"We firmly believe we can emerge as a stronger school than ever. "
hen last we communicated on these pages, our school's future was uncertain, to say the least. The UCLA administration had announced a proposal that would disestablish four professional schools, including ours, as a way to reduce administrative costs. In the fall 1993 issue of UCLA Public Health, we outlined the administration's rationale behind this proposal (including its desire to create a School of Public Policy), along with our reasons for strongly opposing the suggestion that our school be disestablished, with our departments being divvied between the would-be public policy school and the School of Medicine. I will not revisit those arguments here. No doubt you have heard by now that the UCLA School of Public Health is here to stay. The UCLA administration and a committee representing our school worked out an agreement that affirms our place on campus while meeting the university's need to reduce its state-allotted budget. This resolution also paves the way for a strong School of Public Policy with which we can have mutually beneficial ties. We will incur a substantial reduction in funding from the state, but a phase-in of the cuts will enable us to apply our current resources to generating additional extramural support. (The settlement is discussed in more detail beginning on page 4.) As we wind down from a tumultuous year for our faculty, students and staff, I would be remiss if I failed to take this opportunity to thank all of you who have spoken and written on our behalf. Countless health leaders - both alumni and otherwise - have argued forcefully and convincingly for the UCLA School of Public Health's crucial role in contributing to a healthier society. It is impossible to adequately express what your support has meant to us. Now that our place is secure, we turn to the task of demonstrating that your words of praise were deserved. This issue of UCLA Public Health focuses on challenges our school and our profession must meet if we are to assure healthy conditions for the populations of our surrounding region. We are aware of the irony. We don't deny that in light of the state budget cuts, the UCLA School of Public Health faces a challenge of its own - that of maintaining its place among the nation's best public health research and teaching institutions, building on our proud history of contributing to improved health. We know it won't be easy. But, with the help of extramural funding sources and private donors to compensate for lost state support, we firmly believe we can emerge as a stronger school than ever. With what is at stake - the urgent need for public health insights and leadership in our community and beyond - we must.
C. Dr. Abdelmonem A. Afifi
UCLA PUBLIC HEALTH Volume 13, Number I, 1994 Issue
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Abdelmonem A. Afifi, Ph.D. Dean
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Richard Elbaum Director, Health Sciences Communications
Editorial Boord Abdelmonem A. Afifi, Ph.D. Dean
STILL A SCHOOL The UCLA School of Public Health remains standing - and, despite a reduction in state funding, plans to rise to even greater heights.
6
Susan C. Scrimshaw, Ph.D. Associate Dean for Academic Programs
V. Gale Winting Associate Dean for Administration
Emily K. Abel, Ph.D. Associate Professsor, Health Services
CHALLENGES: Ushering in the Public Health Paradigm .... page 7
Richard F. Ambrose, Ph.D. Associate Professor, Environmental Health Sciences
Containing and Counteracting Infectious Diseases .... page 8 Meeting the Long-Term Care Needs of the Elderly .... page 9 Cleaning the Environment While Protecting Jobs .... page 10
Karen August Director of Development
Preparing for the Next Big Earthquake .... page 12 Preventing (or Reducing the Impact of) Violence .... page 13
Joyce Garcia, M.S. '75 Alumni Association
Recognizing and Responding to Culture's Role in Health .... page 14 Promoting Public Health Leadership .... page 16
Jeff Caballero President, Students' Assn.
2 NEWS
Richard Elbaum Director, Health Sciences Communications
18 RESEARCH/FACULTY
20 Dan Gordon Editor
ALUMNI
Kimberly Barbis Designer/Arr Director
ON THE COVER: Populations of the Southern California region face public health problems both familiar and new. Our special section, UCLA Public Health is published by the UCLA School of Public Health for the alumni, faculty, students, staff and friends of the school. Copyright 1994 by The Regents of the University of California. Permission to reprint any portion of UCLA Public Health must be obtained from the editor. Contact Editor, UCLA Public Health , 10833 Le Conte Ave., Los Angeles, CA 90024-1772. (310) 825-6381.
beginning on page 6, looks at eight broad topics and outlines the efforts needed to combat these threats to health. Cover photos: Dave Siegle; Courtesy of Kaiser Permanente. PHOTOGRAPHY: Terry O'Donnell (pp. 4, 7); Courtesy of Kaiser Permanente (p. 8); David Siegle ("Dean's Message," pp. LO, 13, 17); Ted Soqui (p. 12); Felicia Martinez (pp. 14, 15).
Dr. Philip R. Lee
EVENT CELEBRATES THE SCHOOL'S PAST, FUTURE
I
n celebration of the UCLA School of Public Health's past and future contributions to the nation's health, a reception, lecture and presentations by prominent public health leaders have been scheduled for Thursday, June 9 beginning at 6 p.m. at the UCLA Fowler Museum auditorium and patio. Dr. Philip R. Lee, assistant secretary of the U.S. Department of Health and Human Services , will deliver the Lester Breslow Distinguished Lecture. "The future of the school is now secure and it's time to celebrate," says Dean Abdelmonem A. Afifi.
Lee was appointed by President Clinton in May 1993 to lead the U.S. Public Health Service, which includes eight federal agencies: the National Institutes of Health, the Centers for Disease Control and Prevention, the Food and Drug Administration, the Agency for Toxic Substances and Disease Registry, the Health Resources and Services Administration, the Indian Health Service, the Substance Abuse and Mental Health Services Administration, and the Agency for Health Care Policy and Research. In addition to overseeing these agencies and other offices, Lee advises and assists HHS Secretary Donna Shalala, as well as the President and First Lady, on health policies and on all healthrelated activities of the department. Lee served as assistant secretary for health and scientific affairs in the administration of President Lyndon B. Johnson. In his first two years as assistant secretary, from 1965 to 1967, Congress enacted more health legislation than all previous Congresses combined. Prior to his recent appointment, Lee was director of health services in the Agency for International Development. He has served as director of the Institute of Health Policy Studies, School of Medicine, at UC San Francisco for the past 21 years.
SEN. WELLSTONE To DELIVER COMMENCEMENT ADDRESS
S
en. Paul Wellstone (DMinn.) will deliver the keynote address at the UCLA School of Public Health commencement ceremony, scheduled for Saturday, June 18 at 5 p.m. on the Center for Health Sciences Plaza. Wellstone, a liberal activist and political science professor who had never held public office, was elected to the U.S. Senate in 1990 in a stunning upset over the incumbent, Rudy Boschwitz. Wellstone' s Ameri-
2 UCLA PUBLIC HEAL TH
can Health Security Act, which proposes a single-payer healthcare system modeled after the Canadian approach, is among the health-care reform bills currently under congressional consideration. Other commencement speakers will include Carmen T. Mendoza, M.S.P.H., representing the school's alumni association; Christine F. Edwards, M.P.H., for the student association; and Dean Abdelmonem A. Afifi and Associate Dean Susan C. Scrimshaw, who will give welcoming addresses.
UCLA (ENTER FOR HEALTH POLICY RESEARCH Is ESTABLISHED AT SCHOOL OF PUBLIC HEALTH
A
new center has been established at UCLA - based in the School of Public Health - to conduct research on health policy issues affecting Californians and the rest of the nation. The UCLA Center for Health Policy Research will emphasize collaborative research by faculty to provide information on health policy issues to legislators and to community and privatesector leaders. "California in particular has an urgent need for information and analysis on health policy issues, and UCLA's new center is designed to serve this need," says Dr. E. Richard Brown, professor of community health sciences and health services at the UCLA School of Public Health and director of the UCLA Center for Health Policy Research. "California is a large state where policy ,,,
"using both existing databases and our faculty research to develop new sources of data." The center received a $435,000 grant from the California Wellness Foundation to provide data and other information requested by California legislators, state agencies and community leaders. As a result, the center will be able to respond quickly to such requests for policy briefs, option papers, and state-level estimates of health behaviors and health services. Already, the center has released three publications a research report and two policy briefs on health insur-
members of the state Legislature, the California congressional delegation , the governor, and other elected officials. In addition to its public-service mission a nd planning ''''"'''"'"''' ,,,, 11 111 decisions have substantial ' 1111,, of providing California ~1111 1 1 11 consequences, involving the " •11 and the nation with a health of large numbers of people link to the health policy and costing a great deal of money. researchers at UCLA, the center And right now, the policy deciwill provide training opportunities sions are often made with inadefor graduate and post-doctoral stuquate information about the people dents, and will serve as a focal and the institutions they would point at UCLA for health policy affect and the impact of the poliresearchers to share ideas and colcies themselves," says Brown, a laborate on interdisciplinary pronationally known health policy jects. expert who served on the White "We believe this center will help House Task Force on Health Care to give greater focus and visibility Reform last year and has advised a to people engaged in health policy number of local, state and national work, as well as providing a point legislators and policy-makers. of contact between faculty doing "We want to provide policythat kind of research and policymakers with the best information makers locally, statewide and that's available," Brown explains, nationally," says Brown.
VALDEZ APPOINTED TO KEY HHS POSITION
D
r. Robert 0. Valdez, associate professor of health services, has taken a leave of absence from the UCLA School of Public Health to serve as deputy assistant secretary of health (designate) in the U.S.
Public Health Service and director of interagency policy (designate) at the HealthCare Financing Administration. It is the first joint appointment across the two major agencies of the U.S. Department of Health and Human Services. Valdez, who in 1993 served on the White House Task Force on Health Care Reform as co-chair of the Benefits Working Group, is the author of numerous studies on children's health and healthcare finance, as well as research on California's changing demography and the effects of immigration on the state's economy and society.
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our UCLA School of Public Health students have captured third place in the HHS Secretary's Award for Innovations in Health Promotion/Disease Prevention, a national competition among students in all health professional schools. The students David Berger, Moira Inkelas, Sonja Myhre and Alanna Mishler - received the honor for a project they completed for the Communications Development course taught by Dr. Deborah Glik, assistant professor of community health sciences. The project was a booklet called "A Parent's Guide for When Your Child Is Sick,"
BOOK FOCUSES ON HEALTH IMPACT OF TECHNOLOGICAL CHANGE ON WORKERS
" It is essential that the design of the new workplace recognize the central role of the worker in the work process. "
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new book published by the UCLA School of Public Health's Center for Occupational and Environmental Health and UCLA's Institute of Industrial Relations details the effect of new occupational technologies on worker health. Technological Change in the Workplace: Health Impact for Workers is co -edited by Marianne P. Brown and Dr. John R. Froines, professor of environmental health sciences and director of the Center for Occupational and Environmental Health. The book stems from a seminar series organized by the center on the impact of changing workplace technologies on workers' health and safety. The book includes chapters from distinguished scholars such as Dr. Nicholas Ashford from M.I.T., Dr. Barbara Silverstein from the State of Wash-
intended to assist low-literacy parents in dealing with common childhood illnesses. The booklet offers simple guidelines for home treatment, proper use of medica-
STUDENTS PLACE THIRD IN HHS SECRETARY'S NATIONAL COMPETITION
ington Department of Labor and Industries, and Dr. Steven Deutsch from the University of Oregon. "It is clear the United States must create more jobs and establish a coherent industrial policy," Brown and Froines write in the book's introduction. "At the same time, it is essential that the design of the new workplace recognize the central role of the worker in the work process, and that innovative technologies be developed and implemented to achieve that goal. We believe a production process that maximizes worker knowledge, job skill, participation, and health and safety will also maximize production and result in major improvements in quality control and resource use, which in the end will make the United States more competitive in a challenging world economy."
"A Parent's Guide for When Your Child ls Sick" is intended to assist low-literacy parents in dealing with common childhood illnesses. tions and appropriate use of hospital emergency rooms. The students were flown to Washington, D.C. to meet with HHS Secretary Donna Shalala.
DOCTORAL STUDENT WINS WHO FIRST PRIZE
Lalita Bandyopadhyay
L
alita Bandyopadhyay, a doctoral candidate in the UCLA School of Public Health's Division of Population and Family Health, won the 1993 competition on "Gender and Tropical Diseases: Facing the Challenge," organized by the Special Programme for Research and Training in Tropical Diseases of the World Health Organization in Geneva, Switzerland, and Canada's International Development Research Centre . Her paper, entitled "Lymphatic filariasis and the women of India," was based on field work she conducted in India in 1987. For winning the worldwide competition, Bandyopadhyay received $5,000 (Canadian). Her paper was published in a WHO journal and distributed as a background paper at a filariasis conference held in India. UCLA PUBLIC HEALTH 3
ilr!OijlJ:Jl(i:lÂŁ111:1
sti The UCLA School of Public Health remains standing in state funding) plans to rise to even greater heights.
•
ts mission is to assure healthy conditions for people in the region and beyond through teaching, research and community service. But the UCLA School of Public Health has also had another, central concern since June 1993: its own future. That concern is now resolved - and the news is good, bad and hopeful. The good: Discussions involving UCLA Chancellor Charles E. Young, Executive Vice Chancellor Andrea L. Rich and a four-person committee representing the School of Public Health agreed that the school will remain an independent entity rather than being "disestablished" and moving some of its departments into the School of Medicine and others into a new School of Public Policy, as had been proposed last year. The bad: As part of the agreement, the school will incur a state budget reduction of approximately 25 percent - expected to be phased in over a period of several years. The hopeful: The phase-in will allow all programs to be maintained while the school goes about recouping the lost state-funded dollars through other sources, using a model under which other schools of public health have thrived. In the most optimistic scenario, the school - ignited by private donors and its greater reliance on extramural research funding - emerges stronger than ever. 4 UCLA PUBLIC HEALTH
and) despite a reduction
Most importantly, the school remains an independent academic unit. Anything less, the committee argued, and the university could not hope to prepare students for careers in public health - in much the same way that one could not become a pediatrician without attending a medical school and learning about pathology, physiology and anatomy, for instance. "Public health has a coherent set of perspectives and approaches to dealing with health problems," explains Dr. E. Richard Brown, professor of community health sciences and a member of the committee. "Although each component is distinct, all are essential to that process." Breaking up the school and placing its pieces in other parts of the university would have meant a loss of that identity, contends Dr. Susan Scrimshaw, associate dean for academic programs and professor of community health sciences, who also served on the committee. "Very quickly, the programs would take on the character of their larger entities, and the concerted focus on community, prevention and the health of the public would be lost," she says. Scrimshaw, Brown and the committee's other two members - Dean Abdelmonem A. Afifi and Dr. Lester Breslow, professor emeritus of health services - believe the agreement reached with the chancellor and executive vice chancellor recognizes the importance of public health to society, its value on the UCLA campus and the necessity of maintaining a comprehensive school to fulfill public health's mission in the surrounding region. That's why, budget reduction or no, the school will continue to
teach and study health from the broad perspective that is at the field's core, offering the essential elements of epidemiology, biostatistics, environmental health sciences, community health sciences and health services. "Our goals have not changed," says Afifi. Practically speaking, though, the school has to deal with the loss in state funds, Afifi notes - and that's where change is likely to occur. Like some other schools of public health at public universities, UCLA's has always relied on state funding to cover faculty salaries. Private schools and most other state schools have followed another path: State or university funds create a given number of faculty positions, and then private donations and extramural research and training contracts and grants become an additional source for funding faculty salaries, enabling the number of teaching faculty to expand. (Currently, extramural funds are used for faculty salaries only during the summer months.) "Research builds on itself," says Afifi. "We bring in more people to do the research, these people bring in more funds to support not only themselves but additional people, and it becomes a self-enlarging process. That has happened at several schools of public health that have followed this model." With a phase-in of the budget reduction, says Scrimshaw, the school can use its current critical mass to generate the extramural funds needed to compensate for the future cuts. Can the extra funds be raised? Scrimshaw notes that the school has amassed a small endowment from private donors that has helped to fund important priority areas as determined by the dean and the faculty. But the nature of public health - focusing on promoting health and preventing illness more than on curing disease; on communities more than on individuals - renders fund-raising more difficult than for, say, medicine, which benefits from the "grateful patient" phenomenon. With the university gearing up for a major capital campaign, Scrimshaw says, the vocal and financial support of public health alumni and friends is needed now more than ever. Given the school's greater reliance on extramural contracts and grants, an equally significant question is whether funding agencies will offer their support. Asserts Scrimshaw: "A school that has had to justify its existence and has done so successfully is in a stronger position. We have met a challenge, and there is a lot of respect for that. I also think there is a strong sense in the funding community that public health must remain a focus, and should in fact be strengthened - and that it's important to rally behind the field." Even assuming the school's ability to make up for the lost state funds, the shift in focus required in light of the budget reduction introduces a new set of concerns. Up to now, the higher proportion of state funding relative to many other schools of public health has allowed the school to emphasize teaching in a way that those institutions cannot - faculty here have taught more courses and had more student contact on average than faculty at many other schools, Scrimshaw notes. That will likely change, with more teaching responsibilities going to visiting and adjunct faculty than has been the case so far. On the other hand, the school has long sought to bring in more community leaders in public health and other fields to lecture. That,
along with an environment richer with research activity, will make up for any possible reduction in the teaching load of full-time faculty, Afifi believes. "Our emphasis on teaching has to be protected," he asserts. "Our graduates are well-trained, highly respected and in great demand, and we will not let that change." The state support has also given UCLA School of Public Health faculty the luxury of choosing important research topics before they became popular, even if it meant more time and effort in obtaining funding. By the time faculty were publishing their data, Scrimshaw explains, their topic was in demand - and their preliminary research gave them an edge in securing additional funding. "We will lose some of that edge," Scrimshaw concedes, unless the school sees a significant increase in its private endowment. At the same time, the presence on campus of a School of Public Policy, and its close relationship with the School of Public Health by virtue of joint activities and the common interests of the schools' faculties, is likely to produce added benefits. The School of Public Health has itself established a solid health-policy track record through its health services and community health sciences departments, but the greater campuswide emphasis on public policy could provide a further boost by serving as a catalyst for additional interdisciplinary activities. The school already had strong links with faculty in urban planning and social welfare; now that those faculty will become part of the public policy school where public health faculty will be involved in the health policy studies area - those links stand to become even stronger. Courses now taught in the School of Public Health can simply be crosslisted in the new school. Meanwhile, new courses designed for the School of Public Policy are likely to become attractive options as electives for public health students. "At its best, this becomes a win-win situation, and both schools benefit from a symbiotic relationship," says Afifi . "I see this as a great opportunity," agrees Breslow. "Whether that opportunity is realized depends on how people in our school, the new school, and the UCLA administration respond - and I am optimistic about that." Indeed, to deny that the last year was traumatic would be to gloss over the obvious. But the agreement between the school and the campus administration - preserving the School of Public Health while at the same time creating a potentially strong School of Public Policy - marked the beginning of a healing process that representatives of the school believe is now well under way. "Although this is painful to us, it is really part of a pattern of reductions in state support affecting public universities throughout the nation," says Brown. "Of course it's going to hurt," adds Breslow. "But we are a strong school and can withstand a considerable cut, particularly if it is imposed over a series of years to gi ve us the chance to generate extramural funding that will offset the reduction in state support." Breslow points out that institutions that survive adversity often emerge stronger than ever. As Afifi told the Los Angeles Times: "It's easier to come back from a budget cut than to come back from the dead." •
"A school
that has had to
justify its existence and has done so
successfully is in a stronger position.
We have met a challenge, and there is a lot of respect for that."
UCLA PUBLIC HEALTH 5
wo years of national dialogue on reformi g the health-care system has fea ured ample lip service to the terms public health and prevention But i lip service all it is? That' the v· e of Dr.
A Health-y System
tion-oriented approaches, which we in this field see as the major path to health." While he is optimistic that legislators will eventuall y come around to the topic, Breslow adds, "We' re going to have to fight for it." Fielding chairs Partnership for Prevention's health reform adviSchool of Public Health, who sory comm ittee, w hich, with contends that every proposal funding assistance from the Calicurrently under congressional fo rni a Well ness Foundation, consideration fails to adequately recently issued model legislative address the nation's core public language for making prevention health and prevention needs. central to the reform effort. In "None of them says its princiaddition, the committee proposed pal objective is to try to improve a prevention standard that could the health of the American peobe used in assessing all healthple," Fielding observes. And, syste m reform proposals. T he while noting that President Clineight components of the preventon's proposal goes farther than tion standard are: its congressional counterparts, • Individual/clinical preventive Fielding laments that prevention services in the core benefit set is not central in any of the bills; determi ned by an ongoing, scienthat where indicated it only contifically objective process; cerns preventive services for • Community prevention activiindividuals, without tackling the ties of proven effectiveness; broader population-based prob• Social and economic policy lems; that the bills offer nothing changes that make unique contriin the way of community-based butions to health improvement; programs to improve health; and • A revitalized public health presence; that, with the exception of the President's proposal for a tobac• Data collection, analys is and co-tax increase to help fund his reporting that show which system plan, social and economic issues components and tactics work and related to prevention are being which do not; WHERE DOES IMPROVING THE NATION'S HEALTH FIT avoided. • Research on how to create even INTO REFORM PROPOSALS? TRUE FOCUS ON PROIndeed, others at the UCLA more efficient and effective preSchool of Public Health argue, vention services, programs and MOTING HEALTH AND PREVENTING DISEASE REMAINS health-care reform presents a policies; A DIFFICULT CHALLENGE. twofold challenge to the public • Increased numbers of primaryhealth field: helping to make it care providers with training in work in whatever shape it ultiprevention; and mately takes as a result of the political process; and continuing to pro• Public-awareness interventions that contribute to an improved undermote public health concepts that, though gaining in acceptance, are still standing of how prevention can promote good health and longevity. too often either misunderstood or ignored by both policy-makers and Regardless of whether such strategies are adopted, public health acadethe public. mics and practitioners will play a role in implementing and monitoring the new system. "Undoubtedly the bill that gets passed will be something Will prevention become paramount in the reformed system? Rhetoric would indicate that it will, but when it comes to actually spending the created by committee - a series of compromises on compromises that's likely to lack technical and policy coherence," predicts Dr. E. Richard dollars up front rather than waiting until people are ill, the strategy tends to change. "That's the problem with the Clinton bill, that it doesn't guarBrown, professor of community health sciences and director of the antee funding for the community prevention aspects it advocates," says UCLA Center for Health Policy Research. "That will make it very difficult to effectively implement it so that it provides people with good covDr. Lester Breslow, professor emeritus of health services. So far, the legislative and public discussion has focused on the ecoerage, is administratively as simple as possible, and improves the quality nomic aspects of medical services, Breslow notes - namely, the barriers of care for individuals and populations. The challenge will be how best to to access of the system and the high costs associated with care. "These accomplish that, and policy-makers will need a lot of support." Once are very important issues," he allows. "We're spending almost a trillion implemented, Brown adds, it will become important to evaluate the dollars and not doing a very good job with it. But little attention is being reformed system's effects, particularly among underserved populations. paid to health as an outcome of all of this, nor to preventive and populaAssuming the legislation that passes emphasizes managed care - as
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continued on page 17 UCLA PUBLIC HEALTH 7
Stopping the Spread
would be no need to counsel, interview or assess," Morisky explains. A second way in which AIDS education could improve, he contends, would be to place more emphasis on participatory as opposed to didactic educational programs - involving skill-building sessions, group interactions and focusgroup discussions. AIDS isn't the only infectious the principal investigator at UCLA of the disease of concern, of course. Morisky large Multicenter AIDS Cohort Study (MACS), can logically predict an has noted deficiencies in public awareness and education about tuberculosis, increasingly higher proportion of AIDS for instance. The problem is not unrecases among minorities and women. lated to AIDS. Because crowded livLess certain but still likely, Detels adds, ing conditions can contribute to its is continued progress in the treatment spread, a high incidence of the disease realm. "I don't think we'll see a cure in the next decade, but it's not unreasonable is found among the homeless population in Los Angeles; HIV infection to hope that a treatment will be develbreaks down the immune system, oped that can contain the virus so that making carriers more susceptible to individuals who are infected will be able tuberculosis. (In developing countries to lead a relatively normal life and have a in which tuberculosis is endemic, relatively normal lifespan, not unlike however, research is currently being what is currently the case for people with directed to investigate the increased hypertension and diabetes," he says. susceptibility to HIV among individuThe rising incidence of AIDS, shift in als with active TB .) Morisky would populations most impacted, and prospect like to see greater educational efforts of new and better treatments all pose significant challenges to public health. In in county health clinics and more TH E PUBLIC HEALTH FI ELD GRAPPLES health services, for instance, longer surresearch aimed at identifying effective vival will add to health-care costs. "If we ways to ensure that individuals with WITH HOW TO EFFECTIVELY EDUCATE POPthe disease adhere to their treatment. are able to keep AIDS patients alive ULATIONS ABOUT THE RISK OF AIDS, NEW longer through treatment - not only for Encouraging family members and significant others to participate in the their own survival but to keep them nonINFECTIOUS DISEASES ARE EMERGING AND home management - seeing to it that infectious - it's going to increase the OLD ONES ARE RETURNING. the patient keeps appointments and burden on the health-care system, and takes the prescribed medication, for we'll have to figure out ways to deal with instance - has proven to be a valuthat," Detels notes. And, he observes, while much effort has gone into developing an HIV able strategy. Morisky is currently studying the impact of offering incentives to patients who complete their treatment program. vaccine, he sees little evidence that a vaccine able to prevent infection Meanwhile, new viruses will continue to emerge, offering additional currently exists, leaving education as the key to preventing further spread challenges. Dr. Lawrence Ash, professor of epidemiology, worries that a of the virus. Thus far, such interventions have produced mixed results. In national shortage of broad-based infectious disease specialists, along with the major risk group in Los Angeles - homosexual men - significant government budget cuts in infectious disease surveillance, leave the behavioral modifications have resulted in reduced HIV transmission. But country susceptible to outbreaks such as that involving the hantavirus, unsafe behavior among homosexuals hasn't been completely eliminated, which first surfaced in New Mexico last year and was spread by mice, and remains a problem particularly among younger gay males who are infecting dozens of people - in some cases fatally - in a number of just discovering their sexual orientation, Detels says. states. Despite extensive publicity, Detels adds, "I don't think we've had much "That disease seemed to come out of nowhere, but in fact it shouldn't of an impact on young heterosexuals. They understand that they shouldn't be promiscuous, but they don't seem to understand what we have surprised us at all," Ash says. He blames what he views as a slower mean by promiscuous. They consider serial monogamy not to be promisresponse to outbreaks of new diseases on a narrow focus among most infectious-disease researchers. "They're working in the laboratory, at the cuity, so as long as they have one partner at a time, they feel they're not bench, doing very sophisticated molecular biology," he explains. "Few at risk." Dr. Donald Morisky, associate professor of community health sciences, are going out into the community to see what's going on, and so we're often left with nowhere to turn when something new emerges." Budget believes better results could come from more intensive education of cuts have compelled the Centers for Disease Control and Prevention, a health-care providers aimed at enhancing their sexual counseling and hisprime source for such information in the past, to eliminate important tory-taking abilities. "Providers need to ask questions about behaviors training and surveillance programs; to help compensate, schools of public that place individuals at risk, as opposed to just looking at risk groups health will need to step up their efforts, Ash contends. and assuming that if an individual doesn' t belong to that group, there
As
8 UCLA PUBLIC HEALTH
An Age-Old Dilemma
psychologist might sa~ that when it comes to flu and pneumonia vaccines are important the ong-te care needs of the elderly, we among the aged, Wallace notes that the are a nation i denial. larger concern is with aiding those who already have a chronic illness or disability. The population is aging rapidly, with the 85-and-older segme t growing faster than "That can include designing systems so that any - it is expected to triple in the next 45 people can get care in their homes; structuring rehabilitation services to try to increase yea . their functional abilities; and decreasing To l5e sure, most-elder! people are in good health, able to lead their lives independently. environmental barriers that limit their mobility" - a gentler incline on stairs, for But they are also the population most likely to have disabilities demanding special assisexample, would reduce the incidence of tance. And, with no adequate system currentdisability resulting from falls, a serious ly in place to meet their needs, the burden is problem among the aged. often falling on family members or nursing Another important issue barely addressed is differences in nursing-home use by ethhomes; the latter are expensive and rare ly ideal in quality-of-life terms. nicity. Non-Hispanic whites, for instance, "The health-care reform debate is barely are significantly more likely to be found in addressing this issue," says Dr. Emily Abel, nursing homes than African-Americans, Latinos and Asian-Pacific Islanders. "Lots associate professor of health services at the UCLA School of Public Health. Whi le the of people assume that's because family elderly are more apt to need long-term care, members in these cultures are there to provide care," says Wallace, who has studied she contends, the reform agenda has foc used the issue. "And, while you do see a higher on acute care. The difference? "Long-term care requires social services as well as medrate of family care-giving in these populaical services. There are people who need care tions, that doesn't mean there aren't unmet not because of a particular diagnosis but needs in the family unit. "We don't know why these patterns exist. because functional disabilities prevent them from conducting their daily activities." Those If, for cultural reasons, these family memneeds range from assistance in getting out of bers really prefer to provide the care, that's bed and purchasing groceries to hel p with fine. If it's because of barriers in the syshome repairs and transportation to medical tem, that's an access problem that must be addressed." appointments, Abel notes. But for a nation An expansion of in-home personal care already grappling with skyrocketing health costs, such a system would be costly - and services for the elderly - designed to proTHE FAST-GROWING ELDERLY POPUthus, Abel observes, the subject is all but vide assistance with tasks such as bathing, LATION NEEDS LONG-TERM CARE, dressing and walking - was included in ignored. Instead, policy-makers have relied on famithe health-care reform proposal advanced BUT THE HIGH POTENTIAL COST OF ly members - most often the daughters, sisby President Clinton. Whether such a proviSUCH A SYSTEM HAS POLICY-MAKERS ters and spouses of the person in need - to sion will ultimately become law as Condo the work for free. "The assumption is that AVOIDING THE ISSUE . gress considers reform proposals is debatable because of its cost, Wallace says. there's always a free-floating female in every household, a woman who is not employed "Research has looked at whether offering and is able to devote her time to caring for a sick or disabled elderly relahome care to the elderly will save money by reducing nursing-home tive," says Abel, who has studied the effects of family care-giving on the costs," he notes. "While it does lower the number of people going into women who give the care. Family members provide 70-80 percent of all the nursing homes, it doesn't actually save money. People typically put long-term care, she says. "Although some obviously want to do this no off entering a nursing home until the last minute, but if you're offering matter what, we're asking an awful lot of them." them help in their home, they'll take it before the last minute. So you end When a family member isn't available or ab le to give the time and up providing in-home care to a lot of people who wouldn't be in a nursattention required, and the family is unable to afford the expense of hiring ing home at that moment." On the other hand, Wallace adds, such care personal assistance, a nursing home is often seen as the only alternative. clearly improves the quality of life not only for the elderly person, but There, only after the person's resources have been exhausted, Medicaid also for his or her family care-giver - who is often elderly and no longer will cover the costs. Some nursing homes are very good, Abel points out; the paragon of health either. others, she adds, are inadequate. In Abel's mind, the greater welfare of both recipient and family careIn either case, few see them as anything but a last resort - including giver makes the policy well worth the expenditure. But, she asserts, little policy-makers concerned about the escalating costs of funding them. effort has been exerted to make the case to the taxpayers who would have That's why public health strategies focus on a system allowing the elderto foot the bill. ly to maintain their functional independence, says Dr. Steven Wallace, "We're totally unprepared as a nation to cope with the fact that the popassistant professor of community health sciences. "It's somewhat differulation is aging and the number of very old is growing the most rapidly," Abel says. "We're terrified of the cost issue and as a result have been ent from the classic public health priorities, which are usually around primary prevention," Wallace explains. While such primary interventions as unwilling to attempt to provide the services that are going to be needed." UCLA PUBLIC HEALTH 9
Preventing Pollution
ear y every dis ussio of the into the Santa Monic a Bay. "There's still a lot we don't environmental ch Benge facing understand ," says Dr. Irwin Southern California beg" ns with Suffet, professor of environair quality. "Despite 20 ears of mental health sciences and a con structive con ol str tegies, senior faculty member in the we still find ourse ves qu"te short of he air-qualit . goals estab Environmental Science and i=~-'"¡llShe ';:Under the Clea Engineering Program . "We have to learn more about the says Dr. Arthur Winer, professor of environmental health sciences ecology as well as inputs from at the UCLA School of Public storm drains and other sources before we can improve the Health and director of the Envibay's ecological health." Suffet ronmental Science and Engineerand others at UCLA are collabing Program, based in the school. This region continues to vioorating with the Santa Monica late the federal ozone standard Bay Restoration Project and the by more than a factor of two and American Oceans Campaign in collecting information on the harbors a serious fine particulate hazards associated with the problem, Winer explains. In a chemicals found in the bay. 1992 article pub lished in Two other water-related Science, Winer and his co-workissues vital to the region's ers concluded that approximately 1,600 Southern Californians die future environmental health are each year from exposure to fine water reuse and drinking-water particulates. "We need strategies quality, Suffet adds. As Southern California faces future to achieve clean air standards water shortages, the emergence while maintaining a viable economy and allowing for further of treatment processes for growth in the basin over the next water reuse and the develop20 years," he says. ment of criteria to judge the Many of the recent research quality of the reused water will efforts by Winer and his gradubecome crucial. Suffet and Dr. ate students have centered on the John Froines, professor of environmental health sciences at the role of the motor vehicle in creating the problems that now school, are involved in a project plague the basin. While improvcomparing the trace metals and ing congestion, the transportation organic chemicals in the water produced by a traditional treatcontrol measures that have been implemented - metered on ment plant with that produced by Aqua 3, a water reuse plant ramps and carpool lanes, for example - have done little to run by the City of San Diego. clean the air, Winer asserts. "For now, the water reuse treatInstead, he argues, the focus ments are for non-potable reuse, How TO CLEAR THE AIR , SAVE THE WATER AND CRE- but in the future, these reuse should shift to zero-emitting vehicles. "I strongly support systems could develop drinking ATE JOBS? THE ANSWER MAY LIE IN A PARADIGM telecommuting, vanpooling, water. This is one of our chalEMPHASIZING PREVENTION RATHER THAN MITIGATION . lenges," Suffet says. mass transit and other strategies While air- and water-quality designed to lessen our depen dence on motor vehicles, but issues in the area have garnered frankly I don ' t think we're going to see a dramatic drop in the 8 million considerable publicity, other critical questions have received less attenvehicles we have in this basin," he says. "Therefore, we have to try to tion, notes Froines, who is also director of the school's Center for Occupational and Environmental Health. "The effects of pesticide use in make sure those vehicles are going to be clean, which means moving Southern and Northern California is one of the least-studied, most poorly toward electric and natural gas vehicles." A separate concern focuses on understanding how air pollutants cross understood and yet one of the most serious environmental problems we into other environmental media, including water, soil and food, and idenhave. We know that the ground water in the San Joaquin Valley is contaminated by very toxic pesticides, but few are paying attention to the probtifying the routes of human exposure to toxic compounds. "Our databases are often inadequate," says Winer, "so the challenge is to develop effeclem," focusing instead on environmental contamination in urban areas. tive models and experimental data to better understand this issue." Pesticide exposure to farm workers and people living in the affected communities is "frighteningly important," Froines contends. He argues that More research is also needed on the effects of chemicals introduced 10 UCLA PUBLIC HEALTH
the issue has received inadequate attention because the people most affected cause few political ripples, and because pesticide regulators are overprotective of the industry. That raises the issue of environmental justice, a relatively new concept that Froines believes will gain momentum in the coming years. "Unfortunately, people of color tend to live in areas where we have some of the most significant environmental problems," he explains. Froines notes that in Los Angeles, for example, a corridor running south from downtown to Long Beach, heavily populated by Latinos , has an especially high concentration of industry . "Public health needs to interface with the people in these communities and provide the technical information around which II public policy can be developed: who lives there, what are the industries, what are the chemicals that are released, what are the exposures that are occurring and what are their effects on the residents of the community," Froines says . At the same time, he adds, the substantial loss of manufacturing and high-tech jobs in the region underscores the importance of addressing environmental issues in the context of their effect on jobs and economic
growth. Froines believes both can be achieved by moving toward a pollution-prevention paradigm. "Since 1970, our approach has been to manage environmental issues by putting on tall smokestacks and other devices to mitigate or control environmental releases of chemicals," Froines explains. "It seems to me we should begin to address the concept of preventing pollution rather than simply controlling it once it's created." The process redesign and technological innovation required under such a paradigm would have the simultaneous effect of creating jobs, he contends. The U .S. Environmental Protection Agency has identified such a strategy as an important goal. Froines and three other UCLA faculty members representing public health, engineering and urban plan-Or. John Froines ning recently established the Pollution Prevention Education and Resource Center on the campus; they have received significant state funding, have written books and are teaching courses on the subject. "It's clear that the single-disciplinary approach has not worked," Froines says. As such, he sees public health - with its emphasis on prevention and multidisciplinary collaboration - leading the way both in characterizing environmental problems and in conducting hazard surveillance.
"We should begin to address the concept of preventing pollution rather than simply controlling it once it's created.
UCLA PUBLIC HEALTH 11
On Shaky Ground
the 1971 Sy I mar temblor. Loma Prieta pointed out that even when hospitals don't fall down, they can lose their capacity to Northridge earthquake - the fatalisfunction, Bourque notes - whether due to tic sense that we ar all helpless to objects falling to the floor, lack of back-up the whims o Mother ature generator support or gas lines breaking and In reality, t e shakin i the only no adequate back-up system. "There's a aspect of earthqua es that can't be better understanding that hospitals have to controlled. But actions taken before, be prepared to go into an emergency during and after the temblor are mode," Bourque says, as well as a greater vitally linked to the amount of physappreciation for how the breakdown of ical and psychological damage community "lifelines" - utilities and roads inflicted. Given this, and the geolog- can lead to secondary disasters: the outical inevitability of more quakes to break of fires and the inability of fire fightcome, the public health challenge to ers to get to them, for example. the region is substantial. Other public health-related earthquake That's the opinion of Dr. Linda research focuses on psychological distress Bourque, professor of community following the event. Does the earthquake health sciences at the UCLA School itself trigger psychological disturbances? of Public Health, who has studied "There are two schools of thought," says behavioral aspects of the 1987 Bourque, who has studied the issue. "One Whittier Narrows and 1989 Loma is that natural disasters by themselves are Prieta earthquakes, and has begun sufficient to cause something like postsimilar research into the Northridge traumatic stress disorder. Another is that quake. "Our field needs to recognize while the experience is upsetting, it probathat this is indeed an area with pubbly doesn't result in a diagnosable mental lic health ramifications," Bourque illness of any sort." It's possible, Bourque says. "We haven't done enough." notes, that the real distress comes from difWith each major earthquake , ficulties in securing aid. "There's a lot of WHAT WE DO BEFORE, DURING AND AFTER researchers such as Bourque are bureaucracy involved, and the process of learning new lessons. They now EARTHQUAKES SIGNIFICANTLY AFFECTS getting assistance can be stressful," know, for instance, that preparedBourque says. "We need to look into how PHYSICAL AND PSYCHOLOGICAL HEALTH. ness and response are not everywe might be able to make things easier in ARE WE DOING ENOUGH? thing; actions taken by individuals the post-disaster period." during the event itself inf)uence Another point of interest is the role of the their fate. "We're taught to duck and cover - that an inner wall or a hallnews media. Studies show that huge numbers of people turn to the elecway is the safest place to be," says Bourque. That may be, she says, but tronic media - radio and TV - immediately after the shaking, and that not if it means navigating an obstacle course to get there. "We need to newspapers are closely followed in the ensuing days. This raises questrain people to make a quick assessment of their environment when the tions about the messages being communicated. "You get a lot of sensashaking starts and determine whether they might do better just to stay tional reports," Bourque contends. After the Whittier quake, she notes, where they are." many radio stations instructed listeners to turn off their gas. "When Evidence also suggests that people behave more safely at work as a there's no evidence of a gas leak, that's not a smart thing to do," result of work-site preparedness efforts, but that they fail to generalize Bourque says. "It could take weeks for the gas company to get there to turn it back on." that knowledge to public places or their homes. Perhaps the most common dangerous action taken at home stems from parents' instinct to get On the other hand, helpful advice over the air waves can provide an to their children during the shaking. "Parents have a tendency to want to important service, as when they implore listeners to be prepared for the protect their children to the exclusion of everything else," Bourque next one. Immediately after an earthquake there is what disaster explains, "but if the parent gets injured in the process of running to the researchers refer to as a "window of opportunity," says Bourque, during child, that's not helping." which people's heightened sensitivity makes them more likely to heed Many people also fail to realize that they are vulnerable to injury after warnings that they take steps toward better readiness. "We all talk about the quake. The most obvious time is during aftershocks, but physical it," says Bourque. "But do we do anything? In particular, do we do the injuries also occur during clean-up. In her research, Bourque found that hard things?" While evidence suggests that more people now have batthe vast majority of quake-related injuries were cuts and bruises, and tery-operated radios, flashlights and extra water and food, other hazard were likely to occur because, for instance, the person embarks on a baremitigation efforts are neglected either because they' re expensive (e.g., foot search for a flashlight after the shaking stops, not thinking about the structural reinforcements) or they' re simply time-consuming - the greatfact that pictures have fallen off the wall and glass shards cover the floor. est sources of injury are falling objects, but few go to the trouble of boltAdditional research is now focused on the distribution, timing and causes ing their bookcases or placing Velcro on their pictures to prevent them of injuries and how they can best be prevented through education. from falling. The question of hospitals' ability to operate in the wake of an earthExplains Bourque: "People tend to think ' It's not going to happen to quake first became salient when Olive View Medical Center collapsed in me,' so they don't prepare." 12 UCLA PUBLIC HEALTH
Anti-Violence Measures
hree-strikes-and-you' re-out, officials beginning to speak says D r. Susan Sorenson , explicitly of violence as a pubdoes not represent the public lic health issue. health approach to violence. Locally, the shift is perhaps The headline-grabbing new best exemplified by the VioCalifo nia law locking up lence Prevention Coalition of third-ti e violen felons is Greater Los Angeles, which "way too late" a strategy to Sorenson co-founded in 1992. effec ive y curb the everThe district attorney ' s office, growing societal problem of law enforcement, community intentional violence, says the groups, medical schools , associate director of the health departments and the Southern California Injury UCLA School of Public Prevention Research Center, Health are among the diverse which is based in the UCLA entities that have banded School of Public Health. together to develop public "Incarceration's not been health strategies for violence shown to deter anything ," prevention. Other cities across notes Sorenson, who is also the nation have begun using the coalition as a model in an adjunct associate professor developing their own groups. at the school. "For the first time, we have Seen from the public health law enforcement officials sitperspective, the intervention ting down with a university should occur before the violence takes place - or should researcher, who's sitting down at least reduce its lethality, as with prosecutors, who are sitin limiting access to firearms. ting down with health department officials, who are sitting "We might not be able to stop down with a gang worker, people from beating each who's sitting down with a forother up, but we can at least mer gang member, who' s sittake measures to prevent peoting down with someone from ple' s anger from resulting in a battered women' s shelter death," Sorenson says. with everyone looking at vioViolence as a public health lence from a broad perspecissue ? While Sorenson is tive," Sorenson says. "That's among those who have very important." In April, the framed it that way for some time, she didn't always have coalition sponsored a peace much company. "It was seen march focusing attention on victims lost to the "war on the either as a law-enforcement streets." issue, an interpersonal problem, or a social problem, but At the school ' s Injury Prenever a public health probvention Center, Sorenson and ONCE SEEN AS THE TERRAIN SOLELY OF LAW ENFORCElem," Sorenson says . Much others are studying a wide MENT, VIOLENCE HAS EMERGED AS A PUBLIC HEALTH like car crashes, violence was range of issues relating to vioISSUE WITH AN INCREASING EMPHASIS ON INTERVENlence and violence prevention, just something that happened from homicide of Los Angeles to people - and was dealt ING BEFORE THE FACT. children to violence against with only after the fact. women. Sorenson ' s course on But traditional approaches family and sexual violence, have done nothing to slow the which she has taught since 1986, was the first of its kind at a school of rising toll of violent deaths. The nature of the problem has changed with public health, and the school currently offers several courses on intenthe proliferation of firearms, Sorenson contends; from 1984 to 1987, for tional injury and violence. Sorenson is also the training director of a vioinstance, the rate of homicide in which the victim was a young black lence prevention fellowship at the school in which pre-doctoral students male doubled, with shootings alone accounting for the increase. Public conduct research independently and work with the Violence Prevention officials began searching for alternatives - Sorenson points to the Los Coalition. Angeles Police Department's "DARE" (Drug Abuse Resistance EducaResearch is crucial for its ability to lead to better understanding of the tion) as one example. "They realized that if they waited until people were nature of the problem. As an example, Sorenson points to a recent article dealing in and addicted to drugs, it was too late." And in the last two published in the New England Journal of Medicine indicating that years, Sorenson reports, "a radical shift" has taken place, with elected Continued on page I 7 UCLA PUBLIC HEALTH 13
Cultural Consideration
Trial, now receives calls almost n a society that Jong promoted every day from organizations cultural diversity as a melting interested in the videos. "This pot - a slew of backgrounds approach can be used in many blended together as one - it's community-outreach situations," not s rprising that Dr. she contends. "Most urban areas Antronette Yancey's simple , are becoming more diverse culinexpen ive yet highly effective turally, and it's not always posstrateg~ for promoting cancer sible to have staff on hand who screenin s in African-American can address each culture in the aod_.Latina omen had not been most effective way." tried. "Increasingly, we' ve come to Rea l izing that low-income terms with a model of acculturawomen of color were underutition in which people absorb a lizing early cancer detection certain amount of generalized programs such as mammograAmerican culture but also retain phy and Pap smears, Yancey, an - and sometimes even strengthadjunct assistant professor at the en - their familial culture, " UCLA School of Public Health, says Dr. Susan Scrimshaw, prodecided to test whether playing fessor of community health scieducational videotapes in the ences and associate dean for waiting rooms of public health academic programs at the clinics in Los Angeles and New UCLA School of Public Health. York City would inspire more "We see that not only with new women to get screened. immigrant populations, but also Yancey also recognized somewith African-American, Latino, thing else: Health-promotion and Asian populations, even messages delivered through the when they have been here for electronic media, while holding generations." The melting-pot enormous potential to change concept is being discarded , behaviors, had invariably failed Scrimshaw asserts, in favor of a to affect women of color - and view of cultural diversity as a it appeared that the reason was strength. their inability to identify with But diversity also has strong the content. health implications, notes DIVERSITY HAS HEALTH IMPLICATIONS, DEMANDING A So for her study, Yancey proScrimshaw, an anthropologist duced Spanish- and English-lanBROADER VIEW OF HEALTH EDUCATION AND DELIVwho has focused in much of her guage videotapes on breast and ERV. ONE SIZE DOES NOT FIT ALL. work on the role of culture in cervical cancer that were culturmaternal/child health and reproally relevant to her audiences, ductive health. As research by the African-American and LatiScrimshaw and others at UCLA and other schools of public health has na women who make up roughly 90 percent of the patient population at demonstrated, health outcomes often vary widely by ethnicity and acculthe clinics she targeted. turation. Differences have been found in levels of immunizations, in birth To be culturally relevant, Yancey chose spokespersons who shared the weights, and in incidence of diabetes and heart disease, for example. audience's ethnicity - promoting identification with the video subjects "Many have biological bases, and it becomes an epidemiological quesand thus personalizing the risk. The language was made accessible: "It's not that there was a lot of slang," Yancey explains, "but every cultural tion to identify people at risk, with other public health disciplines then determining how to go about prevention and treatment, and how to direct group has its own set of colloquialisms and nuances of speech that make health education and health services in culturally appropriate ways for the them identify more with the speaker." Finally, the locations were familiar people who use them," Scrimshaw says. "In other cases there is a behav- street footage in the introductory portions was of places where viewioral cause - either alone or in combination with the biological - and ers had been or to which they could relate. we need to face issues of culturally learned health behaviors and interacYancey was able to demonstrate that women who were at the clinics on tions with the health system." In either instance, explains Scrimshaw, days when the video was available were significantly more likely to health services and education cannot be delivered in a one-size-fits-all return for a mammogram or Pap smear. "There wasn ' t even a guarantee manner. Then there are the effects of racism, showing up in everything that all of the women in the intervention group would see it," she says. from stress and violence to health-care access problems stemming from "We didn ' t corral them into a room; the videos were just part of the clinpoverty and stigma. ic's ambiance." Yancey explains that "it was important to establish that None of these occur in isolation, which is why Scrimshaw argues that we could have an impact with a minimal resource intervention." public health academics and practitioners need to view health problems Yancey, who also produced public-service announcements using cherished African-American and Latino celebrities to encourage women in in a broader context. If members of a low-income population aren't attending a clinic in high numbers due to Jack of transportation or child those communities to participate in the ongoing Breast Cancer Prevention 14 UCLA PUBLIC HEALTH
care, the problem shouldn't be seen solely in economic terms. "We can't say, Tm a health-care provider; that's not my problem.' If they're not getting to the clinic, it is your problem," Scrimshaw insists. Violence on the streets? "When kids are dying, we can't say that's not our problem either. "There is a very strong sense, particularly in the African-American and Latino communities, that to see our traditional health issues out of the context of racism, poverty and violence is to close our eyes to the problem - and that in itself is seen as racist." In the past, Scrimshaw contends, these communities have often felt exploited by university researchers, used as laboratories without concern for their well-being. That 11 has begun to change, and Scrimshaw hopes a project she is currently involved with will soon represent the norm. The Healthy African-American Families Project, funded by the Centers for Disease Control and Prevention, aims to describe the sociocultural, psychological, and behavioral influences on maternal health during pregnancy and on pregnancy outcomes in two African-American neighborhoods in Los Angeles, as well as the social, cultural and physical-environmental contexts in which pregnancy occurs in these populations. Distinguishing the project from traditional public health research is the level of community involvement. Volunteers from the neighborhoods -
both health practitioners and community activists - have formed an advisory board that has shaped everything from the types of questions asked to how they're asked and of whom. "Every word we write has to have the board members' input and approval on behalf of the community," Scrimshaw says. "They have become involved with this project to the extent that they feel responsible for its success or failure. "It's no longer the same project," Scrimshaw notes. "We originally had thought that we would hire men and women from the community to serve as liaisons who would work alongside our research staff. They very quickly became our research staff. They wanted more than what they considered to be a perfunctory role." As the principal investigator, Scrimshaw still Dr. Susan Scrimshaw plays an important part ensuring that the proper issues are addressed and lending her research expertise. But she now sees herself as a facilitator, exerting less control than she has in past research. "We're learning about the community through them and they're learning about the university through us," she observes. And, while the community researchers might not produce the type of polished data sets that would come from university-trained ethnographers, "the information has a much richer, more honest feel to it," Scrimshaw says. "We' re getting very accurate, valid data. It's not always beautifully presented, but who cares? It's real."
"There is a very stong sense that to
see our traditional health issues out of the context of racism, poverty and violence is to close our eyes to
the problem.
UCLA PUBLIC HEALTH
15
Looking for Leaders
ven the nobles ¡ tenti(i)nS for activities, they developed the meeting the public health chalcourse for the School of Public lenges facing the region are Health's Department of Health Services and offered it for the doomed without that intangible quality that man rn the first time in the 1992-93 acadefield belie e is ins ort supply. mic year; now in its second LeadershiJ2. year, the course is being taught The lac thereof was noted by Andersen, Lammers, and in the influential 1988 InstiDr. Jonathan Fielding, profestute of Medicine report on sor of health services. public health's future. It was How does one teach leaderthe impetus behind the formaship? Andersen concedes it's tion in California of the Public not an easy question to answer. Health Leadership Institute, "But we do know that there are forged in 1991 by the U.S. leaders who have a career Centers for Disease Control development pattern, a philosoand Prevention, the University phy of leade rship and some of California, and the Western issues to raise about what our Consortium for Public Health concerns should be in health - a coalition representing the services and public health," he schoo ls of public health at says . As part of the co urse, UCLA, UC Berkeley and San then, these leaders, representing Diego State University. The a broad range of managerial institute offers a year-l ong and policy-making positions, program for public health offiare brought to the school to leccials from state and local ture and discuss their philosoagencies designed to bui ld phies with the students. their leadership skills, includThe other component emphaing a one-week intensive sizes organizational processes: training experience in an enviThe students, who are required ronment offering opportunities to have had previous work for discussion and debate with experience, are given personal colleagues. assessments designed to point " In terms of our concerns out their strengths and chalabout health-care delivery lenges in leadership developcost, access an d quality ment. Then they're asked to there are clearly major probassess leadership in an organilems , some of which are zation with which they are becoming more pronounced, familiar. that suggest we need some Another leaders hip effort new ideas, new vis ions and involves students at the underWANTED: VISIONARY, INNOVATIVE, PERSUASIVE PUBnew directions," says Dr. graduate level. The UCLA Ronald Andersen, the Fred W. School of Public Health and LIC HEALTH PROFESSIONALS TO ENSURE THAT THE and Pamela T. Wasserman Kais e r Permanente Medical FIELD'S MISSION IS CARRIED OUT. (THE SCHOOL'S NEW Professor of Health Services Care Program annually sponsor at the UCLA School of Public Public Health Leadership ConCOURSE WILL HELP.) Health. Not only is leadership ferences for 180 Latino, sorely needed to channel more African-Ameri can and Native resources toward public health American Indian seniors at targoals, but leade rs need to ensure that the most is gotten out of the geted universities in California. Kaiser executives, UCLA School of Pubresources available, Andersen suggests. lic Health faculty and students from the school ' s Health Careers OpporWhen Andersen was recruited to the school in 1991, he made the comtunity Program (HCOP) serve as mentors for the participants at an intenmitment to develop a leadership course as the capstone of the Dr.P.H. sive, three-day conference designed to develop the leadership skills necprogram, a doctoral track for public health practitioners as distinguished essary for successful future careers in public health. from the Ph.D. program, which is oriented toward research and teaching. "There is a great need for more minority leaders in the field of public So Andersen and Dr. John Lammers, adjunct associate professor of health, especially to work in the communities where they grew up and health services, began assisting the Public Health Leadership Institute with which they are familiar," says Marissa Cortes, director of HCOP. with its efforts to identify and impart leadership principles to public "Our goal in the conferences is to raise awareness among these students of the possibilities in public health." health practitioners at the local governmental level. Building on those
CHALLENGE
16 UCLA PUBLIC HEALTH
A HEALTH-Y SYSTEM continuedfrompage 7
"I don't minimize the importance of providing universal coverage - we absolutely have to, and it can contribute to improved health for the uninsured. But we can go well beyond that. " - Dr. Jonathan Fielding
most bills under consideration do - California will be better positioned to make the transition than others, given that managed care is already a fixture in much of the state. But, Brown says, substantive change in the system will not come easily. Providing universal coverage will require creating mechanisms for all individuals to become enrolled and to ensure that employers are contributing what is required by the new law. Subsidies will have to be adopted. Most of the bills call for health alliances or purchasing cooperatives to be organized. Administration will likely be somewhat streamlined. "Every interest group is going to be affected by whatever kind of reform we settle on, if it's meaningful," says Brown, who served on the White House Task Force on Health Care Reform. He believes a shift toward the public health paradigm has already begun, driven by cost-containment pressures. Certain elements under consideration, if passed, could offer an additional push. But, Brown adds, "It moves very slowly and there' s tremendous resistance." Overcoming that, Breslow suggests, will require better educational efforts by the public health profession. "People still tend to think of health care as something that is done for them when they become ill," he says. "Medical services are important, but probably more fundamental is that we assure the conditions in which people can be healthy." "It's just not true that the health-care system is the major way we maintain and improve our health," says Fielding. "It's one aspect and we're spending almost a trillion dollars on it, so people are tinkering around with the financing mechanisms. I don ' t minimize the importance of providing universal coverage - we absolutely have to, and it can contribute to improved health for the uninsured. But we can go well beyond that."
ANTI-VIOLENCE MEASURES continued from page 13 women are two-and-a-half times as likely to be shot by their husbands as they are to be shot, stabbed, beaten or in any other way killed by a stranger. "That's major news, because the crimi nal justice response has been to protect us from strangers," she notes. "Meanwhile, the firearms manufacturers are targeting women as an untapped market, and they're doing it by exploiting women's fear of strangers, even though women who bring guns into their homes are actua 11 y increasing their risk of homicide." While that message needs to be better communicated, Sorenson says, it's not always enough. "People are afraid, and right now we don't have many alternatives to that fear." Limiting access to firearms - one example of a public health approach to violence prevention - would represent a step in that direction. • UCLA PUBLIC HEALTH 17
Some of the new and ongoing studies at the UCLA School of Public Health.
Health Promotion for Immigrants Dr. Alfred H. Katz, professor emeritus of community health sciences, has received funding from the Barclay Foundation to study "Mutual Aid Organizations' Use in Health Promotion for Immigrants."
Back Supports for Material Handlers in California Dr. Jess F. Kraus, professor of epidemiology and director of the Southern California Injury Prevention Research Center, received funding from the State of California, Department of Industrial Relations for "Evaluation of Back Supports in Material Handlers in California." Current OSHA or state regulations do not require personnel in material handling operations to use any purported injury prevention devices. This project seeks to provide evidence of the effectiveness of back supports to prevent low back injury in material handlers in the home center industries in California.
AIDS Education/Prevention for Mexican-Americans Drs. Donald E. Morisky, associate professor of community health sciences, and Emil Berkanovic, professor and chair of community health sciences, have been awarded a grant from the Universitywide Task Force on AIDS to assess psychosocial and cultural factors underlying HIV I AIDS ed ucation and prevention for Mexican-American popul ations. The collaborative study includes faculty from UCLA and faculty from the University of Guadalajara in Mexico.
Statistical Methods in AIDS Research Dr. Nathaniel Schenker, associate professor of biostatistics, is co-investigator (Dr. Jeremy M.G. Taylor, associate professor of biostatistics, is the principal investigator) of "Statistical Methods in AIDS Research," funded by the National Institute of Allergy and Infectious Diseases through 1996. He is a specialist focusing on sampling and missing data for "Variation in Physician and Patient Use of Mammography," funded by the Agency for Health Care Policy and Research, also through 1996.
Medicare Screening and Health Promotion Dr. Stuart 0. Schweitzer, professor and chair of health services, is continuing research on "The Passport to Health," the UCLA Medicare Screening and Health Promotion Trial. The six-year project, ending July 1, 1994, has focused on the participation of the elderly in health promotion and disease prevention activities, and the effects of that intervention in health behaviors, health-care utilization, and health expenditures. Funding has come from the HealthCare Financing Administration. Schwe itzer is also involved with the Research Program in Pharmaceutical Economics and Policy, which sponsors a year-long seminar series to which prominent pharmaceutical policy researchers are invited to present current research. Schweitzer recently completed two papers (currently under review) , one comparing the timing of new drug approvals in France and the United States, and the other comparing the timing of approvals in 11 countries, including the United States, Canada, and European nations. His research found that
the United States does lag behind other countries in the approval of important new drugs, but that the lag time is not as large as has been suspected.
Long-Term Care Use by Minority Elderly Dr. Steven P. Wallace, assistant professor of community health sciences, and Dr. Ronald Andersen, the Fred W. and Pamela T. Wasserman Professor of Health Services, continue to work with data from the National Medical Expenditure Survey in examining the use of long-term care services by minority elderly. Their current presentations and writing are focusing on the consequences of long-term care financing reform on African-American and Latino elders. They are also investigating the causes of racial and ethnic differences in the pattern of longterm care use (i .e., the lower use of nursing homes by AfricanAmerican and Latino elderly, and the lower use of supportive homecare services by African-American elders). Wallace is evaluation principal investigator of "Women in Action for Health," a three-year pilot health education and community development program for women older than 50. The program, funded by the California Wellness Foundation, is conducted by the Santa Monica Senior Health and Peer Counseling Center with the Samoan and Native American communities in Los Angeles County.
A sample of the recent publications, presentations and awards of the school's faculty. Dr. Emily Abel, associate professor of health services, won the American Sociological Association 's " Distinguished Contribution to Qualitative Gerontology Award" for her book, Who Cares for the Elderly? The award was presented by the association's Research Committee on Qualitative Approaches to the Study of Aging. Dr. Lawrence R. Ash, professor of epidemiology, has collaborated on a new publication for the World Heal th Organization's Division of Communicable Diseases, Bench Aids for the Diagnosis of Intestinal Protozoa. The publication follows up on a previous one on the diagnosis of intestinal helminths and is to be used in laboratories in developing countries for the diagnosis of parasitic infections. He has collaborated on a new book, to be published by the ASCP Press this summer, on the diagnosis of parasitic infections in human tissues. The new atlas will have more than 800 color photomicrographs of a wide range of human parasites. Ash has helped to provide workshops in diagnostic parasitology in collaboration with the Mayo Clinic and the Tulane University School of Public Health and Tropical Medicine. Dr. Jonathan E. Fielding, professor of health services, wrote "Lessons from France - 'vive la difference': The French health care system and U.S. health system reform" and "Immunization status of children of employees in a large corporation" (Journal of the American Medical Association); and "Preventing colon cancer: Yet another reason not to smoke" (Journal of the National Cancer Institute). Dr. Osman Galal, professor of
18 UCLA PUBLIC HEALTH
community health sciences, has been elected as a member of the council of the International Union of Nutritional Sciences during the International Nutrition Conference held in Adelaide, Australia last September. With the Gustave von Grunebaum Center for Near Eastern Studies, Gala! helped to convene a workshop in Cairo recently to discuss health in transition among displaced Israeli and Palestinian populations. Seven UCLA faculty and health officials in the Palestinian Red Crescent along with Israel's health director were invited to participate in a workshop to discuss health priority issues and ways of promoting the health of Palestinians.
Dr. William Hinds, professor of environmental health sciences, wrote "The effect of respirator dead-space and lung retention on exposure estimates" (Journal of the American Industrial Hygiene Association) and "Inhalability and sampler performance for large particles" (Proceedings of the 1993 International Conference on Aerosol Science and Technology). Hinds co -presented "Aerosol Inhalability and Personal Sampler Performance in the 10-145 Âľm Particle Size Range" at the American Association for Aerosol Research 12th Annual Meeting; "Health and Safety Conditions in the Maquiladora Auto Parts Industry in Mexico" at the 121 st APHA Annual Meeting; and "A Dual-Port Smoking Machine for Simulating Human Smoking" at the First Scientific Conference of the Tobacco-Related Disease Research Program. In January, he was elected a fellow of the American Industrial Hygeine Association. Patrice E.F. Jelliffe, lecturer and researcher in community health sciences, received an award from the White House last December as one of six "American heroes who have dramatically improved the health of the world's chil dren." She is completing work as editor and author of the 6th Edi-
tion of Child Health in the Tropics (London: Edward Arnold).
Dr. Alfred H. Katz , professor emeritus of community health sciences, is having a Japanese translation of his 1993 book, Self-Help in America: A Social Movement Perspective, published by Iwasaki Gakujyutu Shuppausha, Tokyo. German and Hungarian translations are also being considered. Dr. Jess F. Kraus, professor of epidemiology and director of the Southern California Injury Prevention Research Center, wrote "Epidemiology of Spinal Cord Injury" in Principles of Spinal Surgery (McGraw -Hill, 1994); "Epidemiology of Mild Brain Injury" in Seminars in Neurology, 1994; "Compliance with the California 1992 motorcycle helmet use law" (American Journal of Public Health); "Fatal injury patterns in motorcycle riders by helmet use" (Journal of Trauma); "Lower extremity injuries from motorcycle crashes: A common cause of preventable injury" (Journal of Trauma); and "Effect of immediate resuscitation on childhood outcomes after aquatic submersion injury" (Pediatrics). Dr. Shane Que Hee, associate professor of environmental health sciences, was named a member of the Biological Monitoring Committee of the American Industrial Hygiene Association and of the American Public Health Association's Standard Methods for Water and Wastewater. Dr. Thomas Rice, associate professor of health services, testified before the U.S. Congress, Committee on Ways and Means' Health Subcommittee in February on "Alternative Health Reform Proposals." Dr. Milton I. Roemer, professor emeritus of health services, was presented the 1993 Edward K. Barsky A ward by The Physicians Forum "for his leading role in promoting international under-
standing through the study and teaching of public health and health care system organization."
Dr. Nathaniel Schenker, associate professor of biostatistics, wrote "Analyses of public-use decennial census data with multiply-imputed industry and occupation codes" (Journal of the Royal Statistical Society, Series C); "Undercount of the 1990 census" (Journal of the American Statistical Association); and "Multiple imputation for threshold-crossing data with interval censoring" (Statistics in Medicine). He was the editor of "Special Section on the 1990 Undercount" for the Journal of the American Statistical Association. Schenker presented "Logistic Regression with Missing Predictors" at the Joint Statistical Meetings last August. Dr. Mel Suffet, professor of environmental health sciences, presented four papers at the symposium "Physical -Chemica l Pro cesses Controlling Contami nation and Mobility in Aquatic Environment" for the Environ mental Chemistry Division of the American Chemical Society, 207th Meeting in San Diego in March. The presentations were "Behavior of Hydrophobic Organic Contaminants in Sedi ments," a keynote paper co authored by students James Noblet and Kathy Hunchak-Kariouk; "Simulation of the Environmental Fate of Selected Pesticides in Agriculture Drains in the San Joaquin River Basin," coauthored by students Lynda Smith and Noblet; "Site Specific Abiotic Hydrolysis and Sediment Water Partitioning of Pesticides in Agricultural Drainage Water vs. Laboratory Water," co-authored by students Noblet and Smith; and "Trace Hydrophobic Organic Pollution from Non-Point Sources into Santa Monica Bay D uring Dry Weather Flow," co-authored by Dr. John Froines, professor of environmental health sciences, Dr. Michael Stenstrom and Ed Ruth of UCLA's Department of
Civil and Environmental Engineering, and students Linda Schweitzer and Mario Capangpangan.
Dr. Jane Valentine, associate professor of environmental health sciences, wrote "Daily selenium intake estimates for residents of arsenic-endemic areas" (Environmental Research); "Dietary Zinc Intake in Arsenic -Endemic Areas" and "U.S. Drinking Water Intake Estimates" in Trace Elements in Man and Animals; and "Health risks from contaminated water: Do class and race matter?" (Toxicology and Industrial Health). Dr. Steven P. Wallace, assistant professor of community health sciences, wrote "The contribution of public health to gerontology: An evaluation of public health curricula on aging" (Gerontology and Gerontology Education). He co-presented "Racial Differences in Long-Term Care: Needs and Policies" at the MultiCampus Program in Geriatrics and Gerontology, Sepulveda VA GRECC in February; and "Minority Elderly Access to LTC: Implications for Health Care Reform" and "The Impact of Race on the Use of Long-Term Care: Policy Implications of Understanding Lived Experiences" at the annual meetings of the Gerontological Society of America in New Orleans last November. Dr. Arthur Winer, professor of environmental health sciences and director of the Environmental Science and Engineering (ESE) Program, authored "Effects of in-use driving conditions and vehicle/ engine operating parameters on "off-cycle" events: Comparison with federal test procedure conditions" with two ESE doctoral students, Michael J. St. Denis and Pablo Cicero -Fernandez , and James W. Butler and Gerald Jesion of the Ford Motor Company in Dearborn, Mich. The paper was published in Air & Waste. • UCLA PUBLIC HEALTH 19
David Stevenson, B.S. '56, D.D.S., graduated from Case Western Reserve with a D.D .S. degree. He served as a U.S. Navy Captain in the U.S. Public Health Service Reserve. Currently, he is in private practice and is a clinical professor at the USC School of Dentistry . He is married to the former Susana Martinez (UCLA ' 56) and has two children, Mark and Maria. Kenneth W. Kizer , M .D. , M.P.H. '76, was the recipient of the 1994 CAHMO Foundation Health Promotion Award, given annually to a Californian who has made significant contributions in the field of health promotion , wellness and preventative medicine. Kizer is currently chairman of the board for the California Wellness Foundation and professor and chair of the Department of Community and International
SAMUEL
Health at the UC Davis School of Medicine. Virginia Hight Laukaran, M.P.H., Dr.P.H. '78, is a senior associate for research at Georgetown University ' s Institute for Reproductive Health. She directs an international research program on fertility and breastfeeding, including a multicenter study of a new family planning method. Christine Oakley, M.P.H. '79, has decided to return to school after 14 years of health education work. She is now a full-time Ph.D. student in sociology at Washington State University in Pullman. Her areas of interest: medical sociology and organizational theory. Stephen Robinson, M.D., Ph.D. , M.P.H. '79, is working for Project Concern International (PCI)
J. TIBBITTS, 1924-1994
Samuel J. Tibbitts, B.S. ' 49, a leader in the health-care industry for more than four decades and chair of the UCLA School of Public Health Dean's Advisory Board since 1990, died on March 20 in his San Marino home. He was 69. Tibbitts was an innovator who helped pioneer cost-saving health delivery systems. He was chairman of the board of UniHealth America, the second-largest multi-hospital system in California, from 1988 - when he helped to create it through the merger of the Lutheran Hospital Society of Southern California, of which he was president, and HealthWest - until his death. Tibbitts also founded PacifiCare Health Systems, one of the nation's first major health maintenance
20 UCLA PUBLIC HEALTH
in the Moluccas as project director. He was recently promoted to Asia Regional Technical Adviser responsible for technical assistance to PCI programs throughout Asia. He has been in Indonesia for more than five years. John Newport, Dr.P.H. '82, is director of contract development for the Harbor-UCLA Medical Foundation, which is the private practice arm of the full-time teaching medical staff of the Harbor-UCLA Medical Center in Torrance. Prior to his current position , he served for several years as a marketing director for Community Psychiatric Centers, Inc. Concurrent with that position, he authored a number of articles published in The California Therapist and the EAP Digest, dealing with stress factors associated with the Persian Gulf War, as well as with coping with per-
sonal and family stress factors related to unemployment. He currently lives in Santa Ana, Calif., with his wife, the former Ann O'Reilly. Alfred J. Zerfas, Dr.P.H . '85, has for the past two years consulted for UNICEF in reviewing annual country reports, programs and national plans of action, and preparing graphics, including a training manual. Other recent consultancies included support for UNICEF/Albania ; student training at the University of Queensland, Australia ; World Bank/Pakistan for nutrition; quality control procedures for NCHS in Pakistan; USAID/India in evaluating a project to support the Integrated Child Development Service; USAID/Manila for Nutrition Programming; and the Academy for Educational Development (Washington, D.C.) in the
organizations, and served as its vice chairman . He founded and chaired American HealthCare Systems, a group of 32 hospital systems nationwide that formed the country's first preferred provider organization, Woodland Hills, Calif.-based PPO Alliance. Stephen W. Gamble, president of the Hospital Council of Southern California, told the Los Angeles Times: "More than any other person, Sam Tibbitts has shaped and guided the evolution of health care over the past 40 years." Tibbitts received a bachelor's degree in public health at UCLA and a master's degree in public health and hospital administration at the UC Berkeley School of Public Health. His career included administrative tenures at California Hospital Medical Center, Santa Monica Hospital Medical Center, and Blue Cross of Southern California. He served stints as president of the California Association of Hospitals and Health Systems and the Hospital Council of Southern California, as chair of the American Hospital Association Board of Trustees, as commissioner of the Joint Commission on Accreditation of Hospitals, as delegate to the White House Conference on Aging, and as chair of the American Hospital Association National Political Action Committee. UniHealth America gave Tibbitts its Pinnacle Award with the inscription: "For his passionate concern for the human family and a lifetime contribution toward the enrichment of the nation's health care community." In 1992, the UCLA School of Public Health received a gift of $100,000 from Samuel and Audrey Tibbitts to establish a fund for health services research on issues related to access, cost containment, and quality of care. Dr. Ronald Andersen, the Fred W. and Pamela T. Wasserman Professor of Health Services, directs the research activities supported by the Tibbitts fund.
design of an interactive computer package (PROFILES) for national nutrition policy, planning and interventions, being tested in Bangladesh. Special concerns include local information use for decision-making/action and use of policy/advocacy tools.
HAVE YOU MOVED? If so, please give us your new address and return this form along with your old mailing label (on the back cover of this magazine). If you are not presently on the mailing list, please give your address and indicate "new entry."
Gary Meunier, M.A., D.Env. '86, has joined Ha mid Rastegar, D.Env. '81 , and M. Alan Joncich, D.Env. '78, at Aspen Environmental Group (Agoura Hills, Calif.) as a partner. Meunier previously worked at Jacobs Engineering Group, where he was a senior scientist and project manager. He wi II manage Aspen's environmental assessment program.
Year of Graduation
Chris Hafner-Eaton , M .P .H. ' 88 , Ph.D. ' 92, is an assistant professor at Oregon State University , Department of Publi c Health, and is director of the Health Care Administration Prog ram. Her work has recently been published in the Journal of the American Medical Association a nd the American Behavioral Scientist, and she has written chapters for several books . Currently, she is running research projects on maternal and child health, the uninsured, and chiropractic outcome comparisons with orthopedic treatment.
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Alan L. Bu chman, M.S.P.H. ' 93, was named medical director of nutrition support services at Methodist Hospital/Baylor Col lege of Medicine. He is also an assistant professor of medicine at the college.
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Thomas W. Wilson , Dr.P.H . ' 93, is an epidemiologist at M.I. Basse tt Hospital a nd assistant professor of clinical public health (epidemiology) at Columbia University . He resides in Cooperstown , N. Y. , with his wife, Dorothea, and daughter, Anna. •
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