The Public Health Advocate

“Life in research is full of serendipity and lucky events,” says Al Sommer, professor and dean emeritus of the Bloomberg School of Public Health. “The trick is taking advantage of them and connecting the dots. My whole life has been connecting dots.”

Some dot connectors are simply better than others, however, and those who have followed Sommer’s illustrious career in public health would say he is a master. What, then, explains his remarkable ability to recognize what others have long overlooked?

“Some people aren’t tone-deaf like me; some people have perfect pitch,” he observes. “I think innovation is the same way. Some people have a certain level of creativity, and you can’t stop them from coming up with new thoughts, new discoveries, new theorems….My gift…is to become intrigued by events I had not anticipated.”

Perhaps best known for championing the value of vitamin A to reduce childhood mortality as well as blindness, Sommer did not directly pursue the knowledge that changed the world of public health. He simply chased his interests and kept his mind open to unorthodox interpretations of the data he methodically recorded.

He often veered well off the beaten path to make his discoveries—and was warned more than once that his choices would destroy his career. His public health journey began in the early 1970s in East Pakistan, now Bangladesh, as an Epidemic Intelligence Service officer for the CDC. He had intended to study cholera, but “a whole series of miserable occurrences” diverted his attention. Shortly after he and his family arrived, a massive cyclone swept through the Bay of Bengal and took the lives of more than 240,000 people. His observations on the bungled response improved subsequent disaster relief efforts.

Within months, a civil war threatened “all the professionals, academics, intellectuals, and politicians”—and Sommer chose a dangerous role: “We hid people in the trunk of our car and drove them to the countryside so they could make their way to India.” When the war ended months later, 10 million refugees streamed back from India, carrying smallpox. Sommer set up a smallpox eradication program—and discovered that the smallpox vaccine works even for those already exposed.

Sommer’s readiness to welcome the unexpected was further demonstrated when he discovered that children’s mortality could be predicted in part by measuring their upper arms. While in Bangladesh, he looked at height, weight, and arm circumference measurements for 8,000 children. “The children in the bottom 10th percentile of arm circumference for their height contributed 50 percent of the deaths over the next 18 months,” he realized. “I thought, ‘Wow! That’s pretty powerful.’”

He sought to compare his findings, only to discover there were no comparable studies. “All the hundreds of millions of dollars that have been spent on nutritional research,” he says with exasperation, “and nobody had ever bothered to compare the predictive value of anthropometric measurement versus a child’s mortality.” When he was finally able to publish his findings, they languished in obscurity until WHO created a nutritional surveillance manual to identify children at risk for starvation—and the only paper they could reference was his.

By the time he returned to Baltimore to continue his studies in public health, epidemiology, and ophthalmology, his perspective was permanently fixed on a public health “millions at a time” approach. He soon began to work on nutritional blindness prevention.

“We did know that serious vitamin A deficiency can lead to visual disabilities and ultimately to permanent blindness,” he says. With grant funding, he and his family spent three years in Indonesia, “carefully examining and documenting, in the most granular way, children with all kinds of eye disease that might be related to vitamin A deficiency.” One such study followed 5,000 children in six villages, but the significance of the data was not immediately obvious.

“The crowning achievement, the unexpected ‘aha’ event,” he says, “was several years later, when I was slowly going through and publishing these massive amounts of data, each one organized around a specific question. It suddenly became apparent that even mild vitamin A deficiency dramatically increased a kid’s risk of dying. . . .We were able to demonstrate that giving a child two cents worth of vitamin A twice a year reduced overall childhood mortality by at least a third. That meant roughly one to two million children would not die if they received vitamin A.”

At the time, vitamin deficits were treated with injections, but the method was costly, time consuming, and impractical for developing nations. Sommer’s studies also found that less expensive, easily administered oral doses worked just as well.

His findings on vitamin A were published in The Lancet—and were met with silence. “Nobody even bothered or deigned to send a nasty letter,” he says. “It was totally ignored.” So Sommer did a randomized trial and “found exactly what we had predicted, a 35 percent reduction in mortality” among children who received vitamin A. The findings were once again published in The Lancet—and this time, he says, “the long knives came out….There were a thousand letters to the editors, none of them supportive, because this was a paradigm shift for too many nutritionists and pediatricians…. Unfortunately, in science, if your data are not what people expect the data to be, then they are not data—they are just a mistake.”

For Sommer, sticking with a discovery is as important as recognizing it in the first place. “If you find a potentially important intervention that could have an important clinical benefit,” he says, “then you have a moral obligation to play that sucker out the entire way and not sit back and say, ‘Well I’ve proven that to my satisfaction. I’m going to move on to the next interesting piece of research.’”

So he “plugged away” at additional randomized trials and helped other researchers with their own investigations—and the results were the same across Africa, India, and Indonesia. To bring closure to the debate, he organized a meeting that produced a declaration known as the Bellagio Brief. It was published in multiple professional journals, finally putting the matter to rest. UNICEF and WHO launched a global vitamin A program, distributing almost a billion capsules annually. A decade “that seemed like an eternity” had elapsed from initial observation until the global program was established.

After being tapped to lead the Bloomberg School, Sommer continued to innovate, creating, for example, the new Department of Health, Behavior and Society. He also continued to publish research results, including a study that dismissed a routinely accepted amount of ocular pressure to diagnose glaucoma.

Sommer likes to quote Louis Pasteur: “Chance favors the prepared mind.” The issue, as he sees it, is not a lack of innovative thinking but “whether you pursue your innovative thought. It’s more than just chance; it’s chance plus seeing ways that things can organize themselves differently than you saw them five minutes ago—and then getting out of the chair” and acting on the insight.

In essence, Sommer is the Data Whisperer, approaching analysis as though he’s in conversation. “Data, tell me what you have to tell me,” he pleads. He advises young researchers, “Don’t just ask the data the question you have in mind—because if you do, you’re going to miss the most important finding that you were not looking for.” He views the capabilities of modern computing to assemble “huge, complex data sets” as an opportunity. “They will have truths buried in them,” he insists, “…but you also have to be innovative to find those truths.”

Sommer has spent a lifetime “recalibrating” his expectations, and he does not regret taking the path less traveled. “Life is full of forks in the road,” he says. “Do what seems most interesting and exciting at that moment in time because you’re much more likely to be happy and successful if it’s something you’re excited about….And if it turns out you’re not so excited about that after a while, don’t worry. There’ll be another fork in the road.”

—Ann Lano