Inventing Public Health Research
Five questions with Alfred Sommer
As a medical researcher in Indonesia in the 1970s, Alfred Sommer discovered that vitamin A deficiencies were more common than generally known and that they dramatically increased childhood mortality rates. He found that these deficiencies could be treated with small, inexpensive vitamin doses, a development that the World Bank has lauded as one of the most cost-effective health treatments in history. Sommer, an ophthalmologist and epidemiologist, won the Albert Lasker Award for Clinical Medical Research and went on to serve as dean of the Johns Hopkins Bloomberg School of Public Health, where he remains on the faculty. He is also a Pew distinguished fellow and spoke with Trend about how invention plays out in public health research.
Specific discoveries of new vaccines, antibiotics, and artificial joints have transformed public health. But you have pointed out that some of the most dramatic changes over time have resulted from us putting knowledge to purpose in other ways. What do you mean?
Our understanding of microbes and germ theory is the most obvious example. Sanitation—getting rid of abattoirs, developing waste treatment plants—has been responsible for 90 percent of the doubling of life expectancy since the late 1800s. The next advancement was water purification. It used to be people got water wherever they could. It was a professor at Johns Hopkins, Abel Wolman, who helped develop systems for water chlorination that had a huge impact in the United States and around the world. Social interventions have also played an important role, like child labor laws. They made a huge difference in allowing children to be educated, to be able to grow, and to be more productive and healthy members of society.
What is the role of the researcher, the discoverer, in bringing his or her findings into society?
When you discover something that is potentially an important observation or discovery, you have a moral obligation to pursue it and show either you are wrong, so you'll be the first person to show that you are wrong, or to show that you are right—because most people may not initially believe these discoveries, because they are such right-angle turns from current understandings. My vitamin A work was like that. At first nobody believed it; even after our clinical trials, there was skepticism. Eventually, other studies duplicated our results. But it took 15 years of persistence before it gained consensus. And here’s an interesting thing: We later found a study from London in 1930 showing that cod liver oil—rich in vitamin A—reduced measles mortality in youngsters by 50 percent. But nobody believed the connection, it did not change clinical practice, and the research was never pursued. So persistence pays.
Are there any shared attributes about these sorts of successful innovations?
It’s the need for data and observations that lead to successful innovations, as well as the fact that almost every major discovery is made by following up an unanticipated observation. The classic example of having data that leads to a “eureka” experience was the discovery of penicillin. For years, Alexander Fleming, like every other budding young microbiologist, had been growing bacteria on agar plates. Occasionally, the bacteria wouldn't grow because it was contaminated with a fungus. And for years, scientists, bright people, would look at it and say, “Oh, another contaminated plate,” and throw it away. Then one day, Fleming looked at the plate and said, “I wonder why the bacteria don't grow when there's a fungus there.” And that led to the observation that this fungus, penicillium, was producing a substance which was killing bacteria or inhibiting their growth.
What are some current developments in public health research that you’re watching that you believe show promise?
Being able to use new information in new ways is just as important as making a unique “eureka” observation, and that’s the promise that big data offer. Here’s an example: In medical school, you learn to write unintelligibly, and when I would fill out a chart on a patient, I would put in whatever was of interest and importance to me at that time. If another doctor came back three months later, he probably would not be able to read it, if he could even find it. Now, with the advent of electronic medical records, essential patient information is always there. That record can be linked with that patient if she returns to the hospital, or it can be linked with other people with similar illnesses or similar presenting signs. That not only serves the patient but allows us to make sure that money spent on health care is being spent well, and providing the benefits we expect.
You wrote a memoir about your career in public health. Its subtitle is Inspiration for Tomorrow’s Leaders. Are we in need of inspiration?
You can never have enough inspiration to get things going. Today, a lot of smart people are working on terrifically important problems. But all too often, those issues are actually quite plebeian. One reason is spending constraints. When funds are less available, there is risk avoidance. Something that is going to move our understanding an inch forward is much more likely to be funded than something that nobody else is considering, which is where breakthroughs actually occur. After all, they're breakthroughs because nobody ever thought of them before. The studies that are funded are safer, but they are rarely going to blaze new pathways to extraordinary insights that then lead us to a new understanding and new interventions.