I •JtHU91£{!ibl
A
"We believe we will convince the administration that the UCLA School of Public Health must stay intact if this university is to remain an important part of the national health scene. "
s most of you already know, the UCLA administration announced a proposal last June that would eliminate four professional schools, including the UCLA School of Public Health, as a way to reduce administrative costs. The so-called "Professional Schools Restructuring Initiative" suggests closing the schools of public health, social welfare, and architecture and urban planning, and moving these schools' faculty into other existing schools and a new school of public policy. The library and information science school would also close, while the school of nursing would be downsized. The school of public policy is proposed to include programs from urban planning, social welfare and public health. As for our school, some of our departments are proposed to move to the public policy entity; the others to the school of medicine. Faculty, students and staff at the UCLA School of Public Health are strongly united against this proposal for these reasons: • Splitting up the school would violate the very basis of public health, a field whose strength lies in the synergism and integration produced by bringing together five core disciplines: biostatistics, community health sciences, epidemiology, environmental health, and health services. • The contract and grant funding that would be lost if our school is closed surpasses any administrative savings the university might accrue from such a decision. Many grants are earmarked specifically to schools of public health. In addi.tion, a number of funding agencies would undoubtedly no longer find UCLA a desirable place in which to invest their public health research dollars. • Many of UCLA's best public health professors were attracted here by the opportunity to teach and conduct research in a school of public health - indeed, one of the elite schools of public health in the country. In all likelihood, closing our school would lead to the departure of many of our top faculty . UCLA would cease to be a major player in the public health arena; in turn, this would weaken its standing in the other health-science areas and in other fields related to public health. We believe we will convince the administration that the UCLA School of Public Health must stay intact if this university is to remain an important part of the national health scene. That is also the case we will continue to make in the weeks ahead as UCLA's Academic Senate deliberates on the proposal before making its recommendation to Chancellor Charles E. Young. I am heartened to report that our position has been fortified by the strong and vocal support coming from all over the world, most notably the health community in the United States. We have heard from numerous concerned professionals - not only our loyal alumni, but also other prominent leaders in health, business, government (including the U.S. Congress and California Legislature), and local communities. Your support has given us tremendous strength during these troubling times. This issue of UCLA Public Health recalls some of the landmark contributions our faculty have made over the years toward a healthier society, including the most recent - the behind-the-scenes guidance of two UCLA School of Public Health professors who headed committees for the White House Task Force on Health Care Reform, stamping their imprint on President Clinton's historic proposal. We also feature an examination of public health's expanding role as societal conditions and the cost-reducing, prevention-emphasizing impetus behind health-care reform increasingly move our field into the forefront. I hope in my next Dean ' s Message to be able to bring you the good news that we will remain an intact school, still an integral part of the public health community at this exciting point in our history, when our approach has never been more relevant. That being the case, I am confident we will continue to build on the track record depicted in this issue.
C. Dr. Abdelmonem A. Afifi
UCLA PUBLIC HEALTH Volume 12, Number 2, Fall/Winter 1993
Abdelmonem A. Afifi, Ph.D. Dean
c
0
N
T
E
N
T
s
4
Richard Elbaum Director, Health Sciences Communications
PUBLIC HEALTH'S TIME Editorial Board
As the field moves to the forefront of the U.S. health-care system, challenges loom.
Abdelmonem A. Afifi, Ph.D. Dean
9 Susan C. Scrimshaw, Ph.D. Associate Dean for Academic Programs
V. Gale Winting Associate Dean for Administration
LANDMARKS Emily K. Abel, Ph.D. Associate Professsor, Health Services
Irwin H. Suffet, Ph.D. Professor, Environmental Health Sciences
The UCLA School of Public Health's pioneering contributions toward a healthier society.
16
PHYSICIAN, PROTECT THY COMMUNITY Karen August Director of Development
Joyce Garcia, M.S. ' 75 Alumni Association
Alumna Suzanne Dandoy fulfills public health's mjssion.
2 Q&A
Jeff Caballero Preside/It, Students' Assn.
Richard Elbaum Director, Health Sciences Communications
Vicki Beck Assistant Director, Health Sciences Communications
Brown and Valdez on the White House Task Force experience.
19 RESEARCH
20 FACULTY 21
Dan Gordon Editor
ALUMNI
Kimberly Barbis Designer/Art Director
UCLA Public Health is published by the UCLA School of Public Health for the alumni, faculty, students, staff and friends of the school. Copyright 1993 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 .
ON THE COVER: After years of touting the benefits of studying populations rather than individuals, the public health profession stands on the brink of a renaissance. A new set of societal problems and the impetus behind health-care reform are two of the reasons the U.S. health-care system appears ready to embrace the public health paradigm. Our cover story (p. 4) asks national, state and UCLA School of Public Health experts to discuss the challenges now faced by public health leaders. PHOTOGRAPHY: Courtesy L.A. Marathon/Chappell Studio Inc., 1990 (cover); Norm Schindler (Q & A).
Brown and Valdez on
The White House Task Force Experience One day last February, two UCIA School of Public Health professors got The Call. "Would you be interested in joining the White House Task Force on Health Care Reform to help the President develop a proposal for sweeping change of the system?" Or something to that effect. Having spent their professional lives illuminating the deficiencies in the current U.S. health-care system and developing alternative proposals, it didn 't take long for Dr. E. Richard Brown, professor of community health sciences and health services, and Dr. Robert 0. Valdez, associate professor of health services, to decide. They spent the next three months in the nation's capital, Brown serving as co-chair of the Working Group on Low-Income Populations and Valdez co-chairing the Working Group on Benefits. The following Q & A with UCLA Public Health took place after they returned.
What did your day-to-day work entail?
Who was in the working groups?
BROWN: We went through a series of stages. First we received a general assignment - to identify the issues that needed to be addressed for the population covered by our work group, people with low incomes. That stage was concluded by a "tollgate," in which representatives from each work group presented to a large meeting presided over by presidential advisers Ira Magaziner and Judy Feder. After some feedback and criticism, we went back to our work groups and moved to the next stage, which was to take all of those issues and develop as many options as we could come up with to address them. There were no on-the-table/off-thetable distinctions at that point - everything was assumed to be on the table, which generated numerous options. After another tollgate session, we began putting the options into small models, then larger models, and finally full -blown recommendations for addressing broad ranges of issues within our areas of responsibility.
VALDEZ: It was an extremely diverse group of folks. The groups were generally composed of people from the various federal agencies Health and Human Services, Treasury, Labor, Agriculture ... almost every agency had representatives. There were people from academia, individuals who had studied and written on a number of these issues for many years. There were representatives from provider groups - physicians, nurses, chiropractors, dentists and others - who brought their clinical expertise to the discussions and debates. There were also people who run and operate health-care systems, people who understand not only the delivery side but also the organizational and financing issues that arise. Working with all of these extremely intelligent, knowledgeable people was exciting but also exhausting because, of course, they all have strong opinions. Overcoming that logjam and trying to move people toward consensus was difficult and, at times, frustrating. We spent the last part of the working-group phase trying to develop consensus on a wide variety of issues where there had not been agreement.
This was within the context of managed competition? VALDEZ: Right. At the end of his campaign and the beginning of his administration, President Clinton said he wanted to implement managed competition as the basis for health-care reform. It was left to his advisers to determine the best way, and that's what we were about. We were trying to flesh out the general notion that he had put forward, give it some detail, some structure, so that a plan could be put forward to Congress.
How difficult was that? VALDEZ: In some cases, easier than I thought it would be. But in other cases, we never could reach a consensus and so our recommendations were sent up with majority and minority opinions.
BROWN: Some of the arguments in my group were over fundamental issues. Should poor people who need subsidies have the same choice among health providers as more affluent people, or should they be limited to only the lowest -cost health plans available? What should happen to the Medicaid program? Should it be eliminated? Should it be folded in? Should it be maintained as a separate stream of 2 UCLA PUBLIC HEALTH
funding, but in which all of the people covered by it would be required to enroll in a health plan through these purchasing cooperatives? How would the special needs of people with disabilities or chronic conditions be met - for example, needs for more specialty services than other people might require, for specialists who might not be included in a smaller managed-care plan?
Did you feel external pressures - say, from some of the groups with a lot at stake in your recommendations? VALDEZ: There was a constant barrage of visits to the White House, some initially set up by the administration for consultation, others set up later in response to the great demand by interest groups and others to express their positions and concerns. In the benefits group, we heard from people interested in alternative therapies, chiropractic, acupuncture, long-term care, nursing homes, hospitals, university hospitals, cancer centers, insurance companies, etc. - alt of the various players in the health-care field interested in benefits: patients with special health problems and providers alike.
Any time you create differences from the way things are today, there' s a redistributive effect that some people in society aren't going to like. It may mean that some people will suddenly get benefits or choices that aren't open to others, or that some people are going to end up paying more money than they do now while others pay less. That sort of redistribution has tremendous political ramifications, and is the factor that has tied up the financing scheme for this proposal more than any other. Politicians get very nervous about redistributing income or benefits. BROWN:
How did these political realities influence your discussions? Although most options could be put on the table, single-payer alternatives that were purely tax-financed were not up for discussion, and that was made explicit. It was also quite clear that some options would be taken more seriously than others. And for at least the first couple of months, all of us were engaged in a guessing game about what was on the table and what was off the table. We were told that just about everything was on the table, but everybody knew that wasn' t the case. Some options were right in the middle of the table, others were off toward the side of the table, others were right at the edge, and some probably had fallen off, but nobody had been told about it yet. It was a source of great frustration, because it meant that we operated in a climate in which we believed that there were limitations on what we could propose, but we didn' t know what those were. BROWN:
Several times during the process there were news media reports about aspects of the plan that were supposedly winning support. How accurate was this coverage, and what effect did it have on your work? BROWN:
It was very destructive. The press would seize on one option
that sounded sensational when it may in fact have been just one option among many, perhaps even put out there just to encourage people to broaden their perspectives, not to seriously consider. When those things hit the press, there would be a tightening of security, making it more difficult for people in the work groups to communicate with each other. You could no longer take your papers and distribute them freely even within your own group; you had to assume that anything that got distributed would end up in the hands of the press and possibly create embarrassment.
Are you worried that the plan that ultimately emerges from the political process will be watered down to the point where it's not major reform? VALDEZ: I hope it's not watered down so much that it turns out to be simply health insurance reform. I'd like to think that Congress will stand up and really address this issue in a way it should be addressed. The President is asking them to take on quite a lot, particularly during a pre-election period. It's going to be difficult for some to take a strong stand. On the other hand, if they don't take a strong stand we're going to be left with this broken system. We can tinker around at the edges, ad infinitum, but it won't fix the fundamental flaws in the way we deliver care to people or control the runaway costs in the system.
What did you get out of the experience personally? VALDEZ: It was exciting, it was thrilling, it was frustrating, it was maddening, it was spectacular...all rolled into one. I learned a lot about my strengths and weaknesses. I met wonderful, socially committed individuals I can call friends and colleagues. I learned a lot I can bring back into the classroom. We have an opportunity to improve the way we deliver medical care in the United States. I believe, as the President does, that the current system fai ls our people, and in particular it fails Latino, Asian, and poor communities. So I appreciate the opportunity to help an administration willing to take on the difficult issues.
I learned a lot about a set of issues that I thought I knew quite a bit about before I went, but learned how much more there is to know. It's personally gratifying to see that some of the issues I raised and fought for in the process - especially ways to improve and protect access for vulnerable populations - are reflected in the proposal. I would favor more of a social insurance or single-payer approach, but I think it's an incredibly important reform. I was glad to have a chance to help shape what is likely to be the most extensive social program legislation ever enacted in this country. • BROWN:
UCLA PUBLIC HEALTH 3
At the same time that public health ' s basic tenets have gained favor - with societal conditions making the approach more relevant every day - the field itself is taking stock, beginning with the Institute of Medicine' s landmark 1988 report on public health' s future . More recently , a past dean and the current dean of the UCLA School of Public Health have lent their voice to the discussion with "The Maturing Paradigm of Public Health," an article currently in press at the Annual Review of Public Health . The common message: From its narrower past when halting the spread of communicable diseases was the main concern, public health now means much more - with a new set of concerns demanding an active role if the field is to fulfill its Institute of Medicine-defined mission of "assuring conditions in which people can be healthy."
U
nder health-care refonn in America, public health is going to experience a renaissance the likes of which members of the public health community can envision only in their fondest dreams. That ' s the opinion of Dr. Hugh Tilson, former state health director for North Carolina and a member of the Institute of Medicine Committee on the Future of Public Health. He bases his premise on three observations: • Central to the nation ' s current rethinking on health care is the discovery of the partnership of prevention with cure - a partnership that is the embodiment of public health . "Lessons that public health has preached for generation s are now being spoken by the curist community," Tilson explains. • A crucial aspect of health-care reform is the integration of services. "Cost-saving requires that we not duplicate, that we take advantage of the health setting to accomplish all of the purposes of health care," Tilson says, so that clinical preven-
tive services now provided primarily by health departments will become part of the mainstream delivery system. • "First and foremost within health-care reform is the notion of creating systems that will be accountable," he concludes. "Public health is the one body that does both the assessment - that is, holds the world accountable - and the assurance, helping to deliver that accountable service to those in need . In an accountable health-care system the role of convener, the fundamental public health role, is going to be needed as never before." The nature of public health agency work would change profoundly in a system that provides access to preventive services, adds Dr. Molly Joel Coye, California's state health director from 1991 until September 1993, when she stepped down to become senior vice president for health systems development at Health Dimensions, a nonprofit hospital group in Santa Clara, Calif. Public health agencies would become responsible for populationbased prevention, she explains for investments in health and epidemiology beyond the scope of what could be done by competing health plans in the same geographic area. Moreover , contends Coye , the major purchasers of health care employers, unions and government - increasingly want to know the result of their investment in terms of the health status of the populations they're covering. "That is rapidly moving the system toward an epidemiologic approach," she says. "As a result, public health will become far more critical to the functioning of the entire health system, and prevention will be better understood as the key to health." Indeed, the soaring costs of treating the sick continue to add credence to the public health belief in the adage "an ounce of prevention is worth a pound of cure." The next step, says Dr.
-
.UCLA PUBLIC HE~
Kristine Gebbie, national AIDS policy coordinator and former state health director in Oregon and Washington, is explaining prevention as not solely something that occurs between an individual physician or nurse and a specific patient, but as a broader community effort. "The serious problems in our society are not amenable to an individual intervention," Gebbie asserts. "As we understand more about the big damagers - HIV infection, unwanted pregnancy, violence - we are realizing that many aspects of society have to be brought together, and the public health paradigm is an effective tool for doing so." Gebbie believes the nation is adopting a view of health that is no longer exclusively medically based but is cross-disciplinary and focused on populations rather than individual patients - the public health model. Public health will also increasingly become part of the everyday practice of clinicians who see the individual patients, predicts Dr. Kenneth I. Shine, president of the Institute of Medicine. He reasons that under a health-care system in which physicians are responsible for groups of patients, they will be better positioned to practice clinical epidemiology and introduce preventive strategies for their populations; that the growing availability of databases on patients enables clinicians to examine the impact of their interventions and determine what works for each patient group; and that medicine has come around to the idea that physicians must be responsible for the environment in which their patients live. "A whole variety of concepts that have historically been thought of as public health have become an integral part of medical care," Shine says.
T
he country's traditional way of thinking about health worrying about one person at a time - has not worked,"
says Dr. Abdelmonem A. Afifi, dean of the UCLA School of Public Health. To illustrate the importance of studying populations, he points to the measurement typically used to assess a nation's health: life expectancy. "No examination of one individual or one disease will give you the answer," he says. "It's a compilation of everything that's happening in the country." In the mid-'70s, Afifi, a biostatistician, took part in a major study to determine the factors that most influence the life expectancy of a nation's population. The No. 1 predictor, confirmed in subsequent research: the literacy rate. "It isn't how advanced your surgical technique is or what access you have to sophisticated drugs that's most important," he explains. "It's how well an individual can take advantage of the knowledge available to her or him. You can't reinvent that knowledge every time you talk to a new person; it has to be done on a population basis." Toward that end, the Institute of Medicine report defined a threepronged public health role: assessment, policy development and assurance. Five years later, most public health leaders agree that the diagnostic capacity remains the field's stong point, but that limited resources and/or political will renders the profession far from its mandate of delivering the conditions in which people can be healthy. A brief critique: • Assessment. The epidemiological component, fundamental to public health, "is where we're the most advanced," says Afifi. The advent of the computer introduced a sophisticated tool for data analysis, though obtaining reliable data remains problematic, Afifi notes. Models have been created to allow communities to assess their own needs. • Policy Development. Everyone agrees that great strides have
been made - in laws on smoking, in environmental regulations, in the movement of public health leaders into key policy roles. "We're coming a long way in leadership development," says Gebbie, who lauds the recent efforts of schools of public health toward that end. But few would grade public health as high in this area as in assessment. "We don't have universal objective methods for policy-setting," says Afifi . "It remains largely a subjective matter without scientific techniques that produce incontestable results." •Assurance. It's the most undeveloped of the three, and part of the reason is that assurance involves advocacy, a role unfamiliar or uncomfortable to many. "It's easier to proceed where the focus is on a matter that is highly technical," says Dr. Lester Breslow, professor emeritus of health services, former dean of the UCLA School of Public Health and co-author with Afifi of the "maturing paradigm" article. "When you're assembling statistics, no one complains; but when you get into policy formation, and particularly assurance functions, you begin to factionalize the body politic." But even where the political consensus has existed, the resources have not. In a climate of diminishing funding and shortages in personnel, says Gebbie, "we're having to rethink exactly what we mean by assurance." What good is a sound policy without the means to deliver on it? Assuring access to needed services? Not always possible. As national, state and local budgets have become tighter, allocation of public health funds has suffered disproportionately - perhaps, Afifi suggests, because prevention is anything but glamorous. "It's difficult to value something that never happened to you," he notes. At the same time, demands are being placed on public health agencies as never before. "We've become the safety net for
the direct delivery of care," laments Dr. Suzanne Dandoy (M.P.H. ' 63), who has headed state health departments in Arizona and Utah and is now deputy state health commissioner in Virginia (see profile, p. 16). "The more this happens, the more our resources are diverted from the prevention issues on which public health is based." Which is why the prospect of health-care reform, of a system of universal access that places more emphasis on prevention, leaves public health leaders cautiously optimistic. Adequately funded and freed of the burden of providing so much medical care, Breslow hopes, health departments can begin paying more attention to the chronic diseases, which now present a greater health threat than the communicable, public health's traditional focus. Public health's time. How will the field respond?
0
ne of the most important pub! ic health issues of the day, HIV I AIDS, offers a compelling illustration of the field's current strengths and weaknesses as seen by the experts interviewed for this article. In the Multicenter AIDS Cohort Study (MACS), the largest and longest-running study of the natural history of AIDS, "we' re using epidemiology, the core of public health, to elucidate important factors related to resistance to infection and copi ng successfully with the disease," says Dr. Roger Detels, professor of epidemiology at the UCLA School of Public Health, dean of the school from 1980 to 1985, and principal investigator of the study at UCLA (seep. 12). The only current method of fighting the spread of HIV is through behavior modification, another traditional public health role, but one in which opposition from religious and political groups to such measures as
UCLA PUBLIC H
7
sex education and passing out needles has produced a mixed record. Mustering the political will to invest in prevention strategies and obtain adequate funding, a role that most now agree is as much the essence of public health as epidemiology, has proved more difficult. Meanwhile, the public health paradigm has expanded dramatically from its beginnings, when the emphasis was on sanitation and infectious diseases. It now encompasses a new set of issues, from chronic illnesses to violence and drug abuse. The latter two, Breslow notes, are typical of societal problems long tackled solely - and with little success - by law enforcement, but which are now being redefined as public health issues. "There are conditions in society that give rise to these problems , the same as they give rise to syphilis or cancer or other problems," says Breslow. Breslow believes the public health community is increasingly recognizing the connection between poor health and such factors as low levels of education, low incomes and social discrimination - and should do more to ally itself with those seeking to combat these problems. In addition, contends Shine, the field needs to do a better job of making connections between the determinants of individual behavior and epidemiology if it hopes to have an impact on the health of communities. Others point to the need for stronger public health leadership. Ineffective strategies for changing unhealthy behaviors have served as greater barriers to the assurance function than lack of resources, argues Coye. On the issue of smoking, for example, most of the country is focused on cessation programs. "It's only been in California that the emphasis has shifted to a frontal assault on the tobacco industry and exposure to tobacco smoke," Coye says. "It's not surprising, therefore, that we see a much more rapid decline in smoking rates in this state."
The Institute of Medicine report, with its message that "public health is a vital function that is in trouble," served as a clarion call for action both inside and outside of the public health field. The American Medical Association passed a resolution imploring all state and local medical societies to seek information from their public health authorities about the status of their communities' health, and to assess their responsibility in improving it. "That was revolutionary," says Tilson. Likewise, the U .S. Public Health Service now must justify programs on the basis of how they contribute to local governments' ability to fulfill the three public health functions as defined by the report. "That report stimulated a lot of dialogue concerning public health' s role and our strengths and weaknesses," Dandoy says. "It described public health in a way that the entire profession now uses. This is not a profession that is as easily defined as, say, orthopedic surgery. I'm sure we all agree about what orthopedic surgery is; I'm not sure everyone agreed on what the mission and role of public health were." Yet, says Afifi, though the report provided a framework , public health remains a synthesis of so many disciplines that its adherents may never operate on the same page. And maybe that's not so bad. "It' s not necessarily an advantage to be uniform and homogeneous," he says. "A business that has a diversified product is better able to change with the times . Public health's divers ity allows for greater flexibility in meeting the changing needs of our society." Given today's emerging set of health issues that call clearly for a public health approach, that flexibility, many believe, may help to produce a public health renaissance. •
The UCLA School of Public Health's pioneering contributions toward a healthier society
he year was 1936, the substance wheat gemi, the subjects rats. Working in the UC Berkeley laboratory of Dr. Herbert Evans, one of the UCLA School of Public Healths first nutritionists made a discovery that would ensure her a prominent place in history. With her chemist husband Oliver, biologist Gladys Emerson was the first to isolate vitamin E, a substance without which rats could not reproduce - and one that, it now appears, plays a crucial role in reducing the risk of atherosclerosis in After her pioneering work leading to the discovery of vitamin E, Emerson conducted ongoing animal research on a succession of vitamins at the Merck Institute for Therapeutic Research. Jn 1957, she became chair of UCLA's Department of Home Economics. Under her guidance, the nutrition division of that department was transferred shortly thereafter to the new UCLA School of Public Health, where Emerson taught until her death in 1984. Jn the schools annals, Dr. Gladys Emerson was the first of many who have made critical contributions to a healthier society. The following pages revisit a few of these watershed moments.
UCLA PUBLIC HEALTH 9
LANDMARKS
LifestY,les of the Fit and Flabby Breslow's Alameda study he Surgeon General's warning about the hazards of smoking still included the qualifier "may." The twomartini lunch was as much a staple of the American culture as the burger and fries. Jane Fonda was a C..._____ Vietnam War protester, not a guru for millions of fitness buffs. It doesn't seem like such a big deal in today ' s context, but to a society that had traditionally viewed health in terms of overcoming disease, the study undertaken by Drs. Lester Breslow and Nedra B. Belloc of the California State Department of Health in 1965 represented a significant departure. Its first findings, published in 1972, by which time Breslow was dean of the UCLA School of Public Health, were downright shocking. Sixty-year-olds who practiced seven behaviors - getting regular exercise and sleep; not smoking, excessively drinking, or snacking between meals; eating breakfast; and maintaining a normal weight - were in the same physical health as 30year-olds who followed two or fewer of the behaviors. By practicing at least six of the seven, 45-year-old men could expect to live 11 years longer than their peers who adhered to three or fewer. "Eleven years," Breslow says today, shaking his head. "From 1900 to 1970, with all of the medical advances - surgery, antibiotics and everything else - the life span for men beyond the age of 45 was prolonged by five years. And simply choosing these specific behaviors accounted for 11." IO UCLA PUBLIC HEALTH
"It was dramatic," says Dr. Walter Schafer, professor of medical sociology at California State University, Chico and director of the Pacific Wellness Institute. "Health researchers had always suspected that our lifestyle habits make a difference for health and longevity, but this was the first large-scale study to actually quantify that correlation, and show that we're not talking about a few weeks or a few months of added life. Eleven years is long enough to catch people's attention." The Alameda study, as it's simply called more than two decades later, began in 1965 as an effort to measure health according to the emerging World Health Organization concept of "physical, mental and social well-being." The researchers surveyed nearly 7,000 adult residents of Alameda County, Calif. about their physical status. At the same time, they decided to add a few questions - they didn't have room for many - about people's daily habits that might affect their health, "behaviors that, conceptually at least, people could influence," says Breslow. The inquiries about smoking , drinking, caloric intake and exercise reflected common, if not yet obvious, notions about healthy behaviors; the amount of sleep (with 7-8 hours considered the healthy range) and regularity of meals served as indicators of people's level of attention to their health. As this relationship between lifestyle and physical health gained increasing acceptance in the public realm, Breslow continued to follow the Alameda group, nailing down the point in subsequent analyses. Most recently, he conducted a study published earlier this year with his son Norman, professor of biostatistics at the University of Washington School of Public Health, in which the Breslows found that the seven healthy habits are as strongly related to disability as they are to mortality. While the Alameda study has helped to spread the word about the value of making healthy choices, Breslow warns that the work is far from over. "Individuals don't make these decisions in a vacuum; they are greatly influenced by the social milieu around them," he says, hoping that policy-makers will pay heed. "We have to address how health can be maintained apart from what medical services accomplish."
LANDMARKS
Only, but Not Lonely Blake on family size and achievement
a
dmit it. When you were a kid, you felt sorry for the classmate who had no brothers or sisters. "There is a great fear that an only child is going to be some sort of weird person," said the late Dr. Judith Blake, the Fred H. Bixby Professor of Population Policy at the UCLA School of Public Health, in a 1989 interview with this magazine. That was before Blake, in her book Family Size and Achievement, proved the opposite. "We looked at this whole issue of whether only children are more isolated, engage less in extracurricular activities, are less liked and so forth," Blake said upon the book's release. "None of that is true - in fact, they come out ahead on these things. And actually it's quite logical. Only children are much more motivated to seek friends outside of the family and hence they have to make themselves attractive to other children or else they will be lonely. In a way, their social skills are more sophisticated than those of children who come from very large families." But for Blake, a professor at the school from 1976 until her death in 1993, the social advantage for children from small families was only the tip of the iceberg. Her book, a landmark contribution to the demography field and winner of the American Sociological Association's prestigious William J. Goode Book A ward for 1989, further reported that adults from one - and two child families attain two years' more schooling than those from families of seven or more children (even after socioeconomic background was taken into account), leading to greater success in later life. After analyzing her data, Blake attributed the educational discrepancy to small-family children's superior verbal abilities.
"The smaller the family, the more interaction children tend to have with adults," she said. "There is much more constant interaction, with parents spending more time correcting grammar and word usage, eating with children more often rather than feeding the kids separately. Plus, these children are listening to adult conversation all the time and are not overwhelmed in a sea of kids."
• • • • • • •
Reprieve for a Common Procedure Massey's vasectomy research
•
1
s it safe to get a vasectomy? In the mid-'70s, when the UCLA School of Public Health was chosen as the coordinating center for the nation's largest-ever collaborative study on the procedure, no one was sure. Research had begun to suggest a relationship between vasectomies and diseases of the immune system, as well as heart disease. In 1977, at a cost of several million dollars, the National Institute of Child Health and Human Development funded a study involving four centers; the UCLA School of Public Health team, headed by Dr. Frank J. Massey Jr., professor emeritus of biostatistics, and including Drs. Roger Detels, Anne Coulson, Potter Chang, Gary Spivey and Jose Quiroga, planned the study and supervised the final analysis. The results, published in the Journal of the American Medical Association in 1984, came as a relief to millions. A total of21,180 men, half of whom had been vasectomized in the past, were interviewed, representing 180,000 years of post-vasectomy follow-up. Fifty-four diseases were pre-selected as having a reasonable or suggested connection with the procedure. Not a single disease occurred significantly more in the vasectomized cohort than in the non-vasectomized group. Today, Massey qualifies the results in that the men interviewed were mostly middle-aged, so the vasectomy's impact on diseases affecting older men, such as prostate cancer, could not be determined. But the study, reported widely by the national and international news media, was able to put to rest many fears. UCLA PUBLIC HEALTH
11
LANDMARKS
Unraveling the Mysteries of AIDS Detels and the MACS study
r. Roger Detels was an epidemiologist at the UCLA School of Public Health in 1981 when a colleague in the school of medicine, Dr. Michael Gottlieb, published the first report of the disease now known as AIDS. In the course of studying multiple sclerosis, Detels had become interested in the idea that bombardment with multiple infection could make the immune system more susceptible to infections by other organisms. The hypothesis was untestable in multiple sclerosis because of its low incidence. But when Detels read Gottlieb's report, he was intrigued. "This was a disease in which you could predict which population was going to get infected, and the infection rate was obviously very high," he says today. So in 1981, with AIDS a mere blip on the societal radar screen, Detels contacted UCLA's gay and lesbian student association and began initiating cohort studies aimed at identifying the risk factors and modes of transmission of whatever was causing the new disease. Three years later, with the infectious agent of AIDS still undefined, the National Institute of Allergy and Infectious Diseases issued a request for proposals to look at the natural history of AIDS in a population of homosexual men. A UCLA group led by Detels responded and, along with three other sites, received funding. On their own, the four groups (representing the UCLA School of Public Health, the Johns Hopkins School of Hygiene and Public Health, the Northwestern University School of Medicine, and the University of Pittsburgh School of Public Health) chose to collaborate in the cohort studies they were initiating. Thus the Multicenter AIDS Cohort Study (MACS) was born. Now in its 10th year (with funding guaranteed through September 1995), the MACS was the first - and remains the largest cohort study specifically formed to examine the natural history of AIDS. It involves nearly 5,000 gay men who voluntarily respond to a several-times-annually interview schedule soliciting information on demographic factors, habits, disease history, and past and present sexual activities, and whose HIV-related status is documented. The study has produced some 400 papers and contributed landmark findings on the epidemiology of HIV infection and the virologic, 12 UCLA PUBLIC HEALTH
immunologic, psychosocial and neurologic aspects of the disease. "What I find exciting about this study is that we're using epidemiology to elucidate disease mechanisms," says Detels, a professor of epidemiology at the UCLA School of Public Health. In its initial years, MACS identified the risk activities for HIV transmission among homosexual men - confirming, in fact, Detels' pre-MACS findings suggesting anal intercourse as the major risk factor for CD4 cell depletion. Once HIV was identified in 1985, the study's focus moved to how the virus causes the disease and how it's transmitted. Last year, the MACS investigators began a new phase, venturing into issues surrounding infection itself. Among the groups targeted: men who practice high-risk behaviors but remain uninfected; those who develop full-blown AIDS rapidly (within five years) after HIV infection; those who, despite having fewer than 200 CD4 cells generally considered a hallmark of AIDS - develop no AIDSrelated diseases for more than three years; and infected men who, without treatment, show level CD4 cells for at least eight years and have not developed AIDS. "We have begun to define the fact that there are some individuals who are very resistant to HIV infection," Detels explains. "If we can figure out what the mechanism of that resistance is, we may be able to start talking about developing protective strategies that are not vaccine-dependent. This is crucial because it' s clearly going to be a long time before we come up with a viable vaccine. If we can find out what that mechanism for containing the virus is, we can offer hope to the millions of people who are already infected."
• • • • • • •
Unick Counts Rapid anthro and epi assessments he high-tech, multi-year health assessment may be appropriate to the western world. But in developing countries, where resources are scarce and time is precious, it's a luxury. In the last decade, two UCLA School of Public Health professors - one a medical anthropologist and the other an epidemiologist - have developed innovative methodologies that allow health planners in the developing world to get accurate answers quickly, circumventing the expensive and time-consuming processes used by their resource-rich brethren. In 1983, Dr. Susan C. Scrimshaw and alumna Elena Hurtado
LANDMARKS
developed a methodological handbook for a United Nations project to study household perspectives regarding health-seeking behavior in 16 developing countries. The Rapid Anthropological Procedures (RAP) were originally intended to be used by anthropologists returning to familiar regions to conduct health- and nutrition-related assessments; soon, though, they were being employed by health planners all over the world as a way of obtaining feedback from the people their programs served. "It demystified anthropology," Scrimshaw, professor of community health sciences and associate dean for academic affairs, explains. The need for rapid assessment based on anthropological strategies grew out of the frustration U.N. leaders were experiencing with the expense, time consumed, and problems with accuracy and validity of standard survey techniques to assess health care. Says Scrimshaw, "In reality, much program planning and evaluation was - and still is !though it may seem that way, concerns about U.S. - based on workers' statements about the services they provided, heal~h-care co~ts did not begin with the 1992 presior on brief visits to health-service sites by more senior officials, dential campaign. As far back as the 1950s, there was a notion that the country was overusing hospitals - to the who might not get the real picture in a few formal hours." The RAP guidelines were designed to allow anthropologists and detriment of its GNP. At the time, Dr. Milton I. Roemer was in Saskatchewan, Canada, other social scientists with relevant training to spend approximately where universal hospital insurance had been in effect since 1947. six weeks seeking the household and community perspective on With colleagues, he conducted a study, published in 1955, on facservices in an area where the government believes an effective pritors influencing hospital utilization in that province. The paper was mary health-care program is in place. RAP's appeal has proved the first to identify factors associated with higher-than-average widespread: The guidelines are now available in English, Spanish, rates of hospital admissions and days of hospital stay. Portuguese, French, and Chinese; Arabic and Indonesian versions Two years later, Roemer are in progress, and translations into additional languages have been was appointed to the faculty proposed by major international funding agencies. of the Institute While Dr. Ralph R. Frerichs was in what was then Burma in 1986, of Hospital he similarly found that health planners lacked sufficient data for Administradeveloping strategies to tackle their country's population-based tion at Corproblems. ''They needed a method that could reach out to people nell Univerat the community level," explains Frerichs, professor and chair of epidemiology. "They were taking surveys, but it took from g---x:----.,~Â sity. There, he consix months to a year to complete and analyze them." tinued these studies using data Building on a just-validated World Health Organization survey from both Saskatchewan and New York method used for immunization programs, Frerichs developed a new State. The study that guaranteed him a permanent place in public approach to information-gathering using a portable, battery-powhealth lore was published in 1959 by the American Hospital Associered computer and printer along with appropriate software to rapidation. The monograph "Hospital Utilization Under Insurance" identified 16 factors that determine hospital utilization rates where ly process, analyze and report the findings. With Rapid Survey patients are covered by private insurance or public financing. Of Methodology, a team could go into the field and present findings in tables and computerized graphs to a local program manager within these, one could easily be controlled: the supply of hospital beds. five days; within 10 days, it could issue a final 50-page report. Roemer (who shortly thereafter came to the UCLA School of Public Health, where he is currently professor emeritus of health services) In the six years it has been offered, 159 students from more than 32 countries have taken Frerichs' course, "Rapid Epidemiological concluded that physicians tended to fill the number of beds availSurveys in Developing Countries," at the UCLA School of Public able to them; thus, limiting the supply could greatly reduce costs. The study's influence on public policy was widely felt, with Health. Most have returned to their native lands to use the method health planners in communities nationwide taking pains to keep their in assessing health problems at the community level ranging from hospital bed supply in check. It wasn't long before health economists diarrheal disease and malnutrition to HIV transmission. Frerichs has began referring to the bed-filling phenomenon as "Roemer's Law," a also conducted workshops for health workers in five countries, as variant of the popularly held "Parkinson's Law," which predicts that well as several cities in the United States. He is now preparing a textbook on the methodology, to be published by Oxford University Press. work will fill the time available for its completion.
If Yon Build Them, They Will Come
Roemer's law on hospital utilization
a
UCLA PUBLIC HEALTH 13
LANDMARKS
The Right Formula for the Developing World-a Mother's Milk Jelliffe's educational mission
e has probably saved more children 's lives than anyone else. How's that for a legacy? If not easily quantified, the contributions of Dr. Derrick B. Jelliffe, the UCLA School of Public Health professor who helped establish the school's population and family health division and headed its international health program, are indisputably staggering. Jelliffe, who died last year, was trained as a pediatrician. But it wasn't through patient care that he touched so many young lives - no clinician could ever come close. And, though he contributed his share of scientific research, notes Dr. Charlotte Neumann, a longtime colleague at the school and author of the aforementioned quote, "he was intolerant of people who conducted a lot of theoretic research without going out to see what was happening." Jelliffe got out, all right, and what he saw was tragic . Infants in developing countries who were weaned from breastfeeding in their first year were frequently dying from infection and malnutrition. "They were put onto dirty, contaminated, diluted, non-nutritional formulas, whereas breast milk cost nothing, was sterile, and had the anti -infective nutrients just made for the baby," Neumann explains. With his wife, Patrice (lecturer and researcher at the school), Jel liffe circled the globe on a tireless campaign promoting lactation's 14 UCLA PUBLIC HEALTH
virtues. He doggedly fought corporations that were introducing commercial formulas into developing countries. "He and others caught on early," says Neumann. "These companies were dressing their people up as nurses, infiltrating maternity homes and giving out formula, telling new mothers about the importance of 'joining the 20th century.' That's sudden and sure death for an infant in an area where there's no clean water, no refrigeration and no money." Jelliffe visited policy-makers, successfully urging numerous governments to restrict the use of formulas and educate their citizens on breastfeeding's nutritional value. Most of all, he targeted physicians and nurses . Explains Neumann: "Many of them were being bought off by the milk companies, particularly in poor countries where the faculty at medical schools have no money and here comes this big company offering all kinds of perks if they would teach that formula was fine ." And, while his focus was in the developing countries (especially in Africa, the Caribbean and the Middle East) where infants were dying, Jelliffe also helped publicize the benefits of breastfeeding to mothers in this country, where the matter is not life-and-death as much as improved health. The Jelliffes lived and worked in developing countries for 30 years and together wrote and edited 22 books directed at health professionals. Derrick Jelliffe and his wife were consultants to UNICEF, the World Health Organization and the National Academy of Sciences, and to 81 countries. With the assistance of UNISYS , they established East Africa's first child health and pediatrics department at Makerere University in Uganda. Jelliffe was the founding editor of the Journal of Tropical Pediatrics and Advances in International Maternal and Child Health. He was the recipient of some of the most prestigiou s awards in the nutritional and pediatric fields . And yet, says Neumann, Derrick B. Jelliffe never emphasized the high-powered, quantitative approach adopted by many of his colleagues. She explains: "He preferred to observe, amass the evidence and publicize."
LANDMA RKS
' Who Would ve
Figured1
Brown and Valdez's uncovering of California's uninsured problem
efore there was a groundswell for health-care reform in California, before there was outrage over millions of Californians uninsured and unable to obtain necessary care - or, when able, placing additional fiscal burdens on already-strained county and state programs for the medically indigent - there was darkness. We didn't know. We knew not everyone was covered by the system, but we had no idea to what extent, or to what effect. That all changed in 1987 with the publication of the first in a series of reports by a UCLA School of Public Health research team composed of Dr. E . Richard Brown, professor of community health sciences and health services; Dr. Robert 0 . Valdez, associate professor of health services; Dr. Hal Morgenstern, associate professor of epidemiology; and doctoral students Tom Bradley and Chris Hafner, which found that 5.2 million Californians - 22 percent of the state's under-65 population - lacked health insurance of any kind, Medicare and Medi-Cal included. "The number of uninsured had been studied nationally, but legislators, the news media and the public in California pay much more attention when things are defined in California terms," says Dail Phillips, principal consultant for the state's Assembly Office of Research, which requested the study. "As it turned out, the problem was worse here than it was nationally." "Californians Without Health Insurance," published by the
UC's California Policy Seminar for the state Legislature, would have been an eye-opener even if all it did was calculate the number of uninsured in the state. But the UCLA School of Public Health group didn't stop there. Analyzing 1986 U.S. Census Bureau data, it found that: • Half of the 5.2 million uninsured Californians were employed, including more than I million adults working full time for the entire year without any health insurance; • One-fourth of the uninsured Californians had incomes at least three times greater than the poverty level - amounting to $33,000 for a family of four in 1985; • More than 1.5 million children were uninsured, including 30 percent of Los Angeles County children. "They told a very straightforward, simple story in understandable terms with a minimum of complicated analysis and commentary," says Phillips. "The packaging of their report was probably as important as the results themselves in getting people's attention." Indeed, the findings - along with subsequent studies by the same group depicting the sharp increase in the number of uninsured, their characteristics, the effect on their health and their costs to the healthcare system - reverberated through Sacramento. "It was used as the framework for subsequent administrative, executive and legislative task forces," says Phillips. Though comprehensive health coverage has yet to pass as a result, Phillips adds, the state, having taken the first steps in that direction, is currently in a better position than most to address the issue.
"Major social reform takes tim e," says Phillips . "There's an educational process that's a prerequisite for making major tradeoffs and taking major action. Those seeds have been planted. The BrownNaldez research started that debate." •
UCLA PUBLIC HEALTH 15
PHYSICIAN, PROTECT THY COMMUNITY Alumna Suzanne Dandoy Fulfills Public Health's Mission 1.
. . .BUT HAVE YOU EVER PRACTICED MEDICINE?
2.
3.
Or. Suzanne Dandoy became so exasperated with the question that in 1988, she compiled a list of issues she addressed in one week as executive director of the Utah Department of Health.
4.
D D
Hel.d a press conference to voice o .. ppos1t10n to construction of a b10logic aerosol test facilit at Conducted a meeting to dyd a nearby army base. . a ress the cone f med10al responders who ma erns o emergency AIDS. Y be exposed to patients with Contacted the Centers for D'!Sease Control to find of inf ants inadvertently gi t . any reports (as happened one day in a ~~:al ~ho1d vaccine instead of DTP Requested that a county attorn eal~h department clinic). midwife who apparent! ey flle charges against a lay death. Y was responsible for a maternal
5.
Attended a meeting of the Governor's Task Fo P regnancy Prevention. rce on Teenage
6.
Assisted a legislator in findin . and federal policies concerni! material for a speech on state dent children. g serv10es to technology--depen-
7.
Met with a physician who wanted . . . assistance m obtaining Medicaid coverage for ho 't r eclamptic patient. sp1 a izat10n of a 16-year-old pre-
8.
Planned a major statewide initi t. childhood immunization le 1 a ive on the need to maintain ves. M et with a gro up 0 f b usmess . leaders to di trol health care costs . scuss ways to con-
9.
10. Talked with a parent who clinic did not change glove:~h~oncerne~ that staff of a local ent patients. n drawmg blood from differ11. Approved policies regarding which covered by Medicaid. organ transplants will be 12. Contacted congressional staff charge on childhood . regarding the new federal survaccmes and the sub costs of providing imm . t· sequent increased UillZa 10ns 13. Responded to a request to det . . small office building are always i:~mme why employees in a The remainder of the time was s agency with a $250 m 'lli b pent on the matters of running an called "adm. . t . l on udget, practicing what is som t . ims rat1ve medicine.,, Oth . e rmes the department spent the· er public health physicians in . ir week launching a st t . improve access to prenatal care, conducting a chol a ewide t program to program for physicians, and hel in . es erol education develop an AIDS prevent· . P g the public education system wn curriculum for the schools.
From JAMA, Oct 14, 1988- Vol 260, No. 14, p. 2113.
16 UCLA PUBLIC HEALTH
ILLUSTRATION BY BRAD HAMANN
By Dan Gordon uzanne Dandoy (M.D., M.P.H . '63) wants you to know that she does, in fact, practice medicine. Always has, always will. Dandoy, whose patients for the last two decades have been the citizens of Arizona, Utah, and now Virginia, has long felt obligated to point this out - to her baffled medical school classmates in the early '60s when she announced she had accepted a residency in preventive medicine/public health with the local health department and, more recently, to readers of the Journal of the American Medical Association, wherein she wrote a 1988 opinion piece that included a recitation of issues she tackled in one week as executive director of the Utah Department of Health (see the previous page). When posed by someone outside the health professions, "Have you ever practiced medicine?" can be dismissed as ignorance. But when Dandoy's fellow physicians ask the question and, thankfully, far fewer of them do these days - she bristles. Behind the question, Dandoy believes, is an assumption that the only physicians practicing their trade are those who provide direct care to the sick. "Physicians who chose public health were historically judged as secondrate," she says. "The reputation of public health was that it was a field for retired pediatricians or physicians who couldn't make it in the private sector."
D
energy and that she will do it well," says Fox. In Arizona, where she was director of the state's department of health services from 1975 to 1980, Dandoy's record includes a successful campaign to transfer the tuberculosis control program into the private sector, closing the state's sanitarium. But as much as anything else, it was her administrative skills that made a difference. "Seven separate health agencies had been pulled together by new legislation 10 months before I took over," she recalls. "I had to organize and stabilize what was really a new department." After a respite from public health practice, during which Dandoy taught courses in community health perspectives and health care organization at Arizona State University's Center for Health Services Administration, it was on to Utah, where she¡ served as executive director of that state's health department from 1985 to 1992. The department's decentralized structure invites the moniker "United Divisions of Health," notes Sheldon Elman, who was her deputy. Dandoy responded, Elman submits,."by providing a framework in which the separate entities could safely pursue innovative programs while always knowing the general direction they were expected to follow." The most far-reaching of these was Utah's " Baby Your Baby" program, which put revenues from a statewide cigarette tax toward a massive campaign to expand access to and education about prenatal care. The program, which achieved a 90-percent recognition rating in public surveys, was put forth by the National Governors Association as a model and duplicated by several states.
andoy fits none of the above. "A lot of people figure that if you can get through medical school, surely you can be a skillful adminstrator, and that's not the case," says Dr. Earl Fox, director of Alabama's state ut don't expect Dandoy's new state to health department from 1986 to 1992 and a foradopt the program any time soon. In mer president of the Association of State and leaving Utah to become deputy state Territorial Health Officials, where he got to health commissioner for the Virginia Departknow Dandoy. "But Suzanne typifies a physician ment of Health last year, she went from a who is both extremely competent in medicine staunch no-smoking state to one whose tobacco and excellent in administration." farmers are key to the economy, rendering new The administrative category is where Dandoy cigarette taxes next to impossible. "This creates has made contributions felt from Phoenix, Salt two problems," Dandoy notes. "You can't use a Lake City and Richmond to numerous other state tax as a disincentive to smoke and you can't capitals and the pillars of power in Washington, create additional revenues for new or existing D.C. health programs." Another difference she found As president of the Association of State and was environmental: "A much lower percentage Territorial Health Officials in 1990-91, she of the population is connected to a municipal moved the association's office to the nation's sewage disposal system, so a big issue here is capital and hired its first full-time staffers, two making sure you have adequate sewage disposal decisions that greatly strengthened the associawith individual septic tanks and on-site systems - Dr. Hugh Tilson tion's voice in representing state health departon everybody's piece of land." Farmer North Carolina State ments at the federal level. During her two-year But the biggest change with the new job was Health Director tenure as president of the American College of in Dandoy's own role. After calling the shots in Preventive Medicine, ending last April, Dandoy Utah and Arizona, she has become operational brought together leaders at the academic, pracdirector of Virginia's public health programs, tice and training levels to examine the future of the preventive medicine removed from the political struggles that marked her previous tenures. specialty, a major undertaking lasting several years. She's served on "After 13 years of dealing with the politics," she explains, "I decided I numerous state and federal task forces on public health issues. "Whenevwas ready to get back to the programs." She has set two priorities: er she's involved with something, you know it's going to get her entire increasing the attention paid to chronic disease and integrating child
"The mark of a true leader is the willingness to stand up and be counted. Throughout her career, Suzanne has been surrounded by controversy because she's not afraid of it. ''
B
UCLA PUBLIC HEALTH 17
health programs. "The politics were exciting and interesting, but when you're constantly battling for resources or programs, it gets tiring over time," Dandoy says. One of her greatest frustrations has been watching demands for public health services increase while resources remain stable or are cut back. "We're frequently seen as the safety net for the direct delivery of care," she says, "and our resources get diverted from the prevention issues on which public health is based." When it came to adopting regu lations, she quips, "I found that if no one liked what I did, it was probably the right choice because it was in the middle." It would be a mistake to draw either of two conclusions from Dandoy's decision to step out of the fray in taking the Virginia position. The first false assumption is that, as a purist, she was irritated by having to weigh politics in making decisions. "That's the real world," she says. "We're affecting people's lifestyles and their economics." The second potential conclusion, that she developed a weak stomach for the controversy, couldn ' t be farther from the truth, says Dr. Hugh Tilson, former state health director in North Carolina. "The mark of a true leader is the willingness to stand up and be counted," he says. "Throughout her career, Suzanne has been surrounded by controversy because she's not afraid of it."
S
uzanne Dandoy knew she was going to be a physician as far back as she can remember. Her parents, who hadn't finished high school, decided that their only child was going to make something of herself - and where better than in medicine? But Dandoy was also influenced by her father's strong social interests. While in medical
school, assuming she wou ld eventually enter private practice, she spent a summer with the Los Angeles City Health Department (which had not yet merged with the county). "I became fascinated with public health," she recalls. When it came time for her medical school class to choose residency programs, Dandoy announced she intended to return to the city health department to do hers in public health. "We' re now seeing more medical students who are interested in social issues," she says. "At the time, my classmates said, 'You're going to do a residency in what?' " While concurrently studying for her M.P.H. at the UCLA School of Public Health, Dandoy was struck by the spirit of cooperation. "I learned about the team aspect of public health," she says. "In medical school you learned about physicians, and everyone else was subordinate to them. In the school of public health you learn about the roles of the health educator, the public health nurse, the environmental scientist, etc., and accept them as part of the team." Today, when speaking to medical students about public health, Dandoy warns them that if they' re after instant satisfaction they should be surgeons - able to make their patients better and send them home the next day. If they can wait months, even years, she adds, consider public health. "The difference we make happens over time," she says. "Sometimes you don't even know it until you look back. Other times you know that what you do will make a difference but that others won't perceive it for some time down the road. But that's OK with me. I do know I make a difference. I make a difference in the health of the public." Practicing medicine. •
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." _ _ _ Degree(s) _ _ _ _ _ _ _ __
Home Phone - - - - - - - - - - - -- - -- - ---Business Phone _ __________________ *If different from name at graduation, please include former name.
WHAT ARE YOU DOING? Please send any professional or personal updates you'd like to see included in the Alumni section. _ _ _ Degree(s) _ _ _ _ _ _ _ _ __
Name
--- ------------ ---------Year of Graduation
Address
- ------------------------------------------------
Class Notes -
---- ----------------- ------------------- - - -----
SEND TO: Editor, UCLA Public Health, 10833 Le Conte Ave., Los Angeles, CA 90024-1772. 18 UCLA PUBLIC HEALTH
A sample of studies ongoing at the UCLA School of Public Health.
Wastewater Treatment and the Malibu Lagoon Drs. Richard F. Ambrose and Shane Que Hee, associate professors of environmental health sciences, and Dr. Irwin Suffet, professor of environmental health sciences, are co-principal investigators of multidisciplinary research to assess the health risk of the Las Virgenes wastewater treatment plant to the Malibu Lagoon. The research includes organic, inorganic, biological, viral, and ecological measurements.
Health-Care Reform's Impact on Children Drs. Jonathan Fielding, professor of health services; Neal Halfon, associate professor of community health sciences; and Robert Valdez, associate professor of health services, are among 13 independent health policy analysts nationwide who are members of the new Child Health Consortium, funded by the Carnegie Corporation to study how children will fare under health-care reform.
Minority Women'~; Attitudes on Prenatal Care Dr. Deidre Spelliscy Gifford, adjunct assistant professor of community health sciences, is working with Dr. Susan C. Scrimshaw, professor of community health sciences and associate dean for academic affairs, on a one-year project to examine prenatal care content and attitudes toward prenatal
care in low-income, minority women in Los Angeles County. She is a co-investigator in the "Healthy African American Families" project, a three-year study funded by the Centers for Disease Control and Prevention and designed to learn more about pregnancy among African Americans. The project aims to involve the local community in the design and conduct of the research.
Breast Cancer Epidemiology Dr. Robert H a ile, associate professor of epidemiology, has been awarded two new grants. In "Loss of Heterozygosity in Bilateral Breast Cancer," a National Cancer Institute-funded study, he is looking at somatic changes in oncogenes and tumor suppressor genes in cases of bilateral breast cancer. Haile is a co-investigator of a study, headed by Dr. Sarah Fox of the UCLA School of Medicine, that will compare the effectiveness of two counseling interventions, telephone and mail, in motivating low-income white, AfricanAmerican and Latina women to be screened for breast cancer. Other researchers on the project include UCLA School of Public Health professors R obert Valdez and Ronald Andersen.
Nutrition Education and Training of Health Personnel Patrice E.F. Jelliffe, lecturer and researcher in community health sciences, is continuing research on colostrum and nutrition education and training of nurses, midwives and auxiliary personnel. She chaired workshops on both at the Internation-
al Nutrition Congress of the International Union of Nutrition Sciences in Adelaide, Australia.
Quality of Life in Men with Prostate Cancer Dr. Mark S. Litwin, assistant professor of health services and urology, is studying the quality of life in men with prostate cancer, funded by the Robert Wood Johnson Foundation; and costeffectiveness in the treatment of urinary tract infections, urinary stone disease and erectile impotence, funded by the American Foundation for Urologic Disease.
HIV Prevention in the Philippines Dr. Donald E. Morisky, associate professor of community health sciences, is the principal investigator of "Behavioral Research rn Support of AIDS/HIV Prevention in the Philippines," a three-year project funded by the National Institute of Allergy and Infectious Diseases to develop and evaluate a behavioral intervention for female sex workers in three study areas of the southern Philippines. He also heads "Tuberculosis: Prevention and Adherence Interventions," a three-year project funded by the National Institute of Nursing Research to plan, implement, and evaluate the effects of an educational program on the compliance behavior and completion of treatment for patients diag nosed as having active tuberculosis.
National Health Systems Dr. Milton I. Roemer, profes-
sor emeritus of health services, is continuing studies of national health systems in various countries.
Health Screening for Medicare Patients Dr. Stuart 0. Schweitzer, professor and chair of health services, continues to head the UCLA Medicare Prevention Demonstration, which studies the effect of health screening and counseling on older adults. The study was recently re-funded for its sixth year.
Violence Prevention Research Fellowships Dr. Susan B. Sorenson, assistant research epidemiologist and associate director of the Southern California Injury Prevention Research Center, is the principal investigator of "Academic Fellowships in Violence Prevention Research," funded by the California Wellness Foundation through 1997. The fellowships will offer diverse learning experiences within the context of an apprenticeship model.
Random-Effects Models Dr. Robert E. Weiss, assistant professor of biostatistics, received a First Independent Research Support and Transition grant from the National Institute of General Medical Sciences to study "Diagnostics and Graphics for Random Effects Models" through 1998. Random-effects models are statistical models used to analyze measurements of the same variables taken over a period of time. •
UCLA PUBLIC HEALTH 19
A sample of the publications, presentations and awards of the school's faculty.
Dr. Linda Bourque, professor of community health sciences, wrote "Human Behavior During and Immediately After the Earthquake" in The Loma Prieta, California, Earthquake of October 17, 1989 - Public Response, published by the United States Geological Service.
Dr. Edith M. Carlisle, adjunct professor of community health sciences, presented "Aluminum: an Essential Element" at the Federation of American Societies for Experimental Biology meeting in New Orleans earlier this year. She chaired a session, "The New Trace Elements," and presented a paper on aluminum at the Eighth International Symposium on Trace Elements in Man and Animals in Dresden, Germany in May.
Dr. Neal Halfon, associate professor of community health sciences, wrote "An integrated case management program for vulnerable children" (Child Welfare). He co-authored "Perinatal alcoho l and drug use : Access to essential services in 12 California counties," published by the University of California's California Policy Seminar.
Drs. Gail Harrison, Osman Galal and Charlotte Neumann, professors of community health sciences, attended the Interna-
20 UCLA PUBLIC HEALTH
tional Nutrition Congress of the International Union of Nutrition Sciences in Adelaide, Australia Sept. 23-30. They presented papers in a workshop chaired by Neumann entitled "Diet Quality and Micronutrient Deficiencies: Functional Consequences (A Three Country Study)." Harrison chaired the U.S. National Committee and was U.S. voting delegate to the congress.
Dr. William C. Hinds, professor of environmental health sciences, gave two presentations at the 1993 American Industrial Hygiene Conference and Expo last May: "Evaluation of Aerosol Inhalability in the I 0145Âľ m Particle Size Range" and "Personal Sampler Performance for Inhalable Particles Using a Life-Size Full-Torso Manikin in a Wind Tunnel."
Patrice E.F. Jelliffe, lecturer and researcher in community health sciences, has become editor of the Journal of Tropical Pediatrics in order to continue the work of the late Dr. Derrick B. Jelliffe. She is an ongoing consultant to the Wellstart International Lactation Program and recently became a member of the advisory board of the World Alliance for Breastfeeding Action.
Dr. Jess F. Kraus, professor of epidemiology and director of the Southern California Injury Prevention Research Center, wrote "Epidemiologic aspects of fatal- and severe-injury urban freeway crashes" (A ccident Analysis & Prevention). He was
given the Faculty of the Year Award by the UCLA School of Public Health Alumni Association in June.
Dr. Mark S. Litwin, assistant professor of health services and urology, wrote "Quality of life in men with prostate cancer: A pilot study"; "Why do sicker patients cost more? A chargebased analysis of patients undergoing prostatectomy"; and "Decreased racial differences in the incidence and mortality of prostate cancer: A phenomenon of increasing age" for the Journal of Urology.
Dr. Matthew P. Longnecker, assistant professor of epidemiology, wrote "A 1-y trial of the effect of high-selenium bread on selenium levels in blood and toenails" (American Journal of Clinical Nutrition) and "The reproducibility and validity of a self-administered semi-quantitative food-frequency questionnaire in subjects from South Dakota and Wyoming" (Epidemiology).
Dr. Shane Que Hee, associate professor of environmental health sciences, is the editor of Biological Monitoring: An Introduction (New York City: Van Nostrand Reinhold, 1993), the first textbook in its field.
Dr. Thomas Rice, professor of health services, wrote "Incomerelated cost sharing in health insurance" (Health Affairs) and, with Dr. Jonathan E. Fielding, professor of health services,
"Can managed compet1t10n solve the problems of market failure?" (Health Affairs).
Dr. Milton I. Roemer, professor emeritus of health services, wrote "National health systems throughout the world" (Annual Review of Public Health); "The meanings of social medicine and public health" (Scandinavian Journal of Social Medicine); and "Higher education for public health leadership" (International Journal of Health Services).
Dr. Stuart 0. Schweitzer, professor and chair of health services, co-wrote " Buy health care with taxable dollars," a commentary for the San Francisco Chronicle. Dr. Jane L. Valentine, associate professor of environmental health sciences, presented "Review of Health Assessments for North American Populations Exposed to Arsenic in Drinking Water" at the International Conference on Arsenic Exposure and Health Effects in New Orleans last July. She was made a consultant to the National Institutes of Health and the science advisory board of the U.S. Environmental Protection Agency.
Dr. Robert E. Weiss, assistant professor of biostatistics , received a Faculty Career Developme nt A ward from UCLA for 1993-94. The award includes one month of summer research support. •
Virginia Marie Benander, M.P.H. '70, retired as school nursing coordinator in the Los Angeles Unified School District and is now traveling and working with church adult programs.
Nancy Flournoy, M.S. '71, Ph.D., presented at the American Statistical Association meeting in August a paper describing a series of experiments (of which she was a participant), just prior to the outbreak of the AIDS epidemic, that led to the discovery that viral infection can be transmitted through the blood.
Richard Berquist, M.D., M.P.H. '75, is founder and president of Fresno Prime Care. He is developing a primary care medical group and medical services organization for the San Joaquin Valley and primary care guidelines for medical management. He is married to Anna Fong, an optometrist in private practice; they have two children ages 9 and 11.
Ronald E. Yates, M.P.H. '75, was recently appointed chief executive officer/administrator at HCA Riverpark Hospital , a 165-bed psychiatric facility in Huntington, W.V.
Brenda Hayes-Wilson, M.P.H. ' 76, D.S.W., is a program specialist in Atlanta with the U.S. Centers for Disease Control and Prevention in the Office of Minority Health.
Douglas P. Manera , D .C.,
M.P.H. '77, is a chiropractor in private practice in Las Vegas. He recently earned his board certification as a diplomate of the American Board of Chiropractic Orthopedists. He has three children: Douglas, 9; Matthew, 7; and Andrew, 2.
Lynda Bluestein, M.P.H. '77, is on the steering committee and is a lobbyist for the Connecticut Coalition Against Gun Violence, which worked successfully for a statewide ban on assault weapons, passed by the Connecticut legislature last June. She is developing a political action committee to support candidates at the local and state level who will advocate for gun and domestic violence issues.
Diane E. Maier, M.P.H. '81, is director of clinical research and quality improvement for the Health Care Initiative Inc., a Denver-based managed care system owned by four physician-hospital organizations to evaluate practice patterns and quality of care. Previously, she was project coordinator of the Mountain-Plains Regional AIDS Education and Training Center and managing editor of a 1,000-page HIV/AIDS curriculum training and reference manual.
Jean Tremaine, M.P.H. '82, is project manager of the FetalInfant Mortality Review Project for the Los Angeles County Department of Health Services. The goal is to discover gaps in services that may have contributed to fetal and infant mor-
tality and recommend improvements.
Susan Karlins, M.P.H. '84, is health education director at Education Programs Associates in the San Jose area. The company provides educational materials for culturally diverse clients and clients with low literacy skills to family planning clinics, maternal-child health providers, public health departments and other agencies.
Robert M. Lewis (formerly Wicks), M.P.H. '86, changed his name earlier this year after being reunited with his natural father. In June, he earned an M.B.A. from California State University, Bakersfield.
Thyne Sieber Rutrough , M.P.H. '86, completed her Ph.D. in population and human ecology at the University of Michigan, Department of Sociology in 1991. She recently completed a National Institute of Aging- funded postdoctoral research fellows hip in the demography of aging at Penn State University, and accepted a position there as deputy director of the Center on Aging and Health in Rural America. She was married in December 1990 to Andrew L.S. Rutrough; their daughter, Abigail, was born this year.
Marilyn Weinstein Grunzweig, M.S.P.H. '89, is senior assistant hospital administrator at Olive View-UCLA Medical Center. She gave birth to a son,
Henry David, in June.
Kathy Black, M.P.H. '90, had a baby girl, Alyssa Brooke, last February. She is now continuing her Ph.D. studies in social welfare at UCLA.
Rob Simmons, Dr.P.H. '90, began a new position as chief eKecutive for school-linked servi.ces with the California Department of Health Services. He heads a team of eight working with the state departments of education, mental health , social services and the governor's office to integrate services for children and families and develop comprehensive, integrated systems, including blending financial streams with managed-care systems.
Joanne P. Wellman, M.P.H . '90, works for the Dental Health Foundation, a contractor for the California Department of Health Services. She has coordinated a statewide oralhealth needs assessment of children.
Grace Dy, M.P.H. '92, is now studying for her medical degree at the UC Irvine College of Medicine.
Pauline Vaillancourt Rosenau, M.P.H. ' 92, Ph.D., was appointed associate professor of management and policy sciences at the Health Policy Institute of the University of Texas-Houston School of Public Health. •
UCLA PUBLIC HEALTH 2 1
UCLA School of Public Health 10833 Le Conte Avenue Los Angeles, California 90024-1772 Address Correction Requested RF74
Nonprofit Org. U.S. Postage Paid UCLA