SPH: When you started at SPH, what was the School’s mission, and how has that mission evolved—or remained constant—over the decades?

Howard Cabral: I think that the core of the mission of SPH has stayed the same even with the tremendous growth that has taken place here.  One can see this in how the mission statement of the School has been so consistent over the years. SPH has always had a sense of itself that I believe was unique. Our close connection to Boston Medical Center (then Boston City Hospital) has been key to this, together with our work with collaborators such as the Massachusetts Department of Public Health, the Boston Public Health Commission, as well as various leading national and global organizations.

Les Boden: From the outset, our school concerned itself with issues of justice and equity. This was especially obvious in health law but was consistent throughout the school. Over the years, these concerns became clearer and stronger. Changes in our society, like the Black Lives Matter movement, strengthened the school’s commitment to these issues.

SPH: While SPH’s mission has remained largely unchanged since the School’s founding, have you observed any shifts in the student body over the years?

Daniel Merrigan: In the early years, SPH was a degree program within the School of Medicine. Its early mission was to provide needed graduate public health education for [professionals] already employed health care and community health. At this time, many public health practitioners had little to no academic preparation for the work that they were doing. A larger proportion of students were older, working full-time, and studying for their MPH part time. For this reason, classes were scheduled primarily in the evening.

Boden: Over the years, we broadened our education mission to include people who came to us with bachelors’ degrees. We also began our first PhD program, in epidemiology, in 1983, and our second, in environmental health, in 1988. Of course, we now have five, including the Biostatistics PhD program, which we share with the Department of Mathematics & Statistics at the Graduate School of Arts & Sciences and which predates the other PhD programs.

Alexa Beiser: Our students [today] are more likely to be much younger, often recent college graduates, and have little work experience. Their primary interest is in public health itself as a career, not as an enhancement to other career paths.

Cabral: When I first came to SPH [in 1984], I was 25 years old and was one of the youngest students in the School. I was working locally with the developmentally disabled at the Fernald State School after my graduation from Holy Cross and was looking to start a career in public health. I happened around the same time to be a volunteer researcher in the well-known Woburn Health Study, and there, I met [Richard] Clapp, emeritus professor of environmental health, who was then the Director of the Cancer Registry for the state of Massachusetts. I was considering a move to New York to attend Columbia but had a young family and the need to continue working full time. [Clapp] suggested that I look into SPH. He said that it was on the leading edge of innovation in public health education and research. He was spot on in his evaluation.

SPH: Have you observed any notable changes to the way that SPH operates that you view as major turning points in the School’s trajectory?

Merrigan: Significant changes occurred as the MPH program became independent from [the School of Medicine] as a bona fide School of Public Health at Boston University. This is when SPH acquired the Talbot Building. Enrollment increased, departments expanded, and the School added more course offerings. The trend shifted from primarily part-time practitioners to include more full-time students, many of them newly minted undergraduates.

Related to this shift in student demographics, the School recognized the need to provide more emphasis on the practice dimensions of professional preparation for future public health practitioners. I had the privilege to serve as the first associate dean for practice at SPH. In this role, I initiated and directed the required practicum for all students and served as the [principal investigator] for two continuing public health workforce development programs: the HIV/substance use certificate program (now the mental health and substance use certificate) and the New England Public Health Training Center.

Cabral: I think that as we have had strong leadership at SPH we have been able to grow, stay on the cutting edge, and yet keep our unique identity.

SPH: Reflecting on your own work or that of your colleagues, how has the field of public health itself evolved—and has the school kept pace with those shifts? What patterns do you see, and what gives you hope?

Boden: Public health has become much more a focus of partisan politics than it was 40 years ago. Students now need much better understanding of this situation and how to deal with it. Also, social media had no role 40 years ago. Using it effectively is now a critical professional skill.

Merrigan: The emphasis in graduate public health education has evolved over the years. In terms of prevention, behavioral epidemiology reigned, and much attention focused on changing individuals’ health-related behaviors. Social epidemiology was in its infancy, and it was not until the turn of the century that more focus was given to the social determinants of health and to recognizing inequities that contribute to many health disparities among marginalized demographic groups. As our understanding of the social determinants of health expands, SPH has embraced convergent, interdisciplinary approaches, systems thinking, and systems analysis to address persistent inequities and other challenges. The school’s research portfolio and extensive curriculum continue to focus on pressing population health issues across the board: climate, advocacy, systems change, global health, etc.

Sager: I think that, in the U.S., the cost of health care has become the strategic problem. Health spending is six times defense spending and rises by $1 trillion every three years. Health spending sponges up dollars that might otherwise be available to seriously address housing, nutrition, environmental, job training/education, income inequality, or any other problem we care about. And, of course, rising cost impedes efforts to insure more people and to cease suppressing use of care by people with insurance via high out-of-pocket costs, narrow networks, prior authorization, or stark lack of nearby doctors, hospitals, dentists, long-term care, or mental health services. Perhaps the main reason costs are so high is that about one-half of health spending is wasted—in the forms of clinical waste, administrative waste, high prices, and theft. It is very possible that, at the bottom of the next recession, Congress will vote to freeze federal health care spending. Patients will lack care and needed caregivers will go broke. Pressure for relief and reform will grow. But despite the pressure, it will be hard to raise taxes by $2 trillion to enact [a] single payer [healthcare system]. But vast amounts of money will still be available. We could recycle the fat—the waste—as clinical bone and muscle.
 
Since health care is very complicated, reforming it is even more complicated. The big challenge, I think, is to start now to plan and test the details of winning health security [for] all Americans, containing costs, getting the right numbers and types of caregivers in the right places, and building a solid floor under access, appropriateness, and quality of care. Winning health security for all requires understanding power and politics generally and inside health care, opportunities for protecting all of us, methods of containing cost that actually work, how money works in health care, securing the numbers and types of caregivers we need—where we need them, and ensuring equity, effectiveness, and efficiency of needed care.

SPH: Is there a specific program or student outcome from your time at the School that you are particularly proud of?

Merrigan: For several years [in the] late 1990’s, I directed the Join Together Leadership Program at BUSPH. This Robert Wood Johnson Foundation initiative was national and included fellows from across the country. I am proud of all our fellows, and most especially, these three individuals stand out: Gavin Newsom, current governor of California; Karen Bass, current mayor of Los Angeles; and Claire McCaskill, former US senator representing Missouri from 2007-2019.

Cabral: Our doctoral program in biostatistics has been an excellent collaborative program and a leader in doctoral training in biostatistics that is academically rigorous and grounded in real world problems. We have attracted students from various backgrounds. Our student Taylor Mahoney Theriault came from the Charlestown neighborhood of Boston and worked her way through Boston Latin School and then Simmons University. [As an undergraduate,] she joined our Summer Institute for Training in Biostatistics (SIBS), an innovative program that began in 2004 and aims to orient undergraduates to careers in biostatistics. After SIBS and her graduation from Simmons, we accepted Taylor into the doctoral program and she contributed much to our community.  Her dissertation work on statistical methods for clinical trials data under the primary mentorship of Joe Massaro from our faculty was outstanding. I was fortunate enough to be a member of her dissertation committee. We are very proud of the work that Taylor is now doing as a lead biostatistician for a local research consulting company.
 
Sager: Students in my PM834 Planning and Regulating to Fix Health Care seminar spend the semester drafting plans to address medium-size health care problems. The better plans typically run 45 to 60 pages. They aim to reduce harm from problems like the shortage of primary care physicians, the shortage of kidneys for transplantation, maternal mortality and morbidity, childhood asthma, falls by elders, burnout or oppression of hospital RNs, and the like. These plans entail measuring the harm people now suffer from a problem, analyzing causes of the harm, identifying policies and programs to weaken the power of the causes, and evaluating the four best programs’ efficacy, cost, political feasibility, and administrative feasibility using available evidence. The students’ plans are generally terrific.

SPH: What would you like to see the next generation of SPH faculty and leaders preserve from the past 50 years, and what do you hope SPH will continue to be known for in another 50 Years?

Cabral: Public health is for the “public” and not just those with the resources to obtain it for themselves. I believe that we are our “brothers’ keepers” and this should be the driving motivation of our work.

Boden: I hope that we will be known as an agent of progressive change that supports health for all and as a place where community involvement is an important component of our public health mission. 
 
Merrigan: My desire [for] the next generation of SPH faculty and leaders to preserve from the past 40-plus years is the inspiration from the words of the public health commentator Geoffrey Vicker: “I believe the history of public health might be written as a record of successive redefining of the unacceptable.”

I hope SPH will be continue to be known for excellence in teaching, research, and practice; relevance—using a justice lens to make informed decisions about what to research, teach, and practice; inclusion—maintaining a community-centered mindset to collaborate with others; and justice for all.