The Long View
December 2, 2009 |  by Rich Shea

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Many in public health now are proponents of life-course orientation. Holly Grason, an associate professor at Hopkins whom Guyer recruited to his department 16 years ago, says this is thanks, in part, to Guyer’s “writings and teachings disseminating it, really infusing the field with it.” What he’s disseminated includes work from colleagues abroad, people like David Barker, a British epidemiologist who, in 1989, after studying various cohorts’ medical records, linked low birth weight to a high risk for coronary heart disease—now known as “the Barker hypothesis.”

“Both of us have learned a great deal from looking across the ocean at research done in countries where they have better longitudinal data than we have here,” says Neal Halfon, a Guyer colleague and community health services professor at the UCLA School of Public Health. “We’ve used that to connect the dots between early and later life.”

“Life course,” however, is far from a household term. As commonsensical as it sounds, it doesn’t jibe with traditional health care, in which “we diagnose and then treat ourselves to better health,” explains Halfon. “Our whole system—the medical-industrial complex, the hospital companies, the insurance and drug companies—has built an infrastructure at the end of a life span.” An infrastructure, he says, that powerful players have a vested interest in maintaining.

“If you want to do more [for health care], you must have a public health approach,” says Deborah Walker, another longtime Guyer colleague and vice president at Abt Associates, a health policy consulting firm based in Cambridge, Massachusetts. “You’ve got to deal with the policies on prices of fruits and vegetables and on what’s happening in communities—the social marketing campaign. We don’t usually do that. And I know Bernie shares that view.”

He does, indeed, and has strong, not-so-positive views on the health care industry and current reform efforts. But it’s because he’s not politically naïve that Guyer chooses to focus on local or regional efforts—a bottom-up approach, Halfon calls it—to effect change. “The way innovation happens in this country is if you can get enough local places to try something and do it well,” Guyer says, “that becomes the model that may eventually be national. Or it may not. But, at least, you’re on the right track.”

Guyer started down his own track in 1968, after taking a year off from medical school at the University of Rochester to do field work in Nigeria. The son of working-class parents who’d left Poland just ahead of the Nazi invasion, he’d been raised in Detroit and had attended Antioch College as a biology major. He’d also married Jane Mason, an anthropology student from Liverpool, England, whom he met while studying abroad in Scotland.

As Jane, who now chairs the Anthropology Department at Hopkins, did research in Nigeria, Guyer worked out of a virology lab, conducting studies in villages to detect diseases among children. “There were vast needs of a population that just couldn’t be met by retail medicine,” he recalls. In 1974, after earning his MD and working for the U.S. Centers for Disease Control and Prevention, he returned to Africa, the Cameroon specifically, as part of a CDC immunization team. “It was a very formative experience,” Guyer says, “because, in those communities, I got to see a part of medicine that related to preventive, population-based treatment.” Public health, he realized, was for him.

Three years later, with three kids in tow, the Guyers returned to the States, where Jane accepted an academic post in Boston. Guyer, meanwhile, worked at earning his master’s in public health and, in 1979, inquired about a job with the Massachusetts Department of Health, figuring he’d make some money moonlighting. Shortly after Guyer was hired as a preventive medicine resident, the director of his unit moved away. Guyer replaced him.

Politically green and scientifically minded, he was soon asking colleagues, “So, what kills kids in Massachusetts?” The top cause, he discovered, was unintentional injuries, but no one knew why. So his first big investigation—funded by a federal grant—was, according to Guyer, “the largest study of children’s injuries done at that point.” It involved a dozen cities and towns in Massachusetts and research on 100,000 children, documenting injury rates for burns, poisonings, fires, car accidents, and other causes. The study resulted in a state injury-prevention program that would eventually spur legislation and spinoff programs, including those for suicide and traffic and home safety.

“The way he operated—using assessments and asking all those questions—is what public health should be,” says Walker, who joined Massachusetts’ health department after Guyer left to teach at Harvard in 1986. “Before he came along, there had never been that kind of attention paid to injuries in children. Now, in almost every health department, there is an office of injury prevention, for intentional and unintentional injuries. Not that it all leads back to what he did, but he was at the forefront.”

Guyer is quick to undersell his own significance. Public health, he preaches to everyone he comes across, is a team effort—involving not just medical personnel but, in the case of traffic safety, for example, businesspeople, politicians, engineers, and law enforcement. “The only way you get these things done,” he says, “is by having teams of good people who complement each other’s skills and ideas.”

It’s a theme he took with him to Harvard, seven years after he’d started working for the state, and after he’d had his fill of politics. Which is not to say he lost faith in fieldwork. “Quite the opposite: I had great war stories, including positive ones, I could share with my students,” he recalls. “And I developed these case studies they loved—real government situations where you have to make quick decisions, use research information, and deal with the politics.

“I tell students that the definition of public health is, ‘It’s where medicine meets politics.’ There’s no public health situation that isn’t political. It can be heavy-duty politics; that’s when it’s really tough. Or it can be politics with a small ‘p.’ But it’s always political.”