Advances – Spring/Summer 2013

Advances From the University of Minnesota School of Public Health

Opening Doors to Health Care What keeps people from seeking the help they need?

Public health can foster mental health A pandemic in the making?

Waiting on H7N9 SPH researcher sees maternal health with new eyes Taking the MOOC world by storm

spring.summer 2013

School of Public Health Leadership

Mary Story Senior Associate Dean for Academic and Student Affairs Debra Olson Associate Dean for Education Beth Virnig Associate Dean for Research Mary Ellen Nerney Assistant Dean for Education Operations Bradley Carlin Head, Division of Biostatistics

Bernard Harlow Head, Division of Epidemiology and Community Health

Dear Friends,

Ira Moscovice Head, Division of Health Policy and Management William Toscano Head, Division of Environmental Health Sciences Joe Weisenburger Chief Administrative Officer/Chief Financial Officer John Merritt Senior Director, Advancement and External Affairs

Advances Executive Editor John Merritt Editor Martha Coventry Contributing Writers Beth Dooley Kris Stouffer Art Direction Cate Hubbard Design cat7hubb@gmail.com Advances is published by the University of Minnesota School of Public Health. To submit comments, update your address, or request alternative formats email sphnews@umn.edu.

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All rights reserved. The University of Minnesota is an equal opportunity educator and employer.

FROM the

Another academic year has come to an end. We are extremely proud of our graduates, who have spent the last few years learning what it takes to support public health locally and globally. Our graduation speaker, the distinguished Lois Quam, executive director of the Global Health Initiative (GHI) at the U.S. Department of State, urged the class of 2013—and all of us—to persist in solving the problems that vex the worldDean wide public health community.

In this issue, we look at two of our country’s most crucial public health challenges: how to remove barriers that keep people from seeking health care (page 2) and how to help people with mental illness lead better lives (page 6).

Our faculty and alumni are exploring the many roadblocks that stand in a person’s way when it comes to accessing care. Cost remains the largest hurdle, but cultural differences or biases can be real obstacles. “Whether people from other countries or cultures decide to seek medical care, or return for follow-up visits, depends in very large part on how they were treated when they came in,” says associate professor Rhonda Jones-Webb.

In our last issue, we touched on public health’s growing responsibility to those with mental illness. In this issue, SPH faculty, along with alum Sue Abderholden, director of NAMI (National Alliance on Mental Illness) Minnesota and this year’s Gaylord Anderson Leadership Award winner (page 17), explain what public health is doing to foster a more holistic view of mental health and to develop the broader delivery systems that we need to forge effective care.

Through a look at the simmering H7N9 virus in China, we offer a primer (page 12) on flu viruses and how they can lead to pandemics. And on page 10, assistant professor Katy Kozhimannil’s groundbreaking research on maternal health takes center stage.

As the summer progresses, associate professor Michael Oakes will bring his Social Epidemiology class to nearly 20,000 students, half from outside the United States.

SPH has entered the wide world of MOOCs—massive online open courses—that gives students around the globe an unsurpassed opportunity for first-rate learning, free of cost. Here’s to the future!

Yours in health,

John R. Finnegan, Jr., PhD Assistant Vice President for Public Health Dean and Professor

Photo by richard anderson

John Finnegan Dean

Contents

Spring.Summer 2013

Features FEATURES 2 Opening doors to health care We have top-notch medicine in America, but factors like cost, fear, and cultural differences keep a significant number of people from seeking the help they need. Public health is working to lower barriers to health care.

6 How public health can help foster mental health About one half of people in the United States suffer from mental illness at some point in their lives. Most get better, but some are beset by chronic and serious distress. What can public health do to help them forge more satisfying lives?

10 Fresh eyes on long-standing problems Katy Kozhimannil’s research is shaking up the way we view pregnancy, childbirth, and young motherhood. While supporting better health outcomes, this SPH faculty member is also discovering cost savings for insurance companies, government programs, and taxpayers.

1 Learning about the flu 2 from a potential pandemic H7N9 is lingering in China. Will this avian flu virus cause the next pandemic, or will it fade away? By looking at possible scenarios for H7N9, we can better understand influenza challenges.

Departments departments 8 Findings

U.S. Department of State advisor Lois Quam speaks at graduation; outsourcing health; ramping up food safety surveillance; employer-based health care coverage declines; should we tell children to clean their plates?

1 4 Make room for fruits and vegetables Recent SPH grad Nora Hoeft is working with Minneapolis’s Healthy Corner Store Program to bring fresh produce to more neighborhoods.

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16 Prize-winning partnerships

School news One of the University’s first massive online open courses (MOOCs) is SPH’s Social Epidemiology, with thousands of people from around the world signed up already; results of the Minnesota Taconite Workers Health Study show an association between time spent working in the taconite industry and an increased risk of mesothelioma.

Minneapolis Health Commissioner and SPH alum, Gretchen Musicant, helped create a public health strategy for her city. The work of its vital partnerships led to a Robert Wood Johnson Foundation Roadmaps to Health Prize.

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Class notes

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Opening doors to health care What keeps people from seeking the help they need?

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Reform is moving through the health care and health insurance systems and medical advances have the potential to keep us living longer. A substantial amount of people, though, find it difficult to seek the care they need. Perhaps the care costs too much. Maybe the medical system appears too complicated to tackle. It could be that they live too far from a clinic, or that all doctors are white, and they aren’t.

The barriers people face are practical, cultural, institutional, and individual, and an array of SPH faculty and public health advocates are working to help people overcome these roadblocks and give them an equal chance at good health.

Illustration By Brian Stauffer

“I can’t afford to go to the doctor.”

According to the National Partnership for Women and Families, The most widespread 40 million workers and more than The most widespread barrier to barrier to seeking 80 percent of low-wage workers have seeking health care is cost. For most no access to paid sick days. This Americans with health insurance, health care is cost. means no time off to see a doctor their policies are safety nets in the during work hours without loss of event of catastrophic injury or illwages. Often a trip to the doctor can also involve finding and ness. They can be gold standard policies with low deductibles most likely paying for childcare. And getting to and from a and low copays. Or they can be minimal policies, where mediclinic even by bus can cost up to $5. cal care costs can add up quickly until the deductible is met, as can office visits and prescription drug copays.

When cultures clash This bare-bones coverage can put the holder among the more than 25 million people in the United States who are conIn 2009, the Minnesota Department of Human Services (DHS) sidered “underinsured” and, with the 50 million who have no funded a study examining why enrollees of Minnesota’s public insurance at all, at tremendous financial risk. Although these health care programs don’t seek preventive services. In addinumbers are predicted to change under the Affordable Care tion to concerns about barriers among enrollees generally, Act, with 32 million more people insured and the underinDHS was interested in disparities among ethnic groups: sured population dropping by 70 percent, seeking medical European Americans, African Americans, Native Americans, care or preventive care may still be a choice of last resort.

Hispanic/Latino, Hmong, and Somali.

In 2012, the Kaiser Family Foundation estimated that real Kathleen Call, professor in the Division of Health Policy or perceived health care costs led 58 percent of people to put and Management, was part of the team that produced the off or go without the health care they needed, an increase of report, as was Donna McAlpine, associate professor and 50 percent from 2011. director of the Program in Public Health Administration and Patricia Walker is a Medical School associate professor Policy. The report turned up valuable information about and staff physician at HealthPartners’ Center for Inter­national people enrolled in Minnesota’s public programs and provided Health. Most people she sees in the clinic are immigrants and a needed perspective on what barriers to care people of color they have insurance, usually Medicare or Medical Assistance, and immigrants face nationwide. but they often struggle to pay health care costs.

Among adults in the DHS survey, half of Hmong enrollees, “Even a copay of $1-$3 for a generic or brand name drug about a third of Native Americans and African Americans, adds up, if you’re on 8-10 drugs,” Walker says. “I ask my about a quarter of Hispanic/Latinos, and over a tenth of patients what their monthly income is and they say $800 a Somali respondents “felt they were treated unfairly due to month. And $400 goes to rent. So $35 for medicines or a their race, ethnicity, or nationality. Even more enrollees, copay on an ER visit is devastating.” regardless of race and ethnicity, felt they were treated unfairly But beyond the cost of insurance coverage or predue to the type of insurance they had or perceptions about deductible expenses, the costs of actually getting to the their ability to pay.” doctor present a financial barrier to health care that is “A concern about these forms of bias is that they will subtle and easy to overlook. keep people from using services until they are really sick,

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her language either. That encounter may leave the Somali which creates an emotional and physical toll on enrollees woman unsure of how others perceive her and hesitant and their families and a financial toll on the health care to enter the American health care system again. system,” says Call.

Jones-Webb explains that cultural competence—a workFor nearly a third of people in America, finding a doctor who looks like them and can put them more at ease is hard. ing knowledge of other cultures’ languages, customs, and religions—is essential learning for providers if immi­­grant In a 2008 survey from the Center for Studying Health families in America are to feel safe and welcome in the System Change, three out of four physicians identified themselves as white and non-Hispanic. Although physician U.S. health care system.

“Whether people from other countries or cultures decide demographics are slowly changing, the system presents to seek medical care, or return for follow-up visits, depends challenges to diversifying doctors in America. in very large part on how they were treated when they came “[If a person wasn’t trained in our country], we make in,” she says. “But, the learning must go both ways. Both it pretty difficult to practice medicine,” says Jim Hart, patients and providers bring biases that can have an effect SPH adjunct assistant professor. “For any physician to get on relationships and a sense of trust.” licensed, he or she has to do a residency for at least three years, and for foreign physicians to get into a residency Provider obligations is no small matter.”

Language, says Patricia Walker, is another “huge Among the many barriers to seeking health care is health barrier” to health care. For English speakers, there may literacy, defined by the Institute of Medicine as “the ability be disconnects between to understand instructions what the doctor says and on prescription drug botwhat the patient hears tles, appointment slips, real or perceived health when the two are speaking medical education brocare costs led 58 percent the same language. For the chures, doctor’s directions of people to put off or go nearly 20 percent of people and consent forms, and who speak a language the ability to negotiate without the health care other than English in their complex health care systhey needed, A 50 percent homes, the doctor-patient tems.” It’s a difficult skill increase from 2011. communication barrier is to gain for many, if not significantly increased. most, Americans.

Hart, who is also a “Health itself is compliphysician, has used a telephone-based interpreting service at cated to begin with and our health insurance system is times. Although much better than no service at all, this complicated, too,” says Hart. “If you have an ache or a method makes it hard to pick up the nuances needed for a pain, how do you interpret that? How do you work into the good diagnosis. The strain of this less-than-personal system? How do you as a patient get your message across?” exchange adds another level of discomfort for the patient.

In the DHS survey’s key findings section, it states, The DHS survey reported that for some people who need an “Relationships are built on communication, and commuinterpreter, mistrust in the accuracy of the translation and nity members feel that their relationships with health privacy of the medical encounter kept them from seeking providers are often impaired…because their provider does health care. not adequately explain things, listen, or spend enough time with them.”

Steep learning curve The medical system can seem like a foreign world, and for those hesitant about seeking care, stepping into that world Rhonda Jones-Webb is an associate professor in the can be a hurdle too high. Providers must be willing to make Division of Epidemiology and Community Health whose it easier for people. To take the time to explain things many research focuses on race and ethnicity and social class of us take for granted—What’s a colonoscopy? Why is a issues. She tells the story of a woman from Somalia who pelvic exam important? What is a prescription and how do visited a doctor’s office in Minneapolis. She checked in you get it filled? Even the difference between a community and sat in the waiting room. Forty-five minutes later, she clinic and an emergency room—they are both places you go went up to the desk to ask what was taking so long. “We’re for care, aren’t they? The medical system has a lot of catchwaiting for the interpreter,” she was told. “But I don’t need ing up to do, says Hart, if it is to truly serve a changing an interpreter!” she answered.

America and welcome people in its doors.

The woman in the story did not look like the woman behind the desk; the assumption was that she didn’t speak

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What can public health do?

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primary care clinic, nurse-managed clinic, or accountable care organization will increase community comfort with the health care system and help make providers more culturally literate.

To address barriers to care, Kathleen Call believes public health should work more closely with community partners.

Some racial and ethnic communities may have different views about the use of health care, for example. They may not be aware of the purpose behind preventive services and screening and instead seek care only when they are sick.

The search for the right pubic health messaging for this issue is a challenge. “A lot of public health messaging is aimed at encouraging people to make individual decisions, like wearing seat belts or quitting smoking,” says Call. “It is only after policies are put into place that enforce healthy behaviors that we see dramatic changes in these behaviors. We need to work to encourage policies that support people and their families to make healthy choices. As a community, we need to be in this together.”

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Helping people seek the care they need, especially those with financial and cultural barriers, is a tall order and public health must play a larger role in making this happen.

A major shift is underway that is bringing public health and medicine together, and out of their traditional silos.

According to Jones-Webb, now the population health and whole-patient thinking of public health can have an impact on the traditional clinical model.

This is being done in two principle ways: training primary care physicians in public health and having public health professionals as part of a clinic’s staff.

Through SPH’s Executive Program in Public Health Practice and the Public Health Medicine program, physicians and medical students can earn an MPH. Adding this training, says Jim Hart, will help give them a way to see the community around them and the challenges it faces in a big-picture way.

Making public health professionals or community health workers with public health training an integral part of a

Hennepin Health Weaving a new safety net “It takes a village” has become a cliché, and for good reason—it’s true, and it is applicable to most of the important things in life. When it comes to sustaining the health of our most vulnerable people, this model of coordinated, accountable care is critical.

On January 1, 2012, Hennepin County launched a pioneering program with just this kind of holistic attention in mind. Called Hennepin Health, it brings medical and dental providers, insurers, nonprofits, and county social services into an organized, committed partnership to serve the county’s indigent adult population and to save Medicaid dollars.

Most of the people the program serves have multiple needs. They may face chronic disease and chemical

dependency, or mental illness and homelessness, for example. Hennepin Health looks at each patient as an individual and calls on the specific support, including from public health professionals, that is needed to keep him or her as healthy as possible.

Melody Mendiola is an assistant professor in the Department of Internal Medicine, the medical director of Hennepin County Medical Center (HCMC) Brooklyn Center Clinic, and a graduate of the Executive Program in Public Health Practice. HCMC is a Hennepin Health partner.

“The exciting thing about Hennepin Health is that it addresses the up­stream psychosocial determinants of health that we historically have not been able to impact through our traditional Western Medicine model,” says

Mendiola. “If people don’t have secure housing and access to food, it might not matter what medications I prescribe, they are going to have a more difficult time managing their health. Hennepin Health helps us be more proactive in partnering with our patients and reaching out to them instead of waiting for them to come into our office, often in crisis.”

In the past year and a half, Hennepin Health has enrolled more than 6,000 people and averages about 200 new patients each month. According to the program, hospitalizations and emergency-room use have declined by more than 20 percent among its patients. And Hennepin Health’s efforts saved Medicaid more than $1 million in 2012.

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Joining forces for better outcomes How public health can help foster mental health

Reading the signs One area where public health has had a major contribution, says Ezra Golberstein, assistant professor in the Division of Health Policy and Management, is in documenting the basic epidemiology of mental illness—identifying its prevalence and its risk factors. Landmark studies such as the Epidemiological Catchment Area Project of the 1980s and the National Comorbidity Survey of the 1990s and early 2000s surveyed general population samples and painted a striking picture of mental illness in the United States. These studies found that

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between one-third and over 40 percent of all Americans suffer from mental illness at some point in their lives.

More recent national studies have put this number at about one-half.

Golberstein’s own area of research involves studying the financing of mental health services. “We now have treatments that really work for

1 in 10 adults and 1 in 20 children take psycho­tropic drugs for a mental health condition. alleviating many otherwise debilitating mental health problems,” he says. “But how we try to improve access to these services and how we as a society pay for these services continues to evolve, especially as the Affordable Care Act expands coverage for mental health and substance abuse disorders.”

But when it comes to prevention, the traditional purview of public health, things are not so straightforward.

Other major public health culprits like heart disease and diabetes have more obvious cause-and-effect lines. Not so with mental illness.

“Primary prevention is still pretty tough, because we don’t have enough research when it comes to the causes

of mental illness,” says Abderholden.

“We can’t say, for example, ‘be a good parent,’ because we know that biology and genetics and all sorts of things are involved. We can certainly do more about secondary prevention— intervening before the first symptoms appear—because we know who’s at risk.

“But tertiary prevention—stopping a disease before it becomes chronic— is where we can really have a huge impact. When we know someone has had their first psychotic episode or beginning to experience symptoms, we want to make sure this doesn’t become a disabling condition.”

Too broad a brush Trying to catch mental illness at its very earliest stages is the goal of many mental health professionals and conducting screenings may be the best way to do that. That methodology, however, generates some controversy.

Donna McAlpine is an associate professor in the Division of Health Policy and Management and director of the MPH program in Public Health Administration and Policy.

She is coauthor of the most recent edition of Mental Health and Social Policy, the standard text for mental health policy students. The textbook got media attention for, among other topics, the questions it raised about the best use of funds for mental health; the new categories in DSM-5, the latest manual from the American Psychiatric Association that classifies mental disorders; and the limitations

Illustration By Christine Roy

“M

ental health was never considered part of ‘health,’” says Sue Abderholden.

“Somehow we neglected the fact that our heads are connected to the rest of our bodies.”

Abderholden is director of NAMI (National Alliance on Mental Illness) Minnesota, has an MPH in Public Health Administration and Policy, and received SPH’s Gaylord Anderson Leadership Award this year (see page 17). With her comments, she’s addressing the historical disconnect between mental health and physical health, and the fields that treat them both.

Those disciplines came closer together as the mental health profession started following a clinical treatment model, but public health has yet to find how it can play a more effective role on the ground to increase the mental health of Americans.

of preventive psychiatry, including screening programs.

“Screenings work to identify more and more people with symptoms that may be related to mental illness, but, as we are beginning to realize, we then run the risk of medicalizing emotions that are a normal part of life, like sadness,” says McAlpine. “What can happen is that we end up classifying people as ill and bringing them into treatment. In reality, of all people identified, only a small portion will go on to develop severe mental health problems. There’s little evidence that early screening improves outcomes or identifies the right people.”

McAlpine believes that screenings and national community studies have helped reduce the stigma of mental illness by showing how common it is—1 in 10 adults and 1 in 20 children take psychotropic drugs for a mental health condition, for instance—but that increasing comfort level with mental illness has been accompanied with a loss of focus on the people with severe and disabling problems.

“Walk down the street in any

large city, like Minneapolis, when the weather begins to warm up, and you will see just how many people are struggling with untreated mental illness,” says McAlpine.

With the limited mental health resources that we have, she says, we should focus on people with the most critical symptoms who are unlikely to get better without help.

Helping people get better When Abderholden first came to NAMI, she sat down with some people who had been through the mental health system. “I asked if anyone had ever gotten a get-well card when they were hospitalized,” she says. “Everyone said no. Just imagine what that says about how the community views you, your illness, and hope for your future.”

As an MPH student, Abderholden learned that you need to talk with the community you’re going to work with. You have to find out what people really want, what they really need.

“When I talk to people with mental illness, it’s clear what they

want—a life,” she says. “Their illness might not be cured, but it might not have to be disabling either. Public health takes a broader view of health.

It’s not just the absence of disease.

We need to apply this thinking to mental illness.”

Both McAlpine and Abderholden see the need for a more holistic view of mental health and broader systems of care, with coordinated and accessible social services.

There may be a model for this kind of support in the new Hennepin Health (see page 5), where mental, clinical, and dental health services are co-located, and public health thinking plays an essential role.

In McAlpine’s opinion, public health should pay much more attention to mental health and work it into curricula. “[As public health professionals] we have an obligation to understand how mental health correlates with social environments, poverty, trauma, and many of the other things public health turns its attention to when looking at downstream causes of disease,” says McAlpine.

“And we need to see—and teach our students to understand—how mental illness often accompanies typical public health diseases like diabetes and heart disease and can, in fact, be more disabling than any of these.”

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Findings

Salmonella response too slow In 2011, an outbreak of Salmonella Heidelberg infections linked to ground turkey sickened 136 people, causing 37 hospitalizations and one death.

The Pew Charitable Trusts recently analyzed the outbreak to determine where the food safety surveillance system could be improved to prevent future damage. SPH professor Craig Hedberg reviewed Pew’s report, which recommends that federal and state officials: Enhance the surveillance system by interviewing all patients promptly and using labs to fingerprint DNA of suspected Salmonella isolates. equire that the brand, processing plant, and purchase R date for contaminated samples are included in the DNA fingerprint.

Communicate with food companies early in an outbreak when production schedules and distribution patterns could help identify contaminated foods.

“The CDC believes there are more than a million cases of Salmonella a year. Yet only 40,000 cases are reported,” says Hedberg, who stresses the importance of following up on each reported illness. “The information gathered from that patient could prevent further infections.”

Common food behavior messages may be counterproductive “Clean your plate” and “no sweets” are common refrains among parents. But these messages may backfire, finds SPH research.

The study shows that the use of controlling food behaviors was common in parents of adolescents.

Not surprisingly, restrictive food behaviors were more common in parents who had overweight children.

Pressure-to-eat behaviors were more common in parents of kids who weren’t overweight.

“In the 1950s, cleaning your plate meant something different,” says study author Katie Loth, a registered dietician and SPH research assistant. “Portion sizes have gotten bigger over time, and if you encourage kids to rely on environmental indicators, like how much food is on their plates or the time of day, they’ll lose the ability to rely on internal cues to know whether they’re hungry or full.”

Results of the study were published in the journal Pediatrics.

“Parents need to allow their children to have freedom when eating,” Loth adds. “Bring lots of healthy food to the table. Then let your children choose how much they want to eat. Let them regulate their own intake.”

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TEDxUMN2013 SPH student Krystal Rampalli presented “Medical Tourism: Your Health Can Now be Outsourced” at this year’s TEDxUMN event.

Grad recap “I had the privilege of working with the School of Public Health early on in my career, so I know firsthand what a difference the research and scholarship at this institution makes,” said Lois Quam to the 2013 graduating class of the School of Public Health.

Quam, a special advisor at the U.S. Department of State, discussed the importance of collaboration, setting ambitious goals, and combining inspiration and skill. She urged the graduates to “keep a constant focus on all those you are helping. . .

They need you. Our country needs you. The world needs you,” she said. “Class of 2013, you are limitless!”

Employer-based health coverage sees 10-year decline A new study, led by the State Health Access Data Assistance Center (SHADAC) and funded by the Robert Wood Johnson Foundation, reports that the share of people under age 65 with employer-based coverage fell from 70 percent in 2000 to 60 percent in 2011. The drop translates to 11.5 million people who no longer receive health insurance through their job or the job of a family member.

A poor economy, with fewer jobs available, is one factor. But the drop in coverage occurred throughout the past decade, not just during the recession. Rising premiums also likely played a role.

From 2000 to 2011, single-employee premiums have gone from an average of $2,490 to $5,081, while family premiums jumped from $6,415 to $14,447. During that same time period, the amount employees contributed toward premiums also skyrocketed, from $435 to $1,056 per year for family coverage.

“Costs for employers and employees have risen steadily and significantly over the past decade,” says Lynn Blewett, SHADAC director and SPH profes­ sor. “As a result, employer-sponsored insurance has eroded substantially.”

Access the full report and state-by-state analyses at shadac.org.

Search for “state-level trends.”

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Katy Kozhimannil brings new approaches to maternal health

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K

aty Kozhimannil’s research into maternal health is garnering national attention, and the notable findings she’s released just this year, including documenting that cesarean delivery rates vary ten-fold across U.S. hospitals, may have a significant impact on how women experience pregnancy, childbirth, and early motherhood. While focusing on the broader health systems and non-medical factors that support good maternal outcomes, Kozhimannil has also documented potential

cost-savings for insurance companies, government programs, and taxpayers.

Kozhimannil, assistant professor in the Division of Health Policy and Management, first became interested in women’s health and health policy when she taught junior high school as a Peace Corps volunteer in Mozambique. “By ninth grade, many of the girls had dropped out because of pregnancy or family obligations,” she recalls. When she returned to the United States, she taught English as a second language and worked

Photo by Paula Keller

Fresh eyes on long-standing problems

Left: Research from SPH asssistant professor Katy Kozhimannil, in photo with her children, is changing how we see the challenges of pregnancy, childbirth, and early motherhood.

with at-risk youth in a YMCA program in the Twin Cities. “These Minnesota girls were facing similar health issues as those in Mozambique. That’s when I realized the [bigger picture] of these concerns.”

Better care, lower costs In her research, Kozhimannil engages obstetricians and midwives as well as non-clinicians and community partners.

Her collaborative approach is aimed at helping providers deliver better care, produce better health outcomes, and, in the long run, save money.

Recently, she examined the role of doulas, trained professionals that provide information, physical assistance, and support during childbirth. Kozhimannil found a 40 percent lower incidence of cesareans among women on Medicaid who had support from a doula, which may be especially important for women who face language and cultural barriers. The statistical information resonated with Kozhimannil’s own experience giving birth. “My doula helped me avoid a cesarean because she was able to explain my options and support me in my choices,” she says. “It was a busy night at the hospital and without a doula, things might have been different. A doula tends just one woman, taking the pressure off the medical staff and allowing them to concentrate on their work, yet most health insurance plans don’t currently pay for this service. This is a case where investing money on the front end could ultimately result in real dollars saved.”

In another study, Kozhimannil found that the type of health insurance a woman carries affects the type of childbirthrelated interventions she receives. Women covered by private insurance received more obstetric procedures, such as cesareans and labor induction. “As the number of obstetric interventions goes up, so does the cost to cover them,” says Kozhimannil.

“This may ultimately be felt in the form of higher premiums, more expensive copays, or higher deductibles for those privately

insured. [If more women, employers, and health insurance companies are aware of this connection between type of insurance and care,] they may realize their potential role in shaping high-quality, high-value health care practices.”

Insuring good outcomes The forthcoming changes initiated by the Affordable Care Act (ACA) inspired Kozhimannil’s research into overall insurance coverage of women. As the ACA goes into effect, she found that one-quarter of reproductive-age women are at risk of being uninsured or having gaps in their health insurance coverage. “This raises real concerns about access to family planning and pre-conception health, which impacts birth outcomes as well as child health and well being,” she says. “As health reform rolls out and new options are available, some people will move from one type of health coverage to another to another (a process called ‘churning’) and pregnant women may be particularly apt to experience this. What’s important to remember is that increased coverage doesn’t always equal access to services.”

Access to health care is crucial before, during, and after pregnancy. In an effort to measure the impact of a statewide policy designed to address postpartum mental health, Kozhimannil studied the impact on Medicaid recipients of New Jersey’s

One-quarter of reproductive-age women are at risk of being uninsured or having gaps in their health insurance coverage.

mandatory screening for post-partum depression. She found it had no beneficial effect on treatment initiation. “The recommended screening tool was well validated, but the policy itself suffered problems of clarity, measurement, and enforcement,” she says, citing issues with monitoring, provider payment, and follow-up. But the law may help reduce the stigma of this debilitating condition, says Kozhimannil.

“Addressing postpartum depression is an important and urgent public health goal.”

Exploring every avenue Looking ahead to future projects, Kozhimannil’s interest in vulnerable populations led her to focus on rural health issues. Much of the research in health care concerns urban populations and is conducted in academic health centers located in large cities. “At the University of Minnesota Rural Health Research Center, we have begun to look at quality and safety of childbirth care in rural areas, where a quarter of all American babies are born,” says Kozhimannil.

Kozhimannil would also like to research complementary and alternative therapies that are used by pregnant women: yoga, massage, herbal supplements, etc.

“Pregnancy websites and blogs are full of references to women using these therapies, and while they might blog about them, women may not be telling their doctor about them,” she says. “There is a gap in the health services literature about this important topic.”

Understanding the whole system of care, including prevention and education, is the best way to look after mothers and babies, says Kozhimannil. “In so many cases, appropriate, evidence-based childbirth care includes a range of options, some of which actually come at less cost than common practices. When we did a cost analysis of doulas, for example, it made the case for providing health coverage for such services very compelling. We’re pleased to say that the Legislature recognized that and, on May 23, it passed the Omnibus health bill which included a provision giving Minnesota’s Medicaid program permission to reimburse for doula services beginning July 2014.”

sph.umn.edu 11

Genetic roul What can happen to flu viruses on the way to a pandemic

In February and March 2013, three people in eastern China became sick with respiratory infections that quickly turned serious. On March 31, Chinese health organizations told the World Health Organization that they had identified the source of the illness as influenza A H7N9.

The news concerned WHO because H7N9 is an avian strain that had never before been isolated in humans.

This new virus turned out to have a 19 percent fatality rate and it began traveling westward across China. As

of July 1, it had killed 40 people and sickened 133 others.

Flu viruses are constantly moving around the world causing seasonal infections that are responsible for 3,000 to 49,000 deaths in the United States each year. But as their genes mutate or trade places with genes from other animal or human flu viruses—a process called reassortment—a particularly lethal new flu strain can emerge. In 1918, the H1N1 virus mutated to cause one of the most devastating pandemics in history, killing 50 million people worldwide.

100 years of flu outbreaks 1918 “Spanish flu” H1N1

1956-58 “Asian flu” H2N2

This is America’s great influenza pandemic. It killed more than 500,000 people in the United States and up to 50 million people worldwide.

The “Asian flu” originated in China and caused about 2 million deaths worldwide, including about 69,800 in the United States.

1968-69 “Hong Kong flu” H3N2 About 1 million people around the world died from this flu strain; 33,800 of those were in the United States.

1997 “Bird flu” H5N1

2009 “Swine flu” H1N1

2013 H7N9

This outbreak marks the first appearance of a flu virus that was transmitted directly from birds to people.

A mix of bird, swine, and human influenza genes, this strain of H1N1 has killed more than 18,000 people around the world and continues to circulate.

As of July 1, H7N9 had killed 40 people and sickened 133 others in China.

Before this year, H7N9 had never been isolated in humans.

Naming rights: What does influenza A H7N9 mean?

The H7N9

The A Flu viruses come in three basic types: A, B, and C. Types B and C are found only in humans. Type C produces the mildest symptoms of the three types and it doesn’t cause epidemics. Type B can produce more severe symptoms and cause seasonal flu outbreaks and deaths.

But type A is the real killer.

It can infect people and animals, jump between species, and adapt readily to different biological environments. It’s the source of pandemics—the storied 1918 influenza that killed more than 50 million people was a type A H1N1 virus.

12 University of Minnesota School of Public Health

On the surface of type A flu viruses are the proteins hemagglutinin (H) and neuraminidase (N). Hema­ gglutinin allows the virus to penetrate cells and infect them; neuraminidase creates pathways for the virus to get back out and infect other cells. There are 17 variations of hemagglutinins (H1-H17) and 10 variations of neura­ minidases (N1-N10).

Strains of type A are named for those combinations, like the two types common in humans, H1N1 and H3N2.

A virus’s common name, like influenza A H7N9 or H1N1 tells us only the family it belongs to. Beyond that, the virus takes on its own distinct, mutable characteristics that may or may not make it lethal to humans on a large scale.

ulette The H3N2 “Hong Kong Flu” in 1968–69 killed 1 million people.

There have been small clusters of H7N9 infection in the ongoling Chinese outbreak that could have resulted from person-to-person transmission, but that has not been verified. Currently, it appears that when humans contract H7N9 infection, it is the result of the virus passing from birds to people. No one knows just what will happen in the weeks and

months ahead.

In a recent JAMA article, SPH environmental health professor Michael Osterholm and his colleagues offered three scenarios for the future of this particular virus:

Scenario 2

Scenario 1

The virus could persist in the animal reservoir, resulting in sporadic human infections.

The virus could disappear in the animal reservoir, ending new human cases.

“In this scenario, the animal virus circulates and changes in a way that makes it more similar “No one knows why an influenza virus to those of human flu viruses,” says Osterholm. fades away,” says Osterholm. “Perhaps it Flu viruses have only one goal—to stay alive.

“Each time a sporadic transmission from an animal takes on additional genes that make it less They are constantly mutating to dodge the to a human occurs, it’s one more roll of the genetic likely to be transmissible among animals body’s immune system, antiviral drugs, and dice. Over time, with enough throws at the table, and therefore not able to infect humans. vaccines. Standard flu shots target type A H1N1 the virus might unfortunately come out the winner All we know is that it changes in some and H3N2, and type B viruses, and they must and change enough to cause sustained way that makes it no longer a be reformulated each year to go after what is human-to-human transmission. threat to humans.”

predicted to be the circulating virus. Recent research We have no idea how long by the University’s Center for Infectious Disease this might take or Research and Policy (CIDRAP) shows that yearly flu even if it will The virus could become readily vaccines have greatly varying degrees of effectiveness, occur.” transmissible because of gene mutation or gene depending on the type of vaccine used—with live or killed reassortment, when influenza viruses in the same cell viruses—and a person’s age. exchange genetic material and form a new flu strain.

The vaccine scramble

Scenario 3

To fight a novel flu strain that has the potential to infect large numbers of people is a race against time. To begin with, the virus has to be isolated, then grown in fertile chicken eggs, developed into a deliverable vaccine, and tested in phase 1 human clinical trials. That process takes about five months.

If the virus does evolve to cause a pandemic, production gears up rapidly to create enough vaccine to inoculate a population. That phase would take about six to 12 months.

By then, the vaccine may have missed a crucial window for prime effectiveness.

“This is what happened in 2009, when H1N1 came out of nowhere to become transmissible to humans,” says Osterholm.

Being ready with a vaccine at this point to protect the world population is problematic for several reasons. “First, the virus you built the vaccine around when it started causing sporadic cases may not now have the same genetic structure that causes the pandemic,” Osterholm says. For example, the H5N1 virus, the often called “bird flu virus,” is very different today than it was when it emerged in Asia almost 10 years ago. “Second, it takes a lot of money to make a vaccine— hundreds and hundreds of millions of dollars. You would have to spend that money to reduce the impact of a pandemic that When it comes to H7N9, “depending on when vaccines are may never occur. And third, we only have limited capacity ordered, the manufacturers’ ability to convert from seasonal for global manufacturing of influenza vaccines. vaccine to pandemic vaccine production, and how quickly the So if we were to go full bore on a pandemic pandemic spreads, it is possible that vaccines will arrive in limited vaccine, we’d have to sacrifice seasonal quantities but after the critical point when they will significantly affect flu vaccine production.” morbidity and mortality, as occurred in 1957, 1968, and 2009,” wrote Michael Osterholm, SPH professor and director of CIDRAP, and his colleagues in JAMA. sph.umn.edu 13

Make room for fruits and vegetables

Less than a third of Minneapolis adults eat the recommended daily servings of fruits and vegetables. To make it easier for people to obtain these foods, the city passed an ordinance in 2008 requiring corner stores to carry five varieties of fresh produce. Since 2009, WIC-certified stores have had to stock a minimum of seven varieties.

To help store owners comply with these rules and increase sales, Minneapolis launched the Healthy Corner Store Program to make produce more “visible, affordable, and attractive.” Now in its second year, the program, funded by the Statewide Health Improvement Program (SHIP), shows promise in improving community health while increasing the stores’ profits.

Nora Hoeft, recent MPH graduate, interned with the program for her field experience, continued on as a health specialist, and documented the program’s success in her master’s thesis. Thirty corner stores participated in the program, and by reviewing the sales figures of seven of those stores, Hoeft found that “produce sales increased by 153 percent, adding about three percent profit to the bottom line.” Hoeft recently received the Student Research Day Award for her work with the Healthy Corner Store Program.

Produce purchases are driven by visibility and attractiveness as well as price. Hoeft’s undergraduate theater and set design major and her job with Mississippi Market Natural Food Co-Op helped her work with the store owners on purchasing, produce handling, and display.

Hoeft emphasizes the importance of establishing trust before beginning the work. “These business owners are wary of government intrusion and they were skeptical of the program at first,” she says “But once they understood it was for them, not about us, they bought in.” Because they don’t stock enough produce to warrant deliveries, the store owners have to shop for and buy the produce themselves. Organizations like Appetite for Change are helping stores stock more produce from local farmers markets and city gardening initiatives.

Hoeft found that personal relationships are fundamental to system change. “In working with the store owners, I’ve a better understanding of their issues,” she says. “They talk freely about the socio-economic factors that keep unhealthy food entrenched. They don’t like selling junk food and cigarettes, but they’re pigeon-holed by the system.”

When it comes to encouraging positive changes, carrots work better than sticks. “More people are eating fresh healthy produce,” says Hoeft. “The stores are making money.”

14 University of Minnesota School of Public Health

Photo by Chris PolyDoroff

Recent SPH grad Nora Hoeft helps corner stores offer fresh produce

Alumni News School News

SPH course among U’s first batch of MOOCs Understanding how forces of society— from family life to government policies to the global economy—impact health is the focus of one of the first massive online open courses (MOOCs) offered by the University of Minnesota.

Nearly 20,000 students signed on for Social Epidemiology, one of five courses the U developed with Coursera, a company partnering with more than 35 top universities around the world to offer free courses online for anyone to take. The seven-week class, which launched in May, drew about half of its registrants from outside the United States.

Being among the first educators to reach a global audience through the MOOC platform attracted SPH associate professor Michael Oakes to the project.

Oakes, an award-winning instructor and McKnight Presi­dential Fellow, also thought the experience would be useful for a book he’s writing.

“This is truly about educating global citizens—in terms of the student base and the subject matter,” he says.

Oakes worked with producers from the University’s media and teaching services— a group he affectionately refers to as “Team Hollywood”—to record the videos that

serve as the basis of the course.

“Preparing for this course has taught me so much about teaching,” Oakes says.

“It’s been tough to teach to a camera— there’s no immediate student feedback to guide me. But it has helped me to organize my thoughts in new ways.”

Oakes sees this first offering as just the beginning in a field that is sure to change. “[It’s like] we are in a time of vinyl records but CD-ROMS are just about to be released,” he says with a chuckle. “It’s an exciting time to be a teacher. It will be interesting to see the impact of MOOCs on our school’s enrollment and reputation.”

U researchers update community on taconite workers study University of Minnesota researchers met with community members and lawmakers in April to share some results of the Minnesota Taconite Workers Health Study.

The researchers confirmed an association between time spent working in the taconite industry and an increased risk of mesothelioma, a rare form of lung cancer. They presented findings that show air quality in communities surrounding taconite mines is cleaner in terms of particu­lates than air found in Minneapolis. And they shared results that current occupational exposure to taconite dust is generally within safe limits.

The Minnesota Legislature commissioned the $4.9 million study in 2008 after data from the Minnesota Cancer Registry revealed an excess of mesothelioma cases in Iron Range workers.

“Our goal was to begin to answer questions around how mining and taconite processing have impacted the health of Minnesotans working in the industry,” SPH dean John Finnegan said to a group of about 100 in Mountain Iron, Minn. “These studies have started to uncover those answers.”

To date, the researchers have confirmed 80 mesotheli­oma

deaths in Iron Range workers and also found higher rates of all types of cancer and heart disease. Within the study population, researchers found that for every year worked in the industry, the risk for mesothelioma went up by about 3 percent.

More study results will be released this year.

advances.umn.edu/w13 sph.umn.edu 15 9

Prize-winning partnerships Minneapolis honored with Roadmaps to Health Prize

“T

The meaning of health Work on this public health strategy for Minneapolis began several years ago, says Musicant. “Before we could create policies to build health we needed to understand what the term health really means to residents in our diverse community. We reached out to neighborhood groups and asked questions such as: ‘Tell me about a time when you, your family, or community were healthy.’ Some groups said, ‘back in the old days’ or ‘when my grandmother was alive.’ We learned that some of the key elements in a healthy community are: space for physical activities, cultural pride, connection to family and friends, and [a way to relate cross-culturally]. Health is holistic.”

The prize recognizes the Minneapolis Health Department’s work with more than 40 community organizations to improve educational opportunities, support smoke-free living, and prevent diabetes and obesity through physical activity and access to healthy, fresh, local food. The Minneapolis Health Department itself, for example, joined a group of community and clinic partners serving 60,000 people to improve patient care.

Better together Education initiatives cited in the award include the Northside Achievement Zone (NAZ) for its successful “cradle-to-career” approach. “This may mean helping parents find respectable housing or meaningful employment as well as providing tutoring and after-school services or transportation for their children,” NAZ President and CEO Sondra Samuels has said.

16 University of Minnesota School of Public Health

Venture North Bike, Walk & Coffee trains neighborhood youth in servicing old bikes to sell at affordable prices to neighborhood residents.

“What we know is that the achievement gap is made up of a lot of gaps, one of them being the ‘belief gap’.”

The HealthyLiving Minneapolis initiative supports a variety of ways to encourage healthy choices. The tobacco-use reduction effort helped several multi-unit apartment complexes such as Riverside Plaza become entirely smoke free. The Healthy Corner Store Program helps neighborhood convenience stores purchase, handle, and display reasonably priced fresh produce. [See MPH alum Nora Hoeft’s story on page 14]. Homegrown Minneapolis, a coalition of citizens and government agencies, works to improve the avail­ability of and access to healthy locally grown and processed foods.

In underserved North Minneapolis, the Venture North Bike Walk & Coffee trains neighborhood youth in servicing old bikes to sell at affordable prices to neighborhood residents. In doing so, it provides real, solid job skills while making bikes easily accessible.

The coffee shop has become a community gathering center and a place for programs on biking and walking.

“It’s inspiring to see how many people we have engaged in this work,” says Musicant. “It takes time and energy to create vibrant partnerships, but it is certainly worth it.”

Photo by AAron Belford/courtesy of venture north

hough Minneapolis is known for its incredibly healthy life­style, we also have one of the largest gaps between ‘haves’ and ‘have nots’ of any city in the country—in economic disparities, in health, in education,” Mayor RT Rybak said at the Roadmaps to Health Prize cere­mony. “Our focus is absolutely on closing those gaps through policy and partnerships.”

This year, the Robert Wood Johnson Foundation (RWJF) inaugurated its Roadmaps to Health Prize to honor U.S. communities who were breaking new ground in helping people live better lives. Out of 160 applicants, RWJF chose Minneapolis for its outstanding partnerships dedicated to increasing community health. Minneapolis joins Santa Cruz, Calif.; Manistique, Mich.; New Orleans; and Fall River and Cambridge, Mass., in being awarded $25,000. “This prize acknowledges a journey well-begun,” says Gretchen Musicant, Minneapolis Health Commissioner. “It’s not an end in itself. We’re on the right path.” Musicant is an SPH alum and the School of Public Health has contributed its support, as well as its graduates, to several Minneapolis organizations cited in the Roadmaps to Health Prize.

CLass notes

Sue Abderholden (MPH ’80)

The SPH Alumni Society named Sue Abderholden as the 2013 recipient of the Gaylord Anderson Leadership Award.

In her role as executive director of NAMI (National Alliance on Mental Illness) Minnesota, Abderholden serves as an advocate for children and adults who face mental illness, as well as an advocate of resources for families of those individuals.

Read Abderholden’s thoughts on mental illness and public health on page 6.

Gaylord Anderson Leadership Award winner Sue Abderholden, left, with recent MPH grad Natasha Wright (see her class note).

Ilian Grigorov (MHA ’12) Ilian Grigorov is the co-founder and lead administrator of City Clinic in Sofia, Bulgaria. The hospital opened in December 2012 and is the most state-of-the-art hospital in the country, equipped with the latest imaging, cardio­vascular, monitoring, and lighting equip­ ment. Grigorov formulated plans for the hospital in his capstone project while attending the Executive MHA program.

Jooyeon Hwang (MS '08, PhD candidate)

Jooyeon Hwang, PhD candidate in the Division of Environmental Health Sciences, will have a fellowship

at the National Cancer Institute/NIH. Her research will focus on improving and validating methods for assessing environmental and occupational exposures in epidemiological studies of cancer.

Michael Osterholm (MS ’76, MPH ’78, PhD ’80) Michael

Osterholm, SPH professor and director of the Center for Infectious Disease Research and Policy (CIDRAP), is a 2013 recipient of the University of Minnesota Award for Outstanding Contributions to Postbaccalaureate, Graduate, and Professional Education.

Winners of the award are inducted into the University’s Academy of Distinguished Teachers, a program of the Office for Academic Affairs and Provost that promotes excellence in teaching and learning.

Elizabeth Reisdorf (MPH ’10)

Elizabeth Reisdorf received the Recognized Young Dietitian of the Year award from the Minnesota Academy of Nutrition and Dietetics. Reisdorf works for Pediatric Home Service in Roseville, Minn., where she provides consultation on homebased nutrition and health services for children with special health care needs and for those who are terminally ill.

Diane Smalley (MPH ’82)

Diane Smalley has been elected Chairman of the American College of Healthcare Executives.

Alicen Burns Spaulding (PhD ’13) Alicen Burns Spaulding

has accepted a position as a Presidential Management Fellow at the National Institute of Allergy and Infectious Diseases/ NIH beginning August 2013.

José Ricardo Suárez (MPH ’05, PhD ’12) José Ricardo Suárez

and colleagues received the “2012 Paper of the Year Award” from the Society of Toxicology, Occupational and Public Health Subsection for the paper “Lower acetylcholinesterase activity among children living with flower plantation workers.”

Environmental Research.

2012 Apr; 114:53-9. Suárez, a physician, is a post-doctoral fellow in the Cardiovascular Disease Epidemiology and Prevention training program in SPH’s Division of Epidemiology and Community Health.

Donald Wegmiller (MHA ’62)

Donald Wegmiller was inducted into Modern Healthcare’s Health Care Hall of Fame. Wegmiller was CEO of a Minneapolis hospital system that became Allina Health System. He later led the health care consulting firm Healthcare Strategies.

Joseph Westermeyer (MPH ’70) Joseph Westermeyer was

named the 2013 recipient of the R. Brinkley Smithers Distinguished Scientist Award by the American Society of Addiction Medicine (ASAM).

Westermeyer, a physician, is a VA HSR&D-funded researcher with the Center for Chronic Disease Outcomes Research at the Minneapolis VA Health Care System. The award recognizes his continuing support of ASAM and his crucial role in guiding alcohol research in America.

an honorable mention in the University of Minnesota’s Graduate School’s 2013 “best dissertation” award competition.

Her dissertation, “Potentially Preventable Hospitalizations among Elderly Medicaid LongTerm Care Users,” was selected from a large pool of submissions.

Wysocki currently serves as a postdoctoral fellow at the Center for Gerontology and Healthcare Research at Brown University.

SPH alumni inducted into the Delta Omega Honorary Society in Public Health Membership in Delta Omega reflects the dedication of an individual to increasing the quality of the field, as well as to the protection and advancement of the health of all people.

Biostatistics: Wei Shen (MS ’94, PhD ’96) Environmental Health: Petrona Lee (MS ’84, PhD ’12) Epidemiology: Nina Alesci (MPH ’99, PhD ’10) Executive Program in Public Health Practice: Andrew McLean (MPH ’11) Health Services Research, Policy & Administration: Rada Dagher (PhD ’07) Public Health Nutrition: Michelle Vaneslow (MPH ’08)

Natasha Wright (MPH ’13)

Natasha Wright, a Presidential Management Fellow, will begin work July 15 in Washington, DC., with the National Cancer Institute/NIH. (See her in photo, above, with Sue Abderholden.)

Andrea Wysocki (PhD ’12)

Andrea Wysocki received

Petrona Lee

Nina Alesci

Rada Dagher, left, with SPH professor Traci Toomey.

sph.umn.edu 17

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420 Delaware Street SE Minneapolis, MN 55455 www.sph.umn.edu

346 graduates School of Public Health class of 2013

Biostatistics 7 MS; 5 PhD (1 Brazil, 3 China, 1 South Korea) Clinical Research 6 MS Community Health Promotion 33 MPH (1 Taiwan) Environmental Health 33 MPH (1 Guatemala, 2 India, 1 Nigeria) Epidemiology 34 MPH (1 Japan, 1 Nigeria, 1 Sierra Leone)

Health Services Research, Policy and Administration 12 MS (1 India, 2 Taiwan); 6 PhD (1 China, 1 India, 1 South Korea, 1 Taiwan) Healthcare Administration— Executive Program 29 MHA (1 China)

Healthcare Administration— Full-time Program 81 MHA (1 Bahamas, 4 India) Maternal and Child Health 25 MPH (1 Nigeria)

Upcoming Events 10th Annual Community Partners Event Minneapolis October 10, 5–7pm, McNamara Alumni Center

Public Health Administration and Policy 38 MPH (1 India, 1 Kenya, 1 Lebanon, 1 Nigeria)

Memorial Hall, University

Public Health Nutrition 19 MPH (1 China, 1 Zimbabwe)

Public Health Associations’

Public Health Practice— Executive Program 12 MPH (1 United Kingdom)

walk from the

of Minnesota UMN SPH Alumni & Friends Reception Boston Held in conjunction with the American annual meeting.

November 4, 6:30–8pm, Boston Children’s Museum, 308 Congress Street (less than a 10-minute Convention Center)

Public Health Practice—Public Health Medicine 4 MPH Public Health Practice— Veterinary Public Health 2 MPH

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