Findings, The Human Mind, Spring 2014

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The Human Mind Why it’s the next frontier in public health

INSIDE > Addiction p. 40

| The case for mental health as public health p. 26 | How scientists think p. 14

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From the Dean Brain Science

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From Our Readers

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On the Heights

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Research News

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My Space

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Alumni Network 42 Decades Later, Still Grateful

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Front cover: This image was produced with a new imaging technique called High Definition Fiber Tracking (HDFT), which allows doctors to clearly see neural connections ruptured by traumatic brain injury and other neurological disorders, much as X-rays reveal fractured bones. HDFT technology was developed at the University of Pittsburgh’s Learning Research and Development Center by a team led by faculty member William Schneider.

Back cover image: This is an example of Diffusion Tensor Imaging, which allows scientists to map the diffusion process of molecules in biological tissues. To date, this technology has primarily been used in the study and treatment of neurological disorders, especially for the management of stroke patients. Because it enables scientists to visualize anatomical connections between different parts of the brain, non-invasively and on an individual basis, the technology represents a major breakthrough for neuroscience. This image was created by Jeremy Strain, a researcher at the Center for BrainHealth at the University of Texas at Dallas.

findings Volume 29, Number 2 Spring/Summer 2014 Produced by the U-M SPH Office of Marketing and Communications

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The Human Mind 14

The Mind of a Scientist

As the example of physicist Richard Feynman shows, intuition is key.

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Fantastic Voyage

Deep inside the brain, scientists seek new clues to health.

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Beginning the Conversation

A video series takes aim at depression among college students.

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Mental Health Is Public Health

A call for action on a crucial—and all too neglected—issue.

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S pecial S ection V ictors for michigan : a campaign supplement

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hen I think of the human brain, I invariably recall what physicist Stephen Hawking said about why the universe exists: “If we find the answer to that, it would be the ultimate triumph of human reason—for then we would know the mind of God.” In a sense, to know the human mind— to understand not just its anatomy, its cellular composition, its intercellular interplay, its neurochemistry and neurobiology, but to really know the human mind—is an equally intoxicating proposition. For despite the increasing sophistication of our knowledge of how the brain works, we remain almost blissfully ignorant of even the most fundamental elements that constitute intelligence, understanding, reason, judgment, sense, emotion, and the many other qualities and activities associated with our minds.

Physiology takes us Martin Philbert only so far. We know, for example, that rage emanates from structures like the amygdala, that reward and reward-seeking emanate in part from the ventral tegmental area and in the interplay between the neurotransmitters epinephrine, dopamine, and serotonin. But even with significant advances in psychiatry, we know little of the causal relationships between our physical, social, and other environments and the formation of the mind. We have barely scratched the surface of the complex range of factors that contribute to functions such as decision-making and memory.

And yet, as you will see throughout this issue of Findings, such matters are at the heart of public health. In fact, if we are to make progress in addressing such critical global health concerns as depression, substance abuse, obesity, and dementia—not to mention the many neurological diseases that threaten health and well-being—public health researchers and practitioners must commit new energy and resources to untangling the brain’s secrets. As the cover

of this magazine promises, the human mind is our next frontier.

In many ways, the broader swath of mental health is a forgotten frontier—perhaps because the component parts of mental health are not simply cells talking to each other, or biochemicals acting in neural pathways, but a combination of forces that no microscope or data set can reveal. Although we’ve made progress in managing the symptoms of many mental illnesses, we have yet to penetrate to the root causes of diseases like depression and schizophrenia, and we have not developed a means of promoting mental health across the socioeconomic spectrum.

As with so much else in our field, diseases of the mind demand a multidisciplinary approach.

Genetics alone cannot explain why an 18-yearold contemplates suicide, or why an 80-year-old can’t remember her name. Nor can psychiatry by itself uncover the mechanisms of addiction or tell us why some young people respond to stress by overeating and others through violence.

Behavior is at the core of public health and at the core of the human brain. In both public health and clinical care, we too often tell people what’s right and urge them to adopt that standard. Eat healthily. Exercise more. Get regular preventive care. As we expand our understanding of the brain, I hope we will make a corresponding change

in our approach to behavior. I hope we’ll use our newfound knowledge of the brain’s circuitry to meet people where they are and to coach them to a place where they can lead healthier lives.

We cannot “be” without a brain. But at the same time, we are much more than our brains. Now that we are examining the very beingness of being, it seems likely that our interdisciplinary approach to the human mind ought to involve not only traditional science but also ethics and philosophy and the social sciences and the arts, and that those areas should advance as rapidly as the technological breakthroughs we are now making in imaging the brain and its functions.

The brain represents an astonishing paradox. Having held several human brains in my hand over the course of my career, I know that they’re all roughly the same.

We all have a neocortex, a brain stem, a cerebellum, a hippocampus, and so on. And yet we’re all unique in our thought processes, in the risks that we’re willing to take and not willing to take. That is both the challenge and the promise that lies before us—that as we further our understanding of where the brain becomes the mind, we can capitalize on those individual differences to improve human health on our newest frontier. <

Having held several human brains in my hand over the course of my career, I know they’re all roughly the same.

Martin Philbert Dean and Professor of Toxicology

Keith Negley/iSpot.com

Brain Science

> F R O M O U R RE A D ER S As my personal journey evolves, I have become actively involved with a national organiA B e t te r O ld Ag e zation called Compassion and Choices (compassionandchoices. org), whose mission is to help people understand, plan for, and achieve a satisfactory passing.

They do this through education, training, counseling, technical assistance, advocacy, and political action. As I’ve participated in meetings, attended lectures, done some reading, viewed some videos, and generally engaged with family, friends, peers, elders, providers, and policymakers about their experiences and insights, I’m impressed with the level of interest by diverse folks who want to learn more, discuss, and be thoughtful about the dying process. There are compelling stories of calm and peaceful passings, of families reunited, and of individuals transformed toward the end. There are also ample tales of despair, pain, anxiety, powerlessness, isolation, hopelessness, and disappointment during this most sacred time. A good death is a significant challenge, but a worthwhile undertaking. Best of all, as I engage in this work I find my concerns/fears about dying diminish, and I’m beginning to experience opportunities for introspection and personal growth. Lots of blessings to count.

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Public health has added an estimated 25 years to the human life span.

What kinds of years will they be?

John Chaich Communications Officer, American Federation for Aging Research New York, New York INSIDe > The pros (and cons) of retirement p. 8

| The art of lastingness p. 26 | A guide to thriving p. 30

> The fall/winter 2013 edition of Findings, “A Better Old Age,” is outstanding. The articles, art work, and arrangement are fabulous. I read it from cover to cover, as did my sister-in-law, who does a lot of work with the Alzheimer’s Association.

Regardless of the publications I receive at home (The Economist, Bloomberg Businessweek, WSJ, Yoga Journal, Rolling Stone …), it seems everyone gravitates towards Findings. Initially, I believe it is because of the amazing cover art work, then the articles draw them in. Findings communicates significant current public health issues in a way that appeals to everyone—to the public. I have a sense of pride when people ask me, “Where did you get this magazine?” and I tell them because of my support of U-M SPH, my alma mater. Keep up the great work.

Findings is making a difference!

Donna Zobel, MS ’88 Troy, Michigan

“A good death is a significant challenge, but a worthwhile undertaking.”

> As a mostly retired, leading-edge baby boomer, I greatly enjoyed and appreciated the recent Findings dedicated to “A Better Old Age” (fall/winter 2013). From the dean’s overview of the essential roles of public health in all of this to the articles on retirement, healthy living, progressive housing, etc., it was all relevant and of interest … highlighted and enriched by the wonderful, heartfelt personal stories.

However, although it was directly or indirectly alluded to in several of the articles, there was little focus on the challenges, choices, processes, and preparation for seeking a “good death”—the inevitable conclusion of our old age. Perhaps some future volume will explore this issue in greater depth.

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Barak Wolff, MPH ’68 Santa Fe, New Mexico The writer is a former director of the Public Health Division of the New Mexico Department of Health.

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your list of “15 Ideas for a Better Old Age” and felt frustrated there was not another idea that focused on taking acIdeas for a tion through the enBetter Old Age gagement of healthy elders. The core part of an idea #16 would be that the elderly themselves, led by healthy elders, can make a difference. The central propositions leading this belief are that: 1) effective change comes about when change agents are active in making changes in their own lives; 2) a body of knowledge and ideas (15 of them and more) are available to guide the healthy

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elderly in their work to change and improve their own destiny; and 3) healthy elders can become volunteer advocates working to change attitudes through example, education, and leadership. The University of Michigan has led many movements for change.

Perhaps it can be a leader for this cause.

Charles Mekaru, MPH ’65, MSW Livonia, Michigan

Detroit’s Rivertown Neighborhood > I plan to distribute extra copies of the

print version of the “Better Old Age” (fall/ winter 2013) issue of Rivertown N Findings to the Neighborhood mayor, city manager, and new planning director of Palo Alto, California.

(Yes, we in the heart of Silicon Valley still find print copy useful for special occasions.) Despite Palo Alto’s worldwide reputation for leadership in the new, always-connected, economy, our city council and citizens are struggling with highquality, systematic senior services, especially the affordable housing component. Real estate priced at mid-Manhattan levels is a limiting factor, but not the salient issue.

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When it comes to affordable care for low-income seniors, Detroit is leading the nation.

ot far from the Detroit River, across the street from the headquarters of the UAW-GM Center for Human Resources, in a repurposed brick building formerly occupied by Parke-Davis, a quiet revolution in senior care is taking place. The first affordable continuing-care retirement community of its type in the nation, Rivertown Neighborhood now offers both assisted living and health care services to more than 190 Detroiters aged 55 and up, and in the next two years will offer independent-living to at least 50 more. A skilled-nursing facility with space for 24 older adults is in the planning stages.

John Thorhauer, president and CEO of United Methodist Retirement Communities, which operates Rivertown Assisted Living, says the development is fast becoming a model for the country at large.

“Nationally there’s a lot of discussion about the future of providing

services to seniors in affordable housing,” he says. “A lot of m are being attempted, but none are as extensive as this, with levels of services and more stable funding sources.”

When all phases of construction and program implementa complete, Rivertown Neighborhood will serve 700 seniors. It’s from the roughly 125,000 Detroiters Thorhauer estimates may for Rivertown’s housing or services, but a crucial first step. “Ou to take people who’d otherwise be in a nursing program and ke at home as long as possible.”

SPH Associate Professor Jane banaszak-Holl, who serve board of United Methodist Retirement Communities, notes th rivertown Neighborhood ►

Gm reNAISSANCe CeNter

UAW -GM

D etroit River

► The UAW-GM Center for Human Resources

leases an enclosed green space to Rivertown so that residents can have an inviting place to walk. Future plans include walking paths, benches, and a sculpture garden.

► Rivertown’s four-story, 80-unit assisted-living facility provides one-bedroom and efficiency apartments for up to 100 Detroiters ages 55 and older who meet certain criteria. Residents pay no more than $605 a month for meals, care, and housing, and some pay as little as $102.

► When one new resident first saw the library

on the fourth floor of Rivertown’s assisted-living facility, she asked, “Who gets to read these books?” “They’re for you,” she was told.

► The ground floor of Rivertown’s main facility

► The Center for Senior Independence is one

► Located across the street from the UAW-GM

includes a facility run by the Center for Senior Independence (CSI). CSI is a Program for AllInclusive Care for the Elderly, or PACE, whose chief goal is to allow senior citizens in nearby communities to continue living independently in their homes. CSI provides up to 300 lowincome Detroiters with daily meals, snacks, activities, personal care, and a range of health services, including dental care, mental health care, recreational and physical therapy, and routine checkups as well as urgent care.

of 83 PACE facilities nationwide (Michigan has six, including two in Detroit). PACE facilities are jointly funded by Medicare and Medicaid.

The PACE model is especially attractive to Medicaid, because of the significant cost savings that come from coordinating care across the entire health continuum. Key partners in CSI are Presbyterian Villages of Michigan and the Henry Ford Health System.

Center for Human Resources, Rivertown is funded by a combination of sources, including United Methodist Retirement Communities and Presbyterian Villages of Michigan, as well as other foundations and community and governmental agencies and organizations. A total of 17 sources provided $17.7 million to fund Rivertown Assisted Living, the first phase of the overall project, with philanthropy accounting for $3.1 million of the total cost.

“Our city council and citizens are struggling with high-quality, systematic senior services.”

The articles on Detroit’s Rivertown Neighborhood and the Masterpiece Living experience will be helpful to Palo Alto’s thought leaders. This is ironic, because Palo Alto at a very local level has a history of fostering world-class senior services. Since the mid-1950s, the Palo Alto Medical Foundation’s Drs. Russell Lee and Walter Bortz have been world-class leaders whose work is very similar to Robert Kahn’s exemplary work.

Neilson Buchanan, MHA ’68 Palo Alto, California

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very interesting issue— on a very vital topic.

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► Detroit’s only affordable assisted-living

► Before m

facility—and one of just two in the state of Michigan—Rivertown Assisted Living provides residents with two meals a day as well as basic utilities and access to round-the-clock care.

Many apartments offer river views.

in assisted couches— member he the hallway “because I

► Rivertown Neighborhood is the first re-

► An afford

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tirement community in the nation to bring together this range of different services designed for low-income seniors. Ultimately, Rivertown’s four facilities—independent living, assisted living, skilled nursing, and a day center with clinical services—will provide care to 700 Detroiters.

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low-incom Departmen ment, is cu to Rivertow which will f as well as a paths, is ex

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Detroit’s Rivertown Neighborhood cont’d > We are members of the Cedars of Dexter the Cedars, and for that we are most thankActive Seniors Community, another facility established by United Methodist Retirement Communities (UMRC), which operates Rivertown Assisted Living (“Rivertown Neighborhood,” fall/winter 2013). Many of the issues covered in the “Better Old Age” issue of Findings have already been addressed by UMRC at

ful. But there were more thought-provoking articles and comments that we felt were worth discussing among those of us in this community and, to that end, we have shared this issue of Findings with friends. Thank you!

Joann and Ralph (MD, MPH ’71) Cook Dexter, Michigan

We Can Do It! > As a former machinist at Douglas

Aircraft during the war years of the ’40s, I was so moved by the cover of the fall/winter 2013 issue of Findings. It was so good to see you recalling the women of those years who are not often celebrated, and yes, to see my gray hair peeking out from under the bandana of the machinist I was in those years. Looking through this most interesting issue, I was able to reconnect in many ways with friends and family who remember their years at Michigan so warmly.

Pearl Zeitz New York, New York The writer is the sister-in-law of the late Irving Zeitz, a graduate of U-M SPH (MS ’50). The Florence and Irving Zeitz Social Justice Internship at U-M SPH honors Irving Zeitz’s memory.

Mountaintop Removal > In the fall/winter 2013 issue of Findings,

several people comment on learning about mountaintop removal in Appalachia, and their interest in helping the efforts to fight it. One grassroots organization they can support is Coal River Mountain Watch (crmw. net). My husband and I contribute to this organization, whose workers, volunteers, and interns seem very dedicated.

Suzanne Jaworski Rhodenbaugh, MPH ’74 St. Louis, Missouri The writer is a former administrator with the Mine Workers Health and Retirement Fund.

Recent Awards The two most recent issues of Findings, “Love’s Touch” (spring/ summer 2013) and “A Better Old Age” (fall/winter 2013), each won a gold Addy award for publication design in the 2014

SPHreads

the SPH social book club

The Big Necessity by Rose George Join the fun at sph.umich.edu/sphreads Read the book & participate in weekly Facebook discussions

American Advertising Awards competition sponsored by the AAF/ Greater Flint Ad Club and the American Advertising Federation.

Connect with friends, faculty, & alumni Tweet with the author, Rose George, on June 17!

Don’t miss out! Visit sph.umich.edu/sphreads Follow the conversation with #SPHreads

We love hearing from you!

Post comments online; e-mail us at sph.findings@umich.edu; or send a letter to Findings, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109-2029; fax 734.763.5455.

Comments may be edited for length and clarity.

> ON THE HEIGHTS India: Building Partnerships Israel: A Promising Collaboration Warren Cook Remembered Art and Memory Noreen M. Clark Public Health Milestone

A Conversation with Bob Kahn

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Mr. Manners What do you do if you’re at a business lunch and you drop your napkin? Which way do you pass bread—to your left or your right? How do you hold a glass of white wine? (Answers below.) These were some of the questions Keith Soster, U-M’s food service director, addressed during a two-hour “etiquette dinner” attended by 50 SPH students last fall.

Funded in part by the SPH Dean’s Office, the sold-out event was designed to give students the confidence they’ll need on job interviews, said Shelagh Saenz, director of the SPH Office of Graduate Career Development, who organized the dinner.

During the two-hour meal, Soster offered tips on everything from introductions (“Avoid a ‘wet fish’ handshake”), to place settings, to table conversation (“Speak in low, intimate tones”). Etiquette “is really about presenting yourself in a good light,” he told the students. “When you’re in a business setting, it’s never about the food.”

Michigan Photography/Eric Bronson

Utibe Effiong, a Nigerian-born student in environmental health sciences, said the evening taught him “what to do and when to do it—that was really important. Dinner in my country is not the way it is in the U.S., so this was really useful.”

Answers: ► Don’t pick up the napkin; ask your waiter for a new one.

► Pass bread to your right. ► Grip a white wine glass by its stem, so the wine stays cool.

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> ON THE HEIGHTS

John Piette, a professor of health behavior and health education at U-M SPH and a VA Senior Research Career Scientist, has joined the U-M Center for Managing Chronic Disease as its new co-director. A global leader in innovation for chronic disease self-management support, Piette works in both the U.S. and Latin America to improve the management of such chronic conditions as diabetes, cardiovascular disease, depression, and chronic pain.

Like many of his colleagues in the center, he’s especially interested in improving care for patients with limited health care access, multiple chronic conditions, and socioeconomic vulnerabilities. n SPH Professor Arline Geronimus, a pioneering researcher who studies health stressors, has been elected a member of the Institute of Medicine of the National Academies. Best known for originating the interdisciplinary theory of “weathering,” Geronimus studies the complex influence of material, environmental, and psychosocial stressors on racial/ethnic health inequalities, from the societal to the cellular level—with implications from fetal life through old age.

In addition to her SPH appointment, she is an associate director and research professor at the Population Studies Center, U-M Institute for Social Research. n The American College of Preventive Medicine has named Eden Wells, MD, MPH ’03, a fellow of the American College of Preventive Medicine.

A clinical associate professor in the SPH Department of Epidemiology and acting director of the school’s Preventive Medicine Residency, Wells specializes in the integration of clinical and public health practice, emergency preparedness, applied epidemiology, disaster epidemiology, emerging public health threats, and preventive medicine education. n

India: Building Partnerships, Building Capacity

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ndia has many of the biggest public health challenges in the world. Clean water is in short supply, and sanitation is poor. Infant mortality rates are high, and malnutrition is pervasive. Immunization coverage is low, and tuberculosis and malaria are serious problems. India leads the world in diabetes. The list goes on and on.

“A small public health investment can go a long way in India.”

So it’s easy to understand why the U-M School of Public Health is interested in India.

If SPH is not doing research and capacitybuilding in the country, it’s missing a huge opportunity to improve global public health.

That’s why a ten-member delegation from U-M SPH spent a week in India last October.

The goals of the visit included finding ways to build on the school’s existing legacy in India by seeking out new partners and opportunities for capacity-building. The delegation spent much of its time at the Public Health Foundation of India in Delhi and the Indian Institute of Public Health–Hyderabad.

Back from left: Ritesh Mistry (health behavior, health education), Matthew Boulton (epidemiology), Victor Strecher (health behavior, health education), Andrew Jones (environmental health sciences), Trivellore Raghunathan (biostatistics), Martin Philbert (dean; environmental health sciences). Front from left: Amy Sarigiannis (staff), Sonia Hegde (doctoral student), Zoe McLaren (health management and policy), and Mousumi Banerjee (biostatistics).

U-M SPH and the Public Health Foundation of India in New Delhi signed a memorandum of understanding in 2012, and they’ve already launched a scholar exchange program and a joint-research project involving immunization programs in poor rural areas. During their talks in October, the two sides discussed how they can build on their relationship to address some of India’s biggest health issues, including problems in the health system that hinder the country’s ability to respond to its challenges.

And yet despite those challenges, India has plenty of positives. The country has a rich, diverse culture. Its population is entrepreneurial and innovative. There are vast intellectual resources waiting to be tapped.

And India is seeking partners. “A small public health investment can go a long way in India,” said Matthew Boulton, associate dean for global public health and director of the U-M SPH Office of Global Public Health.

SPH Dean Martin Philbert, who with Boulton co-led the delegation to India, said, “Ultimately our goal is to build mutually beneficial ties that will improve health in India, here in the United States, and globally.” < —William Foreman, U-M News Service

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Israel: A “Promising and Rich” Collaboration

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he School of Public Health has expanded its global public health program to include Israel, signing a memorandum of understanding in March 2014 with the Clalit Research Institute. SPH research collaborations are now percolating with the Clalit Institute, Ben Gurion University (BGU) of the Negev, and the Ministry of Health.

The idea of a partnership first took hold in July 2013 when epidemiology professor and flu expert Arnold Monto organized a group of seven SPH faculty members interested in conducting research in Israel. Led by Monto and SPH Dean Martin Philbert, the group visited Israel at the invitation of the Clalit Research Institute and Ben Gurion University. The SPH delegation met with well-respected public health organizations and individuals across the country. Israel’s Ministry of Health hosted a half-day session, providing an overview of how Israel’s health care system is organized, financed, administered, and evaluated.

At BGU, faculty met with potential collaborators and discussed mutual research interests. “A number of projects are likely to emerge from our visit,” observed Professor Marc Zimmerman, who will oversee the BGU collaboration. As a first step, Zimmerman noted that SPH is sending four student interns to BGU this summer. “We expect the internship program to grow significantly over the next several years, and to complement the research program that emerges.”

Philbert called the visit an “unmitigated success” that suggests a future of “rich and meaningful engagement.”

“Our effectiveness will only be enhanced by partnerships with the organizations we visited in much the same way that they continue to be in other regions of the world, including West and South Africa, the South American continent, China, and India,” he added.

Research ideas range from water quality to health systems research, youth violence prevention, statistical genetics, flu, and the study of Bedouin populations.

Leading officials from both the Clalit Institute and BGU have subsequently visited SPH to continue discussions about potential collaborations. Research ideas range from water quality to health systems research, youth violence prevention, statistical genetics, flu, and the study of Bedouin populations.

“What started as an idea for a flu burden study has evolved into a promising and rich collaboration,” notes Monto. “It’s a long process that will require start-up funds and initiative on both sides, but the structural pieces are coming together and that’s very promising.” < —Terri Mellow Photos by Marc Zimmerman

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At the 50thanniversary celebration of the Warren Cook Industrial Hygiene Discussional, a focus on threats to the future of the U.S. workforce.

SPH doctoral student Douglas Roehler has been named the 2013 Student of the Year by the Atlas (Advancing Transportation Leadership and Safety) Center.

Roehler, who also holds an MPH (’11) from SPH, is part of the Young Driver and Injury Prevention Group at the U-M Transportation Research Institute. As a researcher, Roehler is most interested in reducing health inequalities generally and injury prevention specifically, all through a behavioral change lens. n

Peter Smith

SPH DIGEST

Warren Cook Remembered

In the final event of the first-ever SPH student competition “Innovation in Action: Solutions to Public Health Challenges,” five teams pitched their innovations to the public—and a panel of judges—in March.

Aimed at stimulating novel solutions to real-world public health problems, the competition focused on three areas: detecting disease and risk control, empowering the underserved, and technologyenabled health and wellness. Three teams took home $2,500 cash prizes and will now work to move their ideas from concept to reality. Throughout the five-month competition, teams trained in a range of skills—from customer discovery to pitching an idea to attracting non-academic funders. Said Vic Strecher, SPH director for innovation and social entrepreneuship, “This competition represents the future of how we’ll be delivering public health around the world.” The competition was sponsored by the Northrup Grumman Corporation and donors to the SPH Innovation Fund. n

Peter Smith

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ith his pathbreaking work on occupational exposures, the late Warren Cook (1900–1992) revolutionized the field of industrial hygiene. Each year, the U-M Center for Occupational Health & Safety Engineering joins forces with U-M SPH—where Cook served on the faculty from 1953 to 1970 as the school’s first industrial hygiene professor— to honor his legacy through the Warren Cook Industrial Hygiene Discussional.

In his keynote address at last fall’s 50th anniversary celebration of the discussional, John Howard, MD, director of the National Institute for Occupational Safety and Health (NIOSH), John Howard emphasized the connections between worker health and economic health and highlighted some of the chief issues threatening the future of the U.S. workforce—including a reduction in the fraction of younger people entering the workforce and a reduction in their health status due to obesity-related diseases, asthma, and chronic obstructive lung disease.

As a staff member of the Travelers Insurance Company, Warren Cook launched the first industrial hygiene sampling and analysis program undertaken by a casualty insurance company. As early as 1926, he investigated the occupational health hazards of fireworks manufacturing—work that ultimately led fireworks manufacturers to ban the use of white phosphorus in their plants. Cook went on to help found the American Industrial Hygiene Association.

The school’s Warren A. Cook Award, given annually to a doctoral student, recognizes outstanding contributions to industrial hygiene research.

Cook’s pioneering investigation into the occupational health hazards of fireworks manufacturing led to the banning of white phosphorus in the fireworks factories.

On the Heights

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Building a Bridge Between Art and Memory

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Above: Students in the new "Memory, Aging, and Expressive Arts" course take part in an early creative exercise.

Top: A participant in the U-M Geriatrics Mild Memory Loss Program created this painting during an art session with students enrolled in the cross-disciplinary course.

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rt is the catalyst for the “Adults with and Expressive Arts.” The team connections between

received funding from the memory loss will has people.” This mantra U-M Third Century Initiative. has guided Associate Professor find that they’re By exploring different Anne Mondro in her work at the empowered facets of art and memory and U-M School of Art and Design. working directly with adults because they’re The core of Mondro’s career with memory loss, Mondro and learning somehas centered on exploring and her colleagues hope to discover establishing a link between new ways to build community thing new that health and the arts, with a reincrease quality of life they thought they and cent focus on memory loss. for people with memory loss. couldn’t do.”

Mondro posits that the arts Roberts suggests their work have immense potential to help ­—Anne Mondro may be a critical step toward those suffering from memory engaging health professionals loss by instilling confidence, reducing anxiety, directly with these important issues. He says and creating community. “Adults with memory art “is a modality that people can continue to loss will find that they’re empowered because derive benefit and meaning from even far into they’re learning something new that they their dementia. Students can get a better feel thought they couldn’t do,” she suggests. “They for what it’s like to be dealing with these issues are engaged and learning and exploring on a day-to-day basis.” The first “Memory, their imagination in new ways.”

Aging and Expressive Arts” course was With this framework in mind, offered in the winter 2014 semester.

Mondro is collaborating with U-M SPH In a separate research project, Mondro Associate Professor Scott Roberts, is working with Cathleen Connell, chair and professor of the SPH Department lecturer Beth Spencer of the School of Health Behavior and Health Edof Social Work, and Associate ucation, to examine the benefits Professor Nancy Barbas of the of art on caregivers and patients Department of Neurology, to with age-related dementia. develop a new cross-disciplinary course entitled “Memory, Aging —Rachel Ruderman

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FINDINGS

I n M emoriam

Noreen M. Clark

With husband, George Pitt (right); son, Alex Pitt; and daughter-in-law, Christine Kolosov

Peter Smith

Myra Klarman

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Reviewing construction of the new SPH building

With public health colleagues in China

Peter Smith

Scottish-born firebrand who loved fly- fishing and helped change the way we view—and manage—chronic disease, Noreen Clark lived with a passion, dignity, and grace that were nothing short of inspiring to those who knew her.

Clark, the Myron E. Wegman Distinguished University Professor of Public Health, director of the U-M Center for Managing Chronic Disease, and former dean of U-M SPH, died November 23, 2013, after a brief illness.

“I’ve always had this sense of wanting to see what’s over the horizon.”

Her legacy is global. She devoted much of her career to helping individuals, families, and communities worldwide develop the means to prevent and manage chronic disease. She was also a devoted wife and mother, a passionate reader, and an inveterate traveler who once remarked, “Maybe it’s part of being an immigrant, but I’ve always had this sense of wanting to see what’s over the horizon.”

In the weeks after her death, friends and colleagues remembered Noreen Clark through a public guest book at sph.umich. edu/noreenclark, from which the tributes on the next page are excerpted.

With U-M President Mary Sue Coleman

In Memoriam: Noreen M. Clark

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The quick wit, the incisive analyses, the bright smile. I am so glad I had a chance to meet her and see her society-changing work in action. —Lara Akinbami, Medical Officer, U. S. Centers for Disease Control and Prevention; Pediatrician, Children’s National Medical Center ••• Thank you Noreen. I will miss your bright, infectious, intelligent, and compassionate spirit. I am fortunate to have been imprinted by the power of your presence, your strength, integrity and humility. —Gillian Barclay, Vice President, Aetna Foundation

Peter Smith

My first impression of Noreen endures: a ball of energy and enthusiasm directed at relieving the burden of disease among the underserved. My fondest memory of her is her participation in a rendition of “A-A-A” (Allies Against Asthma) to the tune of “YMCA” during a grantee meeting. —Elizabeth Herman, Medical Epidemiologist, Air Pollution and Respiratory Health Branch, National Center for Environmental Health, U.S. Centers for Disease Control and Prevention ••• It was my privilege to have transferred into the Department of Health Behavior and Health Education during Noreen’s leadership.

She was, for me, a true mentor—telling me things that I may not have wanted to hear but needed to hear. She was also very supportive during challenging times. Knowing she was there for me helped me relax and enjoy the ride. —Harold “Woody” Neighbors, Professor, U-M SPH Department of Health Behavior and Health Education ••• We are deeply sad to hear that Professor Noreen M. Clark has passed away. It has been years that we have known each other and worked together. She has made tremendous contributions to China, and hundreds of thousands of asthmatic children are benefiting from her work. —Wang Tian-you, Vice President, Capital Institute of Pediatrics, Beijing ••• When asked to describe excellence in a dean, I’d simply tell people to watch Noreen. It gives me joy to remember the pleasure she took in doing so much with such focus and grace.

—Paul Courant, U-M Provost, 2002–2005 ••• I’ll always remember Noreen for the words she shared during class on one of my first days as a student in the MPH program (I had her my first semester for her Intro to HBHE course): “You don’t work in this field to make a lot of money; you work in it because you love what you do.” —Kim Riley, MPH ’91 ••• She had the gift of bringing out the best in people. —Tina Topalian, Health Science Consultant, Respiratory Diseases, Merck Corporation

I remember our dialogue about Italian grammar, your 300 books and my bookcase. Our time in Venice, a conversation in your garden about flowers and plants when we visited, and a place to buy them. Your disposition about people for a lunch/dinner around a table.

—José Di Nannini, Tarzo, Italy ••• I will miss her generous intelligence, which elevated any conversation to something more interesting without leaving anyone behind; her genuine curiosity and interest in others; and that sparkle in her eye that told you she was someone who took great pleasure in life itself.

—Alexandra Jordan, PhD student, Teachers College, Clinical Psychology, Columbia University

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She taught us that what lies behind us and what lies before us are tiny matters compared to what lies within us. Everything Noreen Clark touched she made better. —Ed Roccella, MPH ’69 ••• I love to recall Noreen’s story about one of her pleasures in life, fly fishing. She was in Wyoming, fishing from a drift boat, when the currents brought another boat alongside. Its occupants were then–Vice President Cheney and his entourage. For Noreen, the whole experience of the sport was a joy—the beauty of the water and the landscape, the camaraderie with companions, and of course, catching fish. Cheney seemed to be enjoying none of it. He was grim, and he ignored his mates as he furiously casted and casted. For hours, Noreen could see that Cheney never smiled, never talked, and never caught a fish. Her wicked sense of humor carried the day. When they parted, she waved and smiled and lifted for viewing the fine line of fish that was her catch for the day. —Jeri Sawall, Ann Arbor ••• Tears in my eyes.

A hole in my heart.

A giant, our giant, is gone.

What shoulders to stand on?

A guiding light remains.

Thoughtfulness.

Responsibility.

Persistence.

Leadership.

Creativity.

Integrity.

Humor.

Hope.

Joy. —Marc Zimmerman, Professor, U-M SPH Department of Health Behavior and Health Education <

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FINDINGS

Public Health

Milestone

Eight Million Lives Saved: Celebrating the 1964 Surgeon General’s Report

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n estimated eight million lives have been saved in the United States as a result of smoking measures that began 50 years ago this January, when then–U.S. Surgeon General Luther Terry released the first Surgeon General’s Report on Smoking and Health. The 1964 warning seen by many is Surgeon General Luther Terry as a pivotal presents the 1964 report. moment in American public health and as the opening salvo in an ongoing effort to convince people to stop smoking.

According to a Yale-led study co- authored by three U-M SPH researchers and published in the Journal of the American Medical Association, the 1964 report, and subsequent anti-smoking measures, have significantly reshaped public attitudes and behaviors concerning cigarettes and other forms of tobacco.

Using mathematical models, the researchers found that while some 17.6 million Americans have died since 1964 due to smoking-related causes, eight million lives have been saved—a number that translates into an estimated 157 million years of life.

“We carefully recreated the changes in smoking prevalence and mortality rates by gender, age, and smoking status for all U.S. birth-cohorts going back to 1864, and then explored what would have happened in the absence of tobacco control,” said co-author Rafael Meza, assistant professor of epidemiology at SPH. SPH Professor Kenneth Warner and MPH student Clare Meernik also contributed to the study.

Before releasing his 1964 report, Surgeon General Terry convened a committee of specialists who reviewed some 7,000 scientific articles and worked with more than 150 consultants to formulate the report’s findings. Years after its publication, Terry referred to the report’s release as a “bombshell.” <

Public Health Leaders Call for Renewed Push Against Tobacco Use

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uring a media briefing at the National Press Club in Washington, D.C., to mark the 50th anniversary of the surgeon general’s first report on smoking, leaders from eight health organizations, including U-M SPH, called for bold action in the next phase of the fight against tobacco use. They outlined three goals:

► Reduce smoking rates to ten percent (current prevalence is around 20 percent) in ten years or less (“10 in 10”)

► Eliminate exposure to second-hand smoke in five years

► Put the United States on a path to eliminate death and disease caused by tobacco, which currently results in one of every five deaths

“It has taken us 50 years to cut the prevalence of smoking by just over half.”

Despite the success of various campaigns and programs that started after the original report was issued in 1964, health officials say an estimated 44 million Americans still smoke—about 20 percent of the U.S. population.

“Tobacco control has been an unparalleled public health success story, and yet the remaining burden is sobering,” Kenneth Warner, Avedis Donabedian Distinguished University Professor of Public Health at U-M, told reporters. “It has taken us 50 years to cut the prevalence of smoking by just over half.

None of the organizations here wants to return in another 50 years to a job not done.”

Michael Terry, son of the author of the first report, former Surgeon General Luther Terry, said that even with the celebration of progress at the 50-year mark, his father might not be satisfied with where the nation stands. “He would be disappointed. He would be saying: ‘What have we been doing?’”—Laurel Thomas Gnagey, Michigan News For more on recent developments in tobacco control, see page 40. <

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It h a s b e e n c om pa r e d t o a r i v e r , a book, an onion, a balloon. Over the centuries, people have believed it served as a cooling agent for the heart, as a repository of common sense, as the seat of the animal soul. Its tissues have been dissected, injected with wax, put under a microscope, exposed to X-rays and magnetic resonance imaging. Among those who have pondered its mysteries are Aristotle, Galen of Pergamum, Leonardo da Vinci, Descartes, Christopher Wren, Charlotte Top: A portion of a NASA Landsat 7 image of the Lena River delta in Siberia

Perkins Gilman, and the American novelist Peter De Vries, who termed the brain â&#x20AC;&#x153;a device to keep the ears from grating on one another.â&#x20AC;? It can be picked, beaten, racked, stormed, washed, teased, drained. Its nicknames include gray matter, noggin, between the ears, noodle.

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Without it, who are we?

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The Mind

of a

Scientist What sets someone like physicist Richard Feynman apart from the rest of us?

Hint: It has to do with intuition.

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The Mind of a Scientist

by Eileen Pollack

ost nonphysicists were introduced to Richard Feynman’s unique brand of intuitive, gut-level science during the 1986 hearings to investigate the explosion of the space shuttle Challenger. After days of debate as to whether cold weather might have caused the shuttle’s rubber O-rings to lose resiliency, Feynman ended the argument by dropping an O-ring in a glass of ice water and telling the commission, “I took this stuff that I got out of your seal and I put it in ice water, and I discovered that when you put some pressure on it for a while and then undo it, it doesn’t stretch back. … I believe that has some significance for our problem.”

But even when I was an undergraduate studying physics at Yale in the 1970s, Feynman was larger than life—the prankster who had spooked his fellow scientists at Los Alamos by guessing the combination of the safe that held the secrets to the atomic bomb; the last living link to Einstein, who had attended Feynman’s first lecture, while Feynman was a graduate student at Princeton; the winner of a Nobel Prize for his theory of Quantum Electrodynamics; and the inventor of a stunningly simple set of diagrams that allow physicists to keep track of the complex interactions among particles and antiparticles in space-time. Rangy, tousle-headed, iconoclastic, Feynman exuded what passed for cool among physicists of the era—he played the bongos, was an unabashed devotee of topless bars, and had the perfect excuse for his womanizing in the tragic death of his teenage sweetheart, who had succumbed to tuberculosis while her young husband was saving the free world at Los Alamos.

When I failed my first physics midterm and my professor advised that I “sit down and study Feynman,” he was referring to the three red volumes that contained the intro-

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ductory lectures Feynman had delivered at Caltech in the sixties. The first page of each book displays a photo of the Great Man Himself, so every time I sat down to read The Feynman Lectures on Physics, I was reminded of what a real physicist should look like, his face hawklike in intelligence, everything about his demeanor vibrant and energetic, his hands moving so fast you could almost see the sound waves rising from the drums.

A female student sitting down to read the Lectures had a hard time putting herself in the shoes of the brash, bongo-playing womanizer who had written them. But that was what the lectures really were about.

Feynman’s goal wasn’t to teach you this or that physical law—only a fool would attempt to memorize all the laws of physics. What the author of the Lectures wanted to teach was how to be Richard Feynman. The difference between reading an ordinary physics textbook and reading Feynman was the difference between taking lessons at an Arthur Murray studio and hanging around while Rudolph Nureyev choreographed a new ballet. he comparison to Nureyev isn’t farfetched. According to his biographer, James Gleick, colleagues who watched Feynman concentrate on a problem “came away with a strong, even disturbing sense of the physicality of the process, as though his brain did not stop with the gray matter but extended through every muscle in his body.” Once, when Feynman was an undergrad at Cornell, a classmate came in and saw him rolling around on the floor, which was Feynman’s way of doing his homework. For Feynman, the elements of nature “interacted with palpable, variegated, fluttering rhythms.”

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Colleagues who watched Feynman concentrate on a problem “came away with a strong, even disturbing sense of the physicality of the process, as though his brain did not stop with the gray matter but extended through every muscle in his body.”

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What usually came first for Feynman was the image, the dance.

Only after he had gotten the picture clear in his head did he attempt to communicate his intuition via math.

This was what a male classmate had tried to tell me when I confessed that I was foundering. When confronted with a problem, this student said, you shouldn’t just plug the data into some equation. Rather, you should close your eyes and visualize the objects in the problem moving and interacting.

What usually came first for Feynman was the image, the dance. Only after he had gotten the picture clear in his head did he attempt to communicate his intuition via math. n a slim volume called Feynman’s Tips on Physics, which is basically a transcript of the review sessions that Feynman held for the students who were failing his course at Caltech, he attempts to convey what it means to use physical intuition to solve a problem. The examples Feynman offers are so effective that even if you flunked general science in high school, you can appreciate what he’s doing. (If you flunked general science and ended up working as a carpenter, you will have exactly the sort of physical intuition Feynman is trying to impart.)

Imagine you are faced with a concrete block supported on top of two steel rods that are arranged in a giant inverted V. Each rod has a roller at the bottom, so the block moves up or down as the rods roll closer or farther apart. Now think about the ways the block distributes its weight through the rods to the rollers. Anyone knows that if you shove the rollers closer to each other, so the block is way up high, a lot of the force will be exerted downward on the rods, with very little force exerted sideways.

“If you can’t see it,” Feynman says, “it’s hard to explain why—but if you try to hold something up with a ladder, say, and you get the ladder directly under the thing, it’s easy to keep the ladder from sliding out. But if the ladder is leaning way waaaaay out, so that the far end of the ladder is only a very tiny distance from the ground, you’ll find a nearly infinite horizontal force is required to hold the thing up at a very slight angle. Now, all these things you can feel. You don’t have to feel them; you can work them out by making diagrams and calculations, but as problems

get more and more difficult, and as you try to understand nature in more and more complicated situations, the more you can guess at, feel, and understand without actually calculating, the much better off you are!”

The funny thing is that even though I had never worked construction and would have been doubly lacking in confidence as the only woman in the class Feynman was teaching at Caltech, I did have some of the intuition he was attempting to impart. I would have had a lot more of that intuition if I had grown up building tree houses and tinkering with car engines, or if I had been allowed to take shop in junior high instead of home economics. But even I could have told you where you needed to push to keep that ladder from collapsing. What I didn’t have was the courage to trust my intuition. ven though women are commonly assumed to be more intuitive than men, when it comes to physics and math, they are, on the whole, far less likely than men to trust that intuition. Whenever I thought of a question, I assumed that the answer must be obvious, or that someone had already solved it, and that if someone hadn’t solved it, who was I to think I could?

This was the real lesson I wish I had learned from Feynman: if a question puzzled me, it must be important, and I had—or could develop—the intuition and skill to come up with an answer. Being baffled by the same questions that baffled a Nobel Prize winner doesn’t make a young physics student a genius. But it is a sure sign that the student is thinking creatively—and that she has what it takes to become a scientist. < Eileen Pollack is a professor of creative writing at the University of Michigan and the author of numerous works of fiction and nonfiction, including the novel Breaking and Entering. This essay is adapted from her forthcoming book, Approaching Infinity: A Memoir about Women in Science. Pollack’s essay “Why Are There Still So Few Women in Science?” appeared in the October 3, 2013, issue of The New York Times Magazine.

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Fa n t a s t i c Voya g e A 21st-century journey into the brain It is what lies between the circuitry and the actions that remains elusive.

How do cells and synapses come together in an integrated fashion to represent a memory, to form organized speech, or to experience a perception? How do genes and the environment shape the developing brain? What goes wrong to then cause the hundreds of diseases that affect the nervous system, including Alzheimer’s disease and stroke? And, most importantly, how do we use what we have learned to improve health throughout life?

With the help of insightful investigators from multiple fields­—key among them public health—we can begin to understand what triggers disease and/or drives its progression, and why some individuals are more vulnerable to certain diseases than others. The abundance of new information at our fingertips is daunting. But it also represents huge promise, as these studies by U-M SPH researchers show. —Kristen Gibson, MPH ’14

We have come a long way since ancient Egyptians believed the heart was the seat of thinking and mental functions—or since the Neolithic Era, when trephination (the process of drilling holes in the human skull) was a commonplace treatment for seizures, migraines, and mental health disorders.

Thanks in large part to advances in imaging techniques, we now have substantive knowledge of how the human brain is organized anatomically and functionally. The amygdala, for example, located deep within the temporal lobe, performs a primary role in the processing of memory and emotions.

Wernicke’s area and Broca’s area, each located in the cerebral cortex, guide our understanding and use of language. Additionally, the development of amazing new techniques such as “brainbow,” which enables researchers to identify individual neurons and trace their activity over time, has expanded our knowledge and understanding of the brain at a cellular level.

This vase-shaped symbol represents ieb, or the heart, which the ancient Egyptians believed was the source of wisdom, emotions, memory, personality, and the soul.

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The ThreePound Giant The average human brain weighs less than a bag of sugar. But as new public research reveals, the tiny powerhouse inside our skulls has a huge impact on our health and well-being.

Better Management of Brain Tumor Treatments

Biostatistician Tim Johnson and a team of researchers in the U-M Department of Radiology are analyzing MRI measures in an effort to find quicker ways to determine the efficacy of chemo- and radiation therapies in battling high-grade gliomas, a type of brain tumor. Currently, it takes months to know if a given therapy is working. Johnson and his colleagues hope to speed up that process so that physicians and patients can have results within weeks, not months. It’s potentially life-saving research, Johnson notes, because the sooner physicians know a treatment is not working, the sooner they can alter an existing therapy or introduce a new one.

MS: A Better Understanding

A chronic, often disabling disease, multiple sclerosis attacks the body’s nervous system by damaging nerve fibers and their protective coating. Symptoms can be as mild as numbness or as severe as paralysis or vision loss, and vary depending on the disease subtype. Typically, people with MS must wait months or years before knowing their subtype—but biostatistician Tim Johnson and a team of neuroradiologists hope to change that. By analyzing MRI data from people who have MS and correlating those images with outcomes from two primary functional tests, Johnson and his colleagues hope to find ways to predict MS subtypes so that newly diagnosed individuals know what to expect and can plan accordingly.

Targeted Nanotherapy

Chemo- and radiation therapies attack—and damage—both cancerous and noncancerous cells. But what if a therapy could target cancerous cells only? SPH toxicologist Martin Philbert and U-M’s Raoul Kopelman are developing a nanotherapy consisting of “smart” polymer nanoparticles, or bubbles, that exclusively target cancerous brain tumors in rats. When the solution is injected into the bloodstream, the polymer bubbles bond with the tumors. The scientists then illuminate the tumors with a laser guide. “Within ten minutes all of the cells in the tumor are dead or dying,” Philbert says. “And because the polymer solution is biodegradable, it disappears within hours.”

The nanotherapy has been shown to be effective with cancer cells that don’t respond to conventional therapies. To date Philbert and Kopelman have tested their nanotherapy exclusively on rats; the next step will be clinical trials.

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Strokes and Disparities

Through a large population-based study of stroke in south Texas, SPH epidemiologist Lynda Lisabeth is endeavoring to find out why Mexican Americans have higher stroke rates than their non-Hispanic white neighbors. Her recent findings show that even though stroke risk is decreasing in both populations, disparities persist. PhD student Jeffrey Wing is working with Lisabeth to examine potential links between air pollution and stroke risk in both populations. Wing says his findings to date are “suggestive of an association,” and he wants to know whether that association is stronger among Mexican Americans, who may be more susceptible to the effects of air pollution— including particulate matter emitted by nearby oil refineries.

W See the video “A Brief Guide to Your Brain” at sph.umich.edu/findings.

Your Brain on Values

Can core values motivate physical activity?

Through a collaborative study led by Emily Falk, assistant professor of communication at the University of Pennsylvania, SPH Professor Victor Strecher and a team of researchers are analyzing brain imagery from individuals who recite their core values while undergoing an MRI. These individuals then participate in a physical activity program. By measuring their physical activity and comparing those measurements to the MRI images, the researchers hope to determine how values motivate physical behavior. Preliminary findings indicate a strong connection. “We’re finding that when people recite their core values, it hits a certain reward center in the brain,” Strecher explains. “That center is a very motivating center—so it stimulates physical activity.”

ALS and Pesticides

Stress, Brain Function, and Obesity

The most common motor neuron disease in the U.S., amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease) is a debilitating, ultimately fatal disease. ALS causes motor neurons to degenerate, which leads to muscle weakness and atrophy. SPH Professor Stuart Batterman is conducting a case-control study aimed at confirming an association between ALS and pesticide exposure. “Our study suggests a linkage between past occupational exposure to pesticides and the development of ALS,” he explains. “This linkage has been shown for exposures as far back as 30 years before diagnosis.” Using data from U-M’s ALS Clinic, the researchers are analyzing blood samples for biomarkers of exposure to pesticides, testing for a newly discovered gene that is associated with a small fraction of ALS cases, and examining questionnaires from study participants. If he and his team can confirm the linkage between pesticide exposure and ALS, Batterman says it will provide “one more reason to reduce exposures or reduce the toxicity of chemicals such as pesticides.”

Early-life stressors can impair long-term brain function, says Alison Miller, who studies the impact of chronic stress on child development and obesity. “If you don’t have a chance to recover from early stressors, your ability to plan and think ahead is less likely to be well developed.” In children who’ve undergone long periods of stress without recovery, Miller and her team have found atypical levels of the hormone cortisol—which is released in response to stress. These same children show higher levels of obesity. Miller theorizes that over time, their biobehavioral stress response becomes “blunted.” She’s working to develop interventions to counteract negative social and environmental factors in children’s lives. “The brain continues to be plastic throughout the lifecourse,” she says. “Even though it may be more difficult to change things later on, it’s possible.”

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FINDINGS

By Sara Talpos

beginning the

conversation

Right: Scenes from the inkblots video â&#x20AC;&#x153;Trapped.â&#x20AC;?

Too few college students get help for depression.

Blake Wagner is seeking to change that.

Beginning the Conversation

“Have you ever felt trapped?”

Blake Wagner III poses this question five seconds into a short video from his inkblots series. He is a young man with a messenger bag stepping onto an elevator, pushing the button to floor two. Coffee in hand, he might be going to school or work. The elevator begins its ascent, then stops suddenly.

In voiceover, Wagner begins to list a series of recent events in his life: the worsening of his grandfather’s dementia, a spinal cord injury, a breakup with his girlfriend, the death of his mother. Images of beloved people and

To date, he has completed videos on topics as varied as self-esteem, interpersonal relationships, and academic stress. His goal with the series is to encourage a more open conversation among college students about mental health.

As a young boy growing up in Mansfield, Ohio, Wagner enjoyed spending time with his parents and two younger brothers, camping on the weekends and taking a yearly trip to Cape Cod. He was 19 and attending college when his mother was diagnosed with cancer.

During her illness, Wagner struggled with his

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effective treatments are available. A study1 in the November 2006 issue of the American Journal of Psychiatry reported that 67 percent of adults with major depressive disorder experienced full remission through medication and/or therapy. Health professionals maintain that for adolescents and young adults, successful outcomes may be even higher.

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ohn Greden, MD, executive director of the U-M Comprehensive Depression Center, states that peak ages of onset for depressive and bipolar illnesses are between the ages of

“I felt at times like ending my life, so that I could end my suffering.”

places intertwine with images of Wagner— drinking, crying, and lying in bed alone.

Two minutes and ten seconds into the film, he states flatly, “I felt at times like ending my life, so that I could end my suffering.”

Sitting now, several years later, in the Glass House Café at the University of Michigan School of Public Health, sunlight streaming through the windows, Wagner pauses, trying to string together the exact sequence of events leading up to his diagnosis of depression: “That’s such a blurry time,” he explains.

In many respects, the Wagner sitting in the café seems far removed from the young man in his video “Trapped.” Currently a research assistant at SPH, Wagner works as part of a research team developing a series of videos collectively known as inkblots.

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emotions. “It was hard to disentangle depression from grieving,” he says. “It’s just something that persisted and intensified. It was very physiological for me. I felt completely hollow and numb, and I couldn’t find pleasure in anything that I used to find pleasure in.”

While he was close with his parents, he found it difficult to talk about his feelings of hopelessness. Speaking about his father, he says, “I worried what he might think, and I didn’t want to add to his plate.”

Wagner’s experience with a mental health disorder is not uncommon. In high-income countries such as the U.S., mental disorders account for almost half of the total burden of disease for adolescents and young adults.

These conditions are connected with school dropout, suicide, violence, and substance abuse. Among college students in particular, suicide is a leading cause of death. Fortunately,

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15 and 24. He believes that screening for and treating these disorders during the adolescent years is “vitally important” because “the earlier that these illnesses are found, the more treatable they are.” He explains that “untreated, they just get episodic, recurrent, and progressively worse.”

Greden argues against the practice of watchful waiting: postponing treatment to see whether a person’s symptoms go away over time. Instead, he advocates for an early and vigorous approach. “Almost always, major illnesses are best treated in their early stages,” he explains. He cites diabetes as an example where early intervention can mitigate a disease’s potential long-term effects.

1. Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163;1905-1917.

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But despite the benefits of early intervention, many college students with mental illness do not receive treatment, according to findings by Daniel Eisenberg, associate professor of health management and policy. In 2005, Eisenberg initiated the Healthy Minds Study, a web-based survey of college student mental health. The first survey, distributed to a random sample of U-M students, screened for depressive and anxiety disorders. Remarkably, of students with positive screens, the proportion who did not receive services ranged from 37 to 84 percent, depending on the disorder.

“Since then, we’ve found that the numbers for U-M are generally in the middle of the range when compared with other colleges and universities,” says Eisenberg, citing data from his ongoing survey work, which expanded nationally in 2007 and has reached over one hundred colleges and universities across the country.

Eisenberg’s study has identified a range of reasons for students’ not using services. In the initial report on U-M students, the most frequently identified reason was “stress is normal in college/graduate school.” Other reasons included the belief that the problem would get better without treatment, lack of time, and concern about what others might think.

Wagner mentions some of these findings when explaining his own reluctance to get help: “I prefer to deal with things on my own. I don’t feel like my symptoms are severe enough. Oh—” Wagner leans forward:

“Not having enough time was a big one.” He elaborates: “It’s a really important piece.

If you’re depressed, everything becomes more difficult,” including figuring out how to balance therapy with other obligations.

The inkblots series aims to address some of these concerns by engaging students who might benefit from mental health services.

Eisenberg is the principal investigator for the grant-funded inkblots project with Wagner acting as a co-investigator, leading the development and production of the videos. Rebecca Lindsay, MPH ’11, serves as study coordinator.

Their team is multidisciplinary, employing researchers with expertise in areas such as mental health, information sciences, and social media.

At the heart of the inkblots project is sharing stories. As Wagner knows, part of depression is having a story to tell, a powerful one—and fearing the telling of it.

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wo minutes and sixteen seconds into “Trapped,” we are introduced to Wagner’s roommate “Joe,” who finds Wagner unconscious in the bathroom. The images are not pretty. Joe crouches, lifting his roommate, moving him to the bedroom. Wagner lies in bed and Joe offers him food, his hand hovering above a half-empty bottle of liquor on the nightstand. Though Joe has only known Wagner a couple of months, he recognizes the signs of depression and encourages Wagner to get help.

In conversation today, Wagner explains that his roommate sensed something was wrong and expressed his concerns. “I’m here for you if you want to talk,” he told Wagner, adding that he had himself sought help from a therapist in the past. This conversation persuaded Wagner to do the same: “If he could do it, then I could do it.”

Beginning the Conversation

After rebounding from what he describes as “that dark place,” Wagner began sharing his story in conversations with others. He was amazed by how many people then came forward with their own struggles. They often expressed feelings of isolation, “as if they were the only ones in the world” experiencing the symptoms of anxiety and depression. Speaking about young adults in particular, Wagner says, “We need to start the conversation on mental health because I don’t see or hear it.”

After his mother’s death in 2011, Wagner was diagnosed with depression and prescribed

convenient, confidential, and anonymous.

Wagner acknowledges that there’s a lot of great self-help material out there in bookstores. Yet, for the younger generation—particularly busy students who already struggle to balance classes and jobs—the effort to find the right book can feel overwhelming. “We need answers, like now,” he says, paraphrasing the findings. With this in mind, Wagner set out to create online videos that meet the specific needs of college students.

In 2013, Wagner and his father submitted a proposal to give a presentation on their

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just really relate to that on a personal level.”

In particular, she appreciated how the videos seek to de-stigmatize asking for help. “It’s very un-American to ask for help,” she comments. “I certainly was raised that way with perfectionist tendencies.”

In addition to student endorsements, the inkblots team has garnered praise from outside experts, among them Harvard Medical School’s Paola Pedrelli, director of dual diagnoses research in the Depression Clinical Research Program, who says the videos deliver “self-help skills in a format that resonates

Peak ages of onset for depressive and bipolar illnesses are between the ages of 15 and 24.

an antidepressant, which took “about seven or eight weeks to kick in,” he remembers. Therapy helped, too. “There’s just no question.” Although he worried that his father would respond negatively to the news, Wagner shared his diagnosis with his father, a clinical psychologist at Ohio State, Mansfield. But his father seemed proud of his son for seeking help. Wagner was so surprised by this response that he initially found himself wondering, “You really don’t think I’m a weak person? You’re not concerned?”

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agner and his father, Blake Wagner Jr., had already worked together on mental-health related videos prior to his mother’s illness. In 2011, they teamed up again, conducting student focus groups at several colleges. The goal was to determine what kind of mental health information students most want. Five characteristics emerged. Students want material that is engaging, relevant,

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work at the Depression on College Campuses Conference, sponsored by the U-M Depression Center in partnership with U-M schools and colleges. Eisenberg, who helps organize the annual conference, wanted to promote intervention research, so he invited the Wagners to be part of the closing panel discussion. A couple of months later, Eisenberg asked Blake Wagner III to join the research staff of the Healthy Minds Network.

A unique aspect of the inkblots project is the ongoing use of student focus groups to evaluate the videos’ content, style, and length. Students comment positively on the videos’ goals and approach. “It’s fun because it’s creative,” said one student, adding that the films are informational but “not especially pedantic, which I like.” Another focus group member shared that she has been in recovery for addiction for over three years.

Commenting on “Trapped,” she said, “I could

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greatly with young people” and may reduce stigma and lower barriers to treatment. The inkblots team has also received funding support from the U-M Depression Center, the Blue Cross Blue Shield of Michigan Foundation, the U-M Injury Center, and U-M’s Global Challenges for the Third Century Initiative, which supports nontraditional, multidisciplinary research projects that directly engage the community.

The project’s multidisciplinary approach is evidenced by the videos themselves, which are influenced not just by the latest health research, but also by the humanities.

Early in the project, William Del Rosario was recruited as cinematographer. A graduate of the University of Southern California’s film school, he describes his approach: “It’s really about storytelling.” Many of the films employ metaphor: the closed elevator doors, fireflies, even Mr. Potato Head. (This last

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The Healthy Minds Network An outgrowth of the Healthy Minds survey study, which began in 2005, the U-M–based Healthy Minds Network for Research on Adolescent and Young Adult Mental Health is devoted to improving the mental and emotional well-being of young people through multidisciplinary scholarship. The network now extends to over a hundred institutions nationwide and includes scholars in a range of disciplines, including public health, education, medicine, psychology, and information sciences. Many scholars are affiliates of the U-M Comprehensive Depression Center. The network serves as a resource for secondary and higher education administrators, researchers, clinicians, policymakers, and the public. Individual research projects include The Healthy Minds Study, The Healthy Bodies Study, and inkblots.

one comes from Wagner’s girlfriend, who explained that dating him was “like being in a relationship with Mr. Potato Head.”) Del Rosario suggests that unlike more traditional mental health materials, the films’ creative qualities engage viewers’ emotions, which can encourage self-reflection.

The videos are also informed by relevant scholarly literature. The coping skills and constructs like radical acceptance have an evidence base behind them, largely drawn from the field of cognitive behavioral therapy, or CBT, which combines cognitive strategies

By the Numbers: The Healthy Minds Study

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Percentage of college students who screen positive for major depression

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Percentage of college students who screen positive for eating disorders

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Percentage of college students who received mental health services in the past year

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Percentage of college students with an apparent mental health problem (depression, anxiety, suicidal ideation, self-injury)

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Percentage of college students who screen positive for eating disorders who are not receiving treatment

with behavioral changes and can be applied to the wide range of issues that students face­­­—including stress, interpersonal conflict, self-esteem, and perfectionism. Eisenberg notes that “CBT is one of the most evidencebased modes of talk therapy in mental health.”

When Wagner and Del Rosario describe their work, they speak with excitement, even playfulness. They often work on several scripts at once, and while “Trapped” has a decidedly serious tone, some of the other inkblots videos incorporate humor. This is reflected in their weekend to-do list for upcoming videos: Film a man driving down a country road in a dinosaur costume. Find and film a squirrel who will (somehow) teach a coping skill. Organize a mock Halloween party with kids wearing costumes and parents dressed in marathon gear.

These images make heavier emotional issues seem approachable, even surmountable.

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owards the end of “Trapped,” after Wagner has begun therapy—after the elevator doors have re-opened—images of Wagner’s mother appear from old home movies. Twirling in a pink dress, she smiles as her eyes meet the camera. In voiceover, her son says, “My amazing mother, despite being riddled with cancer, was able to find joy in each day. She often reminded me and my brothers that the present is perfect, even if it doesn’t look or feel that way.” Wagner stands in a forest clearing, breathing deeply.

For all of their emphasis on speed and convenience, the inkblots videos stop short of promising a quick-fix for mental health issues. Therapy emerges as a recurring theme, and the coping skills depicted in the videos could be cultivated over a lifetime. Eisenberg notes that, “in general, we see the videos not just as stand-alone interventions but also as a kind of hook into something more.”

Wagner, too, continues to treat his depression. When he moved to Ann Arbor in early 2013, he found a new therapist. “You spill your guts out—again,” he says, laughing.

Overall, though, he describes this transition as easier than he thought it would be.

Back in the Glass House Café, Wagner returns to the topic of his mother, whose character he has incorporated into several videos. “It’s really incredible to think that she’s continuing to affect people and have an impact,” he says, referring to her ability to embrace the present, even while facing death. He shakes his head. “It’s amazing, the birthing of this project, and how far we’ve come in such a short period of time—how many people we can potentially reach.” < Sara Talpos is a writer based in Ann Arbor. She holds an MFA in creative writing from U-M.

A Conversation Bob Kahn Beginning thewith Conversation

Photos: Peter Smith

Healthy Minds: This Generation and the Next

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SPH graduates Sara Abelson, Sheila Krishnan, and Stephanie Salazar have all worked with Associate Professor Daniel Eisenberg and the Healthy Minds Network and are now furthering that work through public health careers in mental health. An update: Sara Abelson, MPH ’08 Senior Director of Programs, 2008–present Active Minds

Sheila Krishnan, MPH ’08 Campus Prevention Specialist, 2011–present Suicide Prevention Resource Center

Stephanie Salazar, MPH ’08 Program Coordinator for Outreach and Education, 2008–present U-M Comprehensive Depression Center

Sara Abelson, senior director of programs at the national nonprofit Active Minds, develops strategies and partnerships aimed at transforming the way college campuses support student mental health. Active Minds’ peer-to-peer programming is based on data from the U-M Healthy Minds Network showing that distressed students turn to each other before turning to professionals or parents. “We work to ensure that students are educated about the signs and symptoms of mental health disorders and empowered to promote help-seeking without shame or stigma,” Abelson says, noting that today’s students are also “the teachers, parents, policymakers and presidents of tomorrow.”

Abelson oversees a network of more than 400 student-led chapters across the U.S.and a dozen nationally acclaimed programs, including:

Funded by the Substance Abuse and Mental Health Services Administration of the Department of Health and Human Services, the nationwide Suicide Prevention Resource Center promotes “a public health approach to suicide prevention.” As one of the organization’s campus prevention specialists, Sheila Krishnan works primarily with colleges and universities to develop and implement programs to heighten student awareness of mental health issues, boost coping skills, and ultimately prevent suicide. Some of the most common strategies used by campuses she’s worked with include:

As program coordinator for outreach and education at U-M’s Comprehensive Depression Center, Stephanie Salazar has helped develop and run a Peer-to-Peer Program in nine public high schools in Washtenaw County, education and support groups on the U-M campus, a quarterly Bright Nights Community Forum held in local libraries, and an annual Depression on College Campuses conference.

These and other initiatives all have a similar aim: to deepen young people’s understanding of depression and related illnesses, foster education and support groups, and impart the skills young adults need to lower stress and anxiety and reduce depression. Evaluations show that students participating in these programs have a better understanding of depression and feel more comfortable recognizing and reaching out to peers who may need help. Salazar and her colleagues are now disseminating their programs to other U.S. colleges and high schools.

► Send Silence Packing (a traveling suicideprevention exhibit) ► National Day Without Stigma (an awareness campaign) ► The Active Minds Speakers Bureau (firsthand stories of resilience and recovery from young adults) For more: activeminds.org

► Implementation of screening programs (on-campus or online) ► Gatekeeper training (to educate faculty, staff, student leaders, and others on the warning signs and risk and protective factors for suicide, and how to approach at-risk students and refer them for help) ► Communications and social media campaigns ► Programs designed to promote connectedness and positive personal relationships For more: samhsa.gov; sprc.org

Four Top Reasons College Students Don’t Seek Help for Mental Health Problems

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I prefer to deal with issues on my own.

I question how serious my needs are.

Stress is normal in college/graduate school.

I don’t have time.

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Mental health is public health.

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t’s a kind of insanity— a nearly clinical madness—not to provide for mental health needs in public health policy.

People whose mental health challenges are being handled well live richer and happier lives, so there’s a moral imperative there. But for the people who are unmoved by that argument, there is an urgent economic one to complement it. Untreated mental illness is terrifyingly costly: those living with untreated illness are more likely to manifest somatic symptoms, are less able to care for themselves, are less likely to participate in the nation’s economy, will struggle to take care of children whose own behavioral issues generate enormous expense, and may be more inclined to commit criminal acts. We ignore these populations at our collective peril.” <<

The need is huge and unmet, say experts, and we ignore it at our peril.

Andrew Solomon, PhD, author of The Noonday Demon: An Atlas of Depression (2001 National Book Award; 2002 Pulitzer Prize Finalist) and Far from the Tree: Parents, Children, and the Search for Identity (2012 National Book Critics Circle Award)

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n an editorial published at the start of 2014, New York Times columnist Nicholas Kristof argued that mental health is one of the most crucial and “systematically neglected” topics we need to address as a society.

“One-quarter of American adults suffer from a diagnosable mental disorder, including depression, anorexia, post-traumatic stress disorder and more,” Kristof wrote.

Such disorders are the leading cause of disability in the United States and Canada, he added, and pose a greater threat to our well-being than Al Qaeda terrorists. But in polite society a code of silence persists, and Kristof called on his peers in the media to do more to break the taboos surrounding mental health. He also noted the unjust burden imposed on both children and racial and ethnic minorities by untreated mental health problems.

Not two weeks after Kristof’s editorial, the New England Journal of Medicine published an editorial calling for increased global access to “evidence-based treatment and care” for people with mental disorders. “Arguably the most important reason for action is the disturbing evidence that people with mental disorders … are subject to some of the most severe human rights violations encountered in modern times,” the authors wrote.

What role can—and should—public health play in meeting this immense and largely unmet need? That’s the question we put to a range of experts. Their answers follow: Sources:

Vikram Patel, F. Med. Sci., and Shekhar Saxena, M.D., “Perspective. Transforming Lives, Enhancing Communities—Innovations in Global Mental Health,” The New England Journal of Medicine (January 15, 2014).

Brian Stauffer/iSpot.com

Nicholas Kristof, “First Up, Mental Illness. Next Topic Is Up to You,” The New York Times (January 4, 2014).

Mental Health Is Public Health

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ne issue we have to think a lot about is capacity. We have some recent

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f we think about how over 70 percent of our $2.8 trillion health care budget in the U.S. is related to chronic disease, and then we think about how

over 75 percent of chronic disease is related to our behaviors and lifestyles and the decisions we make, then you start realizing how important mental health issues are to both physical health and our economy. If public health is truly interested in the root causes of health and disease, we need to adopt a truer definition of health and pay as much attention to mental health issues as we do to physical health issues, rather than separate them as we’ve done up to now.” <

Victor Strecher, MPH ’80, PhD ’83, Professor and Director for Innovation and Social Entrepreneurship, U-M SPH; Author, On Purpose: Lessons in Life and Health from the Frog, the Dung Beetle, and Julia (2013)

Portion of chronic disease burden in U.S. related to behaviors and lifestyles

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survey data that shows that a majority of primary care physicians don’t think we have adequate capacity today for adults or children who need mental health services. And inpatient mental health services aren’t exactly places where health systems make a profit. So we have to think a lot about how much we value those services, and make sure those services are available, whether they’re good for the bottom line or not.

That’s a complicated piece—and public health is a huge part of it.” <

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FactCheck:

Mental Health Services Capacity in Michigan

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percent of Michiganders report being diagnosed with depression, as compared to 18 percent of Americans.

percent of those on Medicaid and 33 percent of the uninsured report depression and/or anxiety symptoms in Michigan.

Nancy Baum, PhD ’10, MHS, Policy Analytics Team Lead, Center for Healthcare Research & Transformation; Board Member, Washtenaw Community Health Organization

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hen I present a statistical analysis involving mental health, I like to say that mental health is the most endogenous variable ever—it is

affected by just about everything, and it affects just about everything.

If you take a narrow perspective, you are almost sure to miss something important. So a holistic, public health perspective is needed to understand the determinants and consequences of mental health, and how to improve mental health. This presents a major challenge for researchers and practitioners—understanding and influencing mental health is so complicated. The flip side, and the reason I find this area so exciting, is that there is an opportunity for collaborative public health approaches to make a major contribution to societal health and well-being.” <

Daniel Eisenberg, PhD, Associate Professor, Department of Health Management and Policy, U-M SPH

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percent of primary care physicians in Michigan report that the availability of mental health services in their community is inadequate for adults.

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percent of primary care phy- sicians in Michigan report that the availability of mental health services in their community is inadequate for children.

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is Michi- gan’s rank among the 50 states and the District of Columbia in availability of inpatient psychiatric beds.

Source: Mary Smiley; Danielle Young; Marianne Udow-Phillips; Melissa Riba; Joshua Traylor. Access to Mental Health Care in Michigan. Cover Michigan Survey 2013. December 2013. Center for Healthcare Research & Transformation.

Ann Arbor, MI.

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FINDINGS

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epression afflicts one in every six people. It’s the second costliest disorder in the United States, and according to the World Health Organization, the costliest disorder in most of the developed world. When you have something like this

If we’re going to have breakthroughs in mental health, we have to shift to an epidemiological perspective and find out where the people are who need the help. We need to recognize early onset and intervene when it can be most helpful. We need to develop biomarkers and lab tests to identify who is at risk. This is a quintessential public health problem—but it’s also a pediatrics problem, an internal medicine problem, a school and a workplace problem. This is why we need an integrative model, which is a public health model. If anything, public health people are leading the charge, saying we can do this differently.

I don’t hear much of that coming from the general health care delivery system.” < John F. Greden, MD, Rachel Upjohn Professor of Psychiatry and Clinical Neurosciences, U-M; Executive Director, U-M Comprehensive Depression Center; Founding Chair, National Network of Depression Centers

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t’s been clear to me since I began doing my early work in psychiatric epidemiology that many of the things

“The World Bank predicts that by 2020 depression will be the number one global economic burden of any disease.”

that cause emotional distress or pain are the large social factors that impinge upon people’s lives. Something as basic as exposure to stress or to stressful life events—including social problems—is an obvious precursor to what we call mental health and well-being. And those are all very much in the public health paradigm. When one thinks about prevention in public health, social stressors are some of the primary targets if you want to try to create a better sense of emotional well-being for people—especially vulnerable populations.” < Harold W. Neighbors, MA, PhD, Professor, Department of Health Behavior and Health Education, U-M SPH; Associate Director, Center for Research on Ethnicity, Culture and Health

W For a video discussion with SPH Professor Harold W. Neighbors about why mental health is public health, visit sph.umich.edu/findings.

Brian Stauffer/iSpot.com

that is prevalent, disabling, costly, and potentially lethal, you should be doing something about it. So it is a public health issue.

Study after study shows that we should be screening for depressive illnesses at the age of onset, which is typically between 15 and 24, rather than waiting for them to get progressively worse. Almost always, major medical illnesses are best treated in the early stages—look at diabetes. If you ask where a marriage between health care delivery and public health has really shined, it’s in diabetes prevention and management.

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n 2009, I had the privilege of serving on an Institute of Medicine committee that issued a report on the prevention of mental illness and problem behaviors in children, youth, and families. We found that

across the developmental span of childhood, from preconception on, there are effective interventions that can have a lifelong impact. Early in life, home nurse visitation, high-quality center-based care such as Head Start, and high-quality pediatric care make a huge difference, as do targeted interventions during the school years. Moving into adolescence, there’s good evidence we can prevent substance abuse and episodes of depression and even possibly stave off psychotic episodes and schizophrenia through community awareness and by heeding very early warnings signs, or in some cases using cognitive behavior therapy and antipsychotics.

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ne of the things we learn about in public health is that if you test for it, you

have to do something about it—you don’t just test and do nothing. With so many health care organizations now embracing the patient-centered medical-home model of care, pediatricians and primary care physicians are doing more screening. But there aren’t enough psychiatrists to go around, so we need an integrated, interdisciplinary, public-health approach to not only treatment, but above all prevention—screening, education, and outreach.” < Rosalind García-Tosi, ScD, MSW, MPH ’96, Associate Director of Administration, U-M Comprehensive Depression Center

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ed.gov

y father struggled with bipolar disorder for ten years. When he finally got the treatment he needed, he was able to lead a happy and successful life again. To help ensure

When you see so many kids already addicted to drugs or attempting suicide, you say to yourself, we have to go further upstream. We have to intervene before things become so terrible. Kids who have poor physical and mental health outcomes very often have parents who are depressed, so we can also intervene effectively to strengthen parenting. Investing dollars in prevention makes sense. There’s a lot that we could do if we include mental health in the broad public health framework. Public health needs to embrace mental health issues the way it has physical health issues.” < William Beardslee, MD, Director, Preventive Intervention Project, Judge Baker Children’s Center; Chairman Emeritus, Department of Psychiatry, Boston Children’s Hospital; Gardner-Monks Professor of Child Psychiatry, Harvard Medical School

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people get early treatment, we must reduce the stigma around mental illness and increase the funding for services in the community. That’s why I authored the ENHANCED Act to establish national centers of excellence, based on the great work already underway at the U-M Comprehensive Depression Center, to increase the focus on critical research and better treatment of depression and bipolar disorders. My Excellence in Mental Health Act would go even further to help increase the availability of treatment in communities and improve the quality of care offered.

Public health has a vital role to play in all of these efforts.” < U.S. Senator Debbie Stabenow (D–Michigan)

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irst, some of the best epi- demiologic studies say that in any one year, approximately 40 percent of the U.S. population may be affected by significant psychiatric illness— including anxiety disorders, depression and bipolar disorder, schizophrenia, and alcohol/drug abuse or addiction. The numbers are more or less the same in the rest of the developed world.

Second, access to treatment is inadequate. Even in the U.S., only about 20 percent of the people who have depression— to take just one example—receive adequate treatment. As with many illnesses, the first treatment does not necessarily produce the desired outcome. So treatment adherence and good follow-up are major needs—and both are directly linked to outcomes and costs.

Third, psychiatric illnesses like depression frequently go undiagnosed. In primary care settings, 50 percent of cases are missed.

Fourth, the

World Bank predicts that by 2020 depression will d e p r e ss i o n be the number one global economic burden of any disease.

Fifth, it’s not uncommon for patients who present to a physician or are admitted to an emergency room to have both a medical and a psychiatric problem. And when that happens, the psychiatric component of the patient’s clinical picture is generally not addressed at the same level as the medical component.

So mental health is a major health problem, which means it’s a public health problem.

But it’s not generally viewed as a public health priority, in large part because of stigma, I believe, but also because many health professionals are unaware of data like this.” < Allan Tasman, MD, Professor and Chair, Department of Psychiatry and Behavioral Sciences, University of Louisiville Medical School; Treasurer, National Network of Depression Centers; Past President, American Psychiatric Association

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s advances in U.S. public health grow and progress, it is critical that we embrace mental health conditions as matters of public health, rather than simply as clinical concerns. Just as we encourage individuals to

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nly in the last six years have international and national health organizations recognized that:

► Mental illnesses are the second largest contributor to the worldwide disease burden; ► Mental health conditions should be provided with the same out-of-pocket costs to individuals as traditional medical conditions; ► The provision of mental health services is an essential benefit under the Affordable Care Act.

Public health has always taken a lead in community education, screening for illness and at-risk behaviors, linking individuals and communities to care, helping to measure the acute and chronic disease needs of communities, and implementing short- and long-term interventions to mitigate the resulting harm. Public health has also promoted the innovative use of health information technologies for the exchange of critical data on disease and its social determinants. By viewing mental health as a key component of public health, one can see the immense potential for rapid, integrated, coordinated mental health care within the context of primary care.” < Kyle Grazier, MS, MPH, DrPH, Chair and Richard Carl Jelinek Professor of Health Services Management and Policy, Department of Health Management and Policy, U-M SPH; Professor, Department of Psychiatry, U-M Medical School

“The brain is the most complicated of all of our organs by many orders of magnitude, and we are just now getting the biological tools to allow us to interrogate it at the molecular level and to use imaging techniques to see the brain in action.”

pursue treatment for common or chronic diseases, we should advocate to change attitudes and help-seeking behaviors related to mental health—for the benefit of society as a whole.

A prime example is the U.S. Department of Veterans Affairs’ Make the Connection initiative (maketheconnection. net), a public health education campaign to connect veterans and their families with mental health information and services— and help them discover ways to live more fulfilling lives. On the website’s educational pages, veterans and civilians can learn about the types of symptoms and conditions veterans may experience, without unnecessarily labeling or stereotyping veterans.

While Make the Connection encourages veterans to reach out and overcome their life challenges, the campaign also inspires cultural change by showing all viewers that treatment is available—and it works. On both an individual and a population level, Make the Connection is designed to change perceptions about mental health treatment and is leading the charge to move beyond mental health stigma to promote health and wellness.” < Sonja V. Batten, PhD, VA Mental Health Services, U.S. Department of Veterans Affairs

Mental Health Is Public Health

Brooks Kraft © Corbis

more and more, we know that there is a significant biological component to many mental health conditions.

And yet the media and others, including many health professionals, persist in making an artificial distinction between “mental health” and “physical health.” It is time that we stop making this distinction.

Mental health parity is a step in that direction. But, until we end the way those of us who work in health care speak about these conditions, stigma related to mental illness will continue. Until we end the artificial distinction between physical and mental health, research into causes and cures will be limited, and not enough practitioners will choose to work in this field. As long as some see mental health issues as a sign of “weakness” and not a clinical condition, people most in need will not seek care. Isn’t it time for public health to lead the way in changing how we view and talk about these devastating diseases?” < Marianne Udow-Phillips, MHSA ’78, Director, Center for Healthcare Research & Transformation

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hen it comes to mental health, we’re more or less where the war on cancer was in the early 1970s. The brain

WHO’s Mental Health Action Plan

is the most complicated of all of our organs by many orders of magnitude, and we are just now getting the biological tools to allow us to interrogate it at the molecular level and to use imaging techniques to see the brain in action. So the opportunity to make progress against major psychiatric disorders is at hand. That doesn’t mean it’s going to happen quickly, but it means hard science has a beginning foothold in our field. Up to now we’ve been developing treatments by chance and learning to use them by experience, but we haven’t had a rational understanding of what goes on in the brain. Now that we’re getting that understanding, we have the potential for more rational treatment. Eventually we’ll get to prevention.

If you care about public health, you’ve got to care about mental health. As a group, psychiatric disorders cause more social and financial cost worldwide than any other group of disorders—and they’re closely related to such major causes of disability and death as heart attacks, strokes, diabetes, and Alzheimer’s disease.” <

Adopted in May 2013 by the 66th World Health Assembly, the World Health

Organization’s Comprehensive Mental Health Action Plan 2013–2020 sets new directions for mental health, among them a central role for the provision of community-based care and a greater focus on human rights. The plan’s four main objectives are:

► Strengthen effective leadership and governance for mental health ► Provide comprehensive, integrated, and responsive mental health and social care services in communitybased settings

J. Raymond DePaulo Jr., MD, Henry Phipps Professor and Director, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine; Psychiatrist-in-Chief, The Johns Hopkins Hospital

► Implement strategies for promotion and prevention in mental health

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Source: World Health Organization Comprehensive Mental Health Action Plan, adopted by the World Health Assembly, May 2013

► Strengthen information systems, evidence, and research for mental health

ith the Affordable Care Act, we’re going to see more people coming into the system. What’s it going to mean?

We’re going to need to figure out new and collaborative models of care—the idea of a therapist sitting with an individual patient may no longer be the norm.

Public health could help us make the shift to a more population- and preventionbased approach to mental health.” <

Michelle Riba, MD, Professor of Psychiatry and Associate Chair, Integrated Medical and Psychiatric Services, U-M Department of Psychiatry; Past President, American Psychiatric Association

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e know that those who suffer from mental health issues have high rates of co-morbid conditions, such as cardiac disease, and are high utilizers of the medical care delivery system. And,

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The negative impacts of natural disasters on the mental health of survivors are significant and lasting.

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The Human Mind: M e n t a l H e a l t h

Man Down While he was developing “Man Up, Man Down,” an intervention aimed, in part, at helping African-American men address the stigma associated with depression, Harold “Woody” Neighbors became a “man down” himself.

Unmoored by the death of his daughter Kamilah (MPH ’01) in 2010, Neighbors “felt down and out— totally devastated,” as he puts it. “At first I didn’t think I needed help. But I couldn’t deny my symptoms. I began asking myself, Neighbors ‘Who can I talk to?

Where do I go for help? More importantly, how do I start to reveal to other people that I’m in trouble here?’”

As a researcher, he found himself in the curious position of living the “Man Up, Man Down” experience while listening to other black men talk about their experiences with depression. Neighbors drew strength from his own intervention, as well as from family and friends. He also got professional help. “My story has an optimistic, positive end to it,” he says. “I am still profoundly sad, but I am also stronger in some ways.”

The overall experience deepened his commitment to his research. “This work is so much about taking the very private experience of emotional pain and making it public, which makes it social in addition to being personal,” he says. “This is a great way for men to get the help we deserve.

It is unhealthy for us to ‘man up’ to everything. It’s also the way for men to change our characterization as hard-to-reach and underserved.” <

“We’d worried about stigma, but these men didn’t mind coming into this kind of setting, sitting around a table with six to seven other guys, guys and talking.”

A Depression Study Yields Surprises S

everal years ago, Harold “Woody” Neighbors undertook a qualitative

study of depression among black men in four urban settings in the U.S.—Detroit, Raleigh, Atlanta, and Baltimore. The study, called “Man Up, Man Down” (drawn from the phrase “man up,” meaning “don’t complain—just handle your business”), consisted primarily of focus groups in which participants examined their understanding and experience of and with depression.

Findings from the research were striking, says Neighbors, a professor of health behavior and health education and associate director of the U-M Center for Research on Ethnicity, Culture and Health. Not only did Neighbors and his team encounter few problems in enrolling men for the focus groups, but at the end of the study, many participants expressed a desire for the focus groups to continue.

“We’d worried about stigma,” Neighbors recalls, “but these men didn’t mind coming

into this kind of setting, sitting around a table with six to seven other guys, and talking.”

Inspired by his findings, Neighbors immediately sought funding to create a pilot intervention program to address depression among African-American men in Detroit. In partnership with the Detroit Recovery Project and its CEO, André Johnson, Neighbors and his research team are now embarking on that study—an eight-week series of weekly support groups in which participants discuss depression and its impact. Discussion topics include terminology and definitions, symptoms, treatment options, masculinity, social isolation, and issues such as anger and its role in depression.

As interventions go, says Neighbors, “it’s not very expensive. So if we can obtain evidence that the program is a cost-effective way of helping black men feel better, we plan to replicate it in different community centers throughout Detroit.” <

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The Human Mind: M e n t a l H e a l t h Mobile Health Technology in Bolivia

From the Depths of Despair, a Public Health Breakthrough

Matt Phipps

Few resources exist in low- and middle– income countries to help people with depression. But John Piette, codirector of the U-M Center for Managing Chronic Disease, and Mary Janevic, assistant research scientist, are using mobile-health interventions, including an “Interactive Voice Response” telephone system, to provide both self-care support to people with depression and feedback about patients’ needs to community health workers.

Piette and Janevic are currently working with SPH students to introduce this new health technology in Bolivia.

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fter the death of his daughter Julia in 2010, Victor Strecher “essentially lost my own purpose in life,” as he puts it. In an effort to transcend his grief, he began reading what other thinkers—ancient philosophers as well as modern scientists—had to say about purpose. One of those was the Austrian neurologist and psychiatrist Victor Frankl, whose Man’s Search for Meaning recounts Frankl’s experience as a Holocaust survivor and outlines his concept of “logo” or “meaning” therapy. Strecher found Frankl’s approach inspiring. “In most therapy, the focus is typically on the Strecher person needing the therapy, whereas in logotherapy, the focus is on ‘how can I do something bigger than myself?’”

Strecher seized the idea and ran with it.

In his own book, On Purpose: Lessons in Life

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and Health from the Frog, the Dung Beetle, and Julia, published in 2013, he traces his journey from numb grief to a new understanding of health. “I felt like I was running into a wall with the approaches we were taking in our field,” Strecher says. “We weren’t explaining much more than 30 percent of variance in human behavior. I’m now focused more on the deep motivation that stimulates big quantum change in people.”

Among its unconventional cast of characters, the book features Strecher and his family, a classful of SPH students, the Grim Reaper, and an insightful dung beetle named Winston. A free companion app allows readers to chart and track daily progress on their own life’s mission. For more, visit dungbeetle.org. <

W See a video interview with Victor Strecher at sph.umich.edu/findings.

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Mobile health technology provides self-care support to people with depression and feedback about patients’ needs to community health workers.

By enabling people to self-monitor and treat their condition through weekly calls and health education programs, Piette and Janevic hope to improve access to care within given communities. In the long term, they hope to expand the program to other low- and middle-income countries in Latin America. One lesson Piette and Janevic have learned is that community members are invaluable partners.

Piette says, “Local organizations are doing things with community health workers that students and faculty can really learn from and use to improve access to care for vulnerable communities in the U.S.” < —Rachel Ruderman

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The Human Mind: M e n t a l H e a l t h

Health management and policy doctoral student Sasha Zhou doesn’t remember much about growing up in China—her parents emigrated to the United States after 1989’s Tiananmen Square protests, and four-year-old Sasha joined them two years later. Yet while completing a dual master’s degree at SPH, she encountered Chinese headlines detailing suicides among factory workers, psychological fallout from China’s one-child policy, and scarce job opportunities for Chinese with higher degrees. A summer internship in Beijing reconnected her to her roots, and after experiencing a family member’s bout with depression, she realized the bleak state of mental health infrastructure in the country.

Mental Illness and the Military

Spc. Jennifer L. Ocque

Battling Stigma and Disparities in China

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“Psychiatry is the profession doctors go into when they can’t get into other disciplines.”

“For a population of 1.3 billion, there are only 20,000 trained mental health professionals,” says Zhou. “It’s also incredibly stigmatized. Psychiatry is the profession doctors go into when they can’t get into other disciplines.” Zhou’s research highlights the need for structural solutions, especially within the workplace, to address these disparities.

In the meantime, the Chinese government has pledged the equivalent of $1.11 million to train mental health professionals. “It’s an initial step,” Zhou says, “but more still needs to be done.” < —Nora White

aving previously chaired a 2009 Institute of Medicine committee report on the prevention of mental, emotional, and behavioral disorders among young people, former SPH Dean Kenneth Warner has now chaired a second IOM committee study on mental health.

Funded by the U.S. Department of Defense, the new study was aimed at finding ways to prevent mental illness in members of the military and their families.

Warner The committee was also tasked with recommending interventions to reduce the adverse mental health consequences of trauma.

Committee members examined such issues as post-traumatic stress disorder, traumatic brain injuries, depression, substance abuse, interpersonal violence, and suicide. Warner notes that while they were interested in all members of the active-duty military, the committee focused on military members deployed to Iraq and Afghanistan.

The report, Preventing Psychological Disorders in Service Members and Their Families:

Committee members examined post-traumatic stress disorder, traumatic brain injuries, depression, substance abuse, interpersonal violence, and suicide.

An Assessment of Programs, was issued in February. While commending the Department of Defense on its commitment to addressing the prevention of psychological problems in the military, the report focused much of its attention on the lack of a sufficient evidence base to support the military’s interventions and a lack of systematic evaluation and performance measures.

The full report is available at iom.edu/ Reports/2014/Preventing-PsychologicalDisorders-in-Service-Members-and-TheirFamilies.aspx. <

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The Human Mind: M e n t a l H e a l t h Cracking the Code of Mental Disorders

Genetic and Other Causes of Depression in the First Year Medical B Residency urnout and depression are commonplace among medical school graduates during their first year as resident physicians. Working long and stressful shifts—which often come with little sleep, numerous patient handoffs, and heightened potential for medical error—about a third of residents report significant increases in symptoms of depression.

Although many stress-related risk factors have been identified for depression, researchers have found it difficult to identify genetic variants that increase individual risk, perhaps due to the wide variety of stress-related risk factors associated with the disease. Because medical interns are a relatively homogeneous group who come face-to-face with a small set of strong stressors, Srijan Sen, an assistant professor in the U-M Molecular & Behavioral Neuroscience Institute; Laura Scott, an associate research professor in biostatistics and the U-M Center for Statistical Genetics; and Peter Song, a professor in biostatistics, have begun collecting and analzying data from more than 5,000 first-year medical interns. The scientists hope their study will lead to a deeper understanding of stress and its links to depression.

In the study’s next phase, Scott says, the researchers will look across the genome to identify sites where variation between individuals is associated with differences in the risk of depression. “Our hope is that by

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Bipolar disorder is highly heritable, with a ten-fold increased risk for first-degree relatives. There are no effective tools for prevention and limited options for treatment. But Michael Boehnke, the Richard G. Cornell Distinguished University Professor of Biostatistics, believes our genome may hold answers. He and a team of researchers are using DNA sequences of people with and without bipolar disorder to identify genes and pathways that contribute to the risk of developing bipolar disorder.

In the study's next phase, the

By exploring the genetic basis of this debilitating condition, Boehnke and his colleagues hope to build a valuable data resource for future studies and treatment developments. “You’re dealing with diseases that are severe enough and strike so profoundly that their families are affected too,” says Boehnke. “Through this research we might do a better job of predicting who will develop bipolar, and tailoring therapies to individuals.” Piece by piece, whole genome sequencing will provide more data with which to explore and understand this complex disorder.

researchers will look across the genome to identify sites where variation between individuals is associated with differences in the risk of depression. looking for genetic variants that influence risk in the presence of these strong stressors we will have a better chance to understand their interaction with stress,” says Scott.

“The identification of these variants may eventually drive drug development and ultimately improve the lives of those at risk for experiencing the disorder.” —Nora White <

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SPH biostatisticians Laura Scott, Hyun Min Kang, Gonçalo Abecasis, and Sebastian Zoellner are collaborating with Boehnke, along with colleagues at the HudsonAlpha Institute, the University of Southern California, the University of Toronto, and the Institute of Psychiatry in London. —Rachel Ruderman <

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The Human Mind: M e n t a l H e a l t h Mental Health, Decision-Making, and HIV

Alison Wright © Corbis

When young people are newly diagnosed with HIV, they need basic information about the virus, treatments, side-effects, disclosure, and communication. Many also need mental health services in order to cope with depression and/or anxiety.

Clinical child psychologist and SPH Professor Gary Harper has spent years helping adolescents with HIV adjust to the psychosocial and medical challenges of the disease and to make wise behavioral decisions. Harper works in both the U.S. and in Kenya, in part through the auspices of the NIH-based Adolescent Trials Network for HIV/AIDS Intervention.

“Working with young people,” he says, “we try to help them understand this is a chronic manageable health issue.” <

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Better DecisionMaking With advancing health information technology, people often have direct access to their medical test results. But how can we ensure that they understand and can use such results to make health care decisions? Brian Zikmund-Fisher, assistant professor of health behavior and health education, is examining how best to inform people with diabetes of their Hemoglobin A1c values—a method for determining blood sugar control.

Zikmund-Fisher hopes to find the best means for disseminating this data so that it’s meaningful to individuals. Eventually he hopes to develop and introduce a test results “display generator” application that people can access via a freely available website. —Rachel Ruderman <

he associations between low socioeconomic status and poor health outcomes are well documented, but researchers have yet to identify the biological mechanisms that underpin those associations. Scientists hypothesize that changes to the epigenome—the chemical compounds that mark or modify the genome and influence gene expression— may provide a link between the social environment and the risk of disease.

Belinda Needham, a research assistant professor of epidemiology and a sociologist by training, believes it’s “vital to establish whether there’s a causal relationship between Needham socioeconomic status and health.” Toward that end, she’s collaborating on a study aimed at determining whether low socioeconomic status is linked to increased DNA methylation—a key process by which epigenetic change occurs.

Using a population-based sample of 1,264 white, African-American, and Hispanic participants ages 55–94, Needham and her colleagues are examining a subset of 18 genes related to stress reactivity and immune

function. To date they’ve found that low socioeconomic status is, in general, associated with increased methylation in several genes. Individuals who’ve experienced persistently low socioeconomic status stand out most distinctly from a comparison group of people with persistently high socioeconomic status. Interestingly, says Needham, individuals who have experienced upward social mobility from childhood to adulthood are much less distinct from the comparison group.

Low socioeconomic status is, in general, associated with increased methylation in several genes.

“This suggests that the negative consequences of low childhood socioeconomic status for adult health can potentially be ameliorated through increased educational attainment,” Needham says, noting that this research has implications for education policy. “It makes upward mobility that much harder when we don’t have good support for state institutions of higher learning.” <

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The Human Mind: M e n t a l H e a l t h Mental Health Parity and Infrastructure

In Search of a Common Language

rant Fries began his research odyssey 25 years ago, when he and his team built their first Resident Assessment Instrument, or RAI. That instrument was designed to give nursing homes a “common language” with which to assess the caregiving needs of residents.

A professor of health management and policy and research professor in the U-M Institute of Gerontology, Fries went on to develop assessment instruments for vulnerable populations in a broad variety of institutional and noninstitutional settings. The Fries international company over which he now presides, interRAI—a 33-nation consortium—has created assessment instruments for a broad spectrum of needs, including home care, acute and post-acute care, assisted living, correctional facilities, and children’s mental health. Twenty U.S. states and multiple nations and provinces have adopted interRAI instruments.

“Our goal is to try to be the standard for assessment in all vulnerable populations around the world,” Fries says. InterRAI is currently working with New York State to design developmental disability assessment systems, and with Israel to create instruments to assess elderly persons with

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“The problem with mental health is that there are no standard instruments, no standard terminology.” developmental disabilities. Fries and his team are also partnering with the World Health Organization to provide health and mental health assessment systems for developing nations, where resources are considerably limited, and mental health care is an issue of growing concern.

“The problem with mental health is that there are no standard instruments, no standard terminology,” Fries explains.

“Caregivers need to know who’s been caring for a person, whether that care has been formal or informal, and the history of a person’s problems. They need to know about functionality and behavioral issues.”

The information interRAI’s instruments convey is, in some ways, the equivalent of the “elevator speech,” he says. “It gives caregivers an immediate sense of what they need to know about a person in order to provide appropriate care.”

For more visit interrai.org/. <

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Last fall, the federal Mental Health Parity and Addiction Equity Act of 2008 went into effect, requiring group health plans and health insurance providers to ensure that limits on benefits for mental health and substance abuse treatments be no lower than limits on medical and surgical care. With mental health and substance abuse care now part of essential services, Kyle Grazier, the Richard Carl Jelinek Professor of Health Services Management and Policy, is working to make sure the health system’s infrastructure can handle the projected rise in demand for services.

Researchers are also working to facilitate the delivery of mental health services to vulnerable populations.

In collaboration with the Robert Wood Johnson Foundation and other organizations, Grazier is developing new policies and models aimed at improving efficiencies in mental health screening and easing patient access to specialty services—both in primary care settings (the source of most mental health services in the U.S.) and in ambulatory settings funded by Medicare and Medicaid.

She and her colleagues are also working to facilitate the delivery of mental health services to vulnerable populations.

In related projects, Grazier is working to improve access to health care for newly released prison populations in the U.S.—many of whom have mental health issues. She’s also partnering with state officials in Colorado, as well as with a group of developmentally disabled individuals, to identify and meet the health needs of the developmentally disabled in that state. <

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The Human Mind: TEEN m e n t a l h e a l t h Fighting Teen Depression in Violent Communities

Resilience and the Adolescent Mind

Living in a violent environment can cause feelings of distress, hopelessness, and negative thoughts that contribute to mental health problems like depression, especially in teens. So how can we protect our youth who live in violent communities from depression and other debilitating mental conditions?

Although peers are important influences during this time of life, it was social support from mothers that helped reduce depressive symptoms in teens.

Andria Eisman, a PhD candidate in health behavior and health education, studies depression trajectories in high school youth in Flint, Michigan, with a focus on how different forms of violence exposure influence a teen’s risk of developing depression. She has found that, although peers are important influences during this time of life, it was social support from mothers that helped reduce depressive symptoms in teens, while having support from peers isn’t as important. The implications of these findings can help shape future interventions in violence-prone communities.

“Parents remain a key source of support for adolescents throughout the high school years,” Eisman says. “Because of this, parenting-focused interventions, particularly for youth at risk for violence exposure, are an important piece of fostering positive mental health among youth.” —Rachel Ruderman <

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esilience, according to Marc Zimmerman, professor of health behavior and health education, is an idea born out of physics—that a material is resilient to the extent to which it can handle stress. “Buildings are built to sway, to give, but not to break,” he says. So, too, are teens. For the last 30 years, Zimmerman has been examining what makes children and teens resilient to risk factors that might otherwise result in psychological or behavioral problems. Through the Prevention Research Center, a community-based partnership in Flint, Michigan, Zimmerman and his team are developing a number of programs and initiatives aimed at building resilience in young people and reducing youth violence.

A strong ethnic identity, nurturing parents, and engagement in extracurricular activities all bolster resilience in youth and lead to better outcomes.

A cornerstone of Zimmerman’s work is the Youth Empowerment Solutions (YES) program, which encourages adolescents to make positive changes to their community through a curriculum that features adult mentoring and hands-on community projects designed by the participants themselves. Research from this program, which has been ongoing since 2004, has revealed several key findings, including the fact that a strong ethnic identity, nurturing parents, and engagement in extracurricular activities all bolster resilience in youth and lead to better outcomes. Now, Zimmerman and his team are actively working with the Centers for Disease Control and Prevention to develop a framework so that other communities can implement similar programs in culturally distinct settings. “People are fundamentally resilient,” Zimmerman says. “We just need to know how to harness it.” —Rachel Ruderman <

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See a video on mental health and teen violence at sph.umich.edu/findings.

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The Human Mind: m e m o r y Lead Exposure and Alzheimer’s Disease

How Much Information Is Too Much?

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isk disclosure for Alzheimer’s is a hot topic—especially in light of the rising prevalence and cost of the disease in the U.S. Scott Roberts, an associate professor of health behavior and education, is exploring the ethical and practical implications of two types of disclosure for Alzheimer’s disease risk factors: apolipoprotein E (APOE) genotyping and amyloid neuroimaging. As treatments for the disease continue to be developed, these modes of risk disclosure may be increasingly important, he says. But while both types of disclosure have similar underlying issues, each has subtle differences that present unique challenges.

APOE genotyping can reveal certain genetic variants that increase a person’s risk of developing Alzheimer’s disease.

Amyloid images show plaques in the brain, which can also indicate a heightened risk of developing Alzheimer’s, but at present such risks are difficult to quantify. A number of major Alzheimer’s prevention trials currently underway are testing anti-amyloid medications, and if these trials prove successful, Roberts says, “amyloid imaging will be a critical means of identifying atrisk individuals who might be appropriate for these therapies.”

One concern is that the information provided by these tests may lead to discriminatory practices. Although the Genetic Information Nondiscrimination Act, passed

by Congress in 2008, ensures protection

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Research suggests that alterations in the normal process of DNA methylation—which occurs when methyl groups, or chemical tags, attach to a DNA molecule—may increase the risk of developing Alzheimer’s disease.

Scientists also know that exposure to lead can contribute to poorer cognitive functioning. Under the guidance of SPH Assistant Professor Dana Dolinoy, MD/PhD student Zishaan Farooqui is attempting to unearth yet another part of this complex relationship: the influence of early lead exposure on DNA methylation.

against genetic discrimination by health insurers and employers, protection does not extend to long-term care insurance.

Roberts says this is a critical area that may require expansion if APOE or amyloid imaging become more frequently used.

Ethical considerations are paramount and a focus of Roberts’s recent work in the Risk Evaluation and Education for Alzheimer’s Disease (REVEAL) study.

One concern is that the information provided by these tests may lead to discriminatory practices.

Exposure to lead can contribute to poorer cognitive functioning.

Findings from the study—which provides empirical data on the harms and benefits of predictive testing for Alzheimer’s—suggest that adverse psychological responses to risk disclosure are rarer than expected and that individuals who want information can cope with the results. “As we continue to move toward more widespread use of predictive testing,” Roberts says, “it’s important that we create a solid body of evidence from well-designed research studies to guide policy in this area.”—Rachel Ruderman <

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In the lab, Farooqui exposes mice to the metal lead in utero and examines the effects on neuronal DNA methylation.

Studies are ongoing, but Farooqui is confident that understanding this part of the mechanistic relationship will help researchers gain a better understanding of the causal links between environmental exposures and Alzheimer’s.

Farooqui says, “Understanding the mechanistic pathways behind DNA methylation, which may ultimately lead to Alzheimer’s, puts us at the crossroads of basic science and translational policy and prevention approaches.”

—Rachel Ruderman <

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The Human Mind: a d d i c t i o n

An Insider Speaks Out on Menthol J

effrey Wigand, whose story inspired the 1999 movie The Insider (starring Russell Crowe as Wigand), is the highest-ranking former executive ever to speak out against the tobacco industry. A former vice president of research and development for Brown & Williamson, Wigand turned whistleblower in 1995 when, on the CBS news program 60 Minutes, he revealed that Brown & Williamson had intentionally manipulated its tobacco blend to increase the amount of nicotine.

“Additives like menthol make it easier to take up smoking and easier to continue the habit.”

Today Wigand travels the world as an expert on tobacco issues and works to reduce teen tobacco use through his nonprofit organization, Smoke-Free Kids, Inc. In December, Wigand spoke by webcast to students in HMP 618: Tobacco: From Seedling to Social Policy, taught by SPH’s Cliff Douglas. Discussion topics ranged from e-cigarettes (about which Wigand is skeptical) to tobacco marketing and what Wigand describes as the “menthol problem.”

“Tobacco products contain approximately 616 additives, most of which are designed to ameliorate the harshness of tobacco and to increase the potency and addictive potential of nicotine,” Wigand told the students. “Additives like menthol make it easier to take up smoking and easier to continue the habit. Industry officials like to say, ‘If you can hook ’em young, you can hook ’em for life.’ The best way to shut the industry down is to stop its new users—children—so I’m a proponent of eliminating menthol. Menthol also keeps the mentally ill addicted. In fact, Merit ads target schizophrenics.” <

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ur minds cannot exist without our brains.

And addiction changes both by altering not only the physiology of the brain but also the behaviors and decisions we make with our minds.

All drugs of abuse—drugs that get people addicted—change the prefrontal cortex, that part of our brain that determines what we believe is important. The nucleus accumbens—the part of the brain where we feel pleasure—is another area that is changed by repeated drug use.

There are two main reasons people take drugs. The first is that they’re curious. The second is that they are in an unpleasant state of mind and take drugs to self-medicate. When they take a drug over and over again, it causes changes in the brain that overwhelm the brain’s ability to function normally, and they become compulsive users.

The good news is that the change in brain physiology caused by the sustained use of an addictive drug is often reversible. The affected brain cells are not killed by the vast majority of drugs of abuse, but simply become skinnier and less functional. The goal of therapy or recovery is to

The Addicted Brain

The change in brain physiology caused by the sustained use of an addictive drug is often reversible.

allow time and space for those cells to revert to normal, taking advantage of the brain’s plasticity. Medication and/or psychotherapy—or other interventions, such as 12-step programs—reverse the change more quickly.

It’s important to understand that people will always be addicted, they will always look for mind-altering things. Researchers tend not to think in terms of an “addictive personality” but rather in terms of a person who is at “risk for addiction.” Public health can help reduce that risk by working to change attitudes, especially among the vulnerable young. If kids understand how drugs will affect—and potentially harm—them, they are much less likely to use them.

—Don Vereen, Director, U-M Substance Abuse Research Center; Director, Community-Academic Engagement, Prevention Research Center of Michigan; previously Special Assistant to the Director, National Institute on Drug Abuse; Deputy Director, White House Office of National Drug Control Policy <

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The Human Mind: a d d i c t i o n The Root of the Problem: Nicotine Addiction

The E-Cigarette Debate

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he electronic cigarette industry and its proponents claim e-cigarettes can help smokers quit and also reduce their exposure to the harmful substances found in conventional tobacco smoke. Public health officials are concerned that e-cigarettes may perpetuate nicotine addiction, “renormalize” the act of smoking, and have not been proven to aid in cessation or to reduce harm. SPH experts have this to say: “It’s no coincidence that Big Tobacco, the leading expert in mass marketing nicotine addiction, has moved aggressively into the ecigarette business. Lorillard, which makes Newport cigarettes, owns about half of the e-cigarette market, and Philip Morris, Reynolds-American, and other major cigarette manufacturers are rapidly increasing their stake in the market.

Currently, e-cigarettes are marketed freely without regulation, with manufacturers spending millions on ad campaigns that closely resemble the aggressive cigarette ads of decades ago. In the meantime, an increasing number of states and municipalities are taking steps to prohibit their sale to minors and include e-cigarettes in their smoke-free restaurant, bar, and workplace laws.”

“With kids thus far, as with adults, it appears that e-cigarettes are being used by cigarette smokers. Some are doing so with the desire to substitute e-cigarettes for regular cigarettes. Others are using e-cigarettes as a bridge between the times they can smoke. The question is how many vapers (as e-cigarette users are called) will quit and how many will sustain their smoking. To date, the data simply can’t answer that question.

Several factors will play into the future of e-cigarettes, most notably the fact that they will evolve into better products. The important question is when and how the FDA will use its new authority to regulate cigarettes and smokeless tobacco products. Done properly, regulation could dramatically discourage cigarette smoking, while making more attractive e-cigarettes (and equivalent products) available to help people get off of cigarettes. The 50th-anniversary Surgeon General’s report on smoking and health, released this February, calls for the elimination of the use of cigarettes and other combustible tobacco products. It is unlikely that we will see a more important public health goal this century.”

—Cliff Douglas, Director, U-M Tobacco Research Network

—Kenneth Warner, Avedis Donabedian Distinguished University Professor of Public Health <

The question is how many vapers will quit and how many will sustain their smoking.

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A 1994 investigative report developed

by Cliff Douglas, director of the U-M Tobacco Research Network, and broadcast by ABC News, provided the first public disclosure that the tobacco industry had long been manipulating the content and delivery of nicotine to cause and perpetuate widespread addiction in tobacco users. That report triggered a series of investigations, hearings, and litigation, culminating in the 2009 enactment of the Family Smoking Prevention and Tobacco Control Act, giving the Food and Drug Administration regulatory authority over tobacco products.

And yet, says Douglas, tobacco companies continue to carefully engineer their products to have the greatest addictive impact. Nicotine’s powers were laid out in a 1988 Surgeon General’s Report comparing it to heroin and cocaine in its ability to hook users. Nicotine is both a stimulant and a relaxant, and tobacco use is physically as well as psychologically addictive. The report concluded that:

► Cigarettes and other forms of tobacco are addicting; ► Nicotine is the drug in tobacco that causes addiction; ► The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine. <

Tobacco companies continue to carefully engineer their products to have the greatest addictive impact.

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Decades Later, Still Grateful

s a teen, Barney Tresnowski, BSPH ’55, MPH, got a job scrubbing walls at a Catholic hospital in his hometown of Hammond, Indiana. Because of his diligence, he was soon given much bigger responsibilities. “The nuns had no cook on Sundays, so every Sunday I cooked a chicken dinner for 400 people,” Tresnowski explains.

The young Tresnowski was fascinated by the complexity of the hospital environment, but by 1949 he was ready to leave cooking chicken behind and enter U-M on a football scholarship.

His dream of becoming a star player lasted only as long as his knees, and by sophomore year he needed a new dream—and a new scholarship. When Tresnowski learned about the field of public health, it resonated. The match took, and he graduated with a bachelor’s in public health and policy administration in 1955. By 1981, he was running the Blue Cross and Blue Shield Association—40 years after washing hospital walls as a teenager.

Tresnowski credits much of his success to the mentorship of two public health giants: Solomon “Sy” Axelrod and Walter McNerney. Axelrod, an SPH alumnus (MPH ’49) and faculty member, “wanted me to have a feel for everything that was happening in the field at the time,” Tresnowski remembers.

Axelrod later helped design the infrastructure for Medicare and trained its first staff.

McNerney mentored Tresnowski while he completed his master’s degree at the University of Pittsburgh. McNerney subsequently joined the faculty at U-M, where he designed a model curriculum for health care management, and then left U-M to become one of the architects of Medicare and Medicaid. In 1967, McNerney tapped then-31-year-old Tresnowski to work with him at the Blue Cross and Blue Shield Association (BCBS). Tresnowski at first said no, but McNerney convinced him that in taking the job he’d be part of “the biggest thing to happen to the health care industry.”

Peter Smith

By 1981, he was running the Blue Cross and Blue Shield Association—40 years after washing hospital walls as a teenager.

“And in the end, Walt was right,” Tresnowski recalls.

The “biggest thing” was the high-powered maneuvering between BCBS, Medicare, and the federal government that would shape their financial and administrative relationships for years to come.

As much as by his own dreams and hard work, Tresnowski’s highly successful career was shaped by the guidance of his mentors. “That’s what I tell young people—when you’re looking for a job, forget about money, benefits. Think about who is going to teach you, and place yourself in an environment where you are going to learn, particularly in your early years.”—Madeline Strong Diehl

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CL A SS N O TES

1970s

Glenn Fosdick, MHSA ’76, has retired from his post as president and CEO of the Nebraska Medical Center. During his 12-year tenure, Fosdick reduced expenditures, boosted the hospital’s cash reserves from $8 million to nearly $260 million, and introduced multiple quality-improvement measures.  William Leaver, MHSA ’76, is president and CEO of UnityPoint Health.  Michigan Governor Rick Snyder has reappointed Marianne Udow-Phillips, MHSA ’78, to the Early Childhood Investment Corporation board of directors, the state’s leading group for information about and investment in early childhood programs.

1980s

At its annual meeting last fall, the American Public Health Association awarded Rex D. Archer II, MD, MPH ’83, the Milton and Ruth Roemer Prize for Creative Local Public Health Work. Archer is director of the City of Kansas City, Missouri, Health Department.  Linda Blount, MPH ’89, is the new president and CEO of the Black Women’s Health Imperative, a national organization dedicated to advancing the health and well-being of the 20 million black women and girls throughout the U.S.  The Greater New York Hospital Association and the New York Academy of Medicine, together with the Rudin Family Foundation, have awarded Ruth Browne, MPH ’83, the 2013 Lewis and Jack Rudin New York Prize for Medicine and Health. Browne is chief executive officer of the Arthur Ashe Institute for Urban Health and director of the Brooklyn Health Disparities Center.  Judith R. Baker, MHSA ’83, has received a DrPH from the UCLA School of Public Health.  President Obama has appointed Theresa Martha Covington, MPH ’82, to the Commission to Eliminate Child Abuse and Neglect Fatalities. Covington is director of the National Center for the Review and Prevention of Child Deaths, a position she has held at the Michigan Public Health Institute since 2003.  Bob Riter, MHSA ’80, has published When Your Life Is Touched by Cancer: U N I V E R S I T Y

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Practical Advice and Insights for Patients, Professionals and Those Who Care (Hunter House Publishers, 2014). Riter is executive director of the Cancer Resource Center of the Finger Lakes (New York).  As the new vice president of product management for predictive analytics for Texas-based ZeOmega Inc., Barry Zajac, MHSA ’89, will spearhead ZeOmega’s initiatives to further expand the company’s portfolio of care analytics.

1990s

Kevin Chung, MS ’97, the Charles B.G. De Nancrede professor of surgery, plastic surgery, and orthopedic surgery at U-M, is president of The Plastic Surgery Foundation.  The Saint Joseph Mercy Health System (Michigan) has named Robin Damschroder, MHSA ’98, the chief operating officer for two of its hospitals, St. Joseph Mercy Ann Arbor and St. Joseph Mercy Livingston.  Vance Farrow, MPH ’94, an industry specialist for health and medicine for the Nevada Governor’s Office of Economic Development, has joined the executive committee of Shriners Hospitals for Children.  Michelle Gaskill, MHSA ’98, is the new president of Advocate Trinity Hospital in Chicago. From 2008 to 2014, she was chief nurse executive and vice president of patient care operations at Trinity Hospital.  Axiom EPM, a provider of financial planning and performance-management software for health care providers, has appointed David Janotha, MHSA ’90, Industry Vice President of Healthcare.  Maureen G. Phipps, MD, MPH ’99, is the new chair of the Department of Obstetrics and Gynecology and assistant dean for teaching and research on women’s health in the Warren Alpert Medical School of Brown University. She is also chief of obstetrics and gynecology at Women and Infants Hospital of Rhode Island and executive chief of obstetrics and gynecology at Care New England.  During her 20-year career in women’s health, Julie Rabinovitz, MPH ’97, has been chair of the board of the National Family Planning and Reproductive Health Association and senior vice president

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of business operations at Planned Parenthood of Illinois. She is currently president and CEO of the California Family Health Council.  Adventist Health/Community Care has appointed John Zweifler, MD, MPH ’94, chief medical officer for 38 rural health clinics in the central San Joaquin (California) Valley. A clinical professor at the University of California, San Francisco–Fresno, Zweifler is a past residency director and chief for the UCSF– Fresno Family Medicine Residency Program and a past deputy medical executive for the California Department of Corrections.

2000s

Varsha Mathrani, MPH ’04, is serving as a Lok Mitra (“people’s friend”) in Ahmedabad, India, through a project called Moved

By Love. As part of a community health service initiative, Mathrani delivers twice-daily nutritious meals to widows and widowers in the slums near the city’s Gandhi Ashram.  Rachel Quinn, MPH ’04, has joined the Washington State Health Care Authority’s health care policy team as the new special assistant for health care policy and programs.  California Governor Edmund G. Brown Jr. has appointeed Janet Torres, MPH ’05, executive director of the California Health Professions Education Foundation Board of Directors.

Torres has held multiple positions at Santa Ana Building Healthy Communities.

2010s

A federal policy analyst for WE ACT for Environmental Justice, Jalonne WhiteNewsome, PhD ’11, spoke at U-M SPH last November on “Achieving Climate Justice Amidst Climate Chaos.”  Talyah Sands, MPH ’12, has been accepted into the American Legacy Foundation’s Youth Activism Fellowship Program for the January 2014–June 2015 term. As an SPH student, Sands worked for U-M’s Tobacco Consultation Service. She currently serves as a program manager for the American Lung Association in Arizona. <

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FINDINGS M A K I N G A D I F F E R ENCE

gan, to spend the day visiting four men. Research by the Bureau of Prisons shows that inmates who receive visits from Prisoner Visitation and Support have lower rates of recidivism. It’s one reason prison administrators welcome volunteers like Carey.

Some men talk to her about family, others about life inside prison, and many about the lives they hope to lead outside of prison. “The thing that strikes me over time,” Carey says, “is that many do a great deal of inner work—how did I get here? How am I not going to come back? What do I have to change in order not to be one of those that return?”

Fifty-two percent of all federal inmates are in jail on

h av e lo w e r r at e s o f r e c i d i v i s m

visits monthly have no other visitors. The men come from too far away, or from dysfunctional families, or they’ve been in prison so long that relationships with loved ones have withered or disappeared.

Carey visits because the men have asked for her to come— and because she feels it’s vital to overall community health.

Carey is a volunteer with Prisoner Visitation and Support, a national organization headquartered in Philadelphia, which trains volunteers to visit inmates in federal prisons. For the past 13 years, she has driven once a month to the Federal Corrections Institution in Milan, Michi-

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any of the men Ruth Carey, BSN, MPH ’76,

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In Prison Visits, Lessons in Humility drug charges—many of them as a result of mandatory minimum-sentencing laws. Carey says she’s appalled that the U.S. “has a higher percentage of its population in prison than any country in the world—and that population is growing.”

She finds the experience of visiting prisoners “humbling” and the men themselves to be “human beings of worth”— regardless of their situation.

One man she sees started selling drugs at age nine because all his other male relatives were in prison, and he was the only one who could support his family. “I think that my heart has opened a great deal around things I’ve learned about these men’s lives,” Carey says. “It brings tears that their

lives have been so hard.”

A former public health nurse and educator, she views her prison work as a public health service. “Everything I learned in public health was focused on the aggregate population groups of which communities are constituted— and what, about a particular aggregate, is important for the health of the general population. How prisoners are treated when they’re in prisons, psychologically and physically, has an impact on the health of the community when they return. To me it’s a classic public health issue.”

For more, visit prisonervisitation.org. <

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IN MEMORIAM

Rolf Deininger Rolf Arnold Deininger, professor emeritus of environmental health sciences, died at his home in Ann Arbor on All Saints Day, November 1, 2013. He was 79. Born in Ulm, Germany, Deininger earned his undergraduate degree in civil engineering from the University of Stuttgart in 1958, his MS in environmental engineering from Northwestern University in 1961, and his PhD in environmental engineering from Northwestern University 1965. He joined the faculty of U-M SPH in 1964 and received emeritus status in 2006.

His research interests were in the area of water quality, including the safety and security of public water supplies, drinking water supply systems, the design and location of monitoring stations, and the instrumentation and analysis of tools for

detecting contaminants in raw water intakes and distribution systems. His work directly contributed to water quality in the U.S., the European Union, and the Middle East.

Deininger was a member of numerous professional societies and organizations, including the National Academy of Science and Engineering, the American Water

Works Association, the American Society of Civil Engineers, the German Water Pollution Control Federation, the German Society of Engineers, and the International Association of Water Quality. He served as a consultant to such international agencies as the Pan American Health Organization, World Health Organization, UNESCO, NATO, and the World Bank.

A gracious and humble man with a marked sense of humor, he was a skilled builder, craftsman, beer maker, and model train collector, as well as a devoted husband and father and a doting grandfather. He was especially appreciative and supportive of his wife’s career during their 52 years of marriage. Deininger is survived by his wife, Ingrid; two children, Peter (Christina) Deininger and Heidi Deininger; five grandchildren; a brother, Werner (Elisabeth) of Ulm, Germany; two nieces; and a beloved dog, Sparky. <

Hunein F. “John” Maassab Hunein F. “John” Maassab, professor emeritus of epidemiology, died February 1, 2014, in North Carolina. He was 87. A world-renowned scientist recognized for his extensive research into the creation and development of influenza vaccines, Maassab first isolated the Influenza TypeA-Ann Arbor virus in 1960 and by 1967 had developed a cold-adapted virus. Nearly 40 years later, his research resulted in FluMist, a cold-adapted, live-attenuated, trivalent influenza virus vaccine.

“One of our school’s proudest achievements, FluMist is contributing to the reduction of influenza morbidity and mortality worldwide,” said U-M SPH Dean Martin Philbert.

Maassab was born June 11, 1926, in Damascus, Syria. He received his BA and MA degrees from the University of Missouri and his MPH and PhD degrees from U-M. After receiving his doctorate in 1956, Maassab worked as a research assistant in U-M’s

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Department of Epidemiology, ultimately becoming a full professor. He served as epidemiology chair (1991–1997) and was founder and first director of the school’s Hospital and Molecular Epidemiology Program. In 2003 he was named professor emeritus of epidemiology.

As a doctoral student in 1955, Maassab sat in the back of U-M’s Rackham Auditorium and watched his professor, Thomas Francis Jr., announce to the world that the polio vaccine developed by Dr. Jonas Salk was “safe, effective and potent.” Maassab went on to make medical history of his own, and to continue Michigan’s legacy of vaccine research and development. On December 18, 2002, the U.S. Food and Drug Administration’s Vaccines and Related Biological Products Advisory Committee deemed the vaccine Maassab had spent 40 years developing to be safe and effective for healthy people aged five to 49. The vaccine was licensed in June 2003 as FluMist.

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Three programs at U-M SPH honor Maassab: the H.F. Maassab Student Research Award, the Hunein F. Maassab Scholarship Fund, and the Hunein F. and Hilda Maassab Endowed Professorship in epidemiology. Maassab is survived by twin sons, Sammy and Fred. His wife, the former Hilda Zahka, died in 2006. <

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FINDINGS

CareerWatch:

Public Health Careers in Mental Health

IN MEMORIAM

An ongoing Findings series about trends in public health jobs and careers.

Overview

The field of mental health is burgeoning, especially now that the Affordable Care Act has expanded access to services for millions of Americans. While many mental health positions require specialized training above and beyond a public health degree, public health professionals can work to research and understand mental health conditions, pair those needing help with treatment options, evaluate programs, and decrease the stigma traditionally associated with seeking mental health support.

In Practice

Public health positions in mental health exist in organizations as diverse as nonprofits, research institutions, hospitals, outpatient clinics, and private practice. Some jobs focus more on the macro scale of mental health and involve policy work and community program planning and implementation. Other jobs, including positions in clinical practice that would require a secondary degree, use primary, secondary, and tertiary prevention and promotion approaches to working directly with patients. All jobs ultimately contribute to the main aim of promoting health and preventing disease.

Job Opportunities

Public health professionals can work in the field of mental health as researchers, program and intervention planners, directors, and evaluators, and in outreach and marketing capacities. Additionally, grant writers are always needed to seek out research and program funding sources, as are health educators who understand chronic disease and physical health issues through the lens of mental health. With further mental health training, you can serve as a counselor, therapist, or case manager.

Skill Set

For careers involving both public and mental health, having the right mindset—being able to view the cross-linkages between physical and mental health and how they influence overall health—is the most important skill. This

integrated understanding is in sharp contrast to the more conventional practice of viewing physical and mental health as two separate disciplines. For public health careers in mental health, it’s also a plus to have refined interpersonal skills, as many mental health positions involve public engagement as well as research and/or practical experience working with specific populations of interest.

Takeaway Quote

“If you’re thinking about integrating your public health knowledge into a mental health career, it’s essential that you understand the interconnected relationship between physical and mental health. To get the dual skill set to really put you ahead of the game, seek out as many classes and opportunities as you can to work in the field of mental health on various levels—interpersonal, community, policy, research, etc.

If you’re interested in working directly with patients, consider pursuing a master of social work or PhD in clinical psychology.”

—Monica Schmicker, Infant Mental Health Therapist, Hegira Programs, Westland, Michigan

To Learn More

apha.org/about/Public+Health+Links/ LinksMentalHealth nimh.nih.gov/index.shtml waimh.org mphi.org who.int/mental health/en/ SPH student Nora White interviewed Monica Schmicker for this article.

1940s Bernard Greene, MSPH ’4 5  April 4, 2013 Beth B. Smith, BSPHN ’4 8  December 13, 2013

1950s Robert W. Bacorn, MPH ’52  December 20, 2013 Mary T. DeWan, BSPHN ’54  February 22, 2014 Hunein F. Maassab, MPH ’54; PhD ’56  February 1, 2014 Soloman Belinky, MPH ’55  January 29, 2013 Jerry J. Cohen, MPH ’55  December 24, 2013 Robert M. Simons, MPH ’58  September 27, 2011 Rebecca R. Wilson, MPH ’58  November 22, 2013

1960s Majid A. Alousi, MS ’61  February 4, 2009 Robah O. Kellogg, MPH ’61  September 27, 2013 Dean S. Mathews, MPH ’61  March 26, 2013 Francis J. Connolly, MPH ’63  February 21, 2014 Bernice M. Sirianni, MPH ’63  January 27, 2013 George M. Gillespie, MPH ’64  September 22, 2013 Robert F. Petrokas, MPH ’65  December 21, 2013 John R. Trabalka, MPH ’66; PhD ’71  February 23, 2014 Eveline P. Carsman, MPH ’67  March 29, 2012 Terry R. Daenzer, MPH ’68  July 5, 2013 Daniel J. Worthing, MPH ’68  November 16, 2012 David E. Johnson, MPH ’69  May 6, 2013 Gene P. Lewis, MPH ’69  February 12, 2014

1970s Igbo J. Egwu, MPH ’70  January 23, 2014 (date U-M notified of death) Douglas W. Gentry, MPH ’75  November 9, 2013 Deborah L. Klindt, MHSA ’76  September 3, 2012 Larry C. Brantley, MS ’78  November 27, 2013

1980s Karen L. Krause, MPH ’82



October 20, 2013

1990s Christine C. Boesz, DrPH ’97

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November 24, 2013

New on the web online

at

sph . u m ich . e d u

> Zombie Apocalypse 2014

In April, SPH sponsored its second annual zombie invasion, a public health awareness scenario originally developed by the U.S. Centers for Disease Control. The zombie-related disaster simulation actively engaged participants in emergency preparedness and response. Check out photos and video from the apocalypse (if you dare… ): sph.umich.edu/zombie.

July 6–25, 2014

Graduate Summer Session in Epidemiology Now in its 49th year, this internationally recognized program provides instruction in the principles, methods, and applications of epidemiology. A certificate program as well as online and e-learning courses are available.

For more visit summerepi.org.

> Spring Break on the Frontlines

November 15–19, 2014

The Public Health Action Support Team (PHAST), a student group that partners with health departments and community organizations to address public health issues, sent volunteers to Grenada and South Texas for spring break 2014. As they applied classroom knowledge to real-world issues, participants chronicled their trips on the SPH Frontlines blog: umsphfrontlines. wordpress.com/phast-spring-break-2014.

APHA Annual Meeting New Orleans, LA

Even if you’re not registered for APHA, alumni and their guests are invited to Michigan’s KeepIn-Touch reception, Monday, November 17, 6:30 to 8 pm.

For more information contact sphkeepintouch@umich.edu or 734.764.8093.

> Noreen Clark:

A Celebration

On April 3, the SPH and U-M community gathered to remember one of our own. If you were unable to attend— or want to relive the celebration—watch the video: sph.umich.edu/noreenclark.

> Summer Reading

KEE P I N T O U C H

Join the Public Health Summer Book Club as we read Rose George’s The Big Necessity: The Unmentionable World of Human Waste and Why It Matters. Readers can join discussions on our Facebook page, and chat live with the author at an online event. More at sph.umich.edu/ sphreads.

Want to share your real-world knowledge and experience with current or prospective students?

Need a job or have one to fill?

> Something to Say?

> SPH Career Connection

Comment online on any story in this magazine and learn what other readers have to say at sph.umich.edu/findings.

Are you attending a conference, professional meeting, or other event where prospective students could learn about the University of Michigan School of Public Health?

If so, complete our Alumni Materials Request Form at sph.umich.edu/scr/alumni/recruit.cfm, and the SPH admissions team will get you the items you need.

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matches SPH students and grads with companies and agencies.

Check out umsphjobs.org or e-mail sph.jobs@umich.edu.

> If you would like to be part of

Ask an Alum, please send an

email to sph.inquiries@umich.edu.

> Update your SPH contact info from our home

page at sph.umich.edu. Or indicate changes on the address label and mail to the address on the back cover.

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> MY SPACE

Southern Ethiopia, February 2012 (conducting ethnographic research, or “chasing my roots”) “In early 2012 I visited Africa. In a sense I was retracing myself, finding out how I got from there to here. I came to America almost 21 years ago as a refugee from southern Ethiopia by way of Somalia and Kenya. My mother died in childbirth when I was young. That was the end of family as we knew it, because all of us scattered around to relatives. My uncle in California adopted me and my two brothers. I had zero English when I came here—I had to start from square one, but I am now fluent in English as well as Somali, Oramo, and Swahili.

“I’m at Michigan for big reasons. My U-M SPH education will allow me to make real changes where they’re needed. My ultimate plan is to go back to Ethiopia—where there is a huge need for public health—and do health education and health behavior work in water sanitation, HIV/AIDS prevention, and maternal and child health. In particular I want to teach men about women’s health issues so that men understand that if a woman is not healthy and dies from a preventable death, it’s bad for the entire family. This is one area where my language skills and cross-cultural background will be critical.

“Immediately after graduation, I will go back briefly to southern Ethiopia to do health surveillance work and ethnographic research for a book I hope to publish about my experiences.

My story would only be possible in America.

To be able to make a difference wherever I go— regardless of where I go—I’m grateful for that.”

—Ali Omar, MPH '14, health behavior and health education Photo: Ali Omar

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Public health isnâ&#x20AC;&#x2122;t what it used to be.

The challenges we face today are complex and require creative, multidisciplinary solutionsâ&#x20AC;&#x201D; the kinds of solutions the University of Michigan School of Public Health is uniquely equipped to achieve.

Join us in shaping the future of public health.

Victors for Michigan.

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A new era in

public health For more than 120 years, Michigan has been a world leader in public health. As we embark on a new era of discovery

Michigan Photography/Lin Jones

and innovation—and a new campaign for Michigan—we hope you will join us in forging a better world for all of us. The campaign’s focus is on three key initiatives, each of them vital to the future of the school:

The 20th century was marked by two transformative advances in human health: a dramatic increase in longevity, with the majority of those years due to innovations in public health, and a shift in emphasis from the prevention and cure of life-threatening communicable disease to the management of chronic

► Guaranteeing an affordable education We aim to guarantee that all accepted students will have an opportunity to study at the School of Public Health—regardless of their economic circumstances— and will graduate able to pursue a career for the public good without additional debt.

► Deepening the

disorders. Together, these advances have launched a

student experience

new age in public health.

We strive to transform

In the next decade, the

the way our students

School of Public Health will tackle some of the world’s most urgent, complex, and intractable health problems—chief among them widespread childhood obesity, escalating health care costs, unequal access to health resources, and the need for a new economy in public health. We confront these challenges confident that our expertise is strong and our ability to make an impact is great.

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are trained by extending academic rigor from the classroom into real-world experiences that develop a global perspective and a creative, entrepreneurial mindset.

► Serving the public good In collaboration with partners across campus and throughout the world, we will generate innovative ideas and implement solutions to address the world’s most daunting health care challenges.

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As deputy assistant secretary of health in the U.S. Department of Health and Human Services, Anand Parekh, MD, MPH ’02, is working to integrate health care, social services, and public health with an eye toward improving outcomes and reducing health care costs.

In collaboration with the staff of Panzi Hospital in Bukavu and a team of U-M faculty, Lisa Peters, MPH ’08, is using the epidemiological skills she acquired at SPH to bring about change in war-torn eastern Congo.

In his last year at SPH, Noam Kimelman, MPH ’12, launched his own business, Fresh Corner Café, which today brings healthy food to over 25 small-scale retailers throughout Detroit.

We are changing the

As a senior advisor for epidemiologic science and clinical trials at the international health nonprofit PATH, John “Chris” Victor, MPH ’97, PhD ’04, directs trials for new vaccines targeting some of the greatest killers of children in the developing world.

The director general of the Fundación de Santa Fe de Bogotá, Juan Pablo Uribe, MD, MPH ’94, has also served as vice minister of health and national director of public health for Colombia and as the World Bank’s health sector manager for East Asia and the Pacific.

world

Our graduates are the change agents of today.

Throughout the United States and in 85 countries around the world, U-M SPH alumni are making discoveries, developing policy, devising workable solutions to pressing problems, and changing the way we think about health. For more stories of global impact by U-M SPH graduates, visit sph.umich.edu/giving.

The founder and executive director of Latino Health Access in Santa Ana, California, America Bracho, MD, MPH ’88, is building a new paradigm by which community members help each other address diabetes, domestic violence, and other threats to health.

As lead health education specialist in the Immigrant, Refugee and Migrant Branch of the Division of Global Migration and Quarantine, CDC, Erika Willacy, MPH ’04, works to protect the health of immigrants and refugees from places like Nigeria, Peru, Myanmar, and Iraq.

In her role as a Lok Mitra (“people’s friend”), Varsha Mathrani, MPH ’04, delivers twicedaily nutritious meals to widows and widowers in the slums of Ahmedabad, India, in a service project called Tyaag Nu Tiffin (“food of sacrifice”).

Julia Ward MPH ’14

Zhe Fei MS ’14, PhD student

Mikiko Senga PhD ’14

Dean’s Award

Richard G. Cornell Scholarship

Francis E. Payne Fellowship; Rackham OneTerm Dissertation Fellowship

Future work: Development of a more comprehensive public health system in China

Tomorrow’s A single scholarship can lead to global change. Help make the difference by giving now. sph.umich.edu/giving

change agents The University of Michigan will match qualifying student support gifts at one dollar to every four dollars you contribute.

Contact the U-M SPH Office of Development for details.

Megan Rao MPH ’14

Jason Buxbaum MPH ’14

Dean’s Award

Scott Simonds Scholarship Fund; Dean’s Award

S.J. Axelrod/Eugene Feingold Memorial Scholarship

Future work: Health communications, with a focus on how food is marketed to children

Future work: Senior analyst in policy development and reimbursement strategy, Blue Cross Blue Shield of Michigan (Detroit)

Peter Smith

Aspen Institute

Peter Smith

Utibe Effiong MPH ’14 Future work: Work with Nigerian government as environmental and occupational health advocate, with a focus on petroleum exposures in the Niger Delta

Brigette Bucholz MPH ’13

Brian Segal MS ’13, PhD student

Yue Jiang MPH ’14

Marvin and Harriet Selin Scholarship

H. William and Elizabeth A. Klare Memorial Scholarship

Chevron Texaco Award; Environmental Health Sciences Scholarship/Award

Current work: Manager of hospital infection control, Northwest Community Healthcare, Arlington Heights, Illinois

Peter Smith

Future work: PhD in biostatistics, with a focus on social policy– oriented research

Peter Smith

Peter Smith

Current work: Department of Pandemic and Epidemic Diseases, WHO, Geneva, Switzerland

Peter Smith

Peter Smith

Future work: PhD, with a focus on social epidemiology research to inform policy

Future work: A position with a global company, with the aim of reducing environmental health threats

Findings is published twice each year by the University of Michigan School of Public Health Office of Marketing and Communications.

Dean Martin Philbert Director of Marketing and Communications Rhonda DeLong

PRINCE BAAWUAH WANTS TO CREATE A BETTER WORLD.

Editor Leslie Stainton Staff Writers Terri Mellow, Rachel Ruderman, Nora White Video Editor Brian Lillie Web Editor Beth Miller Art Direction/Design Hammond Design

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Regents of the University of Michigan Mark J. Bernstein, Ann Arbor Julia Donovan Darlow, Ann Arbor Laurence B. Deitch, Bloomfield Hills Shauna Ryder Diggs, Grosse Pointe Denise Ilitch, Bingham Farms Andrea Fischer Newman, Ann Arbor Andrew C. Richner, Grosse Pointe Park Katherine E. White, Ann Arbor Mary Sue Coleman, ex officio The University of Michigan, as an equal opportunity/affirmative action employer, complies with all applicable federal and state laws regarding nondiscrimination and affirmative action. The University of Michigan is committed to a policy of equal opportunity for all persons and does not discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, height, weight, or veteran status in employment, educational programs and activities, and admissions. Inquiries or complaints may be addressed to the Senior Director for Institutional Equity, and Title IX/Section 504/ADA Coordinator, Office of Institutional Equity, 2072 Administrative Services Building, Ann Arbor, Michigan 48109-1432, 734.763.0235, TTY 734.647.1388. For other University of Michigan information call 734.764.1817.

YOU CAN HELP. H

AVING SEEN WHAT HAPPENS when people lack access to health care, Prince Baawuah, MPH ’14, wants to use his education in health management and policy to improve both health and economics in the U.S. and his native Ghana. With your generosity, more students like Prince can enter the world of public health. Give to an SPH scholarship fund and help build a better tomorrow.

Our campaign priorities are:

• Guaranteeing an affordable education • Deepening the student experience • Serving the public good

For more information: sph.umich.edu/giving, 734.764.8093, or fraumank@umich.edu

NON-PROFIT ORG U S POSTAGE Office of Marketing and Communications 1415 Washington Heights, Ann Arbor, MI 48109-2029

PAID

ANN ARBOR, MI PERMIT NO. 144