ADVA NC E S T H E M A G A Z I N E O F T H E U N I V E R S I T Y O F M I N N E S O TA S C H O O L O F P U B L I C H E A LT H
NORTHERN ROOTS HOW MINNESOTA HEALTH MODELS CAN CHANGE THE WORLD
Tracking Ebola’s blowback 3
Teaching doctors to see racism 14
Rescuing food for better health 16
Making change for 75 years 24 Spring 2019
SPH BY THE NUMBERS 75
#9
YEARS OLD
#2
RANKED SCHOOL OF PUBLIC HEALTH IN THE U.S.
RANKED MASTER OF HEALTHCARE ADMINISTRATION PROGRAM IN THE U.S.
STUDENTS
130
380
FACULTY
STAFF
RESEARCH
1,408 STUDENTS AT SPH
48
COUNTRIES REPRESENTED BY STUDENTS
21%
AMERICAN INDIANS AND STUDENTS OF COLOR
3RD
$73M
LARGEST RESEARCH PORTFOLIO AT THE UNIVERSITY OF MINNESOTA
RESEARCH AWARDS AND CONTRACTS (FY2018)
EDUCATION
GRADUATES
19
11,000+ 69%
DEGREE PROGRAMS
50K+
UNDERGRADUATES HAVE TAKEN A ROTHENBERGER INSTITUTE COURSE
GRADUATES (LIVING TODAY)
STAYING IN MINNESOTA (2014-17 AVG.)
98%
EMPLOYED WITHIN 12 MONTHS OF GRADUATING
CAMPAIGN PROGRESS
0
20
40 $32M
total raised so far (80% of goal)
2,600
philanthropic donors (1,300 are alumni)
CO NTE NTS SPRING 2019
FROM THE DEAN 2 John Finnegan shares how collaboration has marked our 75 years as a school FINDINGS 3 Research and insights from School of Public Health experts, including the health impact of surviving Ebola, how yoga improves body satisfaction, and the danger of loneliness NORTHERN ROOTS 6 New models, methods, and programs created at SPH can be replicated around the country to make health truly a human right • Interdisciplinary Research Leaders upsets paradigm 7 • Statistical method helps FDA regulate nicotine 10 • Ride share services to get babies vaccinated 11 • Embedding researchers to modernize patient care 12 • Exposing structural racism in medicine 14 • Finding how DNA damage leads to cancer 15 • Rescuing food to feed communities 16 • Novel tool to choose a nursing home 18 • Keeping chemicals out of water systems 19 • Problem-solving method for any situation 20 • System to track foodborne illnesses 22 • Keeping undergrads healthy and in school 23 SCHOOL OF PUBLIC HEALTH TURNS 75 YEARS OLD 25 Our school contributes in vital ways to ongoing and emerging public health challenges. A timeline of the fight against HIV/ AIDS shows our influence.
COVER PHOTOGR APH BY MAT T ANDERSON
School of Public Health Leadership John R. Finnegan Jr. Dean
Head, Division of Health Policy & Management
Beth Virnig Senior Associate Dean for Academic Affairs & Research
Joe Koopmeiners Interim Head, Division of Biostatistics
Kristin Anderson Associate Dean for Learning Systems & Student Affairs
Dianne Neumark-Sztainer Head, Division of Epidemiology & Community Health
Bruce Alexander Head, Division of Environmental Health Sciences
Joe Weisenburger Chief Administrative Officer/ Chief Financial Officer Louis Clark Chief Development Officer
Timothy Beebe
Advances Staff Sarah Bjorkman Director, Communications Heidi Mastrud Director, Alumni Relations Susan Rafferty Chief of Staff
Editor Martha Coventry
Contributing Writers Martha Coventry Sarah Haugen Charlie Plain Design Brian Donahue, bedesign, inc.
Advances is printed on Rolland Enviro 100, a 100 percent recycled paper. Our printer,
Bolger Printing of Minneapolis, is FSC ® certified.
F RO M TH E D E AN “Looking back, we don’t want to lose sight of the real goal ahead of us — creating a world where health is the right and responsibility of every human being. No exceptions.” John R. Finnegan Jr., PhD Dean and Professor
Yours in health,
John R. Finnegan Jr., PhD Dean and Professor
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elebrating the past while steering toward the future is the work of every school of public health. We know that with each advance, we “stand on the shoulders of giants.” Yet, in looking back, we must not lose sight of the goal ahead of us — creating a world where health is the right and responsibility of every human being. No exceptions. Our school turns 75 this year.
Although officially established in 1944, it was part of a much older public health legacy at the University of Minnesota, that dates to 1872, when Dr. Charles Hewitt delivered the first lectures on public health. They were the first such lectures in the nation. Public health has northern roots and we are proud to contribute to the common global good. Our school has always looked to the needs of people around the world and we
NATIONAL NEWSLETTER LAUNCH In April 2019, SPH launched a national monthly email newsletter, “Advances in Population Health.” Our goal is to give readers insights into emerging or chronic public health issues, such as maternal mortality, gun violence, health insurance gaps, and the opioid epidemic — challenges that face individuals, communities, and public health professionals. This is not a publication about our school, but from our school to provide the latest information on critical public health topics. Please sign up at z.umn.edu/advances to subscribe to our newsletter as we, together, move the world toward a healthier future!
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75 years old and thriving! Our notable SPH research has taught us that, as the years go by, they can bring greater focused energy and purpose. Our singular mission to give everyone the chance for a healthy life has only gained momentum since we opened our doors in 1944. SPH research continues to build on earlier discoveries and it moves in new directions as the world changes. On pages 24 and 25, you can see a timeline of our response to one of the greatest public health threats of the last 50 years, the emergence of AIDS as an identified, global disease. For more about our history, please go to z.umn.edu/sph75. In the coming months, you’ll find additional timelines there, including our work around tobacco use, from helping ban cigarette vending machines in Minnesota to conducting seminal research on the health consequences of e-cigarettes.
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have learned the power of partnership to define those needs. We are collaborators with communities wherever we serve. In this issue of Advances, we see evidence of that collaboration in stories about a problem-solving technique, a grassroots organization to rescue unsold produce, a program to tackle foodborne illness outbreaks, and others. Each of these stories also describes a unique model, technique, method, or program that we have developed at our school or have been part of creating. We hope others will adopt or adapt them to tackle public health challenges in their communities. In the year ahead, I trust that we in the public health community will strengthen our commitment to forging a just and equitable country where all people feel welcome and safe.
FINDINGS
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The study found that:
EBOLA SURVIVORS SUFFER ONGOING HEALTH PROBLEMS AFTER RECOVERY
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study of Ebola survivors coled by Professor Cavan Reilly confirms that individuals who recovered from the deadly infection tend to suffer from an increased number of ongoing health problems. Reilly is the associate director of the Coordinating Centers for Biometric Research (CCBR) at SPH, which oversaw the design, conduct, and analysis of the study run in collaboration with the Liberian government and the National Institutes of Health. The study team examined 966 Ebola survivors along with 2,350 close contacts and sexual partners. The contacts and partners were examined in order to help the researchers determine the normal state of health of people in the area. The researchers then compared the health of the survivors to that of the contacts group.
• Compared to the group of contacts, Ebola survivors had increased urinary frequency, headaches, fatigue, and neurological and musculoskeletal problems; • Memory loss was reported in 30 percent of survivors and in less than six percent of their contacts; • Survivors also had twice as much joint and muscle pain as their contacts; • 25 percent of survivors have uveitis, an inflammation of the eye that can lead to blindness. However, the study also found uveitis in 12 percent of the contacts group, which suggests Ebola is not necessarily the cause of the condition; • Genetic material from the Ebola virus can be found intermittently in the semen of male survivors for more than three years. “The findings suggest there’s a great need to provide follow-up care for Ebola survivors to help them deal with lingering health problems,” says Reilly. Reilly and the study team are continuing to follow the health of the Ebola survivors at least through 2020. Learn more: z.umn.edu/survivors
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FINDINGS Infections Increase Odds of Heart Attack and Stroke “The key to explaining the association between acute infections and the shortterm increased risk of strokes and heart attacks is inflammation.” — Associate Professor Kamakshi Lakshminarayan “Infection prevention is key — so vaccination for influenza and pneumonia is important.” — PhD student Logan Cowan Learn more: z.umn.edu/infections
Opioid-Affected Births in Rural Hospitals
IMPROVING BODY SATISFACTION THROUGH YOGA The vast majority of young adults who practice yoga believe it has improved how they feel about their bodies, according to a study by Professor Dianne Neumark-Sztainer. These new findings help address the problem of high prevalence of body dissatisfaction among young adults, which often leads to severe health consequences. “The results of this study give great insight into the small tweaks instructors and studios can employ to improve the positive impact of yoga on people with poor body image,” says Neumark-Sztainer.
Pregnant women with opioid dependency may have particular challenges in receiving the care they need when they live in rural areas. “Some of these rural moms, especially those with clinical complications, give birth in urban, teaching hospitals, often far from home. Yet, our study findings show that more than 60 percent of rural moms with opioid use disorder give birth locally. These rural hospitals may have more limited capacity to care for them and their babies.” — Associate Professor Katy Kozhimannil Learn more: z.umn.edu/births
Learn more: z.umn.edu/body
LEGALIZING MARIJUANA NOT RISK FREE In a growing national trend, several U.S. states have legalized marijuana sales. But, according to research from Associate Professor Darin Erickson, it’s not all “high times” in the first two states to do so, Colorado and Washington. In those states, law enforcement agencies report common problems with underage marijuana use (under age 21) and driving under the influence of marijuana in their communities. Learn more: z.umn.edu/impaired
“This is more evidence that exposure to phthalates — even as early as pregnancy — can have an affect on the developing brains of children. This could have significant childhood and lifelong implications for the babies that are exposed.” — Associate Professor Ruby Nguyen, whose research discovered a link between phthalate levels of pregnant mothers and language development delays in their children. Learn more: z.umn.edu/exposure
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PHOTOGRAPH BY ADOBE STOCK
‘Everywhere Chemicals’ Pose Danger During Pregnancy
EMPLOYER-SPONSORED INSURANCE LEVELS STABLE AFTER ACA MEDICAID EXPANSION The fear proved unfounded that new individual health insurance options and expansion of Medicaid eligibility provided by the Affordable Care Act (ACA) in 2014 would prompt employers to quit offering health benefits. “Policymakers were concerned that employers might drop health benefits to cut costs because their workers now had an option to buy individual coverage, or, if they were a very low income worker, qualify for Medicaid,” says study lead author and Wegmiller Professor of Healthcare Administration Jean Abraham. “Our research shows this wasn’t the case.” Learn more: z.umn.edu/expansion
Preventing Violent Encounters Between Police and Young Black Men In 2016, black men between the ages of 18 and 44 were more than three times as likely as white men of the same age group to be killed by a police officer. Community members are increasingly calling for policies and programs specifically designed to reduce violent encounters between local police and young black men to prevent deaths. Recently, a study from Professor Rhonda Jones-Webb, co-authored by Associate Professor Sonya Brady and predoctoral fellow Collin Calvert, assessed the awareness of such efforts among a diverse group of stakeholders in Minneapolis and St. Paul, MN. They found there was little awareness of programs or policies specifically designed to prevent violence between police and young black men. Jones-Webb underscores important next steps: “...community engagement and involving key stakeholders, such as those who participated in our study, will be critical in identifying communitydriven solutions to prevent future violent encounters between police and young black men.” Learn more: z.umn.edu/preventing
LIFE-THREATENING LONELINESS Social isolation and loneliness are risks to health and mortality as serious as obesity or smoking. Some researchers have cautioned that rural residents could be most vulnerable, but a new study led by Assistant Professor Carrie Henning-Smith and co-authored by Associate Professor Katy Kozhimannil and Professor Ira Moscovice shows that people in rural areas actually reported more social relationships (both family and friends) than urban residents. Learn more: z.umn.edu/loneliness SPH.UMN.EDU
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NORTHERN ROOTS HOW MINNESOTA HEALTH MODELS CAN CHANGE THE WORLD
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COVE R STO RY To make progress toward creating a healthier life for all people, it’s important to learn what others have already done. Proven ideas, concepts, methods, or models can be used or adapted to build new work upon. In the stories ahead, we offer models developed at Minnesota that have the power to disrupt limiting paradigms; make decisions easier; open our eyes to new possibilities; take better care of the young and old; and provide next steps for stopping cancer. Every one of them can be replicated and every one has made an impact. At the root of public health is the essential need to collaborate and share.
JOINING FORCES FOR COMMUNITY WELL-BEING A NEW TEAM MODEL LINKS RESEARCHERS WITH LOCAL LEADERS By Sarah Haugen
PHOTOGRAPH COURTESY OF JOHN FINNEGAN JR.
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or Billy Kirkpatrick, questions around how people with HIV/ AIDS can receive the best care weigh heavily on his mind. As chief executive officer of Five Horizons Health Services in Tuscaloosa, AL, he provides services such as finding affordable housing and transportation for those with HIV/AIDS. But how does this work help people live with the disease in a region where the death rate for HIV-positive individuals is higher than any other in the U.S.? To find answers to his questions, Kirkpatrick teamed up with researchers Safiya George, assistant dean for research and associate professor at the University of Alabama Capstone College of Nursing, and G. Tongi Mugoya, associate professor of rehabilitation at the University of Alabama College of Education.
The three are fellows in a program called Interdisciplinary Research Leaders (IRL) at the School of Public Health. Funded by the Robert Wood Johnson Foundation (RWJF), IRL is building an innovative approach to research where two academic researchers from different fields and a community leader join forces as equal partners to tackle issues vital to communities. The program annually funds 15 teams for three years each. Each member receives equal funding and equal participation in the team experience and curriculum. Through their work, and along with the communities that shape their research, the teams strive to produce actionoriented, community-engaged research to help build a national culture of health where everyone has the opportunity to live a healthier life. It is the mission of RWJF. IRL focuses on two key elements to help the teams build that culture of SPH.UMN.EDU
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health: Grow their skills in designing, implementing, and translating research into action and engage communities to change policy. “There is a lot of research that provides evidence to move communities toward better health, but with IRL, we wanted to ensure research was focused in the right way to be useful and that it gets into the hands of the right people,” says Nancy Fishman, IRL senior program officer at RWJF.
Jan Malcolm, Minnesota Department of Health commissioner, and IRL co-director Associate Professor Michael Oakes.
HOME IN MINNESOTA
THE IRL WAY Now in its third year, the program is changing the game for fellows with a method Oakes calls the “IRL way.” “In academia, we often develop ideas, do the research, and then let the findings disseminate on their own. Rarely does 8
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“In academia, we often develop ideas, do the research, and then let the findings disseminate on their own. Rarely does our work get outside of academic circles.” —Michael Oakes
our work get outside of academic circles,” says Oakes, who is also associate vice president for research at the University of Minnesota. Instead, the IRL way encourages interdisciplinary collaboration, working closely with the community, and ensuring research can be put into action. “IRL fellows partner with the people they aim to help and get a rich understanding of that community,” says Oakes. “This makes research questions better and study findings easier for communities to put into action.” “We’re setting the stage for the people who are most affected to be involved in a hands-on way with the research and implementation of the research,” says Paul Marincel, who leads strategic initiatives at ISAIAH and has been involved in IRL since its start. The IRL way encourages research that creates change fast. According to Oakes, researchers outside IRL currently operate
on the assumption that if a community or policymaker has the information, they’ll use it. But, for Oakes and RWJF, that model is too passive. IRL fellows begin by asking communities what information they need and how they would use it, says Oakes.
CREATING CHANGE THROUGH LEADERSHIP IRL fellows go through rigorous training in research leadership. Their curriculum spans team building, research development, design, dissemination, and how to translate research into action. By building leadership skills, IRL encourages fellows to be more assertive and take their work a step further. “We’re building tools for fellows so they have support in elevating their work,” says Gollust. For George, the lessons learned through IRL changed her view of how
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Schools of public health around the country applied to be home to IRL. Minnesota’s proposal had Professor Michael Oakes as co-director alongside Jan Malcolm, who was vice president of public affairs and philanthropy at Allina Health and is now commissioner of the Minnesota Department of Health. SPH health policy faculty members Sarah Gollust, Ezra Golberstein, and Kathleen Call rounded out the UMN team. As community lead, Malcolm recruited Local Initiatives Support Corporation and ISAIAH (a state-wide coalition of faith communities fighting for racial and economic justice) as partners. “I knew these organizations completely understood the connection between health and community engagement at the deepest level,” says Malcolm. “Minnesota had the right people at the table,” says Fishman. “They had a strong academic team, and the combination of community partners involved in the proposal showed us that they understood the importance of the community perspective.” RWJF chose Minnesota and in September 2016, IRL welcomed its first cohort of 15 teams, including Kirkpatrick, George, and Mugoya.
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her work can be effective. “I now have the skills to present evidence in a useful way so that we can translate findings into practice for policymakers,” she says. In addition to research-related curriculum, IRL training also teaches fellows how to organize communities and use grassroots movements to create policy change. “When it comes to addressing social determinants of health, there is a relatively small group of people who have the power to make decisions,” says Marincel. “With IRL, we’re making that group larger by equipping fellows with the power and the tools to make change.” And fellows who are faculty members are passing what they learn on to their students. “With my students, I’m talking with more conviction about community partnership and have real examples of what this actually means and the role the community can play in shaping research,” says Mugoya. “I tell them, yes, you can gather the data and do the
research, but you have to think about who will benefit from the information and how you’re going to not only publish results, but also help make sure those results reach the right people.”
THE MODEL
Across the U.S., communities face great challenges when it comes to health and well-being. To give everyone the chance for a healthy life will take forging new relationships between researchers and communities. The IRL team model brings together two researchers from different academic fields into equal partnership with a community leader and the team tackles issues that the community defines. By stepping out of the traditional research model, the team and the community can move findings quickly into acton.
THE IMPACT
This collaboration model has implications for the public health workforce. “At the Minnesota Department of Health, we’re working to get community groups around the state engaged in questions about what really produces health and how we can change conditions,” says Malcolm. “By implementing the IRL model we can make a stronger link between research, the community, and public health workforce development.” Oakes believes that the IRL program is having a meaningful impact on all states and their universities: “Evolving our research in this way is a critical piece for universities, and for faculty staying relevant and fulfilling our mission to serve the public’s health.”
One of the first three IRL teams. From left to right, Safiya George, assistant dean for research and associate professor at the University of Alabama Capstone College of Nursing; Billy Kirkpatrick, chief executive officer of Five Horizons Health Services; and G. Tongi Mugoya, associate professor of rehabilitation at the University of Alabama College of Education.
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REGULATING OUT THE NICOTINE DESIGNING NEW METHODS TO GET TO GOOD DATA about how to make that methodology generalizable for other data with the same issues.” For the FDA study, they will do just that — create models to solve the problems inherent in the 12 randomized trials. The goal will be to smooth the data enough to show patterns and trends to be able to give the FDA an answer to its question, and to supply the agency with a generalizable method that can be used to estimate the potential success of other tobacco regulations. “The most exciting thing about this project is that in biostatistics, we rarely have the opportunity to do methods work that has a direct impact on global public health,” says Koopmeiners. “This is one of the rare instances when we do.”
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Assistant Professor David Vock, left, and Associate Professor Joe Koopmeiners.
regulations to reduce the nicotine content of cigarettes?’” says Vock. “We need to develop new statistical tools to address the problems inherent in the data.” To do that, they’ll use a modern approach to statistics, where methodology is specialized for each application, because every trial has its own characteristics. Koopmeiners explains that the way statistical methods were designed 20 years ago involved starting with an abstract idea of a data type you might encounter, then developing methodology that could be used to solve problems with data types that were similar. “But what we’re doing now is looking at real data actually in front of us that have unique problems,” he says. “We then try to develop methodology for that particular data. Later, we think
As they develop, the methods Koopmeiners and Vock design will be tailored to account for the three specific problems in the clinical trials (non-compliance, small sample sizes, and participants not being representative of the general U.S. population.) However, those methods can be used as starting points in a variety of settings when similar statistical challenges are encountered.
THE IMPACT
Momentum is moving toward a new nicotine standard in the United States, and the more data available, the better the science to support that change. Vock and Koopmeiners’ innovative statistical methods will produce more precise estimates of the impact of potential FDA regulatory action and will make a significant contribution to the goal of ending smoking.
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ssistant Professor David Vock says that the job of statistics is to “separate out what is signal and what is noise.” In the field’s parlance, that’s called “data smoothing” and Vock and his biostatistics colleague Associate Professor Joe Koopmeiners are after the “signal” as they help the FDA evaluate the potential impact of regulations that would reduce the nicotine content of cigarettes. Vock and Koopmeiners are working with data from 12 randomized trials of reduced-nicotine content cigarettes with a total of 5,000 participants. However, it can be difficult to estimate the impact of potential regulations using data collected from these trials due to, a) issues of noncompliance, b) small sample sizes, and c) participants not being representative of the general U.S. population. “The tool box of statistics is large, but it’s insufficient using the data we have to answer the FDA’s seminal question: ‘What would happen if we implemented
THE MODEL
USING NEW TECHNOLOGY TO SOLVE AN OLD PROBLEM RIDE SHARE SERVICES AND TEXT MESSAGES HELP MOTHERS GET BABIES VACCINATED
PHOTOGRAPH (INSET ) COURTESY OF UNICEF
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accines are the most powerful and cost-effective means of protecting infants from several life-threatening diseases, including measles. According to the World Health Organization, measles vaccination programs resulted in an 80 percent drop in measles deaths between 2000 and 2017 across the globe. But measles is still a killer and was responsible for 110,000 deaths, mostly among children under the age of five, in 2017. For measles vaccination programs to be effective, babies need to receive their doses on a regular schedule, a difficult-to-impossible task due to many issues — including a lack of transportation to clinics. Assistant Professor Nicole Basta together with colleagues from the UMN School of Engineering and Makerere University in Uganda is piloting a novel intervention in Uganda that may give low-income residents of Kampala an inexpensive, reliable way to overcome that barrier. It combines a
THE MODEL
near-ubiquitous feature of Ugandan life, the cell phone, with recently introduced shared ride services. With the team’s model, socioeconomically constrained mothers will receive a text-message reminder when it’s time to vaccinate their babies. A follow-up text gives access to vouchers for ride services, such as Uber and SafeBoda, to get them to clinics. If the pilot is successful, Basta will scale up the concept to conduct a large, randomized trial to see if the voucher program consistently increases infant vaccination timeliness across Kampala.
The model reduces transportation barriers to timely vaccinations by using shared ride services. A cell phone delivers a text message reminder to a mother when an infant’s vaccinations are due and delivers a transportation voucher to provide access to clinics and other health services.
THE IMPACT
If the trial shows that the intervention can remove transportation barriers and improve access to vaccines, the system could be used to help protect infants in similar settings around the globe from measles and other diseases. Learn more: z.umn.edu/basta
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RAPID INNOVATION MODERNIZES PATIENT CARE MODEL PROGRAM EMBEDS RESEARCHERS IN HEALTH CARE SETTINGS
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new collaboration among three of Minnesota’s most important health research, education, and care delivery organizations — University of Minnesota School of Public Health, Mayo Clinic, and Hennepin Healthcare — trains a cohort of scholars each year in a game-changing, modern approach to health care called learning health
Victor Montori, professor of medicine at the Mayo Clinic, talks at the MN-LHS DesignShop about putting patients at the center of care.
systems (LHS). The model embeds researchers in a health care system, creating a nimble feedback loop among researchers, clinicians, and patients so they can more quickly, and together, improve the quality of care. Though the concept of learning health systems has existed for a decade, embedded researchers remain rare across the U.S., in part due to the limitations of traditional research training programs. This is where the Minnesota collaboration comes in. It developed and leads the Minnesota Learning Health System Mentored Career Development Program (MN-LHS), centered at the 12
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School of Public Health, and it teaches researchers how to systematically generate, apply, and translate evidence quickly while part of a health system. “Busy practices can’t wait for five months to gear up to do a randomized, controlled trial,” says Timothy Beebe, MN-LHS co-director, School of Public Health professor, and head of the Health Policy & Management division. “They want and need information fast and without sacrificing scientific rigor. And when it comes to health systems management, rapid advances and shifts in health care policy, payment reform efforts, and health IT and data are forcing clinical practices to constantly adapt.” It’s estimated that by 2020, medical knowledge will double every 73 days. The traditional research process is not flexible enough to meet this changing landscape and the needs of patients and health care systems — the typical “research to action” or “bench to bedside” timeline takes, on average, 17 years. MN-LHS flips that model by having researchers study in health care delivery settings. This level of proximity brings scientific evidence into practice much faster, creating better outcomes for everyone, especially patients, clinicians, and health systems. Funded with a $4 million grant from the Agency for Healthcare Research and Quality (AHRQ) and the Patient-Centered Outcomes Research Institute (PCORI), MN-LHS will work on a cohort model, with two to five researcher scholars per year embedded in an active health care system for an intensive, mentored research
experience. At the heart of their training is the “DesignShop,” where scholars, mentors, and affiliated faculty from across the state gather with others to solve problems, role play stakeholder engagement scenarios, and get expert input. Fairview Health Services, Minneapolis VA Health Care System, Children’s Minnesota, Ebenezer Senior Living, Essentia Health, and HealthPartners are integral collaborative clinical partners with MN-LHS, mentoring and training the scholars to make meaningful differences in health care contexts serving children, the elderly, underrepresented minorities, rural populations, veterans, and those with multiple health needs.
THE MODEL
The MN-LHS and its model of recruiting, training, and mentoring health services researchers embedded in health care systems is a prototype for increasing the effectiveness of health services research and is replicable, with variations, across the U.S.
THE IMPACT
Collaborations similar to the Minnesota partnership could bring value to decision-making processes, conduct rigorous research responsive to the needs of clinical practices and patients, and rapidly translate research to improve clinical practice and outcomes. Results can include improved personalization, quality, equity, and outcomes of care, as well as reduced waste in the health care system.
The MN-LHS DesignShop serves as part-brainstorm, part-seminar for scholars, mentors, and affiliated faculty. From left to right, Kelli Johnson, Tim Beebe, Cory Schaffhausen, Mark Linzer, and Elisheva Danan
PHOTOGRAPH BY CORY RYAN
A learning health systems approach to reducing opioid prescriptions AT THE MAYO CLINIC, there were major variations in how opioids were prescribed for surgical procedures, even for patients with similar opioid use history undergoing the same procedures. But from 2016-2018, specific multidisciplinary teams, using a learning health systems approach, developed prescribing guidelines for each surgical procedure. In orthopedic surgery, this resulted in a decrease of opioids prescribed by 50 percent, with no observed increase in refills. It’s estimated that this work could reduce the number of excess opioids in Minnesota communities by up to 1 million pills per year. SPH.UMN.EDU
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OPENING EYES TO THE IMPACT OF RACISM ON HEALTH MED SCHOOL CURRICULUM MODEL EXPOSES STRUCTURAL RACISM
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throughout the year. It includes a lecture by Cunningham and four exercises: a reflection that explores privilege; a clinical vignette; an exercise aimed at gaining comfort in talking to patients about racism and health; and a fourth exercise related to considering how physicians diagnose and choose treatments based on a patient’s race. “The long-term goal of work like ours is to cultivate a physician workforce that has a genuine and accurate understanding of how racism has an impact on health and that is able to relate to patients in ways it hasn’t been able to previously,” says Hardeman.
THE MODEL
Currently, the model is for a half-day curriculum for first-year medical students to make them aware of the structural racism inherent in their education and society at large, and how it has an effect on the health of their patients. Students also learn about white privilege. The long-term goal of the curriculum is to have the impact of structural racism a fundamental part of a physician’s working knowledge. Hardeman and Cunningham are continuing to test and build their curriculum to increase it effectiveness.
THE IMPACT
Hardeman and Cunningham are receiving requests from medical organizations around the U.S. who want to adopt or adapt their curriculum for specific contexts and groups. Hardeman is also using elements in her School of Public Health course on structural racism and public health.
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tructural racism is so deeply woven into public policies, institutions, beliefs, and cultural norms that we often don’t even recognize it. As an historic and contemporary influence in the health care system, it can create disastrous results for patient care. History is rife with examples of racism in medicine and they extend into the present day, from the Tuskegee Syphilis Study (1932-1972) to how pain medicine is currently administered. A 2015 study in JAMA looked at 1 million cases of appendicitis in youth under 21 years of age. It found that black patients with severe pain received opioid pain killers significantly less frequently (12 percent) than white patients (33.9 percent). Other research has shown that the reason for the dichotomy may be that
doctors believe, as was taught in many medical schools, that black people don’t feel as much pain as white people, or that a black patient will abuse drugs more readily than a white patient. (In reality, the Kaiser Family Foundation found that opioid overdose deaths for white people are 7-fold those for black people.) Racism has a deep impact on the social determinants of health, like where people live and their education level, yet it is Assistant Professor rarely addressed in Rachel Hardeman medical schools. “Racism is a fundamental cause of racial inequities in health, preventing populations of color from thriving,” says School of Public Health assistant professor Rachel Hardeman. “If our health care system fails to examine racism and structural inequity, it’s missing a critical opportunity to help people.” Hardeman, with leadership from UMN physician Brooke Cunningham and a multidisciplinary, multi-racial group of professionals, developed and piloted a model half-day curriculum to promote effective dialogues on racism for first-year medical students at the University of Minnesota Medical School. Their curriculum fits into Essentials of Clinical Medicine, a course that runs
DECODING HOW ENVIRONMENTAL EXPOSURES LEAD TO CANCER NOVEL METHOD PAVES THE WAY FOR MAJOR ADVANCES IN STOPPING THE DISEASE The method has broad application for researchers who study the effects of many other toxins in the body. For example, Balbo is now conducting new research to determine exactly how consuming alcohol damages DNA and triggers the development of cancer.
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THE MODEL
C
hemicals or environmental exposures can damage DNA, and that damaged DNA can result in cells that become cancerous. What we don’t know is exactly how that process unfolds — and discovering those steps is a Holy Grail of cancer research. “We have exposure to a harmful agent and we have the outcome — the cancer is formed,” says Silvia Balbo, assistant professor and Masonic Cancer Center member. “In many cases, we know there is an association between the two, but we don’t have a clear understanding of the process or the steps that take place, therefore we don’t have a clear idea of where we can intervene to stop that sequence of events from happening.” But Balbo has developed a new way to use mass spectrometry, a technique that can identify chemicals, to move that search forward. In the past year, she used her mass spectrometry method to explore
Silvia Balbo, left, talks with her SPH colleagues Irina Stepanov, center, and Lisa Peterson.
what happens to DNA after exposure to colibactin, a toxin produced by a strain of E. coli bacteria and linked to the development of colon cancer. Her team found and identified a specific DNA modification in cells and animals exposed to the toxin. Little is known about colibactin’s biological and chemical make-up, but Balbo has now identified its DNA-damaging signature. “This is the first time we’ve used this method to identify exactly how a toxin with an unknown chemical structure is interacting with and modifying DNA,” says Balbo. “The next step is to see if we can use this technique to detect the same DNA structural damage in humans and employ it as a diagnostic tool to see if people have been exposed to colibactin or are at increased risk for its harmful effects.”
Using high resolution mass spectrometry, Balbo can isolate DNA and reduce it to the compounds containing the four bases that make up the double helix, then determine which base has been chemically and structurally modified. With this method, she can ascertain what chemical has reached the DNA and caused the damage, then step backward from there to determine how the exposure originated, or how the damaging effect on DNA may be prevented from happening in the first place.
THE IMPACT
This mass spectrometry approach could lead researchers to uncover the genetic chemistry leading to cancer development and Balbo is partnering with scientists across the country in this goal. The method could help discover, for example, what environmental exposures cause very specific head and neck cancers in children who are affected by Fanconi anemia, a project Balbo is currently exploring. There’s even the possibility that the method could improve chemotherapies by testing a microdose of a chemotherapy drug to see how it interacts with an individual’s DNA and then devise a more personalized treatment.
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PUBLIC HEALTH ALUMNI RESCUE PRODUCE FOR LOCAL HUNGER RELIEF
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n the U.S., about 14.5 percent of the general population is food insecure at some point in their lives, meaning that they don’t have reliable access to enough food to keep them healthy. At the same time, 30 percent of the food in America goes to waste every year. That situation felt very wrong for a group of School of Public Health students. In 2015, Samantha Friedrichsen, Kelzee Tibbetts, Eva Weingartl, Hannah Volkman, and Mike Kosiak were all MPH students and, although mostly in different programs, they became friends
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because they shared a common goal. “We believed we could make a difference in public health. And that if we could, we should,” says Friedrichsen.
FINDING THEIR FOCUS As first-year students, Friedrichsen and Weingartl took “Issues in Environmental Health,” a required course for all MPH students. They remember feeling overwhelmed with all the public health issues in the world needing attention. “Our professor said to just pick
one. ‘That’s all you can do,’ he said,” says Friedrichsen. “‘Pick one and try to improve it.’” A year later, the five students founded Twin Cities Food Justice (TC Food Justice), a growing volunteer organization that “rescues” produce from small grocery stores and farmers markets that would otherwise be thrown out and delivers it to organizations that work with food insecure communities. Today, Friedrichsen, Tibbetts, Weingartl, and Volkman remain involved with the organization. They chose produce as their focus because it’s a food item that often goes to waste and is nutritionally dense, and also because food shelves traditionally stock
PHOTOGRAPH BY SELENA SALFEN
FOSTERING FOOD JUSTICE
TC Food Justice volunteers after gleaning produce from a farmer’s field. Samantha Friedrichsen is second from the left; Hannah Volkman is in the back row, second from the right.
non-perishable food items. What’s more, research shows that 93 percent of food shelf clients would like to provide more fruits and vegetables for their family and 90 percent know how to prepare fruits and vegetables. Volkman notes that these statistics dispel the myth that food insecure people don’t know how to or don’t want to eat healthfully.
FILLING A GAP Minnesota has sophisticated hunger relief programs, such as Second Harvest Heartland, that pick up slightly bruised fruits and vegetables by the semi-load from major grocery stores like Target, Cub, and Walmart. Those programs
deliver that produce to food shelves across Minnesota and western Wisconsin, many pallets full at a time. But small hunger relief efforts, like neighborhood food shelves with few volunteers, can’t manage large deliveries of produce and are therefore left with no produce to distribute. At the same time, small grocery stores and farmers markets see their unsold produce going to waste because there is no way to get it to people who could put it to quick use. Responding to those specific needs is where TC Food Justice comes in. Each week, a team of volunteers makes produce pickups by car or bike (average pickup = 81 pounds) from donors and delivers to recipient organizations, including The Aliveness Project, Division of Indian Work, and Brian Coyle Center Food Shelf. Since March 2016, when they made their first pick up at the Seward Community Coop in Minneapolis and delivered it to St. Stephens Men’s Shelter, TC Food Justice has provided more than 86,000 lbs. of produce for hunger relief in the Twin Cities, getting it to people who can use it and taking it out of the waste stream. Volkman says that the organization more and more strives to meet people where they are, drilling down to populations that encounter multiple obstacles to fresh produce. “We recognize that there are people who can’t access the hunger relief system,” she says. “The barriers are endless and include lack of mobility, work hours, transportation, undocumented status…So we look to groups that know communities well to find ways to make it easier for people to get food.” In a new initiative, TC Food Justice is working with Ramsey County Assertive Community Treatment (ACT) Team, which serves adults living with severe and persistent mental illness, to deliver food directly to weekly support groups. And at a public housing highrise in Minneapolis, a team of resident volunteers are organizing a once-a-week pop-up food shelf and TC Food Justice volunteers will work shoulder to shoulder with them to distribute fresh produce.
THE MODEL
TC Food Justice is an organization with a solid foundation built on the public health values of equity and collaboration. It works in close partnership with small grocery stores, food co-ops, and farmers markets to deliver their produce to small established food shelves or temporary hunger relief efforts. It is hands-on, shared work for everyone involved. TC Food Justice rescues 363 pounds of produce for every $50 in operating costs and costs are low because it’s an all-volunteer organization and the produce goes directly to a distribution point, with no need for refrigeration or storage. When starting their organization, the MPH students looked to Boulder Food Rescue and the national Food Rescue Alliance for advice and practical guidance.
THE IMPACT
Increasing availability of fresh produce increases consumption, moving people closer to the recommended five servings a day. Every year since 2016, TC Food Justice has increased the amount of produce it delivers to those who have limited access to grocery stores or traditional hunger relief sites: 2016: 147 food rescues, 11,970 lbs of produce donated 2017: 296 food rescues, 25,055 lbs of produce donated 2018: 475 food rescues, 39,591 lbs of produce donated When it comes to the environmental impact of keeping produce out off landfills, consider the fact that a ton (2,000 pounds) of food waste generates about 144 pounds of methane, which is among the most potent greenhouse gases.
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MAKING THE RIGHT CHOICE A NOVEL TOOL GIVES A UNIQUE, HOLISTIC LOOK AT MINNESOTA NURSING HOME QUALITIES
card is unique in that it includes personreported measures of satisfaction, such as resident quality of life, family members’ satisfaction, and experience of care,” says Associate Professor Tetyana Shippee. Shippee is the next generation of SPH faculty members who research aging, and her mentors Professors Bob and Rosalie Kane did seminal work in quality of care and quality of life measures. Shippee has gone on to do further work on quality of life measures, including for people of varying ethinic and racial backgrounds. She has also helped develop measures of family satisfaction and experience of care for short-stay rehab residents (soon to be on the report card). MN-DHS has recently partnered with her to help develop quality measures for assisted living facilities in the state.
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“Although there are other tools to help people choose nursing homes, …our report card is unique in that it includes person-reported measures of satisfaction.” leader in developing quality of life measures and using them to differentiate among nursing homes. This is how the report card works: You choose how close you want a nursing home in relation to your zip code, and then the top three out of eight quality measures that are most important to you. When you submit the information, you get a list of relevant facilities and how they rate in all eight measures, with your top three highlighted. You can also find information on specific homes or pinpoint facilities on a Minnesota map. “Although there are other tools to help people choose nursing homes, including at the federal level, our report
THE MODEL
An online tool lets users explore nursing homes by location and in relation to eight key quality of life measures, three of which are generated by family input. “Our report card could be very useful for other states and replicable at the national level,” says Shippee.
THE IMPACT
A care facility needs to be evaluated across an array of measures to assure safety, quality of life, and respect for residents. These issues are vitally important to families and the person needing care. To have a trusted, highly researched tool to help in this process is invaluable for the more than 1.35 million people currently in care, and also for the aging U.S. population. View the report card at z.umn.edu/ reportcard
PHOTOGRAPH BY ADOBE STOCK
T
he U.S. Census Bureau predicts that by 2035, there will be more people over the age of 65 than under the age of 18 in our country. And as people age, they need care, often in nursing homes, assisted living facilities, or short-term care rehab centers. What matters to older people and their families varies when it comes to these places. For some, it’s nursing staff-to-resident ratio, others care about the proportion of single rooms, and still others want to know how families rate the facility. But what everyone needs is data-driven information at what can be a vulnerable time. To help people choose a nursing home, Minnesota developed an interactive tool for exploring options and filtering for important information. Called the Minnesota Nursing Home Report Card, it’s a joint venture of the School of Public Health (SPH) and the Minnesota Department of Human Services (MN-DHS). Together, they have made Minnesota the nationwide
A CLEAN SOLUTION FOR A PERVASIVE PROBLEM KEEPING PFAS OUT OF THE ECOSYSTEM and flowing simulated contaminated groundwater through the soil with and without the coagulants. “The idea is to keep PFAS from moving off military bases and into water sources, while other people are figuring out ways to destroy them underground,” says Simcik. While this method has only been tested in the laboratory, Simcik hopes to test it in a real-life situation in the future.
THE MODEL
To contain PFAS molecules, a non-toxic coagulant is injected into the aquifer. It combines with PFAS molecules, the mixture sticks to soil particles, and a permeable barrier is formed that allows clean water to flow through.
ILLUSTRATION BY JESSICA COLLET TE
P
FAS(per- and polyfluoroalkyl substances) are some of the world’s most persistent chemicals. Developed in the 1940s, the thencalled PFCs were perfect for a variety of industrial and consumer products, including non-stick cookware, stain repellents for furniture (Scotchguard), and a specialized foam to fight petroleum fires, called aqueous film-forming foam (AFFF), used across the world and principally at airports and military bases. In the late 1990s, studies began to show that PFAS were everywhere in the environment, including in water, soil, wildlife, and our own bodies. They have been linked to cancer and immune dysfunction, as well as categorized as “obesogens” that can interfere with human weight regulation. The tricky question is what to do with PFAS, especially as they migrate into our water systems and disperse into the environment. Until recently, no one had
discovered an effective and inexpensive way to do that. In 2011, the Department of Defense issued a challenge: It wanted to remediate PFAS-contaminated groundwater near military bases in the U.S. and around the world that had used AFFF. The DoD called for proposals that presented potential solutions. School of Public Health associate professor Matt Simcik knew that when PFAS enter groundwater, they become part of a plume that flows toward a water source, like the Mississippi River. Simcik hypothesized that if you could introduce a coagulant — perhaps a non-toxic compound used every day in drinking water treatment — into that plume to help the PFAS adhere to larger particles, you could then create a barrier that would contain the PFAS, but let clean water flow through. Simcik put his theory to the test in the lab, using soil from an Air Force base
A commercially available non-toxic coagulant combines with PFAS molecules and the mixture then sticks to soil particles. A barrier forms that allows water to flow through, but contains the PFAS. Simcik sees two ways to implement the method in the field. One is to drill a series of wells into an area where PFAS have penetrated into the groundwater and inject the coagulant to form a permeable absorptive barrier. The other method is to inject the coagulant into the ground through an existing drinking water well, creating a barrier around the well through which clean water can be drawn.
THE IMPACT
Simcik believes that his method can be used to sequester PFAS before they reach water in systems like lakes, streams, rivers, and wastewater treatment plants around the globe, protecting public health and the natural world. By treating the contaminated water prior to using it for drinking water, we not only protect people, but also the ecosystems that depend on clean water.
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FINE TUNING DECISION MAKING
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wo groups have been gathering in Minneapolis to make a bold idea a reality — create an intentional community of “tiny homes” to provide stability and better health for people who do not have a place to live. Street Voices of Change, an organization of those experiencing homelessness, and Upstream Health Innovations, a non-profit dedicated to removing barriers to health, are calling their initiative Envision Community. Poor mental and physical health can drive people into homelessness. Being homeless can lead to or exacerbate health issues, and, without stable housing, it’s extraordinarily difficult to get better. It’s a profoundly complex public health issue. The majority of care for people who are homeless is delivered via emergency department visits and hospitalizations. Envision Community will bring together a diverse group of people, including those who have never experienced homelessness, to discover 20
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innovative approaches to protecting the health of people who do not have homes. But several hurdles remain before Envision Community can get up and running, including how to financially support this groundbreaking effort, how to set residence criteria, and how to measure outcomes and success. Exploring those questions was an ideal case study for students in the Master of Healthcare Administration (MHA) program at the School of Public Health, who tackle real-life issues related to health care using the program’s intensive problem-solving method.
SOLVING PROBLEMS The program’s founder James Hamilton formalized the technique in 1946 and it’s practiced by MHA alumni all over the world. Called the “Minnesota Way,” it breaks down nearly any challenge into a series of 14 steps that lead to a greater understanding of the issue. Its most basic premise, and what separates it from
Members of Street Voices of Change and Upstream Health Innovations, along with SPH students, gather in Envision Community’s tiny home prototype.
other methods, is that problem solving is collaborative. SPH instructor Justine Mishek leads the problem-solving curriculum taught by a cadre of faculty and alumni experts. “The number one step in effective problem solving is to take yourself and your ego out of the equation and honor other people’s perspectives,” said Mishek in a recent book about the Minnesota Way. Last year, Mishek’s students spent spring semester exploring solutions to Envision’s problems and, for the financing question, specifically investigated whether or not health insurance companies, who would benefit from reduced costs for people experiencing homelessness, would invest in the community.
JUMPING INTO THE PROCESS After a deep dive into the Envision project to understand its scope and
PHOTOGRAPHS BY CORY RYAN
USING A PROBLEM-SOLVING MODEL TO FOCUS CRITICAL THINKING
“The number one step in effective problem solving is to take yourself and your ego out of the equation and honor other people’s perspectives.” —Justine Mishek
history, the students began working through the Minnesota Way’s 14 steps. They interviewed key decision makers from local health plans, such as UCare and Hennepin Health, and worked closely with the Minnesota Council of Health Plans. They talked to government officials and select people from community organizations doing similar work to Envision. Based on the feedback from these
groups, the students began identifying potential solutions and, after final input from the people they originally contacted and the Envision team, they had three recommendations for the organization: 1) Although some health care insurance companies around the country have financed similar projects out of their bottom line, Minnesota companies are not ready to do that. The students’ advice? Envision should begin talking with Hennepin Health and demonstrate that the project is successful in keeping people healthier. Then secure funding from Hennepin Health and work to get buy-in from additional health plans. 2) When it comes to selecting residents, Envision should choose people who: qualify for housing support (to help defray costs); are high utilizers of health care services (so the impact of success can be more measurable); and are Hennepin Health members (so the payer can easily track advantages to its cost structure.) 3) To monitor health, financial, and social outcomes, use claims data, electronic medical record data, and resident surveys.
The MHA students brought new and critical information to Envision as they explored potential solutions to the group’s funding needs. Impressed with the students’ efforts, the Envision team continues to work closely with the MHA program as it uses its problem-solving technique to help move the community closer to fulfilling its promise.
THE MODEL
Developed in 1946, the Minnesota Way is a technique to bring discipline to critical thinking. Its 14 steps can be followed by anyone, anywhere, and in any situation. Summarized, they are: • Define the problem or situation (What appears to be the problem may not actually be the problem.) • Study the problem or situation (Be curious, ask questions, never assume anything.) • Present your recommendations and a plan of action (Be prepared to compromise.)
THE IMPACT
Health care administration students using the problem-solving method find that they enter summer internships, fellowships, and new jobs with the tools and confidence needed to effectively start a project, involve stakeholders, observe processes, and work independently. Faculty involved have the chance to connect with local organizations to understand current challenges. Health care organizations and projects can make change using the insights provided by the student teams. Learn more about the 14 steps at
Sherry Shannon explains the features of the Envision home to SPH student Samantha Shipley
z.umn.edu/problem-solving Learn more about Envision Community at z.umn.edu/envision
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SEARCHING FOR A PATTERN TEAM D IS THE MODEL FOR FAST, EFFECTIVE FOODBORNE ILLNESS INVESTIGATION
M
ore than 20 years ago, the Minnesota Department of Health (MDH) created a model program to investigate foodborne illness outbreaks. The program, called Team Diarrhea (Team D), is both an intense educational experience for School of Public Health students and a vital tool for MDH in discovering the source and combating the spread of foodborne illnesses. Founded by SPH Professor Craig Hedberg, who led the MDH foodborne disease epidemiology program at the time, Team D is now a nationally renowned outbreak investigation system and has helped make MDH one of the most looked-to health departments in the country for expertise in foodborne illness surveillance. Each year, MDH hires 8-10 MPH students as part-time employees and they work under the direction of experienced epidemiologists. Their principal job is the backbone and first step of all outbreak investigations — interviewing the people involved to track down the source of the illness. “Team D gives us the ability to interview a lot of people very quickly, while collecting detailed information about illness and exposures,” says MDH Foodborne Diseases Unit supervisor Carlota Medus, PhD ’05. “And if the epidemiologists generate continuing hypotheses about the source of the outbreak, the students, since they are embedded, can quickly call people back and ask additional questions.” Having students on staff has an additional advantage, says Medus. If a large infectious disease event occurs, like H1N1 influenza in 2009, Team D can be swiftly trained on the issue and help with data collection and response. 22
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This CDC map shows foodborne illness outbreaks, and rates, across the U.S. from 2009–2015. The high number for Minnesota does not mean that more outbreaks occur in the state, but rather that the Minnesota Department of Health is more effective at identifying them. The efficiency of Team D is a key element of that success.
THE MODEL
Team D has been recognized as such a successful model for collecting detailed interview data in a tight time frame that many states have adopted and adapted it in recent years. Kirk Smith, SPH adjunct professor and head of the Foodborne, Waterborn, Vectorborne, and Zoonotic Diseases Section at MDH, has created five key points to help other health departments recreate the Team D relationship (details on these five points at z.umn.edu/teamd): 1. Recruit MPH or undergraduate public health students 2. Make the students actual employees of your health department (i.e., pay them!) 3. Create an academic work environment and provide academic incentives 4. Train students appropriately 5. Supervise students closely
THE IMPACT
According to Medus, the real impact of Team D can’t be reflected in statistics, but rather in what Minnesota, MDH, and the students gain from the experience. By collecting detailed data on illness and exposures, the students help quickly solve the approximately 40 to 80 confirmed foodborne illness outbreaks identified in the state each year. The investigations, in turn, provide lessons for the food industry and help prevent future outbreaks. The students’ work supports MDH epidemiologists and they get the opportunity to work with real data they’ve generated themselves. The degrees they earn, combined with their experience on Team D, prepare them well for public health professional roles, and many go on to work as epidemiologists at MDH, various Minnesota agencies, and other state health departments, as well as the CDC.
“…I’m hard-pressed to name another class I’ve taken that has taught me so much about the real world around me, and given me tools to use in everyday life.” — Alcohol & College Life student
MAKING BETTER HEALTH A HABIT ONLINE WELLNESS COURSES HAVE A SIGNIFICANT IMPACT ON STUDENTS
PHOTOGRAPHY COURTESY OF THE UNIVERSIT Y OF MINNESOTA
T
he University of Minnesota School of Public Health is one of the best graduate schools of public health in the nation, yet its most far-reaching program when it comes to student engagement serves undergraduates. The Rothenberger Institute (RI) is a model for how to play a significant role in undergraduate health promotion while helping retain students. Since 2002, more than 50,000 students have taken the Institute’s courses. The Institute meets students where they are through one-credit, online health and wellness courses. Its Alcohol & College Life course, one of the first at the University to be offered online, has reached more than 25,000 students who have learned how to play a role in preventing alcohol and substance misuse, how to stay safe in troubling situations, and when and how to step in to help others as an active bystander. The class, along with Sleep, Eat & Exercise;
Success Over Stress; and Sexuality Matters are offered on all University of Minnesota campuses and, in a pioneering partnership model, at multiple Minnesota state colleges and universities (the Minnesota State system).
THE MODEL
Rothenberger Institute’s online health and wellness courses have peer educators who work closely with students. Learning from peers makes the curriculum more relatable for students and reduces potential resistance to feedback and behavior change. Schools and instructors throughout the country can license the curriculum from the University of Minnesota or through CogBooks. Learn more at www.ri.umn.edu.
THE IMPACT
According to the University’s Office of Institutional Research: • 10.9 times: The odds of a firstyear student who took a course returning for a second year of study; • 98%: student-reported improvement in their health behaviors; • Graduation outcomes: RI students are more likely to graduate in four years, compared to non-RI students; and • Diversity in students: A greater proportion of students in RI courses are students of color, first-generation, and Pell-grant recipients, compared to students who didn’t take an RI course.
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S P H C E LE B R ATE S
TRANSFORMING HEALTH FOR 75 YEARS In its 75-year history, SPH has had major impacts on public health challenges When the University of Minnesota founded the School of Public Health in 1944, it was only the seventh such school in the nation. Since then, it has been at the forefront of emerging issues that threaten the health of entire populations.
1980s
1983 Scientists discover the virus that causes AIDS.
HIV/AIDS 1981 On June 5, 1981, the CDC runs in its Morbidity and Mortality Weekly Report (right) an account of five young men in Los Angeles with pneumocystis carinii pneumonia; considered the first official clue to the quickly growing AIDS epidemic.
1986 SPH instructor Jim Rothenberger begins teaching undergraduates about HIV/AIDS. 1982 Public health officials begin to use the term “acquired immunodeficiency syndrome,” or AIDS. Professor Alan Lifson treats early AIDS patients as a medical student in San Francisco.
1987 First use of antiretroviral drugs in U.S. 1989 100,000 people are diagnosed with AIDS in the U.S.
In our 75th year, our school’s vital contributions to ongoing global public health challenges include increasing vaccination rates (page 7); understanding infectious diseases, such as Ebola (page 3); and combating the scourge of racism (page 14). HIV/AIDS is one of the critical public health threats where SPH has a major and ongoing impact. This timeline shows the progression of HIV/AIDS as an identified disease and our role in its history.
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1990 The University of Minnesota with Professor Jim Neaton (left) receives a contract from the National Institute of Allergy and Infectious Disease (NIAID) to design and conduct trials aimed at slowing the progression of HIV, as well as preventing and treating opportunistic infections. 1992 HIV/AIDS is the #1 cause of death for men in the U.S. ages 25 to 44. 1996 Highly active antiretroviral treatment (HAART) introduced.
1990s 1997 U.S. AIDS-related deaths drop 47% in one year. 1999 Neaton is awarded an NIH grant to carry out a global clinical trial (ESPRIT) to study the efficacy and safety of interleukin-2 as an adjunct to antiretroviral therapy.
2000s 2000 AIDS is the #1 cause of death in Africa. 2002 The Strategies for Management of Anti-HIV Therapy (SMART) trial, co-chaired by Neaton, is initiated to compare episodic drug treatment with continuous anti-HIV therapy. 2006
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school/15095449
NIAID funds the International Network for Strategic Initiatives in Global HIV Trials (INSIGHT) with Neaton as PI.
that interleuklin-2 raised CD4+ cell counts (measures of immune system health), but was not clinically beneficial.
SMART trial ends early, showing that interrupting antiretroviral treatment is associated with an increased risk of AIDS as well as diseases such as cardiovascular, renal, and liver disease and cancer. Results immediately change global treatment guidelines. 2008 ESPRIT trial ends showing
2009 Neaton and the INSIGHT group lead the global Strategic Timing of AntiRetroviral Treatment (START) trial comparing early initiation of antiretroviral therapy at a high CD4+ count to deferral of therapy until the CD4+ count declines.
result in a global shift in how HIV is managed. START trial continues follow-up of all participants through 2021.
2010s
umnsph
In the U.S., 1.2 million people live with HIV; 15% are unaware of their infection.
2017 More than 36.9 million people live with HIV across the globe; approximately 43% are women.
2015 Lifson (above) begins a study to see if community health workers in rural Ethiopia can keep people in care who are undergoing HIV treatment. 2015 START trial addresses its primary question early, showing that immediate antiretroviral therapy is superior to deferral of therapy. Study findings
@PublicHealthUMN
2016 Associate Professor Keith Horvath (right) begins studies leveraging smartphone apps for HIV prevention and treatment.
2019 Nature reports that a second patient is cured of AIDS through stem-cell transplantation, but global efforts remain centered on testing for HIV, treating the virus immediately, and ensuring that treatments suppress the viral load. SPH.UMN.EDU
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Nonprofit U.S. Postage
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420 Delaware Street SE Minneapolis, MN 55455 www.sph.umn.edu
How is this
educator
fostering well-being among Minnesota farmers, farmworkers, and their families?
Staying Resilient in Farm Country Managing the stress of a chosen life Farming is a deep tradition in Minnesota, and it is one of the most dangerous and difficult jobs in the U.S. Falling prices, rising labor costs, climate change, and shrinking resources make the need for resiliency and support ever greater.
BRUCE ALEXANDER
To meet this challenge, School of Public Health professor Bruce Alexander guides the Upper Midwest Agricultural Safety and Health Center (UMASH) in forging partnerships across the agricultural community to move farmers, farm workers, and their families toward sustained health. Learn more: z.umn.edu/farm
