Ichiro Kawachi, MD, PhD

IchiroTrained in both internal medicine and epidemiology, Ichiro Kawachi, has been a pioneer in the field of social epidemiology. Dr. Kawachi’s first foray into public health began as a doctoral student in New Zealand in the 1980’s, when he published a paper quantifying the estimated annual deaths due to second-hand smoke. This paper stoked the ire of the tobacco industry but ultimately led to the passage of historic legislation in New Zealand limiting cigarette smoking and tobacco use. Currently the chair of the Department of Social and Behavioral Sciences at the Harvard School of Public Health, Dr. Kawachi is a professor in social epidemiology and has taught for over 20 years. He has published over 500 articles on social determinants of population health. His books include the Health of Nations with Bruce Kennedy, Social Epidemiology with Lisa Berkman (Oxford University Press, 2000; Completely revised 2nd edition forthcoming in summer of 2014); and Globalization and Health and Social Capital and Health co-edited with S.V. Subramanian and Daniel Kim.

Career in Profile

  • 1985 – Received M.D. from Otago University, New Zealand
  • 1991 – Received Ph.D. from Otago University, New Zealand
  • 1993-NOW – Professor, Harvard School of Public Health, Department of Social and Behavioral Sciences

You have several titles: professor, department chair, social epidemiologist, and more recently, behavioral economist/scientist. Tell me a little about your work in each of these roles and which one is consuming the most of your time these days.

I spend about 75% of my time on research, 20% on teaching, and the remainder on administration. I’ve been very conscientious of trying to protect research time. I have a lab – the Society and Health Lab – that currently has a dozen postdoctoral fellows from all over the world. I try to prioritize research including a NIH-funded R01 project on the aftermath of the tsunami and earthquake in Japan. We’re in the field right now, trying to trace the people who were affected by the tsunami.

I’m still very passionate about teaching. I spend at least twenty percent of my time teaching. My classes are Health and Society, which I’ve been teaching here for over 20 years. I do that twice a year in the summer and the fall. I teach about 400 students altogether each year. Recently, I recorded Health and Society for edX. Thirty-two thousand students registered for it. It was really amazing to see this because as you follow the online chat in the classroom, you can see that the very time if you drop a pin from where one of these comments came from, within a day or so, you quickly draw a map of the world. I also teach Behavioral Economics, which started out small and has done the equivalent of going viral in the classroom because we are in the largest lecture theater now at the Harvard School of Public Health. The chair’s duties are administrative, shepherding academic and strategic concerns of the department. I try to keep it to a tenth of my time.

You were trained in medicine, became an epidemiologist, and have been a leader in the field of social epidemiology. You co-wrote the book on social epidemiology. How did you come to do this work?

I trained as a physician in New Zealand. I switched to epidemiology when I got fed up with doing downstream medicine day after day. It wasn’t what I expected. What I had underestimated was the sheer repetitiveness of day-to-day clinical medicine. I trained in internal medicine. I’d say that 80% of my patients had heart attacks, strokes, congestive heart failure, or chronic respiratory disease. If you take those four diagnoses, they comprise about 80% of internal medicine, at least it was when I was practicing. The bread and butter of medicine are these common things.

What do these things have in common? A lifetime of poor behavior, smoking, stress, bad diet, lack of exercise. So I started to realize that there must be a better way to go upstream and try and prevent these people from ever getting any illness. So, that was my initial stimulus to go from clinical medicine to doing something upstream, such as tobacco control.

I became very active in the New Zealand Public Health Association at that time. I was elected as the National Secretary. Just at that time, the Health Minister of New Zealand was Helen Clark, who later became the longest serving prime minister of New Zealand, and who is currently the head of the United Nations Development Program in New York. Under her leadership, she decided to pass legislation to ban all forms of tobacco advertising in New Zealand and to restrict smoking in workplaces. She was way ahead of the curve. She started thinking about this in 1989 and it finally passed in 1991. This was right at the time when I decided to make the switch to public health. So I became very excited by this.

I spent a lot of time lobbying for the passage of this legislation. That’s how I got interested in public health. Through my interest in tobacco control I then did a PhD in Epidemiology and then came to Harvard, now over 20 years ago. My initial reason for coming here was to study the benefits of stopping smoking in large cohort studies. While I was here, I met Sol Levine, who was one of the founding chairs of my current department. I got exposed to this idea of health inequality. I suddenly realized that the problem of tobacco control is actually one of health inequality. I suddenly realized that unless you tackle inequality, you aren’t going to really tackle tobacco control. People smoke because it is one of the cheapest pleasures, it is one of the few things that someone can have for himself/herself in a life that is full of stress and chaos and few options. That got me interested in social epidemiology.

Twenty years ago, when I was recruited into this department, I wanted to use the term social epidemiology to distinguish what I was doing from what I had been doing before, which was chronic disease epidemiology. At HSPH the students have to declare a major field of study for their thesis. One of the first things I did, when I took on one of my earliest doctoral students [was to suggest] that he declare social epidemiology as his field. Much to my annoyance, this was rejected by the school’s Committee on Admission and Degrees. In 24 hours it had come back and the chair of the Committee had said that there is no such field. That got me sufficiently riled and I decided to work on a textbook. Lisa Berkman also had the same idea and already we got a book contract from Oxford University Press. So we decided to write the textbook together and we declared the arrival of this field. These days, no one questions that there is a field of social epidemiology. Len Syme had been doing similar work for years but I guess he never used the term social epidemiology. The same with Sir Michael Marmot. They were doing it. But they hadn’t declared it an academic discipline. The past twenty years can be seen as an effort to build a training program in social epidemiology, which is what we say that we have at Harvard.

Describe your interests and focus in behavioral economics. What are the implications of this field on public health practitioners and policy? Does it represent a fundamental shift in how we are approaching research and interventions?

I became interested in behavioral economics when, five years ago, I became chair of the Department of Society, Human Development and Health. We are now called the Department of Social and Behavioral Sciences. Being a chair of a behavioral sciences department, I decided to review the curriculum. What are we teaching our students about behavior? Much to my amazement, it turned out that there was nothing in our curriculum about behavioral economics, which has been in the background of economics and psychology for the last thirty years, as it really started in 1980.

I was amazed by this gap because on the one hand you have those behavioral economists and psychologists who don’t speak to public health people, yet all of their examples concern health behavior. They’re practicing public health without a license! On the other hand, when I looked at our curriculum, we are the behavioral science department at the School and there wasn’t a single course listed on our whole department roster that taught behavioral health. So I decided that we better quickly fill this gap.

I think behavioral economics is very interesting because it does seem to me a remarkable confluence of ideas – in disparate fields from psychology to neuroscience to economics and public health – to more fully understand the basis of human behavior. I don’t think that by any means it’s a panacea, but it’s something new that we haven’t done. I think if we do it right, it has the potential at least to reduce inequalities as well. Because we know that all the things we speak about in behavioral economics – the heuristics, the biases, and the problems of delayed gratification – all of these things are even more acute in populations that face poverty and scarcity. To the extent that we can address these things, it has the promise of reducing inequalities and boosting the effectiveness of health behavior interventions.

What is a career success or highlight that you are particularly proud of?

My most efficacious paper to this date remains my 1987 article published in the New Zealand Medical Journal, which I wrote when I was a doctoral student. I always tell this to my students, because much as I try to work toward writing elegant papers in high-profile journals, the one that really had public impact is still the one that I wrote as a doctoral student in epidemiology. Back in 1987, the New Zealand Parliament was starting to debate whether or not they should pass legislation to restrict second-hand smoking. I had this idea to calculate how many deaths second-hand smoking in New Zealand causes. I used the technique of Population Attributable Risk, which I had learned in my epidemiology courses. I got some numbers and did a calculation. I discovered that nearly (an estimated) 300 Kiwis (New Zealand residents) were killed every year by inhaling second-hand smoke in the workplace and the home. Three hundred deaths each year might not seem like large numbers, but in New Zealand, that’s roughly two-thirds of the annual death toll from traffic accidents.

My point was that the New Zealand Traffic Ministry spent millions of dollars in anti-drunk driving campaigns, so why didn’t New Zealand government take passive smoking just as seriously. I published in the New Zealand Medical Journal and it had enormous impact. It was picked up by local anti-smoking organizations that held a demonstration in front of Parliament where 300 of them got dressed in crosses and laid down in front of Parliament. Politicians started to cite it in their speeches to Parliament. The next thing I know, I got a letter attacking the paper. Someone submitted a letter attacking the paper and it was written by none other than Nathan Mantel, who every public health student knows because of the Mantel-Haenszel odds ratio. This world famous statistician turned out to be a consultant for the tobacco industry.

When I saw that letter, I knew that I had made an impact. I had sufficiently disturbed the tobacco companies that they had paid this world famous statistician to attack my paper in the New Zealand Medical Journal (which I doubt he had ever read before my article appeared). To this day, I contend that that was the most important, directly policy-relevant paper I’ve written. It just shows that I peaked early. Students can still do really important work. I’ve never had that kind of success since then.

What is a challenge that you’ve faced or continue to face in your career?

A challenge in behavioral economics and social epidemiology is the massive disparity in power between “us” versus “them”. In this country, at least, economic power has become so concentrated in the last 30–40 years, it’s becoming harder and harder to make an impact through the mechanism of democracy. If you want to make some point of view, it is hard to get it represented through the ordinary channels of media.

It’s exactly like Joseph Stiglitz described in The Price of Equality. He articulated what I always wanted to say about income inequality’s corrosive effects on the body politic. His argument is that the concentration of wealth in the top one percent is distorting political decision-making in a functioning democracy. It is distorting media, the rules of the game by which the economy is run, and I think this is a huge challenge both inside and outside of public health.

To get something done within public health, you have to influence institutions, the laws, and regulation. Developing evidence is the initial step. We also say that lots of policies get made on the basis of no evidence. If there is a will to do it, they’ll do it. If you want something to be passed, at least on our side, you have to have evidence. What researchers at the School of Public Health are doing is providing the knowledge base. As has been said before, that is only one of the ingredients. You have to have the political and popular will to do something and you have to have an appropriate strategy to translate that evidence into policy. Unless those things come together, you won’t get change. The problem with growing polarization is that you can produce lots of evidence but the political will is stuck.

Is there a persistent public health problem that still concerns you today?

I have to say that it is health disparities, persisting inequality between rich and poor countries, and persisting inequality within rich countries. The field of social epidemiology is really an attempt to focus attention on that problem.

It is not enough that the average gets dragged up. You have to lift everybody. There is a lot of attention on global health but basically, you don’t need to go that far. Look in our backyard. You will see disparities in life expectancy that span the entire globe. A man born in a New Orleans’ parish has a life expectancy in his ‘50’s, compared to an Asian-American woman born in a rich Bergen County, NJ, who has a life expectancy of 90. A forty-year difference in life expectancy pretty much spans the average differences in the countries of the globe. I tell young, idealistic youth who want to make a contribution to global health that you don’t have to go all the way to Malawi. You can do something in rural Mississippi. Health centers like the one in Mound Bayou, MS, because basically it’s the model of physician responsibility. The primary care doctors basically said that it’s not enough to provide primary care, you’ve got to invest in educating the people, making them leaders, and make it self-sustaining (Editor’s note: Mound Bayou was the first community health center in the country).

This feature was interviewed, transcribed and partially edited by our guest editor, Ted Henson. The photo was provided by Maki Miyashita.

Joseph F. West, ScD

OriginalIntroduction

After graduating from the University of Illinois, Dr. Joseph West worked in child welfare for two years, where he grew frustrated and decided to pursue a PhD in Sociology.  He was en route to a Master’s in Sociology when he worked on the Project on Human Development in Chicago Neighborhoods, where he met Dr. Felton Earls, a professor in Public Health and Social Medicine at Harvard.  Dr. Earls convinced him to switch paths to public health, and became a key mentor as Dr. West became the first African American to obtain a doctoral degree from the Harvard School of Public Health.  Since then, Dr. West has conducted research in numerous areas including smoking cessation and diabetes.  He has also written and produced several plays including Suga Foot Blues, and the memoir Trod the Stony Road.

Career in Profile:

  • 1994 – Graduated from the University of Illinois Urbana-Champaign with a Bachelors in Sociology and a minor in Economics
  • 1999 – Completed his M.Sc. in Health and Social Behavior
  • 2004 – Completed his Sc.D in Social Epidemiology and Health Policy from the Harvard School of Public Health
  • 2004-2006 – Worked as a researcher on the California Foster Care and Chicago Housing Project Study at Chapin Hall Center in Chicago
  • 2006-2007 – Worked as Project Director at the Center for Study Cultural Diversity in Healthcare at the University of Wisconsin Medical School. Studies included the Neighborhood Disparities Project and the Milwaukee Infant Mortality Project.
  • 2007 – 2013 – Served as senior epidemiologist and project director at the Sinai Urban Health Institute. Work included the Block-by Block Diabetes Community Action Project and the Breathing Freedom Smoking Cessation Project.
  • NOW –  Senior Partner at Whitaker Kinne Group

So how did you end up in public health?

After undergraduate at University of Illinois, I spent two years doing child welfare work transitioning young people involved in foster care to adulthood. I got frustrated with that and I felt that I needed and wanted to go back to graduate school. I wanted to get a Ph.D in sociology and was actually taking classes at Roosevelt University in the evening, studying sociology towards a master’s degree, and then I started working on the Project for Human Development in Chicago neighborhoods.

I was working there during the day, I was going to school at night and that’s when I met Dan Kindlon (sic), Steve Buka (sic) and Dr. Earls. Tony Earls, after a conversation about what I wanted to do and study, he said, “You are not a sociologist, you are an epidemiologist”. I didn’t know what that was, and he said,  “Public health is going to be the key for you”,  and he introduced me to Dan Kindlon, who was part of the project, and wrote that book Raising Cain, that became really popular after the Columbine shootings. Then to Steve Buka, that whole group! So I applied to all these graduate schools and I didn’t get into any except to Harvard.

When I got there I realized why I got into Harvard. It was an eye opener about the graduate process for a Ph.D. It’s a subjective process. I got in because of Dr. Earls. He not only wrote a letter of support, he and Steve, all of the HSPH guys who were working on the PHDCN project wrote letters. They said that this school had not graduated an African American out of the doctoral program and that they would support me. They said I’ve been a part of this project, I’ll have my own data and that they think I should get in. That’s what happened, at least my understanding of it. They made it clear that they were going to mentor me. That was my first introduction to the idea of a mentor and how important mentoring is. Because even though I thought I had the scores and the experience, it was the idea that I was going to continue to work with these scientists that are respected in the field and that they were also willing to allow me to explore some of my own interests while in Boston that led me to public health.

What was working on that project like?

It was incredible.  Field research and collecting data in the field is tough. Its funny because now I am the director of a project where I have people go out to do just that. So I understand what they do because I did it for a year.  Its interesting because when you are in people’s homes, not only are you collecting data on the questions that are on the protocol, you are also collecting data based on your interaction and experience with them in that moment.  I was one of the few research assistants that actually did that.  There were people who went into the homes and only asked the questions and circled the boxes on the list, even though at the end, at the back of the protocols there were all these pages with space for notes. People didn’t write down information about what they were seeing and what was going on and what was happening in the house etc. They didn’t do any of that, but I did. I would try to fill up mine, because there was a lot that I thought was relevant in that home or in that community that was beyond the questions and the boxes. With my team now that’s the hardest thing to get them to do. I try my best, but my team is guilty of that.  They don’t feel comfortable writing it and they don’t feel comfortable commenting. I say all this to say that I realized then that I wanted to do more. I wanted to do more than just to collect the data, I really wanted to do more.

What is one of your greatest career challenges?

Finding the time to write.  Whereas some people can analyze a large dataset and then write, I have to interact with the community or with my team on a daily basis. It’s challenging to block off time to write. I’ve also had to learn to speak to different audiences and to different issues.  My greatest challenge has been putting together my body of work.  I’ve found my stride.  I know exactly what I want to write about and where to build my research. I’ve started another book and I’ve got my focus. I feel a bit of pressure because of my age.  I may not have reached some of my personal benchmarks, but I have reset them, and I want to really reach those goals. If you don’t outline your career steps right now, you will probably bounce around, and will not build a cohesive body of work. I want to build a coherent body of work and continue to grow.

What is something in your career that you feel really proud of?

My diabetes work.  I got the grant funding and started working in the community through the Block by Block project, and there’s been some spin off.  We’ve been able to fund other activities in the neighborhood, to start a dialogue about diabetes and food.  We can engage the community around these issues.  In the Lawndale Diabetes Project – a follow up of the Block by Block project – we train health educators to go door to door within the community.  They talk with residents about diabetes, provide basic guidance around diet, exercise etc.  After we work with people to get them advice and support, they can be turned over to disease management and then follow up with doctor appointments etc.  So now, I’m at that point in my career where I have enough, in terms of ideas and experience, to really produce.

I am fascinated that you’ve written a book that is not entirely public health related, and that you are also producing plays that seem public health oriented. Can you talk about those projects?

By my understanding, I was the first African American male to obtain a doctorate from the Harvard School of Public Health.  I wrote Trod the Stony Road to try to make sense of my journey.  I live in the community where the Lawndale diabetes project takes place.  I also lived in East St. Louis, a pretty challenged community.  I had a brother who used to be in and out of prison.  So how does a kid come from this type of background make it all the way to Harvard?  I talk about all the things that I went through, from an attempted suicide when I was 13 to having a gun to my head, and then I talk about grace and my sense of space.  That I was spared for a reason, or maybe for some kind of purpose, was something I needed to make sense of.  I felt like I was just stumbling forward, trying to make sense of it all. That’s why I wrote that book.

As an undergrad I did a lot of theater, and I’ve realized that my creative side is just as important as my scientific side. I like to write!  I’m doing diabetes scientific work, and that’s what for one audience.  But there’s another audience that needs to understand the human side of diabetes.  Suga Foot Blues is the story of a female dancer who has Type II Diabetes. She hasn’t taken great care of herself, so she is going to lose her foot. We all know all the clinical issues that come with poor management of Type II Diabetes … but what about when she goes home and has to deal with the emotional issues?  What happens in that home?  Because it’s not just her, she has a family and they have to deal with it, too.  It’s how I take my day-to-day profession and turn it into art.   It is about the healing power of art, theater and the spoken word; it’s about how you take relevant, quantitative, quantifiable data and translate it into art.

So when it comes to public health, what matters to you and why?

Public health really is about human development and what people need to learn early in life.  Adult behavior change and learning is difficult, even things like washing your hands are difficult. Our relationship to food, our cultural rights and rituals with food…a lot of people are not connected. There are a lot of social networks but people are not connected. We have a culture that promotes recklessness with each other and with our selves.  We all struggle with learning.

Many of the poverty-related health issues relate to lack of empathy and understanding.  It’s not strictly economic.  Before diabetes, I worked on a smoking cessation project where we tried to reach out to young pregnant girls. Most were exposed to large amounts of second hand smoke.  Their challenge was that they didn’t have a place to stay, so they might be with their parents or grandparents, and say their mother had a boyfriend and they both smoked.  “I can’t tell them not to smoke just because I’m pregnant, because they’ll say, ‘You’re the one that’s pregnant, you move.’  Or maybe her boyfriend is really abusive and she can’t tell him to not smoke.  You realize that there are people that don’t have empathy for her or her child’s health. That’s not racism! That’s not poverty! That’s a lack of human development and empathy.

Our diabetes project has a cooking class, and one participant said that when she tried to cook a really nice meal and serve with right portion sizes, her family looked at her like she was crazy.  “I’m supposed to eat this little bit of food?  You are supposed to fill up my plate.  You’re the one that has diabetes, not us!”  If people aren’t supportive, what can you do?

Policy makers also lack human development and empathy.  They create policies without understanding how those policies impact people’s lives.  We have illiterate policy makers and legislators. They can read what’s written, but they can’t understand the human condition.  There’s a gross degree of lack of understanding on both sides of the aisle.

So what is your ideal solution?

That’s a challenge. We have to start on both ends.  We have to engage people at a grassroots level to talk about their own health, well-being, community, family.  I see so much fragmentation and brokenness in communities now.  We have to think about how we can be connected together.  At the other end, we have to get politicians and policy makers and legislators to have honest discussions about policy.  We have not had a truly honest discourse about policy.  Everything is a sound bite, and you can’t grow on a sound bite.