where it matters most. To that end, he retains his faith in the powers of personal persuasion. "I'm lobbying the White House on landmines," he says. "I had a brief encounter with [Secretary of State] Powell, and I'm trying to get in to see [Vice President] Cheney. I believe I can help them appreciate the public health approach to this issue - to think in terms of populations and the overall needs of the country. That's what a degree in public health does for you."