UCLA Public Health Magazine - 1995 by UCLA Fielding School of Public Health

UCLR Public Health VOLUME

14,

NUMBER

1995

ISSUE

Students have followed a variety of paths to get here, and that has made all the difference.

YEAR HAS NOW PASSED SINCE WE SURVIVED the scare in which our school's future existence was in doubt, and I am pleased to report that the past I 2 months have provided a good period of return to normalcy. Our focus since we secured the school's future as an independent entity has been to find ways to compensate for the reduction in the state-funded portion of our budget. On the one hand, we are experiencing a soft landing: The loss of state funds did not have a negative impact on the academic programs of the school this year, thanks to the transition funding that the chancellor has supplied. (The state budget cuts are being phased in over three years.) At the same time, we realize that, in the long term, we must replace these lost state revenues with extramural funding. For that reason, our faculty are redoubling their efforts to obtain additional contracts and grants, and we are moving strongly to vitalize our fund-raising efforts. We have brought in a capable new development director, John Miller, to lead this push (see page 3). As this issue of UCLA Public Health illustrates, our school can never be found wanting in the area of human resources. Our students continue to make as compelling a case as you'll find for the riches offered by a dedicated and diverse groupnot only culturally and ethnically, but also in the wide-ranging life experiences they bring to the school. We continue to offer a curriculum that is on the vanguard of modern public health practice, addressing important issues ranging from violence prevention to disaster response when they are rarely (if at all) covered in other schools of public health. Our faculty continue to take center stage in public health research and public health practice, working locally, nationally and internationally toward improving the health of populations. Our alumni continue to hold a variety of important and influential positions at the forefront of the fight for health. In short, we are continuing to bolster our efforts to face a public health challenge that is growing larger each day.

C. DR. ABDELMON EM A. AFIFI

UC~A Public Health VOLUME 14, NUMBER I, 1995 ISSUE

Abdelmonem A. Afifi, Ph.D. Dean ID

EDITORIAL BOARD Abdelmonem A. Afifi, Ph.D. Dean Judith M. Siegel, Ph.D . Associate Dean for Academic Programs V. Gale Winting Associate Dean for Administration

FRIENDS

NEWS

Lawrence R. Ash, Ph.D. Associate Dean for Student Affairs William Hinds, Sc.D. Professor of Environmental Health Sciences Glenn Melnick, Ph.D. Associate Prefessor ef Health Services

INFECTIOUS DISEASES The fight against a resurging enemy is exemplified by the work of these five faculty.

WORLD WISE

John D . Miller Director ef Development Corinne Peek, M.P.H. Alumni Association

Students need exposure to how culture influences health-related behaviors. They're getting it here-and abroad.

'91

Imee Diego President, Public Health Students Association Richard Elbaum Director, Health Sciences Communications Warren Robak Public Information Representative

Dan Gordon Editor and Writer

IN A CLASS BY THEMSELVES At the UCLA School of Public Health, some of the most interesting lessons come from the students.

FACULTY

ALUMNI

Clay Doyle Design Group Art Direction UCLA Public Health is published by the UCLA School

UCLA Public Hea llh

of Public Health for the alumni, faculty, students, staff and friends of the school. CopyrightÂŠ 1995 by T he Regents of the University of California. Permission to reprint any portion of UCLA Public Health must be obtained from the eclitor.

Contact Editor, UCLA Public Health, rn833 Le Conte Ave., Los Angeles, CA 90095-1772

(310) 825-6381

ON THE COVER: How could we choose a typical student for our cover on the school's atypical student population? We couldn't, so here are several. As suggested in "In a Class by Themselves" (p. 12), the diversity of backgrounds converging here makes all the difference indeed. Cover photography by Mark Hamiel.

The UCLA School of Public Health thanks you for your financial support. The following honor roll acknowledges gifts made from 2/ 1/ 93 to 6/ 30/ 94. Although space limitations only allow listing of individual gifts of $100 or more and corporate and foundation gifts of $5,000 or more, gifts of every amount are important to the school and deeply appreciated. Benefactors: $2,500 and above • Patrons: $1,000 $2,499 • Sponsors: $600 - $999 Sustaining: $300 - $599 Individual: $100 - $299 • Special Gifts: $1,000 and above You and your name are important to us. If your name has been omitted or incorrectly listed in any way, please bring the error to our attention.

BENEFACTORS Mr. and Mrs. Samuel J. Tibbitts (Mr. Tibbitts is now deceased) Health Officers Association of California PATRONS Dr. and Mrs. Abdelmonem A. Afifi Ira R. Alpert, M.S.P.H. Dr. and Mrs. Richard Cohen Carolbeth Goldman Korn, B.S. Mr. and Mrs. Lester J. Mantell Ms. Marvis J. Oehm SPONSORS Dr. and Mrs. Lester Breslow Mr. Robert W. Gillespie Johnson and Johnson Company Matching Gift Program Fund Mr. John J. Mahoney Frank P. Matricardi, Dr.P.H. and Diana M. Bonta, Dr. P.H. Varian Associates Inc. SUSTAINING MEMBERS Dr. Roslyn Allin-Slater and Dr. Grant G. Slater Mr. Charles E. Cable Dr. and Mrs. John E. Coulson Dr. and Mrs. James E. Enstrom Dr. Jonathan E. Fielding, M.D., M.P.H. Mr. and Mrs. Richard P. Freeman Mr. and Mrs. Que S. Hansen Mr. James B. Jacobson Mr. James W. Lin Gabriella M. Miotto, M.D. Ms. Nancy J. Monk Charles N. Moss, M.D., Dr.P.H. Ruth F. Richards, M.P.H., M.A. Dr. Jaime G. Salazar Mr. and Mrs. Richard E. Sinaiko Dr. Barbara R. Visscher and Dr. Fredrick H. Kahn, M.D., D.P.H. Xerox Foundation Mrs. Jeanne C. Waite Mr. and Mrs. Melvin Ziontz

2 U CLA PUBLIC HEALTH

Mrs. Margaret H. Chueh Virginia A. Clark, Ph.D. Sharon E. Conrow, Dr.P.H. Ms. Nancy A. Damiani Dr. and Mrs. Peter C. Damiano Bruce N. Davidson, Ph.D. Allyson R. Davies, Ph.D. Ms. Cynthia A. De Motte Dr. and Mrs. Brian P. Dolan Olive J. Dunn, Ph.D. Mrs. Eliana B. Duque Mrs. Marilyn M. Elder Mr. and Mrs. Sam Elrod Agnes K. Eubanks, M.P.H. Dr. Jean S. Felton Rollington Ferguson, M.D. Paul M. Fleiss, M.D., M.P.H. Mr. and Mrs. Jeffery..!:. Fl o cke ~

Mr. Jack L. Adame Dr. Joseph L. Alexarnder Mr. and Mrs. Hugo A. Almeida Mr. Carlos A. Alvarado Richard F. Ambf ose, Ph.D. Dr. Michel M. Amzallag Dr. and Mrs. Ronald Andersen Mr. and Mrs. David E. Anderson Mrs. Benilda C. Ang Ms. Kazuko Arakawa Mr. Michael A. Aranda Mr. Henry M. Arrigh Sandra Aronberg, M.D. Alicestine D. Ashford, Ph.D. Miss Mary E. Ashley Mr. and Mrs. Donald W. Avant David W. Baker, M.D., M.P.H. Dr. and Mrs. Allan R. Barr Ms. Teri D. Bartholetti Ms. Patricia Satin Mr. Henry Battle Miss Janet L. Jacobson Mr. and Mrs. Robert L. Belstock Patti J. Benson, M.P.H. Mr. Michael K. Berry Dr. and Mrs. Robert M. Bersin Roy P. Betancourt, M.P.H. Dr. and Mrs. Wladyslaw A. Binek Terri L. Blackwell, M.P.H. Ms. Patricia E. Blake Mr. Carl A. Blomquist, Jr. Stewart N. Blumenfeld, Ph.D. Mr. and Mrs. Michael L. Boehnke Debra L. Boyd, Ph.D. Ms. Kimberly J. Bradley Dr. and Mrs. E. Richard Brown Ms. Judith A. Buckalew Ms. Carol W. Buitrago Mr. Martin B. Buser Xuanqing Cai, Ph.D. Mrs. Dennice L. Calihan Ms. Maria D. Canfield Mrs. Teresa J. Carlson Douglas G. Cave, Ph.D. Dr. and Mrs. Victor K. Chan Victor K. Chan, M.D. Dr. and Mrs. Richard Y. Chew Mr. Stephen J. Chew Joan M. Chow, D.P.H. Dr. and Mrs. Hung B. Chu

Ms. Felicia A. Flores-Workman Ms. Elizabeth D. Fowler Vardi h L. Fox, M.D. Betsy Foxman, Ph.D. Dr. and Mrs. Ralph R. Frerichs David M. Gittelman, M.P.H. Ms. Elizabeth B. Glaser Mark E. Granoff, M.D. Ms. Rochelle S. Green Nancy E. Greene, M.P.H. Mr. Joseph M. Haley Ann S. Hamilton, Ph.D. Jeffrey I. Hananel, D.O. Sarah H. Harlan, M.P.H. Ms. Nancy J. Haselow Dr. Saul H. Heiting Mrs. Rosalyn D. Hewertson Mr. Horace W. Hinkston Hoffmann-La Roche Inc. Ms. Elise M. Holloway Dr. and Mrs. Donald R. Hoover Dr. and Mrs. Carl E. Hopkins Mr. and Mrs. Der C. Hsieh Jack H. Hudes, Dr.P.H. Lieutenant Joselito S. Ignacio Dr. and Mrs. Larry H. Iida Ms. Gayle M. Insel Mr. and Mrs. W. Mark Jasper Ms. Mary J. Jenkins Katherine Jew, M.P.H. Miss May Jew Bekki J. Johnson, Dr.P.H. Dr. Kathleen A. Johnson Mr. Jack N. Kalaydjian Mrs. Marlene P. Kamienny Neal D. Kaufman, M.D. Mr. and Mrs. Harvey D. Kern Richard K. Kiel, Jr., M.P.H. Mr. and Mrs. Masao Koketsu Dr. and Mrs. Joel Kovner Dr. Dorine G. Kramer Ms. Anna J. Kraus Mrs. Mary E. KullmanCourtright Dr. and Mrs. Calman Kurtzman Mrs. Gail C. Larson Mr. Michael T. Lee Mr. and Mrs. Anmin Liu Dr. and Mrs. Clifford W. Lo Dr. and Mrs. Irvin M. Lourie Bryan R. Luce, Ph.D. Dr. and Mrs. Kung J. Lui Mr. and Mrs. Herbert L. Lundblad, Jr.

Ms. Deborah L. Maddis Roberta E. Madison, Dr.P.H. Dr. Robert A. Mah Ms. Ann G. Mahony Maureen Mangotich, M.D., M.P.H. Helen I. Marieskind, Dr.P.H. Ms. Ana M. Marin Mrs. Kathryn G. Marti Ms. Lisa G. Matras Thurma G. Mc Cann, M.D. Ms. Charlotte M. Mc Creary Dr. William A. Mc Gann Ms. Wendy B. Mc Grail Mr. and Mrs. Craig M. Mc Millan Mrs. Evangeline D. Mefford Mrs. Gail Meikle ML and Mrs. Lester A. Meis Norma n Melnick, M.P.H Mr. Gary M. Meunier Jean L. Mickey, Ph.D. Ruth M. Mioke)(, Ph.D. Mrs. Adrien ne D. Mims M~me A. M0decki Ms. Nancy J. Monk Mr. Kurt W. Moore Ms. Linda L. Moraga Hal Morgenstern, Ph.D. Dr. and Mrs. David J. Morris Mr. and Mrs. Marc D. Moser Ms. Denise Myers Mr. and Mrs. Donald W. Myres Harvey L. Negoro, M.D. Drs. Alfred and Charlotte Neumann Dr. and Mrs. John F. Newport Mrs. Wilma P. Nicholson Terry R. O'Bryan Dr. and Mrs. Edward J. O'Neill Etsuji Okamoto, M.D., Assistant Professor Delores V. Olambiwonnu, M.P.H. Mr. and Mrs. David V. Olivadoti Larry K. Olsen, Dr.P.H. Dr. Joan Otomo-Corgel and Mr. Richard Corgel Mr. Ernesto 0. Parra Ms. Dorothy M. Paynes Mr. and Mrs. John W. Percy Ms. Carol L. Peterson Lieutenant Steven K. Petroski Carl E. Pierchala, Ph.D. Robert S. Plourde, Ph.D. Ms. Lynda C. Powell Shane S. Que Hee, M.D. Mr. Christian Rainer Ms. Cathleen S. Reems Susan C. Reetz, M.P.H. Dr. and Mrs. Keith S. Richman David L. Rimoin, M.D., Ph.D. Denise J. Roe, Dr.P.H. Dr. and Mrs. Milton I. Roemer Mr. Joseph R. Rosenberg H. Jeffrey Rostami, Ph.D. Mr. Curtis J. Rozas Ms. Eve R. Rubel! Mrs. Connie C. Sanchis Dr. Kenneth P. Satin Mrs. Susan M. Sazer Mr. Anthony H. Schiff Mr. Daniel L. Schwartz Kendra L. Schwartz, M.D. Miss Teresa E. Seeman

Mr. John M. Shahan Julie Shaperman, M.P.H. Mrs. Barbara S. Shaw Dr. and Mrs. Brian T. Sherrington Mr. Christian S. Shinaberger William Shonick, Ph.D. Judith M. Siegel, Ph.D. Malcolm M. Simmons, Ph.D. Ms. Marti S. Slawson Daniel F. Smith, Dr.P.H. Dr. Sam S. Snyder Ms. Bernadine Sonnier Dr. and Mrs. oward M. Staniloff Kimberley 0. Stewart, D.D.S. Jacqueline E. Stiff, M.D. Dennis W. Strum, Ph.D. Mr. anil Mrs. Ellis J Statz Joseph H. Sugerma n, M.D. Dr. Marian E. Swendseid Ms. Susan P. Taylor Dr. and Mrs. Forest Tennant, Jr. Ms. Sara L. Thier Mr. and Mrs. Citron Toy Ms. Shelly M. Ushio Mr. and Mrs. Frank H. Wahpepah, Jr. Mrs. Jeanne C. Waite Bao T. Wang, Dr.P.H. Mrs. Irene K. Watkins Irene V. Wesley, Dr.P.H. Dr. G. Darryl Wieland Dr. and Mrs. Arthur M. Winer Judith S. Wolstan, M.P.H. Ms. Elizabeth Woolfe Mei M. Wu, Ph.D. Ms. Eleanor D. Young Mr. and Mrs. Lee Zusman

ORGANIZATIONS Health Officers Association of California MATCHING GIFT COMPANIES The Aerospace Corporation Alliedsignal Foundation Inc. Arthur Andersen and Company Foundation Chevron U.S.A. Inc. Corporate Headquarters Glaxo Inc. Goldman Sachs Fund GTE Foundation Johnson and Johnson Company Hewitt Associates Hoffmann-La Roche Inc. IBM Corporation National Medical Enterprises, Inc. Rockwell International Corporation Trust Southern California Edison Company TRW Foundation Times Mirror Company United Way of the Inland Vlys Allocations and Designations Upjohn Company Varian Associates Inc. Xerox Foundation

JUNE SPEAKERS INCLUDE BROWN, IVIE AND JAMISON

MILLER TO ENHANCE PRIVATE SUPPORT

The list of prominent speakers at the UCLA School

John D. Miller joined the UCLA School

of Public Health in June includes Dr. E. Richard

of Public Health in February as

Brown, Sylvia Drew Ivie, and Dr. Dean Jamison.

director of development. Miller has

Brown, professor of

been active in development work on behalf How has your role changed

community hea lth

of local, national and international causes

sciences and health

and concerns. He originally came to UCLA as

in the light of the recent cuts in state-

services and director of

associate director of development for health

supported funding?

the Center for Health

sciences, and later accepted the position of

We need to communicate that UCLA has

Policy Research at the

development director for the School of Public

increasingly become a state-assisted university

UCLA School of Public

Health because of his personal interest in and

as opposed to the state-funded institution it

Health, is president-elect

commitment to the public health cause.

once was. The fact that only a fraction of the

He recently spoke with UCLA Public Health.

funds that support the university comes from

commencement ceremony, scheduled for

How did you become interested in public health?

opportunity for the school to develop closer,

Saturday, June 17 at 3 p.m. on Collins Court at

I've spent a good deal of time overseas, and one

more dynamic relationships with our

UCLA's John Wooden Center.

of the things I discovered in the course of my

constituencies: our alumni, our network of

of the American Public Hea lth Association . He is the keynote speaker at the school's

I vie, a health advocate with a particular

the state creates both a need and an

travels is that many U.S.-trained physicians who

public health professionals, and the

had assumed overseas assignment seemed to be

communities we serve. In the long ru n, great

interest in the interplay

following public health models rather than the

good can come from strengthening these ties.

between minority issues

traditional medical models in which they had been

Generous state support allowed our school to join the elite ranks of public health in a

and health-care

trained. When I asked them about it, invariably

outcomes, is the featured

they told me two things: Other countries could not

remarkably short time. Generous private

speaker at the

afford our expensive medical technology, and they

support from our alumni and friends will keep

Sanville/Delta Omega

found they were able to make a greater overall

us there and move our school into exciting new

Lecture, June 9 at the UCLA Faculty Center. She

contribution to the health of needy populations

frontiers of education, research and service.

is executive director of T.H.E. Clinic for Women, a

through public health strategies. These

Los Angeles-based primary health-care clinic

encounters piqued my interest in public health,

offering a variety of services to an ethnically and

and I have continued to follow the field.

FOUR STUDENTS EARN PRESTIGIOUS DISTINCTION

Where are you focusing your efforts?

named finalists for the prestigious Presidential

culturally diverse patient population. Jamison was invited

Dr. Dean Jamison

Four UCLA School of Public Health students were

to deliver the annual

In several areas. We need to expand the Dean's

Management Internship Program. The program,

Lester Breslow

Council and attract new donors. We're also

established by President Carter in 1977, aims

Distinguished Lecture,

seeking increased contributions from our existing

"to attract to federal service men and women of

June 8 at the UCLA

donors, many of whom have been giving at a

exceptional management potential who have

Faculty Center. He is a

particular level for many years. UCLA's upcoming

received special training in planning and

professor in the UCLA

fund-raising campaign will be extremely

managing public programs and policies." The

schools of public health

significant for the School of Public Health. We are

finalists, who are nominated by their academic

and education, and is director of UCLA's Center

now in the process of recruiting new members to

institutions, are chosen based on outstanding

for Pacific Rim Studies. Jamison edited the

the Dean's Advisory Board and sharpening the

academ ic credentials, excellent communication

1993 World Development Report: Investing in

board's focus on major gift development. Also,

and leadershi p skills, and a commitment to

Health, published by the World Bank. He was

we're seeking to broaden representation to ensure

public service. From the UCLA School of Public

elected to the Institute of Medicine of the

that the advisory board reflects the variety of

Health, they are Imee Diego, Bessie Lee,

National Academy of Sciences in 1994.

interests and disciplines found within our school.

Dorothy Tan , and Noemi Villafranca.

IÂŽ

U CLA PUBLIC HEALT H 3

•

'" Faculty Leads Renewed Fight Agair As the field of public health expands to encompass the growing list of issues that affect the conditions in which people can be healthy, the importance of combatting public health's long-time nemesis continues to loom large. Infectious diseases, once thought to be destined for the history books-at least in developed countries such as the United States-have returned with a vengeance. The most ominous foe, of course, is the human immunodeficiency virus. But at the same time that AIDS has justifiably occupied much of our attention, seemingly new infectious

BREAKING NEW EPIDEMIOLOGICAL GROUND ON AIDS

hrough three differently focused research and training grants, Dr. Roger Detels, professor of epidemiology at the UCLA School of Public Health, covers substantial epidemiological ground in the battle against HIV I AIDS. The Multicenter AIDS Cohort Study (MACS), which Detels has headed at UCLA since it was establish ed in 1984, continues to reveal critical insights as it begins its second decade. In the early years, MACS identified HIV transmission risk factors for homosexual men (who constitute the study's cohort) and the relationship of CD 4 cell levels to risk of AIDS. More recently, attention has turned to three perplexing populations that, if better understood, could provide crucial information for the fight agai nst AIDS: • People with few CD4 cells who continue to thrive. One man in the MACS has had

been exposed to a virulent virus is unlikely to me." A second possibility? They initially contracted a virus that wasn't virulent, and that prevented infection by the virulent virus. Or, possibly, these men's immune mechanisms are more efficient than others'. If that's the case, Detels wants to know why. • People who are repeatedly exposed to HIV, yet don't become infected. Perhaps the most interesting population in the MACS study includes men who were repeatedly exposed to HIV -they had anal-receptive intercourse with a median of 92 different partners within a two-year period, at a time when the infection rate among gay men in Los Angeles was approximately 50 percent- without becoming infected. "If we can figure out why that's the case, we might be able to use a non-viral vaccine to stimulate the component of the i111mune system that's providing resistance," Detels explains. Detels recently demonstrated that this population has a higher-than- average

"When a country is at the beginning of an epidemic, the first task is often convincing people they're at risk ." -Dr . Roger Detets

diseases have surfaced and old ones have become more prevalent. As the following examples illustrate, UCLA School of Public Health faculty are approaching infectious diseases from a number of perspectives, as dictated by the complex issues presented by this continuing public health problem.

By Dan Gordon 4 UCLA PUBLIC HEALTH

8 CD 4 cells (norn1alis l,200) since 1986, and has remained well. "Clearly, there are compensatory mechanisms in the immune system," says Detels, who is now looking at the role CDs cells play in such cases. • Those who have retained competent immune systems despite being HIV-infected for a decade or more. "Some people are coping very well with the virus," Detels observes. He offers three possible explanations. One is that they were infected with a virus that wasn't virulent. "The problem I have with that," Detels notes, "is that in the early 1980s, many gay men in Los Angeles were having sex with many different peopie, and the idea that they would not have

number of active CDs cells, which, when stimulated, produce cells capable of killing infected viral cells. But because this population has had multiple partners, it's difficult-if not impossible-to determine the precise mechanism of resistance. For that, Detels has turned to a group of women in Manipur, located in northeastern India. With funding from the World AIDS Foundation, he is studying wives of HIVinfected intravenous drug users- the men were identified through previous research by one of Detels' students. The population is ideal for study, since cultural norn1S make it highly unlikely that any of the women

FACULTY PORTRAITS BY TERRY O'DONNELL

st an Old Foe are dmg users or engaging in sex with anyone but their husbands. Detels and his Indian colleagues are looking at which women resist infection, and also at whether the virus' IV drug- transmitted strain is capable ofbeing transmitted sexually; ifthe newly infected women show another strain, then, as Detels suspects, individuals are capable of harboring multiple strains of HIV. Since 1988 , Detels has directed the UCLA / Fogarty Collaborative International Training Progran-i in Epidemiology Related to HIV I AIDS. The program has helped to stock participating nations from Southeast Asia, Latin America and Eastern Europe with AIDS surveillance experts. Both UCLA-based and in-country training is involved; for those who have current responsibility for controlling their country's epidemic, Detels and the program's other AIDS experts travel to give intensive, short-term courses-they helped set up central surveillance systems in Thailand, Myanmar, Indonesia and the Philippines. Others come to UCLA for training in the public health aspects of HIV I AIDS, designed to prepare them to assume leading roles when they return to their home countries. The program also generates joint research between the UCLA School of Public Health and its international collaborators. Candidates for training at UCLA are selected jointly by Detels and leaders in the participating countries, who also provide input to the thesis (for master's students) or dissertation (for doctoral students) the student develops while here. "We want those projects to be relevant and useful to the particular country," Detels explains. Thus, students from the Philippines, where the AIDS epidemic is in the early stages, are looking into where the reservoir of HIV infection resides. In Thailand, where the epidemic is rampant and prostitution has proved to be a big part of the problem,

MACS SITE PHOTOS BY RONI RAMOS

the focus is on changing behaviors in the brothels. "When a country is at the beginning of an epidemic, the first task is often convincing people they're at risk," Detels explains. "Once that's accomplished, you have to help them figure out where the virus is being spread. Once you know that, you can tum to developing, implementing, and evaluating the effectiveness of intervention programs targeted at specific populations." Detels pauses. "Sounds simple," he says with a chuckle. As a leading epidemiologist in the fight against an insidious disease, he knows the task is anything but easy.

SYSTEMATICALLY STUDYING HIV/AIDS COSTS, SERVICES

e know something about the social trauma inflicted by AIDS in the past 15 yearshundreds of thousands diagnosed with the disease, two-thirds of whom have died, most of them in early adulthood. We know about the complications confronting people with HIVI AIDS, we're learning about the difficulties facing their loved ones, and we're still wrestling with the stigma attached to the illness- the ambivalence (and meanness) with which people with AIDS are treated in society. Far less is known- in precise figures, anyway-about the disease's impact on

hospitalization and often intensive-care treatment within the hospital, with lots of tests, lots of stress, and lots of procedures." In short, lots of high-cost activity in a system struggling to contain costs. Meanwhile, the number of cases continues to rise, and emerging technology is of uncertain benefit and won't come cheap. At the same time that the United States has run up a huge tab for AIDS treatment, it's become clear that certain people are not receiving adequate care-either they're treated too late, too infrequently, or by unqualified personnel. These people, Cunningham notes, tend to come from the most disadvantaged groups in American society-women, minorities, drug users, the poor. "And it so happens that those are the same segments in which the epidemic is increasing the most," he adds. More costs-human and financial. It's not that AIDS expenditures have never been calculated. The best estimate comes from a 1992 federal study; using those figures, the cumulative medical cost of the epidemic in the United States has reached $ l 5 billion. Approximately $u9,ooo is spent on health care for each person with AIDS over his or her lifetime. But with the epidemic changing, those numbers quickly become obsolete. Demographic data on p eople with AIDS are scant. And when it comes to health policy, the U.S. system's acute-care orientation is

Care Policy and Research, is using a stateof-the-art probability sampling method that will enable policy-makers to forecast how costs would change with the advent of new policies, treatments, or incidence patterns. "Nothing like this exists for any disease," Cunningham asserts. "We'll have accurate statistics for thousands of characteristics." The project will enroll 3, 700 subjects receiving care from approximately 60 major and l 20 smaller health-care providers in 30 randomly selected locales, representing the spectrum of practice settings where HIVI AIDS cases are seen. Cunningham, who heads the access portion of the study with UCLA School of Public Health colleague Dr. Ronald Andersen, the Fred W. and Pamela T. W assem1an Professor of Health Services, will examine the equity of treatment. Are women less likely to get treated than men? Are the poor less likely to receive treatment than the non-poor? "There's suspicion and plenty of preliminary evidence suggesting that there are disparities," Cunningham says. By clarifying these issues, the researchers will inject a healthy dose of rationality into future decisions on AIDS resource allocation. Policy choices about how best to give care to people with HIV and AIDS can be based on precise estimates of expected benefits and costs -even if finding cheap solutions will not get any easier.

"AIDS has so many different manifestations and produces so many inter-related needs, both medical and non-medical, but our system-despite the best policy intentions-continues to be organized in a fragmented way." -Dr. William Cunningham the U.S. health-care system. What is the financial cost? What, if any, are the barriers to AIDS patients' receiving quality care? Where, geographically and in terms of health- care settings, do they receive the best-and worst-treatment? And how would changes in prevalence, policy and therapy affect all of these issues? "AIDS h as produced a tremendous shock to the health- care system," says Dr. William Cunningham, assistant professor of health services at the UCLA School of Public Health. The reasons are familiar, but worth stating: "It's a disease characterized by catastrophic complications and manifestations that are extremely varied, requiring

6 U CLA PUBLIC HEALTH

exactly the wrong medicine for effective, efficient AIDS management. "AIDS has so many different manifestations and produces so many inter-related needs, both medical and non-medical, but our system- despite the best policy intentions-continues to be organized in a fragmented way," says Cunningham. "As a result, AIDS has becom e a microcosm of our health- care system 's basic ills." C unningham is now part of the most ambitious effort yet to document national HIVI AIDS costs and services. The HIV Cost and Services Utilization Study, a $15 million, five-year cooperative proj ect sponsored by the U.S. Agency for Health

TACKLING HIV WITH A FUNDAMENTAL APPROACH

r. Scott Layne has come to the UCLA School ef Public Health with the intention ef establishing a worldclass laboratory that will use a novel approach to tackle questions fundamental to HIV and the huma n immune system it attacks . With sufficient extramural funding, Layne hopes to establish the Laboratory of Viral ImmunoKinetics. The new facility will expand on the techniques Layne developed while at the Los Alamos National Laboratory, developing mathematical models and computer simulations ef the fundamental reactions ef HIV particles as they

irifect immune cells, and ef immune cells as they battle irifection. Layne, associate prefessor ef epidemiology, recently talked about prospects for the new lab with UCLA Public Health. How did you come up with the term "viral immunokinetics "? The fundamental question about HIV is how our immune system's protective activity compares with the growth rate of the virus. There are two opposing kinetic processes. Once the virus gets into the body, it has the ability to expand and infect other cells, like a growing chain reaction. The immune systen1 has an ability to hold viral growth in check by generating either antibodies or cytotoxic cells that will come in and gobble up the virus before it has a chance to spread to other cells. For a vaccine to be effective, the growth rate of the virus cannot be greater than the ability of the immune system to hold it in check. What has hampered the efforts to come up with a vaccine so far, and how will your approach be different? We need to know where our immune system stands with respect to HIV's ability to grow. Some questions we need to answer include: Can HIV always overwhelm our inunune system?; Does our irnnrnne system ever have a chance of controlling HIV infection?; Are there some strains of HIV that grow better than others in our immune system? At present, we have not even begun to answer these questions in a quantitative fashion. The goal of the Laboratory of Viral IrnmunoKinetics will be to combine tools from mathematics, physics, and virology to answer these fundamental questions. I believe that we have failed to answer these questions thus far because no one has used this necessary multidisciplinary approach. Only by using such an approach can we make the necessary measurements that will lead us to developing a vaccine. Furthermore, this quantitative approach will need to be applied to many different viral strains from around the world. What's the basis for your mathematical approach? First of all, we must ask what are the basic reactions that a virus undergoes when it infects a cell, and what are the basic reactions that the immune system undergoes when it blocks infections. We know that

HIV has a certain number of receptors on its surface that allow it to attach and thereby infect cells. Meanwhile, antibodies are working to block these receptors. That's one reaction. Another reaction occurs as the molecular receptors on the surface of the HIV particle fall off with time, causing the virus to lose its infectivity. So there is a simple model in which you have the virus colliding with and infecting a cell, antibodies are blocking it, and the virus is losing its infectivity. Based on this, you then develop a mathematical model to guide and sharpen the laboratory experiments and advance the model. A similar approach needs to be undertaken with cytotoxic cells and their interaction with HIV infected cells.

What has this approach achieved? Using this combination of modeling and experimentation has already led to some important discoveries. For example, our model predicted that the blocking activity of antibodies should decrease as cell densities increase. When we went into the laboratory to look for this behavior, we found it. Without first using a mathematical model, we would not have known to even look for this phenomenon. As it turns out, this finding is quite important to the development of a vaccine against HIV. It demonstrates that antibodies induced by a vaccine will fail to protect against infection

We currently know very little about the How did you become interested in this physical properties of HIV, which is a approach? very important issue. We have informaIn the summer of I 987, I was finishing gradtion on the genetics of the virus, but we uate studies in applied physics at Stanford, do not know how genetic variations relate and my fonner colleagues at Los Alamos to physical variations. Some strains of HIV invited me to join them in developing a appear to be more transmissible than othmathematical model on HIV epidemiology. ers, but we don't know why. These n10re In the process of developing the epidemiotransmissible strains may require a n10re logical models, I saw that we knew very liteffective vaccine to protect against infectle about HIV infectivity and the processes tion. So the issue of the physical properthat governed HIV infection of inunune ties of HIV and the developrn.ent of an cells. This led me to learn more about the virus itself and to begin thinking about effective vaccine are related to one another. For viruses from around the world, we whether viral infection could be understood need to measure a number of basic physiin tenns of certain kinetic reactions. All of cal properties, including the length of this work was taking place in a scientific time that a viral particle remains infecenvironment where mathematical models were commonplace. So it was a natural protious, the fraction of viral particles that are infectious, and the number of viral partigression to use this paradigm in thinking cles produced by an infected cell. All of about solving the mysteries of HIV. these physical properties will give us I have been surprised that mathematical information to guide vaccine develop- , models have been so successful in helping ment, since more robust viral particles to understand the processes associated with may require stronger vaccines. HIV infection and blocking by antibodies. I believe that this success can be applied to help understand other viruses as well. You've talked aboutfocusing on HIV strains in Thailand, where transmission is so high. Strains from that geographic region REMEMBERING THE appear to be at least IO times more infec"FORGOTTEN" VIRUSES tious than strains here in the United States, and we don't know why. There s antibiotics and other effective are a couple of possible explanations for drug regimens were introduced the increased transmissibility. The first is in the 20th century, many mistakenly assumed that tuberculosis, malaria that sexually transmitted diseases act to

"The bottom line is that when you go into the laboratory to perform experiments, mathematical models act as a sharp toot for helping you to interpret the data." -Dr. Scott Layne when cell densities are high. So people who have inflammations in areas w here HIV first invades, such as in genital ulcers or inflamed rn.ucosa, may not be protected by a vaccine that induces antiboclies alone. The bottom line is that when you go into the laboratory to perform experiments, mathematical models act as a sharp tool for helping you to interpret the data, and they tell you how you should be setting up experiments. The m athematical models also help to identify new and unexpected behaviors of the immune system.

What are some of the questions you will be addressing iti the laboratory?

8 UCLA PUBLIC HEALTH

facilitate the transmission of infection in Thailand. The second is that there may be sexual practices in Thailand that lead to a greater sharing of blood or boclily fluids. However, a third possibility is that something has changed about the physical properties of the virus. For example, the virus may be more stable, a greater fraction of the viral particles may be infectious, or more viral particles may be manufactured by infected cells. W e need to know whether changes in the physical properties of the virus are related to increased transmissibility, since more transmissible viruses would enlarge the scope of the global AIDS epidemic.

and their infectious-disease brethren would be wiped off of the map. It hasn't happened, of course. "TB is the most glaring example," says Dr. Lawrence Ash, professor of epidemiology and associate dean for student affairs. "We had reasonably good drugs for treating it, we closed sanitariums... and then a number of things happened. W e started having resistant strains of the organism, we had exposure to larger numbers of people in conjunction with HIV infection, and the incidence rate began to climb." Then there are the viruses that seem to come from nowhere. In fact, notes Ash, these " new" diseases have typically Ian-

guished for years in nature, known only to the scientists who follow such things. So when dozens of people in the Southwest were infected by the hantavirus in 1993, the seemingly mysterious ailment became known as "four-corners disease ." As it turns out, the disease was neither mysterious nor limited to the four-corners region of the United States. "It had been known in Europe since the 1920s," Ash says. "We had probably experienced cases of hantavirus- maybe even deaths-prior to this outbreak. The only reason it came to light is that there was a clustering of cases." Given today's dramatically improved diagnostic capabilities in which the tools of molecular biology are employed, it's no surprise to Ash that new organisms are being identified. What's more troubling, he believes, is a trend away from focusing on what, in the light of more prevalent diseases, might seem exotic. "There's been an information explosion in every scientific area- I don't care whether you're talking about biochemist1y, anatomy, or infectious diseases," Ash argues. In schools of public health and medicine, where there is a finite amount of time for instruction, this has forced difficult curricular decisions over what will be taught. The loser? "It's easy to take away from things that don't seem. that relevant in the United States," Ash laments. To be sure, parasitic and tropical diseases in general are considered exotic. "The feeling is that if you don't go through Brazil, you're not going to get schistosomiasis," Ash says. But with increased travel and immigration, the situation is no longer static, he adds, and cannot be ignored. Moreover, less prevalent viral, parasitic and bacterial diseases have been overshadowed-both in attention and in the devotion of resources-by AIDS. "The fundamental decision has been made that we will put more and n1ore money into HIV research," Ash says. While he doesn't question the importance of that strategy, Ash notes that the unique epidemiology of the AIDS virus n1eans that much of what is learned from HIV study is not othe1wise applicable. As a result, "gaps develo p in what we know about other areas. We have students being trained who don't have a broad perspective, and eventually we're going to run out of individuals who understand the big picture."

Much of the work in infectious diseases now involves studying organisms at a molecular level. "There's no question that people being trained nowadays have to understand those applications," Ash says. "The problem is that they will know a great deal about a particular organism, but if you ask them simple questions-how is it maintained in nature, how do people get it, what are the dynamics of the ecology of this disease ... that's not something they're being taught." While the Centers for Disease Control and Prevention is still capable of a rapid response to new infectious-disease outbreaks, its resources have diminished, its focus is changing, and, Ash observes, "we don't have a critical mass of people scattered in different geographic areas who can also bring their expertise to problems that develop. " It's why, with Ash's help, the UCLA School of Public Health is giving high priority to the " new" infectious disease epidemiology.

CHANGING BEHAVIORS TO STEM A RESURGING DISEASE

ith the immune-system breakdown of HIV-infected individuals contributing to a new upturn, tuberculosis- which killed l in every 500 American s in 1906 but seemed almost obsolete 7 5 years later- had reversed its downward trend in 1985 and

time, these patients may have developed a resistance to the drugs, and getting them back into care upon recurrence becomes more costly. The challenge: how to overcome barriers and improve TB patients' compliance to treatment. In l 98 5, Morisky received funding from the Centers for Disease Control to develop and evaluate a program aiming at improving compliance to anti-tuberculosis medical regimens. By offering TB patients educational counseling along with material incentives for staying in the treatment program-everything from bus tokens and grocery store vouchers to monetary payments-Morisky demonstrated a dramatic increase in the proportion of preventive patients completing care. Two y ears ago, Morisky received National Institutes of Health funding for a threeyear follow-up designed in part to separate the effects of the incentives from the effects of the education. This time, active TB patients at three Los Angeles health ce nters have b een divided into four groups: those receiving education and counseling, those receiving incentives, those receiving a combination, and patients receiving standard care . (Morisky's project staff includes co- investigators from the Los Angeles County TB Control unit, students at the UCLA School of Public Health and UCLA undergradu-

might be a deficiency in knowledge about the disease and its treatment; in others, it's the lack of social support (in which case a close friend or relative can be brought in to participate in the treatment program) or stigmatization-some patients are isolated by their family and friends throughout the treatment out of the mistaken impression that they remain infectious. Most often, the intervention winds up focusing on how to get patients to follow a daily medication-taking protocol- often involving multiple drugs and in some cases producing side effects-and continue with their medications and monthly appointments well after their symptoms have ceased. "Most people think that if their syrn.ptoms are gone, their problems are gone," says Morisky. "But the TB is still in their body, and the only w ay to rem ove the bacilli is by continuing the drug regimen for the six months. " "W e look at the factors that are clinicbased, such as long waits or, perhaps, not having access to translators," says C abrera. "But we're also interested in client- based barriers to finishing treatment- b eliefs about the treatment and the disease. We're trying to look at patients' treatment in the context of their daily lives." If patients haven't adhered to the daily regimen, they are asked why, and given suggestions-for instance, to take it at the sam e time each day, whether it's when they brush their

UMost people think that it their symptoms are gone, their problems are gone. But the TB is still in their body, and the only way to remove the bacilli is by continuing the drug regimen tor the six months." -Dr. Donald Morisky by 1990 again reached epidemic proportions in the United States. In 1992, C alifornia had the nation's highest TB incidence, and Los Angeles C ounty the second- high est rate of TB cases. Part of the problem involves the nature of the disease and the intense medication regirn.en required to stave it off TB patients are typically asked to visit a chest physician monthly and take medications every day for six months (until recently, nine ni.onths). But symptoms generally disappear after the first month of m edications. "As soon as that happens, many patients drop out of care," says D r. Donald Morisky, associate professor of community health sciences. By that

10 UCLA P UBLIC H EALTH

ates who are part of the university's Student Research Program.) Traditionally, notes proj ect director D an C abrera (Ph.D. '95), TB patients are told about their disease and the importance of following their treatment regimen, "but there isn't an emphasis on identifying those factors that might be barriers to completing treatment." In the study , patients in the groups that receive monthly educational counseling see a health educator who looks at the results of a baseline interview (questions regard TB- related knowledge and attitudes), then conducts a five-minute, tailored intervention addressing potential problem areas. In some cases, the problem

teeth or before their favorite TV program. In addition to assessing the independent effect of the educational counseling, comparing it with the material incentive's effect and m easuring the impact of the two in combination, Morisky will examine the educatio nal program 's cost-effectiveness. It's an issue of great interest to Los Angeles C ounty's tuberculosis control effort: T he additional time sp ent w ith each patient adds to the cost of TB control, but if it reduces the number of patients w ho drop out of care- only to later require additional treatment or hospitalization and potentially infect others- it might contribute to an overall cost reduction. l!lli

The High Institute of Public Health University of Alexandria

EGYPT The National Research Center Dokki, Giza

EGYPT The Nutrition Institute Ministry of Health, Cairo

EGYPT The Center for Child Survival School of Public Health University of Indonesia

INDONESIA Ben Gurion University and The Ministry of Health

IS RAEL African Medical Research and Education Foundation (AMREF) University of Nairobi School of Medicine

KENYA The College of Public Health University of the Philippines

PHILIPPINES The Department of Obstetrics and Gynecology Faculty of Medicine Prince of Songkla University

THAILAND Child Health and Development Center (CHDC) School of Medicine Makerere University, Kampala

UGANDA Institute of Public Health (IPH) University of Makerere Medical School

UGANDA

sked what aspects of public health interest them, a growing number of students who enter the Department ofConmrnnity Health Sciences at the U CLA School of Public Health mention international health. Dr. Osman Galal, who, as director of the school's international health program, is among the leaders of efforts to increase students' awareness of other countries' public health issues, concedes that the term itself is one of convenience. "I would hate to say that health could be divided into international and domestic," says the professor of conmrnnity health sciences, an expert on the social and political causes of nutritional problems in children who was born in Egypt, received his medical degree from Cairo University, and served as director of the Nutrition Institute in Cairo. Semantics aside, Galal remains steadfast in his conviction that public health studentsparticularly in a city such as Los Angeles-need significant exposure to other cultures and the ways in which people's beliefs and behaviors affect health and public health practice. Galal is the principal investigator of a three-year Fogarty International Training and R esearch Program that, beginning this sununer, is sending six minority doctoral candidates a year to identified sites overseas for internships lasting between three months and a year. The purpose, Galal says, is to provide international experiences within the students' dissertation focus, raise their skill levels, and prepare the students for future work with the multi-ethnic populations of California. Students can choose from among several sites at universities and institutes in the Middle East, the Far East, and Africa; Galal hopes soon to expand into Latin America. The sites are all places where UCLA School of Public H ealth faculty- particularly Galal and Drs. Ralph Frerichs, Roger Detels, Gail Harrison, Donald M orisky and C harlotte Neumann- have established relationships through their research activities. "We're not starting from scratch anywhere," Galal explains. So students can work on AIDS issues in Thailand and Indonesia; on maternal/ child health in Kenya and U ganda; on nutrition and behavioral control of schistosom.iasis in Egypt; and on acculturation of Ethiopian inmiigrants in Israel, to name a few of the possibilities. Galal, who joined the faculty in 1991, moved to continue and enhance the school's international ties early. A student who had come from the High Institute of Public Health in Alexandria, Egypt, to conduct doctoral studies here had expressed interest in forn1alizing the ties between the two institutions. Galal wrote a grant proposal and received funding from the Bi-national Fulbright Commission for a faculty exchange partnership program in which participants share ideas on curricular enhancements and develop jqint research proj ects. Already, five High Institute faculty members have spent a niinimum of four weeks here, and a like number of U C LA School of Public H ealth faculty n;.embers have visited Alexandria. "Both sides are learning from each other, and creating enriching opportunities for faculty and students," Galal says. H e hopes the program will serve as a model for similar exchanges involving the U C LA School of Public H ealth and other institutions abroad. "So much of public health is now a behavioral science-changing a style of life to improve health or prevent diseases," Gala! says in explaining the importance of an international health background. " Lifestyle is heavily affected by culture. California, and Los Angeles in particular, has become home to all sorts of cultures- it's been said that 127 languages are spoken in Los Angeles schools. If we're talking about health and we look at what's going on in Los Angeles, it's beconiing a niirror image of what's going on in many developing and developed countries. "We're trying to prepare students who will be dealing with all of these cultures." i!lll

UCLA PUBLIC HEALTH 11

12 UCLA PUBLIC HEALTH

A VICTIM OF OVERUSE BY POLITICALLY correct wannabees, the term diversity has practically lost its meaning in the past few years. But consider the student body at the UCLA School of Public Health.

A world-class student body demands an innovative curriculum. On this and the pages that follow, five UCLA School of Public Health courses that reflect important directions in public health practice and science are featured.

COURSE: Epi 417-Injury Prevention

They hail from America's suburbs, small towns and inner cities-and from countries large and small in Africa, Asia, Europe, Latin America and the Middle East. They are fresh from their undergraduate experience and seasoned, established professionals. And perhaps most striking of all, they come for distinct reasons, travel divergent paths during their time at the school, then go on to perform vastly different tasks in disparate locales.

Strategies and Countermeasures

INSTRUCTOR: Dr. Jess Kraus, professor of epidemiology and director of the Southern California Injury Prevention Research Center It's not surprising that Epi 417 stands apart from what many other schools of public health offer; after all, it wasn't until the middle of the 1980s that injuries-both intentional and unintentional- began to be taught within an academic framework. "The classic infectious and chronic diseases always took precedence," says Kraus.

emse ve s

"Injuries were viewed largely as accidents-uncontrollable, chance phenomena." Kraus, who was teaching classes on injury epidemiology well before Epi 417 was first offered a decade ago, has students evaluate the strategies

Dr. Tony DuBose had planned to be a forensic pathologist. But the 1991 graduate of Brown Medical School quickly realized he was more happy seeing patients; after a one-year residency in family practice, he enrolled in the UCLA School of Public Health for the first half of an occupational medicine residency. (DuBose earns his M.P.H. this year, then rotates through various agencies during the program's practicum phase.) DuBose reports ga ining valuable lessons, not only in industrial hygiene, but also about other professionals in the occupational health field. "It's a very team01iented approach," he explains, "and I can now appreciate where all of these other people are coming from and what their focus of expertise will be so that I'll know where to go to get answers." Another student comes to the defense of the school's physician-students-the

discussions among her health-services peers sometimes come down hard on M .D.'s, a view she doesn't necessarily endorse. "They bring a clinical perspective to class discussions, and an experience in the health-care system that most of us don't have," says Imee Diego. Diego, who receives her M.P.H. this spring and is one of four UCLA public health students chosen for the prestigious Presidential Management Intern Program (seep. 3), entered the school with the idea that she would walk out a hospital administrator; her two years here have pointed her instead toward a career focused on health policy. "I came hoping to be academically challenged," she says. While she never questioned whether her hope was being realized, it took a conversation with a group of students in a business-school course for Diego to discover how far she'd come. "One of them was telling me,

and countermeasures to injuries that have been successful, as well as those that have failed. (While both intentional and unintentional injuries are covered, the greater focus in Epi 417 is on the latter, since the intentional brings up issues of motivation that are fodder for other courses.) The success stories include seat belts, air bags, helmets, fire alarms and smoke detectors; the failures, Kraus submits, stem from too much reliance on education and unenforced legislation. Driver training and education remained popular while never proving effective, he notes. "A lot of things are done based on intuitive grounds rather than scientific evidence." The societal cost of injuries-in loss of life, suffering, medical care and disability, to name a few-is staggering, Kraus says. "Prevention has been the watchword of public health since its

BY DAN GORDON

PHOTOGRAPHY BY MARK HARMEL

inception, eons ago," he asserts. "Injuries are preventable."

UCLA PUBLIC HEALTH 13

COURSE:

EHS 257Critical Review of the Scientific Basis of Occupational Health Standards INSTRUCTOR: Dr. John Froines, professor of environmental health sciences and director of the Center for Occupational and Environmental Health

As developments in the current U.S. Congress illustrate, environmental regulations are rarely established without the influence of politics. The final look of a new policy depends on such subjective decisions as how risks are assessed, how technological innovations are considered, and whether a costbenefit analysis is included. EHS 257 doesn't ignore the politics surrounding the standards, but focuses most heavily on their scientific underpinnings. Special attention is devoted to six industrial chemicals: cotton dust, lead, formaldehyde, cadmium, methylene chloride, and butadiene. Each has widespread exposure and is associated with important scientific questions related to health, ranging from the respiratory effects caused by formaldehyde to the neurologic, reproductive and hypertensive impact of lead. In one case-cotton dust-a standard sparked cries from the industry that it would go bankrupt, that buyers would turn to foreign countries for their cotton. To the contrary, notes Froines, the standard led to the development of innovative technology that reduced energy costs and increased productivity. The regulation for lead was "probably the most advanced, scientifically based standard that the Occupational Safety and Health Administration ever promulgated" at the time it was developed in 1978, Froines contends. Today, he argues, "it is not adequate" based on current medical knowledge. Students visit these and other issues, and also critique proposed OSHA regulations that have yet to be reviewed, and develop a standard for a chemical that has none.

14 UCLA PUBLIC HEALTH

'You know so much about how health systems are organized,'" Diego recalls. "I had thought everyone knew about managed care and HMOs , but that experience reminded me that I'm leaving here with an expertise." Diego gives due credit to the school's renowned health-services faculty ("they're very approachable, not intimidating"), as well as to extracurricular sources such as speakers brought in through a lunchhour series. But, she adds, many lessons come from her fellow students. The diversity of backgrounds represented in the classroom makes for lively discussions in which multiple points of view flourish . Diego was interested in Germany's health-care system, so she talked with a classmate-a physician from Germany. Even across the school's five departments the experiences differ: A friend in epidemiology helped Diego incorporate the concept of risk factors into a policy paper on children's health status, for instance.

pencer MacNeil, who entered the school's Environmental Science and Engineering program last fall, befriended Ray Chavira, an M.P.H. student (environmental health sciences) from East Los Angeles, and in the process learned much about that community's struggle to stimulate the local economy without compromising its physical environment. Dena Herman returned to Southern California for her M.P.H. in community health sciences after spending seven years in Europe, where she studied community nutrition. For her, the most enriching aspect of the experience here was the ability to hear firsthand from students about issues important to their home countries. In a class on HIV I AIDS and social behaviors, for instance, there were students from Thailand and Indonesia. "They could tell you how programs were actually working in these countries, because they were helping to implement them," she says. David Zhang could tell classmates about Tiananmen Square-the biostatistics doc-

toral student from mainland China was there during the pro-democracy student demonstrations of 1989. Zhang, who was an undergraduate at the time, had already decided to come to the United States for graduate education; when the Chinese goverru11ent began to exercise tighter control over students who were applying to leave the count1y, Zhang wasn't sure he'd make it out. He did, and an-ived at UCLA in 1993 after earning his master's in statistics at the University of Cincinnati. Immediately, he noticed something he hadn't seen in the Midwest: "a lot of Asian faces." But in choosing roommates, Zhang (whose research focuses on survival analysis) has opted for diversity: "Living with Chinese fellows would be culturally convenient, but I wanted to be exposed to other cultures," he explains. Leo Tacata, a second-year epidemiology student who grew up in the Bay Area, was attracted partly by the depth of public health issues facing Los Angeles. "The dynanucs are so different here," he says.

"The people, the traffic, the environment ... there are a lot of challenges-exactly the kind of place where you want to be if you're studying public health." Tacata has canvassed the region as an assistant to Dr. Jess Kraus, professor of epidemiology and director of UCLA's Southern California Injury Prevention Research Center. Driving into ethnically diverse neighborhoods in Los Angeles, San Bernardino and Riverside counties to conduct surveys as part of Kraus's workplace assaults study, Tacata has learned not just about the subject at hand, but also about the perspectives of the interviewees. "People are always curious and ask me questions, and we get into discussions," he says.

hile individual research projects tend to be confined to students in the school's doctoral programs-MacNeil, for one, will investigate an environmental issue once he completes his initial course work, part of the D.Env. requirement-there are occa-

COURSE:

Biostat 235Causal Inference INSTRUCTOR: Dr. Thomas R. Belin,

assistant professor of biostatistics Does smoking cause lung cancer? Today, the answer seems obvious. But only a little more than 30 years ago, when the U.S. Surgeon General's Office first endorsed the causal link, there were intense debates in which many reputable scientists argued that the evidence was less than conclusive. Perhaps, they suggested, the rock-solid correlation could be explained by a genetic predisposition both to take up the smoking habit and to develop lung cancer. Subsequent studies (involving identical twins, for example) have discredited that conclusion, but other debates over when correlation can be considered causation-particularly in nonrandomized studies, given that randomized controlled trials are considered a basis for inferencecontinue to rage. In the first-ever offering of Biostat 235, Belin divided the course into two major themes: an analysis of real-life debates over causal inference, both old and new; and a focus on what the tools of statistics-most notably some newly developed technologies and theories-can bring to the decision-making process. Part of the latter includes forming strategies for designing and analyzing observational studies, and controlling for potentially confounding variables. "Rather than going through a series of mathematical theorems and proofs, one of our goals in the course is to take a step back and ponder the foundations for inference, especially in nonrandomized studies," Belin explains. Among the controversial issues for students to ponder: the impact of media images of violence, the potential for lead in the environment to harm children, the effects of electromagnetic fields, and the modern version of the smoking debatethe relationship between secondhand tobacco smoke and lung cancer.

UCLA PUBLIC HEALTH 15

COURSE:

HS 110-Ethrnc, Cultural, and Gender Issues in America's Health Care System INSTRUCTORS: Dr. Gerald F.

Kominski, associate professor of health services; Dr. Nancy Harada, assistant professor of medicine Other courses have examined health status and access across populations, but HS 110 is among the first to delve into the specific ways in which culture, ethnicity and gender influence healthseeking behaviors, access and health outcomes, as well as how research on minority health issues squares with the real-world issues health-care providers face. While Kominski and Harada coordinated and provided continuity for the course (which debuted in the Spring Quarter), guest lectures were given by faculty representing a variety of disciplines and perspectives from the UCLA School of Public Health, the School of Medicine, and, in one case, the American Indian Clinic in Bellflower, Calif. Among the populations selected for study: African Americans, Latinos and Chicanos, Native Americans, Asian Americans, women (of all ethnic groups), the elderly, and gays and lesbians. Kominski points out that little is known about the extent to which behaviors and structural barriers affect health-status differences across populations. "This is an area that has been ignored in the past," he says. "We're just now seeing a commitment to address these issues with federal research dollars." Still, he asserts, many health-care providers make the mistake of treating clinical conditions with a blind eye to the patient's cultural bent "There's a lot of evidence suggesting that compliance behaviors, for instance, are significantly influenced by culture," Kominski says. One of the goals of the course is to build on such evidence; another is to determine how findings can be translated into effective strategies for improving health outcomes for disadvantaged groups, whether through behavioral influence or policy development.

16 UCLA PUBLIC HEALTH

sional exceptions. Laura Griffith (epidemiology) and Shaista Malik (community health sciences) are two of three M.P.H. students who initiated community-based violence studies under California Wellness Foundation fellowships. Griffith, for one, is thankful for the school's diversity of strengths: She enrolled here after completing her undergraduate education at UC Santa Cruz, where she directed an AIDS education program for students. For Griffith, who was interested in international HIV work, the choice was a naturalthe school, behind the AIDS surveillance contributions of Drs. Roger Detels and Ralph Frerichs in a number of countries, is well known in that field. But between applying to UCLA and starting here as a student in the fall of1993, Griffith's interests shifted, and she decided she wanted to study violence, specifically against women. No problem: "I just happened to come to a place where there was an injury prevention center, and where violence prevention was a major focus, which is rare in public health schools," Griffith says. "I got very lucky." Griffith, whose family settled in Eureka, Calif-a town with a population smaller than UCLA's-turned her attention to the role of girls in gangs. "I felt like everything about them in the popular media was sensationalist," she explains. "You'd hear about the movement toward mixed-gender gangs, but all that would be reported was that a girl shot somebody. There was nothing about what motivated these girls to do what they were doing, or what could be done to help them." Griffith approached Dr. Susan Sorenson, associate professor of community health sciences, about her interest, and Sorenson infom1ed her of the fellowship opportunity; now, Griffith is completing one of the first descriptive studies of female gang members ages 12-16-an age group young enough that interventions have the best chance of success, she notes. Malik, who moved to California from her native Pakistan when she was l l, is examining the effects of exposure to community and family violence on the attitudes and behaviors of adolescents, using a questionnaire administered in five high schools in the Long Beach Unified School District, where Malik spent a year teaching biology before corning to the UCLA School of Public Health. In mid-study she was sur-

prised to find a large number of respondents reporting that they had left gangs. To explore the reasons, Malik asked students from a sub-sample to write an essay on factors that would influence their decision about whether to remain part of a gang. "This is the way education should work-you learn something in class and then you have the opportunity to apply it," Malik says. "I never expected I'd already be at the point where I'm conducting my own study, something that can be published." The experience has proved so satisfying that she intends to enroll in the school's Ph.D. program and pursue a research career.

ot every student knows exactly what he or she wants to pursue or where to pursue it, which is why Diego, as president of the Public Health Students Association (PHSA) in 1994-95, made finding ways to help students with career development a top priority. "With the way the job market was going at the time, we weren't sure whether once we graduated with a master's degree we'd have employers knocking at our doors, or whether we would have to knock on doors to find them," Diego says. After a brainstornung meeting in which students voiced their concerns, the PHSA leadership met with the school's administration with an offer to work jointly toward a solution. "We provided the student support and input on areas that the dean needed to address," Diego explains. "The dean's office provided its guidance and assistance." One of the results was a career development series in which students could seek advice from outside consultants on resume building, job-search strategies and interviewing techniques. Both Diego and the school's administration would like to see a career fair added for future years, and are working to institutionalize such programs at the school. A second goal involved increasing the lines of communication among students. Central to that concern was students' desire to have a meeting place where they could study or simply relax. Again working with the dean's office, the association secured such a space within the school's corridors-space that includes an office suite for PHSA's executive council, a conference room, a student lounge area, and computer stations for students to use both

for their studies and to retrieve information about jobs. Diego, who also organized social events for students throughout the year, is one who had no shortage of contact with her peers: She lived with three other UCLA School of Public Health students, all of whom. she m et through the health services program. "The four of us had someone from outside of the school over for dinner recently and it was hard to avoid talking about health care," she recalls, smiling.

hile some students, busy with their course work and outside commitments, establish few contacts during their time at the school, many others take advantage of the opportunity for extracurricular education-not to mention the chance to make friends-by getting to know their classmates. DuBose, who went through the program balancing farn.ily obligations, a part-time job and a heavier course load than most, says he'd be nowhere without

his new companions. "There comes a time when you can't make it to class, and if you don't have any friends, you're sunk," he says. "We all help each other." Indeed, within many courses there are group projects, facilitating student interaction and the chance to establish lasting relationships. It was during such bonding experiences that Malik came to realize that, differences and all, the UCLA public health students also had a great deal in common. The battle over the r 994 state ballot initiatives was heating up, and Malik began to notice something close to unanimity-along with a good deal of activism-among the students on certain key issues: in support of universal health care, against the tobacco-company-sponsored initiative that would have lifted certain smoking bans, against the state's anti-illegal-immigration initiative. Recalls Malik: "I became aware that I was with people who, while different in a lot of ways, share many of the same n1otivations."

COURSE:

CHS 298-Selected Topics in Disaster Relief and Humanitarian Assistance INSTRUCTOR: Dr. Steven Rottman,

professor of community health sciences and medicine The Northridge earthquake in 1994 and the Oklahoma City bombing last April were well-publicized reminders of the complex interplay of the numerous fields involved in the response to masspopulation disasters. Recently, the World Health Organization has lamented the lack of a broad, university-based program focusing on disaster relief, and the Federal Emergency Management Agency called on schools of public health to develop disaster-related curricula. "UCLA has experts from the natural sciences, engineering, sociology, medicine, management and public health-all fields that have an impact on large-scale disaster planning and relief," explains Rottman, a board-certified emergency physician with a longstanding interest in pre-hospital and disaster care. "So this school is an ideal setting in which to bring these resources together in a graduate-level curriculum." Eventually, Rottman hopes to offer a concentrated program within the school's Department of Community Health Sciences, including both in-depth classroom training and field experiences. For starters, CHS 298 (developed in response to numerous requests from students) provides an overview of selected topics related to both natural and man-made emergencies. Students learn about the disciplines that work together; the natural forces that cause mass population disasters; the logistical difficulties-due to factors that can include the size of the coordinating effort, challenging terrain, and the presence of armed conflict-involved in establishing relief services for large numbers of displaced people; the varying strategies and services of leading relief agencies; the methods for conducting a hazard analysis and surveying the needs of an affected population following a natural disaster in a given region; and the type of research that might be useful in studying the consequences of disasters and the effectiveness of relief efforts.

UCLA PUBLIC H EALTH 17

Dr. Susan B. Sorenson, associate professor of community health sciences, testified before the Los Angeles County Board of Supervisors on domestic violence last February. Her 1994 paper on child homicide and maltreatment history, published in the American Journal of Public Health, won the 1995 Robert Chin award for research in child abuse and social policy, given by the American A space-limited sampling of the new, ongoing

injury prevention; and "Northridge Earthquake

and just-completed research, publications,

Casualty Study" (California Department of

Psychological Association.

Dr. Jeremy M.G. Taylor, professor of

presentations and awards of UCLA School of

Emergency Preparedness and Injury Control)

Public Health faculty:

to assemble a detailed database on the

biostatistics, heads "Statistical Methods for

casualties and building damage from the

AIDS Research" (National Institutes of Health)

January 17, 1994 quake.

and "UC Universitywide AIDS Research

Dr. Abdelmonem A. Afifi, professor of

Program -

biostatistics and dean, together with co-author

Marker Processes and HIV Disease

Virginia A. Clark, professor emerita of

Dr. Joanne Leslie, assistant professor of

biostatistics, completed the 3rd edition of

community health sciences, is project director

received the Dwyer Award for Young Faculty

Computer-Aided Multivariate Analysis, to be

of "Adolescent Reproductive Health and

Achievement from UCLA's Jonsson

published in 1995 by Chapman & Hall. The book

Sexuality in Africa," a project of the Pacific

Comprehensive Cancer Center.

highlights the latest versions of six PC-based

Institute of Women's Health (of which Leslie is

statistical packages.

co-director) to provide research support and

Progression," both through 1996. In 1994 he

Dr. Jane Valentine, associate professor of

technical assistance to African researchers and

environmental health sciences, presented

research institutions. Funding comes from the

"Environmental Arsenic Exposure in the

vice chair of community health sciences, is

Population Sciences and Health Sciences

Western United States -

examining "Community Response to the

Divisions of the Rockefeller Foundation.

Approaches" at the International Conference on

Dr. Matthew P. Longnecker, assistant

a delegate to "China for Environmental Health,"

Dr. Linda Bourque, professor and

Arsenics in Calcutta, India in February. She was

January 17, 1994 Northridge Earthquake," funded by the National Science Foundation.

Methodological

Data collected includes injuries suffered,

professor of epidemiology, is the principal

sponsored by the Citizen Ambassador Program

damage to homes and personal property,

investigator of "Organochlorine Residue Levels

of the Dwight D. Eisenhower Institute in

and preparedness activities before and after

and Risk of Breast Cancer" (National Institute of

Spokane, Wash.

the quake.

Environmental Health Sciences), a case-control study to see if blood levels of DDT and PCBs are

Dr. Neal Halfon, associate professor of

related to breast cancer risk.

Dr. Steven P. Wallace, assistant professor of community health sciences, was a participant in the federally sponsored National

community health sciences, will develop a health index for the State of California with

Dr. Shane S. Que Hee, associate

Forum on Geriatric Education and Training,

funding recently awarded by the California

professor of environmental health sciences, has

which met last April to develop a national

Wellness Foundation. The health index will be

been appointed to the Biological Monitoring

agenda for action in geriatrics and gerontology

used at both the state and community levels

Committee of the American Industrial Hygiene

education that will be used in the national

to measure health status and resources. Halton

Association.

debates over health professions reform.

Dr. E. Richard Brown, professor of community

Dr. Judith Siegel, professor of community

Dr. Arthur Winer, professor of

health sciences and health services and director

health sciences and associate dean for

environmental health sciences and director of

of the Center for Health Policy Research; and

academic programs, wrote "Looking for

the Environmental Science and Engineering

is conducting the task in collaboration with

colleagues at RAND.

Mr. Right?: Older single women who become

Program, received funding from the California

mothers" (Journal of Family Issues),

Air Resources Board for "Development of

Dr. Jess F. Kraus, professor of

examining why older, single women want to

Intermedia Transfer Factors for Toxic Air

epidemiology and director of the Southern

become mothers and how their pre-mother-

Pollutants"; "Characterization of Ozone

California Injury Prevention Research Center

hood motivation and experiences compare to

Episodes in the South Coast Air Basin"; and

(SCI PRC), received funding for "Media and

those of married mothers.

" Critical Evaluation of a Biogenics Emission

Injury Prevention Program" (California Office of

System for Photochemical Grid Modeling

Traffic Safety) to educate the radio traffic

in California."

reporting community about realistic approaches to using radio traffic reports for promotion of

18 U CLA PUBLIC H EALTH

Focus:

DEPARTMENT OF HEALTH SERVICES

Dr. Ronald Andersen, the Fred W. and Pamela T. Wasserman Professor of Health Services, received the Leo G. Reeder Award for Distinguished Service to Medical Sociology from the American Sociological Association.

Dr. Roshan Bastani, assistant professor, received a $1.2 million grant from the National Cancer Institute (NCI) for a telephone counseling intervention aimed at indigent women in Los Angeles County, with the goal of increasing adherence to follow-up of breast abnormalities suggestive of breast cancer. In another large project, she is attempting to increase breast and cervix cancer screening and follow-up in women seen in Los Angeles County Health Department facilities.

Dr. E. Richard Brown, professor of community health sciences and health services and director of the Center for Health Policy Research, will become president of the American Public Health Association in November of this year. Brown is currently leading efforts to create the California

vice chairman of the Partnership for Prevention, a national public-private partnership attempting to advance prevention on the national agenda.

Dr. Patricia Ganz, professor, is playing a leading role in several studies, including the Breast Cancer Prevention Trial, a double-blind, placebo-controlled trial of tamoxifen for women at high risk of breast cancer (funded by the National Cancer Institute); the Breast Cancer Survivor Study on Sexuality and Intimacy (also NCI-funded); and the Department of Defensefunded UCLA Menopause Study, a randomized intervention trial of breast cancer survivors with uncontrolled menopausal symptoms, aiming to improve quality of life outcomes.

Dr. Gerald Kominski, associate professor, received two grants from the Health Care Financing Administration. "Improving

services researchers at UCLA, UC San Francisco, RAND, UC San Diego, and Drew University of Medical Sciences.

Measurement of Hospital Output and Productivity" will use California hospital data to measure changes in the intensity of services

professor, is the principal investigator of "Access to Care and Quality of Life in HIV Disease"; "Access, Process and Outcomes in HIV Disease"; "Oral and General Health Status and Utilization Among AfricanAmerican Elderly"; and "HIV Cost and Utilization Study," in which he heads the large study's access portion (see p. 4).

Dr. Jonathan Fielding, professor, recently co-founded the UCLA Center for the Health of Children, Youth and Families, a combined effort of the UCLA schools of public health and medicine whose broad mission is to improve the health of children and families. He is president-elect of the American College of Preventive Medicine, and was named

Dr. Milton I. Roemer, professor emeritus, received the Duncan Clark Award from the Association of Teachers of Preventive Medicine last April. He is continuing his research on comparative national health systems. Dr. Stuart Schweitzer, professor, is

Consortium for the Study of Managed Care, a collaborative effort involving leading health

Dr. William Cunningham, assistant

Dr. Thomas Rice, professor, recently completed a three-year study, funded by the Robert Wood Johnson Foundation, on the impact of payment reductions for Medicare surgical procedures. Rice found substantial evidence that physicians increase the volume of services provided to privately insured patients when Medicare fees decline.

provided to hospital patients from 1989to1992 against the increase in hospital charges. "Business Health Care Purchasing Coalitions" examines the development of voluntary purchasing cooperatives in selected markets across the United States.

Dr. Mark S. Litwin, assistant professor, is studying the quality of life in men with prostate cancer; resource utilization in urologic disease; and cost-efficacy in the treatment of patients with urinary tract infection, kidney stones and impotence. He wrote "Quality of life outcomes in men treated for localized prostate cancer," published in the Journal of the American Medical Association.

Dr. Glenn Melnick, associate professor, is conducting a research project to determine the effect of managed care and health-care competition in California and two other states.

continuing to study pharmaceutical economics and policy. Schweitzer's hypothesis is that competition in the pharmaceutical industry is greater than people realize, and is successful in moderating quality-adjusted pharmaceutical prices.

Dr. Paul Torrens, professor, chaired the Institute of Medicine's Committee on the Prevention of Nicotine Addiction in Children and Youth in 1993 and 1994. The committee's report, Growing up Tobacco Free: Preventing Addiction in Children and Youth, was released late last year and published by the National Academy of Sciences.

Dr. Robert Valdez, associate professor, is on a two-year leave of absence to serve in a unique position for the U.S. Department of Health and Human Services. He was appointed deputy assistant secretary for health in the Public Health Service and director of interagency health policy for the Health Care Financing Administration. It is the first joint appointment between the department's major health-care agencies. ÂŽI

UCLA PUBLIC HEALTH 19

Dr. Gerhard Kraske, M.P.H . '84, M.D. , graduated from George Washington University School of Medicine in

1990 and in 1993

completed an internal medicine residency program at the West Los Angeles VA Medical Center, where he is currently in an allergy and immunology fellowship program. Upon completion of the fellowship, Kraske plans to enter private practice in the Midwest or on the

Dr. Stephen M. Shortell, M.P.H. '68,

Society for Parenteral and Enteral Nutrition.

Ph.D., was awarded the Baxter Health Services

He was a nutrition program fellow with

Research Prize. He is the A.G. Buehler

Project HOPE and served as a consultant to

Distinguished Professor of Health Services

the Nicaraguan Ministry of Health.

Management and professor of organization

East Coast.

Marie LaFargue, M.P .H. '86, is director of the Wound Care Center at Daniel Freeman Memorial Hospital in Inglewood, Calif. She

behavior at the J.L. Kellogg Graduate School of

Richard S. Greene, M.P.H. '82, has worked

was appointed

Management, Northwestern University. Shortell

for the U.S. Agency for International Development

Diversity and Outreach Committee of the

also holds professorships in Northwestern's

since

Department of Sociology and School of Medicine.

Herbert Rees Memorial Award in recognition of

Affiliate, and was given an award for leadership

"outstanding and innovative contributions toward

and service to the organization last year.

Hutton A. Addy, M.P.H. '74, was

the improvement of public health services in

1984. Last year, he received the agency's C.

1994-95 chair of the Cultural

American Diabetes Association , California

nominated dean-designate for the new

Cameroon." After four year in Cameroon, he was

Etsuji Okamoto, M.P.H. '88, is developing

School of Medicine and Health Sciences at

given an assignment as supervisory health

a statistical model to evaluate the disease

the University for Development Studies at

population development officer at the USAID

structure using health insurance claims forms .

Tamale in the northern region of Ghana.

mission in Bangladesh.

The project is funded by Ministry of Education

His appointment began in October

1994.

grants for pioneering research . Okamoto is an assistant professor of public health at Kinki

Merle Brodie, M.P.H. '76, is executive direc-

University Medical Center in Osaka , Japan .

tor of the Palomar Pomerado Health Foundation, the fund-raising arm of Palomar Medical Center and Pomerado Hospital, in San Diego.

which includes the county hospitals and

Diane Ross Simon, M.P .H. '78, earned an M.A. in marriage and family therapy in 1993 and

San Fernando Valley as well as L.A. CountyUSC and its affiliated facilities. In that role,

is currently seeing clients as an M.F.C.C. intern

she is responsible for the development and

health centers of the Antelope Valley and

with Care Associates, and running groups for

implementation of the network's Vertical

families of children with disabilities. She lives

Integration Plan and Provider Network -

with her two sons in Woodland Hills, Calif.

COUNTY CONVERSION: MARILYN GRUNZWEIG

James D. Barber, M.P.H. '79, last year

Few have blazed the trails that Marilyn

became president of the Hospital Council of

Grunzweig (M.S.P .H. '89) finds herself

half of the county's effort to convert to managed care. The change is crucial, Grunzweig explains, because the county needs revenue from Medi-

Southern California, the largest metropolitan

following as she helps the Los Angeles

Cal patients to help fund indigent care. With

hospital association in the nation and the

County Department of Health Services

Medi-Cal becoming increasingly attractive to

largest professional trade association in Los

convert to a managed-care system.

Angeles County. Barber previously served as

"Denver," she finally says after naming a

private providers, the county has lost a significant portion of that revenue base.

administrator of Daniel Freeman Memorial

few smaller systems that have made the

"We're trying to organize into a managed-care

Hospital in Inglewood, Calif.

transition. "We're modeling some of what

delivery system that will retain current Medi-

we're doing after the Denver system." But

Cal enrollees and attract new ones,"

Dr. Gordon L. Klein, M.D., M.P.H. '80,

even there, the comparisons go only so far

Grunzweig says. That means offering them the

was recently promoted to professor of

when you're working with the nation's largest

option of geographically convenient,

pediatrics at the University of Texas' Childrens

health-care system.

aesthetically pleasing centers where a team is

Hospital. He chairs the gastroenterology

Grun1weig is director of special projects

responsible for coordinating their care, where

advisory panel of the Committee of Revision of

(and the executive director's sole professional

they have 24-hour telephone access and

United States Pharmacopoeia, and is on the

staff) for L.A. County's North/East Network,

where waiting times are reasonable.

technical advisory group of the American

20 UCLA PUBLI C H EALTH

Robert Korman, M.P.H. '92, is CEO and president of Benchmark Quality Institute, executive director of the Institute for Productivity Improvement, CEO of the International Disaster Institute, and director/ founder of the Institute on Longevity and Wellness. He is based in San Francisco.

Three Questions: We need to know w h ere you are, how you 're d o ing and how you think we're doing. Please help us by taking a m omen t to fill out the relevant sections below.

Gregory P. Oliva, M.P.H. '92, became the new coordinator of the California Cardiovascular Disease Prevention Coalition, part of the Cardiovascular Disease, Outreach, Resources, and Epidemiology (CORE) Program, effective in September 1994.

1. 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 ofthis magazine). If you are not presently on the mailing list, please give your address and indicate "new entry." 0New Entry

Adrienne Werner-Carroll, M.P.H. '92, is currently working as the New Mexico wellness coordinator for QualMed Pla ns for Health, Inc., in Albuquerque.

Current Address - - - - - - - - - -- -- - - - -- - -- -- - -- -

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Briony Raymond, M.P.H. '93, is a consultant to the United Nations' Population Fund evaluations unit on globally funded projects related to traditional birth attendants. She has also conducted evaluation of maternal-child health / fami ly practice projects in Latin America. ÂŽI

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2. WHAT ARE YOU

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At the same time, the county is contracting with HMOs to provide specialty and inpatient care for their patients. "That's something we have always done well, because of our affiliations with the UCLA, USC and Drew schools of medicine," Grunzweig notes. Grunzweig participates in the negotiation-and-contracting process with outside providers, and oversees the process of integrating county health centers (which weren't previously involved in primary care) into the hospital system. "You're talking about medical-staff integration, nursingstaff integration, all of the centers' ancillary services and resources.. .it's a huge process," she says. So huge that she has periodically called professors she met while a student in the UCLA School of Public Health's program in health services and administration. "I've asked them to send students out to help with what the county is undertaking," Grunzweig explains. "Those contacts I made while in ÂŽI the program have been invaluable."

Vear of Graduation _ _ _ Degree(s) _ _ __

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3. HOW ARE WE DOING? Please give u s your though ts about any thing co vered in this issue , ab o u t th e magazine in gen eral and ab o ut topics you'd like to see in future issu es. Name _ _ _ _ _ _ _ _ _ _ _ __

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