FSPH Magazine Autumn/Winter 2014-15

PUBLIC HEALTH AUTUMN/WINTER 2014-15

The UCLA Fielding School of Public Health Magazine

the

Dream Immigrants come to America seeking a good life.

Will it be a healthy one?

dean’s message AMONG OUR COUNTRY’S GREATEST ASSETS are its immigrant communities. Nowhere is that strength more evident than here in L.A. The Los Angeles metropolitan area is home to 4.4 million foreign-born people, ahead of such global centers as London and Hong Kong. More than 140 nations are represented. In the City of Los Angeles, 40 percent of residents were born in another country – an even higher percentage than in New York City. Immigrants fuel our global economy and form the backbone of our rich and thriving culture. They also represent our future – more than half of the region’s children have at least one immigrant parent.

This wonderful diversity is well reflected in the makeup of the talented and dedicated student population at the UCLA Fielding School of Public Health. Many of our students were born in other countries, or raised by parents who immigrated to the U.S. And for many more, regardless of their own family story, a desire to improve the health of immigrant and global communities draws them to public health and to our school, which affords unique opportunities due to its ideal location in this truly international city. Yet, the appeal extends far beyond the Fielding School’s location. Students recognize the depth of commitment and expertise of our faculty and alumni – leaders on the front lines of developing and implementing solutions that address the health needs of all communities.

Immigrant health represents a bridge between two of our school’s core commitments – transforming health here in the United States, and developing global partnerships to do the same in other countries. Our global health initiatives are grounded in the knowledge that what we learn locally, in one of the world’s most populous and diverse metropolitan areas, is relevant beyond our borders. And in today’s increasingly interconnected society, our partnerships in more than 60 countries provide invaluable opportunities to learn from successes and challenges elsewhere.

In this issue, we are proud to showcase some of the powerful ongoing work of our faculty, students and alumni to identify concerns and implement successful strategies that are advancing the health of immigrant communities in Los Angeles and beyond. By working closely with immigrant communities at home to ensure that their life here is a healthy one, we can better meet our goal of building a healthier world for all.

Jody Heymann, MD, PhD Dean

2 THE DREAM Immigrants come to America seeking a good life.

Will it be a healthy one?

PUBLIC HEALTH

autumn/winter 2014-15

The UCLA Fielding School of Public Health Magazine

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features FSPH STUDENTS

A world of difference

Path to the fielding school

4 Growing Up in an Immigrant Family Six first-year MPH students describe how their childhood experiences shaped their dreams and brought them to the Fielding School.

FACULTY AND STUDENT LEADERSHIP

In Los Angeles, California and the nation

access to care

8 A Promise Yet to Be Fulfilled The Affordable Care Act aims to move the nation

toward universal coverage. But Fielding School experts point out that for some immigrants, basic, quality health care is no closer to becoming a reality.

standards 28 school work 31 contracts

and grants

health disParities

12 Life in America: Hazardous to Immigrants’ Health? Over time, the health

status of immigrant groups tends to decline. Fielding School faculty untangle the causes and promote solutions.

occuPational safety and health

17 Reducing Hazards, Restoring Dignity Through education, research and policy

advocacy, the UCLA Labor Occupational Safety and Health Program, led by the Fielding School’s Linda Delp, is a powerful ally for the mostly immigrant low-wage workforce of Los Angeles.

screening and Prevention

20 Church Service Korean Americans have disproportionately high rates of chronic hepatitis B infection, which is associated with liver cancer and cirrhosis. In a partnership with the Los Angeles Korean community, a Fielding School team promotes screening through small group discussions in more than 50 local congregations.

ALUmNI ImPACT

neighborhood transformation

Spearheading change

22 Balance of Power Whether working with families to better manage their children’s asthma

or helping residents take on an oil plant leaking toxins within walking distance of their homes, Fielding School alumna Ashley Kissinger assists a disenfranchised population in finding its voice.

community engagement

24 Family Ties Mindful of the teachings of her civic-minded parents, Mary Anne Foo brings together diverse immigrant communities to work toward common goals.

statewide worker mobilization

26 In Safer Hands Through a grassroots effort, Fielding School graduates have empowered the low-wage, Vietnamese immigrant-dominated nail salon workforce to fight for healthier conditions.

PHOTOGRAPHY: Margaret Molloy: Cover; TOC: header, photos for articles on pp. 8, 12, 17; pp. 2-3; p. 8: child, waiting room; p. 9 examining room; p. 10: examining room; p. 11: all clinic photos; p. 12: dancers; p. 15: family, woman writing sign; p. 16: shopping; p. 18: car wash; p. 19: car wash photos, Molina portrait; p. 28: CicLAvia; p. 29: all Fiesta photos; p. 30: mentorship; p. 33: Kalla; back cover; Shweta Saraswat: TOC: photo for article on p. 4; p. 5: Santos; p. 7: Torres; p. 8: Wallace; p. 9: Vargas Bustamante; p. 10: Ponce; p. 11: Pourat; p. 12: Kagawa-Singer; p. 14: Ortega; p. 22: tape, stove; p. 23: Kissinger portrait, promotora group photo; p. 27: woman working on nails; p. 30: Race to Health; p. 32: Ford. Owen Lei: p. 5: Srikantharajah; p. 6: Okoro, Lopez; p. 7: Azeemuddin; p. 13: Wang, mahjong; p. 15: Nobari, Sawyer, vegetables; p. 16: Gee; p. 18: Delp; p. 21: Bastani; p. 28: Wu/Cheshire; p. 30: Banerjee, Needleman; Betsy Winchell: Dean’s Message; Frederic J. Brown for Getty Images: p. 16: Chinatown; Yoonsoo Kim: p. 20: church stage; Kevin Mak for OCAPICA: p. 25: taiko; Barbara Kinney for The Clinton Foundation: p. 28: No Ceilings; Reed Hutchinson: p. 30: CHPR gala; p. 31: Detels; Christa Renee: p. 33: Gold; © iStockphoto: pp. 4-7: polaroid frames; p. 17: waste management; pp. 24-25: pulmeria graphic; p. 26: manicure; p. 33: people graphic. COURTESY OF: Mary Anne Foo: TOC: photo for article on p. 24; p. 24: stairway; p. 25: Foo portrait, top three insets; Chelsea Santos: p. 4: collage photos; Janani Srikantharajah: p. 4: collage photos; Amarachi Okoro: p. 4: collage photos; Andrea Lopez: p. 4: collage photos; Naada Azeemuddin: p. 4: collage photos; Maria Torres: p. 4: collage photos; UCLA Labor Occupational Safety and Health Program: p. 19: protest photo, top right; solución photo, bottom right; L.A. County Federation of Labor: p. 19: workers’ protest photo; UCLA-Kaiser Permanente Center for Health Equity: p. 20: women on bench; p. 21: church photos; Esperanza Community Housing Corporation: p. 22: cockroaches, mold; p. 23: photos of children; Orange County Asian and Pacific Islander Community Alliance: p. 25: taiko drummers; Julia Liou: p. 26: Liou portrait; Thu Quach: p. 27: Quach portrait; Lisa Fu: p. 27: Healthy Nail Salon Program logo graphic, insets: stretching, meeting, signage, mask; Zuo-Feng Zhang: p. 29: Partnerships in China; Cynthia Goldsmith for Centers for Disease Control and Prevention: p. 29: Ebola virus; Nancy Halpern Ibrahim: p. 33: Ibrahim • Special thanks to the Venice Family Clinic.

Jody Heymann, MD, PhD Dean Carla Wohl Assistant Dean of External Affairs

Carla Denly Director of Communications and Executive Editor

Owen Lei Sr. Communications Associate and Photography Editor

UCLA Fielding School of Public Health Home Page: www.ph.ucla.edu

Dan Gordon Editor and Writer

Shweta Saraswat Communications Associate and Photography Editor

UCLA Public Health Magazine is published by the UCLA Fielding School of Public Health for the alumni, faculty, students, staff and friends of the school. Copyright 2014 by The Regents of the University of California. Permission to reprint any portion must be obtained from the school. Send request to communications@ph.ucla.edu.

Martha Widmann Art Director

Email for Student Application Requests: app-request@admin.ph.ucla.edu

the

Dream DRAWN BY THE PROMISE OF FREEDOM and opportunity, immigrants have come to America throughout the centuries, often arriving with little more than a strong work ethic and a simple dream – of a good life for themselves, their children, and their grandchildren.

Over 40 million people currently living in the United States were born in another country; many more were raised by parents who immigrated here as children or adults. The Fielding Schoolbased California Health Interview Survey has found that more than half of the people residing in the Golden State are immigrants or the sons and daughters of immigrants. In Los Angeles, the numbers are even higher.

Is the immigrant experience in this country a healthy one?

As the stories in this issue suggest, in many cases it is not. But as a leading school of public health in one of the world’s most diverse cities, the Fielding School is uniquely positioned to change these outcomes. In the pages that follow, you will read about students whose immigrant upbringing brought them here, poised to make a difference; about deeply rooted partnerships within Los Angeles that are identifying and implementing innovative strategies to improve the health of immigrant communities; and about the leadership of Fielding School faculty and alumni, both locally and nationally, that is making a profound impact on the health of our nation’s newest members.

Immigrants are central to our economy. They enrich our culture and strengthen our society. All of us have a stake in immigrants’ health. At the Fielding School, we are determined to help pave the way for the fulfillment of the dream.

EDITORIAL BOARD Haroutune K. Armenian, MD, DrPH Professor in Residence, Epidemiology; Thomas R. Belin, PhD Professor, Biostatistics; David D. Clark Assistant Dean for Student Affairs; Hilary Godwin, PhD Associate Dean for Academic Programs; Professor, Environmental Health Sciences; Pamina Gorbach, DrPH Professor, Epidemiology; Moira Inkelas, PhD Associate Professor, Health Policy and Management; Richard J. Jackson, MD, MPH Professor and Chair, Environmental Health Sciences; Marjorie Kagawa-Singer, PhD, MN Professor, Community Health Sciences; Michael Prelip, DPA Associate Dean for Practice Across the Life Course; Professor in Residence, Community Health Sciences; Beate Ritz, PhD Professor and Chair, Epidemiology; May C. Wang, DrPH Professor, Community Health Sciences; Zuo-Feng Zhang, MD, PhD Associate Dean for Research; Professor, Epidemiology; Frederick Zimmerman, PhD Professor, Health Policy and Management; Lauren Harrell and Sean Buono Co-Presidents, Public Health Student Association; Beatriz Solis, MPH ’96, PhD ’07 President, Public Health Alumni Association UCLA FIELDING SCHOOL OF PUBLIC HEALTH AUTUMN/WINTER 2014-15 3

FSPH STUDENTS • patH to tHe FielDiNG scHool

Growing Up in an Immigrant Family

Six first-year MPH students describe how their childhood experiences shaped their dreams and brought them to the Fielding School.

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5 6

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Janani Srikantharajah

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Andrea Lopez

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Marisol Torres

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Amarachi Okoro

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Chelsea Santos

4 AUTUMN/WINTER 2014-15 UCLA FIELDING SCHOOL OF PUBLIC HEALTH

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Naada Azeemuddin

Chelsea Santos AS A FIRST-GENERATION FILIPINA AmERICAN, I am the product of two cultures melded into one. The aroma of home-cooked Filipino dishes, holiday parties with singing and dancing, and the constant shift between English and Tagalog made up pieces of the simple but colorful mosaic of my childhood. My parents would frequently share stories of their upbringing – stories marked by stark contrasts between life in the United States and in the Philippines, reminding me of the value of gratitude, grit and empathy.

During my college career at UC Riverside, I went on a medical mission to the Philippines with the nonprofit organization Philos Health. Alongside an American medical team, I helped to carry out a long-term nutrition program for children in the province of Bohol and worked with the medical staff in the local community. I saw the gravity of the need for basic medical equipment, infant and maternal care, and physicians in rural areas, as patients often walked miles from their village to reach our medical stations.

After the trip, I became even more intrigued with the idea of treating the community by addressing social, economic and political determinants of health.

I realized that the complex challenge of keeping communities healthy hinges on interdisciplinary collaboration and the power of empathy. My MPH from the UCLA Fielding School of Public Health will give me the skills to effectively address health disparities in communities of need and to practice those skills while measuring health outcomes. This is the perfect place to grow as a student and future public health physician.

From their stories, the image of my parents in the United States for the first time, with only two large trash bags in hand, remains most visceral to me. Those trash bags symbolized a new life of freedom from hunger and economic hardship. It is my family’s immigrant experience that drives my passion for preventive medicine, community health and human rights.

“The image of my parents…with only two large trash bags in hand remains most visceral to me. Those trash bags symbolized a new life of freedom from hunger and economic hardship.”

Janani Srikantharajah

“From an early age, I knew about inequality.

I saw it in the neighborhood kids, the liquor stores, the abandoned lots… I saw how the neighborhood environment affects health.”

mY FAmILY (ethnically Tamil) was forced to emigrate from Sri Lanka as political refugees when I was barely 3. I grew up in a low-income neighborhood in Vallejo, Calif., attending schools that consistently performed below state standards and witnessing violence at my doorstep. From an early age, I knew about inequality. I saw it in the neighborhood kids, the liquor stores, the abandoned lots and unemployment that seemed to plague every family on my block. I saw how the neighborhood environment affects health.

There were no South Asian families in Vallejo. My best friends were African American and Filipino. My only exposure to being Tamil was in my home, where the dysfunction between my parents, the regret that they were here and not in Sri Lanka, and their constant financial struggle made me less interested in connecting with my roots than in identifying with the community around me. I loved the friends and neighbors who helped build my identity. They gave me pieces of their cultures. They took care of me when my family could not. I grew up seeing the world not only through my experiences, but also through the eyes of the people of color from the diverse cultures around me.

I could have been the kid who never left the neighborhood, or the child freedom fighter my father always wanted. I am neither. The privilege I possess today, as I pursue my MPH and MD degrees, affords me a future that I couldn’t have dreamed of at times in my past. People ask if I plan to work with refugees. My feeling is that there is much work to be done in our own backyards. I believe public health is the vehicle through which I can contribute to change. I am at the Fielding School to learn about implementing programs and policies to realize social justice.

UCLA FIELDING SCHOOL OF PUBLIC HEALTH AUTUMN/WINTER 2014-15 5

FSPH STUDENTS • patH to FspH

Amarachi Okoro

“[My parents] instilled in me the importance of hard work and never forgetting to give back – in their actions as well as their words.”

mY PATH TO PUBLIC HEALTH began with my parents, who immigrated to the United States from their village in Nigeria. They instilled in me the importance of hard work and never forgetting to give back – in their actions as well as their words. A large portion of the little money my parents made went to taking care of family in Nigeria. During our trips there, we would bring necessities such as clothes and toiletries to our extended family. Later in life, I learned that these necessities also included money for tuition and rent.

Although the San Gabriel Valley area where I grew up was considered diverse, as a first-generation Nigerian-American I was in the extreme minority within my community, a reality that only grew more evident as I began taking honors and advanced placement classes. Pursuing a higher education in an environment where people were surprised to see me, or assumed that I would not perform, cultivated feelings of alienation and exclusion. I was often questioned as to why I did not fulfill various stereotypes.

My interest in health had begun at a young age. My family could not always afford childcare, so my mother, a nurse, would take me with her to the hospital or to house visits around east Los Angeles County. As I tagged along, I witnessed the impact health could have on a person – not just physically, but also socially, psychologically and environmentally. I am pursuing an MPH as well as a medical degree because it became evident through these experiences that to achieve my goals, I need to work on a broad scale. Through my education at the Fielding School, I will become a physician able to take the daily interactions I have with individuals in underserved communities – my communities – and become an advocate to help them gain the dignity of good health.

Andrea Lopez I GREW UP IN THE SANTA mARIA VALLEY of California, a place known for its tri-tip and strawberries. Like many immigrant parents, mine emphasized hard work, education and a sense of social responsibility. Both came to the United States from Mexico. My father was drawn by the promise of economic opportunity. He was 22 and arrived with a fourth-grade education, but he learned English, earned his GED and has worked in retail management most of his life. My mother was 10 when she joined my grandfather, who was already in Los Angeles and working in the service industry. She graduated from high school, but finances prevented her from continuing her education. My parents are typical Mexican immigrants – hardworking and resilient. It is because of them that I want to use the opportunities I have to serve the public.

My journey to public health began in high school. As a hospital volunteer, I saw immigrant patients who delayed care until their conditions were unbearable. Lack of access due to immigration status or socioeconomics kept them away from preventive services. As an undergraduate, I volunteered at a free clinic and came to realize that access is only the first obstacle. Interpreting for patients, I observed cultural and language barriers. I remember one patient approaching me after her appointment because she didn’t understand her medication instructions but was too intimidated to ask her doctor. I have seen the frustrations of my own mother and grandmothers in trying to manage their diabetes with complex medication regimens and side effects. I have observed the social and economic barriers they face in navigating the health care system.

The UCLA Fielding School of Public Health is the next step in my journey. Here I hope to gain the training necessary to conduct community-based, policy-driven research and implement culturally relevant public health initiatives in resource-limited settings.

6 AUTUMN/WINTER 2014-15 UCLA FIELDING SCHOOL OF PUBLIC HEALTH

“Like many immigrant parents, mine emphasized hard work, education and a sense of social responsibility.”

Naada Azeemuddin

“With my MPH, I want to make health care, and particularly preventive care, more accessible to underserved communities such as the one I came to know in Watts and the low-income immigrant communities like mine.”

WORKING AS A mENTOR for high school students in Watts and downtown Los Angeles throughout my undergraduate career as part of UCLA’s Mentors for Academic and Peer Support program, I have come to realize many struggles facing underserved communities, both in education and health care. Not only were my students’ academic aspirations stunted by social stereotypes and irrational societal expectations, but I also began to notice the negative effects socioeconomic factors had on their health.

In Watts, every student I met had experienced the premature death of someone close to them. Many struggled with health issues such as obesity and depression, yet they hadn’t seen a primary care physician in years – and in some cases the only time they could recall consulting with a doctor was in an emergency room. Many of these students were from low-income immigrant families. Some of them were undocumented, and fearful of their peers learning the secret they had been hiding for years.

As a child of Indian immigrants who has been without reliable access to medical care for the majority of my life, I understood their situation. But I never fully appreciated the consequences of lacking access until my mom came down with a severe eye infection. I was horrified by the number of clinics that denied her service or refused to perform medical testing because she was uninsured, leaving her condition undiagnosed for months.

With my MPH from the Fielding School, I want to make health care, and particularly preventive care, more accessible to underserved communities such as the one I came to know in Watts and the low-income immigrant communities like mine. My education has always been a priority to my parents, who overworked themselves to provide me with this privilege. Getting accepted into such a prestigious public health program as the Fielding School is a tremendous opportunity. I intend to make the most of it.

marisol Torres WHEN I WAS IN THIRD GRADE I found myself, for the first time, in a school where the only language spoken was English.

“Write a sentence,” my teacher instructed, after distributing a vocabulary list.

“A sentence?” I asked myself in Spanish. “¿Que es...sentence?”

My family had come to the United States from Mexico with little money and no knowledge of English. As a child learning the language, I had to speak on my parents’ behalf to salespeople, teachers, government employees and even doctors. My family’s health decisions often depended on how well my siblings and I were able to translate, how well we understood the complicated systems, and how well we were able to stand up for ourselves. I wasn’t the best at it, but we had no choice.

It was hard not to draw a connection between the hardships we experienced as immigrants and the patterns I began noticing within my own family and in other lowincome Latino families around me – teenage pregnancies, alcohol and drug abuse, and high school dropout rates, to name a few.

By the time I was in sixth grade, my teacher was asking me to join the advanced students in my class. I couldn’t believe it – a girl whose parents didn’t know English, whose mom hadn’t made it to middle school. I went on to become the first in my family to go to college, and now I am at the Fielding School – known for its diverse student population and development of future leaders.

I am excited about courses emphasizing the human rights and cultural aspects of health issues, as well as the need for accessible services and more culturally competent professionals. My experience as a Spanishspeaking Latina immigrant from a low-income family uniquely positions me to challenge the systems that create health disparities. The Fielding School is the ideal place to be continuing that journey.

UCLA FIELDING SCHOOL OF PUBLIC HEALTH AUTUMN/WINTER 2014-15

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“My experience as a Spanish-speaking Latina immigrant from a low-income family uniquely positions me to challenge the systems that create health disparities.”

FACULTY AND STUDENT LEADERSHIP • access to care

The Affordable Care Act aims to move the nation toward universal coverage.

But Fielding School experts point out that for some immigrants, basic, quality health care is no closer to becoming a reality.

A Promise Yet to Be Fulfilled The Patient Protection and Affordable Care Act (ACA) will extend insurance coverage to an estimated 25 million more people in the United States by 2016, according to the Congressional Budget Office. But for many U.S. immigrants, the ACA’s promise of improving access to health care is not being fulfilled.

Fielding School faculty experts point out that the two major provisions that expand coverage under the federal health care law – the ability to purchase subsidized plans through federal and state-run health insurance exchanges, and the expansion of Medicaid eligibility in participating states – are unavailable to many immigrants. This exclusion, they note, could have the effect of reducing access for a group that already faces challenges to receiving quality health care, beyond the issue of insurance coverage.

Under the ACA, immigrants lawfully residing in the United States are prohibited from obtaining federally subsidized insurance through Medicaid if they have been in the country less than five years, even if they are income-eligible. The ACA also explicitly excludes the approximately 11 million undocumented immigrants living in the United States, both from buying insurance through the exchanges (subsidized or otherwise) and from obtaining coverage under the Medicaid expansion.

“Our estimates project no change in insurance coverage “Our estimates project no change in insurance coverfor undocumented immigrants – they have access problems now, age for undocumented immigrants – they have access and the ACA will do nothing to improve that.” —Steven Wallace problems now, and the ACA will do nothing to improve that,” says Dr. Steven Wallace, professor and chair of the Fielding School’s Department of Community Health Sciences and lead author of an analysis prepared by the Fielding School-based UCLA Center for Health Policy Research (of which Wallace is associate director) on the ACA’s impact on coverage for immigrants. Nationally, the Wallace-led report estimated, three-fifths of nonelderly adults who are undocumented immigrants are uninsured.

Wallace’s report, which used data from the center’s California Health Interview Survey (CHIS), noted that 2.2 million undocumented immigrants live in California. His group found that while undocumented immigrants represent 7 percent of Californians, they make up almost a quarter of the state’s total uninsured 8 AUTUMN/WINTER 2014-15 UCLA FIELDING SCHOOL OF PUBLIC HEALTH

population. Nearly half of California’s undocumented immigrants have lived in the United States for more than 10 years, the study reported.

Dr. Arturo Vargas Bustamante, assistant professor of health policy and management at the Fielding School, sees other potential perils for undocumented immigrants. The ACA’s employer mandate – the requirement that all businesses with more than 50 employees provide coverage or pay a penalty – could deter smaller employers from offering insurance if it’s cheaper for them to simply pay the fee and send their employees to the exchanges. For the small percentage of undocumented workers who receive job-based insurance but are ineligible to purchase plans through the exchanges, this could mean the end of coverage. Enforcement of the mandate has been delayed until 2016.

“For many immigrants who have been living in the country legally but for fewer than five years, the continued exclusion from Medicaid coverage means greater vulnerability,” says Vargas Bustamante, who helped to develop Mexico’s health care reform law more than a decade ago as a member of the administration of then-President Vicente Fox. In his research, Vargas Bustamante has found that U.S. immigrants who had been in the country fewer than

five years were hit disproportionately hard during the 2007-2009 Great Recession because of exclusion from federal programs that cushion the impact of economic hits to low-income and unemployed populations, such as Medicaid, unemployment insurance and supplemental nutrition assistance programs.

Immigrants have been ineligible for federally financed Medicaid in their first five years in the U.S. since the passage of federal welfare reform in 1996, although some states, including California, provide Medicaid coverage to recently documented immigrants using only state funds. California is also providing Medicaid eligibility to Deferred Action for Childhood Arrivals recipients (those brought to the U.S. without authorization as children) who are similarly not eligible for federal funding.

The fear of deportation and/or losing the ability to achieve legal status represents another access barrier for undocumented immigrants – and in some cases for their lawfully residing family members.

Wallace notes that three-fourths of undocumented immigrants live in a household with at least one citizen. Nearly one in six California children has at least one undocumented parent, with more than 80 percent of those children being U.S. citizens. “In these mixed-status families, there can be a logical reluctance to walk into a county welfare office without papers and say ‘I want to sign my child up for health insurance,’ even though they are eligible and the government has tried to assure people that the information required by the programs is used only to determine eligibility,” Wallace says. Sometimes the mere presence of an undocumented relative in the household of an otherwise eligible family can be a deterrent to applying for benefits, Wallace adds, for fear of putting that relative at risk.

In a 2010 analysis using CHIS data, a research team headed by Vargas Bustamante reported that undocumented immigrants from Mexico are 27 percent less likely to have visited a doctor in the previous year

UCLA FIELDING SCHOOL OF PUBLIC HEALTH AUTUMN/WINTER 2014-15 9

Nearly

one in six

California children

has at least one undocumented parent, with more than 80 percent of those children being U.S. citizens.

“For many immigrants who have been living in the country legally but for fewer than five years, the continued exclusion from Medicaid coverage means greater vulnerability.”

—Arturo Vargas Bustamante

California’s

2.2 million

undocumented immigrants represent 7 percent of the state’s overall population – but make up almost a quarter of the state’s uninsured population.

and 35 percent less likely to have a usual source of care (a place one typically goes to when sick, other than an emergency department) than documented Mexican immigrants. “The recently approved Patient Protection and Affordable Care Act will not reduce these disparities unless undocumented immigrants are granted some form of legal status,” Vargas Bustamante and colleagues wrote.

Proponents of excluding undocumented immigrants from the health insurance exchanges have argued that they contribute to high costs and emergency department crowding. But a Fielding School team found that in California, undocumented immigrants see doctors and visit ERs significantly less often than U.S.-born citizens and documented immigrants. “Most people who go to the emergency room have insurance and are not worried about providing documents. The undocumented who end up in the emergency room have often delayed getting any care until they are critically sick,” says Dr. Nadereh Pourat, the study’s lead author and director of research for the UCLA Center for Health Policy Research, as well as professor of health policy and management at the Fielding School.

The findings of Pourat’s team, based on CHIS data and published in a 2014 issue of the journal Health Affairs, suggest that including undocumented immigrants in ACA provisions would not overburden emergency departments and health providers.

At the same time, the study presents evidence that undocumented immigrants seek fewer outpatient services, particularly preventive care – potentially leading to more advanced disease and higher public expenditures. “Not only are they not using expensive services that you would hope could be avoided, but

“If access to care and the quality of that care are compromised just because you can’t communicate with your doctor, that should be fixable. You shouldn’t need your 13-year-old to go with you to an exam to translate.” —Ninez Ponce they are not using the services that you want people to receive,” Pourat says.

As important as health insurance coverage is to determining whether immigrants receive appropriate health services, it is not the only factor. In Pourat’s studies she has examined access barriers that lead to a lower level of cancer screening and other preventive services among many immigrant groups. She has concluded that even among the insured, being in the country for a shorter period of time is associated with more difficulties navigating the health care system, resulting in a lower use of important services.

“We often talk about health literacy,” says Wallace. “Usually, that means whether patients

understand how to use their prescriptions or follow instructions for managing their chronic conditions.

But another kind of health literacy is whether you understand what your insurance covers, when you should be getting well visits, and how to make an

appointment when you need to see a new doctor.”

Wallace adds that getting in the door isn’t enough; access to quality health care often requires being able to connect with a provider, both linguistically and culturally. In Los Angeles County alone, approximately 100 languages are spoken. Particularly for smaller immigrant groups, the difficulty in finding a provider who speaks the same language and understands the culture is often an access barrier, even among the insured.

Dr. Ninez Ponce, professor of health policy and management at the Fielding School and director of the school’s Center for Global and Immigrant Health, says that for California’s immigrant population, access to linguistic services has improved in the last decade as Medicaid and commercial plans have begun addressing the language needs of their patients through the use of live interpreters, language hotlines, and efforts to diversify the health care workforce. Ponce believes CHIS, which since its inception in 2001 has gone to great lengths to measure health status and access to care through outreach in multiple languages to accurately capture the state’s diverse population, has helped to promote the changes. Among other things, CHIS provided data that assisted the California Pan-Ethnic Health Network in sponsoring the 2003 Health Care Language Assistance Act, a first-of-its-kind state law holding health plans accountable for the provision of language services. Ponce, who has been the survey’s principal investigator since 2012, participated in the initial planning process when CHIS was being developed by the late Dr. E. Richard Brown, founding director of the UCLA Center for Health Policy Research.

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A health economist, Ponce describes her focus as unconventional: Rather than studying health care spending in terms of dollars, she assesses what she considers to be transaction costs – including the cost of communicating with a physician when there are language barriers. “It’s important to understand these costs not just for the average consumer, but for those who are left behind by eligibility, cultural and linguistic barriers,” Ponce says. “If access to care and the quality of that care are compromised just because you can’t communicate with your doctor, that should be fixable. You shouldn’t need your 13-year-old to go with you to an exam to translate.”

Ponce, whose family moved to the United States from the Philippines when she was a child, says the many Fielding School students who come from other countries provide constant fuel for her efforts to improve immigrants’ access to quality care.

“As a professor I am inspired by my students’ life stories,” Ponce says. “So many of them have a family member whose care was compromised because of language or cultural barriers. I’ve met students from dozens of countries, and on a daily basis they remind me that this work isn’t just academic, but can change lives.”

Unfortunately, she adds, in times of scarce resources the threshold for receiving benefits tends to be raised and immigrants – particularly those who are undocumented – are often among the first groups excluded. Ponce argues that anti-immigrant sentiment can be harmful to both immigrants and society as a whole. “Not long ago there was a strong movement for English-only policies,” she says. “Of course immigrants want to learn English, but it can take 10-15 years to become proficient. In that time, if you and your doctor have trouble communicating about something like cancer screening, a tumor can develop and that is going to be costly not only to the patient, but also to the system.”

Indeed, Wallace notes, beyond the humanitarian reasons, providing health insurance to undocumented immigrants makes economic sense: As a population that on average tends be younger, healthier and less likely to use health care, they could contribute to lower premiums by improving the risk-sharing in state insurance pools. Expanding coverage to all immigrants could also reduce the burden of uncompensated care, another cost borne by society.

“The great majority of undocumented persons in California are adults who contribute greatly to California’s economy by working in physically demanding service, agriculture and construction jobs,” says Pourat. “It makes economic and ethical sense to make sure they have affordable health coverage options so they can stay healthy.”

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“The great majority of undocumented persons in California are adults who contribute greatly to California’s economy.

It makes economic and ethical sense to make sure they have affordable health coverage options.”

—Nadereh Pourat

FACULTY AND STUDENT LEADERSHIP • HealtH Disparities

Over time, the health status of immigrant groups tends to decline.

Fielding School faculty untangle the causes and promote solutions.

Life in America:

Hazardous to Immigrants’ Health?

America is a nation of immigrants, drawn from all parts of the world by the promise of freedom and a good life for themselves and their children. But a substantial body of evidence suggests that for the newly arrived, life in the United States can be hazardous to their well-being. When they get here, immigrants are on average healthier than their native-born American counterparts. But the longer they stay, the worse they fare on measures such as heart disease, hypertension, diabetes and mental health.

The factors contributing to the declining health status of immigrant groups over time and through the generations are as varied and complex as the panoply of cultures that comprise our immigrant-rich country.

Part of it has to do with an unfamiliarity with U.S. society and its complicated health care system. Many immigrants lack health insurance. But Dr. Marjorie Kagawa-Singer, a professor at the Fielding School who focuses on developing standards for the delivery of care that appropriately considers patients’ culture, notes that even when cost is removed as a factor, a number of barriers can prevent immigrants from accessing important health services. “If someone is new to this country, doesn’t “If someone is new to this country, doesn’t speak speak the language, and has to learn to navigate our system, it’s like the language, and has to learn to navigate our system, plopping us in the middle of Siberia and expecting us to figure out it’s like plopping us in the middle of Siberia and expecting what we need,” she says. (For more on access to care issues for imus to figure out what we need.” — Marjorie Kagawa-Singer migrants, see page 8.)

While levels of health literacy and adherence to traditions vary considerably, many immigrants across the educational and cultural spectrum hold beliefs about disease and how the body works that diverge from the biomedical model practiced in the United States, Kagawa-Singer adds, and many health care practitioners are uneducated on those differences. “When you have problems in both health literacy among patients and cultural competence among practitioners, you get this perfect storm

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professor who focuses on early childhood obesity, including the impact of the social and physical environment. “It’s less the case that immigrants are bringing their preference for traditional diets, because most low-income countries now have access to the processed foods we’ve been eating for the past few decades,” Wang notes.

But even when their tastes are similar to those of non-immigrants, immigrants who arrive in the United States with minimal financial means face considerable challenges to eating well. “Education alone doesn’t work in a community that doesn’t

of people who will not be able to utilize the health care system even when it’s offered,” says KagawaSinger, who since 2000 has headed the Los Angeles site of the Asian American Network for Cancer Awareness, Research and Training, the first federally funded cancer prevention and control research initiative focusing on Asian Americans.

In lectures and short courses on cultural competence, Kagawa-Singer advises health professionals to demonstrate their trustworthiness and compassion. “It’s not the health problem you’re treating, it’s the person,” she says. “When patients recognize you’re making the effort and respecting their dignity, they’re going to be much more forgiving and willing to teach and learn.” The challenge, she notes, is that the U.S. health care system is designed for short encounters, despite the fact that it may take longer to get to know and understand patients from different backgrounds.

For some time, public health experts have postulated that immigrants decline in health as they assimilate and adopt the health habits of their communities – including diets high in fats and processed foods, along with reduced physical activity. To some extent that equation has changed with the globalization of the food supply, says Dr. May C. Wang, a Fielding School

have the ability to access healthy food,” Wang says.

“And in the very poorest communities, trying to change the environment by placing healthier foods where people live, work and go to school is challenging. It’s hard to create the demand, and in many of these communities people don’t have the resources to make the necessary environmental changes.”

The problem is compounded for immigrant groups, she explains, because they tend to have fewer social ties, are constricted by language barriers and often lack the know-how to pursue resources that could help them.

Wang works closely with the Public Health Foundation Enterprises (PHFE) WIC Program, the largest local WIC agency in the country, serving more than 300,000 families a year – the vast majority of which are non-English speaking immigrants.

Although the overall childhood obesity rate has plateaued and in some cases declined in the United States in recent years, Wang notes, so many public health strategies have been implemented that it’s difficult to pinpoint which have been most responsible. Moreover, the obesity rate among the mostly immigrant Latino children (the majority of the WIC population in Los Angeles) remains substantially higher than for other groups. Among the low-income,

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“Education alone doesn’t work in a community that doesn’t have the ability to access healthy food.”

— May C. Wang

preschool-aged Latino children enrolled in L.A. County’s WIC program in 2011, nearly 22 percent were obese. Utilizing the extensive PHFE WIC database, Wang and her colleagues are seeking to

It’s been called the Latino Paradox – the observation that despite social and economic disadvantages, newly arrived Latino immigrants are by many measures healthier than other groups. But the evidence also shows that the longer “As people immigrate and become acculturated, these immigrants are in the United in some cases they lose family and social ties, and without States, and through successive generathose support systems they lack the safety net to help tions, the paradox disappears: Risks of protect them from the effects of poor mental health.” chronic conditions such as diabetes, — Alex Ortega cancer and heart disease increase. “The better understand the impact of various strategies suggestion is that they’re adopting unhealthy Amerito improve diet and reduce early childhood obesity. can lifestyles,” says Dr. Alex Ortega, a Fielding School “The goal is to build the capacity for designing professor whose work focuses on the physical, medieffective interventions that recognize the specific cal and mental health needs of Latino children and challenges faced by immigrant families,” Wang their families. Ortega is also principal investigator of explains. “We are examining the social and physical the UCLA Center for Population Health and Health environments in which immigrants live and how Disparities, a $10 million, five-year effort funded by these affect their ability to put into practice nutrition the National Institutes of Health to study and reduce knowledge they acquire from participation in the cardiovascular disease risk in East Los Angeles, in part WIC program.” by changing the local food environment.

The Road to Healthier Eating

Through research in Los Angeles and California’s Central Valley, two FSPH doctoral students are paving the way toward strategies to improve diet and reduce obesity in low-income immigrant communities.

THE TENDENCY FOR IMMIGRANT FAMILIES to adopt unhealthy American diets over time has long been recognized as a public health concern.

But for two Fielding School doctoral students, more explanation is required. Taking very different tacks, Tabashir Nobari and Mirna Troncoso Sawyer are painting a more detailed portrait of the factors that place immigrant families at risk for obesity, pointing the way toward strategies that could be effective in combatting the phenomenon.

Nobari, a doctoral student interested in the impact of neighborhoods on child obesity risk, notes that there is growing recognition of the importance of the local food environment: Poorer neighborhoods, where residents are more likely to be overweight or obese, are often characterized by a preponderance of unhealthy fast-food restaurants and stores selling mostly processed foods, with minimal access to affordable fresh produce. But less attention has been paid to how child obesity risk is influenced by the socio-cultural aspects of neighborhoods – a factor Nobari suspected was particularly relevant for immigrant families, who may lack the language skills to fully participate in their new living environments.

With that in mind, Nobari led a group that explored whether young children of low-income immigrant families would be at reduced obesity risk if they lived in immigrant enclaves – neighborhoods where most people share language and culture – thus enabling these families to benefit from social support. Nobari examined the relationship between body mass index among more than 250,000 lowincome children ages 2-5 and the concentration of neighborhood residents speaking the same language as the children’s mothers, using data from the Special Supplemental Nutrition Program for Women, Infants and Children in Los Angeles County, as well as from the U.S. Census.

Reporting in the peer-reviewed journal Social Science & Medicine, Nobari’s team concluded that for young children in low-income immigrant families, living in an immigrant enclave lowers the obesity risk. “This says that the social capital of the neighborhood – the sense of belonging – is very important,” Nobari says. “The stronger social networks in these neighborhoods may serve to reduce the stress in the mothers, strengthen cultural norms regarding healthy diet and body size, and provide information on available resources these families can access. Immigrant enclaves may also improve

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Less attention has been paid to a similar phenomenon Ortega has studied.

He has found that among children in Latino families, the longer they have lived in the United States and the more generations their family has been here, the higher the risk for poor mental health. Among the possible explanations: “As people immigrate and become acculturated, in some cases they lose family and

the food environment by encouraging businesses to cater to more traditional cultural tastes.”

For her dissertation, Sawyer was determined to go beyond the observation that the diet among immigrant Latinos tends to become unhealthier over time. “I wanted to go into people’s houses and see how an immigrant family’s daily life influenced the decisions about what they were going to eat,” she says.

Sawyer was granted such access through a partnership with Grimmway Academy, a charter school in the Central Valley community of Arvin, California, that features an “edible schoolyard” – an organic garden and kitchen classroom integrated into the curriculum to promote healthy eating.

“It’s like an oasis in this community that is saturated with junk food,” Sawyer says. Through the partnership, Sawyer recruited 21 low-income Latino immigrant families willing to be interviewed and observed at home, school and in the community over the course of two years. Sawyer found that in some families, parents feeling the stress of long working hours and the demands of caring for multiple children adopt a “path of least resistance” approach, serving their children the food they prefer rather than healthy and/or traditional fare.

But Sawyer also saw evidence that when children are exposed to healthy foods – in this case, through their school – they are more likely to request such foods at home. Her study was conducted during the initial phases of Grimmway’s “from scratch” school lunch program. Sawyer found that within the same families, children at the charter school began requesting that their parents provide the fresh fruits, vegetables and other foods they were eating at school, while siblings attending other schools preferred fast or processed food.

The daughter of Mexican immigrants whose father had spent time doing farm work in the Central Valley after arriving in the United States, Sawyer was struck by the irony that in Arvin, as in many Central Valley communities, immigrant Latino workers harvest produce and fruit for the nation – but have little access to it for their own families.

“You drive past the fields and see all these fruits and vegetables, then you see families picking up their children from school in their farmworker clothes and realize that most of what is available to them is not raw, but processed food,” Sawyer says. “Unfortunately, this is how health disparities are propagated.”

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Tabashir Nobari (top) and Mirna Troncoso Sawyer

“The usual suspects – culture, genetics, socioeconomic status – are clearly important, but they don’t fully explain the health disparities we see.”

— Gilbert Gee

social ties, and without those support systems they lack the safety net to help protect them from the effects of poor mental health,” says Ortega, who notes that similar findings have been reported for other immigrant groups.

While some have suggested that public health strategies should explore ways to encourage immigrants to maintain the lifestyles of their home countries, Ortega believes that to be impractical.

“You can’t expect immigrants to come here and not

more hamburgers and exercising less,” he says. “But another aspect of being here a long time is that you experience more discrimination.”

In his work, Gee seeks to measure the impact of that discrimination on mental and physical health.

He points out that immigrants go from feeling at home in their country of origin to being viewed as a racial minority. “People take shortcuts in the way they see you,” Gee says. “Suddenly you’re not Sri Lankan but simply Asian. Some immigrants, after

become acculturated,” he says. Rather, he argues, policies should seek to strengthen social networks and support for immigrants, as well as improving access to mental health services in low-income immigrant communities.

9/11, are perceived as potential terrorists. It can be stressful enough to come to a new society and learn a new language, but it’s doubly stressful when you’re also dealing with these negative stereotypes.”

Research has consistently found associations between people’s reports of discrimination and a variety of health problems, Gee says. In a study of Asian-American immigrants, his group found that clinical depression was more likely to be predicted by experiences of discrimination than by standard measures of acculturation.

For Gee, this underscores the notion that civil rights policies are also health policies. “When we’re changing the way we define immigrants, that is likely to have a health impact,” he says. Gee suggests that more recent efforts to pass English-only laws have created a hostile climate for immigrant groups, potentially to the detriment of their health.

Despite these concerns, Gee’s studies have reminded him that immigrants tend to be a resilient population. “It takes a large measure of bravery to move to another country,” he says. “If you think about uprooting your family and bringing young children to a new society, that’s phenomenal.”

While assimilation may be a significant factor in the worsening health, on average, of many immigrant groups as they spend more time living in the United States, other factors are clearly at play, says Dr. Gilbert Gee, a professor at the Fielding School and member of the UCLA Kaiser Permanente Center for Health Equity. “The usual suspects – culture, genetics, socioeconomic status – are clearly important, but they don’t fully explain the health disparities we see,” he says.

In fact, Gee believes that some of what is attributed to assimilation when it comes to immigrant health trends may actually be the result of the way immigrants are looked upon in their new home. “The general thinking is that as immigrants become more Americanized, they change their behaviors – eating

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FACULTY AND STUDENT LEADERSHIP • occUpatioNal saFetY aND HealtH

Reducing Hazards,

Restoring Dignity Los Angeles generates more than 10 million tons of trash each year, much of which makes its way to waste-recycling facilities where workers – many of them Latino immigrants, many without legal documents – sort and separate recyclable items from non-recyclable waste. Laboring at long conveyor belts, they work at a pace that puts them at high risk for repetitive-motion injuries. If not properly protected, they can be exposed to hazardous materials – from dead animals to used syringes.

Karla Campos was one such worker. The unacceptable conditions she saw at her facility led Campos to speak out, ultimately at the expense of her job. Her experience illustrates the vulnerability of Los Angeles’ low-wage immigrant workers to job-related health and safety hazards – and the critical role played by the UCLA Labor Occupational Safety and Health Program (UCLA-LOSH) in promoting their health.

Campos, brought to the United States from Mexico by her mother when she was 8, hadn’t been working at her recycling job long when she became outraged by the conditions. “Coworkers were getting hurt because they didn’t have the right equipment,” she says. “One lady got pricked by a dirty needle and the company just gave her hand sanitizer and told her she was going to be OK. She never complained because she said she needed to support her kids and couldn’t lose her job. The company takes advantage because they know these are undocumented workers.”

Campos and several of her coworkers refused to remain silent. They contacted the local Teamsters union, which brought in UCLA-LOSH, part of the Fielding School’s Center for Occupational and Environmental Health, to educate a group of the facility’s workers on the potential hazards and their rights. After failing to get an appropriate response from their supervisors, eight workers decided to file a formal complaint with California’s Division of Occupational Safety and Health (Cal/OSHA). UCLA-LOSH collaborated with a community partner to guide workers through the process, consulting on how to document the hazards and engage with inspectors at the site.

In the end, Cal/OSHA issued citations to three employers – the waste hauler, recycling facility operator and temporary staffing agency – for violating standards designed to protect workers from unguarded machines, unsanitary conditions, confined space and heat hazards, among others. During the inspection, Campos was one of the workers who called attention to the problem areas. She was fired by the company but continued to be engaged in the process. Today Campos is an organizer with the Teamsters, fighting for change in the industry.

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Through education, research and policy advocacy, the UCLA Labor Occupational Safety and Health Program, led by the Fielding School’s Linda Delp, is a powerful ally for the mostly immigrant low-wage workforce of Los Angeles.

“Our role in public health should be not just to get rid of hazards, but also to promote worker health and safety in ways that enhance the dignity, pride and satisfaction people get from their jobs.”

— Linda Delp (MPH ’84, PhD ’06)

Approximately 84 percent of the low-wage workforce in Los Angeles is foreign-born (nearly threefourths are Latino), and 56 percent are without their legal documents. Many work multiple jobs – in restaurants and warehouses, construction and manufacturing; as janitors, maids and housekeepers; and in agriculture, to name a few. Often, these jobs are rife with health and safety hazards. An analysis

by UCLA-LOSH has found that undocumented workers who experience serious on-the-job injuries are significantly more likely to encounter negative or illegal reactions from employers, such as being forced to work despite injury, being fired shortly after injury, or receiving threats of deportation.

Shifting power dynamics have made many lowwage workers less willing to speak out about safety concerns, according to Dr. Linda Delp (MPH ’84, PhD ’06), director of UCLA-LOSH and adjunct associate professor of community health sciences in the Fielding School. Delp points to the decline of unions; the erosion of employer/employee relations as companies increasingly hire through temporary staffing agencies; and the growing economic pressures to accept hazardous conditions in an uncertain job market as examples of the forces operating against workers exercising their rights.

Immigrants – particularly those lacking legal documents – are especially vulnerable for several reasons. Because their options are limited, they are more likely to hold high-risk, high-stress jobs. Language barriers may prevent effective communication with supervisors or safety inspectors. And many fear retaliation if they raise safety concerns or report injuries.

“In a number of industries, undocumented workers’ legal status is not an issue until they speak up or try to organize,” says Delp.

Since 1978, UCLA-LOSH has served as an indispensable ally for these workers through education, research and policy advocacy. These efforts involve partnering with worker centers, labor unions, community health centers and others to empower workers by informing them of their rights and to build capacity to support workers in seeking recourse.

UCLA-LOSH has engaged car wash and other outdoor workers to better understand how to prevent heat illness, including their rights to shade, breaks, and access to sufficient drinkable water. An initiative supporting warehouse workers in becoming more active in the health and safety inspection process has led to groundbreaking citations against both a Los Angeles-based warehouse operator and a temporary staffing agency, sending a message that temp agencies can’t be used to circumvent compliance with workplace health and safety requirements. Through the

Occupational Health Internship Program, UCLALOSH builds the capacity of partner organizations, providing interns – including students from the Fielding School – who gain valuable real-world experience about how work affects health.

Once, there was a widely held stereotype of immigrant workers as afraid to organize or otherwise exercise their rights. While many do shy away from speaking up out of legitimate fears, Delp points to a number of recent examples locally in which immigrant workers have proved quite willing to fight for better conditions.

UCLA-LOSH has worked closely with the Community Labor Environmental Action Network (CLEAN) Carwash Campaign, which was established in 2008 to support the efforts of car wash workers in Los Angeles to organize for better conditions. Rose-

marie Molina, a 2009 UCLA graduate who serves as the campaign’s strategic coordinator, notes that the approximately 10,000 car wash workers in Los Angeles are mostly immigrants from Mexico and Central America, the majority of them undocumented. “They are part of the underground economy, and very exploited,” Molina says. Workers commonly earn tips only, making as little as $35 for a 10- or 12-hour day, she notes. Many are not afforded rest or meal breaks, and are not provided drinking water or proper equipment to protect themselves from toxic chemicals.

The campaign brought in UCLA-LOSH, which has offered a combination of technical expertise about hazards and “train the trainer” heat-illness prevention program and leadership development courses, preparing campaign and worker leaders to educate employees on their rights. Approximately 1,000 workers have been reached, leading many of them to begin monitoring their worksites – assisted

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The economic toll of work-related injuries and illnesses is estimated at

by UCLA-LOSH interns – to assess compliance with Cal/OSHA requirements that they be provided “agua, sombra y descanso” (water, shade and rest), as well as to document any violations. As a result of the campaign’s overall efforts, workers at 16 car washes in Los Angeles have voted for union representation with the United Steelworkers, their collectively bargained agreements addressing many of the health and safety concerns.

“UCLA-LOSH provides an incredible service to very small organizations like ours by enabling us to do so much more,” says Molina. “Most people think about worker exploitation in terms of wages and hours, but LOSH helps people understand that work and health are related.”

The CLEAN campaign also highlights the value of the UCLA-LOSH internship program. Paul Camarena, a Fielding School student in Delp’s class who became one of two interns assigned to the campaign, helped to create a health and safety curriculum that became an integral part of the program to train the car wash workers. “The nature and severity of the exploitation that this community of workers faces is a reality I won’t soon forget,” Camarena says. “I share a culture and language with many of the car wash workers, and it felt good to show them that there are people who care enough to fight alongside them.”

$250 billion in medical and indirect costs.

“Most people think about worker exploitation in terms of wages and hours, but LOSH helps people understand that work and health are related.”

— Rosemarie Molina (left), strategic coordinator, CLEAN Carwash Campaign

The costs of work-related injuries and illnesses are enormous – to workers, their families and the nation. At an estimated $250 billion in medical and indirect costs (including loss of productivity), it’s an economic toll that rivals that of cancer, Delp notes. Then there is the human toll, particularly for low-wage immigrant workers struggling to build a better life in their new environment.

“The stress in your job and in your overall life is hard to appreciate for those of us who haven’t experienced it – especially for workers who don’t have their legal documents,” Delp says. “They’re living in constant fear of losing their job or being deported, compounded by the hazards of fast-paced work, in many cases holding two jobs, and juggling life issues on top of all that.”

But in nearly a decade of interacting with a wide spectrum of low-wage immigrant workers as UCLA-LOSH director, Delp has learned that even in some of the worst conditions, people take pride in their work.

“Workers can do amazing things when there is an environment of camaraderie and an avenue to be heard – and when they know that people respect the contribution they’re making to society, and they are provided the kind of protections they need,” Delp says. “Our role in public health should be not just to get rid of hazards, but also to promote worker health and safety in ways that enhance the dignity, pride and satisfaction people get from their jobs.”

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Approximately

84 percent of the low-wage workforce in Los Angeles is foreign-born.

Church SERVICE

FSPH IN LOS HEPATITIS B FACULTY ANDANGELES STUDENT •LEADERSHIP • SCREENING SCREENING AND AND PREVENTION PREVENTION

For the large Korean American immigrant community in Los Angeles, chronic infection with the hepatitis B virus (HBV) looms as a significant – and too often unspoken – health threat, associated with the highest rates of liver cancer for any ethnic group in Los Angeles. Knowing one’s HBV status can be critical – it allows those who test HBV-negative to be immunized against the virus while pointing the way toward early treatment as well as more vigilant efforts to prevent transmission for those who are positive. But most adults in L.A.’s Korean-American community have never been screened

Korean Americans have disproportionately high rates of chronic hepatitis B infection, which is associated with liver cancer and cirrhosis.

In a partnership with the Los Angeles Korean community, a Fielding School team promotes screening through small group discussions in more than 50 local congregations.

and are unaware of whether they carry the virus.

In an effort to change that, a research team from the Fielding School’s UCLA Kaiser Permanente Center for Health Equity and Center for Cancer Prevention and Control Research, working in partnership with leaders of Los Angeles’ Korean-American community, set out to increase HBV screening in the population through small group discussions led by trained community members. For their study testing the impact of this strategy, they chose unlikely venues: 52 Korean churches in Los Angeles.

“When we started, people questioned the feasibility of having discussions about a sexually transmitted virus at church,” says Dr. Roshan Bastani, the Fielding School professor with leadership roles in both centers who headed the study. “But if you want to target a general population of Koreans in Los Angeles, you have to go where they tend to gather. We learned that most Koreans go to church, and that it’s not just religious but also a social experience where non-religious services are delivered to members. In talking with church leaders and other members of the community, we were encouraged to pursue what they saw as an important project.”

If not treated, chronic HBV infection can lead to liver cirrhosis in as many as one in four carriers, which can ultimately progress to liver cancer. HBV is also highly infectious – spread not only via sexual contact and sharing needles, but also through household items such as razors or toothbrushes, or from an infected mother to her child during birth. Because it is so common in many Asian countries, HBV disproportionately affects Asian Americans, particularly newer immigrants. The problem is particularly serious among Korean Americans.

In Los Angeles, an estimated 12 percent of the Korean-American population is infected – and because the virus causes no symptoms until the liver damage becomes severe, the majority don’t know it. Although routine HBV vaccination of children has been implemented in the United States and much of Asia for two decades, most adults were born before HBV vaccination of children became commonplace and can benefit from immunization only once they are tested and found to be HBV-negative. The potential for uninfected adults to get vaccinated, and for carriers to receive early treatment and monitoring while taking measures to prevent transmission to others, all point to the public health benefits of promoting HBV screening.

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The Fielding School team relied heavily on the wisdom of its Korean-American community partners for both the design and implementation of an intervention aiming to increase screening. A seven-member community advisory committee included two church pastors, a pastor’s wife, a church elder, a church health leader, a physician and a representative of a Korean-American non-profit faith-based organization. Fifty-one bilingual community members were hired as staff members for the study and trained to administer surveys and facilitate the small group discussion sessions with the churches – ensuring that the intervention could be sustained beyond the three-year study period.

One member hired for the study team with deep roots in the Los Angeles Korean community, Hosung Kim, was assigned the task of inviting the participation of pastors and other church leaders. “My role was to convince them that our project could improve the lives of their members through health care awareness,” says Kim, who covered the activities of Korean churches as a reporter working for a Korean newspaper chain. “I explained that because the overwhelming majority of Korean immigrants participate in Sunday services, this would provide the best opportunity to recruit participants from a wide variety of walks. Most of the responses were very positive.”

Of the 52 Korean churches that participated, half were randomly assigned to the study’s intervention arm, which featured small group discussions on hepatitis B among Korean adults who had either not previously been tested or couldn’t recall their results; the other half, which served as the control group, discussed nutrition and physical activity. The HBV discussions provided facts about hepatitis B and liver cancer, the risk for Koreans, and the rationale for testing. Through scripts and role-playing, participants were guided on how to bring up the topic with their doctors and encouraged to discuss HBV with family and friends.

Testing and vaccination were framed within Korean medicine concepts of keeping the body healthy.

The project identified and addressed factors that prevent many Koreans from getting tested, even when they are aware of the HBV risk. Many participants expressed fear about the consequences of learning they were infected, or the potential for bringing shame to their family if they tested positive. There was also concern about the cost of the test – 57 percent of the study participants reported lacking health insurance. In an effort to overcome that barrier, the project staff provided a list of clinics offering low-cost or free HBV screening.

In the end, the discussions proved highly effective: Participants in the intervention group were three times more likely to get a hepatitis B test than those who were in one of the groups that discussed nutrition and physical activity. “Few previous studies have attempted to identify effective strategies to promote hepatitis B screening among Koreans,” says Dr. Beth Glenn, associate professor of health policy and management at the Fielding School and a member of the study team.

“We were excited to see that a one-time, small-group discussion intervention produced a meaningful increase in hepatitis B screening in a population at high risk for hepatitis B and liver cancer.”

Any concerns the Fielding School team had about testing the intervention in Korean churches were quickly eased. “For some of our projects, even when we are actively recruiting, it can be hard to find people to participate,” says Dr. Alison Herrmann (PhD ’12), project director for the study. “In this case we would simply go to the churches, set up a table with our banner, and people would come to us. Part of it had to do with the sense of community in the churches, where if something was going on, members wanted to know about it. But we also found that the interest in health-related issues was tremendous.”

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“When we started, people questioned the feasibility of having discussions about a sexually transmitted virus at church.

In talking with church leaders and other members of the community, we were encouraged to pursue what they saw as an important project.”

— Roshan Bastani

ALUMNI IMPACT • NEIGHBORHOOD TRANSFORMATION

For the mostly undocumented Latino residents of an economically distressed neighborhood in South Los Angeles, the health challenges inherent to living in an unfamiliar country with poor access to care are compounded by injustices all too common in low-income populations. Ashley Kissinger (MPH ’12) has become intimately familiar with two of them: the substandard housing conditions that send many of the community’s children to emergency rooms, and the toxic emissions leaked into the neighborhood by an urban oil-drilling site, leading hundreds of residents to experience health-related symptoms.

This doesn’t sit well with Kissinger, who served as a Peace Corps volunteer in Guatemala before earning her degree in Environmental Health Sciences at the Fielding School. “This is a highly diverse and vibrant community that hasn’t had a voice,” Kissinger says.

As project manager for Esperanza Community Housing Corporation, Kissinger is helping the community develop that voice. Under the leadership of Fielding School alumna Nancy Halpern Ibrahim (MPH ’93), Esperanza reaches about 120,000 people a year through partnerships with families living in the downtown Los Angeles-adjacent Figueroa Corridor on community development efforts to tackle poverty and the problems that spring from it. And as Kissinger has learned, grassroots public health strategies can make a world of difference for an otherwise marginalized community.

Balance of Power Whether working with families to better manage their children’s asthma or helping residents take on an oil plant leaking toxins within walking distance of their homes, Fielding School alumna Ashley Kissinger assists a disenfranchised population in finding its voice.

Kissinger manages the Healthy Breathing Program, a collaboration between Esperanza and California Hospital Medical Center. With community health promoters (promotores de salud), she visits the homes of families in which a child has gone to the emergency room or been hospitalized for asthma, providing education and assistance in identifying and addressing concerns with the living environment. The program aims to reach as many as 500 children and their families. Says Kissinger: “We hope to show that an investment in public health can save hospitals a substantial amount of money through reduced trips to the ER.” The substandard housing conditions in the area help to explain why asthma can be such a problem for the children who live there. “We see families, living in terrible conditions, that are afraid to speak up because slumlords will use their immigration status as retaliation,” says Kissinger, who has given presentations to pediatric medical trainees on the importance of considering the home environment when taking medical histories and developing management plans for asthma patients. Severe infestations of cockroaches, bed bugs, dust mites and black mold – known asthma triggers – are common. Kissinger’s team has worked with a family whose 4-year-old girl has been to the ER five times in six months, living in a home with a severe cockroach infestation. Overcrowding is also common, as in the case of the family of seven sharing a one-bedroom apartment with a bathroom covered in black mold – to the detriment of their 11-year-old boy, who struggles with asthma.

At the home visits, the promotores identify asthma triggers, make recommendations for their removal and offer advice on the use of cleaning products that can help eliminate the allergens. They distribute materials such as air purifiers, as well as making referrals to quality, affordable health centers and environmental health resources. A major part of the program involves health education. “Many children aren’t on their asthma medications because their parents don’t know how to give them,” Kissinger says.

Ganar confianza – to win trust – is the project staff’s mantra. Kissinger has been greeted with apprehension by some residents suspicious that she was a bill collector from the hospital, or with immigration enforce-

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ment. “If we are going to shorten the learning curve we have to get to know families, and to do that we have to establish trust,” she says. “We are beginning to see that, and it’s leading to encouraging results.”

Trust also proved to be an asset when Esperanza assisted community members in a grassroots campaign to stop an oil producer from operating in their neighborhood.

Hidden behind tall trees and high, nondescript concrete walls, an urban oil-drilling site sits as close as 25 feet from former substandard buildings purchased by Esperanza and renovated to provide quality housing affordable to low-income families.

Kissinger notes that many didn’t even know the plant was there until 2010, when the company began to substantially increase production and residents

started to report noxious odors, fumes and health symptoms that included headaches, spontaneous nosebleeds, chronic fatigue, eye and throat irritation, and nausea. “My 3-year-old son has constant, heavy nosebleeds,” a tenant of one of the Esperanzaoperated buildings near the plant told Kissinger.

“He’s never had nosebleeds before. I have to change his sheets every night because of the blood. I feel like I can’t take my kids outside anymore.”

In 2013, People Not Pozos (People Not Oil Wells) was established by community members in opposition to oil production in the neighborhood.

Initially, some were reluctant to take on powerful interests. “It was a sense of, ‘We’re going to go up against this huge oil company? Yeah, right,’ ” recalls Kissinger, who helped to provide scientific background and translate exposure data for the effort.

“But their stories resonated, and they kept saying, ‘We’re doing this for our children. We came to this country because we wanted a better life for them.

We didn’t cross the border to live like this.’ ” Soon, residents were holding “Pozole Not Pozos” meetings where they would serve Mexican soup and update each other on the latest developments.

In consultation with Esperanza, they registered official complaints with the South Coast Air Quality Management District (SCAQMD) – several hundred over the course of three years. At town hall meetings held by the air quality agency, dozens of residents turned out to speak. Among those who became

“Getting my MPH from the Fielding School gave me the tools to be able to make a difference.

To be invited into people’s homes, establish relationships and use those tools to make a major impact on their lives is extremely rewarding.” — Ashley Kissinger (MPH ’12)

active in the campaign was the woman whose son was experiencing nosebleeds. A recent immigrant from Mexico, she testified before the Los Angeles City Council and SCAQMD, and helped to document health symptoms in the community.

Kissinger, who provided testimony before multiple Los Angeles City Council meetings and represented People Not Pozos in front of the U.S. Environmental Protection Agency, believes the turning point came when a Los Angeles Times article published in September 2013 attracted the attention of U.S. Sen. Barbara Boxer, who held a news conference urging the U.S. EPA to investigate and began pressuring the company to cease production until it was deemed safe. At a tour of the site by federal and county environmental health officers, several reported being overcome by the vapors. In November 2013, the oil company agreed to voluntarily suspend operations and spend $700,000 to improve the site.

It was required to provide 15 days notice to the EPA of any intention to reopen. Esperanza and People Not Pozos are braced to continue the fight.

That suits Kissinger just fine. “Getting my MPH from the Fielding School gave me the tools to be able to make a difference,” she says. “To be invited into people’s homes, establish relationships and use those tools to make a major impact on their lives is extremely rewarding.”

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OPPOSITE PAGE: For many of the residents of an economically distressed community in South Los Angeles, substandard housing conditions include known asthma triggers such as cockroach infestations and black mold.

THIS PAGE: The Healthy Breathing Program, a collaboration between Esperanza Community Housing Corporation and California Hospital Medical Center, works with families of children with asthma to improve the home environment and better manage the children’s asthma.

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ALUMNI IMPACT • COMMUNITY ENGAGEMENT

Mindful of the teachings of her civic-minded parents, Mary Anne Foo brings together diverse immigrant communities to work toward common goals.

FAMILY Ties When Mary Anne Foo (MPH ’93) was 9, her parents gave her a children’s book series on civil rights for her birthday. She wasn’t pleased. “I wanted a Barbie; I wanted to be like Barbie,” Foo recalls. “And my mom told me, ‘Mary Anne, when I was 9, I had been taken from my home and placed in a Japanese internment camp during World War II. I want you to remember that. I want you to grow up wanting to change the world.’ ”

Mary Anne Foo (MPH ’93) started the Orange County Asian and Pacific Islander Community Alliance in 1997 with three interns and Foo as the lone staff member. Today, O CAPICA boasts a staff of nearly 60, who between them speak 16 languages.

A fourth-generation Chinese/Japanese American, Foo was raised in a rural region of Northern California under the constant specter of racism, but her parents urged her to be proud of her background and assured her she could contribute to a better world. By the time Foo was entering the workforce, she had embraced her unusual upbringing – the stories about Jim Crow and Brown v. Board of Education, the trips to Sacramento to talk with policy makers, her mother’s insistence that she join the National Organization for Women at age 6. “I started to see what advocacy could do and I began to focus on health care as a civil right,” Foo says. “All of my parents’ lessons suddenly made sense.”

Foo has applied those lessons, enhanced by early communitybased work experience and what she describes as two pivotal years learning about immigrant health issues at the Fielding School, to build the Orange County Asian and Pacific Islander Community Alliance (OCAPICA) into a nationally renowned organization working with the approximately 60 Asian and Pacific Islander ethnic groups in the county. OCAPICA promotes the health and well-being of Orange County’s Asian and Pacific Islander (API) communities, as well as other underserved populations, through research, advocacy and education. Starting in 1997 with Foo as the executive director and lone staff member along with three interns, OCAPICA now boasts an annual budget of almost $5 million and a staff of nearly 60, who between them speak 16 languages.

Foo moved to Southern California in 1990 to pursue her MPH at the Fielding School. “I wanted to learn more about public health, and specifically immigrant health,” she says.

“I chose UCLA because it was the best place to do that. The

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Fielding School has always pushed its students to work in neighborhoods and understand immigrant communities.”

She began working for the County of Orange, just south of Los Angeles, at a time of dramatic growth in the area’s API population – including a large wave of Southeast Asian refugees. “I could see that there were many Asian and Pacific Islanders in Orange County but not many organizations serving them, and hardly any federal funds coming in, especially around health care,” Foo recalls. “So I started talking with leaders of community organizations about coming together as a coalition, sharing grant money and working together to meet the growing needs of the population.”

With three other community leaders, Foo launched OCAPICA to bring in resources, address disparities and organize the county’s API communities around common goals. It started with a $76,000 grant from The California Endowment to address the public health implications of welfare reform on the county’s immigrant population, and quickly expanded from there. In 1999, when the organization received a five-year, $5 million grant from the Centers for Disease Control and Prevention to address disparities in breast and cervical cancer affecting API women, Foo brought in her former Fielding School professor, Dr. Marjorie Kagawa-Singer, along with two alumni, Sora Park Tanjasiri (MPH ’89, DrPH ’96) and Tu-Uyen Nguyen (MPH ’98, PhD ’04). Together they helped OCAPICA publish some of the first data of its kind on strategies designed to improve breast and cervical cancer screening for women in eight immigrant and refugee communities.

OCAPICA has continued to expand its scope with increased funding and ever-growing community ties. There are now active programs in mental health and wellness for youth and families; civic engagement and voter empowerment; youth employment; and academic mentoring and college readiness. “We have always been focused on health, but we look at it through a public health model – encompassing a broad range of issues that include housing, education and access to jobs,” Foo explains.

“Mary Anne Foo is a go-to person for elected officials and others in Orange County whenever they want information about the needs of the API community,” says Tammy Tran, who has worked closely with OCAPICA as the former district director for state Sen. Lou Correa (D-Santa Ana) and current senior community liaison to the API community for Southern California Edison. “She not only is a long-time leader, but she also has a staff of subjectmatter experts who, along with the OCAPICA board,

“I started to see what advocacy could do and I began to focus on health care as a civil right. All of my parents’ lessons suddenly made sense.” — Mary Anne Foo

are very engaged in the community. They make sure our leaders understand and are held accountable to addressing the community’s needs.”

“Our staff are the people we serve,” Foo says. “Because they understand and live in the community, they know how to reach the community.”

Foo learned about reaching communities as a Fielding School student. “My public health education helped me appreciate that the work has to be grassroots rather than top-down, and you have to start where the community is,” she says. “If people can’t put food on their table, you can’t just go in and say, ‘Stop smoking.’ What I learned is that you have to think about policy change, systems change and population health rather than focusing on individuals.”

It’s been nearly two decades since she cofounded OCAPICA, and Foo continues to draw life lessons from the immigrant communities the organization serves. “Many of these people have gone through horrific experiences, and to come here and want a better life for themselves and their families, that resilience is just amazing to me,” she says. “The strengths and values they contribute make our community a better place and keep me passionate about our work.”

The diversity within OCAPICA’s target population presents challenges. “Every immigrant group has distinct cultural backgrounds and experiences,” Foo says. “People haven’t always wanted to work together, and there has been some prejudice among our communities. But we see that changing with the next generation. Now we have different groups working together and with other communities toward common goals.” Not surprisingly for someone schooled from an early age on the teachings of Frederick Douglass and Martin Luther King, Jr., Foo adds: “I find that really exciting.”

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Through a grassroots approach, OCAPICA works with the approximately 60 Asian and Pacific Islander ethnic groups in Orange County to promote health and well-being.

ALUMNI IMPACT • STATEWIDE WORKER MOBILIZATION

Through a grassroots effort, Fielding School graduates have empowered the low-wage, Vietnamese immigrantdominated nail salon workforce to fight for healthier conditions.

In

Safer Hands

Nail salons offering “manis” and “pedis” have become a booming business in the United

States, setting up shop on seemingly every corner and approaching $8 billion in annual sales. In California, an estimated 80 percent of nail salon workers and owners are Vietnamese, drawn to a profession in which it’s easy to obtain a license and set up a storefront, and speaking fluent English isn’t required. “The Vietnamese community made this an affordable luxury by offering quick, inexpensive manicures and pedicures featuring creative art designs,” says Julia Liou (MPH ’00), director of program planning and development for Asian Health Services, an Oakland-based community health clinic.

But at what risk? The low-wage workers, predominantly women of childbearing age, typically spend long hours in small, poorly ventilated spaces handling products containing a multitude of chemicals known or suspected to be harmful to human health. So in 2005, Liou co-founded the California Healthy Nail Salon Collaborative to advance research on the health effects of the workplace exposures, promote public awareness, advocate for better policies, and build leadership among the salon workers and owners. Nearly a decade old, the collaborative includes more than 40 organizational members and allies statewide, as well as members of the nail salon workforce – many of them newly emboldened by the growing movement to speak out.

Liou continues to manage the collaborative, but she gets plenty of help. Her former Fielding School classmate Thu Quach (MPH ’00, PhD) brought her epidemiology training to the effort from the beginning, chairing the research arm of the work – including “The Vietnamese community made this an affordable luxury. convening a national Research Advisory Committee.

This is an economic cornerstone for the population, and they take Quach is a research scientist with the Cancer Prevenpride in their work.” —Julia Liou (MPH ’00) tion Institute of California and research director for Asian Health Services, a member and fiscal sponsor of the collaborative. Lisa Fu (MPH ’03) is the collaborative’s outreach and program director, based in Los Angeles.

Headaches, dizziness, rashes and breathing difficulties are among the symptoms well documented in the salon worker population, Quach says. More ominous is the suggestion that the occupational exposures might increase the risk of respiratory illnesses, birth defects and cancer. Unfortunately, chronic impacts have been little studied, and industry regulations are minimal. Although the U.S. Food and Drug Administration is responsible for the safety of cosmetics, the agency can’t require pre-market testing or demand safety data from manufacturers. Of the thousands of chemicals used in beauty, personal care and salon products, Quach notes, 89 percent have yet to be independently tested for safety and impact on human health.

“You have numerous chemicals being mixed, new products coming out all the time, limited available data on health effects and weak accountability for the manufacturers,” says Quach. “That would make it difficult for the workers to protect themselves even if there weren’t language barriers.”

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When concerns are raised, many salon workers feel they have no choice but to accept the risk. “This is an economic cornerstone for the population,” says Liou, “and they take pride in their work.”

Absent stronger regulations, the collaborative has partnered with counties and cities through its California Healthy Nail Salon Campaign. In 2010, San Francisco County adopted legislation creating a program to assist shops in implementing safer practices while recognizing their efforts by publicly designating them as Healthy Nail Salons. In partnership with the San Francisco Department of the Environment, the collaborative helped to establish the Healthy Nail Salon criteria, a list of 10 requirements that include using less toxic products, providing personal protective equipment and improving ventilation. Since then, the collaborative has worked with Alameda and San Mateo counties, as well as the City of Santa Monica, to develop similar programs.

experiencing,” says Fu. “When the workers speak for themselves and demand changes in the industry, that’s very powerful.” Once the issue is brought to consumers’ attention, Fu adds, they are strongly supportive.

Thu Quach has heard the refrain from countless nail salon workers over the years – Vietnamese immigrants who know about the health risks, but feel they must sacrifice so that their children can have a better life. It’s a refrain she first heard from her own mother.

Quach was 4 when her family fled Vietnam, staying in a refugee camp for a year before moving to the United States. Here, her mother got her cosmetology license and began working at Vietnamese nail and hair salons. The many chemicals she encountered on the job always gave her pause; Quach remembers her mother saying, “I hope you never have to do this kind of work.”

The California Healthy Nail Salon Collaborative has engaged Vietnamese nail salon workers through a variety of efforts, including a core-leader curriculum to build skills in organizing, outreach and public speaking; and a campaign to establish Healthy Nail Salon criteria.

Initially, salon workers and owners greeted the collaborative’s outreach efforts with suspicion. Many saw the staff as an extension of the state Board of Barbering and Cosmetology, which would conduct unannounced inspections and impose fines for infractions the salon owners didn’t understand. “We had to convince them we were there to help, and recognize that they had other priorities besides their health that we needed to address if we wanted to build trust,” Liou says. Her group succeeded by recruiting staffers who spoke the language and understood the culture.

Beyond winning the trust of salon workers, the collaborative has sought to build leadership within the community. A core-leader curriculum was established to train workers and owners in organizing, outreach and public speaking skills. This has led to once-reluctant nail salon workers going to Sacramento and Washington, D.C., to meet with policy makers and provide testimony before committees.

“Many customers who go into nail salons don’t really think about what the workers are

At the Fielding School in the early 2000s, Quach studied epidemiology and grew fascinated with issues around occupational health and workers’ rights. The nail salon boom had just begun, and Quach decided to investigate the health effects of the chemical exposures, about which little was known. Just as Quach was delving into the data, her mother was diagnosed with cancer. She died a year later. As an epidemiologist, Quach knows it’s impossible to say whether the cancer was a result of her mother’s work, “but you wonder.”

She and Liou had met in an FSPH classroom and became close friends. When Liou secured funding for the California Healthy Nail Salon Collaborative, she knew where to turn for research leadership.

What once felt like a personal crusade for Quach has become part of a much larger movement.

“This has helped me realize that there are many other children of immigrants with the same experience,” she says. “It’s been gratifying to see so many taking up this cause.”

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“You have numerous chemicals being mixed, new products coming out all the time, limited available data on health effects and weak accountability for the manufacturers.

That would make it difficult for the workers to protect themselves even if there weren’t language barriers.”

—Thu Quach (MPH ’00, PhD)

school work Alumna and Her Wife Establish Endowment to Support Students

For Dr. Lan Sing Wu (MPH ’72), the journey to a successful career in public health spanned three continents, six countries and significant financial hardships. Now retired, Wu (pictured above right) is determined to make it easier for dedicated Fielding School students to pursue their education. After learning of the achievements of current students at the Fielding School – and also the need for student scholarships, FSPH’s top priority for the UCLA Centennial Campaign – Wu and her wife, Catherine Cheshire (pictured above left), have established an endowment to support partial scholarships for FSPH students in need.

A portion of their estate will be designated to the same fund.

Born to Chinese parents in the Netherlands, where her father worked for his country’s embassy, Wu and her siblings

ENVIRONMENTAL RESEARCH PARTNERSHIP – FSPH student Jimmy Tran conducts a survey at CicLAvia to gain an understanding of health and neighborhood impacts as part of a series of studies by the CicLAvia Research Group.

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returned to China with their mother as Europe became embroiled in World War II – soon to find themselves fleeing Shanghai as Japan and China waged war. In 1947 the family moved to Mexico, where Wu’s father had continued his job in the foreign service.

Three years later, with the communist government of Mao Tsetung now in place at home, Wu’s family was granted asylum in the United States as political refugees.

They arrived in the San Fernando Valley in 1950 with little money and speaking no English; nonetheless, Wu excelled in school and worked multiple jobs to attend and graduate with a degree from UCLA, after which she completed medical school and a family practice residency. During the Vietnam War she went to coastal Nha Trang to serve two stints treating civilians as a physician volunteer, and there she began to recognize the power of public health. “I saw patients with avoidable conditions such as tetanus, cholera and tuberculosis,” Wu recalls. “I realized the impact that could be made with a focus on vaccination, clean water, better housing and other public health concerns.”

When Wu returned to California, she enrolled at the Fielding School to earn her MPH. She spent the rest of her career promoting public health principles – as an administrator reviewing the quality of care in clinics for low-income patients through the Office of Equal Opportunity program; staff physician for the Student Health Center at Humboldt State University in northern California; public health officer for Humboldt County; and through volunteer work in Guatemala and Mexico. Now she hopes to pave the way for the next generation of Fielding School students to make an impact through public health.

NO CEILINGS – Former U.S. Secretary of State Hillary Clinton and Melinda Gates launched No Ceilings: The Full Participation Project at the 2014 Annual Meeting of the Clinton Global Initiative.

FSPH’s WORLD Policy Analysis Center, led by founding director Dean Jody Heymann, is the lead partner for policy data on the progress of women and girls around the world.

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FSPH Establishes New Formal Partnerships in China

Pictured from left to right: Drs. Jikuan Sun, Yuanli Liu, Timothy Brewer, Liming Li, Jody Heymann, Zuo-Feng Zhang, and Yu Jiang at Peking Union Medical College.

Dean Jody Heymann, Associate Dean for Research Zuo-Feng Zhang and UCLA Vice Provost Timothy Brewer traveled across China to meet with public health leaders and solidify collaborations. The Fielding School has now signed memoranda of understanding with six public health schools in China, including the country’s top-ranked institutions, as well as leading provincial Centers for Disease Control and Prevention.

KEEP IN TOUCH

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Faculty, alumni, students and staff gathered to celebrate the new academic year at the second annual

FIELDING FALL FIESTA in October.

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Banerjee Joins FSPH as New Chair of Dept. of Biostatistics Dr. Sudipto Banerjee joined the Fielding School of Public Health this autumn as chair of the Department of Biostatistics. Banerjee is a recipient of many honors, including the Mortimer Spiegelman Award from the Statistics Section of the American Public Health Association, and is also an elected fellow of the American Statistical Association. His research includes statistical analysis and modeling of geographically/spatially referenced datasets, Bayesian statistics, statistical computing, and interface modeling with geographical information systems (GIS). Prior to joining FSPH, Banerjee was a professor at the University of Minnesota’s School of Public Health.

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Alumni-Student Mentorship Program Launched at the Fielding School

The Fielding School has established an Alumni-Student Mentorship Program that spans all five academic departments and has paired roughly 130 student mentees with alumni mentors who will offer professional insight and guidance.

To learn more, please visit http://bit.ly/fsphmentorship.

Needleman Named Chair of Dept. of Health Policy and Management Dr. Jack Needleman, longtime professor in the Department of Health Policy and Management at the Fielding School, has been appointed the Fred W. and Pamela K. Wasserman Chair of the Department of Health Policy and Management. Needleman’s recent research has focused on studies of quality and staffing in hospitals, and on the evaluation and design of performance improvement activities. In addition to his duties with the department, Needleman serves as associate director of the UCLA Patient Safety Institute. Before coming to UCLA in 2003, he was a member of the faculty at Harvard’s School of Public Health.

CHPR 20TH ANNIVERSARY GALA – The Fielding School’s UCLA Center for Health Policy Research celebrated its 20th anniversary and recognized the recipients of the center’s Health Impact Awards: retiring Rep. Henry Waxman; Cástulo de la Rocha, founder, president and CEO of AltaMed; and the California Pan-Ethnic Health Network, whose executive director, Sarah de Guia, accepted on behalf of the organization. Pictured, left to right: Dr. Gerald Kominski, Laurie Kominski, Janet Waxman, Rep. Henry Waxman, and Dr. Stuart Schweitzer.

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RACE TO HEALTH – The Fielding School is building a team of students, faculty, alumni, staff and friends to run the 2015 LA Marathon alongside Dean Jody Heymann, with proceeds to benefit student fellowships at FSPH. For more information, please visit http:// bit.ly/RacetoHealth.

contracts & grants 2013-14 This section includes new contracts and grants awarded in 2013-14. Due to space limitations, only funds of $50,000 or more are listed, by principal investigator.

EMMELINE CHUANG VA Women’s Health Patient Aligned Care Teams (WH-PACTS) Women’s Health Teamlet Evaluation (WH-TE) (Veterans Affairs, $231,000) SANDRA DE CASTRO BUFFINGTON Global Media Center for Social Impact Operating Funds (The Nathan Cummings Foundation, $75,000) ROGER DETELS AND SUNG-JAE LEE UCLA/Myanmar Training Program in Advanced HIV/AIDS Methodologies (Fogarty International Center, $1,434,851 for 5 years); UCLA/Thailand Ministry of Public Health Epidemiology Training Program on AIDS (Fogarty International Center, $1,477,670 for 5 years) ROGER DETELS AND OTONIEL MARTINEZ-MAZA The Natural History of AIDS in Homosexual Men (National Institute of Allergy and Infectious Diseases, $21,998,203 for 5 years) DAVID EISENMAN AND DEBORAH GLIK Examining the Relationship Between Public Health Departments and the Nongovernmental Sector to Support Stronger Partnerships for Effective Recovery (DHHS/Office of Assistant Secretary of Planning and Evaluation & RAND Corporation, $153,804 for 2 years)

PAMINA GORBACH UCLA/Cambodia HIV/AIDS Training Program in Data Management and Analysis (Fogarty International Center, $1,441,711 for 5 years); 24 Month Challenge: Acceptability of BioSurveillance Household Devices in Peru and Cambodia (U.S. Navy Office of Naval Research & Tulane University, $164,863); The Microbicide Trials Network (National Institute of Allergy and Infectious Diseases & Magee-Womens Hospital, Research Institute and Foundation, $263,950 for 7 years)

CHANDRA FORD HIV Testing, Linkage and Retention in Care: Contextual Factors and Disparities (National Institute of Nursing Research, $1,548,950 for 4 years)

JULIA HECK Maternal Comorbidities, Prescription Drug Use in Pregnancy and Childhood Cancer (National Cancer Institute, $322,558 for 2 years)

PATRICIA GANZ Stress Reduction and Healthy Living in Younger Breast Cancer Survivors: Intervention Development and Evaluation (Susan G. Komen Breast Cancer Foundation, $625,000 for 3 years); UCLA Center of Excellence for Cancer Survivorship (Livestrong Foundation, $679,150 for 3 years); Livestrong Survivorship Study for Young Adults with Cancer (Livestrong Foundation & Fred Hutchinson Cancer Research Center, $113,550)

JODY HEYMANN Progress of Women and Girls: A Focus on Gain and Gaps in Global Policies Since the 1995 Beijing Platform for Action (Bill and Melinda Gates Foundation, $678,652); Public Policies for Economic and Population Health: A Focus on Girls and Women (William and Flora Hewlett Foundation, $1,100,000 for 2 years)

DEBORAH GLIK AND DAVID EISENMAN The Effect of Variations in Commercial Mobile Alert Service (CMAS) Message Content and Social Setting on Behavioral and Psycho-Physiological Response Among Diverse Populations (U.S. Department of Homeland Security, $964,111 for 2 years)

MOIRA INKELAS Identifying Measures and Methods for Evaluating and Driving Change in Community Systems (Doris Duke Charitable Foundation, $100,000) MARJORIE KAGAWA-SINGER Increasing Diversity in Cancer Control Research (Minority Training Program in Cancer Control Research – MTPCCR) (National Cancer Institute & UC San Francisco, $135,235)

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Dr. Roger Detels, professor of epidemiology, works with health professionals from China and Southeast Asia as director of the UCLA/Fogarty AIDS International Training and Research Program.

LEEKA KHEIFETS Pooled Analysis of Childhood Leukemia and Distance to Power Lines (Electric Power Research Institute [EPRI], $434,782 for 2 years) GERALD KOMINSKI, DYLAN ROBY AND NADEREH POURAT Evaluation and Transition Planning for the Low Income Health Program (CA/Department of Health Care Services, $1,668,776 for 3 years); California Health Policy Research Program Renewal (The California Endowment & UC Berkeley, $296,521 for 2 years) Dr. Chandra Ford, associate professor of community health sciences, examines disparities in HIV testing and care.

ANNETTE MAXWELL Alliance for Reducing Cancer Northwest (National Association of Chronic Disease Director & University of Washington, $137,899 for 3 years) WILLIAM McCARTHY AND LILLIAN GELBERG Is MYPLATE.GOV Approach to Helping Overweight Patients Lose Weight More Patient-Centered? (Patient-Centered Outcomes Research Institute, $1,930,205 for 3 years) YING-YING MENG Oral Health and Nutrition Exploratory Study (Los Angeles County Children and Families First [AKA First 5 LA], $78,150); Health and Health Behaviors of Japanese Americans (Keiro, $79,885); Chronic Illness Burden in California (California Healthcare Foundation, $54,043) JACK NEEDLEMAN Nurse Driven Staffing Project (Valley Medical Center, $53,662; SEIU United Long Term Care Workers, $53,662); The Effect of Changes in the Emergency Medical Treatment and Active Labor Act (EMTALA) Policies on Hospital Utilization and Patient Safety (Robert Wood Johnson Foundation, $100,000 for 2 years) NINEZ PONCE Medi-Cal Monitoring with the California Health Interview Survey (California Healthcare Foundation, $150,000) NINEZ PONCE AND DAVID GRANT California Health Interview Survey (CHIS) (County of Sonoma, $140,000 for 2 years; DHHS/Agency for Health Care Research and Quality, $99,719 for 2 years; California Children and Families Commission, $1,500,000 for 1.5 years; CA/ Department of Health Care Services, $1,600,000 for 2 years); 2013-2014 California Health Interview Survey (CHIS 20132014) Public Health Institute-Community Transformation Grant Three County Oversample (DHHS/Centers for Disease Control & Public Health Institute, $196,020 for 2 years)

NADEREH POURAT Health Care Coverage Needs of Uninsured Populations After Implementation of the Affordable Care Act (Blue Shield of California Research and Education Foundation & UC Berkeley, $56,879); Case Studies of Integration of Medical, Behavioral, and Social Services in Safety Net-Based Medical Homes (Blue Shield of California Research and Education Foundation & UC San Francisco, $119,990) NADEREH POURAT AND GERALD KOMINSKI Evaluation of the Delivery System Reform Incentive Pool (DSRIP) Program (CA/Department of Health Care Services, $1,000,000 for 2 years; Blue Shield of California Research and Education Foundation, $650,000 for 2 years) DYLAN ROBY Facilitating the Low Income Health Program (LIHP) Transition: Community Training and Data Reports (Blue Shield of California Research and Education Foundation, $124,516) DYLAN ROBY AND DAVID ZINGMOND Adult Medicaid Quality Grant (CA/Department of Health Care Services, $300,000) ANNETTE STANTON Contributors to Adherence in Breast Cancer Patients Initiating Endocrine Therapies (The Breast Cancer Research Foundation, $240,000) DONATELLO TELESCA Consistent Model Selection in the PÂťN Setting (National Cancer Institute & Texas A&M University, $91,414 for 2 years) ONDINE VON EHRENSTEIN Pesticide Exposure and Childhood Autism (National Institute of Environmental Health Sciences, $407,266 for 2 years) STEVEN WALLACE Describing Dignity Driven Decision Making (D4M) (The Scan Foundation, $166,313 for 1.5 years); Unauthorized Immigrant Health Subcontract (The California Endowment & University of Southern California, $59,000) STEVEN WALLACE AND JANET FRANK Emerging Issues in Minority Aging Research (National Institute on Aging, $250,000 for 5 years) WENG KEE WONG Designing Efficient Designs Under Model Uncertainty for Biological Studies (National Institute of General Medical Sciences, $1,040,319 for 4 years)

32 AUTUMN/WINTER 2014-15 UCLA FIELDING SCHOOL OF PUBLIC HEALTH

make an impact, invest in

PUBLIC HEALTH

Endowing one student fellowship can result in a lasting legacy of impact on people and communities in need – here in Los Angeles, and around the world.

Each FSPH graduate impacts tens of thousands of lives:

THE NUMBERS BEHIND THE NEED:

UCLA students’ contribution to tuition has increased

326%

by while state support has decreased by

66%

(from 1985 to 2013, when adjusted for inflation).

90%

of public health students at UCLA are in need of financial aid.

19 of 20

%.

top MPH students who were offered scholarships chose UCLA in 2014.

Ma

rk

G

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ld

’9 4

Support our students and invest in the power of public health at http://giving.ucla.edu/ph h el

ped

re d u c e s e w a

ge

ristin Ka

Nonprofit Org. U.S. Postage PAID UCLA

Box 951772 405 Hilgard Avenue Los Angeles, California 90095-1772 www.ph.ucla.edu Address Service Requested

“Throughout history, immigrants have enriched our country.

Their journey – then, now, and in the generations to come – belongs to all of us.

Promoting immigrants’ health honors our past and invests in our future.”

–Dr. Ninez Ponce

Professor of Health Policy and Management; Director, UCLA Center for Global and Immigrant Health at the Fielding School