Advances – Spring 2005

SPH Epidemiologist Urges Flu Readiness • page 14

Advances SPRING

2005

from the University of Minnesota School of Public Health

TOBACCO SPH Experts Work to Stamp it Out— Globally, Nationally, and Locally

CALCIUM IN THE CANCER FIGHT

What’s Wrong with Long-Term Care?

U LAUNCHES BIOINFORMATICS CENTER

SPH Student Graduates at 82

Table of

FROM THE INTERIM DEAN Dear Friends,

Photo: Richarfd Anderson

Tobacco, the public health scourge of the last century, remains front and center on the public health agenda worldwide. While tobacco prevention and cessation campaigns seem to be slowly stemming the tide of tobacco use in the United States, its use is exploding in other parts of the world, particularly in developing countries where tobacco companies seek expanding markets for their products.

This edition of Advances explores issues related to tobacco control and the stellar work being done by our faculty, staff, alumni, and students at home and abroad. We are working in a variety of settings from the laboratory to the halls of the state legislature to advance public health in the face of this worldwide scourge. Our report begins on page 2.

Contents 2

Feature: Tobacco

Through targeted research aimed at specific populations

Advances

here and abroad, SPH experts are working toward a clearer understanding of why people smoke, what helps them stop, and how to prevent them from starting in the first place.

SPRING 2005

8 With a memorable commencement ceremony just behind us, we already look forward to the next school year. We are pleased to offer two new interdisciplinary concentrations to SPH students that constitute the equivalent of a minor (see page 15). They are global health and complementary and alternative medicine, two growing areas in the field that have been in demand by our students.

Division News

Startling findings on prescription drug errors, how maps can improve public health initiatives, the chemistry of cancer, and more

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If you are an alum of the SPH’s veterinary public health (VPH) program, watch your mailbox and check out the announcement on page 13. The SPH is holding an event this summer that will be a reunion of sorts of VPH alums and also will celebrate more than 50 years of the veterinary public health program. VPH program founders will be on hand and a new scholarship will be announced.

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Philanthropy

Veterinary Public Health unveils new scholarship, planned And finally, the search for a new dean for the School of Public Health is well underway with hopes that someone will be named to the position in time for the start of the fall semester.

giving opportunities, and highlights from the 2005 SPH scholarship reception

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Yours in health,

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School News

The School launches concentrations in global health and alternative medicine, Tommy Thompson speaks at SPH commencement, preparing for the next flu pandemic, and more

SCHOOL OF PUBLIC HEALTH LEADERSHIP John R. Finnegan, Jr. Interim Dean

John Connett Head, Division of Biostatistics

Judith Garrard Associate Dean for Research

Roger Feldman Acting Head, Division of Health Services Research and Policy

Debra Olson Associate Dean for Public Health Practice Education Mary Story Associate Dean for Academic and Student Affairs

Robert Jeffery Interim Head, Division of Epidemiology and Community Health William Toscano Head, Division of Environmental Health Sciences

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Advances Editor Diana Harvey Managing Editor Kristin Stouffer

How what you do for a living affects what you see on the

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scale, and why learning never stops for an 82-year-old grad

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Alumni News

Minneapolis City Council staffer takes on the smoking ban,

Contributing Writers Adam Buhr Catherine Jacobs Mary Lawson Kristine Menas Art Direction Todd Spichke Riverbrand Design

Student News

and the latest from SPH alumni

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F E AT U R E S TO RY

TOBACCO SPH experts work to stamp it out – globally, nationally, and locally

A 40-year-old farmer in China. A young pregnant mother of two in Los Angeles. A 13-year-old boy in India. All of these people live considerably different lives but they share something deadly. They all smoke. And if they don’t quit, the odds are they will die from it.

Tobacco use is the single largest preventable cause of disease and premature death in the world. According to the World Health Organization, one in 10 adults worldwide—about 5 million—die from tobacco use each year. That figure is expected to double by 2030. Right now, about a third of the world’s male population smokes, as does one of every five teens ages 13 to 15.

The sheer numbers suggest why tobacco prevention is a public health priority. But they also present a challenge: how to address a problem that affects such a disparate and widespread population. Tobacco use encompasses multitudes of ethnicities, ages, nationalities, and economies. Strategies that might work for U.S. teens don’t necessarily translate to adolescents in the Philippines, and interventions aimed at African American women won’t work with Native American populations.

School of Public Health researchers are fighting the tobacco epidemic with targeted research aimed at specific populations globally, nationally, and locally. These SPH experts are working toward a clearer understanding of why people smoke, what helps them stop, and how to prevent them from starting in the first place.

Tailoring Initiatives Globally and Locally The nations of the world do not share the burden of tobaccorelated disease and death equally. Over the next two decades, deaths due to tobacco will soar to 4.2 million annually in Asian countries, nearly twice that of developed regions. Two Asian countries that are likely to be hardest hit by the tobacco epidemic are India and Indonesia. SPH professor Harry Lando is working with health professionals in those countries to establish a foundation for tobacco research. Both countries present unique challenges.

It’s estimated that 47 percent of males and 14 percent of females smoke in India, varying widely by region. Alarmingly, a recent survey in south India indicates that medical students have the highest rates of smoking among university students, suggesting that interventions focusing on medical personnel are critically needed. “Doctors can take a leadership role in changing tobacco consumption,” says Lando.

If tobacco control in India is in its infancy, it’s almost nonexistent in Indonesia, where kreteks, a blend of ground cloves and tobacco, are favored among smokers as young as 10 years old. Cigarette smoking in Indonesia presents a dilemma due to the massive economic value of tobacco. The tobacco industry pays some $2 billion U.S. dollars in taxes to the Indonesian government every year and employs two million workers. The kretek industry is the second largest employer after the government.

But Lando says his research presents a nonthreatening strategy to educate a population. “We’re getting a foot in the door to bolster tobacco control,” he says.

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University of Minnesota School of Public Health

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FEATURE STORY Lando’s team has selected six collaborating researchers (three in India, three in Indonesia) and together they have established research centers at universities there. “What I find most exciting are the unexpected consequences of this project,” says Lando, “While I was conducting a workshop in Indonesia, the university there decided to go smoke free.

That wasn’t a part of our project, but it was a good outcome.”

Lando’s other global initiatives include serving as the President of the Society for Research on Nicotine and Tobacco and as chair of the SRNT Global Network Committee. He has also taken the lead in organizing global tobacco pre-conference meetings. A March 2005 preconference gathering in Prague drew more than 300 researchers from 50 countries.

On this side of the globe, SPH professor Jean Forster is working with American Indian communities in Minnesota to create an intervention strategy specific to the Twin Cities Indian youth population. Compared to other ethnic and racial groups, American Indians in the Midwest use tobacco earlier, at higher rates, and with more severe health consequences. But little is known about this problem because previous research has failed to include American Indians in the planning, implementation, and interpretation processes.

The project, funded by the Minnesota Partnership for Action Against Tobacco (MPAAT), uses a community-based participatory research model to develop a partnership between the School of Public Health and local Native American community members. The partnership uses standard data collection methods and traditional activities like storytelling, feasts, and talking circles to make the findings accurate and useful to the Indian community.

“We spent three years listening, talking, and working together before we officially began this research,” says Forster. “This is the first time this kind of tobacco research has truly been for the Indian people, by the Indian people.”

Helping People Quit Many studies have shown the multitude of benefits for smokers who quit. But none have actually proven that smoking cessation programs lead to longer lives—until now. SPH biostatisticians John Connett, professor, and Melissa Skeans, research fellow, are co-authors of a report on the first randomized clinical trial to show that stopping smoking can add years to life.

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University of Minnesota School of Public Health

topics. “We didn’t want to make all the information just about smoking,” says Hennrikus. “We included other information that would also be interesting and useful to the mothers.” That strategy prompted the researchers to provide the mother and confidant teams with scrapbooks, disposable cameras, and vouchers for film processing. “We hope they’ll work on it together,” she says.

In a 14-year study following 5,887 middle-aged smokers with mild lung diseases the researchers found that, overall, those people who were randomly assigned to an aggressive smoking cessation program had a 15 percent lower death rate than those assigned to a control group. Those participants who succeeded in quitting completely fared the best, with a 46 percent lower death rate than those who continued to smoke. The findings were published in the February 15, 2005 issue of the Annals of Internal Medicine.

“Since only about 20 percent of those in the smoking cessation program quit smoking, one may think that it wasn’t working.

Some people quit, restarted, and quit again,” says Connett.

“However, quitting had such a statistically large impact on the overall population that even though many of those assigned to the smoking cessation program quit and started smoking again, as long as they were smoke-free for periods of time, they tended to have better outcomes than those who continued to smoke.”

For pregnant women and mothers, the need to stop smoking takes on a heightened importance. SPH associate professor Deborah Hennrikus has recently completed research that counsels parents of new infants to avoid smoking around their children. Researchers hope to not only reduce children’s exposure to environmental tobacco smoke (ETS) but also introduce a first step for parents to quit smoking.

To help quit, or instead of quitting, some smokers turn to modified tobacco cigarettes—products the tobacco companies claim are safer than regular cigarettes. SPH professor Chap Le helped to design and analyze studies on modified cigarettes that were conducted by researchers at the University’s Transdisciplinary Tobacco Use Research Center (TTURC).

The studies found no evidence that modified cigarettes cut exposure to tobacco toxins enough to reduce the risk of disease.

Secondhand Smoke: Worse Than You Think Whether you're at home or out having fun, being around tobacco smoke is causing you more harm than you might think. In recent years, SPH epidemiologist Kristin Anderson has authored groundbreaking studies that prove what has long been suspected: second-hand smoke increases levels of a tobacco-specific carcinogen, which could increase the risk of lung cancer in non-smokers.

The first study compared carcinogen levels in 45 non-smoking women: 23 women were spouses of smokers and 22 were spouses of nonsmokers. Women who lived with smokers had carcinogen levels that were five times higher than in women who lived with a nonsmoker. The second study compared biomarker levels of 18 nonsmoking participants before and after a four-hour visit to a casino where smoking was allowed.

On average, the carcinogen levels doubled after four hours in the casino. “These findings show that environmental tobacco smoke exposes nonmokers to tobacco-specific lung carcinogens,” says Anderson.

Another initiative aimed at parents, the Baby Steps project, uses a social support intervention strategy to prevent mothers from smoking during their pregnancy and in the months following birth. Participants in the study are asked to select a female confidant—a friend in their social network who they rely on and trust—to help them not smoke.

In the wake of this and other research, the producer of one brand of modified cigarettes that had advertised “All of the taste . . . less of the toxins” pulled its product from the market. But other brands remain and more are expected.

Youth Interventions Ninety percent of smokers take the first puff of a cigarette before their twenty-first birthday. And every day in America 6,000 kids start smoking. Jean Forster wants to know what’s behind these numbers. She directs several research initiatives to find out how kids become smokers and what can be done to get them to stop.

One of Forster’s largest studies follows 3,600 Minnesota teens and 600 from surrounding states, who were ages 12 to 16 when the study began. The project, funded by almost $1 million a year from the National Cancer Institute, tracks tobacco use and attitudes toward tobacco products over time.

Each teen is interviewed by phone every six months, providing a snapshot of tobacco-use trends and the effectiveness of state and local tobacco control programs.

Since the study began five years ago, Minnesota’s $10 milliona-year anti-smoking campaign aimed at teens met the budget axe. The campaign was credited with helping reduce youth smoking in the state by 11 percent. The significant policy change has created what Forster refers to as a natural experiment, meaning her study will be able to compare tobacco-use before, during, and after the campaign to determine its effectiveness in keeping teens off tobacco.

Hennrikus’ team checks in with the confidants monthly and provides them with tip sheets, tasks that promote quitting smoking, and information about other pregnancy health 5

FEATURE STORY

“The smoking and smoke-free events had the same percentage of smokers and the same attendance,” says Hennrikus.

“It’s going to be interesting to see the effects of these policy changes on young adults and adolescents,” says Forster, who points out that some of the teens in the study now have graduated from high school. “We’ll be tracking them into adulthood, which will provide more insight.”

Forster says to keep kids from smoking, anti-smoking messages can’t exist in environments that allow youth easy access to cigarettes. She’s worked with various communities in Minnesota to craft and evaluate policies that reduce the prevalence of tobacco in commercial and community settings.

A new study is looking at 60 communities in the state that have adopted a smoke-free parks and recreation policy.

SPH professor Cheryl Perry, director of the School’s Center for Youth Health Promotion, is leading research to prevent tobacco use among sixth- to ninth-graders in Delhi and Chennai, India. Project MYTRI—which means “friendship” in Hindi, India’s official language—includes 32 schools and more than 12,000 students. The project, along with Harry Lando’s work in Asia, has earned the School of Public Health the distinction of being the only organization to lead two of the 14 worldwide collaborative projects funded by the Fogarty International Center at the National Institutes of Health.

Forster finds it encouraging to work with communities that are willing to enact tobacco policies. She’s disappointed in recent state-level policies, especially considering that Minnesota was once considered a leader in reducing tobacco use. “We’ve really fallen in a major way,” she says. “We’re in a position of knowing what policies work but lacking the political will to implement them.”

If young people can’t smoke at a coffee shop or concert will they go somewhere else? Deborah Hennrikus worked with local nightlife venues to help answer that question. Seven venues in the Twin Cities hosted smoke-free Saturday nights that featured live music. Hennrikus’ team partnered with a weekly alternative newspaper and the University’s radio station to promote the events. Surveys of attendees indicated that being smoke-free had little effect on the turnout or makeup of the group, in terms of smokers and nonsmokers.

Project MYTRI relies on printed materials, school-based activities, and peer leadership to educate kids on the dangers of tobacco use. Initially, the SPH research team was discouraged from including sixth-graders in the study.

“Teachers there said at that age the kids aren’t even aware of tobacco,” says Melissa Stigler, SPH project director and a lead investigator on the study.

Unfortunately, the teachers were wrong. Initial data shows that children as young as sixth grade are using tobacco— and at higher rates than the eighth-graders. “This trend is the inverse of what we see in the western world,” says Stigler.

“Usually with adolescents, tobacco use increases with age and grade.” The Project MYTRI team recently submitted their research to the United Kingdom-based journal The Lancet. The team hopes to be among the first to document these trends and take action to reverse them.

Light, Ultra-Light, and Regular Cigarettes—All Equally Bad Researchers at the University’s Transdisciplinary Tobacco Use Research Center (TTURC) have found that light and ultra-light cigarettes are just as harmful as regular cigarettes, and marketing messages that imply otherwise are just plain misleading. SPH professor Chap Le was the head biostatistician of the study led by Stephen Hecht, of the University’s Cancer Center.

A Project MYTRI community coordinator, Usha Rani, demonstrates a tobacco prevention activity to students who will become peer leaders for their sixth- and eighth-grade classes in Chennai, India.

School Launches New Course in Tobacco and Alcohol Prevention This fall, the SPH will launch a new course focusing on strategies for the prevention and control of tobacco and alcohol. “We’re interested in looking at issues that are parallel in these two areas,” says SPH associate professor Rhonda Jones-Webb, a behavioral scientist specializing in alcohol research. She will team teach the course with colleague Harry Lando, an expert in tobacco control. The pairing of the two areas will allow students to examine the similar roles that the alcohol and tobacco industries play in promoting their products, particularly abroad and in developing countries.

The course will also focus on why policies for alcohol and tobacco prevention have differed, and what school-, family-, and community-based strategies have worked.

The study found no significant differences in the amounts of nicotine and cancer-causing substances taken in by smokers of regular, light, and ultra-light cigarettes.

The results suggest that there is no decreased risk for lung cancer in smokers of ultra-light and light cigarettes compared with smokers of regular cigarettes—and that labels such as “light” and “ultra-light” are misleading because consumers interpret them to mean reduced health risk.

The study also indicates that government methods of classifying cigarettes need updating. The current method used by the Federal Trade Commission to classify cigarettes is useless in determining the levels of toxins taken in and may be inadvertently contributing to the public misconception that light and ultra-light cigarettes are less harmful.

Tobacco Timeline Here is a selective chronology of significant national developments related to smoking and health, highlighting the role Minnesota has played.

1964 1975 “Smoking and Health: Report of the Advisory Committee to the Surgeon General,” the first major U.S. report on smoking and health, is published. Report concludes that cigarette smoking is a cause of lung cancer. SPH professor Leonard Schuman serves on the advisory committee for the landmark report.

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1965 Congress passes the Federal Cigarette Labeling and Advertising Act, requiring health warning on all cigarette packages: “Caution: Cigarette Smoking May be Hazardous to Your Health.”

University of Minnesota School of Public Health

1971 Cigarette advertising ends on radio and television.

Minnesota enacts the first comprehensive clean indoor air act in the nation, which restricts smoking in most buildings open to the public.

1985 Minnesota enacts the first state legislation to earmark a portion of the state cigarette excise tax to support smoking prevention programs.

1988

1992

1994

“The Health Consequences of Smoking: Nicotine Addiction,” a report of the Surgeon General, is released. SPH professor Harry Lando serves as a scientific editor for the report.

First federal legislation enacted to require states to adopt and enforce restrictions on tobacco sales to minors (Synar Amendment).

“Preventing Tobacco Use Among Young People: A Report of the Surgeon General” is released. SPH professor Cheryl Perry is lead editor on the report.

1997

1998

The Federal Trade Commission charges the R.J. Reynolds Tobacco Co. with unfair advertising practices for the use of the “Joe Camel” campaign to pitch cigarettes to children and youth.

RJR filed suit against the FTC alleging harassment.

The Minnesota/Blue Cross and Blue Shield lawsuit against the tobacco industries is the first state lawsuit to go to trial. After months of testimony, the lawsuit is settled—minutes before the case goes to the jury—with landmark concessions made by the tobacco industries.

2005 A smoking ban for bars and restaurants goes into effect in the Twin Cities counties of Hennepin and Ramsey.

For a more detailed timeline, go to www.epi.umn.edu/research /tobctime.shtm 7

ENVIRONMENTAL HEALTH SERVICES

Helping Small Businesses Become Safer Businesses

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University of Minnesota School of Public Health

The Chemistry of Cancer Furan is a chemical that can be found in air pollution, cigarette smoke, and even some foods. Furan is toxic and causes cancer in rodents and possibly humans as well. But little is known about just how furan interacts with our cells to cause cancer. Environmental health researchers Lisa Peterson, an SPH associate professor, and Michael Byrns, an SPH research fellow, are working to better understand furan’s potentially deadly path.

The standing theory is that furan causes toxicity in the liver, which then leads to cancer. Peterson and Byrns wanted to test their theory that furan causes cancer by being genotoxic, meaning it damages DNA. In a lab at the University’s Cancer Center, Byrns developed a method to detect furanderived DNA adducts, or damage, in rats.

While his model doesn’t initially show that furan directly damages DNA, Byrns says it may be because adducts are toxic rather than carcinogenic. “Toxic adducts can kill the cells before you have a chance to analyze them,” he says.

The team’s next step may be to use the same methods on mice. “It’s possible that research may show us a different metabolic pathway since mice develop a different type of liver cancer than rats,” says Byrns.

“It is important to establish the mechanism by which furan causes cancer so that we can develop effective biomarkers to determine if similar processes are occurring in humans exposed to furan,” says Peterson.

Division Welcomes New Faculty The Division of Epidemiology and Community Health welcomes three new faculty members.

Darin Erickson, assistant professor, was previously a research associate in the division. His work as a behavioral methodologist supports the division’s research programs. His research interests include alcohol prevention, latent variable analysis, and longitudinal and time series analysis. He received a Ph.D. in Social Psychology from the University of Missouri.

Calcium May Protect Women from Cancer A study led by School of Public Health epidemiologist Andrew Flood finds that women consuming more than 800 milligrams of calcium a day reduced their risk of colorectal cancer by as much as 26 to 46 percent. A 26 percent reduction in risk of colorectal cancer occurred regardless of whether the calcium came from diet or supplement. Women who consumed high levels of calcium from both diet and supplements reduced their risk by almost double than those women who received calcium from either source alone.

The study involved 45,354 women in the United States who did not have a history of colorectal cancer. The women were categorized into groups according to information they provided about their diets and lifestyles. They averaged 62 years of age upon entering the study and were followed for an average of eight and a half years. During that time, 482 women in the study developed colorectal cancer.

“It is especially notable that the risk reduction was present regardless of the source of the calcium and that simultaneously consuming high levels of calcium from both diet and supplements further reduced risk,” Flood says. “These findings suggest that it was the calcium per se, and not merely dairy products or some other variable, that accounted for the reduction in risk.”

Flood says consuming a diet rich in calcium, one that provides at least 800 mg per day—which is actually lower than the current recommended daily allowance of 1,200 mg per day—is a safe and effective way for women to help guard themselves against colorectal cancer.

Eileen Harwood, assistant professor, was previously a senior research associate in the division. She came to Minnesota with a Ph.D. in Sociology from the University of Georgia to develop epidemiologic research in program and policy evaluation related to alcohol consumption, distribution, and marketing. She teaches courses in program evaluation and epidemiology methods.

Alan Lifson, professor, previously had a primary appointment in the Department of Medicine at the University’s Medical School, with an adjunct appointment in the division. His areas of research include HIV/AIDS and international health. He teaches courses in the control of infectious diseases. He has an M.D. from the University of California, San Francisco and an M.P.H. from the University of California, Berkeley.

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Photos: Paul Bernhardt

As the owner of Flaire Printing in Minneapolis, Mark Kuzma is responsible for everything that happens in his shop, from customer service to equipment updates to employee training.

It’s up to him to stay informed of workplace safety standards— a task that requires two things precious to small business owners: time and money.

Environmental Health Sciences professor Lisa Brosseau is working with owners of small manufacturing businesses to arm them with the resources needed to maintain healthy workplaces. Considering that 98 percent of all U.S. private industries employ fewer than 100 people, the need for this information is great.

Brosseau conducted focus groups with Twin Cities small business owners to create a series of monthly workplace safety newsletters that they would find useful. Content included OSHA inspection requirements, electrical safety, and hazardous materials storage. She is testing the effectiveness of the newsletters in a randomized, controlled trial but says the feedback she has already received is encouraging.

“About half of the owners on our small business advisory board have told me they’ve made significant safety changes since we started the project,” says Brosseau. “They’ve called the Minnesota Safety Council or their business association for an audit or employee training.”

For the owners who had already established workplace safety practices, the focus groups connected them to a valuable network of small manufacturing professionals.

“As a small business owner, you get so wrapped up in your own world,” says Kuzma. “It was good to learn that we’re all working to solve the same problems.”

EPIDEMIOLOGY AND COMMUNITY HEALTH

HEALTH SERVICES RESEARCH AND POLICY

BIOSTATISTICS

Structure of Medical Group Practices Affects Drug Errors Prescription drug errors have been called a “hidden epidemic” in the field of patient safety. While most research related to prescription drug errors has focused on hospitals, SPH professors John Kralewski and Bryan Dowd have conducted one of the first studies to examine drug errors in medical group practices. Their findings show that the structure and culture of a medical group practice influence the number of drug error rates.

Brad Carlin Photo: Eric Miller

Robert Kane

Kane on Long-Term Care: “It Shouldn’t Be This Way” Photo: Tim Rummelhoff

School of Public Health professor Robert Kane is one of the country’s top researchers on aging. He’s an expert on medical care for the elderly, nursing homes, and assisted living. He’s written more than 30 books and 300 articles on aging and long-term care. A few years ago, Kane had to arrange long-term care for his elderly mother who had suffered a stroke. Despite a lifetime of professional expertise and a long list of personal contacts, he couldn’t get the system to work right.

“I was livid,” says Kane. “If someone with my experience and knowledge couldn’t make the system work, what chance does someone coming to this for the first time have?”

After getting mad, Kane got inspired. He and his sister, Joan West, began work on a book designed to help families navigate the confusing world of hospitals, clinics, and long-term care. Part memoir, part self-help, It Shouldn’t Be This Way: The Failure of Long-Term Care (Vanderbilt University Press) explores the illogical reality where Americans annually pay more than $200 billion for care that no one likes.

Kane also launched PPECC (Professionals with Personal Experience with Chronic Care). A national organization now 600 members strong, PPECC members share their personal experiences in hopes of raising public awareness and bringing reform to a system Kane calls “broken.”

“Major changes are needed,” he says. “Who better to begin this revolution than those who have had to struggle with the system?”

More information on PPECC can be found at www.ppecc.org.

It Shouldn’t Be This Way is available at Amazon.com and major book retailers.

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University of Minnesota School of Public Health

“Our research is guided by the belief that most patient care errors result from systems failure rather than flawed professional judgment,” says Kralewski, whose team focused on organizational variables like financial incentives, clinical support systems, physician workload, and practice culture.

After analyzing some 250,000 prescriptions written by physicians in the 78 group practices included in the study, Kralewski and Dowd found that even by the narrowest definition of “serious error” there were 13 errors per 100 prescriptions. When less serious, non-life-threatening errors were included, this figure increased to nearly 30 percent of the prescriptions.

Practices in which physicians saw more patients per hour, those that wrote more prescriptions per patient, and those in rural areas had the highest error rates. Practices with case manager programs had the lowest. Contrary to conventional thinking, neither practice-level nor physician-level incentives affected error rates.

Culture also played a role but the findings were conflicting: practices with a cohesive practice style had lower error rates, but so did practices that value physician autonomy and individuality.

“Our study shows that prescription drug errors in medical group practices is a serious problem,” says Kralewski.

Using Maps to Tell Spatial Public Health Stories You’re a researcher charged with determining whether a uranium recycling plant is the culprit behind an apparent increase in lung cancer in neighboring homes. You’re armed with a map of the area, a collection of risk estimates, and limited census data. Can you make the connection? You can if you’re SPH professor Brad Carlin.

Carlin spoke about how he uses statistical models to make sense of geographically referenced environmental data at the 2005 Mayo Professor of Public Health Lecture.

He was named a Mayo Professor two years ago for his pioneering work in the field of biostatistics. The Mayo program honors SPH faculty who are internationally recognized scholars and provides them with financial support.

“Statisticians are increasingly faced with the task of analyzing data that are presented in maps,” says Carlin. “Our job is to determine what variables can help explain the spatial patterns we observe.” For instance, one might want to determine why a cluster of neighboring counties seems to have significantly higher rates of breast cancer. Or how a geographic pattern of emergency room visits for asthma treatment can be explained by a complex combination of ozone exposure, socio-demographic characteristics, and patient zip codes.

Carlin says recent innovations in two things have made this work possible: geographic information systems (GISs), which simultaneously manipulate and map geographic data; and software using Markov chain Monte Carlo (MCMC) methods that allow the fitting of the complex statistical models to explain patterns in the data.

“Biostatistics is the fundamental language of public health,” says Carlin. “Biostatisticians are charged with not only the surveillance of important public health problems, but also their explanation and future prediction.”

SPH Helps Launch New Bioinformatics Center Advances in the health sciences in the 21st century will rely on deciphering the human genome, a task that requires interdisciplinary expertise in bioinformatics and computational biology. The University of Minnesota is poised to become an important player in the human genome field with a new Consortium for Bioinformatics and Computational Biology (CBCB), a collaborative project representing nine collegiate units on the Twin Cities campus, including the School of Public Health.

The CBCB will be funded with $5 million from Microsoft Corp. and matched with University funds. The Microsoft payment comes from a settlement agreement of an antitrust class action lawsuit that the State of Minnesota had brought against the company.

Division of Biostatistics Head John Connett has been a founding member of the consortium and will help oversee the hire of a CBCB director. “The consortium means broader and deeper resources for faculty who are already conducting research in this rapidly expanding field,” says Connett. “It also means more opportunities for public health faculty who wish to expand their lines of research into computational biology to ask questions about the human genome and population health.”

“The consortium will help the School take an even more commanding position in attracting research dollars and star students, as bioinformatics continues to rise in prominence in the life sciences and public health,” says School of Public Health Interim Dean John Finnegan. “It’s exciting to be part of a university that now has such a program, and to be working with researchers who are at the forefront of this new era of discovery.”

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PUBLIC HEALTH EDUCATION AND OUTREACH

Veterinary Public Health Scholarships

American Indian health is a topic of the 2005 Public Health Institute.

Public Health Institute Adds Focus Areas and Workshop on American Indian Health

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University of Minnesota School of Public Health

First chalkboards were replaced by white marker boards.

Then overhead projectors were tossed out in favor of PowerPoint presentations. Now, the classroom itself is transforming. More and more SPH students are opting to take courses online from the comfort of their own homes at the hour or day of their choosing. As a result, SPH faculty members are changing the way they teach.

SPH Interim Dean and Professor John Finnegan was an early adopter of technology-enhanced learning. As Associate Dean for Academic Affairs, he initiated the first School-wide investment in online courses in 1999.

“Digital learning is changing the face of education,” says Finnegan. “For this School to be successful, we need to embrace and enhance our digital learning capabilities.”

For that reason, Finnegan is consolidating the technology teams in the Division of Epidemiology and Community Health and the Centers for Public Health Education and Outreach under Associate Dean Deborah Olson, with the aim of serving the needs of the entire School. The new team, called the Digital Learning Group, will help faculty bring their courses online or otherwise add technology to enhance their courses.

And, importantly, the talent and services of the Digital Learning Group (DLG) will be made available to outside organizations interested in creating online learning modules for their employees. The DLG has already done this for the Minnesota Department of Health and Hennepin County.

“We hope this effort will help bring people up to date in their view of learning and realize the potential that technology brings to education,” says Finnegan.

2005 Scholarship Reception Honors Donors and Students

Donor and SPH professor, John Kralewski, at left, and his daughter, Ann Kralewski Young, present SPH Interim Dean John Finnegan with a gift to the John E. and Marjorie L. Kralewski Family Fellowship at the School’s annual reception to honor donors and recognize scholarship recipients. The impact of this gift will be doubled by a new University matching program. The Kralewskis created the fellowship to support students in the School’s Division of Health Services Research and Policy.

Planned Giving Opportunities Planned gifts can be a wonderful way to support a cause that is important to you while making sure that your financial needs, including those of your family, are accounted for.

While planning for these future needs, you help to build a future for others. By designating a planned gift to the Minnesota Medical Foundation (MMF) to support the School of Public Health, you help to advance world-class research, education, and service.

You don’t even have to use cash to make your gift. You can name the Minnesota Medical Foundation in your will or trust; make MMF a beneficiary of an IRA or pension; donate appreciated securities, real estate, or a family business; or use one or more of these assets to make a gift and receive lifetime income for you and your loved ones.

If you have already included a planned gift to support the School of Public Health, please make us aware so we can celebrate and recognize your support now. If you would like to learn more about planned giving options, please call Carmela Kranz at 612-626-8481.

SPH student Karen Everstine, at right, receives the Harold R. Shipman Award for Excellence in Environmental and Occupational Health. She was one of 50 SPH students to receive an award or scholarship at the May 16, 2005 reception.

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Photos: Bill Alkofer

Each year the Public Health Institute keeps getting bigger and better. During the University’s May session, the Centers for Public Health Education and Outreach (CPHEO) annually launch the Institute’s series of courses, speakers, and special events. The aim is to create a unique opportunity for public health workers to immerse themselves in a chosen field of study—for a single course or the entire three weeks. The 2005 Public Health Institute, which ran this year from May 23 to June 10, boasted three new focus areas: Maternal Child Health and Nutrition, Evaluation Methods, and Applied Biostatistics.

The new focus areas gave professionals more reasons to get out of the office to develop their skills. The Applied Biostatistics focus area responded to increasing demand from past Institute participants and those in the field.

Evaluation Methods addressed the issues that face most public health professionals, whether they are analyzing data from a focus group or designing a program evaluation.

Maternal Child Health and Nutrition explored pressing topics such as child obesity and sexuality education.

A new workshop, “American Indian/Alaska Native Health Care Issues, Policy, and the Federal Budget,” was led by former Director of the U.S. Indian Health Service (IHS), Michael Trujillo. The workshop is the first to outline a national integrated health care program that includes both direct care and community health services. Guest speakers included tribal leaders and IHS officials.

For more information about the 2005 Public Health Institute, visit www.sph.umn.edu/publichealthplanet.

SPH Forms Digital Learning Group to Enhance Online Education

This year marks more than 50 years of Veterinary Public Health at the University of Minnesota. This reinvigorated program is benefiting from strong institutional commitment and has become a signature program at the University.

Widespread concern about food safety and biosecurity, antibiotic resistance, and the transmission of disease from animals to humans has dramatically increased the need for veterinarians with advanced degrees in public health.

In honor of the successes of alumni, program leaders and founders are initiating a new scholarship for Veterinary Public Health students and have stepped forward to make challenge gifts to promote alumni giving. A formal challenge amount will be presented soon. The Veterinary Public Health Endowed Scholarship will provide permanent scholarship support for veterinary students pursuing a combined D.V.M./M.P.H. and mid-career veterinarians returning to complete an M.P.H. The new scholarship will be announced during this summer’s American Veterinary Medical Association Annual Convention in Minneapolis at a special lunch reception on Monday, July 18 at the Minneapolis Hilton. The reception will celebrate alumni, honor the program founders and donors, and publicize this new award. If you are an alumnus of the program and would like more information about the event or the scholarship, please call Adam Buhr at 612-626-2391.

PHILANTHROPY

Photo: Bill Alkofer

SCHOOL NEWS

Tommy Thompson delivers the 2005 SPH commencement address.

Preparing for the Next Flu Pandemic Influenza experts recognize the inevitability of another flu pandemic. To fight it everyone from world leaders to local public health officials must rapidly ramp up their preparedness, says SPH professor Michael Osterholm in the May 5 issue of the New England Journal of Medicine.

“An influenza pandemic has always been the greatest global infectious disease threat,” says Osterholm, director of the Center for Infectious Disease Research and Policy.

Ten pandemics of influenza A have occurred in the past 300 years. The flu pandemic of 1918 killed an astonishing 50 million to 100 million people. Today, with a world population of 6.5 billion even a relatively “mild” pandemic could kill many millions of people.

So how do we prepare? Replace the current painstaking method of making influenza vaccines—which require specially grown chicken eggs and months of culturing—with cell-culture technology for production.

Create an operational blueprint for the best way to get through one to two years of the pandemic, including a detailed plan for staffing temporary hospitals and vaccinating volunteers and health care workers.

Develop an international consensus on who would receive the extremely limited antiviral agents that would be available, as well as other critical items like masks for respiratory protection and antibiotics to treat secondary bacterial infections.

A global just-in-time economy has left us with no surge capacity of the supplies needed to control a pandemic.

“We need bold leadership at the highest levels of governments in the developed world,” says Osterholm. “These governments must recognize the economic, security, and health threats posed by the next influenza pandemic and invest accordingly.”

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University of Minnesota School of Public Health

Tommy Thompson Speaks at SPH Commencement Former Secretary of the U.S. Department of Health and Human Services Tommy Thompson discussed his tenure as the nation’s leading public health figure at the 2005 School of Public Health commencement address. He spoke of how public health had languished before the attacks of September 11, 2001, and it can serve as a powerful force for working toward peace in a post 9/11 world.

“It was clear that I had a better vantage point than most other citizens and that public health had been neglected,” he said of the days surrounding the terrorist attacks. “We have come a long way since the fall of 2001 and we can never again be complacent.”

Thompson spoke of health diplomacy—the need to export public health and medical care to those countries desperately in need. He highlighted his efforts working with mothers and children in Afghanistan and the greater challenge of global AIDS. He said of his travels to African villages afflicted by the pandemic: “It changed me forever.”

“Students, as you advance in your careers, I urge you to spend some time abroad. Do something for others,” he said.

At commencement, Thompson was awarded an honorary degree, doctor of laws, from the University of Minnesota in recognition of his contributions to public service.

“I want to thank the students for undertaking something so important to America’s future,” he said. “This country badly needs you, and I’m here to publicly and personally say thank you.”

SPH Adds Two New Concentrations New areas of emphasis will soon give students pursuing an M.P.H. an opportunity to hone their skills in two increasingly popular and pivotal fields of public health. Starting this fall, the School of Public Health is offering both global health and complementary and alternative medicine as concentrations. Concentrations are, in effect, “minors” and appear on students’ transcripts.

The Global Health Interdisciplinary Concentration (GHIC) curriculum provides an in-depth look at some of the most vexing and momentous public health problems of our time.

“In terms of the future of public health, the global emphasis is really the crux of the matter,” says professor Ian Greaves, GHIC faculty coordinator.

Public health spans national borders. The unprecedented volume, speed, and reach of travel allow infectious diseases to spread faster than ever before. But global health extends far beyond the transmission of pathogens. “It relates to trade, economics, international relations, politics, and conflicts,” says Greaves.

Skilled professionals are needed to meet the challenges.

Rapidly changing public health issues around the world need to be monitored and measured. Culturally appropriate intervention measures need to be devised. GHIC will provide the tools necessary to fulfill those needs, while meeting a strong and growing demand from students who want a global perspective on public health.

The program provides both academic and applied learning.

The 12-credit curriculum includes a domestic or international field experience in global health. “Students will have an opportunity to look beyond industrialized nations and into dynamic sets of circumstances in the developing world,” says Greaves. “It is a really an exciting opportunity for students.”

Consumers are putting complementary and alternative medicine (CAM) on the public health radar. According to a 2002 survey conducted by the National Center for Health Statistics, 62 percent of adult Americans used some form of CAM therapy or practice. The expenditures are in the billions of dollars and growing. The trend is influencing health care policy and reimbursement systems.

The evolution is also making the application of epidemiological methods to CAM necessary, according to SPH professor Pamela Schreiner. She proposed the Complementary and Alternative Medicine Interdisciplinary Concentration (CAMIC). “It is time to put these therapies and practices to the test and do what public health does—bring information to the public and help them use it,” says Schreiner.

The 12-credit CAMIC curriculum consists of coursework from the University’s Center for Spirituality and Healing, a nationally recognized leader in integrative medicine.

“Combined…we are stronger than our two parts are individually. It is time for this to happen,” says Schreiner.

Karen Lawson, director of Integrative Clinical Services at the Center for Spirituality and Healing, agrees.

“We want the system of health care to be better, to be more efficient, to be more effective, and the only way to do that is through bringing innovation and integration into the public health arena,” she says.

Lawson says the merger of CAM and public health is a natural fit that could help expand the possibility of how chronic illness and the pursuit of health are dealt with in our culture. And it could provide financial benefits.

“Conventional medicine is limited to drugs, surgeries, and invasive procedures. It is going in the direction of higher costs, but not always higher efficacy,” says Lawson. She believes CAM therapies and practices can provide improved ways to treat some chronic illnesses for less money. “It makes sense.”

SPH Faculty and Staff Honored With Awards Professors John Nyman and William Toscano are the 2005 recipients of the Leonard M. Schuman Teaching Award, the School of Public Health’s highest teaching honor.

Professor William Hueston received the Charles Hewitt Creative Teaching Award. The honor commemorates the University of Minnesota’s first teacher of public health.

Peter J. Hannan, senior research fellow, is the first recipient of the new SPH Academic Professional and Administrative Staff Excellence Award.

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STUDENT NEWS

Class notes

Graduating at 82 is Part of a Lifetime of Accomplishments for SPH Student

Photo: Bill Alkofer

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University of Minnesota School of Public Health

Attention Full-Time Workers: Get Off the Couch and Out to the Gym! Do you, like millions of full-time workers, find yourself switching on the TV, playing video games, or firing up the computer in what little free time you have? If so, there’s a good chance you’re skimping on heart-healthy physical activities, says SPH student Meghan Warren.

Warren, a pre-doctoral fellow in the Division of Epidemiology and Community Health, led a study analyzing data from the population-based National Health and Nutrition Examination Survey (NHANES). As part of NHANES, participants were asked how many daily hours outside of work they watch television, play video games, or sit at a computer.

When Warren’s team analyzed the 1,573 full-time workers and 508 part-time workers who reported engaging in these sedentary activities, great differences emerged. Full-time workers who spent five or more hours watching TV, playing video games, or using the computer in their leisure time spent 10 fewer minutes per day exercising than those full-time workers who didn’t engage in these sedentary activities.

In contrast, part-time workers who spent five or more hours engaged in sedentary activities, spent 11 more minutes per day exercising than those who didn’t spend any leisure time in front of a television, video game, or computer.

“Many full-time workers say that one of the biggest barriers to getting enough exercise is that there’s not enough time in the day,” says Warren. “Our study suggests that if they shift their interests, they would have more time for physical activity.”

If you have news to share, please send it to SPHNews@umn.edu.

Natalie Collins outside of her office at Minneapolis City Hall

City Council Staffer Helps Bring Smoking Ban to Minneapolis When Natalie Collins was a student researcher on a tobacco control study led by SPH professor Jean Forster back in the late 1990s, she had little idea she would have the opportunity to shape one of the hottest political issues to face Minneapolis in decades: a smoking ban in the city’s bars and restaurants.

Collins is policy aide to sixth ward Minneapolis City Council member Dean Zimmermann and drafted the ordinance that he introduced for a citywide smoking ban.

The smoking ban passed the Minneapolis City Council July 23, 2004, and went into effect on March 31, 2005.

All of the city’s bowling alleys, pool and billiard halls, and bars and restaurants are covered by the ban. And unlike bans in neighboring cities and counties, no establishments are exempt. So far, Collins says, compliance has been good and complaints have been restricted to a few bar and restaurant owners. Collins hopes research into sales and employment data will prove that the ban does not negatively affect business.

Collins says her public health background influences nearly every issue she faces in her work for the city.

“Whether it is a transportation issue or a zoning issue, we look at how a particular policy will contribute to the wellbeing of the residents of and visitors to the city of Minneapolis,” she says. “Public health—looking at how people can be healthy—couldn’t be more relevant to local policy work.”

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Photo: Chris Polydoroff

Maurice “Mike” Mazzarella likes to tell his professors that graduate school is similar to life in the Navy. The chain of command, the structured days, the politics—he says they all remind him of his 30-year career as a naval dentist and biomedical researcher, as does being among a group of people younger than himself.

“I’ve always been around young people,” says Mazzarella, who at the age of 82 is in the School of Public Health’s Mike Mazzarella receives his M.P.H. degree from graduating class of U of M Regent John Frobenius and a word of 2005. “After congratulations from commencement speaker Tommy Thompson 10 years in the Navy, you become one of the older ones.”

His career began when the U.S. Navy called Mazzarella to active duty in the last days of World War II. From there, he went on to earn graduate degrees in dentistry and bacteriology.

That combination earned him the distinction of being the only dentist to serve on three consecutive deployments of the U.S.S. Woodrow Wilson, one of the first nuclear submarines.

Mazzarella monitored the bacterial levels in the air of the vessel. His naval work took him to ports around the world.

In the field of dentistry, he became an internationally recognized expert on dental aerobiology. At home, he was known as father to six children and husband to Emilia, a Navy nurse.

Soon after retiring, Mazzarella learned he had GI Bill funds to spend. In 1987, he enrolled in the master’s program in Environmental Health Sciences at the SPH. That year, his fellow classmates honored him with the Herbert M. Bosch humanitarian award. Always an applied researcher, Mazzarella’s master’s project evaluated an instrument used by the University’s dental school. After he concluded that it dispersed bacteria, the school stopped using it.

“In applied research, nothing is more rewarding than producing results that have the potential to improve people's lives,” says Mazzarella.

Mukta Arora (M.S. ’00) is one of four University faculty to become an AHC Clinical Research Scholar, an honor given by the University’s Academic Health Center. She will receive research support of $50,000 annually for up to three years under this new career development program for junior faculty performing patient-oriented clinical research.

Jared Erdmann (M.P.H. ’03) was selected to join the Emerging Leaders Network (ELN) of Minnesota. ELN is a program aimed at identifying and nurturing future public health leaders. Erdmann is a research director at Hispanic Advocacy and Community Empowerment through Research (HACER).

Dave Johnson (M.P.H. ’00) was elected president of the Minnesota Public Health Association, representing more than 400 members. He is an epidemiologist for the Minneapolis Department of Health and Family Support.

Andrea Leinberger (M.P.H. ’04) was hired as program coordinator for Minnesota International Health Volunteers, a nonprofit that focuses on the health of women, children, and communities internationally and domestically. She is working with the Twin Cities Somali community.

Scott Parker (M.H.A. ’62) has been inducted into the Health Care Hall of Fame, sponsored by Modern Healthcare magazine. The program was created to honor health care visionaries who exemplify the best in executive leadership and public service. Parker is president emeritus of Intermountain Health Care, based in Salt Lake City, Utah.

Jared Swanegan (M.P.H. ’04) was hired as a senior healthcare quality improvement specialist for Metropolitan Health Plan, a not-for-profit, state-certified HMO and an enterprise initiative of Minnesota’s Hennepin County.

Merry Jo Thoele (M.P.H. ’03) is the recipient of the 2004 University of Minnesota School of Dentistry Distinguished Dental Hygiene Alumna Award. She was recognized for her professional leadership and work related to adolescent smoking and the affect of environmental tobacco smoke on infants. In 2004 she joined the School of Dentistry faculty as an adjunct assistant professor in the Department of Preventive Sciences.

Tricia Todd (M.P.H. ’93) has moved into a joint position among the SPH, the University’s Health Career Center, and the Minnesota Department of Health’s Office of Public Health Practice. She will work on health workforce development, providing liaison support to each organization.

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