NOVEMBER 2011
UCLA
PUBLIC HEALTH
making THE AFFORDABLE CARE ACT a
REALITY
32 MILLION MORE PEOPLE COVERED
UCLA
HIV SCREENING SAVING LIVES UNINTENDED PREGNANCIES DECLINE CANCERS DETECTED EARLIER RISE IN MENTAL HEALTH SERVICES LIFTS MOODS AMERICANS EATING HEALTHIER School of
Public Health
UCLA
PUBLIC HEALTH
Gene Block, Ph.D. Chancellor
Linda Rosenstock, M.D., M.P.H. Dean, UCLA School of Public Health
Sarah Anderson Assistant Dean for Communications
Carla Wohl Assistant Dean for Development and Alumni Affairs
features
Dan Gordon Editor and Writer
Martha Widmann Art Director
E D I TO R I A L B OA R D Roshan Bastani, Ph.D. Professor, Health Services Associate Dean for Research
Thomas R. Belin, Ph.D. Professor, Biostatistics
Pamina Gorbach, Dr.P.H. Associate Professor, Epidemiology
Moira Inkelas, Ph.D. Assistant Professor, Health Services
Richard Jackson, M.D., M.P.H. Professor and Chair, Environmental Health Sciences
Michael Prelip, D.P.A. Associate Professor, Community Health Sciences
May C. Wang, Dr.P.H. Associate Professor, Community Health Sciences
Ashley Kissinger and Simrin Cheema Co-Presidents, Public Health Student Association
Christopher Mardesich, J.D., M.P.H. ’98
UCLA
Public Health Alumni Association
School of
Public Health
4 10
CHANGING MINDS: Population Strategies TROUBLE for Improving Mental AT HOME Health When a 9.0 earthquake The societal burden of depression, anxiety and other non-physical disorders is enormous, exacerbated by the social stigma surrounding mental illness. The potential payoff from public mental health approaches is huge.
and subsequent tsunami devastated northeast Japan last March, a current M.P.H. student was seeing patients in Tokyo and a recent Ph.D. graduate, also Japanese, was preparing to defend her dissertation. Both have returned to the affected areas multiple times to help.
PUBLIC HEALTH Under the Microscope
MAKING THE AFFORDABLE CARE ACT A REALITY
in every issue 23 RESEARCH HPV vaccine in underserved communities…pediatric obesity services…healthy workplace practices… pesticides and Parkinson’s risk…training communitybased organizations in research…international drug price comparisons…household disaster preparedness.
12 Training in state-of-theart laboratory techniques prepares the school’s students to bridge the gap between basic science and population health.
18 16 MARJORIE KAWAGASINGER As a cancer nurse in the 1970s, she had an up-close view of the wide disparities in cancer outcomes. Ever since, she has worked with the affected populations to address concerns while training a cadre of researchers to follow in her footsteps.
For decades, public health has argued for the need to transform the health care system. That day has finally come, and SPH faculty are playing a key role in shaping the outcome.
28 STUDENTS 30 FACULTY 32 NEWS BRIEFS
PHOTOGRAPHY Reed Hutchinson / TOC: under the microscope, Kawaga-Singer; p. 5: Aneshensel; p. 6: Mays; p. 8: Cochran; p. 11: Kamiya; pp. 12-16, 28-29
Courtesy of Izumi Kamiya and Akiko Sato / TOC: tsunami; pp. 10-11 Courtesy of STRIDES / p. 7 Courtesy of UCLA School of Public Health / pp. 2, 32-33 iStockphoto © 2011 / |TOC: mental health, Affordable Care Act; pp. 4-6; pp. 8-9: puzzle pieces; pp. 18, 20-22, 25
Thinkstock © 2011 / p. 26 Getty Images © 2011 / Cover: illustration by Diana Ong; pp. 23-24
School of Public Health Home Page: www.ph.ucla.edu E-mail for Application Requests: info@ph.ucla.edu UCLA Public Health Magazine is published by the UCLA School of Public Health for the alumni, faculty, students, staff and friends of the school. Copyright 2011 by The Regents of the University of California. Permission to reprint any portion must be obtained from the editor. Contact Editor, UCLA Public Health Magazine, Box 951772, Los Angeles, CA 90095-1772. Phone: (310) 825-6381.
2
dean’s message DURING A RECENT PRESS CONFERENCE in Washington, DC, Sen. Tom Harkin of Iowa noted that as a nation, we spend more than $2 trillion on health care but only invest 4 cents of every dollar on prevention – this despite the knowledge that for each dollar spent on prevention, we save $6. Those statistics or similar numbers have been calculated, discussed and debated by public health professionals for decades. What makes Sen. Harkin’s comments particularly relevant is where he made them. The press conference was convened by Department of Health and Human Services (HHS) Secretary Kathleen Sebelius and Surgeon General Regina Benjamin to announce the first National Prevention Strategy – a plan whose main goal is to increase the number of Americans who are healthy at every stage of life. The strategy, created under the Patient Protection and Affordable Care Act (ACA) of 2010, provides an unprecedented opportunity to shift the nation from a focus on sickness and disease to one based on wellness and prevention. Our cover story takes a look not only at how the ACA is being implemented, but also at the critical role our school’s faculty members are playing in informing national health reform policies. As a member of the Institute of Medicine, a National Academy of Sciences organization created to provide independent, objective and evidence-based advice to policymakers, I was asked to chair a committee on women’s preventive health services. Requested by HHS, the committee, consisting of a diverse array of specialists, was asked to review what preventive services are necessary for women’s health and well-being and should thus be considered in the development of comprehensive guidelines for preventive services for women. Over the course of several meetings we reviewed existing guidelines and assessed the evidence on the effectiveness of different preventive services. The committee identified diseases and conditions that are more common or more serious in women than in men, or for which women experience different outcomes or benefit from different interventions. Significantly, we were asked to assess and make recommendations about preventive services without considering cost. You can read more about our recommendations on page 21, but of critical importance from a public health perspective is that the evidence of the effectiveness of prevention was the sole driver of policy adopted for women’s
UCLAPUBLIC HEALTH
health services.
3 2011-12 DEAN’S A DV I S O RY B OA R D
I’m not alone in playing a role in health reform; you’ll also read in the cover story and our story about mental health about other members of the school’s faculty who have been tapped to help inform state and national policy based on their expertise in public health and prevention. This is an exciting time for those of us in the field of public health: The Affordable Care Act holds much promise – beyond the expansion of health care coverage – for bettering the health of millions of Americans. On a personal note, as is reported in our News Briefs section (page 32), I will be stepping down as dean at the end of this academic year. In the June issue we will spend some time reflecting on the tremendous success of our faculty, students and alumni over the past decade; in the meantime, as we begin the academic year I am buoyed by the opportunities for public health at a national level, and inspired by the talented, creative and passionate students who are poised to become the next generation of public health leaders.
Ira R. Alpert * Lester Breslow Sanford R. Climan Edward A. Dauer Deborah Kazenelson Deane* Samuel Downing* Robert J. Drabkin Gerald Factor (Vice Chair) Jonathan E. Fielding Dean Hansell (Chair) Cindy Harrell Horn Stephen W. Kahane * Carolyn Katzin * Carolbeth Korn * Jacqueline B. Kosecoff Kenneth E. Lee * Thomas M. Priselac Monica Salinas Arthur M. Southam* Fred W. Wasserman * Pamela K. Wasserman * Thomas R. Weinberger Cynthia Sikes Yorkin
*SPH Alumni
Linda Rosenstock, M.D., M.P.H. Dean
TOTA L REVENUES Grants and Contracts State-Generated Funds Gifts and Other Fiscal Year 10-11 $69.3 million
UCLAPUBLIC HEALTH
CHANGING MINDS:
4
T HE
SOCIETAL
BURDEN OF DEPRESSION , ANXIETY AND OTHER NON - PHYSICAL DISORDERS IS ENORMOUS , EXACERBATED BY THE SOCIAL STIGMA SURROUNDING MENTAL ILLNESS .
T HE
POTENTIAL
PAYOFF FROM PUBLIC MENTAL HEALTH
Population Strategies for Improving Mental Health
APPROACHES IS HUGE .
On the World Health Organization’s list of the 10 leading causes of disability as measured by years of healthy life lost, four are related to mental health. According to Healthy People 2020, the 10-year agenda of the U.S. Department of Health and Human Services for improving the nation’s health, mental disorders account for one-fourth of all years of life lost to disability and premature
UCLAPUBLIC HEALTH
death – more than for any other group of illnesses, including cancer and heart disease. But the societal impact of mental health is even larger. Healthy People 2020 notes that poor mental health can impede people’s ability to practice healthy behaviors and maintain good physical health. Then there’s the economic cost. Between factors such as lost work time, unemployment, substance abuse, suicide and unfulfilled lives, Healthy People 2020 estimates the annual cost of untreated mental illness to be $100 billion. Until recently, though, public health efforts to promote exercise and healthy diet and reduce the risk of chronic physical conditions have received far more attention than population-based efforts aimed at preventing or controlling depression and other mental disorders. “In a sense, mental health has been a neglected stepchild of public health,” observes Dr. Carol Aneshensel, professor of community health sciences at the UCLA School of Public Health and a recent recipient of the prestigious Dean’s Scholar award. One of the problems, Aneshensel suggests, is that mental illnesses are not well understood by most of the population, including many public health professionals. “They are highly stigmatized,” she says. “People
5
“[Mental disorders] are highly stigmatized. As a result, many people with depression don’t want others to know and won’t seek treatment.” —Dr. Carol Aneshensel
UCLAPUBLIC HEALTH
Much has been learned about genetic factors that contribute to mental disorders, but public health researchers at UCLA and elsewhere have shown that social factors are equally important and, once identified, present targets for interventions with the potential to have a major impact. “People can have a predisposition for a mental disorder, but whether it presents itself or not can have a lot to do with their living conditions and social settings,” says Dr. Vickie Mays, professor of health services at the school. Mays, who teaches a course on the social determinants of mental disorders, explains that experiences ranging from economic hardship, job loss and discrimination to traumatic events such as war or natural disaster can elevate the risk of a mental illness, while factors such as fulfilling relationships or a job that contributes to one’s self-worth can be protective. “In public mental health we need to do more to promote things that will enhance quality of life so that people are resilient should they come up against difficult times,” Mays says.
feature
don’t want to live around others with mental health problems, and they don’t want to work with them. This perception isn’t just for people with severe conditions like psychoses; it applies to people who have depression as well.” Public health campaigns to raise awareness of just how common mental disorders are have been helpful, but there is still a long way to go. For many, depression and anxiety remain “something you should get over,” Aneshensel says. “People tend to think that everyone feels depressed or anxious at some time, without realizing that having a major depressive disorder or an anxiety disorder is different from ordinary experiences of feeling sad or anxious. As a result, many people with depression don’t want others to know and won’t seek treatment. What they need the most in their daily life is to interact with people, and instead they withdraw.” For those who do seek help, the combination of antidepressant medication and psychotherapy has been shown to be effective. But lack of sufficient – or any – coverage for psychotherapy compels many to settle for medication alone, or not to receive treatment.
Mays was part of an Institute of Medicine committee that was asked to review the Healthy People 2020 objectives and identify leading health indicators that would sharpen the focus of the agenda. Her committee was influential in a final report that included the objective “improve mental health through prevention and by ensuring access to appropriate, quality mental health services.” There is also a growing recognition of the relation between chronic physical disorders and mental health. “We’re learning that if we want better outcomes for primary care, particularly in treating chronic diseases, we can’t ignore the patient’s mental status,” Mays says. “A patient with diabetes, for example, is much less likely to adhere to instructions for keeping the diabetes under control if his or her depression is untreated.” Similarly, in research with Dr. Susan Cochran, professor of epidemiology at the school, Mays has found that efforts to ensure that people with HIV adhere to medication regimens and avoid risky sex are much more likely to succeed when their mental health needs are being addressed. Cochran, whose research focuses on the ways in which social adversity affects mental health at the population level, conducted some of the earliest studies of the impact of sexual orientation on mental health. Few social groups have faced the level of adversity that gays, lesbians and bisexuals have – until 1973, homosexuality itself was classified as a mental illness by the American Psychiatric Association. Until the mid-1990s, Cochran notes, it was difficult to conduct epidemiological studies of mental health by sexual orientation because household surveys didn’t identify same-sex couples. The few studies that were done found no evidence of mental health differences between the gay, lesbian and bisexual population and heterosexuals, despite wide differences in stressful experiences.
6
“People can have a predisposition for a mental disorder, but whether it presents itself or not can have a lot to do with their living conditions and social settings.”
UCLAPUBLIC HEALTH
—Dr. Vickie Mays
But once surveys began to enumerate sexual orientation and large public data sets became available, Cochran embarked on a series of trailblazing studies documenting significant differences. She has found that the risk for mood, anxiety and substance-abuse disorders is one-and-a-half to two times higher for sexual minorities than for the general population. Cochran notes that part of the disparity is related to lifestyle differences – as an example, the adults who are least likely to abuse alcohol are women raising young children, and heterosexual women are much more likely than lesbians to become parents. But Cochran has also shown that a significant factor in the higher levels of depression and anxiety among gays, lesbians and bisexuals is their greater vulnerability to being victimized. “There are much higher reports among sexual minorities of being bullied or otherwise mistreated even as a child,” says Cochran, who was recently appointed to the World Health Organization’s Working Group on the Classification of Sexual Disorders and Sexual Health. “Development of minority sexual orientation is sometimes associated with gender atypicality, and there is something very traumatizing to youths about being bullied and rejected for that. We think that is the source of the higher rates of suicide attempts, and it’s probably playing a role in the higher rates of depression and anxiety in adulthood.” By identifying mental health disparities affecting sexual minorities and the factors contributing to them, Cochran is paving the way for successful public health interventions. “One of the tenets of epidemiology is that we best deal with health threats when we can quantify them,” she says. “When we don’t know whether a factor is truly associated with risk in a population, planning an intervention is premature and may not succeed.” Aneshensel’s work addresses another factor consistently associated with rates of mental disorders: socioeconomic status (SES), and especially the effects of neighborhood characteristics on the mental health of people living in them. For more severe and persistent mental illnesses, including schizophrenia and bipolar disorder, the
impairment itself can lead to downward social mobility through difficulty succeeding in education and employment, Aneshensel notes. But for other disorders, it is largely low SES that raises the risk. “Being chronically exposed to financial stress, poor working conditions and poor living conditions is a strong predictor of disorders such as depression and anxiety,” Aneshensel says. Moreover, she notes, people with low SES tend to have fewer resources to draw on. In particular, they have less social support and lower self-efficacy – the sense of having control over what happens in one’s life. But in studies using large national samples, Aneshensel has found that even when taking SES into account, neighborhoods have a significant effect on mental health: People with modest incomes fare better psychologically if they live around more affluent neighbors than if they live in a poorer community. “You benefit from the assets that affluent people bring – safe neighborhoods, better schools and social services, better places to shop,” Aneshensel explains. Her group was also among the first to show similar effects of neighborhoods on levels of cognition. Aneshensel explains that in better-off communities, people tend to have more social contact (which is associated with better cognitive functioning) and to interact with others who have more resources to share. Aneshensel’s findings on the effects of neighborhood characteristics on the risk of both depression and cognitive impairment point to the potential for neighborhood-level strategies for reducing these risks. “Revitalization programs that address hazards and lack of beneficial social institutions in impoverished neighborhoods are imperative,” she says. “Having a safe place where people can meet for social activities can make a big difference.” Putting aside the specifics of the intervention, Aneshensel adds, “When you show that a neighborhood has an effect on the mental health of residents beyond their own characteristics, it says that individuals aren’t entirely responsible for their own emotional and psychological well-being – that there are outside adverse factors that we all have a social responsibility to address.”
7
feature
Making STRIDES Toward Positive Mental Health Outcomes for Teens
UCLAPUBLIC HEALTH
Ashley Roberts and Anne Sutkowi heard a similar response from nearly everyone they told about STRIDES, a teen suicide-prevention program they conceived as first-year M.P.H. students at the UCLA School of Public Health, then implemented the next year at Olympic High School in Santa Monica, CA. STRIDES aims to improve students’ self-esteem, social support and sense of self-efficacy through a 10-week program that includes twice-a-week interactive discussions as well as physical activity – an exercise program that trains students to participate in a 5K run at Dockweiler State Beach in Playa del Rey, CA. Roberts and Sutkowi developed STRIDES for their community service project as part of the Albert Schweitzer Fellowship, which supports programs in underserved communities; they obtained permission to implement it as part of the health class at the continuation high school, where students are at risk for negative mental health outcomes that include depression, substance abuse, risky sexual behavior and suicide. “We saw this as a great opportunity to get the students talking about these issues and then, through the 5K training, to give them a manageable goal that would provide a feeling of accomplishment and create a sense of community among them, thereby increasing their social support,” says Roberts. “As runners ourselves, Anne and I have seen what running can do – it’s a great way to release stress, make lasting friendships and feel like you’ve achieved something. We wanted to pass that along to these students.” Their plan was met with considerable skepticism. “As much as we wanted to believe we could get kids excited about running, people would tell us that no high school student wants to do that,” recalls Sutkowi. But STRIDES turned out to be a resounding success. Twice a week for the 10 weeks, Roberts and Sutkowi spent 20-25 minutes leading discussions about topics that included self-esteem, positive body image, and managing anger and stress. The students set goals, discussed barriers and learned tools for taking on challenges. For the next part of each course session, Roberts and Sutkowi led students in stretches and jogs as part of the 5K training. In evaluations conducted both before and after the program, Roberts and Sutkowi found that STRIDES participants reported increased self-esteem and support. Powerful evidence of the program’s success could also be seen at the first annual STRIDES 5K Run/Walk, where 150 community members turned out to see the students achieve their goal. “These were kids who had been told they lacked motivation; some had even been called failures…and they all succeeded,” says Sutkowi. “I’ve never been more proud.” Although Roberts and Sutkowi have graduated, they continue to oversee the program. Four of the school’s current M.P.H. students are now involved – two as the classroom coaches, leading the twice-a-week discussions and trainings; and two to plan the 5K event and recruit community members to turn out in support of the students. The UCLA School of Public Health alumni have also begun applying for grant funding that would enable STRIDES to expand to other schools.
8
“Mental health problems are so prevalent that we don’t have the resources to deal with all of these issues through one-on-one psychotherapy. But there are things that we can do as part of a public mental health approach that would improve the health of populations in big ways.”
UCLAPUBLIC HEALTH
—Dr. Susan Cochran
One of the reasons clinical depression ranks so high among causes of disability, explains Dr. Kenneth Wells, professor of health services at the school, is that unlike diseases more common in older populations, it affects people throughout their lives. Wells notes that the impact of untreated depression is comparable to the impact of a heart attack on a person’s function in a year. Yet, because of the stigma, depression is not easy to discuss. This is particularly the case in underserved minority communities, where lack of access to affordable, quality mental health care compounds the issue. In the mid-1990s, Wells headed a large national study looking at ways to improve the quality of mental health services offered in primary care practices. The study found that underserved minority groups benefited far more than whites from the increased access to depression care. “The reason was that there had been so little previous exposure among these groups that many treatmentresponsive people were receiving care for the first time,” Wells says. His group also found that the improved health outcomes through depression care for these underserved populations resulted in an average 15 percent gain in family wealth over two years. The knowledge that underserved minority groups have so much to gain from better depression treatment led Wells and colleagues to seek partnerships with community-based organizations in Los Angeles in developing a collaborative research project to determine how best to reduce the depression burden. The result was Community Partners in Care, a randomized trial funded by the National Institute of Mental Health to examine whether agencies and communities working together through a grassroots, capacity-building approach is a better method of improving depression services and patient outcomes than agencies working alone. As many as 100 agencies are participating, and several hundred community-based mental health providers have received training. Approximately 4,500 individuals receiving services in the community were screened and those who were depressed were enrolled in the study, most of them from under-resourced communities of color and many having household incomes of less than $10,000 a year. “These are highly vulnerable groups that we are tracking through the process of identification and entry into treatment or other community resources,” Wells says. Although it’s too early in the study to know how effective the community-engagement approach will be, “this shows it’s possible to take on such a difficult issue through a community/academic equal partnership.” Insurance coverage for mental health treatment has historically been inferior compared with coverage for other health services, but two recent developments represent steps in the right direction. The federal Mental Health Parity and Addiction Equity Act of 2008 requires group health plans and health insurance issuers to ensure that benefits for mental health and substance abuse disorders are on par with physical health benefits. And the passage of the Affordable Care Act in March 2010 promises to build on that parity while increasing insurance coverage for the poor and near poor. “These are really important changes for the communities that we’re engaged with, and there is now a lot of rethinking going on in anticipation of those changes,” says Wells. In the past, notes Mays, mental health coverage has not only lacked parity with physical health; it has also not been well integrated into primary care settings. The combination of the mental health parity act and the passage of health care reform makes this an exciting time for public mental health, Mays says, but it also increases the importance of questions that she and others are seeking to address, including how best to integrate mental health and substance abuse services in primary care settings.
In California, the 2004 passage of Proposition 63, the Mental Health Services Act, expanded the state’s county-level mental health services along a broad continuum of prevention, early intervention and service needs. That prompted the California Department of Mental Health to partner with the California Health Interview Survey (CHIS) to include new mental health content in CHIS, the nation’s largest state health survey. The result of that change is the release this fall of some of the first comprehensive data on mental health for California adults. Using data from the 2007 California Health Interview Survey, the UCLA Center for Health Policy Research (which is involved in running CHIS and is based in the School of Public Health) found that approximately 2.2 million California adults, or 8.3 percent, report having mental health needs. Among them, half say they have received no treatment and another one-fourth have received minimal but inadequate treatment. In addition:
9 • Traditionally disadvantaged or stigmatized groups, including American Indian and Alaskan Natives, mixed-race Californians and sexual minorities, report the highest levels of mental health needs.
feature
“Many new people will be coming into health services,” Mays says. “They will need to be screened for mental health disorders, and we have to make sure the screening tools that are used are appropriate for diverse populations. Primary care physicians should understand the relationship between physical and mental health and how the mental health response is manifest in diverse populations, and we have to make sure the pathways for addressing mental health needs are seamless and can lead to better outcomes.”
• Lack of insurance and participation in public health insurance is associated with higher rates of mental health needs. • People with mental health needs have higher rates of chronic health conditions, including high blood pressure, heart disease and asthma. • Adults with mental health needs are more likely to engage in negative health behaviors such as smoking, binge drinking and obesity, and to report significantly worse overall health, than those without mental health needs. “Maintenance of a healthy population cannot be achieved without attention to its mental health needs,” concludes the report, which was led by Dr. David Grant, CHIS director. The report, along with studies by UCLA School of Public Health faculty and others, are helping to identify the best opportunities for public health interventions – actions that are essential to addressing a major societal need, and offer the potential to yield substantial benefits. “Mental health problems are so prevalent that we don’t have the resources to deal with all of these issues through one-on-one psychotherapy,” says Cochran. “But there are things that we can do as part of a public mental health approach that would improve the health of populations in big ways.”
UCLAPUBLIC HEALTH
TROUBLE AT HOME
10
W HEN
A
9.0
EARTHQUAKE AND SUBSEQUENT TSUNAMI DEVASTATED
J APAN
NORTHEAST LAST
M ARCH ,
CURRENT
A
M.P.H.
STUDENT WAS SEEING PATIENTS IN
T OKYO
A RECENT
AND
P H .D.
GRADUATE , ALSO
J APANESE ,
WAS
PREPARING TO DEFEND HER DISSERTATION .
B OTH
HAVE
Two SPH Students Assist in Izumi Kamiya, a primary care physician with a practice on a sparsely populated island in Okinawa, Japan, was working in an outpatient clinic in Tokyo one afternoon last March when she felt a jolt so strong her office computer fell to the floor. There was no power for as far as she could see, the result of a 9.0-magnitude earthquake centered 230 miles to the northeast. As the day unfolded, Kamiya, six months away from entering the UCLA School of Public Health as an M.P.H. student, would learn that the quake had triggered a 23-foot tsunami on the northeastern coast of Japan that would kill more than 24,000 people and displace tens of thousands in one of the most devastating natural disasters of modern times. Akiko Sato was in Westwood when she learned about the tsunami that would bring unthinkable destruction to an area she knew well. Sato grew up near Tokyo, then got her undergraduate education in northern Japan. Trained as a nurse, she was at the UCLA School of Public Health preparing to defend her Ph.D. dissertation on a topic all too relevant to the tragedy unfolding in her home country: the effects of the 1987 Whittier Narrows and 1994 Northridge earthquakes on disaster preparedness levels of Los Angeles County households.
RETURNED TO THE AFFECTED AREAS MULTIPLE
UCLAPUBLIC HEALTH
TIMES TO HELP.
Kamiya, who had trained in emergency medicine, hoped to get to the devastated areas right away to assist where she could but, while disaster medical assistance teams were immediately flown in from around the country, it would be late March before she was able to get to the affected areas by car. Volunteering in Miyagi Prefecture through an organization that brought in physicians to treat disaster victims, Kamiya provided medical care in makeshift shelters, partially destroyed houses and what was left of tsunami-battered hospitals, first in late March and again in late April. On her first visit, to Tagajo City, she spent several days in a hospital, sleeping in a hallway. Kamiya filled in on the night shift to provide relief for the local doctors, many of whom had been working tirelessly despite being disaster victims themselves. “This was an atypical earthquake disaster – relatively few people suffered from trauma, and most of those died from the tsunami,” Kamiya says. Despite relatively few injures there were, of course, many other needs. In visits to evacuation shelters, Kamiya found conditions in which more than 1,000 people were sleeping in tight quarters and families of four were sharing a single rice ball for meals. Many individuals
11 contributed by spending time with survivors. “They need people who will listen to their stories and allow them to share their feelings,” Sato says. Through her recent scholarship, Sato was able to see where better preparation could make a difference. “The tsunami was more than anyone could have predicted, but it shows us that better community and neighborhood planning is needed,” she says. She made plans to return to assist with needs assessments and evaluation of disaster preparation and response programs.
feature
reliant on medications for chronic conditions such as cancer, heart disease and hypertension were going without – their drugs washed away by the tsunami. Upper respiratory infections and gastrointestinal conditions were epidemic. Kamiya was also part of a group that checked the infrastructure of partially collapsed houses where people were still living. When Kamiya returned several weeks later, it was to Onagawa, a fishing port that had been devastated by the tsunami, which in that area had reached heights of more than 60 feet. “Most of the town, including the town hall and health centers, had been swallowed,” she says. “Four-story reinforced concrete buildings, trains and ships were washed away to the
“It’s going to take awhile to get some of those pictures out of my mind.” —Akiko Sato
Tsunami Recovery
mountains. Cars and ships were upside down. It was like a battlefield.” Kamiya worked in the only medical facility remaining in the town (standing on a 50foot-high hill, its first floor was nonetheless flooded). It was six weeks after the disaster, and uncontrolled chronic diseases continued to be rampant.
—Izumi Kamiya
UCLAPUBLIC HEALTH
Preparing to defend her doctoral dissertation, Sato remained at UCLA through the spring, her heart heavy. In June, four days after completing her defense, she arrived in Tohoku, Iwate Prefecture. Sato spent two weeks there, working for a nongovernmental organization that had been established to respond to the disaster. She provided food and distributed donated goods, visited evacuation centers and helped survivors move from these centers to temporary housing. As much as anything else, she
Sato is now based in Ethiopia, focusing on the issue of malnutrition in her new position working for the World Health Organization. Recalling her experience in Japan, she frequently pauses to gather her emotions. “It’s going to take awhile to get some of those pictures out of my mind,” she says. Kamiya is at UCLA, in the midst of her first year in the school’s M.P.H. program in the Department of Community Health Sciences, drawn by experiences she had as a physician that reinforced the connection between medicine, science and policy, and by her concern about health disparities among socioeconomic groups in Japan. Like Sato, she is a long physical distance from Japan, but her home country is never far from her thoughts.
“Most of the town had been swallowed. Concrete buildings were washed away to the mountains. Cars and ships were turned upside down. It was like a battlefield.”
PUBLIC HEALTH
12
Under The Microscope Brian Chen spent much of his doctoral education at UCLA working at T RAINING
IN
STATE - OF - THE - ART LABORATORY TECHNIQUES
a laboratory bench, applying the most advanced molecular and genetic methods to learn more about the epidemic of type 2 diabetes. As part of a group headed by Dr. Simin Liu, Chen used cutting-edge technologies for genotyping, measuring the length of telomeres (the structures at the end of chromosomes, considered biomarkers for aging), and analyzing blood protein levels, among others. “It was no holds barred,” he says. “If there was a molecular or genetic technique that could help us address a question we had about type 2
PREPARES THE SCHOOL ’ S STUDENTS TO BRIDGE THE GAP BETWEEN BASIC SCIENCE AND POPULATION
UCLAPUBLIC HEALTH
HEALTH .
diabetes, we learned how to do it and then applied it.” Given that UCLA is among the world’s leading research universities, Chen’s experience with stateof-the-art laboratory science approaches in Westwood hardly seems surprising. What might be surprising to many casual observers, though, is where Chen received that experience – not in the medical school or in one of the basic science departments on campus, but in the School of Public Health. Chen, who received his Ph.D. last year and is now a postdoctoral fellow conducting molecular epidemiology studies in Liu’s lab, is one of many students who have honed their laboratory skills through various grants and programs within the school’s epidemiology and environmental health sciences departments. While the big-picture, population-based approach of public health strikes some as incongruous with the cellular-level focus of laboratory work, Chen saw the school as a natural fit for his interest in making connections between basic discoveries and population-level health. “In public health we’re interested in the relevance of certain genes or molecules in vivo, so we are trained to not only conduct the assays, but to go the next step and determine their clinical and public health significance,” Chen says. “In a sense, we pick up where the basic scientists leave off.”
13
feature
work that’s needed to effectively tackle the major epidemics of our time,” he says. “They can help to integrate the biological context with the social and economic causes, as well as the policy issues. We need more people who can speak all of these languages.” As a laboratory-based researcher trained in public health, Liu believes he has a perspective different from many of his non-public health colleagues in the basic sciences. “I keep in mind the ultimate benchmark for our molecular work, which is the betterment of the public’s health,” he says. “Having a broader understanding of the many factors that go into an epidemic helps me to generate research questions that I can take back to the lab to look for biological insights in support of clinical and population observations – or, on the flip side, I can use that biological understanding to inform policies.” “Many people think public health research is only about communities,” says Dr. Zuo-Feng Zhang, professor of epidemiology at the school. “But it’s very important to take the bench science and translate that to the population, and to do that we need people with laboratory skills.” Since 1999, Zhang has trained students in the molecular epidemiology of cancer through a National Cancer Institute grant that supports the work of as
ABOVE: Dr. Sydney Harvey, associate professor of epidemiology and former director of the public health laboratory for Los Angeles County, heads the school’s LabAspire program, which is addressing a major shortage by training future public health lab directors. OPPOSITE PAGE: Dr. Simin Liu (facing camera in photo on right), professor of epidemiology and medicine, co-directs a metabolic disease research program that trains students in both molecular biology and population-based science. Pictured with him is Brian Chen (Ph.D. ’10), who graduated from the program and now works with Liu as a postdoctoral fellow. UCLAPUBLIC HEALTH
Chen was supported during his doctoral studies by a five-year, $2.5 million grant from the Burroughs Wellcome Fund that promotes training designed to bridge the gap between the population and computational sciences and the laboratory-based sciences. At any one time, as many as five doctoral students are receiving education in metabolic diseases from faculty in both the School of Public Health and the David Geffen School of Medicine, learning both molecular biology and population-based science. “Our goal is to take people out of their silos and bring their different skill sets together,” says Liu, professor of epidemiology and medicine, and co-director of the program. “Few people have skills in both the cutting-edge technology coming out of the life sciences and the more analytical, quantitative skills of epidemiology. We want to provide comprehensive, interdisciplinary education and research training that will enable these scientists to develop better insights and system strategies to curb the epidemics of obesity, diabetes and other metabolic disorders.” Having a strong laboratory component brings significant benefits to a school of public health, Liu says, in part by ensuring that a solid biological foundation informs community-based work and population-based studies. “Students who can integrate biomedical sciences with epidemiologic principles and methodologies will be well-positioned to take leadership roles in pursuing the multidisciplinary
14
UCLAPUBLIC HEALTH
Dr. Robert Schiestl, professor of environmental health sciences, co-directs an interdepartmental program that trains students in molecular toxicology.
many as five Ph.D. students and two postdoctoral fellows at any one time. In addition to education on the fundamentals of laboratory-based cancer epidemiology, students learn how to isolate DNA and how to identify and study biological markers for disease risk through genotyping. “The techniques are very much the same as what they would get in a medical school, but in medical schools the study populations tend to be patients, whereas most of our studies are looking at people without disease,” Zhang explains. Zhang and other researchers are using molecular epidemiology – which employs the tools of epidemiology to elucidate biological processes – to identify early genetic alterations that are associated with diseases. Since cancer is a process that often occurs over the course of many years, identification of these biological markers could lead to vital strategies for early detection and treatment, as well as prevention. As principal investigator of the Los Angeles site for the Multicenter AIDS Cohort Study (MACS), the landmark project that since 1984 has examined the natural history of HIV/AIDS, Dr. Roger Detels has overseen students who learn the techniques of molecular epidemiology under the guidance of several faculty whose labs focus on immunology. “As we deal with more and more sophisticated agents, we need to understand what those agents are doing at the molecular and cellular level if we’re going to be able to put together an adequate response,” Detels says. To Detels, though, experience with modern basic science techniques is important not only for those who are going to be involved in hands-on lab work themselves. When epidemiologists and others in public health receive results from public health
laboratories, he notes, a familiarity with how those measurements are made can be critical. “You have to have some feel for the quality of the results you’re getting from the lab, and for that you need to have an understanding of how they were derived,” Detels explains. The school is also playing a key role in training future public health laboratory directors through a statewide program called LabAspire. Public health labs serve as vital resources for health departments, conducting the tests that are essential to identifying, tracking and controlling new and ongoing infectious diseases, food-borne illnesses, environmental hazards and bioterrorism threats, to name a few. But California faces a severe shortage of qualified public health laboratory directors. Through LabAspire, the UCLA and UC Berkeley schools of public health are addressing the shortage. Six Ph.D. students are currently training in the LabAspire program at UCLA, gaining a combination of managerial skills and know-how in areas such as virology, molecular biology, parasitology, immunology and bacteriology. “Foremost in their preparation is the basic science, but it’s also important that they gain leadership and management skills and understand the budgetary aspects of running a laboratory,” says Dr. Sydney Harvey, former director of the public health laboratory for Los Angeles County, who is now an associate professor in the school’s Department of Epidemiology and head of the school’s LabAspire program. “This is a very important public health workforce issue,” says Dr. Hilary Godwin, professor of
environmental health sciences at the school. “These laboratories are the first line of defense for local municipalities in tracking infectious diseases and managing epidemics and outbreaks.” Godwin, who serves as the primary adviser to three of the school’s six current LabAspire students, is affording her students the opportunity to work in the Global Bio Lab at UCLA, a state-of-the-art facility for using high-throughput techniques to support infectious disease surveillance and basic infectious disease research. Elsewhere at the school, approximately 20 students are being trained in molecular toxicology through an interdepartmental program funded by the National Institute for Environmental Health Sciences. Rather than working with genes and proteins by themselves, students in the program are studying their interaction with environmental chemicals such as diesel exhaust, arsenic, benzene and nanoparticles to determine their potential for harming human health. As with the other laboratory training programs, graduates are in great demand. “Between the government, industry and academia, our students are having no trouble getting good jobs,” says Dr. Robert Schiestl, professor of environmental health sciences and co-director of the program, which is directed by Dr. Oliver Hankinson.
feature
Chen was drawn to molecular epidemiology by its potential to address two major epidemiologic challenges: the need for more precise measurements and insights into biological mechanisms. “Questionnaires and interviews continue to be the mainstay of epidemiologic research, and they have served us well for making major discoveries such as linking cigarette smoking to lung cancer, where the effects were so huge that the methods were sufficient,” Chen says. “However, for more subtle links, such as the health effects of diet, even greater accuracy is needed.” With the sequencing of the human genome – and, in the near future, the proteome (all of the proteins in the body) – the ability to make measurements on a massive scale is creating a new challenge. “People are realizing that we don’t know how to handle all of this data,” Chen says, “so we’re seeing multiple disciplines coming together in an effort to bring order to the chaos. In public health, where we deal with large populations and hundreds of thousands of samples, we are well positioned to play an important role in this effort.”
15
Students learn high-throughput techniques for infectious disease surveillance and basic infectious disease research under the guidance of Dr. Hilary Godwin, professor of environmental health sciences, at the Global Bio Lab at UCLA.
UCLAPUBLIC HEALTH
16
AS
A CANCER
NURSE IN THE
1970 S ,
SHE HAD
AN UP - CLOSE VIEW OF THE WIDE DISPARITIES IN CANCER OUTCOMES .
E VER
SINCE , SHE
HAS WORKED WITH THE AFFECTED POPULATIONS TO ADDRESS CONCERNS WHILE TRAINING A CADRE OF RESEARCHERS TO FOLLOW IN HER
UCLAPUBLIC HEALTH
FOOTSTEPS .
Marjorie Kagawa-Singer:
Boosting Research Capacity in Communities of Color From the start of her career
as a cancer nurse in the early 1970s,
Dr. Marjorie Kagawa-Singer sensed that something was wrong with the approach to preventing, controlling and treating diseases, particularly in communities of color. As an undergraduate nursing student making home visits during her public health rotation, KagawaSinger was struck both by how little patients knew about their disease and the contrast between the integrity they felt at home and the anonymity of being in a hospital. Her subsequent work with cancer patients, both on hospital clinical research units and in community settings as a nurse consultant to the American Cancer Society, only confirmed her resolve that more emphasis needed to be placed on prevention – efforts to keep people from ever needing hospitalization. Kagawa-Singer was disturbed by something else she saw. “The disparities in cancer outcomes for communities of color compared to mainstream non-Hispanic white groups were glaring,” she says. When KagawaSinger looked into the research literature for factors that might explain these disparities, she found descriptions of various ethnic groups as fatalistic about their diagnosis and non-compliant with treatment recommendations. This didn’t resonate with her life experience, growing up in then-segregated Berkeley, CA, around communities of color. So in 1982, Kagawa-Singer decided to go back to school, enrolling in UCLA’s Ph.D. program in anthropology – a field that allowed her to pursue a combined focus on psychophysiology and socio-cultural issues. In the 22 years since she earned her degree – the last 17 of them with a joint faculty appointment in UCLA’s School of Public Health and Asian American Studies Center – Kagawa-Singer has worked closely with communities of color on cancer-control issues ranging from prevention and early detection through survivorship,
Most recently, Kagawa-Singer received a major grant from the National Cancer Institute – $1.3 million – for a five-year study that will compare coping strategies and quality of life among Chinese-, Vietnamese- and Japanese-American breast cancer survivors. Twenty years ago, Kagawa-Singer applied for a smaller grant on the same topic – and was rejected. She believes her success in resurrecting the study reflects a sea change over the last two decades characterized by a greater appreciation for concepts Kagawa-Singer has promoted throughout her career. “Funders have finally recognized that the ‘one-size’ approach to health disparities doesn’t fit all – you can’t use measurement tools and strategies that are successful in the non-Hispanic white population and expect them to work equally well in communities of color,” she says. Kagawa-Singer is also heartened by the growing number of people of color who are following her path and engaging in community-based cancer research. In the past, she says, researchers have followed a “deficit model” – focusing on what minority communities lack in comparison to the dominant European-American culture. Led by researchers from these communities, Kagawa-Singer says, the emphasis has shifted to finding a given community’s strengths and building on those strengths to improve health outcomes. Kagawa-Singer has been instrumental in increasing the pipeline of cancer researchers from communities of color, through not only AANCART but also her leadership of the National Cancer Institute-funded Minority Training Program in Cancer Control Research, which has supported master’slevel minority students and master’s-trained professionals in pursuing a doctorate and a career in research. Indeed, the opportunity to mentor students is what continues to drive her. “My plan had been to work in the community and ‘fight the enemy’ in academia where they were asking the wrong questions, and then I ended up in the enemy camp,” she recalls, laughing. “At first I was frustrated not to be on the front lines. But then I realized that my role was to increase the cadre of researchers who understand this approach. We now have 142 doctoral-prepared researchers and faculty from underrepresented communities across the country. That has been the greatest reward.”
17
“Funders have finally recognized that the ‘onesize’ approach to health disparities doesn’t fit all – you can’t use measurement tools and strategies that are successful in the nonHispanic white population and expect them to work equally well in communities of color.” —Dr. Marjorie Kagawa-Singer
UCLAPUBLIC HEALTH
The disparities in cancer outcomes that KagawaSinger first encountered when she was starting as a nurse are as troubling today as they were then. “You see it along the entire care continuum,” she says. “Communities of color are less likely to get screened and to receive timely, quality care, and are more likely to experience severe pain at the end of life.” Kagawa-Singer never bought the notion that fatalism was behind the lower utilization of cancer screening. “I see it as more of a rational response to untenable circumstances,” she says. “If you know you’re going to get substandard care, or if you can’t afford it because well-paying jobs are closed to you, why use time and money that could be spent generating resources for your family, and subjecting yourself to the inequities of care?” From the start, Kagawa-Singer’s approach has been to work closely with affected groups to understand and better address these disparities. “Coming from those communities, I know the wisdom in them,” she says. Kagawa-Singer has put that philosophy into practice as principal investigator for the Los Angeles site of the Asian American Network for Cancer Awareness Research and Training (AANCART), the first cancer prevention and control research initiative targeting Asian Americans. To implement AANCART’s goals of reducing the cancer burden among Los Angeles-area Asian Americans through education, research and training of Asian American health workers in community cancer prevention, Kagawa-Singer formed a steering council consisting of representatives of 17 community-based organizations serving the region’s diverse Asian American population. “They have been partners since day one; we act as a resource,” she explains. “This approach has built confidence and trust in these communities, which include many immigrants who had never heard of surviving cancer before this project started.“ Kagawa-Singer also works with the Orange County Asian and Pacific Islander Community Alliance on Racial and Ethnic Approaches to Community Health. The community-based effort, funded by the Centers for Disease Control and Prevention, has successfully promoted breast and cervical cancer screening in seven monolingual Asian American and Pacific Islander populations through an approach that employs community navigators – peers who assist the mostly uninsured, non-English speaking women in everything from making and following up on appointments to providing transporta-
tion and accompanying them on their screening exams. “Many of the women tell us they would never have gone unless the navigator was there with them, helping to answer their questions and communicating with the practitioners,” Kagawa-Singer says. “We have eliminated barriers, leading to thousands of women getting screened for the first time.”
faculty profile
as well as issues around palliative and end-of-life care. Her research has documented cultural differences in how diverse populations access and utilize cancer care based on their perceptions of cancer and the health care system.
18
making THE AFFORDABLE CARE ACT a
REALITY Thereportof the Preventive Services for Women Committee F OR
DECADES ,
PUBLIC HEALTH HAS ARGUED FOR THE NEED TO TRANSFORM THE HEALTH CARE SYSTEM .
T HAT AND
DAY HAS FINALLY COME ,
SPH
FACULTY ARE PLAYING
UCLAPUBLIC HEALTH
A KEY ROLE IN SHAPING THE OUTCOME .
of the Institute of Medicine was released July 19 and hailed by U.S. Health and Human Services Secretary Kathleen Sebelius as “historic.” Less than two weeks later, the recommendations in Clinical Preventive Services for Women: Closing the Gaps were adopted as proposed: Under the Patient Protection and Affordable Care Act (ACA) of 2010, eight preventive services determined by the committee to be necessary for women’s health and well-being were added to the list of services health plans will be required to cover without copayments or deductibles. Thus, by 2013 an estimated 90 million Americans will be in employer plans with no cost-sharing for annual well-woman visits, screening for gestational diabetes, breastfeeding support, HPV testing, STI counseling and HIV screening, contraception methods and counseling, and screening and counseling for interpersonal and domestic violence (see page 21).
19
GAINING ACCESS It is estimated
that 32 million uninsured Americans will gain access to insurance through the Patient Protection and Affordable Care Act of 2010. Among the key issues on the advisory committee’s agenda is how best to ensure that health effects are considered in policies across all sectors, including the role of the health impact assessment, which Fielding and other members of the school’s faculty have been leaders in developing and promoting (see “A Broader View of Health” in the November 2010 issue of UCLA Public Health). Health impact assessments evaluate public health consequences of proposed policy decisions in other sectors and suggest actions that could minimize adverse health effects and optimize beneficial ones. In September, a 14-member National Research Council panel chaired by Dr. Richard Jackson, professor and chair of environmental health sciences at the school, and including Fielding, issued a report
UCLAPUBLIC HEALTH
The ACA created the National Prevention, Health Promotion, and Public Health Council, consisting of senior officials across the government, to elevate and coordinate prevention activities across departments; and established a Prevention and Public Health Fund – described by Dr. Jonathan Fielding, professor of health services at the school and director of the Los Angeles County Department of Public Health, as “absolutely critical, because there has been
no dedicated source of federal funding for public health departments to perform core functions and effectively fulfill our mission.” Fielding notes that the law also strengthens the national Task Force on Community Preventive Services, which conducts systematic reviews and makes recommendations on the effectiveness of programs and policies designed to improve health at the population level for policymakers, practitioners and other decision-makers. The prevention council is receiving guidance from a panel appointed by President Obama that includes both Rosenstock and Fielding. The 15member Advisory Group on Prevention, Health Promotion, and Integrative and Public Health is offering input to the council and the administration on public health and prevention, including development and implementation of the National Prevention Strategy, which was released in June. “The formation of the prevention council recognizes that what we can do through health services has its limits, and that we have to look elsewhere if we want to make large improvements in our nation’s health,” says Fielding. “Obviously we still need to address disparities in access and utilization of services, but we have not focused sufficiently on other determinants of health in populations.”
cover story
“This report provides a road map for improving the health and well-being of women,” said Dr. Linda Rosenstock, dean of the UCLA School of Public Health and chair of the committee, at a news conference announcing the recommendations. “The eight services we identified are necessary to support women’s optimal health and well-being. Each recommendation stands on a foundation of evidence supporting its effectiveness.” After decades of false starts and political disappointments, comprehensive health care reform legislation was finally passed by Congress and signed into law by President Obama on March 23, 2010. Now, Rosenstock is among a number of faculty at the school who are helping to inform ACA implementation through their research, analyses and expertise. And if the new law falls short of including everything public health advocates would have wanted, it offers much to be excited about, beyond the estimated 32 million people who stand to gain coverage. “The Affordable Care Act emphasizes public health and prevention in a way that is unprecedented in any prior major health legislation in the United States, from a mandate to develop a national prevention strategy to public health workforce development and improving public health systems,” says Rosenstock. An ACA provision ensuring that important preventive health services are covered with no outof-pocket costs led to a list of such services being developed by three independent bodies. The list includes, among others, blood pressure, breast cancer and colorectal cancer screenings; diabetes and cholesterol tests; and immunizations. The new law also called for including additional preventive services specific to women’s health, which led the U.S. Department of Health and Human Services to charge Rosenstock’s Institute of Medicine committee with identifying gaps in the recommended services pertaining to women’s needs.
20 requested by the U.S. Department of Health and Human Services on the potential use of health impact assessments to improve the nation’s health. Other UCLA School of Public Health faculty members have also been playing significant roles in shaping the ACA and its implementation. Dr. A. Eugene Washington, who has a joint appointment on the school’s faculty as well as serving as vice chancellor for UCLA Health Sciences and dean of the David Geffen School of Medicine at UCLA, is chair of the Board of Governors for the Patient-Centered Outcomes Research Institute, mandated by the ACA to assist patients, clinicians, purchasers and policymakers in making informed health decisions. Dr. Neal Halfon, professor of community health sciences at the school and director of the UCLA Center for Healthier Children, Families and Communities at the school, was twice invited to the White House to share ideas with the administration’s health care reform team. Since 2003 Halfon has
and colleagues have provided input for the administration’s plans to implement accountable care organizations, which are being promoted through the ACA to reduce unnecessary costs and improve quality of care through better coordination of services. Amid the often-heated debate during the final days leading to passage of the historic health reform legislation, the UCLA Center for Health Policy Research, based in the school, also played an important role. Five days before the final vote, the center released a study projecting, based on 2007 data, that nearly 2 million Californians lost their health insurance during 2008 and 2009 as the nation’s economy sank into a deep recession. The report received widespread media coverage and was pointed to by members of Congress as an indication of the need for reform. The study drew from the California Health Interview Survey (CHIS), which has become an indispensable source of data on many aspects of health and health insurance in the state. Conducted by the center in collaboration with the California Department of Public Health and the Department
PROMOTING HEALTHY DIET AND EXERCISE Community Transformation Grants
UCLAPUBLIC HEALTH
are helping states and communities tackle root causes of chronic disease, such as smoking, poor diet and lack of physical activity, by transforming the environments where residents live, work, play and go to school. led a group called the Blue Sky Initiative, which also includes School of Public Health faculty members Helen DuPlessis, Robert Kaplan and Samuel Sessions. The initiative is an effort to promote transformational changes in the health care system by fostering broad discussions outside the constraints of politics and economics. With the Blue Sky group, Halfon met with administration officials as well as members of the Senate Finance Committee, the Senate Committee on Health, Education, Labor and Pensions, and the House Labor and Human Resources Committee to promote the idea of a prevention trust fund as well as other strategies to prioritize prevention. The group also provided ideas on ways to make the primary care delivery system more focused on health promotion, and to use the ACA to enhance the children’s health system. Since passage, Halfon
of Health Care Services, CHIS is the largest state health survey and is widely respected and cited across the political spectrum. During the legislative process, CHIS was used to produce estimates on the impact of various reform options on California’s population. And since the ACA’s passage, CHIS has been employed widely to guide implementation. Among other things, the survey is providing estimates of the number and characteristics of people who will be newly eligible in 2014 for Medi-Cal (California’s Medicaid program) or the California Health Benefit Exchange – created as part of the ACA to help the state’s consumers and small businesses shop for and buy competitive health insurance, with or without subsidies. “It’s important for both of these programs to know what their customer base is going to look like in terms of age, health status and other variables, for both budgetary and risk-pooling purposes,” says Dr. Shana Alex Lavarreda, director of health insurance studies for the UCLA Center for Health Policy Research.
21
cover story
CHIS is also used to estimate the proportion of various populations with particular health needs, such as those with chronic conditions. Health care reform has introduced new matters of interest to the state, and the center has worked with agencies to include questions that will help guide efforts to effectively implement public programs. “All of these things are critical for understanding the likely impact in California of health care reform as it’s being implemented –
FOCUS ON PREVENTION AND The Affordable Care Act PUBLIC HEALTH
creates a new Prevention and Public Health Fund designed to expand and sustain the necessary infrastructure to prevent disease, detect it early, and manage conditions before they become severe. including who is going to benefit, who is left out of the benefits and what the costs are for different populations that will be covered,” says Dr. E. Richard Brown, director of the UCLA Center for Health Policy Research and principal investigator of CHIS, who also served as a senior adviser to the 2008 Obama presidential campaign and then to the House Energy and Commerce Committee on issues of health data and statistics. The center is also the chief evaluator of California’s county-based health care coverage expansion programs, which seek new and innovative ways to expand coverage to eligible low-income, uninsured individuals not already covered by Medi-Cal. Described by the state as “a bridge to reform,” these programs are working with the low-income uninsured populations that will become eligible for Medi-Cal or subsidies through the California Health Benefit Exchange starting in 2014. Beginning in 2007, the center worked with the state’s Department of Health Care Services to evaluate the impact of the Health Care Coverage Initiative, a three-year, federally funded demonstration project in 10 counties to enroll uninsured, Medicaid-ineligible adults with incomes up to 200 percent of
PROMOTING WOMEN’S HEALTH Under the Patient Protection and Affordable Care Act of 2010, the following eight preventive services for women – as recommended by an Institute of Medicine committee chaired by Dean Linda Rosenstock of the UCLA School of Public Health – will be among the services that new health plans must cover at no cost to patients:
UCLAPUBLIC HEALTH
1. Screening for gestational diabetes in pregnant women between 24 and 28 weeks of gestation, and at the first prenatal visit for pregnant women identified to be at high risk for diabetes. 2. The addition of high-risk human papillomavirus DNA testing to conventional cytology testing in women with normal cytology results, beginning at 30 and no more frequently than every three years. 3. Annual counseling on sexually transmitted infections for all sexually active women. 4. Annual counseling and screening for HIV infection for sexually active women. 5. Provision of the full range of Food and Drug Administration-approved contraceptive methods and sterilization procedures for all women with reproductive capacity, including education and counseling on contraceptive methods to address the high rate of unintended pregnancies in the United States. 6. Comprehensive lactation support and counseling by a trained provider to ensure successful initiation and duration of breastfeeding for all women wanting to breastfeed, and costs of renting breastfeeding equipment. 7. Screening and counseling for interpersonal and domestic violence, including elicitation of information from women and adolescents about current and past violence and abuse in a culturally sensitive and supportive manner. 8. At least one well-woman preventive care visit annually for adult women to obtain the recommended preventive services, including preconception and prenatal care.
22 the federal poverty level in a county-based program providing a coordinated set of services. Last year, the program was expanded to include all 58 counties in the state under a new name, the Low Income Health Program. The programs are considered laboratories for ACA implementation – and, given California’s role as an early adopter of health care reform principles, they are also being watched closely across the country. “Our evaluation can shed light on important concerns,” says Dr. Gerald Kominski, professor of health services and associate director of the UCLA Center for Health Policy Research, who is leading the effort. “Given the estimates that 32 million currently uninsured Americans are going to enroll in either Medicaid or for subsidies through the Health Benefit Exchanges in 2014, we will have an early indication of some of the barriers, to the extent that they exist, in enrolling eligible populations.” In addition, Kominski notes, there are concerns that in 2014 the newly insured might overwhelm the system with demand for health care, since in many cases they will have coverage for the first time in years. Findings from the Health Care Coverage Initiative suggest that there will be a spike in utiliza-
ees will respond to that behavior.” Kominski and colleagues are continuing to analyze the data, but have provided preliminary results to the California Health Benefit Exchange board. California was the first state to adopt legislation creating a Health Benefit Exchange, which has the potential to bring much greater stability and affordability to the health insurance marketplace, Kominski notes; his group estimates that as many as 4 million Californians will buy insurance through the exchange. But there are still many unanswered questions, including how active the exchange board will be in pursuing strategies for purchasing health services on behalf of individuals who qualify for subsidies. Indeed, there is still considerable uncertainty about how many aspects of the ACA will be implemented and how it will evolve, which is why faculty at the UCLA School of Public Health will be in high demand for their expertise for years to come. No one suggests the law is perfect. Fielding notes that it is short on mechanisms to control rising health care costs. Although the ACA has a provision to fund comparative effectiveness studies – weighing the benefits of competing health care interventions – he points out that the focus is on clinical rather than health care system approaches, and prohibits
FAMILY PLANNING Nearly half of
UCLAPUBLIC HEALTH
pregnancies in the United States are unintended. The full range of FDA-approved contraceptive methods, as well as patient education and counseling for all women with reproductive capacity, will be covered by health plans without cost-sharing requirements. tion of services by newly enrolled individuals, but that it will be manageable and will taper off after their first year of enrollment. Kominski, who will become director of the UCLA Center for Health Policy Research January 1 (see page 33), is also heading a team of center researchers working with the UC Berkeley Center for Labor Research and Education to conduct micro-simulations on how changes under the ACA will affect job-based insurance. “Employers are still the primary source of insurance for most Californians, so it’s important to understand what they are going to do in response to changed incentives and the changed market,” Kominski explains. “Our micro-simulation model predicts employer behavior under the new law, as well as how employ-
research on the relative cost-effectiveness of different approaches. Brown notes that even with the estimated 32 million people gaining insurance, certain groups will continue to be uncovered, including undocumented immigrants. But for Brown, long a leading voice for health care reform whose research in the 1980s provided some of the earliest documentation of the nature and extent of the uninsurance problem, there is nonetheless reason to be hopeful. “The country has taken a very important step in the direction of reforming our health care system – not just moving us closer to the goal of universal coverage, but improving quality and creating more of a system of care as opposed to a fragmented set of delivery and payment mechanisms with no coordination,” Brown says. “This is not nirvana, but it provides a foundation for further changes and reforms that will continue to improve the system.”
23
research
research highlights Low HPV Vaccine Awareness Associated with Low Usage Rates Among Underserved Groups LOW-INCOME, ETHNIC MINORITY ADOLESCENT GIRLS in Los Angeles County are using the human papillomavirus (HPV) vaccine at lower rates than national estimates, researchers at the UCLA School of Public Health have found. These lower vaccination rates are associated with low levels of awareness about HPV, the most common sexually transmitted infection in the United States; and about the availability since 2006 of a safe and effective vaccine, which protects against the two strains of the virus that cause the majority of cervical cancers and is recommended for girls as they approach adolescence. The study, headed by Drs. Roshan Bastani and Beth Glenn of the school’s faculty, was conducted in collaboration with the Los Angeles County Department of Public Health’s Office of Women’s Health and published in the journal Cancer Epidemiology, Biomarkers & Prevention. Through interviews conducted in six languages, the researchers surveyed nearly 500 mothers of adolescent girls eligible for the vaccine (ages 918) who were users of the Office of Women’s Health telephone hotline. Only 29 percent of their daughters had received at least one dose of the vaccine, and only 11 percent had completed the three-dose series. National data for the same time period found that 44 percent of adolescents had initiated the HPV vaccine and 27 percent had completed the series. The researchers found that the strongest predictor of vaccine initiation was the mother’s HPV awareness. More than half of Korean mothers and approximately one-third of Latina, Chinese and AfricanAmerican mothers in the sample had not heard of HPV. Among mothers of unvaccinated girls, 66 percent reported lacking sufficient information about the vaccine to make a decision and 74 percent said they did not know where their daughters could obtain the vaccine. “The HPV vaccines represent a breakthrough in the primary prevention of cervical cancer, and girls from medically underserved populations, who are at elevated risk to develop cervical cancer in their lifetimes, may benefit the most,” says Glenn. “Our findings suggest that many mothers from high-risk groups may be unaware of HPV and the availability of an effective vaccine. Interventions, including culturally targeted messaging, may be helpful and should provide not only vaccine education but also referrals to local clinics where the vaccine can be received for low or no cost.”
The strongest predictor of vaccine initiation was the mother’s HPV awareness. Among mothers of unvaccinated girls, 66 percent reported lacking sufficient information about the vaccine to make a decision.
UCLAPUBLIC HEALTH
Paying for Pediatric Obesity Services Now Can Save Money Later
24
An investment in a program in which a multidisciplinary health care team provides 26-75 hours of service to overweight and obese children is recovered in 6.5 years for privately insured patients and 3.5 years for patients insured by Medicaid.
a significanT PorTion of The $3 BiLLion the United states spends annuallyonpediatricobesitycouldbesavedbystreamliningmedicalcoverage toaddresshealthissuesaffectingyoungobesepatientsnowratherthanwaiting totreatconditionstheydevelopastheygetolder,accordingtoastudyledbya memberoftheUcLaschoolofPublichealthfaculty. formorbidlyobesechildren,accesstomultidisciplinaryservicescanleadto successfuloutcomes.Butbecauseclinicianslackauniversalsetofguidelinesto follow, health insurers and hospitals often evaluate insurancecoverageforobesityservicesonacaseby-casebasis.Thiscreatesacriticalbarrierbetween patientsandhealthcareproviders. in an effort to guide providers, patients, and payersinbetterservingobesechildrenandenabling thebesthealthoutcomespossible,aUcLa-ledwork groupfromthefocUsonafitterfuturecollaboration of the national association of children’s hospitalsandrelatedinstitutionsreviewedexisting successful programs to evaluate what works best. The group concluded that comprehensive, multidisciplinary intervention programs should include a health care team with a medical provider, a registereddietitian,aphysicalactivityspecialist,amental health specialist and a coordinator, and that the teamshouldprovideatotalofatleast26-75hoursof servicetooverweightandobesechildren. while some may argue that up to 75 hours of serviceisalotoftime,thegroupdeterminedthatthe investment of services would be recovered in 6.5 yearsforprivatelyinsuredpatientsand3.5yearsfor patientsinsuredbymedicaid. “with pediatric obesity, the focus has been on therelateddiseasesthatusuallycomelater,suchasdiabetes,heartdiseaseand hypertension,”saysleadstudyauthordr.wendyslusser,associateprofessorof health services at the school and medical director of the UcLa fit for healthy weightprogramatmattelchildren’shospitalUcLa.“however,whatweseenow isthattheobesechildoradolescentmaysufferfromgastrointestinaldisorders, mentalhealthissuesandmusculoskeletalproblemssuchasbackachesorknee problems.Byinvestinginthehealthissuesoftoday,wecanimprovethehealth conditionsoftomorrowandultimatelyimpactthefuturecosts.”
UCLAPUBLIC HEALTH
Exercise Breaks, Healthy Food Policies Can Improve Workplace Health, but Barriers Remain ProVidingfinanciaLandTechnicaLassisTanceforcommunity-based organizations to institute health-promoting workplace programs significantly increased implementation of new food procurement policies and exercise breaks,agroupofresearchersledbyUcLaschoolofPublichealthfacultyhas found.however,thesixhealthandsocialservicesorganizationsinthestudy– each of which had demonstrated outreach capacity in minority communities – were less successful at convincing organizations within their professional or socialnetworkstoadopttheseandothercoreworkplacewellnessstrategies. Thestudy,publishedinthejournalPreventing Chronic Disease,evaluateda programrunbytheLosangelesBasincenterforexcellenceintheelimination ofhealthdisparities(ceed),acollaborationofUcLa,theLosangelescounty department of Public health, and partnering community organizations. with a grantfromthecentersfordiseasecontrolandPrevention’sracialandethnic
Approaches to Community Health Across the US (REACH US), CEED is attempting to disseminate culturally appropriate physical activity and nutrition based interventions at worksites in minority communities, including Instant Recess – structured 10-minute group activity breaks; walking meetings; providing healthy refreshments at meetings and events; substituting fruit baskets for candy dishes; including healthy options in vending machines and cafeterias; and posting stair prompts and improving stair access. Among the organizations choosing not to participate, competing priorities, budget cuts, lack of upper management support, liability concerns because of fear of risk of injury to employees, and lack of compensation were cited. CEED intends to explore a new strategy that will rely on “sparkplugs” – public health leaders actively promoting fitness – to disseminate wellness strategies within their networks. “Given that we spend so many hours at work, small changes in the work environment can have a positive impact on health among large numbers of employees,” says Dr. Annette E. Maxwell, professor of health services and lead author of the study. “We want activity breaks and healthy food choices to become the norm at worksites and other venues, but it takes an enthusiastic leader to get the ball rolling.”
25
research
High Risk of Parkinson’s Disease for People Exposed to Pesticides COMBINED EXPOSURE to three chemicals commonly sprayed on crops to fight pests in California’s Central Valley triples the risk of Parkinson’s disease for people who work near where the pesticides are sprayed, a research team headed by Dr. Beate Ritz, professor of epidemiology at the UCLA School of Public Health, has found. The study results, published in the online edition of the European Journal of Epidemiology, are the first to implicate one of the pesticides, ziram, in the pathology of Parkinson’s disease. Ritz and colleagues had previously reported that people who lived near where farm fields were sprayed with the fungicide maneb and the herbicide paraquat had a 75-percent increased risk for the disease. The more recent study also found that combined exposure to ziram and paraquat alone was associated with an 80 percent increase in risk. “Our estimates of risk for ambient exposure in the workplaces were actually greater than for exposure at residences,” says Ritz. “And, of course, people who both live and work near these fields experience the greatest PD risk. These workplace results give us independent confirmation of our earlier work that focused only on residences, and of the damage these chemicals are doing.” In addition, Ritz notes, this is the first study to find strong evidence in humans that the combination of the three chemicals confers a greater risk of Parkinson’s than exposure to the individual chemicals alone. Because these pesticides affect different mechanisms leading to cell death, they may act together to increase the risk of developing the disorder.
COMMUNITY REPRESENTATIVES CAN BE TRAINED to engage effectively in research and to use others’ findings for policy advocacy and program development, according to a study conducted at a three-day community-based health-research training program offered by the UCLA Center for Health Policy Research.
UCLAPUBLIC HEALTH
Short-Term Training Bolsters Research Capacity of Community Organizations
Combined exposure to three chemicals (ziram, maneb and paraquat) commonly sprayed on crops to fight pests in California’s Central Valley triples the risk of Parkinson’s disease for people who work near where the pesticides are sprayed.
“our findings suggest that an intensive, short-term training program can achievelargeimmediategainsintheconfidenceofstaffofcommunityorganizationsinusingdataandresearch,aswellaslonger-termbehaviorchange,”says dr.stevenwallace,professorandchairofthedepartmentofcommunityhealth sciences at the UcLa school of Public health and associate director of the UcLa center for health Policy research, who led the study, published in the American Journal of Public Health. wallace’sgroupevaluatedtheimpactofthedataanddemocracyinitiative, a community capacity-building program of the center’s health daTa program. The initiative was designed to enhance the knowledge and ability of staff in community-basedgroupstouseresearchdatainpolicyadvocacyandprogram development.a “train-the-trainer” model was used to teach community-health assessment methods:after taking an intensive course over several days, the trainerstaughtothersintheirorganizationsorcommunitiesinanefforttofurther buildcapacity. Thestudyanalyzedparticipants’confidenceintheirabilitieson19coreskills beforeandfollowingtheexperience,andfoundsignificantimprovementsimmediatelyafterthecourse.infollow-upsurveysconductedayearlater,participants reported that they increased their use of community assessment skills in their work,aswellastheiruseofdata. “The community is an influential determinant of health, but little is known aboutcommunityresearchcapacity,”sayswallace.“ourstudycontributestoa betterunderstandingoffactorsinfluencingcommunitycapacitytouseresearch inplanningandpolicy,andrespondstodemandsforevidence-basedpractices that have been identified by healthy People 2020 as significant to improving communityhealth.”
26
Drug Prices Much Lower in Poor Countries Than in United States
UCLAPUBLIC HEALTH
Patients in developing countries paid only 17 percent of the U.S. price for patented drugs, 36 percent of the U.S. price for off-patent products, and 3 percent of the U.S. price for essential drugs.
PharmaceUTicaL Prices in the United states tend to be significantly higher than in other countries,withpricesinpoor,developingcountriesbeing thelowestofall,accordingtoastudybytwoUcLa schoolofPublichealthfacultymembers.Thestudy results come at a time of growing concern that the highcostsofpharmaceuticalresearchanddevelopment might create a burden for poor patients in developingcountries.Thestudywasfundedbythe eliLillycompanyandpublishedinHealth Affairs. drs. stuart schweitzer and william comanor lookedatpricesof30drugsin29countriesbetween 2000 and 2007, conducting separate analyses for patented drugs, drugs whose patents had expired, anddrugsthattheworldhealthorganizationclassifiesas“essential.”Theyfoundthatpricesofallthree categoriesofproductswerelowerinothercountries –includingwealthyones–thanintheUnitedstates, and in some cases the differences were substantial. for example, patients in wealthycountriesotherthantheUnitedstateswerechargedonly37percentof the U.s. prices for patented drugs. Prices of off-patented products in these wealthycountrieswereabout81percentofU.s.prices,whilepricesofessential drugswereonly14percentoftheU.s.prices. Pharmaceuticals in middle-income countries were discounted even more, andpatientsindevelopingcountriespaidonly17percentoftheU.s.pricefor patenteddrugs,36percentoftheU.s.priceforoff-patentproducts,and3percentoftheU.s.priceforessentialdrugs.
“it appears that pharmaceuticals in poor countries are priced close to the marginalcostsofproductionanddistribution,”saysschweitzer.“Thissuggests thatpatientsinthesecountriesarenotburdenedwithpayingthecostofpharmaceuticalresearchanddevelopment.”
UCLAPUBLIC HEALTH
U.s. hoUsehoLds are more LiKeLy to prepare for terrorism and other potentialhazardswhentheyseeotherspreparingandwhentheyreceiveinformationthatincreasestheirknowledgeaboutpreparednessandconvincesthem thatpreparednessbehaviorsareeffective,accordingtoaUcLaschoolofPublic healthstudy. The study, published in the journals Environment and Behavior, Risk Analysis and the Journal of Homeland Security and Emergency Management, found that few households reported developing emergency plans (2.8%), purchasingthingstobesafer(2.3%),stockpilingsupplies(1.4%),orduplicatingdocuments (0.9%) exclusively because of concerns about terrorism. substantially more households reported developing emergency plans (29.5%), purchasing things to be safer (21.8%), stockpiling supplies (34.2%), or duplicating documents(36.3%)becauseofnaturalhazards,fornon-hazard-relatedreasons,or foracombinationofreasonsthatmightincludeterrorism. Under the direction of dr. Linda Bourque, professor of community health sciencesintheschool,andwiththecollaborationofformerandcurrentdoctoral Preparedness Actions by studentsmegumiKano,michelewood,rotreaseregan,andmelissaKelley,the national survey of disaster experiences and Preparedness conducted U.S. Households in Response to Terrorism Threat telephone interviews with residents of 3,300 households in the continental 100% Unitedstatesbetweenapril 2007 and february 2008. 83.2 areasthatexperiencedthe september11,2001terror59.1 58.5 50% ismattacks(newyorkcity and washington, dc) or 36.3 were threatened by 9/11 34.2 31.3 29.5 (Losangelescounty)were 21.8 2.8 2.3 0.9 1.4 oversampled to enable 0% appropriatecomparisonsto Learned Duplicated Became Stockpiled Developed Purchased About Terrorism Documents More Vigilant Things to Be Safer Supplies Emergency Plans be made between “highvisibility”areasandtherest For Any Reason oftheUnitedstates. For Terrorism Only Bourque’sgroupfound that across all racial and ethnic subgroups ad throughout the continental United states, seeing others engage in preparedness activities was the strongest direct predictor of taking preparednessactions.observingotherstakingactionalsohadanindirecteffect onmotivatingpeopletoactbyenhancingknowledgeaboutpreparednessandits perceivedeffectiveness,aswellasencouraginghouseholdstoproactivelyseek moreinformationaboutterrorism,otherhazards,andpreparedness. “evenafter9/11,householdpreparednessforterrorismandotherkindsof disasters remains low throughout the United states,” Bourque says. “But this shows that seeing others prepare, receiving information multiple times from multiple sources and actively looking for information about preparedness can haveanimpact.”
research
Information, Seeing Others Act Motivates Preparedness for Terrorism and Other Hazards
27
28
student profiles Removing the Stigma, Promoting Mental Health
“People I talked with didn’t understand the need for treatment of psychological and cognitive problems. A lot of them felt they were weak if they said they were depressed.”
UCLAPUBLIC HEALTH
— Courtney Coles
WHEN COURTNEY COLES was growing up in Austin, Texas, she sensed something was amiss with her family’s response to her great-grandmother’s diagnosis of Alzheimer’s disease. “They didn’t really understand what it meant,” Coles says. “They said we should just pray about it and she would get better, rather than focusing on facilities or therapies that might be helpful.” As she began educating herself and talking with people in her community, Coles found that there were many misconceptions about neurologic and mental illness. “There is a stigma, particularly in the African American community,” says Coles. “People I talked with didn’t understand the need for treatment of psychological and cognitive problems. A lot of them felt they were weak if they said they were depressed, and that they just needed to think more positively.” As a senior biology student at Baylor University, Coles worked in an emergency room and had experiences that confirmed her resolve to pursue a career in which she could help to remove the stigma and steer more people with mental disorders toward appropriate treatment. “People would come in who had reached the point of being suicidal,” she says. “When we would sit down and talk with them to explain that psychotherapy was a great option, or that there were medications that could help, they understood. But when they talked with other people in their lives – their family members, their pastors – they got a different understanding. I knew that research and having evidence-based information to give these people would be really helpful.” So after graduating from Baylor, Coles enrolled in the UCLA School of Public Health as an M.P.H. student in the Department of Epidemiology. Now in her second year, she has taken advantage of opportunities to conduct research on issues of interest to her. Last summer, Coles began working as an intern in the Los Angeles County Office of Health Assessment and Epidemiology, analyzing data from the Los Angeles County Health Survey. Specifically, Coles studied the nature of cost as a barrier to mental health and other services, broken down by factors that included race, ethnicity, gender and insurance coverage. Coles was also part of a group at the school headed by Dr. Vickie Mays, professor of health services, that studied perceived discrimination among African Americans, Latinos and whites in mental health and substance abuse treatment services. She recently started a study with Mays of the experience of racial discrimination among African American men and whether it has an impact on physical health. After completing her M.P.H. education, Coles plans to apply to the school’s Ph.D. program in the Department of Health Services. New federal laws – both the Patient Protection and Affordable Care Act of 2010 and the Mental Health Parity and Addiction Equity Act of 2008 (see page 8) – hold the promise of increased access to mental health treatment. “I want to study mental health services in the African American community,” Coles says. “With these changes there is great opportunity, and research will be an important tool for making sure that people in the community are getting the services they need.”
29
students
Pediatrician Seeks to Improve Quality of Care Through Better Communications When Patients Are Discharged
“I wanted the public health degree so that I’d have the skills, credibility and network of connections to be able to work on health issues outside of the clinical setting.” — Ryan Coller
UCLAPUBLIC HEALTH
THROUGHOUT MEDICAL SCHOOL and his training at UCLA as a resident and then chief resident in pediatrics, RYAN COLLER knew there was one more degree he needed. “I’ve always seen child health as a field that extends beyond the walls of the clinic and the hospital,” says Coller, now a second-year M.P.H. student at the UCLA School of Public Health. “I wanted the public health degree so that I’d have the skills, credibility and network of connections to be able to work on health issues outside of the clinical setting, as well as to have that broader context to inform my clinical work.” Coller is a fellow in the Child and Family Health Training Program, based in the school’s Center for Healthier Children, Families and Communities. In addition to his coursework, he educates UCLA pediatric residents, sees patients, and is engaged in health services research with a focus on quality of care issues. Coller is particularly interested in the communications that occur during patients’ transition from the hospital back into the community. “It’s been well documented that we don’t do a very good job of this,” he says. “Studies have found low patient and provider satisfaction with the discharge process. Too often there are medication errors, duplicate testing and lack of follow-up on issues that were pending at the time of discharge from the hospital.” As provisions under the new health care reform law increase the emphasis on quality of care – linking reimbursement levels with quality measures and patient readmission rates, for example – these concerns are getting more attention. Coller is currently documenting the communications between hospital providers and primary care physicians when patients are discharged, and looking at whether more thorough interactions result in fewer patient readmissions and emergency room visits. Ultimately, he plans to study the impact of potentially more effective forms of communication with primary care providers at the time of discharge, including formal processes to ensure that information about patients’ follow-up care is properly transmitted. The issue of quality of care first piqued Coller’s interest in medical school. “That’s when I learned how much health care costs in the United States, and yet our quality outcomes aren’t proportionately that much better – and in some cases are worse – than in countries where health care is less expensive,” he says. Focusing on the issue in the School of Public Health, he adds, “I’ve gotten a much richer understanding of what quality of care really means and how it can be measured and studied.” Beyond the scholarship, Coller has valued the opportunity to develop relationships with faculty mentors who are experts in the field he intends to pursue. Coller hopes to continue working at an academic medical center such as UCLA, combining clinical practice with research focused on discovering and implementing ways to deliver higher-quality care to pediatric patients. “I love getting to work with patients on-on-one in the clinic and in the hospital, but I recognize that what I do in those interactions doesn’t necessarily extend beyond the patient and family I’m working with,” Coller says. “With the tools I’m getting from the M.P.H. program, I can address systems-level problems with the potential to have an impact on a much broader base of patients and families. To me, that’s really exciting.”
30
contracts & grants 2010-11 This section includes new contracts and grants awarded in fiscal year 2010-11. Due to space limitations, only funds of $50,000 or more are listed, by principal investigator.
RICHARD AMBROSE Developing the Technical Basis for California’s Status and Trends Assessment of Wetland Extent (California Natural Resources Agency & Southern California Coastal Water Research Project, $84,083) ONYEBUCHI ARAH Deepening our Understanding of Quality Improvement in Europe (DUQUE) (European Commission-Directorate General Information Society & Autonomous University of Barcelona (Spain), $337,808 for 4 years) SUSAN BABEY California Fitness Test Results by County, City, School District 2004-2009 (California Center for Public Health Advocacy, $86,000); Estimating the Causal Effect of Interacting with Pet Dogs and Cat Ownership for Children (National Institute of Child Health and Human Development & RAND Corporation, $114,383 for 2 years); Longitudinal Associations of Neighborhood Environment with Obesity and Health (National Heart, Lung, and Blood Institute, $707,518 for 2 years) ROSHAN BASTANI UCLA Career Development Program in Cancer Prevention and Control (National Cancer Institute, $2,481,631 for 5 years) E. RICHARD BROWN California Health Interview Survey (CHIS) (California Department of Public Health, $2,858,000 for 2 years; Kaiser Foundation Research Institute (Southern California), $550,000 for 2 years; Kaiser Foundation Research Institute (Northern California), $550,000; United American Indian Involvement, Inc., $100,000; The California Endowment, $3,036,655 for 2 years; California Department of Mental Health, $2,400,000 for 3 years); CHIS 2009 Policy Research Studies (The California Endowment, $524,086 for 2 years); On-line Analytic System for Use with Unrestricted Data from the National Health Interview Survey (Centers for Disease Control and Prevention & Westat, Inc., $151,491 for 2 years) WILLIAM CUMBERLAND Biostatistics Training for AIDS Research (National Institute of Allergy and Infectious Diseases, $1,240,751 for 5 years)
UCLAPUBLIC HEALTH
ROGER DETELS Cardiovascular and HIV/AIDS Effects on Brain Structure Function and Cognition (National Institute on Aging & University of Pittsburgh, $331,100 for 5 years); Multicenter AIDS Cohort Study (National Institute of Allergy and Infectious Diseases & University of Pittsburgh, $161,441 for 2 years)
ALINA DORIAN Project to Establish the Groundwork for Public Health/Joint Regional Intelligence Center (JRIC) Exercise (County of Los Angeles/Department of Health Services, $50,000) JONATHAN FIELDING Acculturation and Physical Activity: Forecasting and Improving Latino Health (National Institute of Environmental Health Sciences, $423,500 for 2 years) PATRICIA GANZ Improving Outcomes for Breast Cancer Survivors: Measuring the Comparative Effectiveness of Survivorship Care Programs Within the UCLA-Livestrong Survivorship Center of Excellence (The Breast Cancer Research Foundation & ASCO Cancer Foundation, $500,000 for 5 years); Examining Tumor Associated Macrophages in Breast Cancer Specimens (National Cancer Institute & National Surgical Adjuvant Breast & Bowel Project Foundation, $50,000); UCLA Center of Excellence for Cancer Survivorship (Lance Armstrong Foundation, $220,000); Stress Reduction and Healthy Living in Younger Breast Cancer Survivors: Intervention Development & Evaluation (Susan G. Komen Breast Cancer Foundation, $500,000 for 2 years) SHEHNAZ HUSSAIN Molecular Epidemiology of B-Cell Activation, DNA Repair and HIVAssociated Lymphoma (National Cancer Institute, $640,376 for 5 years) MARJAN JAVANBAKHT Pharyngeal Gonorrhea Among Young People: Implication for Prevention (National Institute of Allergy and Infectious Diseases, $618,059 for 5 years) MARJORIE KAGAWA-SINGER AANCART: The National Center for Reducing Asian American Cancer Health Disparities (National Cancer Institute & University of California, Davis, $900,000 for 5 years); Culture, Social Support and Quality of Life: Asian American Breast Cancer Survivors (National Cancer Institute, $1,358,471 for 5 years) CHRISTINA KITCHEN Characterizing the Role of Immune Activation in HIV Persistence (AMFAR, The Foundation for AIDS Research, $120,000) ANNETTE MAXWELL Community Dissemination of an Evidence-Based CRC Screening Intervention (American Cancer Society, $1,723,000 for 4 years); An RCT to Promote Mammography Among Chinese American Women (National Cancer Institute & Georgetown University, $646,026 for 5 years)
31
WILLIAM MCCARTHY Policy-Oriented Reduction in Smoking by Residents/Staff of Homeless Shelters (Centers for Disease Control and Prevention & County of Los Angeles Department of Health Services, $595,000) NADEREH POURAT Characteristics of Californians Who Are Eligible for Coverage Under Health Care Reform (California Healthcare Foundation, $82,516); Assessment of California Safety Net Providers (Blue Shield of California Research and Education Foundation & University of California, San Francisco, $66,558) MICHAEL PRELIP UCLA Center for Population Health and Health Disparities Research Education Program (National Heart, Lung, and Blood Institute, $335,387 for 5 years)
faculty
WILLIAM MCCARTHY, MICHAEL PRELIP, DEBORAH GLIK, CHRISTIAN ROBERTS, THOMAS BELIN Family and Neighborhood Interventions to Reduce Heart Disease Risk in East L.A. (National Heart, Lung, and Blood Institute, $9,887,726 for 5 years) Project 1: Promotora-based Latino Family Cardiovascular Disease Risk Reduction: Remaking the Home Environment (McCarthy); Project 2: Vascular Function, Cardiovascular Disease Biomarkers and the Latino Paradox (Roberts); Project 3: Corner Store Makeovers in East Los Angeles: Improving Healthy Food Access (Prelip & Glik); Administrative Core (McCarthy); Training and Career Development Program Core (Prelip); Research Methods Core (Belin)
PETER SINSHEIMER Alternatives Analysis of Non-Lead Alloys Used in Potable WaterSupply Applications (California Metals Coalition, $100,000) STEVEN WALLACE Turning Knowledge into Action: Fighting Air Pollution in Two Immigrant Communities (Centers for Disease Control and Prevention, $500,000 for 2 years); Data for Falls Prevention in California (Archstone Foundation, $125,000 for 2 years); California Health Interview Survey (CHIS) American Indian Alaska Native Oversample 2011 (Native American Health Center, $90,000); CHIS American Indian Alaska Native Oversample (San Diego American Indian Health Center, $100,000) MAY WANG Social and Family Environments and Child Obesity in Diverse Neighborhoods (National Institute of Child Health and Human Development, $97,127)
welcome JAMES GIBSON Assistant Professor, Environmental Health Sciences DAMLA SENTURK Assistant Professor in Residence, Biostatistics
PHYLLIS WEISS Urban Networks to Increase Thriving Youth Through Violence Prevention II (DHHS/Centers for Disease Control and Prevention, $100,000) ZUO-FENG ZHANG Career: Effects of Volatility and Morphology on Vehicular Emitted Ultrafine Particle Dynamic (National Science Foundation, $346,799 for 3 years); Assessing Children’s Exposure to Ultrafine Particles from Vehicular Emissions (U.S. Environmental Protection Agency & Health Effects Institute, $100,000)
BEATE RITZ Parkinson’s Diseases Susceptibility Genes and Pesticides (National Institute of Environmental Health Sciences, $3,185,765 for 5 years); Pesticide Exposure and Childhood Cancer (PECC) Study (National Cancer Institute, $409,293 for 2 years) HECTOR RODRIGUEZ Comparing the Effectiveness of Diabetes Care (Agency for Health Care Research and Quality, $2,987,640 for 3 years) ROBERT SCHIESTL Effects of Intestinal Microflora on High-LET Radiation Mediated Toxicity and Genomic Instability (NASA/Ames Research Center, $1,320,000 for 3 years) KIMBERLEY SHOAF Southwest Regional Public Health Training Center (DHHS/Health Resources and Services Administration, $3,250,000 for 5 years); Border Infectious Disease Surveillance Public Health Emergency Preparedness Community Outreach Project (Centers for Disease Control and Prevention & Public Health Foundation Enterprises, $50,000) UCLAPUBLIC HEALTH
32
news briefs
dean to step down
recess is back
UCLAPUBLIC HEALTH
atatimewhenamericansareleadingincreasinglydigitalandsedentary lifestyles,coupledwithgrowingobesityrates,theUcLaschoolofPublic healthhaspartneredwiththePortland-basedoutdoorclothingcompanyKeen tore-energizeadultsatworkandmakeworkplacerecessascommonas casualfridays. Therecessrevolution,basedontheinstantrecessprogramdeveloped bydr.Toniyancey,professorofhealthservicesandco-directoroftheUcLa KaiserPermanentecenterforhealthequity,ispartofanationwidemovement topromotehealthierandhappierlivesbyincludingthefunfactorofdaily “recess”breaks.overthesummer,theKeenrecessrevolutionTourvisited Portland,sanJose,denver,andminneapolis,withaculminatingworldwide recessdayheldinwashington,dc,onseptember14. Keenhasalsosponsoredthedevelopmentofaninstantrecesscorporatetoolkit,withcontentsuppliedbyUcLaandaffiliatedresearchers,tobe distributedfreeofchargetoanyinterestedemployerthisfall.oneunusual featureisa“costs-benefitscalculator”thatcorporationscanusetocompute theirownreturn-on-investmentforimplementinganinstantrecessbreakdaily. recentstudiesshowthattakingshortactivitybreaksduringtheworkdayis beneficialforanindividual’shealthandwellbeing,aswellasforacompany's moraleandproductivity.
dr.Lindarosenstock(above),deanoftheUcLa schoolofPublichealth,hasannouncedthatshe willstepdownattheendofthisacademicyear. inher11yearsasdean,rosenstockhas helpedtoenhanceanalreadyworld-classfaculty byrecruiting30talentedanddiversefacultymembers.duringhertenure,contractandgrantactivity hasmorethantripled,withladder-trackfaculty (tenure-trackfacultywithstate-fundedsupport) generatinganaverageofmorethan$850,000 peryear,oneofthebestrecordsoncampus. Thequalityoftheschool’seducationalprograms isrecognizedaroundtheworld,drawingstudents frommorethan35countriestocreateoneofthe mostdiversestudentbodiesamongallschoolsof publichealth.applicationstotheschoolhavesoared nearly50percent,increasingstudentselectivityand competitiveness.Theschoolisconsistentlyranked inthetop10byU.S. News & World Report. insharingrosenstock’splanstostepdown, UcLaexecutiveVicechancellorscottwaughsaid, “Lindahasbeenatremendousassettotheschool, toUcLaandtotheUniversityofcalifornia,and wewillmissherleadershipgreatly.”
INTERACT WITH US! You can learn about happenings at the school, participate in discussions on public health topics of the day or reconnect with former classmates and favorite faculty members through the school’s Facebook page, and follow UCLASPH on Twitter for important updates. In addition, alumni are invited to join the UCLA School of Public Health Alumni Network on the professional networking site Linkedin.
33
news briefs
new center leadership celebration continues Two of the school’s centers, the UCLA Center for Global and Immigrant Health and the UCLA Center for Health Policy Research, have announced new leaders. Dr. Onyebuchi Arah (above left), associate professor of epidemiology and associate dean for global health, is the new director of the UCLA Center for Global and Immigrant Health. Arah is an expert on the global context of health and health care and the burden of disease, particularly in developing countries. He takes over for Dr. Gail Harrison, who founded the center and has served as director since it was established in 2008. The center includes faculty from all of the departments in the school, as well as from the schools of medicine, dentistry and nursing, all of whom have research or teaching interests in global and/or immigrant health. Dr. Gerald Kominski (above right), professor of health services and associate director of the UCLA Center for Health Policy Research, will become that center’s new director on January 1. Kominski is an expert on the costs and costeffectiveness of medical programs and technologies, with a particular emphasis on Medicare payment policies for hospitals and physicians. He takes over for Dr. E. Richard Brown, professor of community health sciences, who founded the center and has served as its director since 1994. One of the nation’s leading health policy research centers as well as the premier source of health policy information for California, the center strives to improve the public’s health by advancing health policy through research, public service, community partnership and education.
To celebrate its 50th anniversary, the school has launched a number of programs to provide alumni and friends with an opportunity to engage and learn with world-class faculty. A monthly webinar series, SPH: Continuing the Conversation, allows viewers to join, via computer, interactive discussions with faculty experts on the most critical issues facing public health. The Health Forum at UCLA (SPH) is a series of regularly scheduled free public programs featuring health leaders discussing and debating the way forward. Finally, the Ruth Roemer Symposium on Social Determinants of Health has been scheduled for mid-January, to be held in downtown Los Angeles. Visit www.ph.ucla.edu for a schedule of upcoming events.
DID YOU KNOW? You are a lifetime member of the UCLA School of Public Health Alumni Association if you are a graduate of the UCLA School of Public Health and its executive programs. If you would like more information about the activities of the Public Health Alumni Association, please call (310) 825-6464 or email phaa@support.ucla.edu.
UCLA VOLUNTEER DAY – UCLA School of Public Health students and staff joined with 6,000 Bruins to provide volunteer community service at 26 locations throughout Los Angeles. SPH volunteers painted at Sylvan Park Elementary School and cleaned living quarters, prepared food and painted at the Union Rescue Mission.
UCLAPUBLIC HEALTH
UCLA
UCLA
PUBLIC HEALTH School of
Public Health
School of Public Health Box 951772 405 Hilgard Avenue Los Angeles, California 90095-1772 www.ph.ucla.edu Address Service Requested
Nonprofit Org. U.S. Postage PAID
UCLA