UCLA Public Health Magazine - November 2003

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NOVEMBER 2003

UCLA

PUBLIC HEALTH complementary & alternative medicine:

UCLA

a healthy trend?

School of

Public Health

We have a drug problem in the U.S. No, not that one. Stuart Schweitzer tackles the complex cost and policy issues around prescription meds.

Virginia Li's life as daughter of Chinese wartime leaders, successful immigrant and influential public health scientist is traced in her riveting memoir.

Doctoral student Yee-Wei Lim gave up clinical practice in Singapore to take a broader look at health care, including expanding access for L.A.'s indigent.

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UCLA

PUBLIC HEALTH

Albert Carnesale, Ph.D. Chancellor

Linda Rosenstock, M.D., M.P.H. Dean, UCLA School of Public Health

Sarah Anderson Assistant Dean for Communications

Julie Tisdale Pardi, M.A. Senior Editor

fe a t u r e s

Dan Gordon Editor and Writer

Martha Widmann Art Director

E D I TO R I A L B OA R D Richard Ambrose, Ph.D. Associate Professor, Environmental Health Sciences

Thomas R. Belin, Ph.D. Associate Professor, Biostatistics

F. A. Hagigi, Dr.P.H., M.B.A. Associate Professor, Health Services

William Hinds, Ph.D. Professor, Environmental Health Sciences

Hal Morgenstern, Ph.D. Professor, Epidemiology

Michael Prelip, D.P.A. Assistant Professor, Community Health Sciences

Susan B. Sorenson, Ph.D. Professor, Community Health Sciences

Thomas Cruz, Genus Heidary Co-Presidents, Public Health Student Association

Joyce A. Page, M.S.P.H., J.D.

UCLA

Past President, Alumni Association

School of

Public Health

4 Forecasting Public Health Trends for California Model for projecting population health status trends under different scenarios would better inform the policy-making process.

6 Virginia Li: Helping Communities to Blossom The seeds of a public health career were sown during a childhood in wartime China, where she now returns regularly to consult. Her new book tells the compelling story.

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Complementary & Alternative Medicine

8

Tackling Tough Questions on Pharmaceuticals

in every issue 22 STUDENTS

19 16 As CAM’s popularity continues to rise, researchers examine the efficacy of the therapies and the reasons patients are turning to solutions outside the doctor’s office.

Centers for Environmental Quality and Health

As the population ages and chronic illness increases, demand for prescription drugs soars. Who will pay for them?

24 RESEARCH Cancer screening disparities...practice structure and physician performance... gaps in children’s health and access...willingness to sell handguns illegally...driving risks for teens...quality indicators for county programs.

29 FACULTY 32 NEWS BRIEFS

Solving environmental threats to health has never been more complex – or more important. The new CEQH is poised to meet the challenge.

ON THE COVER The growing popularity of complementary and alternative medicine in this country has led to unprecedented efforts to learn about the reasons people choose CAM and the effectiveness of the therapies themselves. Cover photo/illustration by Martha Widmann. Images sourced from: 2003 © Getty Images.

PHOTOGRAPHY Reed Hutchinson / TOC: CAM, Pharmaceuticals; p. 2; pp. 10-12; p. 15; pp. 20-23; p. 31; p. 33: Anderson Yvette Roman / cover and TOC: Li; p. 6 Wendy Hunter / TOC: CEQH; p. 16: L.A. skyline, worker health and safety; p. 18 Andrea Hricko / p. 16: children and refinery Courtesy of Susan Kanowith-Klein / p. 35 Courtesy of the L.A. County Department of Health Services / p. 4 Courtesy of the UCLA School of Public Health / p. 5; p. 17 Getty Images © 2003 / p. 13; p. 19; p. 26 Photo/illustration for Forecasting feature by Martha Widmann. CA map: Getty Images © 2003

School of Public Health Home Page: www.ph.ucla.edu E-mail for Application Requests: app-request@admin.ph.ucla.edu UCLA Public Health Magazine is published by the UCLA School of Public Health for the alumni, faculty, students, staff and friends of the school. Copyright 2003 by The Regents of the University of California.

Permission to reprint any portion must be obtained from the editor. Contact Editor, UCLA Public Health Magazine, Box 951772, Los Angeles, CA 90095-1772. Phone: (310) 825-6381.

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dean’s message A SCHOOL’S EXCELLENCE IS JUDGED by the caliber of its students and faculty. Both our faculty and students continue to prove their excellence on many fronts. The impressive work of two of our students is highlighted in the Student Profiles section. A sign that many outside the school are recognizing our excellence is the fact that for the second year in a row, student applications to the school have increased by 10 percent.

We also continue to see an impressive increase in faculty research productivity, as measured by grants and contracts (see graphic on the facing page). The quality and breadth of research are inspiring, with our faculty conducting research in such varied areas as complementary and alternative medicine (see the story on page 8), the environment (page 16) and pharmaceutical economics and policy (page 19).

In addition to research, another important role of the public health researcher and practitioner is advocacy. Several of our faculty worked tirelessly to defeat Proposition 54 (the so-called racial privacy initiative), which, if passed, would have severely hampered our research and public health efforts.

Recognition by outside organizations is another measure of excellence.

While the next issue of the magazine will contain a more comprehensive listing of all of our faculty honors, I would like to highlight some faculty who will receive distinctive honors at the American Public Health Association’s annual meeting November 15-19 in San Francisco. If you are attending, don’t forget to stop by the UCLA Reception on Monday the 17th from 6:30 p.m. to 8 p.m. at the Westin St. Francis Hotel.

• E. Richard Brown will receive APHA’s 2003 Sedgwick Award. The Sedgwick Memorial Medal for Distinguished Public Health is APHA’s oldest and most prestigious award. The citation notes his roles as a past president of APHA, founder/director of our UCLA Center for Health Policy Research, development of the California Health Interview Survey, and his involvement in advising several U.S. Senators and the White House on health care reform.

• Jonathan Fielding will receive APHA’s 2003 Milton and Ruth Roemer Prize

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for Creative Local Public Health Work. This important award, named in honor of

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two of our school’s most cherished faculty members – the late Milton Roemer and his wife, Ruth Roemer, who remains active on our faculty – recognizes his outstanding contributions as director of public health and health officer for Los Angeles County.

• APHA will also honor Diana M. Bontá with its 2003 Presidential Citation in recognition of her public health leadership both in California and the nation.

As director of the California Department of Health Services, Bontá oversees one of the largest departments in California state government. She joins the ranks of past presidential award winners such as Rosa Parks and Rosalynn Carter.

It is difficult to write about excellence at the school without mentioning Lester Breslow, so I am excited to announce that on the 30th anniversary of the Breslow Lecture, none other than Dr. Breslow will be our keynote speaker. Who better than he to give the distinguished lecture? This is a fitting tribute to the lecture series and our renowned scholar, teacher, and friend. Please mark your calendar for April 19, as I know this will be a memorable event.

It is with great pride that I report on the excellence attained at the school. It is a continual process, and with the efforts of our faculty, students and staff and the support of our friends, I know that we will achieve even greater heights.

Linda Rosenstock, M.D., M.P.H.

$42.7 M

Dean

$38.2 M

$29 M CONTRACT & GRANT AWARDS

$19.2 M

$18.2 M $15.9 M

1997-98 Other State Federal

1998-99

1999-00

2000-01

2001-02

2002-03

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1996-97

$17.3 M

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4 M ODEL

FOR

PROJECTING POPULATION HEALTH STATUS TRENDS UNDER DIFFERENT SCENARIOS WOULD BETTER INFORM THE POLICYMAKING PROCESS .

Forecasting Public Health Trends for California Forecasting is common across a wide variety of disciplines, and projecting the future often helps to inform the policy-making process, whether it’s the population trends produced by demographers or the fiscal projections of economists. But conspicuously absent from many discussions are projections on the population health impact based on various scenarios.

“We would like to create a model in which we could compare various policy alternatives to see which investments could provide maximum benefit per dollar expended.”

UCLAPUBLIC HEALTH

—Dr. Jonathan Fielding

“We do a lot of work trying to understand what’s happened in the past, and we learn from that,” says Dr. Jonathan Fielding, professor at the UCLA School of Public Health and director of public health for Los Angeles County. “We also spend a lot of time conducting surveys to examine the health status, health risks, health problems, and health improvement opportunities today. The key piece that we haven’t been looking at sufficiently is the future. Even if nothing changed in terms of current trends, what would the health of the American people be 10-20 years from now? What would be the opportunities? How big would the disparities be compared to now? And, more important, how big an impact can alternative policies and programs that could be implemented today make on our health in 10, 20 or 30 years?”

So Fielding and two of his School of Public Health colleagues, Drs. Gerald Kominski and Hal Morgenstern, are leading an effort to develop a Population Health Forecasting Model that would project population health status trends in California. With funding from The California Endowment, the researchers are creating a framework that they hope will eventually facilitate projections on a broad range of health outcomes based on variables that include health behaviors, technological advances and demographic trends.

“California has rapidly changing demographics when you consider the aging population, lots of immigration into the state and one of the most ethnically diverse populations in the nation,” notes Kominski. “So it’s important to have information about population health status not only as it stands today, but also as it will be down the road based on current trends. Right now we don’t have a clear idea of what the impact of these changes is going to be on the future health and health needs of the population.”

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“California has rapidly changing demographics. So it’s important to have information about population health status not only as it stands today, but also as it will be down the road based on current trends.”

—Dr. Gerald Kominski

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health risks on population health than most sectors could venture. “The best economic forecasts are only looking out a year or two ahead,” Fielding says.

“We have the ability to project, with good tools, over a much longer period of time, and use that data to inform public policy.”

On the other hand, health forecasting presents complex methodological challenges. With so many different risk factors and behaviors to be considered, pinpointing the causes of health outcomes – even when the only one being considered is mortality – is difficult. Moreover, Kominski notes, economic models are built on nearly a century of data on various relationships in the U.S. economy, providing information that is amenable to forecasting short-term changes. Health forecasters lack analogous data.

The group is relying on a number of health surveys, including the California Health Interview Survey – the nation’s largest state health survey, based in the UCLA School of Public Health; as well as U.S. Census Bureau and California vital statistics data going back more than a century. In addition, in an effort to meet the methodological challenges, the UCLA School of Public Health team has assembled an advisory group consisting of experts from the public health and health care fields as well as from other sectors in which forecasting is more advanced.

For the initial feasibility study, the Population Health Forecasting Model is focusing on the potential future impact of a single set of interventions, involving physical activity. The reason behind that selection is twofold. The UCLA team did not want to reinvent the work of others, and models have been developed in areas such as cardiovascular disease risk factors and smoking behavior, but not to estimate the effects of changes in physical activity.

In addition, notes Fielding, “There is a lot of concern about the adverse impact of lack of physical activity on health broadly, specifically about the increase of overweight and obesity.”

But, while one issue is being used to demonstrate feasibility, the researchers intend to complete the project with a model that, though subject to further refinement, will be capable of accepting input on a more comprehensive set of variables, as well as a wide array of health outcomes.

“My vision for this project is that it would become the health equivalent to the UCLA Anderson Forecast,” Kominski says, referring to one of the nation’s most closely watched economic predictors. “In the long term, we would like to present not just a snapshot, but a projection of what impact changes in population characteristics, economic conditions, and medical technology are going to have on the short- and long-term future health of the state’s population.”

feature

Even if health behaviors and health-related technology remained constant over the next 10 years, the distribution of disease in California would change based on population trends. For example, the higher birth rate among Latinos portends a rise in Type 2 diabetes, all else being equal, given the higher incidence of the disease in the Latino population (double that of non-Latinos).

But UCLA’s Population Health Forecasting Model aims not just to project based on inaction.

“We’re interested in building the capability to ask how we can improve the health of California’s population,” says Kominski. “We would like to create a model in which, holding these other changes constant, we could compare various policy alternatives to see which investments could provide maximum benefit per dollar expended. That would be a very important tool for policy-makers, research funders and even direct service providers.”

Furthermore, the model could provide input on the health impact of policies that are not meant to be health-oriented – an after-school program, for example. “So much of what we do in society has an influence on health, whether it’s direct or indirect,” says Morgenstern. “Part of the project is to determine what the pathways will be between the intervention and health status, and attempt to model that in some way for the purposes of projecting change.”

Morgenstern believes that in the absence of such a model, decisions on many policies are often made with little, if any, consideration of their health implications. “This can add a dimension to policymaking that is often minimized,” he says. “Whether considering the health impact will change the decision-making process is open to question at this point, but certainly the opportunity is there.”

As an official involved in decision-making at the county level, Fielding suspects that, if the forecasting model proves feasible, many entities will find it to be valuable as they mull critical policy questions.

“We’re making a lot of decisions in government with tools that can be improved,” he says. “I hope that having county-level data will help our department, our board of supervisors and others who make decisions in the health sector as well as other sectors to understand the trade-offs between alternative decisions.” In addition to assisting California policymakers at the state and local levels, the model has the potential to be put to good use nationally, Fielding adds, given the different health concerns and population demographics across the states.

In one sense, the scarcity of previous attempts to forecast population health is surprising, says Fielding, because the substantial base of research in epidemiology, a core public health discipline, enables a more forward-looking assessment of the impact of

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6 T HE

SEEDS OF

A PUBLIC HEALTH CAREER WERE SOWN DURING A CHILD HOOD IN WARTIME

C HINA ,

WHERE SHE

NOW RETURNS REGULARLY TO CONSULT.

H ER

NEW BOOK TELLS THE COMPELLING STORY.

Virginia Li:

Helping Communities to Blossom “From One Root Many Flowers: A Century of Family Life in China and America” (2003: Prometheus Books), by Dr. Virginia C. Li, professor of community health sciences, is many things. It’s the story of a girl growing up during the Sino-Japanese War; of her father, first a general and then the wartime governor of Guangdong Province under Chiang Kai-Shek, intimately involved in the final struggles of the Communist Revolution; of her mother, whose heroic efforts helped save the lives of thousands of refugee children; of an immigrant family’s triumphs in America; of a vibrant culture and

UCLAPUBLIC HEALTH

a nation long embroiled in political turmoil but rapidly modernizing and braced for a brighter future.

It’s also the story of Li’s journey to the United States as a teen, her ascent to prominence as a public health scientist and educator, and her eventual return to a newly opened China, where she travels, sometimes several times a year, to consult at the invitation of the Chinese government, universities and international organizations.

Her memoir portrays a life that has been anything but dull, and reveals Li’s passion for making a difference – once even at the risk of offending China’s then-leader Deng Xiaoping, who hosted a banquet for Li’s parents in 1982. In the book, Li, who accompanied her parents, recounts: Cigarette smoking was ubiquitous in China … Near the end of the banquet the dignitary who sat next to me was ready to light a cigarette for me. I seized the opportunity to tell everyone, but especially Deng Xiaoping, about the harmful effects of cigarette smoking … I was engaged in research in tobacco use and smoking prevention at the Johns Hopkins University at

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“I went as an educator and as a scientist, not to go back and rediscover my roots. But in the process, as I saw China firsthand over an extended period of time, the teacher became the learner.”

—Dr. Virginia Li

UCLAPUBLIC HEALTH

Virginia Li has vivid childhood memories of bombings, enemy attacks and retreats. Her father, Li Hanhun, was “torn between two conflicting sets of values”: The born leader with a strong sense of loyalty and duty to country “also had the heart of a poet who abhorred killing and believed in the nonviolent teachings of Buddhism.” Displaced from his homeland, the former chief executive and his wife moved their family to New York City and opened a successful Chinese restaurant.

Li’s mother, Wu Chufang, overcame the suicide of her psychologically abused mother – who took her own life when Wu was 14 months old – and went on to direct a rescue operation that saved 30,000 newly orphaned refugee children from occupied territory, organizing a massive housing and educational effort to assist them. Several years earlier, when Li’s father had asked Wu what she most hoped for after their marriage, she replied, “a university education.” After bearing three children, Wu got one.

Like mother, like daughter – when Virginia Li was the mother of three young children, she returned to school and earned her M.P.H. and Ph.D. She decided on public health as a way to provide technical assistance to developing nations. “From a very young age, I felt I had a responsibility,” Li says. She also learned that there was much work to be done in her adopted country. As a doctoral student studying the anti-poverty program in a poor African American neighborhood in Durham, N.C., in the 1960s, Li says, “I saw the other America, and acquired a passion for community development.”

On the faculty at the University of Maryland, the Johns Hopkins University School of Hygiene and Public Health, and, since 1982, the UCLA School of Public Health, Li has made community development a constant theme. (Another theme, as Deng Xiaoping learned, was smoking cessation. In the mid-1970s, Li conducted the first large-scale clinical trial of the impact of having primary care physicians routinely counsel their patients on the hazards of smoking. The study was part of a body of evidence that made such counseling a national priority.)

She conducted her first community-development demonstration project in the early 1970s, training community organizers in Baltimore to engage highrisk inner-city teens in recreational activities as a way to interest them in health issues.

Nearly two decades later, when Li was contacted by the Ford Foundation to help design a women’s

reproductive health program in an impoverished section of rural Yunnan, China, she argued that the clinical component should represent only a small piece of the effort – that developing the women’s sense of self-worth and capacity-building were even more important. The funding agency agreed, and the result was a multi-faceted program in which the village women were partners at every step, and barely missed a beat once the grant period expired. Among other things, 63 semi-literate village women were given cameras and asked to take pictures of the local conditions over a 12-month period as a way to communicate their needs to policy-makers. Their efforts were published in a photo-book, with Chinese and English captions as dictated by the photographers.

Currently, with financial support from the school’s Bixby Program in Population and Reproductive Health, Li is working with Dr. Roger Detels, professor of epidemiology, to pilot-test a reproductive health Web site for rural health workers and teachers in remote villages of Yunnan Province.

“This is about giving an agency one computer and teaching the people who work there how to use it and get information,” Li explains. “They’re quite excited, because they see this new world opening up through access to our Web site as well as others.”

Li returned to her country of birth for the first time in 1974 as part of a study group looking at China’s cooperative medical system and preventionfocused “barefoot doctors,” a system that had dramatically increased life expectancy over a relatively short period of time. Since 1981, she has been a frequent traveler to China through invitations from the World Health Organization, the Ministry of Health, and various universities. “I went as an educator and as a scientist, not to go back and rediscover my roots,” she says. “But in the process, as I saw China firsthand over an extended period of time, the teacher became the learner.” Convinced that there was a story about her land of birth that Westerners were seldom told, she decided to share her observations with the world beyond academia.

The book was designated “Pick of the Month” for September by the Web site Bookviews.com.

“Americans have long been fascinated with China, and especially now that she is a major player on the world stage,” Li says. “Because of inaccessibility and ideology, there is much not told and much that is misinterpreted. I wanted to tell the story of China from the latter part of the 19th century to the present, through the story of my family, in the hope that it will enhance public understanding of China during a period of war, foreign imperialism, revolutions, and rapid social change.”

faculty profile

the time and got just a bit carried away.

Deng listened. When I finished my little lecture, he looked me straight in the eyes and said, “You are absolutely right.”

Then he lighted his cigarette.

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Complementary & Alternative Medicine: A S CAM’ S POPULARITY CON TINUES TO RISE , RESEARCHERS EXAMINE THE EFFICACY OF THE THERAPIES AND THE REASONS PATIENTS ARE TURNING TO SOLUTIONS OUT SIDE THE DOCTOR ’ S OFFICE .

Expanded Options for Wellness Also Raise Concerns When the Journal of the American Medical Association devoted its November 1998 issue to complementary and alternative medicine (CAM), the same year that the National Institutes of Health upgraded its Office of Alternative Medicine to center status, it was clear that a phenomenon had taken hold in the U.S. health care system. Increasingly, sick people are going beyond

UCLAPUBLIC HEALTH

the boundaries of the doctor’s office.

According to the 1999 National Health Interview Survey, nearly one in three adults seeks so-called CAM therapy – a broad, ever-changing category that includes, but is by no means limited to, manipulative methods such as chiropractic, osteopathy and massage; homeopathic and naturopathic medicine; mind/body interventions; dietary supplements and herbal therapies; energy therapies such as qi gong, Reiki and therapeutic touch; and traditional Chinese practices such as acupuncture.

What’s going on? One of the primary factors driving the growing interest in CAM is the increase in chronic illness in the United States. “People are living longer, and thanks to certain successes of conventional medicine, more people

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Ph.D. As a trained social and personality psychologist with an emphasis in health – particularly elderly and minority health – and adherence behaviors to screening, O’Donnell is interested in understanding how knowledge, attitudes, beliefs, motivations, and barriers are related to the decision to use or not use CAM. She is currently a postdoctoral researcher in the School of Public Health-based Division of Cancer Prevention and Control Research, studying whether CAM use among minority populations impedes or supports Western cancer screening practice. “Most CAM research focuses on Caucasians,” O’Donnell notes. “Paradoxically, many CAM therapies originate in Asia; yet, little is known about the patterns of use among Asians who live in the United States.” O’Donnell is also working on a project exploring the predictors of CAM use among younger breast cancer survivors. “This area of research can no longer be ignored as an important aspect of health and wellbeing,” O’Donnell says.

“Given CAM’s rise in popularity, it is essential that physicians are aware of the possible barriers that its use may present to their recommendations for cancer screening or other preventive health behaviors.”

UCLAPUBLIC HEALTH

Attempting to define and categorize CAM is tricky, Goldstein notes. Prominent researchers in the field have classified it as encompassing therapies not taught in conventional medical schools.

But many medical school curricula now cover approaches as “alternative” as herbalism and therapeutic touch, and an estimated two in three U.S. medical schools are offering coursework in CAM. The National Center for Complementary and Alternative Medicine defines it as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”

But because of a historic bias in research funding as well as other factors, many CAM therapies have little scientific data to support them.

Suzy O’Donnell,

cover story

are living with chronic illnesses,” says Dr. Michael S. Goldstein, professor of community health sciences at the UCLA School of Public Health and author of Alternative Health Care: Medicine, Miracle, or Mirage? (Temple University, 1999). “But there have not been concomitant advances in medicine’s ability to offer a cure for many of these chronic problems.” Add to that a second group of people, Goldstein notes – those who are highly motivated and concerned with staying healthy and getting healthier, and find medicine’s curative bent to be insufficient.

“We in public health need to acknowledge the extent of this phenomenon, in both CAM and self-care,” Goldstein says. “Most things that have to do with people’s health are taking place in a nonprofessional context. If we’re interested in changing people’s health behaviors for the better, especially in terms of prevention and dealing with chronic illness, we have to understand that CAM is a big part of the picture.”

Goldstein disputes the popular notion that it was ever different. “These other streams of health care – home remedies and what we would today

call CAM – have been prominent throughout this country’s history, and they never became as marginalized as conventional medicine made them out to be,” he says.

“Most medical physicians always felt that anything that wasn’t medicine was quackery, and refused to even talk to their patients about it,” agrees Dr. Scott Haldeman, adjunct professor of epidemiology at the school. “Until the late 1980s, it was considered unethical for a physician to associate with an acupuncturist, a chiropractor or a homeopath. So their patients would use these therapies and not tell them, and the medical world had no concept of what patients were doing.”

While many physicians remain skeptical of CAM therapies, they at least now recognize that CAM is an important phenomenon that the scientific community needs to address, Haldeman adds.

Meanwhile, many physicians have begun to embrace aspects of CAM that were long ignored.

“There are plenty of good studies, for example, demonstrating that adjunctive cancer therapies that use meditation and other mind/body work can reduce side effects of conventional medical treatment and improve well-being,” notes Dr. Dawn Upchurch, professor of community health sciences at the school. In addition, she notes, insurance companies are increasingly likely to cover certain CAM therapies, including chiropractic, acupuncture and, in some cases, massage, adding more fuel to the trend.

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Paul Hsu,

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M.P.H. ’03 Growing up with stories about friends and relatives utilizing acupuncture and herbal remedies in their everyday lives, “alternative” medicine seemed routine to Hsu, currently a Ph.D. student in the school’s Department of Epidemiology. “ ‘Don’t eat all that watermelon before you go to bed’ was commonly dispensed with ‘Eat your vegetables,’ ” Hsu recalls. (In Chinese herbal lore, watermelon is considered to have cold properties, and is thus believed to be something the body should avoid before going to sleep.) Hsu admits to being skeptical at times, but adds, “It’s hard to argue with an almost 5,000-yearold system of healing when you’re a kid.” As an adult, he has been surprised at how little research has been conducted on CAM. He has been introduced by Dr. Scott Haldeman, professor of epidemiology, to some of the leading figures and studies in alternative medicine, and has learned how to analyze and evaluate results rationally and in an objective manner.

“The chance to further apply these tools, especially in herbal medicine or acupuncture, would be both challenging and rewarding,” Hsu notes. “Perhaps the time is not too far off when a patient can have valid alternative options for treatment, and I will know that I did not give up my watermelon in vain.”

Haldeman, who teaches a course at the school called “Assessing the Validity of Alternative Therapies,” has focused on evaluating the evidence that does exist, and developing guidelines for determining the applicability of clinical trials. “The public’s utilization rate is huge, the cost is huge, and the question is, Does any of this do any good?” he explains.

Not surprisingly, Haldeman says, some of the most common conditions for which people seek alternative therapies are those that are often treated without positive outcomes by conventional medicine – conditions such as chronic back or neck pain, headaches, certain gastrointestinal complaints, and general psychological or stress-related concerns.

The most popular providers are the chiropractors.

Haldeman, who has a Doctor of Chiropractic degree as well as an M.D. and Ph.D., notes that the research on manipulation and manual therapy is more advanced than for other forms of alternative care. Acupuncture, too, has attracted its share of research, with studies suggesting positive short-term effects on pain in general, though there is less evidence on acupuncture’s impact on specific types of pain. There are also hints that the therapy could be effective for other purposes, such as treating addiction and weight control, though that is by no means established, Haldeman says. Controlled clinical trials in the homeopathic field have mostly come from Europe, and it has been difficult to conclude from the data thus far that there is a particular condition or conditions that can benefit from homeopathy, Haldeman says. Some evidence suggests that massage and touch therapy can positively affect babies and the elderly.

But everyone agrees that there is much more work to be done in establishing the scientific basis of many popular CAM therapies. “In the past, there’s been limited incentive for people to do research on these techniques,” says Goldstein.

“Most of them can’t be patented, so there’s no one who stands to make a lot of money like a pharmaceutical company would from a successful new drug. And many of the techniques are very hard to evaluate because they’re highly individualized.”

Critics of CAM have pointed to the lack of data on the effectiveness of many of the therapies, but that’s also true for many aspects of conventional medicine. “It’s amazing how little we know about the effectiveness of a lot of therapies,” says Dr. Hal

Morgenstern, professor of epidemiology. “Many things that physicians do have not been well evaluated.”

What’s more, funding for research on the safety and efficacy of CAM therapies has been rising dramatically. The Office of Alternative Medicine was established by Congress in 1991 with a $2 million budget for the fiscal year 1992. For FY 2004, the budget is expected to exceed $116 million.

Goldstein and Dr. Deborah Glik, also a professor at the UCLA School of Public Health, were among the first researchers supported by the Office of Alternative Medicine, which funded their study of patient satisfaction with homeopathic treatment.

Previously, Goldstein had examined factors that led some conventionally trained medical doctors to become involved with CAM. He also spent two years conducting research at The Wellness Community, a support group for cancer patients, nearly all of whom combined alternative therapies with conventional treatments. Goldstein has taught a course at the school on alternative medicine for the last decade.

He is currently co-principal investigator and program director of CHIS-CAM, the National Cancer Institute-funded follow-up study to California Health Interview Survey (CHIS) 2001

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cover story

“The image was always that there is scientific medicine and then there are other fringe kinds of things, but now we’re seeing an acceptance that health care is a pluralistic enterprise.”

— Dr. Michael S. Goldstein

UCLAPUBLIC HEALTH

examining the use of complementary and alternative medicine among approximately 8,000 California adults, more than half of whom have had cancer or other chronic illnesses. Among the questions being asked of those surveyed in the follow-up study are which CAM modalities they have used, why they chose them, their assessment of whether they benefited, whether they told their medical doctor and, Dr. Eric Hurwitz (facing if they did, how their doctor reacted. page) has conducted “Up to now, national studies of CAM utilization studies comparing haven’t had large enough samples to separate out chiropractic and medical care for patients with people with serious illnesses, or to look at utilization low-back and neck pain. by ethnicity or income,” says Goldstein. “At the same time, most of the CAM studies with people who are sick involve clinically based populations. CHIS is a community-based study, so the hope is that our data are going to be much more valid in terms of understanding how people in California are actually using CAM.” In studying a specific population – long-term survivors of breast cancer – Dr. Patricia Ganz, professor in the schools of public health and medicine and director of the Division of Cancer Prevention and Control Research, found that women who were distressed were more likely to have used CAM therapies.

Ganz and colleagues are now analyzing data from a follow-up study of approximately 600 women between two and 10 years after breast cancer treatment. The current study asked the women in great detail about their use of complementary and alternative strategies – everything from mind/body techniques to diet, exercise, meditation and acupuncture. In addition to gathering detailed information about CAM use, the wide range of time since treatment among the cohort should provide interesting data on when survivors are most likely to turn to CAM, and the diversity of the group will enable the researchers to explore differences by ethnicity.

“Most studies have looked at prevalence of CAM use, but not necessarily at the reasons patients are using it,” Ganz notes. “If a patient is feeling anxious and

Dr. Michael S. Goldstein (above), among the first researchers funded by the National Institutes of Health to study CAM, authored a book on the phenomenon.

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“Acupuncture treatment is not standardized; it is individualized.

The problem with some of the Western studies is that they haven’t taken into account different diagnostic categories for determining what the treatment should be.”

UCLAPUBLIC HEALTH

— Dr. Dawn Upchurch

is self-medicating, it could be that more conventional In light of recent evidence on increased medical or supportive care, such as counseling or risks associated with prescribed medications, might be appropriate.” The hormone therapy for possibility that distressed patients are turning to menopausal symptoms, CAM therapies without their physician’s knowledge Dr. Dawn Upchurch is cause for concern, Ganz adds. “Studies are now (above) is conducting a being funded to subject alternative strategies to the pilot study on the potensame rigor that we do conventional treatments, but tial benefits of acupuncuntil we have results, the efficacy of many of these ture as an alternative. therapies is unknown,” she says. Because the supplement industry isn’t regulated, Ganz is concerned that patients who buy “natural” remedies at health food stores can’t know what’s in the products; in addition, certain herbal remedies such as St. John’s Wort, a popular product purported to relieve symptoms of depression, can negatively interact with conventional medications.

Morgenstern first participated in a CAM study in 1974, conducting a survey of the operations of chiropractors in North Carolina the summer before he started as a doctoral student. In the late 1980s, by which time he had joined the UCLA School of Public Health faculty, one of Morgenstern’s students was interested in doing research on the effectiveness of chiropractic. That student, Dr. Eric Hurwitz, went on to join the school’s faculty and collaborate with Morgenstern on two randomized clinical trials in a large managed care plan in La Habra, Calif., one comparing chiropractic and medical care for patients with low-back pain and the other comparing the treatments for neck pain.

When Hurwitz had been in chiropractic school, he began researching the literature and found that there was little evidence for what practitioners in his profession did – and, likewise, little evidence for what physicians did to treat musculoskeletal pain. The back pain study he and Morgenstern conducted found

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13 a focus on the whole person and her environment, and emphasizes the importance of addressing the root causes of symptoms rather than the symptoms themselves. “The diagnostic categories are different from those in Western medicine,” says Upchurch.

“The treatment is not standardized; it is individualized. Part of the problem with some of the Western studies that have been done on acupuncture is that they haven’t taken into account these different diagnostic categories for determining what the treatment should be.”

Applying rigorous scientific research to Traditional Chinese Medicine and many other CAM therapies is particularly challenging, notes Dr. Deborah Ackerman, adjunct associate professor of epidemiology. “The randomized, placebocontrolled clinical trial is great if it’s a pill, because the actual treatment looks exactly like the active treatment,” she says. “But when the treatment is some sort of an interpersonal relationship with an acupuncturist, or a therapeutic massage, conducting a well-designed randomized clinical trial is much more difficult.”

Ackerman would lead an effort to assess the clinical- and cost-effectiveness of mind-body health interventions as director of the Health Outcomes core of a proposed multidisciplinary Mind-Body Interactions and Health research program based in UCLA’s Center for Neurovisceral Sciences and Women’s Health. If funded, the Health Outcomes group, which includes several other faculty members from the School of Public Health, will develop methodologically sound approaches that include a thorough evaluation of patient characteristics related to factors such as degree of spirituality, level of optimism, and expectations about the treatment.

“These are all characteristics that have been found to affect patients’ health either directly or indirectly, and we want to know how these characteristics interact with patients’ responses to treatment,” Ackerman explains.

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few clinical differences between patients who received chiropractic and those receiving medical care after 18 months of follow-up. But there were significant differences in patient satisfaction – those randomized to chiropractic tended to be much more satisfied with their care, and reported more symptom improvement than patients randomized to medical care, even though, in terms of validated outcome measures of pain and disability, they were similar.

“We know that chiropractors talk to patients more about a treatment plan and what they can do for their symptoms,” says Hurwitz, assistant professor of epidemiology. “Those communication factors might have influenced patients’ perception of their symptoms, and probably influenced satisfaction as well.” While chiropractic patients have been found to be more satisfied in the past, Morgenstern notes, the significance of this study was that the patients were randomized to one group or the other, and entered their treatment with no biases.

Given the tendency for people to seek alternatives where conventional medicine has little to offer, CAM therapies for women with menopausal symptoms are particularly important to evaluate at a time when the recent evidence of increased risk of cardiovascular disease, breast cancer, and stroke associated with hormone therapy leaves no standard treatment.

Upchurch has begun a pilot study of the use of acupuncture, which empirical studies suggest might be a useful alternative treatment for menopausal symptoms.

Initially, Upchurch is investigating the level of agreement among acupuncturists in their diagnostic assessment of menopausal women based on principles of Traditional Chinese Medicine, which includes

Ellen B. Gold, Ph.D. Gold, professor of epidemiology and preventive medicine at UC Davis, is principal investigator of the UC Davis clinical site of the Study of Women’s Health Across the Nation (SWAN), a longitudinal study at seven sites that is following 3,300 midlife women from five racial/ethnic groups as they experience the menopause transition.

Together with Dr. Gail Greendale, principal investigator for the SWAN UCLA site, Gold and doctoral student Yali Bair identified characteristics of women who choose CAM during the menopausal transition and examined types of CAM used, whether the women discuss such use with their clinicians and whether their clinicians ask about such use. Gold and Bair recently collaborated with Greendale and Dr. Dawn Upchurch, professor in the UCLA School of Public Health, on a grant application for additional analyses of SWAN CAM use data regarding factors that influence initiation and continuation of CAM use during the menopause transition.

Despite the difficulties evaluating certain CAM practices, methodologies can be devised that can prove revealing, says Haldeman, whose own research has focused on the efficacy and complication rates of various treatments for back and neck UCLAPUBLIC HEALTH

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Shannon Rhodes Rhodes’ own positive experiences with a variety of CAM modalities – including acupuncture, Chinese herbs, homeopathy, and neuromuscular re-education – fueled her professional interest in CAM as an adjunct to more traditional medical treatment and prevention strategies.

Prior to beginning the M.P.H. program in the school’s Department of Epidemiology, she participated in several literature reviews on CAM topics, all of which left her thinking about the difficulties presented when attempting to study the efficacy of many CAM modalities. As a result, she is interested both in understanding what constitutes the optimal study design and outcome measurements for the diverse CAM techniques, and in integrating CAM with established medicine to decrease costs and improve quality of life for chronic disease populations.

“In learning about the variety of modalities, I have become increasingly intrigued by the concept of holism and health,” Rhodes says, “and am looking forward to studying the impact of psychological and social components on general health and on recovery from specific conditions.”

pain. One of the major challenges is cultural. “You have to choose your subjects carefully, because there is evidence that preference affects response to a treatment approach,” Haldeman notes. “If you would rather have acupuncture than medical therapy, you’re more likely to experience a better response to acupuncture, and vice versa.”

As interest in and funding for CAM studies continue to grow, public health researchers expect to get answers to basic questions. “We really need to know more about which interventions work and which don’t, and for what populations,” says Morgenstern. “We’re just touching the surface now.”

The mind-body questions are particularly compelling, Goldstein notes. “In the past decade, for example, there has been a tremendous rise in

research about the relationship of spirituality and religious practice to all sorts of health outcomes,” he says. “At this point, there’s not much evidence that religion or spirituality is curing people of illnesses, but there is a good deal of data indicating that people who practice a religion are more apt to be healthy, and more likely to respond to illness in a way that keeps them alive longer and functioning better.” Another important area warranting investigation, he adds, is the field of nutrition and dietary supplements – an area that has the advantage of lending itself to the Western model of clinical trials.

Then there’s the issue of cost. Early CAM researchers advanced the notion that the trend would alleviate the problem of soaring health care costs in the United States by replacing expensive

Federal Funding for CAM Research

by Millions, 1992-2004

$114.1

$116.2

$104.6

$89.2

$68.7

$50

$19.5

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$12 $3.4

$2

$2

1992

1993

1994

$5.4

1995

$7.7

1996

1997

1998

1999

Office of Alternative Medicine National Center for Complementary and Alternative Medicine

2000

2001

2002

2003

2004 (est.)

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cover story “The public’s utilization rate is huge, the cost is huge, and the question is, Does any of this do any good?”

— Dr. Scott Haldeman

UCLAPUBLIC HEALTH

interventions with cheaper ones. “That’s been very hard to prove,” Goldstein says. “You can show that one intervention is less expensive than another for a particular problem, but as people become more knowledgeable about their health, as is typically the case for those who use CAM, they tend to utilize more services. So the issue of the financial repercussions of CAM remains in flux.”

As more evidence is published on which CAM therapies are effective and which are not, some observers believe the mainstream health care system will eventually incorporate all of the successful CAM modalities, leaving no need for CAM. “I’m not inclined to believe that will happen in the near future,” says Morgenstern. “I suspect there will always be some alternative to what medical doctors are trained to do.”

It’s true that, with the notable exception of chiropractors and, in some states, naturopaths, most CAM practitioners have minimal licensure and education requirements, making it difficult for consumers to know the level of experience and competence of providers they might choose to see. For many years, this has fueled the argument that CAM leaves the population vulnerable to quackery. Goldstein notes that there is little evidence that the problem of incompetent providers has been significantly greater in CAM than in conventional medicine.

“This notion that people with a problem that can be solved by Western medicine are instead going to some quack – I’m sure there are some cases like that, but it’s very rare,” he says. “Only about 5 percent of the people who use CAM do not also use conventional medicine. People tend to come to CAM after they’ve exhausted what conventional medicine has to offer.”

Goldstein sees the CAM phenomenon in the context of medical pluralism.

“The image was always that there is scientific medicine and then there are other fringe kinds of things, but now we’re seeing an acceptance that health care is a pluralistic enterprise – analogous to the recognition of pluralism in a more general way throughout American society,” he says. “We’re finally discovering something that’s always been there, but was kept underground.”

Dr. Scott Haldeman (above), who teaches “Assessing the Validity of Alternative Therapies” at the school, evaluates the evidence for CAM therapies’ efficacy and is developing guidelines for determining the applicability of clinical trials.

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Casting a Wider Net: S OLVING ENVIRONMENTAL THREATS TO HEALTH HAS NEVER BEEN MORE COMPLEX

–

OR

MORE IMPORTANT.

T HE

NEW

CEQH

IS POISED TO MEET THE CHALLENGE .

Centers for Environmental Quality & Health Stress Teamwork For researchers seeking to identify and

UCLAPUBLIC HEALTH

Air pollution, environmental toxins, and worker health and safety are among the many issues the CEQH is addressing through its research, training and community outreach.

mitigate environmental threats to health, the challenges have never been more profound. Increasingly, pinpointing the dangers and developing solutions to these complex problems has become an impossible job for any one scientific discipline.

With that in mind, the UCLA School of Public Health has marshaled the participation of a wide range of experts from across the UCLA campus and beyond.

The newly formed Centers for Environmental Quality and Health (CEQH) aims to expand the scientific knowledge base, provide top-notch training of graduate and undergraduate students to address these issues, and interact with Southern California communities and policy-makers in translating research findings into appropriate actions. “The CEQH strongly enhances our ability to conduct multidisciplinary research, training and community outreach,” says Dr. John Froines, professor of environmental health sciences at the school and CEQH director.

Researchers in an individual discipline can learn something about a problem, but moving toward a solution requires broader expertise, Froines explains. This type of team effort has already taken hold in many of the CEQH’s centers. For example, the Southern California Particle Center and Supersite (SCPCS) links exposure measures and characterization of the responsible particles and chemicals with epidemiology, toxicology, and human clinical studies. The CEQH will make such efforts easier, and Froines believes it will facilitate additional steps. “One of

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“We now have the infrastructure in place to be able to identify progressive directions that make Los Angeles more livable.”

—Dr. John Froines

UCLAPUBLIC HEALTH

By casting a wide net in terms of its scientific expertise, the CEQH will ensure that its research methods as well as the problems it studies will remain at the scientific cutting edge, Froines says. One particularly intriguing area for future study is the emerging field of nanotechnology, a new frontier of science that exploits the fundamentally unique properties of materials roughly 75,000 times smaller than the width of a human hair. From chemical sensing, optics and electronics to computers and medicine, nanotechnology is expected to bring revolutionary advances.

But it also could come with unanticipated health implications. The SCPCS already conducts research on nanoparticles; recently, Froines and colleagues reported that ultrafine particulates, the smallest airborne pollutants produced by automobile and diesel truck exhaust, can cause severe damage to human lung cells. Froines expects CEQH scientists to move further into the field of nanotechnology as it affects occupational and environmental health.

But at the same time that they explore new areas, the centers will continue to emphasize research and training in the existing problems that aren’t going away, including air pollution. “We have a long-term commitment to studying air pollution in the basin and throughout California,” says Froines. One recent example of the importance of this work came from a study that found that being on or within 50 meters downwind of a freeway dramatically increases one’s exposure to ultrafine particles. Dr. William Hinds, professor of environmental health sciences and lead author of the project, is following up with a study of indoor air quality in apartment buildings adjacent to freeways. Hinds is measuring carbon monoxide, nitrogen oxides, and the size distributions of ultrafine particles outside and inside of the apartments to determine how much protection a building provides against ultrafine particles.

The traditional focus also includes worker health. The COEH was established in 1978 with a mandate from the California Legislature to increase the state’s commitment to occupational health through research and training. The UCLA Labor Occupational Safety and Health (UCLA-LOSH) Program, part of the COEH, teams with workers, unions, community-based organizations, academics and health professionals to improve environmental health and safety conditions for workers, with a special emphasis on those in Southern California.

The program has focused many of its research and outreach efforts on particularly vulnerable groups.

For example, classes on workplace health and safety are offered for Spanish-speaking workers in an effort to fill a substantial unmet need, according to Marianne Parker Brown, the program’s director and a lecturer in the School of Public Health. “Many of them don’t know they have a right to a safe workplace, and don’t know where to turn if they have problems,” she says. LOSH also has worked with local school districts to develop a curriculum on worker safety for teens, who have among the highest injury rates in the workplace. Since 1987, LOSH has provided health and safety training for hazardous waste workers.

UCLA’s CEQH also includes the Southern California NIOSH Education and Research Center, one of 16 multidisciplinary centers in the United States supported by the National Institute for Occupational Safety and Health for education and research in the field of occupational health. The center, directed by Hinds, supports graduate degree programs in industrial hygiene, occupational medicine

feature

our priorities will be to link with people in fields such as economics, law, business management, and work organization, because when you get down to addressing problems, it’s not just the scientists who are central – it’s also the legal/policy/economic side,” he says.

The CEQH is focusing on issues of particular interest to policy-makers and regional planners in California. Recently, a study led by Dr. Beate Ritz, associate professor of epidemiology at the UCLA School of Public Health and faculty member of the CEQH’s Center for Occupational and Environmental Health (COEH), found that pregnant women living close to heavily traveled highways are at greater risk for adverse birth outcomes, including preterm birth and low birth weight. Ritz’s group is following up with more precise risk estimates based on truckrelated traffic and the influences of meteorology.

Dr. Wendie Robbins is also looking at adverse birth outcomes resulting from environmental and occupational exposures, but, while Ritz’s epidemiologic studies focus on large population samples, Robbins, assistant professor in both the School of Nursing and the School of Public Health, works in the laboratory evaluating human sperm cells for chromosomal abnormalities. She recently found that exposure to air pollution and tobacco smoke can lead to aneuploidy of the sex chromosomes – subtle changes suggesting the need for further study.

Aneuploidy can be transmitted to the offspring through sperm, and is the largest single genetic cause of mental retardation and developmental disabilities in humans.

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and occupational health nursing. Research projects examine everything from exposure to potential toxins in the workplace to the ergonomic problems facing certain occupations and detection and prevention of job-related psychosocial stress factors.

The CEQH multidisciplinary focus will strengthen these types of studies, says Dr. Philip Harber, director of the occupational medicine residency program of the Department of Family Medicine and the Southern California NIOSH Education and Research Center.

Harber studies occupational respiratory epidemiology, assessing the risk of lung disease resulting from workplace exposures to materials such as coal, beryllium, and asbestos. He recently concluded a large study of the North American carbon black industry to esti-

18

Members of the Southern California Particle Center and Supersite’s Particle Instrumentation Unit are visited by colleagues from Mexico during a meeting in which they made plans for a future collaborative study.

UCLAPUBLIC HEALTH

3:34 PM

mate the impact of the material as a guide to potential occupational health standards. “Teaming with other researchers in the CEQH can help to provide perspective on the implications of our work as it relates to exposure assessment and regulations,” Harber explains.

New environmental health problems are being identified and studied. The CEQH, in collaboration with UC Berkeley, was designated by the Centers for Disease Control and Prevention as a Center for Excellence in Public Health Tracking – a partnership with the California Department of Health Services to monitor environmental hazards and create researchdriven policy options for a national tracking system.

The CEQH is also linking with UCLA’s new Center for Genes, Environment, and Parkinson’s Disease, one of three such centers in the country funded by the National Institute of Environmental Health Sciences.

Ritz, the UCLA center’s co-director, is investigating the impact of exposure to pesticides suspected of playing a role in increasing the risk of Parkinson’s

disease, taking advantage of more than three decades of data collected as part of California’s mandate on reporting commercial and agricultural pesticide use.

The CEQH also includes an increasing emphasis on international issues, which can often help researchers to better understand problems at home.

With funding from NIOSH, Robbins is leading a team examining the reproductive effects of occupational exposure to boron in male workers who mine the element in Liaoning Province, China, where exposure levels are reported to be significantly higher than in the only boron mining plant in the United States, U.S. Borax in California. Animal studies have found that certain levels of exposure to boron can cause testicular atrophy; human studies to determine whether boron is a reproductive toxicant have been inconclusive – perhaps, Robbins suggests, due to the limited range of exposures that have been evaluated.

“If we can determine what the toxic level is, that information can be used to protect workers all over the world,” Robbins says.

Similarly, Dr. Zuo-Feng Zhang, professor of epidemiology, has joined with Froines and others to study the possible link between air pollution and lung cancer, comparing data collected in Los Angeles and the Chinese city of Taiyuan, where air pollution levels have been found to be approximately 10 times worse than in Los Angeles. “When you’re looking at low environmental exposure with small variations in one population, it is very hard to link the exposure to the risk of the disease,” Zhang explains. “International comparisons allow us to make greater contrasts to see important effects.”

The international emphasis is also important in the context of globalization, Froines notes. “On top of the significant air pollution problem that we already have in Los Angeles, we have this expanding port in Long Beach where products made in China, the Philippines and other nations are being brought in and transported to other cities,” he says. “It’s anticipated that globalization is going to triple the number of diesel trucks on the 710 freeway leading out of Long Beach, resulting in tremendous concentrations of ultrafine particles for the dozens of surrounding cities, as well as more pollution problems for the entire basin.”

Froines expects that the CEQH will take a more active role in discussions on how to solve that and many other environmental problems that affect the quality of life in Southern California. “We now have the infrastructure in place to be able to identify progressive directions that make Los Angeles more livable,” he says. “We shouldn’t lose sight of our initial missions, but we also can and should look at the problems in a much broader way than in the past.”

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AS

THE

feature

Public Health’s Drug Problem:

POPULATION AGES AND CHRONIC ILLNESS INCREASES , DEMAND FOR PRESCRIPTION DRUGS SOARS .

W HO

WILL PAY

FOR THEM ?

SPH Program Tackles Tough Questions on Pharmaceuticals It is among the most vexing set of questions facing the U.S. health care system: As an aging population drives an ever-greater demand for prescription drugs, who will pay, and how much? Can public and private insurers afford to cover the new and often more expensive medications that would improve the health of patients with chronic conditions? When cheaper alternative drugs are as good – or nearly as good – should insurers pay for the more expensive product? Can a reimbursement system be devised that rewards appropriateness, providing incentives for patients and their doctors to choose the least expensive path? And if we do find a way to clamp down on what we pay for pre-

nies to develop new, innovative drugs?

These are all critical public health issues…and yet, the pharmaceutical industry receives minimal attention in most schools of public health, according to

UCLAPUBLIC HEALTH

scription drugs, does that in turn reduce the incentive for pharmaceutical compa-

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at the school, in which guest speakers would address these issues. Since then, they have added a research program and a course on the role of pharmaceuticals in the health care system. The Program in Pharmaceutical Economics and Policy, co-directed by Schweitzer, Comanor and Dr. Michael Intriligator, professor of economics and political science, is an interdisciplinary research and teaching effort that attracts doctoral and master’s students from the School of Public Health as well as students from other parts of the university and other institutions (including USC, UC Santa Barbara and RAND).

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UCLAPUBLIC HEALTH

Earlier this year, students in a Pharmaceutical Economics and Policy course were connected with students in Paris via videoconference.

Dr. Stuart Schweitzer, professor of health services at the UCLA School of Public Health.

“A lot of people in public health have viewed this industry more as something that a management school ought to look at, given that it is a manufacturing industry,” Schweitzer says. “But most business schools see it as part of the health industry, and if they don’t have a health care interest, they ignore it as well.” As a result, Schweitzer says, few universities have programs dedicated to the drug industry, and none that he knows of has a pharmaceutical economics and policy program in a public health school – except UCLA. “There are three elements of the U.S. health care system,” says Dr. William Comanor, professor of health services at the school. “Two are obvious: physicians and the hospital sector. But a third and very important dimension of health care is the development of pharmaceuticals. Indeed, there is considerable evidence that pharmaceutical therapy may be even more important for health status than physician or hospital services, although clearly all three are important.”

Prior to 1990, Comanor notes, the UCLA School of Public Health’s curriculum was, like that of most other public health schools then and now, conspicuously devoid of discussions on the pharmaceutical part of the equation. “It seemed to me that what was needed was to specifically study and explore the role of pharmaceuticals in health status, and that’s done in a school of public health,” he says. “In addition, our students weren’t getting an introduction to this very important dimension of the health care system.”

So in 1990, Schweitzer and Comanor created the Seminar on Pharmaceutical Economics and Policy

Coming from a position in which she conducted technology assessment at the Southern California headquarters of Kaiser Permanente, Stephanie Teleki (Ph.D. ’02) was drawn to the Pharmaceutical Economics and Policy program during her time as a doctoral student at the school.

“Pharmaceuticals are such a huge part of health care that it’s important to understand the economic and policy aspects in almost any public health field you are in,” says Teleki, “whether your focus is the U.S. system, in which the issues include Medicare prescription drug benefits and the exponential premium increases, or you work internationally, with issues such as how to pay for HIV/AIDS drugs.”

In Teleki’s case, the issue was direct-to-consumer advertising. Amid growing interest among consumers in health information, the U.S. Food and Drug Administration in 1997 clarified a policy that makes the United States one of two nations (the other being New Zealand) that allow pharmaceutical companies to advertise their products directly to consumers.

Critics have argued that the FDA policy increases demand for pricey drugs that might not be appropriate. Teleki, who had been involved in helping Kaiser’s physicians stay abreast of information their patients were receiving, did her Ph.D. dissertation on the impact of direct-to-consumer advertising for COX-2 inhibitors, a class of drugs for arthritis, on the appropriateness of care. Teleki is now an associate policy analyst at RAND. Judith Connell (Dr.P.H. ’02) is director of research and development for the La Habra, Calif.based Institute for Healthcare Advancement, a nonprofit foundation focusing on health education, particularly health literacy. “I attended the seminar to learn more about current research,” she says. “It’s a great forum where students, faculty and practitioners in the field get to meet and discuss important issues.”

Other graduates have gone on to work in health plans, government agencies, academia and the pharmaceutical industry. “Interestingly, one of the fastestgrowing areas within pharmaceutical manufacturers

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has been in their economics departments,” says Schweitzer. “All firms are trying to better understand the costs of drug development, and to measure the economic benefits of drugs.”

feature “We’ve made dramatic strides not just in longevity but in the quality of life that older people can look forward to, and invariably that’s associated with drugs. It’s one of the reasons drug costs keep rising.

We have to figure out what’s appropriate for people, and then we have to figure out a way of paying for it.”

—Dr. Stuart Schweitzer (above, left)

“The pharmaceutical industry isn’t a savior, but it isn’t a devil either.

It’s important that we take a balanced view, and that’s what we’re trying to introduce to our students.”

—Dr. William Comanor (above, right) UCLAPUBLIC HEALTH

In the last decade, the share of health expenditures going to pharmaceuticals has risen from approximately 8% to nearly 11%. While insurance coverage has expanded for pharmaceuticals, in general it has failed to keep pace for particular groups, such as the elderly, leading a growing number of patients to wonder why they’re paying so much for their prescription drugs. It’s also increasingly likely that people will have major pharmaceutical bills – anyone undergoing organ transplant, for example, faces up to $25,000 in pharmaceutical charges up front and another $10,000 per year. The annual tab for HIV/AIDS drugs is roughly $12,000.

Meanwhile, the aging population translates to more chronic conditions.

“We’ve made dramatic strides not just in longevity but in the quality of life that older people can look forward to, and invariably that’s associated with drugs,” says Schweitzer. “When someone is diagnosed with hypertension at age 50, the drug companies have a captive consumer for the next 30-40 years. That’s true for an increasing number of conditions that we’re figuring out how to control today, from heart disease and diabetes to sexual dysfunction. It’s one of the reasons drug costs keep rising. And you don’t solve the problem by clamping down on expenditures.

We have to determine what’s appropriate for people, and then we have to figure out a way of paying for it.”

Approximately two-thirds of all drugs are covered by insurance, Comanor notes – a far cry from 1990, when 59% of prescription medications were paid out of pocket. That change coincides with the rapid growth of managed care plans, which have attempted to decrease pharmaceutical consumption deemed to be inappropriate. In at least one sense they have succeeded, Comanor says: Approximately half of all prescription orders in the United States are now filled by generic drugs, which are considerably less expensive than branded products.

That’s up from 40% in 1993.

Any program focused on the pharmaceutical industry also has to look beyond U.S. borders – the industry is multinational, with American companies represented all over the world and foreign companies, especially from Japan and Europe, operating in the United States. Other public policy issues involve patenting and licensure to enable competing companies to make drugs, as well as the impact of the industry’s ever-increasing tendency toward mergers and whether that is cause for concern. This much is clear, notes Schweitzer: “The cost of developing drugs has risen markedly – one estimate puts it at more than $800 million to bring a drug to market, partly because very few drugs that are developed are successful enough that they make it to market.” Thus, Schweitzer notes, while drug companies tend to be a popular target among consumers concerned about the price of their medications, the United States needs to be careful not to follow the experience of Italy, where meager reimbursement has led to a brain drain in the pharmaceutical industry, leaving scant research and development.

Through the guest lectures she attended in the Seminar on Pharmaceutical Economics and Policy, Teleki recalls, she gained an appreciation for these and other complexities. “It was great to have that real-world exposure, because often in public health we don’t see that side – the fact that there are companies trying to be viable businesses,” she says.

“The pharmaceutical industry isn’t a savior, but it’s not a devil either,” concludes Comanor. “It’s like everything else – somewhere in the middle. There are good and bad things about the pharmaceutical industry and the role it plays, just like there are good and bad things about the hospital sector and the physician sector. It’s important that we take a balanced view, and that’s what we’re trying to introduce to our students.”

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student profiles Circuitous Journey Has Rewarding Finish For Biostatistics Student Susan Alber

“To be able to take difficult material and make it more digestible for students learning it for the first time gives me a great sense of fulfillment.”

UCLAPUBLIC HEALTH

— Susan Alber

THE PATH SUSAN ALBER HAS TAKEN in her post-high school education – starting as a student at the Berklee College of Music in Boston and ending up in the UCLA School of Public Health’s Ph.D. program in biostatistics – has been, to say the least, unconventional.

She has attended seven colleges, and had fulltime jobs at four universities. After deciding a career in music wasn’t in the cards, she earned an associate degree in biology, then attended Cornell University for a B.S. in nutrition. That was followed by several years as a technician in a food microbiology lab at Rutgers University before Alber returned to Cornell for an M.S. in nutrition. It was back into the workplace before she decided on biostatistics, first earning an M.A. at UC Berkeley before heading south to UCLA for her doctoral studies.

“I’ve wandered around for a long time to get here,” Alber says, laughing. “I was always bored and unhappy with the jobs I had, or that I could see having in the future.”

That began to change with her first statistics class at Rutgers, along with the research she did there in developing mathematical models for predicting bacterial growth rates. As a scientist, Alber had never much enjoyed the often-tedious process of collecting data. “But once the data is collected and you’re at the point where you can look at it and learn something from it…that part I find really interesting,” she says.

For her doctoral work, Alber is analyzing data on the effects of lead on cognitive functioning. The toxicity of high levels of lead in the blood is well established, but the subtle behavioral and cognitive impairment resulting from lower levels has been a source of controversy. Alber’s dissertation research will develop a new version of the statistical modeling strategy known as longitudinal data analysis to examine data on the impact of lead on laboratory rats’ abilities to learn specific responses to an alternative series of environmental cues.

Alber’s ambition involves not just conducting research in biostatistics, but also teaching it. Through her many experiences, she has discovered that it’s an activity in which she excels. “Enough people have told me I’d be a good teacher that I’m starting to believe it,” Alber quips. She suspects her aptitude for teaching stems from the fact that learning about statistics hasn’t come easily for her. “When you have to struggle, and look at something in many different ways before it clicks in, you can more easily appreciate what is confusing to others,” she says.

Having had experiences at so many universities, Alber says the instruction she has encountered as a student in the UCLA School of Public Health’s Department of Biostatistics has been second to none. “We are fortunate to have a number of really wonderful and exceptional teachers,” she says. “They care about teaching, and put a lot of energy into it.” Insisting that the Ph.D. will be her final degree, Alber looks forward to following in the paths of her instructors via a university position that will emphasize teaching: “To be able to take difficult material and make it more digestible for students learning it for the first time gives me a great sense of fulfillment.”

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“I had contact with people who did health services research, and it led me to think more broadly about health care than just seeing patients on a one-to-one basis.”

— Yee-Wei Lim

UCLAPUBLIC HEALTH

YEE-WEI LIM PRACTICED AS A FAMILY PHYSICIAN in his native Singapore for five years, but as he moved into new settings – finally ending up at the Ministry of Health, where he worked on health-policy and health-promotion project development issues – he grew more interested in the big picture of health care.

“I had contact with people who did health services research, and it led me to think more broadly about health care than just seeing patients on a one-to-one basis,” Lim says.

The new thinking led him to come to the United States in 1997, where he enrolled in the UCLA School of Public Health and is on track to receive his Ph.D. from the Department of Health Services at the end of this year.

As a physician practicing in a variety of settings in Singapore, Lim had become intrigued by certain patterns. Working in a neonatal intensive care unit, he observed that patients with lower socioeconomic backgrounds seemed to have poorer birth outcomes. As an emergency room physician, he noted that certain types of patients were more likely to use the ER inappropriately. He saw inconsistencies in how physicians delivered care for the same conditions.

Once he got to UCLA, Lim became interested in a new set of issues related to the problem of access to care for vulnerable populations in the United States. (Access to care is less of an issue in Singapore, which has a universal health care system.) His dissertation examines the access to primary and secondary care for Los Angeles County’s indigent population, and how the L.A. County Department of Health Services’ restructuring of its public health care system in the mid-1990s has affected its delivery of care to this population.

The restructuring effort, which began in 1995, was focused in part on attempting to expand primary care for indigent patients and reduce their reliance on hospital and emergency room services. The PublicPrivate Partnership (PPP) program, in which the county contracted with private safety-net clinics to provide care for the uninsured, was introduced. Lim found in his research that the advent of the PPP program resulted in an increase in the number of uninsured patients going to the primary care clinics, as well as total patient visits. “This is a significant positive finding, because if indigent patients have access to primary care, they’re less likely to go to the emergency room for non-urgent conditions,” says Lim. “That reduces the overcrowding problem at county hospitals, reduces the costs to the county, and gives better access to the uninsured patient.” County health department decision-makers have been interested in the results, Lim says.

Upon completing his doctoral studies, Lim hopes to continue doing research in primary care delivery and its relation to hospital utilization and outcomes, as well as investigating the financing and organization of safety-net providers in the community and examining how the safety-net network could be developed and sustained under a variety of financial arrangements. “I have learned a lot from the doctoral program,” Lim says. “The faculty have been great mentors, and the hands-on research projects while I was doing my coursework really helped to solidify what I learned in class. I have thoroughly enjoyed the experience.”

student profiles

Student Goes From Examining Patients in Singapore To Examining Health Care Delivery in L.A. County

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UCLAPUBLIC HEALTH

Dramatic Racial/Ethnic Differences in State Cancer Screening Rates Point to Hundreds of Thousands at Risk USE OF POTENTIALLY LIFE-SAVING cancer screening procedures among California adults varies dramatically depending on race and ethnicity, according to a new study by the UCLA Center for Health Policy Research, based in the School of Public Health.

The differences — attributed to cultural, education, language and other barriers — persist even when comparing like income levels or health insurance Percent with Recent Cancer Screening Test by Race/Ethnicity, status across racial and ethnic groups. Lower screening rates reduce the odds Adults Under Age 65 Covered by of early detection for hundreds of thousands of Californians and survival rates Medi-Cal, California, 2001 for those who develop cancer.

The report is based on data from the 2001 California Health Interview Colorectal Survey (CHIS 2001) and funded by The Cancer Mammogram PSA Test PAP Test Screening California Endowment. Researchers Race/Ethnicity % % % % examined screening rates for cervical, breast, colorectal and prostate cancer 85.8 72.0 51.1 31.5 White among whites, Latinos, Asians, blacks, Latino 92.2 70.4 35.8 30.1 American Indian/Alaska Natives, and 54.3 70.4 49.1 * Asian Native Hawaiian and other Pacific Islanders.

African American 90.3 74.8 44.2 45.3 “Our findings underscore the reality * American Indian/Alaska Native 91.4 71.1 58.7 that racial and ethnic disparities in Native Hawaiian & * 76.0 * * cancer screening and other important Other Pacific Islander health services can be found even * Other/Multiracial 87.3 72.1 53.3 within similar socioeconomic groups, 86.2 71.6 46.2 28.8 All With Medi-Cal such as low-income families and MediCal beneficiaries,” says Dr. Ninez A. Ponce, a center researcher and author on the study who is assistant professor of health services at the school.

Screening saves lives by detecting cancer or pre-malignancies at a time when treatment typically is most successful. Five-year relative survival rates for breast, prostate, colorectal and cervical cancer rise above 90 percent if the tumor is discovered before it spreads to other parts of the body. Once a tumor has metastasized, survival rates drop to 34 percent for prostate cancer, 23 percent for breast cancer, 15 percent for cervical cancer and 9 percent for colorectal cancer.

The report includes detailed screening rates for the four cancers by 1) race/ ethnicity alone, 2) income and race/ethnicity, and 3) Medi-Cal coverage and race/ethnicity. Among the key findings: • Asians report lower rates of screening than whites for all four cancers.

• Latinos report lower screening rates than whites for breast, colorectal and prostate cancer.

• Native Hawaiians and other Pacific Islanders consistently report some of the lowest screening rates in the state.

• American Indian and Alaska Natives are less likely to have been screened for breast or prostate cancer than whites.

The UCLA research team focused on the use of cancer screening tests among adults who have not been diagnosed with the site-specific cancer: Pap testing for cervical cancer; mammography for breast cancer; fecal occult blood test, colonoscopy or sigmoidoscopy for colorectal cancer; and the PSA (prostate specific antigen) test for prostate cancer.

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research

Coordination of Services More Important to the Success of Medical Practice than Physician Continuity

Physician Performance Range on Aggregate Measures

Minimum

Maximum 100

99 87

62 54

48

Diabetic Management

Cancer Screening

Ambulatory Costs

(% of patients tested)

(% of patients tested)

(minimum is % of maximum)

From Parkerton PH, et al., Physician Performance Assessment: Nonequivalence of Primary Care Measures. Medical Care 41(9):103447, 2003. Reprinted with permission.

UCLAPUBLIC HEALTH

NEITHER PHYSICIAN CONTINUITY – patients seeing the same doctor for most of their visits – nor part-time practice was associated with outcomes measures of cost, patient satisfaction or important health care services, according to the results of a large study of patients in a managed care plan. The study, led by Dr. Patricia Parkerton, assistant professor of health services at the UCLA School of Public Health, concluded that the presence of specific practice structures that coordinated care was more important.

Parkerton’s group examined the practices of nearly 200 primary care physicians responsible for 320,000 adult patients who were members of Group Health Cooperative, a health plan in the Puget Sound region of Washington. Physician performance was measured as it pertained to four areas: cancer screening, diabetic management, outpatient costs, and patient satisfaction. Results have been published in Medical Care and The Journal of General Internal Medicine, and will be published in January’s Family Practice.

“Analyzing physician performance data can identify effective primary care practice structures and processes, ultimately benefit100% ing patient care,” Parkerton says. The variability in physician performance within one system of care was striking, as was the per80% formance variability of individual physicians.

A physician’s good performance in one area 67 (e.g., cancer screening) was not likely to be 60% mirrored in other areas (e.g., patient satisfaction); only one doctor – less than 1 per40% cent – performed in the top third on all four measures.

Parkerton’s group found that structural 20% aspects of physician practices were signifi17 cantly associated with better patient outcomes. The level of coordination within a 0% practice was improved by the length of time Patient a clinical team worked together, a larger clinSatisfaction ical center, and formal practice sharing. On (% of patients responding the other hand, factors related to continuity with “excellent”) were not associated with better physician performance. Part-time physicians did not achieve poorer outcomes on any of the measures, including patient satisfaction; indeed, practices that had part-time physicians and those with reduced appointment hours fared better on performance measures of cancer screening and diabetic management. Parkerton’s research team suggests this may be the result of effective communication methods on the part of these practices – including telephone and e-mail contact with patients and strong coordination among members of the patient’s health care team.

“This study demonstrates the advantages of working within a delivery system to understand its operational issues, and highlights our need to develop organizational supports to increase physician effectiveness,” Parkerton concludes.

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Report Indicates Disparities in Children’s Health Status That Can Significantly Affect Ability to Learn and Grow

26

The report notes that the lack of access to health care and quality childcare for many young Californians may have long-term consequences for their development and ability to grow and learn.

A UCLA CENTER FOR HEALTH POLICY RESEARCH STUDY based on data from the 2001 California Health Interview Survey (CHIS 2001) has found wide gaps in the health and access to care among California’s children under 6 years of age.

“The Health of Young Children in California: Findings from the 2001 California Health Interview Survey” examines the health, access to health care and well-being of young children, all of which affect children’s ability to reach their greatest potential in school and in life. The report notes that the lack of access to health care and quality childcare for many young Californians may have long-term consequences for their development and ability to grow and learn. Hardest hit are low-income and minority children, particularly Latino children, who represent 50 percent of California’s youngest children.

According to the report, there is room for improvement in conditions affecting all children. “CHIS shows that health and dental care as well as parent activities at home are falling short of what is needed for young Californians of all incomes and ethnicities,” says report lead author Moira Inkelas, adjunct assistant professor in the UCLA School of Public Health and assistant director of the UCLA Center for Healthier Children, Families and Communities.

The report also provides the first statewide data on California’s potential to close the gap for children who are eligible for health insurance but not enrolled.

Approximately 202,000 children under the age of 6 are uninsured. According to CHIS 2001, about 80 percent of those children are uninsured despite being eligible for the public programs Healthy Families or Medi-Cal. In particular, Latino children and those in low-income families are four times less likely to have health insurance. The report states that targeted outreach, enrollment and retention efforts are needed to extend health insurance to more children and develop policies and programs to fill existing gaps.

The study also found that many preschool-age children spend no time in structured preschool settings. There are large disparities in preschool attendance among California’s ethnic populations. CHIS 2001 shows that, overall, approximately 22 percent of children ages 3–5 years are in a preschool program such as Head Start, preschool or nursery school. Of children ages 3–5 years, only 13 percent of Latino children are enrolled compared to 36 percent African American, 32 percent American Indian/Alaska Native, 29 percent non-Hispanic white and 23 percent of Asian/Pacific Islander children.

CHIS 2001, the largest health survey ever conducted in any state and one of the largest in the nation, is the first health survey to provide detailed information on the health of young children in California, both statewide and for many counties.

UCLAPUBLIC HEALTH

Survey of Firearm Dealers in 20 U.S. Cities Shows Some Are Willing to Make Illegal Handgun Sales SOME GUN DEALERS ARE WILLING TO SELL HANDGUNS even when the buyer indicates the end user is prohibited from purchasing a firearm, according to a unique UCLA School of Public Health survey of dealers in 20 of the nation’s largest cities. The findings appeared in the June 2003 edition of the journal Injury Prevention.

The survey results demonstrate the need for changes in laws about gun sales and transfers, and for more resources to conduct gun sale compliance checks, according to Dr. Susan B. Sorenson, professor of community health sciences and the study’s lead author.

“In the absence of federal handgun registration, firearm dealers carry the primary burden in the United States for ensuring guns are not sold to individuals who are prohibited from buying one,” Sorenson says. “While dealers are in a

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research

position to exercise judgment when a customer is explicit about buying a firearm for someone else, some dealers appear willing to ignore or sidestep relevant information to a sale — even when told that the end user was prohibited from purchasing a firearm.”

Sorenson’s team conducted telephone interviews with 120 handgun dealers, six from each of the 20 largest U.S. cities with 10 or more dealers. Those cities included Baltimore; New York City; Philadelphia; Memphis, Tenn.; Nashville, Tenn.; Jacksonville, Fla.; Oklahoma City; Houston; Dallas; San Antonio, Texas; El Paso, Texas; Austin, Texas; Forth Worth, Texas; Cleveland; Indianapolis; Denver; Seattle; Phoenix, Ariz.; Los Angeles; and San Diego.

Dealers within each city were randomly assigned to a male or female interviewer Dealer Willingness to Sell a Handand then randomly assigned to one of three purchase conditions: 1) the handgun When Caller Indicates it Is for: gun was for the caller, 2) the handgun was a gift for a girl or boyfriend, 3) the handgun was for a girl or boyfriend “because she/he needs it.” Dealers were 100% told, “I've never done this before. What do I need to know?” Federal law allows licensed firearm dealers 80% 87.5 to sell a firearm to any person who is not a prohibited purchaser, such as a convicted felon. Guns may also 72.5 be purchased as gifts. But selling a handgun would 60% be illegal under the “need” condition.

The findings showed most dealers were willing to 52.5 40% sell a handgun regardless of the end user. When the handgun was identified as for the caller, 88 percent of dealers would make the sale; as a gift, 71 percent; 20% and as a gift for someone who “needs it,” 53 percent.

A follow-up survey of 20 additional telephone 0% calls was made after the study was complete. The Self Boy/girlfriend Boy/girlfriend caller told the dealer, “My girl/boyfriend needs me to as gift because s/he buy her/him a handgun because she/he isn’t allowed needs it to.” In 16 of the 20 calls, the dealer responded with an unequivocal “no,” while four agreed to sell a handgun.

Teens at Substantially Higher Risk for Injury Crashes When Driving at Night, Carrying Other Young Passengers

UCLAPUBLIC HEALTH

WHEN TEENAGERS DRIVE AT NIGHT or in the presence of other young passengers, their risk of having a crash resulting in injury is dramatically raised, according to findings from a study by members of the Southern California Injury Prevention Research Center, based in the School of Public Health, which also found that the presence of an adult passenger older than 30 significantly lowers the injury crash risk for teen drivers.

It has long been known that teenage drivers have higher crash rates than adult drivers. “Because young drivers lack maturity and driving experience, they are less able to identify hazards and are more likely to exhibit risky driving behaviors, such as speeding and following too closely,” notes Thomas M. Rice, a Ph.D. candidate who conducted the study, published in the journal Injury Prevention, with Dr. Jess Kraus, the center’s director, and Corinne Peek-Asa. But this study, Rice notes, was the first to estimate the independent effects of both nighttime driving and passenger transport on the risk of injury crash occurrence among the young drivers.

The researchers analyzed data from crashes involving 16- and 17-year-old drivers in California during a five-and-a-half year period before implementation of the state’s graduated driver licensing system, designed to reduce the problem of high crash rates among young drivers by introducing adolescents into the driving environment in several stages, with the early stages intended to keep them out of high-risk driving situations. They found that teenagers driving alone are

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more than three times as likely to cause crashes as those driving in the presence of an adult 30 or older – and that those carrying teenage passengers are notably more likely to cause crashes than those driving alone.

The likelihood of causing an injury crash increases with advancing late night hours for both male and female teens, rising to as much as tenfold during the later time periods. The hours of 10 p.m. to midnight are particularly dangerous for teen drivers, given that more are on the road at that time. More drivers are critically injured between 10 p.m. and midnight than during any other two-hour late-night time interval, according to the study.

“Several other studies have identified this time period as risky for teenage drivers, yet a majority of graduated licensing systems in the United States ignore this time period,” says Rice. “States with nighttime driving restrictions could reduce the number of critical injuries to drivers by expanding the restrictions to include these hours. The incorporation of passenger restrictions into existing graduated systems should also result in fewer severe and fatal injuries.”

UCLAPUBLIC HEALTH

SPH Researchers Develop Measures of Performance for Use in L.A. County Health Department Programs MEASURABLE PERFORMANCE INDICATORS addressing the delivery of services by a local health department have been developed by a team of UCLA and RAND researchers.

The effort took place at the behest of Dr. Jonathan Fielding, who serves in the dual role as professor of health services at the school and director of public health for the county. Fielding asked Drs. Mark Schuster, Steven Asch and Stephen Derose to assist him in setting clear goals and quantifiable performance metrics for the county’s 40-plus public health programs. “While there has Components of Quality been a huge effort to define and measure quality in medical care, this effort has Measurement for a Local not been matched in the public health sphere,” Fielding explains.

Health Department Fielding and the team of research consultants worked with program directors and senior members of their staffs to define quality with respect to their programs – asking questions such Structure Process Outcomes as what the programs were trying to achieve and how the directors would know if they were successful. “This is part of our efforts in Los Angeles Local Health Health Status Department County to make sure we are using the best eviCharacteristics dence to develop effective public health programs Technical and policies,” says Fielding.

Excellence CommunityShort-term The result was a set of specific program Social Based Results of Functioning goals and related performance indicators, sumOrganization Activities Characteristics marized in two articles – one published last year Interaction Excellence in the Annual Review of Public Health, and one in Population press at the American Journal of Preventive Consumer and Community Satisfaction Medicine. All told, the researchers developed 61 Characteristics indicators, with an emphasis on measuring the quality of process in services delivery.

“This was a great example of a productive Reprinted with permission from The American Journal of Preventive Medicine, DeRose SF et al., Developing Quality Indicators for Local partnership between a university, a think tank, and a local health department,” Health Departments: Experience in Los Angeles, in press. says Schuster, associate professor of health services and pediatrics at UCLA and senior natural scientist at RAND. “We had the opportunity to work on an applied issue of importance to the department, and also to publish articles in public health journals so that others could learn from the experience.”

“We have learned in the health department that focusing on quality, measurable goals and quantifiable program indicators requires a considerable ongoing investment,” says Fielding. “One of the major problems is the lack of data collection systems for many of the key indicators. Continued emphasis on these issues is essential in building a set of interventions for improving the health of the population that are thoroughly grounded in the best evidence.”

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DEBORAH L. ACKERMAN OCD Treatment Outcomes: Beyond Phase 3 Drug Trials (NIH/National Institute of Mental Health, $80,716)

Health Interview Survey (CHIS) (Robert Wood Johnson Foundation, $1,100,000); The 2003 California Health Interview Survey (CHIS) (The California Endowment, $3,898,989)

ABDELMONEM A. AFIFI Integrated, Multi-Level Interventions to Improve Adolescent Health Through the Prevention of Sexually Transmitted Diseases Including HIV (Health Research Association, Inc., $105,121)

SUSAN D. COCHRAN HIV/AIDS, Drug Abuse and Mental Health Among Stigmatized (NIH/National Institute on Drug Abuse, $571,605); Risk for Psychopathology Among Lesbians and Gay Men (NIH/National Institute of Mental Health, $336,756)

RICHARD F. AMBROSE Coastal Water Quality: The Role of Wetlands in Mitigating the Effects of Urban and Rural Runoff (UC Irvine, $59,088); Influence of Nutrient Loading on the Invasion of an Alien Plant Species, Giant Reed (Arundo Donax), in Southern California Riparian (UC Riverside, $56,000); Determining Long-Term Changes in Species Abundances & Community Structure in Southern California Rocky Intertidal Habitats (UC Santa Cruz, $211,420)

MICHAEL D. COLLINS Murine Strain Sensitivity to Cadmium Teratogenesis (NIH/National Institute of Environmental Health Sciences, $301,211); Cadmium Teratogenesis to Murine Strains Proteomics (NIH/National Institute of Environmental Health Sciences, $222,450)

RONALD M. ANDERSEN UCLA/RAND Health Services Research Training Program (DHHS/Agency for Health Care Research and Quality, $364,296); RWJF Pipeline, Profession, and Practice: Community-Based Dental Education (Robert Wood Johnson Foundation, $371,796) MARION T. BAER Partners in Excellence for Leadership in MCH Nutrition (DHHS/Health Resources & Services Administration, $238,359) ROSHAN BASTANI UCLA Cancer Education and Career Development Program (NIH/National Cancer Institute, $563,299); Asian American Network for Cancer Awareness, Research, and Training (AANCART) (NIH/National Cancer Institute, $221,301) THOMAS R. BELIN Imputation for Moderate Sized Mental Health Studies (NIH/National Institute of Mental Health, $250,925) BARBARA A. BERMAN UCLA School of Public Health Curricular Innovation (Association of Schools of Public Health, $150,000); Step Up Pre-Doctoral Scholarship (Association of Schools of Public Health, $90,000) JULIENNE ELIZABETH BOWER Mechanisms of Radiation-Induced Fatigue in Cancer (NIH/National Cancer Institute, $63,585)

New and ongoing contract and grant funds received in fiscal year 02-03. Due to space limitations, only funds of $50,000 or more are listed, by principal investigator.

STEVEN D. COLOME Children’s Health Initiative-Microenvironmental and Personal Pollutant Exposures (U.S. Environmental Protection Agency, $80,000) WILLIAM G. CUMBERLAND Biostatistics Training for AIDS Research (NIH/National Institute of Allergy and Infectious Diseases, $204,160) PAMELA LEE DAVIDSON Evaluation of Pediatrics Warmline-TAC (NexCare Collaborative, $57,137); Geographic Variation in Breast Cancer Stage at Diagnosis (UC Breast Cancer Research Program, $139,059) ROGER DETELS Training & Community Intervention to Prevent Drug Use & HIV Transmission in Vietnam (NIH/Fogarty International Center, $493,678); Natural History of AIDS in Homosexual Men (NIH/National Institute of Allergy and Infectious Diseases, $3,345,603); International Training Grant in Epidemiology Related to AIDS (NIH/Fogarty International Center, $1,373,691); Interdisciplinary Training in HIV/AIDS Epidemiology (NIH/National Institute of Allergy and Infectious Diseases, $231,260); Training & Community Intervention to Prevent Drug Use & HIV Transmission in Vietnam (NIH/Fogarty International Center, $279,818) CURTIS D. ECKHERT Characterization of Borate Binding to Nucleotides in Vitro and in Vivo Using 11B NMR and Electrospray Ionization Mass Spectometry (UC Toxic Substances Research & Teaching, $50,000); Microlocalization and Quantitation of Risk Associated Elements in Gleason Graded Prostate Tissue (U.S. Army/Material Command Headquarters, $417,082) JOHN R. FROINES Center for Excellence for Environmental Public Health Tracking (UC Berkeley, $152,619); UCLA-Mexico/Latin America Training and Research Program (NIH/Fogarty International Center, $163,962) PATRICIA A. GANZ Mechanisms of Radiation-Induced Fatigue in Breast Cancer

UCLAPUBLIC HEALTH

E. RICHARD BROWN California Health Interview Survey (CHIS) (NIH/National Cancer Institute, $999,194); Using CHIS to Study Latino, Asian American/Pacific Islander, and American Indian/Alaska Native Health Needs (The California Endowment, $192,961); Studying Health Indicators Among African Americans: An Invitational Symposium (The California Endowment, $57,940); Housing and Neighborhood Environment Module for the 2003 California

faculty

contracts & grants 2002-03

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30 (UC/Breast Cancer Research Program, $150,000); Biopsychosocial Mechanisms of Fatigue in Breast Cancer Survivors (The Breast Cancer Research Foundation, $203,766); Breast Cancer Treatment Outcomes in Older Women (Boston University, $54,642) DEBORAH C. GLIK Technical Assistance to Department of Health Services (CA/HHS/Department of Health Services, $252,308); Evaluation of Hepatitis B Movie Campaign (CA/HHS/ Department of Health Services, $104,421); Media Campaign to Prevent Alcohol Use During Pregnancy (Association of Schools in Public Health, $282,622); Pre-empt: Pre-event Message Preparation for Terrorism (Association of Schools of Public Health, $356,190) PAMINA M. GORBACH Developing Interventions for Men Who Have Sex with Men with HIV and STDs in Los Angeles (UC Universitywide AIDS Research Program, $69,144); Testing and Counseling Women for Human Papillomavirus Infection (County of Los Angeles/Department of Health Services, $228,510); Subcontract: Southern California Primary Infection Grant (UC San Diego, $75,587); HIV Prevention Trials Network (HPTN) (Health Research Association, Inc., $134,412) NEAL HALFON Ventura County Center for Excellence (California State University, Channel Islands, $299,329); Statewide Data Collection and Evaluation of Proposition 10 Funded Programs (SRI, International, $1,844,664); Prop 10 Policy and Communication Support Program (Rogers Associates Inc., $450,000); Vivian Weinstein Child Advocacy Fellows Program (W. M. Keck Foundation, $250,000) WILLIAM C. HINDS Education and Research Center (DHHS/Centers for Disease Control, $976,633); Analytical Chemistry Cores (Southern California Environmental Health Sciences Center, $120,000)

UCLAPUBLIC HEALTH

ERIC L. HURWITZ Psychosocial Behavior and Immune Factors in Back Pain (NIH/National Center for Complementary & Alternative Medicine, $121,770)

Centers (DHHS/Centers for Disease Control, $905,500); Evaluation of California Initiatives to Reduce Violence Against Health Care Workers (University of Iowa, $68,545) VIRGINIA CHENG LI Evaluation of Reproductive Health Internet’s Impact on Family Planning Quality of Care in Yunnan, China (Ford Foundation, $50,000) MARK S. LITWIN Urologic Diseases in America (NIH/National Institute of Diabetes, Digestive and Kidney Disease, $4,487,490) MICHAEL C. LU Maternal Quality of Care Indicators (CA/HHS/Department of Health Services, $260,000); LA Best Babies Collaborative (Healthy Births Planning & Network Support) (Cedars-Sinai Medical Center, $198,164) WILLIAM J. McCARTHY Analysis of California Adolescent Tobacco Data (UC TobaccoRelated Disease Research Program, $205,340); Tobacco Use Among Californians of Asian Indian Ancestry: A Statewide Survey (CA/HHS/Department of Health Services, $376,661) YING-YING MENG Uncontrolled Asthma and Exposure to Air Pollution (DHHS/Centers for Disease Control, $200,000) HAL MORGENSTERN Marijuana Use and the Risks of Lung and Other Cancers (NIH/National Institute on Drug Abuse, $268,096) CHARLOTTE G. NEUMANN Nutrition Friendly School Certification Process Pilot Study (DHHS/Centers for Disease Control, $446,098) ANNE R. PEBLEY Neighborhood Effects on Children’s Well-Being (RAND, $76,884) NADEREH POURAT Availability of Dental Providers in California (California Dental Foundation, $354,145); Subcontract – Health of Children in California’s Immigrant Families (National Immigration Law Center, $60,000)

MOIRA INKELAS Evaluation of California Medi-Cal Home Project (California Healthcare Foundation, $199,585)

MICHAEL L. PRELIP March of Dimes San Bernardino County Prop 10 Narrowcast and Physician Evaluation (March of Dimes Birth Defects Foundation, $57,237)

MARJORIE KAGAWA-SINGER Breast Health Education Project for Hmong Women and Men (UC/Breast Cancer Research Program, $168,608); Increasing Diversity in Cancer Control Research (UC San Francisco, $126,055)

SHANE S. QUE HEE Permeation of Irritant Mixtures Through Protective Material (DHHS/Centers for Disease Control, $225,022); Field Glove Permeation Instrumental Methods Development (Association of Schools of Public Health, $150,104)

GERALD F. KOMINSKI Managed Care in California (Department of Managed Health Care, $130,354)

MARIZEN RAMIREZ Risk Factors for Injury During Sports Among High School Athletes with Disabilities (DHHS/Centers for Disease Control, $100,000)

JESS F. KRAUS Epidemiology and Costs of Mild Traumatic Brain Injury in Nonhospitalized Patient Populations (DHHS/Centers for Disease Control, $287,917); Injury Prevention Research

BEATE R. RITZ Extended Follow-up of the Rocketdyne Worker Cohort (UC Davis, $109,200); Ergonomic Interventions for Garment Work

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LINDA ROSENSTOCK Public Health Traineeship (DHHS/Health Resources & Services Administration, $101,552); Pacific Public Health Training Center (PPHTC) (DHHS/Health Resources & Services Administration, $323,888); Traineeship in Underserved Communities (The California Endowment, $448,649); Diversity in Health Professions (California Wellness Foundation, $150,000)

DR. ANNE L. COLEMAN (Epidemiology) has a joint appointment in the School of Public Health and the Department of Ophthalmology at the David Geffen School of Medicine at UCLA. Her research is directed toward the diagnosis, treatment and societal impact of glaucoma, cataracts and agerelated macular degeneration (AMD), including the study of lifestyle limitations imposed on patients with these kinds of eye diseases.

Anne L. Coleman

STEVEN ROTTMAN Training and Education for Disasters in Public Health (Association of Schools of Public Health, $204,289); Training and Education to Increase Competency in Emergency Public Health (Association of Schools of Public Health, $986,730) DELIGHT E. SATTER American Indian and Alaska Native Health Status and Access to Care (NIH/National Cancer Institute, $95,172) MARK A. SCHUSTER UCLA Center for Adolescent Health Promotion (DHHS/Centers for Disease Control, $2,013,800)

Leeka Kheifets

FRANK J. SORVILLO Evaluation of the Public Health Impact of Baylisascaris Procyonis Infection (Association of Schools of Public Health, $70,687) IRWIN H. SUFFET Advanced Oxidation Processes for the Treatment of Candidate Containment List (CCL) Chemicals (Duke University, $136,502) DAWN M. UPCHURCH STIS/HIV Risk in Young Adults: A Multilevel Approach (NIH/National Institute of Child Health and Human Development, $622,796)

Gloria E. Mao

STEVEN P. WALLACE New Tools for Improving Health Policymaking in California (The California Endowment, $865,250); Improving the Health and Quality of Life of Older Persons in California: New Local Area Data for Program Planning and Policy Development (The California Endowment, $61,544; Archstone Foundation, $53,516)

DR. GLORIA E. MAO (Epidemiology) focuses her research on the interactions between genes and environmental exposures in carcinogenesis. She is studying biomarkers for prostate cancer and using genetic polymorphisms to identify populations at increased risk for the disease. Mao’s current focus is on genes in the vitamin A pathway and prostate cancer. She received her Ph.D. from the UCLA School of Public Health’s Department of Environmental Health Sciences and was a postdoctoral researcher in UCLA’s Division of Cancer Prevention and Control Research.

THOMAS M. PRISELAC (Health Services), president and CEO of the Cedars-Sinai Health System, joins the school as an adjunct professor. The CedarsSinai Health System, which Priselac has headed since 1994, is the largest private hospital in the western United States. Priselac has a master’s degree in public health, health services administration and planning from the University of Pittsburgh.

MIRIAM COTLER (Health Services) GEOFFREY JOYCE (Health Services)

Thomas M. Priselac

MIRIAM LAUGESEN (Health Services) LORI PELLICCIONI (Health Services) MAREN SCHEUNER (Health Services) CARL VOLPE (Health Services) WALTER ZELMAN (Health Services) PAULA TAVROW (Community Health Sciences)

UCLAPUBLIC HEALTH

ZUO-FENG ZHANG Cancer Epidemiology Training Program (NIH/National Cancer Institute, $228,238); Molecular Epidemiology and Gene-Environment Interaction (NIH/National Institute of Environmental Health Sciences, $438,653)

DR. LEEKA KHEIFETS (Epidemiology) most recently headed the Radiation Studies Program at the World Health Organization. Previously, she was a technical executive at the Electric Power Research Institute, where she directed a multidisciplinary electric and magnetic fields (EMF) research program. Widely known for her work in environmental and occupational epidemiology, Kheifets serves on international and national committees that provide advice to governments on environmental policy.

Seven new visiting faculty are at the school in 2003-04:

RICHARD G. WIGHT AIDS Caregiving Stress Among Midlife and Older Women (NIH/National Institute of Mental Health, $430,518) ARTHUR M. WINER Estimates of Nitrous Oxide Emissions from Motor Vehicles and the Effects of Catalyst Composition and Aging (CA/EPA Air Resources Board, $159,976)

31

faculty

(DHHS/Centers for Disease Control, $413,037); Air Pollution and Adverse Birth Outcomes (NIH/National Institute of Environmental Health Sciences, $305,000); Parkinson’s Diseases Susceptibility Genes and Pesticides (NIH/National Institute of Environmental Health Sciences, $520,876)

new faculty

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news briefs

dr. gail harrison elected new public health to institute of medicine minor program For the first time, 25 UCLA undergraduate students are taking courses offered by the school toward a minor in public health.

The Public Health Minor, first offered this fall, will provide opportunities for undergraduates to gain a foundation in public health.

Interest in public health among UCLA undergraduates has grown in recent years, sparked by a popular undergraduate introduction-to-public-health course developed by Drs. Lester Breslow and Ruth Roemer. “In the last five years, we have seen a fairly substantial undergraduate enrollment in our 100-level introductory courses for M.P.H. students,” notes Dr. Gerald F. Kominski, professor and associate dean for academic programs at the School of Public Health. “The minor provides these students with an opportunity to receive formal credit for this coursework.”

Many of the undergraduates enrolling in the Public Health Minor are interested in pursuing a graduate degree in public health, either alone or in conjunction with a medical degree. “Based on our first group of applicants, we are attracting excellent students,” Kominski says.

Dr. Gail Harrison, professor and vice-chair of the school’s Department of Community Health Sciences, has been elected to membership in the prestigious Institute of Medicine (IOM) for her many contributions to the field of human nutrition and health.

Harrison, who holds graduate degrees in nutritional sciences from Cornell University and in biological anthropology from the University of Arizona, has been a member of the school’s faculty since 1992. Her research focuses on functional consequences of malnutrition and food intake, and on dietary and nutritional assessment in various populations. She has conducted field research in the Middle East, Africa, Asia and Latin America, and is past president of the Society for International Nutrition Research.

Harrison has served as a consultant to various national and international organizations, including UNICEF, the World Health Organization, the U.S. Department of Agriculture, and the National Institutes of Health. She is a senior scientist in the UCLA Center for Health Policy Research.

The IOM is a unit of the National Academy of Sciences, a federally chartered organization that advises Congress and other government groups about key issues relating to science and health policy. Members are drawn from health professions and other disciplines. Harrison’s election brings to seven the number of current UCLA School of Public Health faculty who are IOM members; the others are Drs. Ronald Andersen, Lester Breslow, Robert Brook, Jonathan Fielding and Dean Jamison, along with Dean Linda Rosenstock.

C A M PA I G N U C L A S C H O O L O F P U B L I C H E A LT H Cumulative Progress Through Fiscal Year 2002-03 $35,000,000 $33,029,500 30,000,000 25,000,000 $23,336,915 20,000,000

$18,852,239

15,000,000

UCLAPUBLIC HEALTH

$10,037,344 10,000,000 $ 8,165,239 5,000,000

$ 4,453,851 $ 1,969,479

0

FY 95-96 FY 96-97 FY 97-98 FY 98-99 FY 99-00 FY 00-01 FY 01-02 FY 02-03

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spotlight: public health alumni association

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news briefs

NEW ASSISTANT DEAN FOR COMMUNICATIONS

2:20 PM

The Public Health Alumni Association seeks to build and strengthen personal and professional connections between the UCLA School of Public Health and its current students and alumni. The association aims to raise the visibility and profile of the school, thereby increasing its reputation, value, and involvement within the public health, health care, and local and international communities.

Likewise, the association strives to increase public health awareness in the lay community. To foster these goals, it supports and strengthens alumni participation in programs that promote the school’s research, education, and community service. These programs include public health lectures and forums, networking activities, alumni contributions, and student career and mentoring programs.

DID YOU KNOW...

SARAH ANDERSON has joined the school as assistant dean for communications.

Anderson has held a variety of key communications positions.

Most recently she was at Rogers & Associates, where she led the team designing and implementing media relations strategies for First 5 California, charged with distributing tobacco tax monies to programs targeting children ages 0-5.

Anderson also served as communications director for Rep. Elizabeth Furse (OR) and later for Rep. Loretta Sanchez (CA).

Earlier work included serving as research director and then communications director for the League of Conservation Voters.

PHAA BOARD OF DIRECTORS — l. to r., first row: Genus Heidary, David Swanson Hollinger, Katherine Minnium, Maureen Flannery, Joyce Page, Joy Blevins, Ruth Roemer; second row: Marjorie Kagawa-Singer, Tom Cruz, Catharina Wong, Michelle Popowitz, David Krasnow, Christopher Mardesich. Absent from the shot are Clifford Howell, Rosa Pechersky, Kynna Wright.

first-ever SPH alumni directory in the works

UCLAPUBLIC HEALTH

The UCLA School of Public Health, working with Harris Publishing Company, the nation’s leading publisher of alumni directories, is collecting information that will be used to publish the school’s most comprehensive alumni directory to date.

The directory will be a valuable resource containing personal, academic, and business information on all of the school’s alumni. It will enable alumni to locate and network with colleagues in their specialty areas, or to find an old study partner.

Information to be included in the directory is being obtained through a questionnaire mailed to all alumni. Alumni who have not returned a directory questionnaire are asked to do so as soon as possible. For more information or if you have not received a questionnaire, contact the Office of Development and Alumni Relations at (310) 825-6464.

You are a lifetime member of the UCLA School of Public Health Alumni Association (PHAA) if you are a graduate of the school and its executive programs.

• Activities of the PHAA are growing.

For more information, please call Susan Kanowith-Klein at (310) 825-6464, or e-mail phaa@support.ucla.edu.

• The SPH ALUMNI e-NEWS brings information on events and people of special interest to alumni three times a year. If you are not already receiving this newsletter and would like to get it, please send your e-mail address with your name and current home and business addresses to publichealth@ support.ucla.edu.

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Save the

DATE The 30th annual Breslow Lecture and Dinner will be held April 19, 2004 in the Grand Horizon Room of UCLA Covel Commons, beginning with a reception at 6 p.m.

Lecture namesake Lester Breslow, M.D., M.P.H., Sc.D., professor emeritus of health services and dean emeritus of the school, will deliver his first-ever address at this occasion, titled “The Third Revolution in Health: Implications for Public Health.”

For more information, please contact the SPH Office of Development and Alumni Relations at 310-825-6464 or publichealth@support.ucla.edu.

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