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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2006.103317
FACES OF PUBLIC HEALTH |
Donya Currie Arias is a freelance writer and editorial consultant in Fredericksburg, Va.
Correspondence: Requests for reprints should be sent to Donya Currie Arias, MA, 60 Bayberry Ln, Fredericksburg, VA 22406 (e-mail: dcarias{at}cox.net).
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It’s that neat combination of head and heart, which is why he is so effective.—Geeta Rao Gupta
President, International Center for Women’s Research
WHEN COLUMBIA UNIVERSITY hosted a tribute dinner to honor Allan Rosenfield’s 20 years as dean of the Mailman School of Public Health, organizers scrambled to set up an extra tent because the initial 400-member guest list soon swelled to more than twice that size.
"Everyone really likes this guy," actor and human rights activist Richard Gere noted at the event. "Allan Rosenfield is one of the few individuals I can think of who is pretty much universally respected," said New York City Health Commissioner Thomas Friedan. "How on earth does one do justice to the achievements of one human being which have meant so much to so many people around the world?" mused United Nations Secretary-General Kofi Annan.
Rosenfield has been praised by the likes of former President Bill Clinton and Senator Hillary Rodham Clinton, global health advocate and rock singer Bono of U2, public health workers in Thailand, HIV/AIDS advocates abroad and in the United States, women’s rights pioneers, and global health leaders.
One of the public health world’s most outspoken advocates for women’s health, human rights, and equity in health care, Rosenfield did not set out to become a public health legend or even to work in the field. He planned to follow in his father’s footsteps and set up a private obstetrician/gynecologist (OB/GYN) practice near Harvard’s Brigham and Women’s Hospital, where he would teach on a part-time basis. However, a year as a US Air Force doctor in Korea (after the war) followed by a year at a teaching hospital in Nigeria opened Rosenfield’s eyes to the great need for improved health care worldwide. "I was, I guess, touched by the health problems of poor countries," Rosenfield said humbly from his office in upper Manhattan, his phone ringing constantly and e-mail after e-mail flowing into his computer’s inbox.
When he finished working in Nigeria, Rosenfield still planned to return to the United States to set up a private practice and teach both medical students and OB/GYN residents. Then the Population Council came calling and hired Rosenfield as an adviser on reproductive and maternal and child health for Thailand’s Ministry of Public Health. What was supposed to be a 1-year appointment turned into 6 years and spawned a landmark model of reproductive health care access in rural areas. This changed Rosenfield’s working life forever.
"That was a turning point in my career," Rosenfield said about his time in Thailand, where he developed a model checklist for auxiliary midwives in rural areas that allowed them to prescribe oral contraceptives in lieu of relying on hard-to-come-by physicians. Within a year, more than 3000 auxiliary midwives were prescribing birth control pills across the country. "I got more and more involved, sort of in the big picture instead of one-on-one patient care," Rosenfield said. "It’s important to have good doctors providing good care, but I sort of felt there were plenty of people doing that in the States."
When he arrived in Thailand, the average family had 7 children, and the country’s annual population growth rate was close to 3%. Thai health officials credit Rosenfield’s efforts with dramatically changing those figures: by 2000, the average family had 1.6 children, and the population growth rate was 0.8%. While living in Bangkok, Rosenfield and his wife, Clare, had 2 children, Paul and Jill, both of whom spent their earliest years there and then returned to work in Thailand while in college. Clare has been a steadfast supporter of her husband’s work throughout the years and believes strongly in his vision for improving public health. "He is just a noble soul with a big heart whose meaning comes from serving the needs of others," Clare said in a video shown during the Columbia University tribute dinner.
After his time in Thailand, Rosenfield was recruited by Columbia University in New York City, where he became a professor of both public health and obstetrics/gynecology; he later founded the school’s Center for Population and Family Health (now the Heilbrunn Department of Population and Family Health in the Mailman School of Public Health). While there, he recruited Judith Jones to help him find ways to provide reproductive health services in upper Manhattan, NY, where adolescent pregnancy rates were high and access to care was low. The center’s innovative programs included the Young Adult Clinic (an evening clinic for girls and young women), the Young Men’s Clinic, and school-based clinics throughout the area. All these clinics thrive today and serve as models of health care access in lower-income urban areas.
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Jones, who is now a clinical professor of population and family health at the Mailman School of Public Health, spoke at the tribute dinner about Rosenfield’s leadership skills and also his caring. She described him as "a committed physician who sees the needs of people, not places, and recognized that gaps in care can strain the healthy development of the individual. Allan deeply believes that health care is a right, not a privilege."
Rosenfield said his view of health care boils down to equity in education and health care for all, particularly among under-served women. "I guess the bottom line is equity, and that’s in our country as well," Rosenfield said about his long-held belief in universal access. "I find it totally unacceptable that we still have 44 million people uninsured, 70% of them working poor people, in one of the wealthiest nations in the world. I think that’s terrible."
Throughout his entire career, Rosenfield has been passionate about women’s health. He and epidemiologist Deborah Maine coauthored a paper published in 1985 in the Lancet titled "Maternal Mortality—A Neglected Tragedy. Where is the M in MCH?" "In discussions of MCH [maternal and child health] it is commonly assumed that whatever is good for the child is good for the mother," Maine and Rosenfield wrote. "However, not only are the causes of maternal death quite different from those of child death, but so are the potential remedies."1
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In another groundbreaking paper published in the American Journal of Public Health in May 2001, Rosenfield addressed maternal-to-child-transmission (MTCT) of HIV and asked "Where is the M in MTCT?" He had the audacity, some might say, to question the policy of using mothers as mere vehicles for giving HIV prevention medication to developing fetuses. He also noted that when MTCT programs first started, there were no funds available for antiretroviral treatment in poor countries. "Decreasing maternal–infant transmission of HIV without treating the mother or father adds to the already high number of orphaned children,"2 Rosenfield wrote. "Many of these orphans have become street people, because AIDS has ravaged their traditional extended families. Do we expand treatment to decrease MTCT without treating women, only to increase the number of orphans? It is difficult to believe that this question even needs to be asked."2
Difficult, indeed, but Rosenfield has never shied away from asking the difficult questions or from seeking funding where seemingly none existed to develop programs that would work with few resources. "We’ve got to be practical and do what’s possible in the setting that exists," said Rosenfield, who has spoken out against the "doctor-only" mind-set. "What I have said publicly at a couple of OB/GYN meetings is, ‘What some of you are saying, in effect, is if there isn’t an obstetrician available, let the woman die.’ " Controversial, maybe, but Rosenfield felt strongly that it needed to be said.
"I guess the bottom line is elimination of poverty, equity in health care in both the US and abroad are the core issues I believe in, where I do have some expertise and ability to talk about the issues," said Rosenfield during a televised interview with journalist Charlie Rose in July 2006.3 Rather than talk about himself, Rosenfield turned the conversation back to health care access, AIDS and women’s rights, and other public health issues. "I’m a strong supporter of health care reform here. . . . If you’re very sick and need high-tech health care, this is the best place to be, but in terms of universal access, we’re way behind."3
Among the initiatives that Rosenfield has spearheaded are the Prevention of Maternal Mortality Program (a collaboration with several West African countries that linked local health providers with women who need care), the Averting Maternal Death and Disability Program (funded in 1999 by a $50 million Bill & Melinda Gates Foundation grant, which at that time was the largest grant in Columbia University’s history), and the MTCT-Plus Initiative (a family-based program that provides care and treatment to more than 100 000 mothers and children).
Rosenfield believes maternal mortality is still one of the world’s most neglected tragedies. Despite the numbers—millions of children die yearly compared with a maternal mortality rate of about 500 000—the differential in the maternity mortality ratio between poor countries and the West is far larger than for child mortality. "The bottom line is we know the cause of maternal deaths," Rosenfield said. "It’s a question of governments deciding this is important and giving it priority." For example, Sri Lanka has made maternal health a priority during the past 40 years, and despite the country’s relative lack of wealth, the vast majority of women deliver babies in a hospital-like setting and the maternal mortality ratios are low.
"The fact that Rosenfield is a man speaking out for women’s rights and health care issues carries particular weight in some circles," said Mary Robinson, executive director of the New York-based Ethical Globalization Initiative and former president of Ireland. "There aren’t too many men who actually understand the link between poverty and lack of access to care and women not being equal," Mary Robinson said. "Allan has always cared."
Geeta Rao Gupta, another colleague of Rosenfield’s and president of the International Center for Women’s Research, said Rosenfield’s clinical experience "helps him make the case for the injustices women face. I think it also counts a lot because he’s male." In many countries where women still are viewed as secondary to men, the cry for equality in health care and education "coming from a man has different resonance and gets more traction," Gupta said. "He’s actually directed the field [of global public health] to change course, to think differently," Gupta said. Yet it is not merely Rosenfield’s expertise that impressed her, she said, but also his caring. "It’s that neat combination of head and heart, which is why he is so effective."
Rosenfield became dean of the Mailman School of Public Health in 1986, and during his leadership, the school’s budget rose astronomically from $12 million to $161 million. Joseph Graziano, associate dean for research and professor of Environmental Health Sciences at Mailman School of Public Health—and Rosenfield’s colleague since 1991—described him as a "marvelous" man. "It stems from who he is—his sense of caring for every single person under his guidance." That extends from professional to personal, said Graziano, who awoke in his hospital bed after a sudden illness to see Rosenfield’s smiling face looming above him. "The extraordinary thing to me about Allan’s career is when the AIDS epidemic first emerged and so little was known about it, he was immediately drawn to the problem and saw it as the crisis it became," Graziano said. Although Rosenfield could have delegated the duties of sitting on boards and committees that addressed AIDS to his subordinates, he sat on those committees and boards himself to get a frontline look at the problem. "He gave of himself in a major way," Graziano said. "Allan personifies the public health heart." In other words, he sees the world as his patient, particularly communities in need. "Allan sets the standard for what it means to be a public health professional."
Rosenfield announced in mid-2006 his plans to step down as dean of the Mailman School of Public Health, a move he had been planning but that was hastened by illness. He was diagnosed in late 2005 with amyotrophic lateral sclerosis (ALS) and in April 2006 with myasthenia gravis, both of which are eroding his motor nerve function. As a result, Rosenfield has had to give up a global travel schedule that sometimes had him flying overseas and back in 2 days. Regretfully, he also has been forced to scrap his plans for devoting more time to tennis and skiing. Because of breathing difficulties, he relies on a wheelchair to get around. However, after he welcomes a new dean, Rosenfield plans to continue working on the important global public health agenda that has become his life’s work. "You either give up or you keep working," Rosenfield said, quickly changing the subject to the need for equity. "Equity and health care and education are things I believe in very strongly, and I think it’s a major public health agenda."
A crystal bowl filled with brightly colored condoms—a gift from Planned Parenthood—sits on a table in Rosenfield’s office underneath a watercolor painting by his wife and next to a certificate of appreciation from Ipas, a women’s health and rights group, that reads in part, "For your contribution to the women of the world. . . ." Rosenfield has almost run out of room in his office for awards and commendations, such as the engraved crystal bowl from the Global Health Council that quotes from a T.S. Eliot poem: "Do not follow where the path may lead. Go instead where there is no path, and leave a trail."
According to his many friends, colleagues, and admirers, Rosenfield has done just that. "Allan has been a leader in public health, reproductive health, and women’s health for decades, and he has never backed down even an inch even in the face of significant adversity," Friedan said during the Columbia University tribute dinner. "His contributions have improved health, particularly women’s reproductive health, from a time when he was almost a lone voice in the field to a time when reproductive rights have been accepted nationally and internationally, to the present time, when sadly, they are under attack again both nationally and internationally. And yet we know that these attacks will not succeed in large part because of Allan’s leadership."
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Footnotes |
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Peer Reviewed
Editor’s Note: Allan Rosenfield is the only dean I have known in my close to 2 decades at the Mailman School of Public Health—first when I was a doctoral student in the former Division of Epidemiology and now as a faculty member in the Department of Sociomedical Sciences. Allan has been a champion of the belief that women’s health should not come UNDER child health. In other words, the key issues globally related to women’s health are much broader than those related to being a mother. Nonetheless, given the international focus of this issue, he preferred to have this feature article published alongside the important included articles on international child health priorities, but asked that I reinforce his core belief of a woman’s right to health over and above her role as mother and caretaker of her children.
Mary E. Northridge, PhD, MPH
Editor-in-Chief, AJPH
Accepted for publication July 30, 2006.
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References |
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 TOP References |
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1. Rosenfield A, Maine D, Maternal mortality-a neglected tragedy. Where is the M in MCH? Lancet. 1985;2(8446): 83–85.[Web of Science][Medline]
2. Rosenfield A, Figdor E. Where is the M in MTCT? The broader issues in mother-to-child transmission of HIV. Am J Public Health. 2001;91:703–704.[Web of Science][Medline]
3. Charlie Rose with Allen Rosenfield [transcript]. "Charlie Rose." PBS. July 7, 2006. Available at http://video.google.com/videoplay?docid=-7414526377127316438. Accessed December 4, 2006
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