Findings, Our Common Journey: Global Health in a Connected World

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> The next great plague? p. 12 | Flint’s water crisis p. 14 | The toxic truth about e-waste p. 18

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Thanks to the widespread use of telemedicine in Haifa and Tel Aviv, SPH Assistant Professor Sara Adar and scientists in Israel are able to identify the specific time people experience heart attacks, arrhythmia, and other acute cardiac events, and to track associations between these events and hourly measurements of airborne particulate matter.

Their novel research—which harnesses the power of big data—can help local regulators develop policies to reduce air pollution and can inform global efforts to improve cardiovascular health, especially in polluted areas.

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premature deaths worldwide are estimated to occur annually as a result of ambient air pollution.

Source: World Health Organization

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Worldwide, the leading cause of death in children under five is respiratory infections—among them pneumonia, seasonal influenza, and respiratory syncytial virus, or RSV. In high-income countries like the U.S., children who get these infections typically receive treatment and survive. In low- resource countries, infected kids often die.

They also spread the disease to others.

Vaccines remain the best, most costeffective way to prevent these deadly diseases in both children and adults, says SPH Professor Arnold Monto, who is conducting studies to assess the efficacy of new vaccines for both seasonal influenza and, in the future, RSV.

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children under five are estimated to die each year from acute lower respiratory infections.

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Tuberculosis is the leading infectious cause of death in the world. But inadequate treatment has given rise to multi- and totally-drug-resistant TB, a dangerous new global threat to health. To fight these superbugs, SPH Assistant Professor Zoe McLaren is using sophisticated statistical analysis techniques to pinpoint areas of greatest need—and sparsest data—in endemic countries like South Africa.

Health officials can then target these areas for aggressive medical and social interventions that will advance the global drive toward eradication.

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people—one-third of the world’s population— are infected by tuberculosis bacteria.

AP Photo/Rajesh Kumar Singh

Source: World Health Organization

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Food insecurity and climate change are serious public health challenges in their own right, but they are also linked to each other.

This is especially true in low- and middleincome countries, where the well-being of millions of farmers is directly tied to food systems that are increasingly susceptible to temperature extremes and volatile rainfall patterns. SPH Assistant Professor Andrew Jones works in Peru, Burkina Faso, and Malawi to find out if increased agricultural biodiversity can help farmers better manage the risks associated with climate change, thereby combating food insecurity by creating more resilient food-production systems.

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people go hungry every day.

AP Photo/Diana Ulloa

Source: World Food Programme

India, one of the world’s largest tobacco consumers, is a prime target of policy interventions to reduce tobacco use.

Policies don’t guarantee compliance, however, especially in settings where tobacco use is embedded in the culture, and implementation resources are minimal.

SPH Assistant Professor Ritesh Mistry investigates the efficacy of new policies on adolescent behaviors. He’s found that policies focusing on normative change, such as advertising restrictions—including at the point-of-sale—are equally or even more important than supply-reduction policies. This research is vital to the development of global policies to reduce tobacco consumption and save lives.

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billion people are expected to die of tobaccorelated causes in the 21st century.

Brett Cole

Source: The World Bank

In the developing world—home to four-fifths of the global population—non-communicable diseases like cancer are fast outpacing traditional enemies such as infectious diseases and malnutrition. But without widespread surveillance systems and registries, developing nations can’t begin to address the rising threat of cancer.

That’s why SPH faculty Mousumi Banerjee and Laura Rozek are partnering with colleagues in India, Bangladesh, and Thailand to create and implement robust infrastructures for cancer surveillance and registration—so that health officials can then develop targeted, life-saving research, prevention, and treatment programs.

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percent of the world’s total new annual cases of cancer occur in Africa, Asia, and Central and South America. Together, these regions account for 70 percent of the world’s cancer deaths.

Source: World Health Organization

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On the Web

Whenever you see this symbol, it means you can check out additional, exclusive content on this topic online at sph.umich.edu/findings.

Video extras in this issue: > > >

Mexico City Refugee health African internship

Connect with SPH Links at sph.umich.edu.

From the Dean Doing the Right Thing

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Alumni Network 42 A Voice at the Table

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43 The Beauty of it

On the Heights

44 Global Health, Global Prosperity

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46 Eyewitness to Ebola

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51 New on the Web 52 My Global Health

On the cover: French-born photographer Marc-Grégor Campredon captured this image along the rail lines outside the train station in Moshi, Tanzania, at the foot of Mount Kilimanjaro. Campredon spent two years in Tanzania, from 2011 to 2013, with his wife, SPH alumna Lora Campredon (MPH ’15).

Back cover: The back-cover shot of the inaugural 75thanniversary celebration at SPH—and the architecturally rendered birthday cake here—were taken by Ann Arbor photographer Peter Smith, whose work has graced the pages of every issue of Findings for the past 15 years.

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findings Volume 31, Number 2 Spring/Summer 2016 Produced by the U-M SPH Office of Marketing and Communications

22 Fe ature Articles

Our Common Journey 18

In Plain Sight

Think you’re doing the planet a favor by recyling that cell phone? Think again.

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Future Perfect

From megacities to mega-waistlines, modernization exacts a price. Just ask Mexico.

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War’s Toll

When peace evaporates, health does too—sometimes for decades.

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S p e cia l S e ctio n V ictors for michi g a n campai g n

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Again, the solutions we need won’t necessarily come from the “developed” world.

Many solutions require larger, more systematic approaches. For example, malaria is a global issue, and one might think it’s primarily about getting rid of the bug and getting a better medicine. But it’s really about harnessing rainwater and fresh water supplies, channeling them into systems that provide potable water, and eliminating the breeding grounds for mosquitoes. That’s not to say we don’t need better medicines for malaria, but we ought to be simultaneously thinking about vaccines and about the kind of engineered environment that would prevent the problem from occurring in the first place.

The same principles apply in Flint, Michigan, where a switch in the city’s water supply in 2014 resulted in widespread lead contamination. What happened in Flint is a sobering reminder that safe, potable water is a fundamental human right—one that is too often denied the world’s most vulnerable populations. As we work now to address Flint’s water crisis, we must dedicate ourselves to devising solutions that are sustainable, cost-effective, socially responsible, and just plain right.

Flint has much in common with other water-constrained places on the globe, and in this Flint is also a reminder that public health is inherently global. The term “global” may, in fact, be superfluous, because health is the bottom line everywhere, whether we’re talking about Flint, Michigan, or Accra, Ghana, or rural Afghanistan or Mexico City. It’s about access not just to health care but to fundamental resources, chief among them safe, secure supplies of water, food, and air.

One of the deep lessons I’ve learned from sitting in the back seat of bumpy jeeps, sometimes next to SPH students, is that at its best, exposure to global public health has great value even if you end up working in a windowless office here in the U.S. And that’s because we live in a globalized system of markets, supply chains, goods, resources, and, on the negative side, pollution and disease. Understanding one’s role in a globalized economy is ever more important, and it’s why as many of our students as possible should experience international work during their years at SPH. Otherwise, in our efforts to do the right thing, we stand little chance of getting it right. <

Safe, potable water is a fundamental human right—one that is too often denied the world’s most vulnerable populations.

Martin Philbert Dean and Professor of Toxicology

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n recent years, we in public health have rather selfishly framed global public health as: “What happens ‘over there’ happens here.” We remind people that in the United States, we’re no more than 14 to 18 hours away from anywhere in the world, and as we saw last year with Ebola, a disease that breaks out in one country can reach our shores in hours.

All this is true, of course. But there are far more noble reasons for engaging in global public health, chief among them that it’s the right thing to do. We in the so-called “developed” world Martin Philbert have solutions, technologies, and approaches that can save lives, and it’s our obligation to help where we can.

At the same time, just because we’ve got the latest whiz-bang technology doesn’t mean we should apply it. This school’s deep heritage in community-based partnering makes that clear, and it’s one reason U-M SPH is a durable partner with colleagues around the globe.

We understand that global public health requires cultural humility, sensitivity, and trust, and that perhaps more often than not, we need to sit back, listen, learn, and allow our global partners to lead.

In my role as dean, I’ve been in many less-advantaged communities. One thing I’ve seen time and again is that poor people are resilient, they’re resourceful, and they’re innovative. We need to incorporate that wisdom into our thinking.

We can be the most precise, sophisticated, and innovative scientists, and be precisely and innovatively wrong in the implementation of our solution—either because it’s too complex or it’s impractical. It’s one reason we now have so much innovation and social entrepreneurship activity in the school, so that our students can learn to innovate smartly.

It’s not enough to have a brilliant solution—the solution has to be intuitive enough for people to adopt. And it’s got to be “sticky,” so they’ll keep adopting it and make it a habit.

Solutions to global health challenges can also be found in approaches we’ve already implemented, or in lessons we’ve already learned. Too often, we’re driven by a mania to find ever more novel and innovative approaches. I would argue that public health ought to spend at least as much time reflecting on past interventions—both successes and failures— and drawing ideas from that solid foundation.

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Go Blue!

public health is, how they can connect with public health in their daily lives, and and presents current public health information that’s related to them. Findings not only provides a full picture of public health, with a broad range of topics, but it also gives very specific perspectives on public health by offering a wide variety of informative, interesting, and smart stories and pictures. I am looking forward to the next issue of Findings.

Shumenghui Zhai Philadelphia, Pennsylvania

You see what happens when public health is stuffed at the bottom of a gigantic department devoted to the payment of billions of dollars for health services at every level.

> I was happy to read about all of the great events for prospective students (“Age of Abundance,” fall/winter 2015 Findings). I remember trying to think about what school I should go to, and not really knowing what to do. Going to Michigan ended up being the best decision! I ultimately chose to concentrate in both health behavior and health education and epidemiology, a decision that has helped me to work on policy development and program development and evaluation, to conduct research, and most importantly, to approach issues from a comprehensive perspective. There is not one problem I don’t feel confident in tackling, and I owe that in large part to education I received at Michigan. From public service to private sector work, I have been able to benefit from a great foundation.

Monique Rucker (Glover), MPH ’99

> I got my first Findings magazine at the 2015 conference of the American Public Health Association and immediately loved it. I was deeply impressed by the design and the quality and diversity of each story. As a public health professional, I love the way Findings tells people what

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Public Health in Michigan > This may not be the appropriate vehicle to vent on something most important to this 97-year-old former state health officer, but don’t you think it’s time that there be a concerted effort to once more place a Michigan Department of Public Health on a par with the other major state departments? You see what happens when public health is stuffed at the bottom of a gigantic department devoted to the payment of billions of dollars for health services at every level. There is little or no public health input, as witness that up until recently, the state’s chief medical executive—Michigan’s public health director—was a part-time employee! The Public Health Code calls for a full-time public health physician as the head. We worked for over four years to develop the Public Health Code, a task that required the input and cooperation of both houses in the legislature, all three of Michigan’s major universities, the governor, and local health departments—all coordinated by the Michigan Department of Public Health. If I were ten years younger, you couldn’t stop me from starting over. Is this ringing any bells out there? Does anybody care?

Maurice S. Reizen, MD, MSPH ’46 Novi, Michigan The writer is a past director of the Michigan Department of Public Health (1970–1981) and past medical deputy in health promotion and disease prevention administration for the Michigan Department of Public Health (1982–1984).

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Where Ideas Come From > (Re: “The Ideas Issue,” fall/winter 2015) My original thinking in so many areas can be tracked back to two wonderful people from the University of Michigan. They are my heroes: Professor and Interim Dean William C. Gibson and Dean Henry Vaughan. They taught a 25-year-old boy with three years of professional environmental health experience the amazing concept of thinking outside of the box. They taught me not to just look at single points of data, but also to look at the entire picture, Henry Vaughan and to dream of how to develop concepts that could be put into practice— concepts that would not only resolve a given problem but would be the basis of resolving future problems. They taught me to learn from every experience and how to grow into a man. Although I was a father of two tiny daughters, I still had to learn what it was to become a thinking, mature individual in my professional field, and to recognize not only the broad scope of environmental health but also the broad scope of public health and what it would mean if I could add a little bit to the conversation about “how” to make this a better world by helping to prevent disease and injury and to promote good health.

My original thinking in so many areas can be tracked back to two wonderful people from the University of Michigan.

Kudos to them and to all of you at U-M SPH for giving me the most wonderful career in the world, which I hope to practice well into my 90s. My 500 graduates with degrees in environmental health science are strong public health advocates and have gone on to wonderful careers. Your teaching has been multiplied by not only these individuals, but also by the thousands of students I taught in my community health courses.

Herman Koren, MS, MPH ’59 Professor Emeritus of Health and Safety, Indiana State University Belleair Beach, Florida

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Undergraduate Degree

Statistically Speaking

> The headline “Regents Approve First U-M

> Regarding Alan Bloom’s letter on “Big Data” in

Undergraduate Degree in Public Health” (On the Heights, fall/winter 2015) is not correct. In the 1950s, the School of Public Health did offer a bachelor’s degree that one entered in the junior year after two years in the U-M College of Literature, Science and Arts (LSA). It was listed in both the LSA and SPH catalogues. In the spring semester of my freshman year, in 1957, I spoke with [SPH Professors] Benjamin Darsky and Sy Alexrod about the program and took the required classes to enter it in the fall of 1958. Toward the end of my sophomore year, in the spring of 1958, they informed me that, sadly, the program would not continue due to a loss in funding from the Kellogg Foundation. They kindly offered to let me enter in the fall of 1958 as the only student in the undergraduate program. I decided that instead of being the only student in a program that was ending, I would continue to work toward a BA in LSA. I am pleased that 50 years later, starting in the fall of 2017, you will offer both a BA and BS in public health!

“From Our Readers” (spring/summer 2015): The late SPH Professor John Kirscht used to remind students in every session of his class on the psychosocial aspects of health behavior that the word “data” is plural (singular is “datum”).

Therefore, correction is required both to the title of the article to which Mr. Bloom refers in his letter (“10 Ways ‘Big Data’ Is Changing the Way We Do Public Health,” fall/winter 2014) as well as to Mr. Bloom’s statement regarding “all this data I have been collecting ... .” Literacy seems to be declining significantly in this country. Grammatical and spelling errors are ubiquitous. Let’s not let that decline invade academia!

Linda Fishman, BA ’60, MSW ’61 Atlanta, Georgia Editor’s note: The writer is correct. According to the Report of The School of Public Health, 1951–1952, reprinted from the President’s Report for 1951–1952, University of Michigan, “In September 1950, with financial support from the W.K. Kellogg Foundation, there was inaugurated an undergraduate program leading to the degree of Bachelor of Science in Public Health, designed to cover the fields of (1) nonmedical administration and (2) sanitary science. The first degree was granted in June, 1952.” U-M SPH awarded the first of 20 BSPH degrees in June 1952 and the last in June 1959.

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.

Back Issues Back issues of Findings are available upon request. Visit sph.umich.edu/findings to review past issues. To request print copies, specify which issue and e-mail sph.findings@ umich.edu.

Joanne Gessula, MPH ’81 New York, New York Editor’s note: In choosing to pair “big data” with the singular verb “is,” Findings was heeding usage guidelines from both the Chicago Manual of Style and the Associated Press Stylebook. The latter reads: “Some words that are plural in form become collective nouns and take singular verbs when the group or quantity is regarded as a unit.

Right: The data is sound. (A unit.) Right: The data have been carefully collected. (Individual items.)”

Recent Awa r d s

Findings magazine won the gold award for Best Specialized or Unit-Level Magazine in the 2015 Pride of CASE V District Awards Program. Part of the international Council for the Advancement and Support of Education (CASE), CASE District V encompasses Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. The Findings award was one of 17 overall for U-M in the 2015 Pride of Case competition. The spring/ summer 2015 (“Becoming Detroit”) and fall/winter 2015 (“The Ideas Issue”) issues of Findings both won gold awards in the 2016 Addy competition, sponsored by the Greater Flint Ad Club and the American Advertising Federation.

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 Editor Leslie Stainton Video Editor Brian Lillie Web Editor Beth Miller Web Administrator Patty Bradley Art Direction/Design Hammond Design Business Manager Rebecca Minch

Copies of Findings may be ordered from the editor. Articles that appear in Findings may be reprinted by obtaining the editor’s permission. Send correspondence to Editor, Findings, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029, or phone 734.936.1246, or send an e-mail to sph.findings@umich.edu. Findings is available online at sph.umich.edu/ findings. ©2016, University of Michigan To opt out of receiving the print version of Findings and read our publication exclusively online at sph.umich.edu/findings/, e-mail us at sph.optout@umich.edu.

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Regents of the University of Michigan Michael J. Behm, Grand Blanc Mark J. Bernstein, 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 Mark S. Schlissel, 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.

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On the Heights

One day in 1953, Detroit resident Irene Auberlin watched a television show about orphaned children in war-torn Korea. Instead of turning off the TV and going back to her life, Auberlin, a 57-year-old self-described “housewife with time on my hands,” mobilized friends and family to send baby clothes and formula to Korea. Her impromptu relief organization soon evolved into World Medical Relief, which since 1953 has shipped nearly a billion dollars’ worth of medical equipment and supplies to people in need around the world. Last September, as part of the annual U-M SPH Practice Plunge, first-year SPH students furthered Auberlin’s vision by volunteering at the organization’s headquarters in Southfield, Michigan.

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Front Lines, Front Pages

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“Public Health at Its Best”

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SPH and World Medical Relief

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CARt, the brainchild of an interdisciplinary student team from U-M, took first place in the 2015 Accelerate Michigan Innovation Student Competition, a statewide contest highlighting Michigan as “the destination for innovation.”

Designed to reduce the transportation barriers that keep people from accessing healthy foods, CARt is an interface between grocery retailers and a rideshare program. Under the name Fresh Fare, the same project won second place at last year’s U-M SPH Innovation in Action Competition. CARt team members include SPH students Ali Jensen, Stacey Matlin, and Christine Priori, and Mikaela Rodkin of the U-M School of Natural Resources and Environment and Ross School of Business. n U-M SPH Senior Associate Dean for Global Public Health Matthew L. Boulton, whose many responsibilities include editor-in-chief of the American Journal of Preventive Medicine, is the 2016 recipient of the American College of Preventive Medicine’s Ronald Davis Special Recognition Award. Named for the late Ronald M. Davis, a former member of the U-M faculty and former president of the American Medical Association, the award recognizes outstanding achievement in or contribution to the field of preventive medicine. Previous recipients of the award include former U.S. Surgeon Generals David Satcher and C. Everett Koop, and William Foege, first recipient of U-M’s Thomas Francis Jr. Medal in Global Public Health. n The U-M Comprehensive Cancer Center has named Bhramar Mukherjee associate director for population science research. Mukherjee, the John D. Kalbfleisch Collegiate Professor of Biostatistics and professor of epidemiology at SPH, “is a stellar researcher in biostatistics, epidemiology, and disparities,” says Cancer Center Director Ted Lawrence, who cites these as key issues the center aims to address.

Mukherjee will oversee the center’s research on cancer screening, detection, and prevention, as well as research on cancer outcomes, disparities, and new models of cancer-care delivery. n

SPH experts weigh in on the greatest

The Next A

s the global health and development cor respondent for NPR, Jason Beaubien has covered a range of health issues, from circumcision drives in Kenya to drug-resistant malaria in Myanmar and abortion in El Salvador. He was part of a team of NPR reporters to win a 2015 Peabody Award for their extensive reporting on West Africa’s Ebola outbreak.

Last September, Beaubien, an alumnus of U-M’s Knight-Wallace Fellows program, returned to campus to give the 30th Graham Hovey Lecture on “emerging epidemics in a globalized world.” Beaubien described various scenarios that could give rise to “the next great plague,” and warned that we are poorly prepared to address such an eventuality. “The great conundrum today in global health,” he said, “is that powerful forces are bringing economic well-being to more and more people— but they’re also bringing more disease.”

Prompted by Beaubien’s remarks, we asked U-M SPH experts in global public health to tell us what they think are the greatest threats to health in the next decades: Cancer is the number one killer worldwide— and its global burden is growing, as more and more people live longer and develop cancer in lower- and middle-income countries (LMICs).

These countries typically have too few doctors and resources to pay for chemotherapy and other treatments, so the ratio of mortality to incidence in LMICs is much higher than in countries like the U.S. Early diagnosis helps.

We need to invest in infrastructure to encourage early screenings, and we need standards of care for early diagnosis. If we can downstage cancers through early diagnosis and treatment, and give people an extra decade or two of life, that can mean the difference

between a sustainable existence for a family and poverty. Personalized medicine is also promising. By using genetic technologies to identify those tumors that will respond best to particular drugs, we can tailor treatments, reduce costs, and make a huge impact in resource-poor LMICs. Laura Rozek, Associate Director, SPH Office of Global Public Health

Cancer is the number one killer worldwide— and its global burden is growing, as more and more people live longer and develop cancer in lower- and middleincome countries.

Climate change is fundamentally altering our thinking about future threats to human health. Already we’ve seen an unprecedented number of injuries and fatalities from severe weather events. We’ve experienced changes in vector ecology and the spread of illnesses like dengue, and we’ve seen how changing water and food supplies are leading to more diarrheal illness and malnutrition. We’ve also seen how environmental degradation can spawn forced migration and civil conflict.

These are just a few examples.

Matthew Boulton, SPH Senior Associate Dean for Global Public Health

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threats to public health we’ll face in the coming decades

Mark Stephen/iSpot.com

Great Plague?

I would argue that the epidemiologic transition of low- and middle-income countries— and the accompanying aging of populations worldwide—is going to have a huge impact on global health challenges in this and the next century. Along with this goes the nutrition transition. The increased global availability of high-caloric foods, in combination with an aging and more sedentary population, is creating a potentially devastating public health crisis through various chronic diseases. Two other issues will be critical to maintaining public health: water availability and disorders associated with civil strife. As we’re already seeing, the latter leads to refugee crises and is accompanied by infectious and nutrition-related diseases, as well as mental health problems.

Mark Wilson, Professor of Epidemiology

with climate change is the ‘nutrition transition.’ That’s the idea that developing countries are increasingly experiencing the kinds of diseases we’ve experienced in the West for many decades, especially diet-related chronic illness. This transition is happening in the context of countries that lack the infrastructure and health-system capacity to handle these changes. In many ways, these countries are experiencing a ‘double burden’ of malnutrition—a burden of persistent, intractable infectious illness, and at the same time a rapidly rising prevalence of obesity and chronic disease. To me, climate change and the nutrition transition are the two most pressing public health challenges facing the globe right now—and they both have roots in dysfunctional food systems.

Andrew Jones, Assistant Professor, Nutritional Sciences

The increased global availability of highcaloric foods is creating a potentially devastating public health crisis through various chronic diseases.

Estimates are that in the next 15 to 35 years, climate change will cause an additional 250,000 deaths per year from conditions like malaria, diarrheal disease, heat stress, and undernutrition. That’s a huge health burden, and unless we make some very dramatic changes, we can expect it to worsen. Coupled

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To me, the greatest global threats to health are large-level structural factors: poverty, inequality, oppression, discrimination. Yes, a new virus may come onto the scene, but most likely that virus is going to end up in marginalized populations. If we don’t combat the underlying structural and social/cultural factors that affect health, then we’re vulnerable to anything. We don’t have a pill for racism, we don’t have a vaccination for oppression, and it’s a lot more challenging to address those issues than it is to find a bacteria or virus. I work in HIV, so I often think of that as an example. What has continued to fuel the HIV epidemic—even in highly industrialized countries like the U.S. —are structural inequalities.

One of the biggest global threats to health is complacency. I see it with a disease like polio, which is so close to being eradicated.

I see it in my own research on HIV.

As the refugee crisis reminds us, war and conflict are a major threat to health on a global scale. Climate change is another.

And if we think about last year’s Ebola crisis, it’s clear we need to strengthen our health systems. But I think one of the biggest global threats to health is complacency. I see it with a disease like polio, which is so close to being eradicated. I see it in my own research on HIV. There have been major achievements in the response to HIV—15 million people worldwide on HIV treatment, that’s a great global achievement—but to make sure these achievements continue, we have to keep up the momentum, and complacency is a big threat. It influences the level of response, it influences funding. And often those who suffer the most from our complacency are the most vulnerable populations, the hidden and marginalized populations. < Elizabeth King, Assistant Professor, Health Behavior and Health Education

Gary Harper, Professor of Health Behavior and Health Education

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Christian Randolph

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When word broke last fall that the water supply in Flint, Michigan, had been contaminated with lead as a result of a switch in the city’s water supply in 2014, the state’s seventh-largest city became a global news story. U-M SPH alumni, faculty, students, and staff are at the forefront of efforts to address the crisis.

In April, SPH Dean Martin Philbert established a Flint Task Force to partner with the Flint community; with local, state, and federal agencies; and with other U-M faculty to investigate best-practice, sustainable solutions to protect the health of Flint residents. For updates visit sph.umich.edu/flint-crisis/.

Here, members of the U-M SPH community weigh in on the emergency.

We wanted to know, what lessons have you learned? What’s next?

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overnmental public health is not set up to make quick assessments and quick decisions, especially a public health department like the one in Genesee County, which has been so eviscerated financially. But the question of ethical responsibility is something we have to deal with. At what point do people have an ethical obligation to abrogate a technical role and take on the role of public advocates? These are questions people need to ask. In my view, it’s better to err on the side of overly communicating than waiting until you know for sure that every element you’re saying about prevention or secondary prevention is actually on point.

Another lesson to be learned is that sometimes you don’t need to know who to punish—you just have to figure out what happened and get it fixed. So it never happens again. The Flint community needs to rebuild and heal, physically, mentally, psychologically, economically, and socially. Our obligation is to use our body of knowledge and our energy to carry this out. Solutions can only be found and implemented as a team. No one person or organization has all the answers.

Peter Levine, MPH ’80, Executive Director, Genesee County Medical Society

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ealth doesn’t just happen in a doctor’s office, it happens in all sectors of the community. I don’t believe we would be at the current action level responding to the crisis in Flint if our community’s health care leaders—doctors, hospitals—as well as university and business leaders hadn’t come together to identify the health risks and speak out with urgency to address this.

We’re so fortunate in Flint that we have strong partnerships and the kind of collaborative infrastructure that the public health world increasingly suggests is necessary to address population health issues. We talk about the importance of infrastructure, of funding public health on a national scale and on a state and local scale. And yet it’s always the first thing that is cut, or one of the first things. We can’t do that anymore.

Kirk Smith, MHSA ’08, President and CEO, Greater Flint Health Coalition

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e need to invest and prioritize in the evidence-based interventions that will mitigate this exposure, that will promote childhood development, and that will build childhood resilience. We are trying to flip the story.

We’re trying to build that model public health program. Because these kids did absolutely nothing wrong. Their only fault was that they lived in a poor city that was almost bankrupt and that didn’t treat their water. So we have to be their advocates. Our goal is that our kids have a much better tomorrow than even their yesterday was.

Mona Hanna-Attisha, MD, MPH ’08, Program Director, Pediatric Residency, Hurley Children’s Hospital, Hurley Medical Center, MSU College of Human Medicine, Department of Pediatrics and Human Development

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f we’re thinking about a solution, I’d like to think about something that’s scalable.

Flint is not the only place in the U.S. that has had a problem. Back in November of 2000, the city of Washington, D.C., made a technical decision to switch their water purification process from using chlorine to a chemical called chloramine. Basically that change in the chemistry, without an appropriate adjustment in buffering, resulted in significant elevations in blood lead for all the same reasons that occurred in Flint. But that decision wasn’t imposed by an emergency manager, it was selfinflicted. It also wasn’t publicly disclosed for three years. So here we have an unfortuante example where, for different reasons, the same problem emerged. In fact, there are lots of cities where this has happened in the past 10 or 15 years. This is not rare, unfortunately. There are examples of solutions, such as the city of Lansing, Michigan, which has been replacing its lead-service lines over the last decade. This is a case that merits further study and could serve as an example for the rest of Michigan and the entire country.

Al Franzblau, MD, Professor of Environmental Health Sciences, U-M SPH

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Professor Rita Loch-Caruso and Mona Hanna-Attisha, MD, MPH ’08

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or me, the takeaway from Flint is that we need our government agencies to be empowered to advocate for the public’s health. In Flint, we had the example of an Environmental Protection Agency staff member, Miguel Del Toral, who advocated protective measures, but then administrative decisions blocked appropriate follow-up action. So the right thing happened, and the wrong thing happened. Regardless, it’s important that people recognize that the EPA is necessary and must be an advocate for public health protection. And if we don’t like what the EPA is doing, we need to be talking to our legislators and other government officials.

For me, the takeaway from Flint is that we need our government agencies to be empowered to advocate for the public’s health.

My colleagues and I in the Michigan Center on Lifestage Environmental Exposures and Disease are especially concerned about the Flint water contamination because the very young, including the unborn, are much more sensitive to the toxic actions of lead. Even at low levels, children’s brains, especially, are vulnerable to lead exposure. < Rita Loch-Caruso, Professor of Environmental Health Sciences, U-M SPH; Director, Michigan Center on Lifestage Environmental Exposures and Disease

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“Public Health at Its Best” M

any simple solutions for human poverty already exist, but the challenge is figuring out how to deliver them, said the newest recipient of the Thomas Francis Jr. Medal in Global Public Health.

Sir Fazle Hasan Abed accepted the Francis award—one of the most prestigious given by U-M—at an April 8 ceremony in Ann Arbor.

The Bangladeshi man left a successful career in business more than four decades ago to become the founder and chairperson of the world’s largest nongovernmental development organization.

“In global development, it is not the lack of new, bright ideas that is impeding progress—rather it is our ability to implement these ideas well, effectively, and at scale,” said Abed, whose organization was once known as the Bangladesh Rehabilitation Assistance Committee but is now simply called BRAC.

For more than 40 years, BRAC has used a business approach to give people—especially women and children—the tools and resources they need to overcome poverty. The organization owns 16 social enterprises—among them hotels and conference centers, a dairy business, and a bank—which together provide economic resources to support its social programs in education, health care, skills and job training, and empowerment. BRAC has reached an estimated 138 million people in 12 countries in Asia, Africa, and the Caribbean.

In his introductory remarks, U-M SPH Dean Martin Philbert described Abed’s record of achievement as “simply extraordinary. It is public health at its best.”

Abed himself was more modest. Asked later if he had any regrets in his career, Abed said he had none. Then he amended his answer.

“The only regret I have is that maybe I should have gone a little faster.” <

“It is not the lack of new, bright ideas that is impeding progress—rather it is our ability to implement these ideas well, effectively, and at scale.”

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j In our common u toward global good health, r we travel paths as diverse n as the worldâ&#x20AC;&#x2122;s languages e and as individual as our y own DNA. Those paths come riddled with obstacles and strewn with setbacks, but as these reflections make plain, they confer a collective wisdom that is the bedrock of public health.

These comments are excerpted from personal stories by the following U-M SPH students, alumni, faculty, staff, and visiting scholars: Amruta Bahulekar, Eyoel Berhan, Scott Greer, Sarah Gutin, Amaal Haimout, Sarah Ketchen Lipson, Emily Renda, Jhordan Wynne, and A.Z. Read more on pages 52â&#x20AC;&#x201C;53 and at sph.umich.edu/findings.

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FINDINGS

by Beth Miller

Ever wonder what happens to the phones and computers you discard at the recycling center?

Here’s an answer.

Photos by Rachel Long and Krystin Carlson

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hotographs hint at the scale of the operation. But they don’t convey the stench of burning tires, or the din of hammers and machetes, or the combined voices of hundreds of people laboring to extract metals and other precious materials from the world’s mounting supply of electronic waste. Nor do photographs capture the ways that tens of thousands of tons of e-waste can alter a landscape like this—a roughly eight-acre site called Agbogbloshie, in Ghana’s capital city, Accra, about four miles from the presidential palace.

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Every day, at unregulated recycling sites like this across Africa, China, and Southern and Southeast Asia, workers confront the e-waste that a fast-paced digital worldâ&#x20AC;&#x201D; primarily the United States, Western Europe, and Chinaâ&#x20AC;&#x201D; deems obsolete. The initial idea behind the transfer of used electronics was to bridge the global technology divide between low- and high-income countries, and to give outdated equipment a useful afterlife in an impoverished area. But for the most part the process has become a convenient way for wealthy nations to inexpensively dispose of their hazardous electronic trash.

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It’s true that places like Agbogbloshie bring needed employment opportunities and income to thousands, says Rick Neitzel of the U-M SPH Department of Environmental Health Sciences, but because most such sites lack proper tools and infrastructure, they pose enormous health and environmental hazards. At Agbogbloshie, Neitzel has seen workers in flip-flops take machetes and hammers to computers and lead-acid batteries, and he’s watched chemicals spatter into the air and onto people’s skin.

Workers at sites like this tend to live with their families either in adjacent neighborhoods, which

lack clean water, sanitation, and medical care, or at the recycling site itself—where the air, water, and ground are contaminated with lead, cadmium, arsenic, and mercury, and where poor sanitation fosters disease.

Last year, in partnership with colleagues at the University of Ghana School of Public Health, Neitzel and his research team set out to assess the impact of toxic heavy metals and noise exposure on laborers at Agbogbloshie. But as Neitzel notes, the health hazards extended beyond Agbog-bloshie itself. “You see cattle and poultry roaming among the e-waste, and you know those animals are being sold at markets. So not only are

the air, water, and soil on and around the site contaminated, but these hazards are getting into the food chain as well.”

The team’s research at Agbogbloshie ended abruptly last summer when the Accra Metropolitan Assembly labeled the site and surrounding neighborhood a flooding hazard and razed it, evicting nearly 15,000 people. As of this spring, it was unclear whether a new recycling center would be built in or near Accra, but if one is, Neitzel hopes to work with e-waste workers to develop and implement safer practices. Meanwhile, he’s seeking other global sites where he can collaborate on issues like pollution, sanita-

“Waste-producing countries need to take more responsibility for where the e-waste is going.”

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tion, and water. “We want to work with communities to find out what is feasible, sustainable, and will continue long after we’ve left the scene,” he says.

Neitzel believes the rest of the world needs to take action, too. “Waste-producing countries need to take more responsibility for where the e-waste is going and how it is handled when it gets there.

Consumers and manufacturers are driving the problem. We need to get more involved and connected to the process.” < For sustainable e-waste recycling at the University of Michigan: sustainability.umich. edu/ewaste.

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Mexico, like scores of countries around the globe, is in the midst of a transition that some believe is the greatest public health challenge facing the world today.

by Leslie Stainton

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bout an hour north of Mexico City by car, on a windswept plain near the town of Tula, a quartet of giant stone figures presides over an ancient pyramid. These monumental sculptures—known locally as gigantes—speak of a charged world where gods and goddesses had the power to bring on rains or ward off disease or generate life itself.

More than 2,000 years after their construction, these weathered beings remind us of the ways human existence has and has not changed. We, too, confront challenges

health. Access to high-quality health care is uneven. And infectious diseases persist. Not far from the Tula gigantes, cholera broke out three years ago.

To confront these realities, Mexicans need not stone gods but human ingenuity, technological innovation, and “structural interventions,” says Tonatiuh Barrientos-Gutiérrez of the National Institute of Public Health of Mexico, and a former U-M SPH postdoctoral fellow. “We have to rethink the provision of health services.”

Following is a look at some of the top public health issues facing a nation in the midst of an unprecedented transition—one that’s happening not just in Mexico, but around the world.

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infrastructure, environmental degradation, and the health burdens that come from millions of people living closely together.

Even in pre-Hispanic times, the megalopolis we now call Mexico City was a financial, industrial, and commercial center. Two millennia later, wealth, power, and services remain concentrated here, and the city draws more than 1,000 new residents every day.

The presence of so many people means Mexico City’s groundwater is increasingly depleted, its air polluted, and

Present like drought and disease. But we have new threats as well, and in places like Mexico, many of them are a result of what scientists call the “epidemiologic transition”—a theory developed in the 1970s to explain the dramatic health changes experienced by countries as they modernize. Chief among those are a plunge in infectious-disease rates and a coincident surge in chronic diseases.

Mexico could be a poster child. Chronic diseases—many linked to dietary patterns— account for more than two-thirds of the country’s global disease burden. Obesity and diabetes have reached such epidemic levels that by 2050 it’s estimated as much as 20 percent of Mexico’s population could have type 2 diabetes.

Chronic respiratory diseases like asthma are on the rise. Cancer rates have spiked. Environmental toxicants threaten both maternal and child

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Urbanization

As the jet from Detroit swoops in over Mexico City, traversing a virtual jigsaw puzzle of streets and neighborhoods, the enormity of the place overwhelms. At a population of over 22 million, this is the largest metropolitan area in the Western Hemisphere—one of the world’s 35 “megacities,” which collectively occupy just four percent of the earth’s surface. By 2017, more than half the world’s population is expected to live in vast urban settings like this.

The challenges these places can pose are as gargantuan as the cities themselves: traffic miasmas, unclean air and water, inadequate

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water contaminated. “It was really a beautiful place,” remembers Marisa Mazari, coordinator of the graduate program in sustainability sciences at the Universidad Nacional Autónoma de México, who has lived in the city most of her life. “It was surrounded by forests. It was fresh, we could breathe clean air, you could feel free with all the mountains. Now the air is bad, you’re not sure what kind of water you receive, and traffic is terrible.”

The average daily commute in Mexico City is four hours, round-trip. Residents of some neighborhoods spend as many as six hours a day in traffic.

That’s time that could be spent taking walks, exercising, or cooking healthy foods, suggests Tonatiuh Barrientos-Gutiérrez of Mexico’s National Institute of Public Health.

Traffic—and the pollution it generates—worsens

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The country has one of the highest obesity rates in the western hemisphere. Ten million Mexicans—ten percent of the population— have type 2 diabetes. Rafael Meza, a Mexico City native and assistant professor of epidemiology at U-M SPH who specializes in mathematical modeling, estimates that between 30 and 50 percent of infants born today in Mexico will be diagnosed with diabetes in their lifetimes.

Statistics like these are typical of the epidemiologic transition, which some scientists refer to as the “nutrition transition.” Mara Téllez-Rojo of the National Institute of Public Health of Mexico speaks of the “double burden of nutrition” in Mexico. In parts of the

study is to expedite the diagnosis of diabetes.

If the disease can be diagnosed ten years earlier than it is now, she notes, costs could drop and health outcomes improve.

Recently, Mexican legislators imposed both a ten percent tax on sugary beverages and an eight percent tax on hypercaloric “junk” food. Michigan’s Rafael Meza conducted mathematical modeling studies to gauge the probable health impact of the soda tax. He concluded that by 2050, the tax could help prevent between one and 1.5 million cases of diabetes nationwide. His projections helped persuade legislators to pass the tax, which went into effect in 2014. Initial data show the tax has helped lower sugary beverage consump-

country, there’s undernutrition. At the same time—and often in the same family—there’s obesity.

Téllez-Rojo, together with SPH Professor Karen Peterson and others, directs a longitudinal study, ELEMENT, aimed at clarifying the role of environmental exposures—including nutrition—in fetal and child development. Researchers in the study—a collaboration among U-M SPH, Mexico’s ABC Hospital, and both the National Institute of Public Health and National Institute of Perinatology of Mexico—are especially interested in the dietary patterns of pregnant women.

Peterson, who chairs the SPH Department of Nutritional Sciences, says a key goal of the

tion by six percent. Other Latin American countries are paying attention, says Meza, who recently presented his findings in Guatemala.

Heriberto Rodriguez/MCT

conditions like asthma and cardiovascular disease and may be linked to both diabetes and miscarriage.

In a city with few green spaces, fresh fruits and vegetables can be costly. Water is another “huge issue,” adds Barrientos-Gutiérrez. “I don’t think I know anyone who feels OK drinking the water from the tap.” Essentially forced to buy bottled water, many Mexicans opt for sugary sodas instead.

“We used to be self-sustaining,” Mazari says, shaking her head. “Now it’s like we’re bringing in everything. We’re bringing in energy, we’re bringing in water. We’re bringing in food.”

Twenty years ago, Mazari coauthored a study of the environmental sustainability of

Mexico’s capital and its surrounding basin.

“The urban ills that plague Mexico City may be so far advanced as to preclude any viable rescue attempts,” the authors wrote. “[It’s] an ominous prospect for a megalopolis that is paradigmatic of megacities throughout the developing world.”

Obesity

Fast, cheap food abounds in Mexico—especially since the implementation of the North American Free Trade Agreement in the mid1990s. Like people in other middle-to-high income countries around the world, Mexicans now spend more time in front of their TVs or computers and less time moving, and they consume more soda. Mexico is the world’s leading per capita consumer of sugary beverages today.

Environmental Exposures

Nestled in the middle of a basin surrounded by mountains, Mexico City is one of the most polluted cities in Latin America. Ozone and particulate matter levels exceed World Health Organization recommendations by as much as two-thirds, according to Jose Luis Texcalac-Sangrador of the National Institute of Public Health of Mexico.

U-M SPH Associate Professor Marie O’Neill is working with Texcalac-Sangrador and others to assess the impact of air pollution and other environmental exposures, among them noise and temperature extremes, on preterm birth—a costly and long-term burden, given that children

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born pre-term frequently have poor lung development and cognitive functioning.

With SPH Professor Karen Peterson and colleagues in Mexico, O’Neill is also examining environmental exposures through the collaborative study ELEMENT, now more than 20 years old. The ELEMENT scientists are tracking environmental exposures in women before and during pregnancy and gauging the impact of those exposures on infants and children—including cognitive development and risk for obesity and metabolic syndrome.

Foremost among the environmental toxicants they’re studying is lead, which in Mexico comes chiefly from ceramics and paint, and—prior to 1997—leaded gasoline. One in three people

made in the fight against chronic disease, structural interventions are necessary. Tobacco is a prime example. “We were very unsuccessful for many years in trying to control the way in which people were smoking,” he recalls, “because we were trying to change behaviors and not the environment.”

After Mexico signed the World Health Organization Framework Convention on Tobacco Control in 2004, the country began introducing more aggressive tobacco control policies, such as higher prices for tobacco

in rural Mexico is born with lead poisoning.

The team’s findings suggest that lead is stored in the bones and affects health at key moments in the lifecourse, including pregnancy, early childhood, and adolescence. Current U.S. Centers for Disease Control and Prevention guidelines for lead exposures during pregnancy come from the ELEMENT study.

products, health warning labels on tobacco packaging, bans on smoking ads, and smokefree environments. Smoking prevalence and intensity rates have both dropped as a result.

But it’s not enough, according to U-M SPH alumna and Assistant Professor of Epidemiology Nancy Fleischer, PhD ’10, who is working with scientists at the University of South Carolina and Mexico’s National Institute of Public Health to examine social environments in seven Mexican cities, including the capital. The researchers hope to learn how economic deprivation, social norms, social cohesion, and violence affect smoking cessation and quit behaviors. Fleischer is also collaborating with SPH colleague Marie O’Neill to understand the role of social context in adverse-pregnancy outcomes in Mexico City.

Findings from their work could lead to the

Tobacco Use

His two-year tenure as a postdoctoral fellow at U-M SPH convinced Tonatiuh BarrientosGutiérrez of Mexico’s National Institute of Public Health that if real advances are to be

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kinds of structural interventions BarrientosGutiérrez sees as essential to lowering Mexico’s chronic disease burden.

Maternal and Child Health

Between 2000 and 2006, the Mexican government—with major input from U-M SPH alumnus Julio Frenk, then minister of health (see sidebar, pages 24–25)—launched the country’s first comprehensive health insurance program, Seguro Popular. Suddenly millions of previously uninsured Mexicans had access to care, among them pregnant women, many from low-income communities.

“No one had been taking care of these women,” says physician Felipe Vadillo-

Ortega, an adjunct professor of environmental health sciences at U-M SPH and faculty member at the Universidad Nacional Autónoma de Mexico.

Over the past four years, Vadillo-Ortega, in collaboration with Michigan’s Marie O’Neill and others, ran a study at a Mexico City hospital where participating women received free prenatal care as many as eight times during their pregnancies—up to four visits more than stipulated by Seguro Popular.

The approximately 900 women in the study saw specialists in obstetrics and gynecology, nutrition, and fetal medicine. Vadillo-Ortega describes the study as a model of care that

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about the incidence of diarrheal disease and the growing presence of enteric pathogens and antibiotic resistance in the area. A multidisciplinary team of scientists, among them U-M SPH epidemiologists Joseph Eisenberg and Rafael Meza, is conducting a longitudinal study of the health impacts of a new $782 million wastewater treatment plant, which opened this year in the valley. Because some communities in the area now receive treated wastewater and others receive untreated wastewater, Eisenberg and Meza have an unprecedented opportunity to evaluate the plant’s impact on the incidence of diarrheal diseases in children and on the presence of enteric pathogens and antibiotic resistance in communities across the valley.

“We have a lot to learn from each other” A conversation with Julio Frenk, Minister of Health of Mexico, 2000–2006

Leslie Stainton

may reduce complications like preterm labor, preeclampsia, and gestational diabetes, and improve birth outcomes.

Marisol Castillo-Castrejón, a Mexican nutritionist and U-M SPH postdoctoral fellow, is contributing to the study by exploring associations between environmental factors— including green spaces and food environments—and lifestyle patterns and outcomes in pregnant women who live in highly populated urban areas. A better understanding of such factors may inspire interventions to improve health and reduce health

care costs. The researchers also hope their findings will contribute to new national regulations for prenatal care and increased access to and usage of green spaces in Mexico City.

Infectious Disease

Although infectious diseases may have diminished as a result of the epidemiologic transition, they haven’t gone away. At scenic Xochimilco, the last vestige of the pristine lake that once surrounded Mexico City and is now fed by wastewater from the capital, scientists are on the lookout for pathogens like enterovirus and rotavirus. Health officials are worried, as well, that with climate change, which has already led to increased downpours and flooding during Mexico’s rainy season, diseases like Dengue fever and Zika may reach the capital.

An hour north of Mexico City, in a 400square-mile valley irrigated by untreated wastewater from Mexico City, officials are concerned

The issue is not as simple as it may seem. “As clean water becomes an increasingly scarce resource, the value of wastewater cannot be ignored,” says Mexican geologist Christina Siebe of the Universidad Nacional Autónoma de México, who is collaborating on the study.

Thanks to growing urbanization, there’s more wastewater worldwide than ever before, and little if any of it is treated, Eisenberg explains, so this research has global ramifications. Findings from previous research in the valley informed the original guidelines for wastewater re-use set by the World Health Organization in 2006 and will inform a planned revision of those guidelines. < For a video on SPH in Mexico City: sph.umich.edu/findings.

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uring his tenure as Mexico’s minister of health, from 2000 to 2006, SPH alumnus Julio Frenk, MPH ’81, PhD ’83, helped launch the country’s first comprehensive universal health insurance, Seguro Popular. The initiative predates the Affordable Care Act by nearly a decade.

Earlier this year, Frenk, now president of the University of Miami, spoke about the impact of Seguro Popular in Mexico and what lies ahead.

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Mexico has undergone a rapid change from a middle-income to an upper-middle-income country, with many attendant health concerns.

How has Seguro Popular addressed the accompanying epidemiological transition?

The big agenda is to improve quality of care.

We’ve improved access. Now we need to ensure that the services to which people have access are of the highest quality. (It won’t surprise you that I emphasize quality because I studied with [quality expert Avedis] Donabedian, my beloved mentor at Michigan.) There are places in Mexico where quality of care is excellent, and there are places where it’s really lacking. My observation is that the big difference is quality of leadership—so emphasizing leadership through education is key.

Another big area—and it’s equally relevant for the Affordable Care Act—is in developing a whole new generation of preventive

You’ve held leadership positions in both government and academia.

Any advice for U-M SPH students who might be trying to decide between those two areas?

The common thread in my career is my strong belief that knowledge is the most powerful instrument for enlightened social transformation. Sometimes you’re on the side of producing that knowledge, and sometimes on the side of using that knowledge. In either case, we need to translate that knowledge into evidence. My advice to students is to embrace the notion of career plasticity. It’s the same thing, by the way, between working in a domestic setting and an international setting. My first academic position

Leslie Stainton

Mexico, like a lot of middle-income countries, has experienced the most intense health transition in human history. We’ve basically gone from a health situation dominated by acute infectious diseases that affect mostly children, to one dominated by chronic, mostly noncommunicable, diseases that affect children and adults.

Seguro Popular achieved several things. First, it substantially increased funding for health.

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Secondly, half the population was uninsured, and paying for care had become the #1 cause of personal bankruptcy. Those uninsured people are now covered, and all evidence shows a major reduction in catastrophic expenditures.

We were also underinvesting. As minister of health, my main job was to use good evidence to persuade President Vicente Fox and Congress that health care was a priority for investing. We did that through a combination of more efficiency—we cut administrative costs—and a reallocation of monies from other priorities to health care. Health care became the fastest growing area of the federal budget, and most of it was driven by Seguro Popular.

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strategies. If you do not invest in stopping people from getting sick in the first place, the system will go broke.

What role, if any, do other nations have in helping to bring about these improvements?

I believe Mexico and every other country, including the U.S., needs to be a participant in a global dialogue about the best ways to improve health.

We all have a lot to learn from each other. That’s why we wrote into law a requirement to evaluate health reform in Mexico. The reason was not only internal, to be accountable to taxpayers, but it was because that way we could build a body of evidence on what works and doesn’t work—and that evidence becomes a global public good.

Other countries can derive lessons to adapt to their own circumstances. That process of shared learning is a major part of global engagement.

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was at the University of Michigan. Since then I’ve been back and forth—national, international, academia, policy. That’s the concept of career plasticity, which I frankly think is a good thing—because you learn to see the world from the other side.

What do you see as the greatest health challenge facing the world today?

Failure of effective global governance. By that I mean countries failing to understand that we are interdependent, and we need to work together.

Look at Ebola. We are interdependent, when it comes to health matters, like never before. Michigan’s own [Professor] Ken Warner, one of my heroes, has shown that the only way to deal with a global threat like tobacco consumption—and a global force like the tobacco industry—is through international cooperation. You cannot be effective if you are not active on the global scene. <

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Long before combat erupts—and decades after it ends—

by Sara Talpos

Refugees during the final days of the Battle of the Bulge in Belgium, 1945

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those who inhabit the world’s conflict zones bear its burdens.

1978

It was time to leave Syria.

The professor of Islamic history and Arabic literature had spoken publicly against his country’s regime, criticizing its human rights record and its denial of civil liberties. In the past, he had been harassed and even arrested for voicing dissent. But this time, government officials had gone a step further, issuing an ultimatum: Keep quiet, or die.

“Bashar al-Assad’s father, Hafez, was in power back then, and he ruled with an iron fist,” explains Ali Abazeed, who is in his second year of a dual MPH/MPP degree program at U-M SPH. As he describes the challenges his parents faced in Syria, Abazeed is quick to acknowledge that the current president is just as ruthless at stifling dissent and popular protest.

Abazeed’s parents fled to northeastern Algeria, a country with which they’d had no previous connection. They spent the next eight years settled in a mountainous city there, high above sea level. Years later, Abazeed’s mother would recall the cool breezes—or hawayyat, Arabic for wind—that descended into their village on hot summer days.

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What words does a 13-year-old use to speak about death? To describe grief?

Afghanistan was in the midst of an internal civil war when M.’s younger brother fell ill from an infectious disease. The family lived

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A girl undergoing treatment for leishmaniasis, Kabul, 2002

in Kabul, where medical professionals were scarce. His parents knew of a physician in a nearby village. They sent M., their oldest son, by bike—but the physician was away. By the time M. returned home, his brother had died.

His mother was also sick and died a few years later. “She used to say, ‘I am praying that you will be a doctor,’” says M., who spent last fall at U-M SPH analyzing data as a visiting scholar with CRDF Global, an independent nonprofit that promotes international scientific and technical collaboration. Following his mother’s wishes, M. went on to become a general practitioner with a specialty in infectious disease. He quickly discerned that solving his country’s biggest health problems required a public health framework. Medicine alone was not enough to serve the needs of people living through decades of war.

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War has a profound effect on global public health. Violent confrontations cause death and disability, but so do war’s secondary effects, which include infectious disease, malnutrition, untreated chronic conditions, and mental health problems such as PTSD and depression. Providing just one

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example, in 2014, a PLOS Pathogens paper announced “a public health emergency of global concern”: an outbreak of infectious diseases throughout Syria and the surrounding countries. As a direct consequence of war, medical facilities had been attacked. One hundred and sixty doctors were killed and hundreds more jailed. Vaccine coverage in Syria dropped as low as 45 percent in some parts of the country. Polio reappeared after 15 years of eradication.

As refugees began fleeing Syria in 2011, diseases spread across the region. In 2012, Lebanon recorded just nine cases of measles.

One year later, the number of cases rose to 1,760, with the vast majority occurring among Lebanese nationals. Unrest in surrounding countries “exploited deficiencies in Lebanon’s measles immunization coverage,” explain the paper’s authors.

The incidence of a disfiguring vectorborne disease called cutaneous leishmaniasis also rose, particularly in Lebanon’s Bekaa Valley, where today nearly 75,000 Syrian refugees live in informal tented settlements.

From the paper’s final section: “Without security, there can be no health.”

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Left: Syrian refugee children in a shelter in Lebanon, 2012 Facing page: Afghan children carrying water through a cemetery in Kabul, 2015

Andrew McConnell

After that long and stressful mission, Nellett returned to Kandahar about a month before coming home. This gave him a chance to decompress. In the end, he says, he was lucky to have time to adjust to life outside an active war zone. “Some guys will be in combat, and then two days later they’re in America. It’s a lot to take in.” Even an operating toilet can be a noteworthy experience for a veteran returning from Afghanistan or Iraq. For Nellett, it was the smell: “I didn’t expect to smell America,” he says. It’s scented with pine needles.

The 17-year-old refugee from Aleppo wore a red and white wristband with a cedar tree in the style of the Lebanese flag.

Inside the tented settlement in the Bekaa Valley, where he was staying, he spoke with Ali Abazeed, who visited the camps this past summer as part of a 12-week internship at the American University of Beirut. “He wore the wristband so that maybe one day, when he encounters a Lebanese checkpoint, the guards will see the bracelet, think he’s Lebanese, and let him pass through,” explains Abazeed. In the meantime, the young man was stuck.

“I don’t think you can separate policy from health,” continues Abazeed. Take the example of infectious disease: can we identify the conditions that contributed to the current outbreaks of measles, cutaneous leishmaniasis, and other diseases among refugees? Answering the question, he believes, requires a thorough understanding of health outcomes as an outgrowth of the region’s politics, history, and economics.

Abazeed’s connection to Syrian politics is personal. In March of 2011, a group of schoolchildren in his parents’ hometown of Daraa spray-painted the wall of an abandoned school: The people demand the downfall of the regime, they wrote in Arabic, using the slogan chanted in Egypt, Libya, and other countries as the Arab Spring unfolded. The schoolchildren were arrested. When the town elders went to the police and requested the release of their children, they were told, “You should go back home and get to work on new children because you’re never going to see these children again.” That was the beginning of the Syrian uprising.

Three of the schoolchildren were Abazeeds.

On the Ground

2008

“We knew we were in trouble when they airdropped disposable razors,” says U-M alumnus Tim Nellett (BA ’15), program coordinator for the university’s Peer Advisors for Veteran Education (PAVE) program. Nellett was serving in Afghanistan, his second deployment with the Marine Corps Infantry. His company had been told to pack for a ten-day mission. They were to uproot the Taliban from an area in the Helmand Valley, then return to Kandahar. But after ten days, plans changed.

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“Some guys will be in combat, and then two days later they’re in America.

It’s a lot to take in.”

Nellett and his company spent the next four and one-half months in the rural area, building fortifications, setting up checkpoints, going on patrols, and working with locals to protect the area from Taliban incursions. Occasionally this meant combat.

“When you’re on deployment, your friends and family miss you,” says Nellett, “but you miss everything—the entirety of your life, because you’re so completely removed.”

2013

Kaes Almasraf misses Iraq. “I love America,” he says, “but in Iraq, I have memories, I have friends, I have relatives, I have my work.”

The former dentist and manager of a primary care clinic in Baghdad brought his family to Michigan in 2013, when he began to fear for their safety. “You feel like you become a stranger in your country,” he says, describing how decades of war have heightened religious tensions within Iraq. “In our country, the people suffer from a lot of wars, beginning in 1980 with Iran—then, then, then.” People are tired and poor he says, and the “miserable conditions can lead weak people to do things like kidnapping.” He wants his wife and daughter to be safe.

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Even in peacetime, a county’s landscape may remain pockmarked with evidence of war. Lebanon is much safer for its citizens than Iraq, but along its borders, the military has been demining the area since 1990. “A lot of these munitions look like toys to children,” says second-year SPH student Phoebe Harpainter, who spent last summer conducting an internship with the Land Mines Resource Center at the University of Balamand.

Having studied the public health effects of land mines for decades, her supervisor, Habbouba Aoun, has helped establish a national prosthetic and orthotic technical unit to treat those with potentially disabling injuries. More than 3,600 people have been injured or killed by land mines in Lebanon since 1975. Mine injuries now occur less than

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Left: A Kurdish Syrian mother and her son in a refugee camp in Turkey, 2014 Below: Syrian refugees at a rail station in Budapest, Hungary, 2015

once a month—but the infrastructure Aoun and others created has found a new use.

Among Syrian refugees in Lebanon, one in 30 has been injured by war. Others, particularly children, have conditions such as scoliosis and cerebral palsy that require orthotic prosthetics. These devices make it more likely that the treated children will attend school.

2015

M. describes himself as “thankful from God”: for the opportunity to be a scholar, to conduct research that could benefit the Afghan people. Still, he acknowledges that at times, it has been difficult to concentrate on his professional work. Early during his fellowship at SPH, the Taliban took control of the northern provincial capital of Kunduz. “Hundreds of innocent people living in their houses were killed,” says the soft-spoken researcher.

“Children, women, old people killed because of the war.” Afghanistan has been a conflict zone for more than 30 years.

Among Syrian refugees in Lebanon, one in 30 has been injured by war.

Between Worlds

2015

“My God, this must be hell during the winter,” Ali Abazeed thought when he visited the informal tented settlements in the Bekaa Valley last summer. The settlements sit between two mountain ranges. “It’s a de facto wind tunnel.” When Abazeed and his Lebanese colleagues visited the camps to interview refugees about their health needs, the first thing the refugees would do was offer the researchers drink and food. “These are people who have almost nothing,” Abazeed remarks. Despite the hospitality, it was clear conditions had taken a toll.

Abazeed wants to devote his career to finding ways to improve the plight of refugees. His ideas include the establishment of a refugee studies center aimed at improving the existing model for accepting and welcoming refugees.

He would also like to see a global effort to create infrastructure for helping them get jobs. “When you’ve been stripped of your livelihood and put into an unfamiliar territory and you’re not doing anything productive, you lose confidence that you are of some use in this world. It has an impact on your health. I think that mental health is the biggest issue in these communities. It’s a language that’s not yet spoken fluently.”

The most common mental health problems associated with refugees include post-traumatic stress disorder (PTSD), depression, and generalized anxiety disorder.

Risk factors include the number of traumas a refugee has experienced, an often prolonged asylum application process, detention, and the loss of culture and support systems.

According to the Refugee Health Technical Assistance Center, which is funded by the Office of Refugee Resettlement, a branch of the U.S. Department of Health & Human Services, “different studies have shown rates of PTSD and major depression in settled refugees to range from 10–40 percent and 5–15 percent, respectively. Children and adolescents often have higher levels, with various investigations revealing rates of PTSD from 50–90 percent and major depression from 6–40 percent.”

Abazeed reflects on the situation: “‘Refugee’ is an inherently tragic word. It means you’re not welcome at home, and you’re essentially not welcome in this other place that you’re going. And so you exist in this black hole without a home, without the familiarity of daily life. How can you not suffer from some form of psychological distress?”

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The Afghan people are thankful for the support of the United States, M. says, but he would like to see more mutual understanding between the two nations’ peoples. He is troubled by a phrase he has heard in the U.S.: Islamic terrorism. He wants Americans to know that Islam means peace, that the majority of Afghan people do not support terrorism. Rather, they are being sacrificed in the conflict. “We are proud Muslims, but not terrorists. We condemn terrorists.”

M. brought data from Afghanistan to SPH, hoping to better understand ascariasis, one of the most common worm infections in people worldwide. While at Michigan, he worked with SPH epidemiologist and Senior Associate Dean for Global Public Health Matthew Boulton to analyze the results. M.’s goal was to return to Afghanistan and improve public health, and especially to eliminate death and morbidity caused by a widespread lack of awareness of transmissible disease. This won’t be easy in a country whose people face continuing violence.

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Peace Through Scientific Collaboration The University of Michigan School of Public Health is one of a handful of U.S. training sites for CRDF Global, a nonprofit organization that promotes international scientific and technical collaboration—with the ultimate aim of fostering global peace and prosperity. Through CRDF’s global fellowship program, funded by the U.S. Cooperative Biological Engagement Program, scientists from developing countries have the opportunity to study, conduct research, and work with colleagues at U.S. institutions like SPH. More specifically, CRDF has asked SPH, under the leadership of the school’s Office of Global Public Health, to be a regular training site for public health professionals from Afghanistan and Iraq. In 2015, SPH hosted two CRDF global scholars from Afghanistan.

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“When I see pictures of these poor refugees, I can identify,” says Irene Butter, SPH professor emerita of health management and policy.

More than 70 years ago, Butter and her family, German-born Jews, were deported to Bergen-

Butter herself was separated from her mother and brother, and sent to a displaced persons camp administered by the United Nations Relief and Rehabilitation Association, a precursor to today’s UN. Butter has saved the letters she wrote to her mother from the camp. They share a common theme: “Where, when, and how are we going to be reunited?” she asks, her voice reflecting the urgency of that time.

“Where are we going to live?” Butter and her mother and brother didn’t have citizenship and didn’t want to return to Germany, “even if it were possible,” Butter recalls. They had family in America, but the war was ongoing, and communication was slow.

How many more days for the world’s newest wave of refugees?

War’s burdens: From top, Irene Butter (left) with her mother and brother, Gertrude and Werner Hasenberg, pre-war; Butter and her father, John Hasenberg; one of numerous letters Butter sent her mother from a displaced-persons camp in Algeria; Butter (seated, far right) at the camp in Algeria, 1945

Belsen. By the time they were released, in 1945, typhus and dysentery had spread through the concentration camp, and her father, weakened by disease, died shortly after being freed.

Butter’s camp was not in war-torn Europe, but in northeastern Algeria. She remembers something very unusual—a hot wind that covered the land with sand and dust. When it’s blowing, she later recalled, “you don’t want to be outdoors.” The wind is called khamsin—Arabic for “fifty,” the number of days the wind is said to stay.

How many more days for the world’s newest wave of refugees? Where will they be settled? Will they find jobs? What effect will they have on the culture of their new countries? Butter acknowledges these are difficult questions.

Who will take responsibility? Who will find the answers?

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Romanian refugees after the Soviet occupation of Bessarabia, 1942

Home

2015

“We were scattered to the four winds,” says Tim Nellett, describing the individuals in his military unit after they returned from deployment. After leaving the Marines, Nellett was ready to put the military behind him.

But as a U-M student, he realized he missed parts of his former life, “mainly my friends and the people I served with and how close we were.” Inevitably, they returned to their various hometowns across the United States, which was quite a difference from spending every waking moment of their lives together. Says Nellett, “To have them be completely gone is a lot, is a blow.”

Nellett discovered U-M’s Student Veterans of America chapter during his senior year. Though he was worried that it might be comprised of people “who are still ridiculously in love with the military,” he soon learned that it was “people like me—vets that don’t want to do anything with the military, but just want to hang out with other vets.” As Nellett’s involvement grew, he felt more connected to the university.

He eventually became a peer advisor for PAVE, a newly formed peer-to-peer program providing outreach, support, and resource linkage for student veterans. Following graduation, he became the national program coordinator.

SPH alumna Marcia Valenstein, a professor of psychiatry at U-M and research scientist at VA Health Services, Ann Arbor, helped develop PAVE. She has extensive clinical experience treating veterans and is a national expert on peer-to-peer programs. Such programs, she explains, “are highly acceptable to veterans, who often believe that it takes another veteran to understand what they have experienced and to assist in the transition back to civilian life.” Nellett believes PAVE is similar to the military’s buddy system, where people work together and look out for each other. “I think that people miss doing that.

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That’s where we get the really fired-up vets who are engaged and want to give back.”

Nellett has mixed feelings about the public’s increased awareness of veterans living with PTSD, depression, and TBIs. Speaking about PTSD in particular, he says that on the one hand, awareness is good. “You used to not even have a word for PTSD. It was ‘shell shock,’ and people didn’t really understand it.”

Now, with increased awareness, there’s more research, support, and treatment options. But Nellett and other veterans have experienced a downside. In the minds of the public, mental illness has essentially become the face of the wars in Afghanistan and Iraq. Civilians sometimes assume that all veterans must have mental health disorders, and that’s just not the case, says Nellett.

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Among veterans of Operation Enduring Freedom in Afghanistan (2001–2014) and Operation Iraqi Freedom (2002–2010), 11 to 20 percent experience PTSD in a given year. This is a higher rate than among the broader American population, where seven to eight of every 100 people experience PTSD at some point in their lives. Still, there’s no doubt that PTSD has a broad reach. “It’s framed as a military problem, but it’s really not,” says Nellett. He believes it’s important to keep this in mind because it can help veterans feel less alone with their problems.

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Irene Butter also gives back.

She speaks at Ann Arbor schools about her experiences as a Holocaust survivor. She cofounded both the Raoul Wallenberg Medal and Lecture at U-M and Zeitouna, a group of Jewish and Palestinian women who live in Ann Arbor. Their motto: Refusing to be enemies. The group has existed for 13 years, meeting every other Wednesday to use dialogue as a process to learn from each other and to address complicated issues.

In 2013, Kaes Almasraf took a job at the Arab Community Center for Economic and Social Services (ACCESS) in Dearborn as a case worker for the Refugee Health Empowerment Program. Most of his clients come from Iraq. A long-time community partner of SPH, ACCESS helps refugees gain employment and education in health care and other fields through training, internships, and other programs.

Says Almasraf of refugees, “Each one of them when he arrives here is trying to put his feet on the ground, to be helpful to his family, to be helpful to himself, to grow. . . . We can build—or try to build—a new life for them.

Because they need it. We don’t want such newcomers to be lost here. We don’t need to hear that a refugee came here and started saying, ‘I don’t like America.’ No. If we put our hand in their hands, they will love America.

We need to give them a good sign about the good country they are in right now.”

When Ali Abazeed’s parents arrived in Dearborn, Michigan, in the 1980s, they immediately felt comfortable. Ali’s father cites his appreciation for the social systems, the relationships between people, and political freedoms—for example, the freedom to pursue education or open a store. He wonders what will become of his family remaining in Syria, of the thousands of refugees who are still waiting—caught between checkpoints, living in tents. In Syria, military personnel had monitored his movements, but in this new place, nobody asked, “Where are you coming from? Where are you going?”<

Sara Talpos is a writer based in Ann Arbor.

For a video interview with Ali Abazeed: sph.umich.edu/findings.

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RESEARCH NEWS g l o b a l h e a lt h i n a c o n n e c t e d w o r l d

Influenza in the Tropics W

ith pneumonia now the #1 infectiousdisease threat to children worldwide—and respiratory diseases a greater threat to kids’ health than diarrheal diseases—Aubree Gordon knows her work on seasonal influenza in Nicaragua is urgent.

Twelve years ago, when she began her research, there was much debate among scientists as to whether influenza was a significant threat in tropical countries. Conventional wisdom held that flu “only transmits when it’s cold and dry,” recalls Gordon, an assistant professor of epidemiology at SPH. No one had even tested for influenza in Nicaragua. Gordon launched the first comprehensive flu testing in the country and helped create both a dedicated influenza laboratory and a nationwide surveillance system.

Although at first she focused on the burden and seasonality of flu in Nicaragua, Gordon has since expanded her work. In four ongoing studies in collaboration with Nicaraguan colleagues, including the Ministry of Health, she is examining transmission patterns, repeat infections, and the development of immunity.

She and her colleagues are also working to understand the percentage of pneumonia in Nicaragua that is associated with influenza.

Their work to date has contributed to the introduction of seasonal flu vaccines in Nicaragua and has helped strengthen the country’s ability to respond to outbreaks of influenza and other respiratory diseases.

“From a scientific perspective,” Gordon says, “we’re not only broadening the understanding of influenza in tropical regions but also our understanding of susceptibility to influenza in general. Although some of our findings are specific to the tropics, others translate to temperate and developed settings as well.” <

Children in two ongoing studies, the Pediatric Cohort Study and the Birth Cohort Study, receive medical care as part of their participation. All told, more than 8,000 Nicaraguans will take part in Gordon’s research studies in 2016.

Once a year, blood samples and other data are collected from participants in the Pediatric Cohort Study and the Birth Cohort Study.

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The Zika Virus: What Do We Know?

Photos by Morgan Arnold

First discovered in 1947 and named after a forest in Uganda, Zika virus spreads primarily through the Aedes mosquito, and until recently was of little concern to public health officials. Prior outbreaks of Zika virus disease in tropical Africa, Southeast Asia, and the Pacific Islands had produced symptoms so mild that people who contracted the illness seldom went to the hospital and rarely died. But in May 2015, Brazil reported its first confirmed Zika virus infection—and health authorities noted potential links to birth defects and poor pregnancy outcomes. On February 1, 2016, the World Health Organization declared Zika virus a public health emergency of international concern. On April 13, 2016, the U.S. Centers for Disease Control and Prevention announced that Zika virus causes microcephaly and other birth defects. U-M SPH scientists Aubree Gordon and Arnold Monto, both experts in infectious-disease transmission, offer these insights: “To do the studies we need to do to learn more about Zika, we need to get the diagnostics figured out, and people are working on that. Beyond that, there’s a lot we don’t know about pathogenesis. We don’t know where humans are infected or how long you can test for Zika. How important is sexual transmission? We know it occurs, but not how often. We know that men can transmit the virus, but we don’t know if women can. We know that other types of mosquitoes can be infected with Zika—we don’t know if they can transmit. We don’t know what the absolute risk is of transmission to the fetus. Are there other developmental deficiencies that aren’t apparent at birth? At what point in a pregnancy is a woman at risk? How important are asymptomatic infections?”

To help track their research studies in Nicaragua, Gordon and her team have developed a customized informatics system, which is also available to the country’s Ministry of Health.

Aubree Gordon, Assistant Professor of Epidemiology, U-M SPH “What we thought was a simple problem has turned into a much more complicated problem. In countries which have the known mosquito vector for Zika, there’s a major crisis—similar to rubella or German measles before the vaccines—in terms of frequent fetal malformations. The World Health Organization has rightly called this a global public health emergency. One issue is whether Zika can be transmitted by more common mosquitoes, possibly mosquitoes in temperate zones. Another is whether there are additional person-to-person routes of transmission besides sexual. Does the fetal malformation we’re seeing in countries like Brazil involve factors in addition to Zika—some past infection or environmental exposure, for example? We’ve got a lot to learn. And while the global response has been exemplary, Zika is a reminder that global emergencies will continue to occur, and we need to implement a global health infrastructure to respond to them.”

Arnold Monto, Thomas Francis Jr. Collegiate Professor of Public Health, U-M SPH <

Field workers collect flu samples and information as part of Gordon’s ongoing study of household influenza transmission in Nicaragua.

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researchDigest Cross-Cultural Comparisons When Shervin Assari first came to the U.S. in 2010 as an international student, he was struck by the country’s demographic diversity. Since then, Assari, who holds an MD as well as an MPH (’11) from SPH and is a former postdoctoral fellow at the U-M Center for Research, Ethnicity and Health, has carved out a research niche for himself by comparing perceptions of health and well-being among residents of more than a dozen different countries.

Now a faculty member in the U-M Department of Psychiatry, Assari is chiefly interested in how cultural and social contexts, notably socioeconomic status, affect health—with a particular focus on chronic medical conditions, including depression.

Good Governance, Sound Policy

H In the United States, income is a far more significant determinant of both chronic disease and perception of wellbeing than in poorer countries.

His findings are illuminating. In the U.S., for example, income is a far more significant determinant of both chronic disease and perception of well-being than in poorer countries. In most countries in the world, women report worse perceived health and well-being than men. But whereas in Costa Rica, Argentina, Barbados, Cuba, Uruguay, and Puerto Rico, existing medical conditions explain the gender disparity, in other countries medical conditions do not. Overall, says Assari, “my research suggests that the social determinants of health work differently across different populations, and that who we are and where we live shape both our vulnerability and our resilience.” <

aving grown up both in England and Wisconsin, Scott Greer learned early on to make crosscultural comparisons. “I wondered why certain things were done in one way in one country and differently in another,” he remembers. Today, he says, countries like the U.S. can learn a lot from places like Europe—and vice versa. An expert in the politics of health policies, Greer is an associate professor of health management and policy at U-M SPH and Senior Expert Advisor on Health Governance for the European Observatory on Health Systems and Policies.

He’s also the senior author of a new book commissioned by the World Health Organization, Strengthening Health System Governance: Better Policies, Stronger Performance, which Greer describes as a “truly useful toolkit” that both governments and health leaders can use to draft and implement effective new policies. All too often, good policies fail for any number of reasons, Greer says—because they’re underfunded, or they’re struck down in court, or they fall prey to corruption, or they get lost in a dysfunctional government.

“The world is full of great leaders who are undercut by the system they’re working in—and of people who aren’t good leaders, but who do a good job because of the system they’re working in,” Greer explains.

“We want the latter—and if you get a great leader and a great system, then bravo!”

Distilled from a vast body of literature, Strengthening Health System Governance offers a fivepart framework policymakers and government officials can use to evaluate policies: transparency, accountability, participation, integrity, and capacity, or TAPIC. The book includes case studies from across Europe and covers a range of specific health policy topics, among them pharmaceutical procurement, hospital management, primary-care reform, intergovernmental relations and communicable-disease control, and response to austerity.

Already in use in Estonia, Finland, and Belfast, the book will be available for free download later this year at bit.ly/Greer-book. WHO officials are also using it to evaluate the European Union. <

“The world is full of great leaders who are undercut by the system they’re working in.”

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HIV in Russia: A Growing Epidemic

researchDigest Midlife Health

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lizabeth King’s attraction to Russia runs deep. As an undergraduate, she majored in Slavic languages and literatures. She also lived in Russia for four years before starting her MPH. Now an assistant professor of health behavior and health education at U-M SPH, she’s focused on the prevention and treatment of HIV among females who inject drugs and those who engage in sex work—populations with double the risk of contracting the HIV virus.

The situation “is pretty gloomy,” King says. The UNAIDS 2014 Gap Report showed that Russia was one of a half dozen countries, including Indonesia and Nigeria, where the HIV epidemic is still growing, and treatment coverage is low. The findings surprised King, since Russia is a high-income country that theoretically has the resources to address the problem.

Russia is one of a half dozen countries where the HIV epidemic is still growing, and treatment coverage is low.

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Women’s Midlife Health

Findings from Qatar and Lebanon

King spent the summer of 2015 in Russia researching access to HIV testing and, for women diagnosed with HIV, the barriers to getting enrolled in HIV treatment programs. Her goal is to create programs that would support women to enroll in HIV treatment and adhere to the treatment services. The efforts in Russia have fallen short. Many of the original harm-reduction activities offered by treatment programs, including needle exchange and distribution, condom distribution, health education, and referrals for HIV testing, did not fully account for womenspecific needs.

So outreach vans specifically for women were created. For her dissertation fieldwork, King spent a year traveling around in these mobile vans, which are designed to reach out to women with heightened risk for HIV acquisition in different hot spots around the city. Because the vans “catered toward women involved in street-based work,” King says, they have proven to be “an effective outreach service that reaches women where they are.”

She and her colleagues in Russian nongovernmental organizations and Russian universities are currently working on a research grant to develop a pilot program for interventions for women who are most at risk. “We’re looking at the gender constraints on their access to HIV treatment, doing a gender assessment of access to their services to understand where we could really make a difference,” King explains.

Her work is consistent with overarching global health goals. “Curbing the HIV epidemic is a global public health goal, and Russia is one country where the epidemic is growing most rapidly,” she says. —Julie Halpert <

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Siobán Harlow, professor of epidemiology and director of the U-M Center for Midlife Science, has launched a new BioMed Central journal, Women’s Midlife Health (womensmidlifehealthjournal.com), featuring articles and reviews on the physical and mental health of women during midlife, with a focus on aging, reproductive aging (including menopause), and their interrelationship. The journal is interdisciplinary and open-access.

Students at select universities in Qatar and Lebanon appear to have a higher prevalence of mental health issues—including depression and anxiety—than students at U.S. universities, according to early findings in a study by Qatar-based psychiatrist Ziad Kronfol and SPH Professor Daniel Eisenberg.

Eisenberg, who also directs the U-M Healthy Minds Study, says he and his colleagues don’t yet know how to interpret their findings, but it’s possible that stigma, which can affect a young person’s decision to seek help for mental health issues, is a factor.

Proximity to conflict in the Middle East may also be a factor. Cross-comparison global studies of mental health can be revealing, Eisenberg says, particularly in assessing the impact of changing attitudes and treatment options. He soon hopes to expand his work on the mental health of young people to include studies in China.<

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researchDigest International Student Health Nearly one million international students study in U.S. colleges and universities, more than in any other country in the world. (U-M is among the top 15 schools nationwide in terms of international student enrollment.) International students face a number of unique challenges, including cultural adjustments, which create an increased risk for depression, anxiety, and other mental health problems.

Just 28.3 percent of international students with significant symptoms receive mental health treatment.

A New Model for Global Health

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lobal health requires a keen eye for the greatest needs, and creative solutions to meet those needs. Frank Anderson, a clinical associate professor of health behavior and health educa- tion at U-M SPH and associate professor of obstetrics and gynecology at the U-M Medical School, is the leader of a project, 1000+OBGYNS, that goes above and beyond those criteria. The goal of the project—a partnership between U-M and major universities and teaching hospitals in Ghana—is to protect the health of mothers and babies in sub-Saharan Africa, where over one million newborn deaths and 300,000 maternal deaths were reported in 2013. These are among the highest birth-related mortality rates in the world.

But they needn’t be. When doctors have access to best practices and advanced training in obstetrics and gynecology, Anderson says, many birth-related deaths are preventable. That’s why he and his project team want to train 1,000 new OB/GYNs in sub-Saharan Africa in the next ten years and measure the impact on maternal and perinatal mortality. To date the team has trained and retained over 140 OBGYNs in Ghana, leading to improved outcomes throughout the country.

Anderson and his colleagues seek to replicate this “Michigan Model” with academic partnerships between African and American institutions in 14 countries in sub-Saharan Africa.

The project team has also provided a series of free collections related to OB/GYN practice on the project website, 1000obgyns.org, and they plan to distribute complete website content on USB drives to OB/GYNs throughout sub-Saharan Africa and to make content available on local wireless networks. “Every country deserves robust, well-functioning obstetrics and gynecology departments that can train people and provide leadership,” says Anderson. “What we’re proposing can be replicated anywhere and with any discipline.” < —Peggy Korpela

Anderson and his project team want to train 1,000 new OB/GYNs in sub-Saharan Africa in the next ten years.

Nyani Quarmyne/UNICEF

These findings raise important questions for policymakers and postsecondary institutions, about whether and how to invest more in mental health services and programs to support large and growing populations of international students at U.S. colleges and universities. < —Sarah Ketchen Lipson

UNICEF/GHAA2015-00680/Quarmyne

According to data from the Healthy Minds Study, an annual national mental health survey run out of U-M SPH, 44.4 percent of international students in the U.S. screen positive for mental health problems (versus 41.9 percent of U.S. students). The most glaring difference between international and U.S. students is in mental health service utilization: just 28.3 percent of international students with significant symptoms receive mental health treatment, as compared to 44.9 percent of U.S. students.

Levels of stigma surrounding mental illness are much higher among international students. Nearly 30 percent indicate that they would “think less of a person who has received mental health treatment,” as compared to just 6.9 percent of U.S. students.

Pregnant women at a prenatal clinic in Ghana.

Research News

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g l o b a l h e a lt h i n a c o n n e c t e d w o r l d

Best Methods: StatCore Launched in 2015, and led by SPH Professors Yi Li and Bhramar Mukherjee, a new SPH initiative called Global StatCore aims to provide biostatistics education and support to institutions across the globe, especially those lacking the depth of statistical knowledge necessary to reach their full potential in public health research.

Pippa Ranger

By teaching people to “seek the best method out there, global health research can truly benefit.”

Meaningful Change in India

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lthough much of Bhramar Mukherjee’s research centers around genetic-environmental interactions, a recent project takes a more sociocultural focus. “I have always struggled with finding true social relevance in my work in biostatistics,” says the U-M SPH professor of biostatistics and epidemiology.

Mukherjee is especially aware of the maternal and child health burdens that face underserved populations in her native India, particularly in rural areas where access to physician care is extremely limited. The routine checkup that most Americans take for granted, she says, is virtually nonexistent in parts of India.

To address the problem, Mukherjee developed a study to test the feasibility of using community health workers to screen pregnant women and young children for risk factors and to direct those who need it to appropriate medical care. She received funding for the study from the Trehan Foundation and the MCubed Diamond Program, which pairs donors with U-M research projects, and launched the study in 2015.

To date it’s been a success. Women are eager to participate and to get care they may not otherwise have been comfortable seeking. This kind of empowerment, Mukherjee says, is a key goal of the project. But she and her team have found that the community health workers, too, are newly empowered. Although these women were recruited to serve as cultural liaisons, the health workers now say they have a larger purpose within their home communities, and they regard the help they’re providing as important. Mukherjee and her team hope to continue forging a road into meaningful change in India through this practical and biostatistical approach. < —Sydney Egan

The routine checkup that most Americans take for granted is virtually nonexistent in parts of India.

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Even countries traditionally strong in math and science may be deficient in biostatistical expertise, say Li and Mukherjee. StatCore is designed to address such deficiencies by providing teaching modules recorded on DVD and supplemented by on-site instruction by from SPH faculty. The hope is that StatCore will act as a catalyst, building intellectual resources and training researchers who will in turn train others. By teaching people “not to settle” but rather to “seek the best method out there,” Mukherjee says, “global health research can truly benefit.” Funding to launch the program came from the SPH Dean’s Office, but eventually StatCore will charge for services after providing an initial free consultation. —Sydney Egan

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ALUMNI NET WORK CL A SS NOTES

1950s

A Voice at the Table

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ike more than a dozen other states in the U.S., Washington state allows school- children to go unvaccinated if their parents’ philosophical beliefs are opposed to immunization. SPH alumna and Washington resident June (Grube) Robinson, MPH ’88, knows what can happen if communities fail to immunize at appropriate levels, and she’d like to make it tougher for Washington parents to opt out of vaccinations for their children. A program manager at Public Health Seattle & King County and a member of the Washington State House of Representatives since 2013, Robinson recently sponsored legislation to eliminate personalbelief immunization exemptions in her state.

Although the legislation did not pass, it did generate a lot of important discussion, both locally and nationally, and Robinson isn’t giving up. Earlier this year, she spoke to SPH student Peggy Korpela about her overlapping careers in public health and politics.

What first led you into public health?

After college, I went to Jamaica as a Peace Corps volunteer. My focus there was in maternal-child health and nutrition. I worked with public health nurses and community health aides in their public health system. Our emphasis was on young children 0-3 years old. I went on home visits with the women who were trained as community health aides, and we would weigh the babies and talk with the moms about nutrition. My experience as a Peace Corps volunteer is what turned me on to public health as a career choice.

Do you still think back on that experience?

Yes, I thought back to Jamaica when I was working on the vaccination bill, about the mothers who carried their babies for miles on small mountain paths to get to the clinic to have their babies immunized. I just think, by comparison, that complaints in the U.S. are sort of ridiculous.

My experience in Jamaica continues to motivate me to work on issues of equity and justice. It’s powerful to have the public health platform to help make broad connections between all the different influences on health. It’s the perfect way to view policy and say, “How will this affect people’s health and lives in a broad way?” Nearly everything we do as policymakers influences health. It’s important for more people who are trained in public health to get into policy, to get engaged and not be afraid of the policy process.

“I thought about the mothers who carried their babies for miles on small mountain paths to get to the clinic to have their babies immunized.”

What led you to expand your public health work into policy and politics?

I’ve worked for a long time in advocacy for affordable health care and services for individuals so they can live a healthier life, and so I was always banging at the door, so to speak, asking for services and money from policymakers. Public health is always trying to influence policy in some way. I eventually wanted to bring my voice to the table, so this is a continuation of my career in public health.<

In 2017, Herman Koren, HSD, MPH ’59, will publish his 20th book, Best Practices and Resources for Environmental Health, Safety, Protection, Sustainability, as part of the “Best Practices Series for Public Health Programs” published by the Information Technology Group, CRC Press, Taylor and Francis Group.

Koren, a professor emeritus of health and safety, Indiana State University, is series editor.

1970s

Lisa Getzfrid, MPH ’78, is senior vice president of operations and COO of Health Partner Plans, a not-for-profit managed health care organization serving over 257,000 members in Greater Philadelphia.  A partner in the Midwest law firm of Honigman Miller Schwartz and Cohn, Ken Marcus, MPH ’78, has been named a fellow of the Health Law Section of the State Bar of Michigan. Marcus also serves on the Small or Rural Hospital Council of the Michigan Hospital Association, the Advisory Board of BNA Medicare Report, and the Life Members council of the American Health Lawyers Association.  Kenneth H. Mizrach, MPH ’74, director of the Department of Veterans Affairs, New Jersey Health Care System, received the 2015 Spirit of Planetree Lifetime Achievement Award in honor of his leadership in advancing patientcentered care.  David A. Oot, MPH ’74, has received the Dr. James E. Douthat Outstanding Achievement award from the Lycoming College Alumni Association. During his 40-year career, Oot has designed and managed maternal and child health initiatives, including HIV/AIDS and family-planning programs, for government and nonprofit sectors worldwide.

1980s

Ronald W. Chapman, MPH ’85, is the new Yolo County (California) Health Officer.  Jennifer Krock Cowel, RN, MHSA ’87, is CEO and president of Patton Healthcare Consulting, Inc., a consulting firm specializing in hospital accreditation, regulatory compliance, and patient safety. She is also the author of Statistics Basics: A

Alumni Network

Y Resource Guide for Healthcare Managers.  West Bloomfield, Michigan, resident Paul LaCasse, DO, MPH ’84, has left his post as president of Beaumont Hospital–Farmington Hills to focus on his role as executive vice president of Beaumont Health’s Post-Acute Care Division and Diversified Business Operations.  The Oregon Senate has confirmed Jill Mason, MPH ’87, as a trustee for the governing board of the Oregon Institute of Technology (Oregon Tech). Mason is an associate professor and director of community-based rotations at Oregon Health & Science University School of Dentistry in Portland.

Oot has designed and managed maternal and child health initiatives for government and nonprofit sectors worldwide.

1990s

Brian Bolden, MD, MPH ’94, is a hospitalist at Wilkes-Barre (Pennsylvania) General Hospital.  Carol Janney, MS ’96, PhD, has joined the faculty of the Michigan State University College of Human Medicine as a community health researcher and assistant professor of epidemiology and biostatistics.  Peter A. McCullough, MD, MPH ’94, vice chief of medicine at Baylor University Medical Center, has joined the Scientific Advisory Board of NephroGenex, a pharmaceutical company focused on developing treatments for kidney disease. McCullough is also a faculty member at the Texas A&M University Health Sciences Center and chair of the National Kidney Foundation’s Kidney Early Evaluation Program.  Formerly CEO of Stanford (California) Health Care, Amir Rubin, MHSA ’96, is now executive vice president at the Minnetonka-based UnitedHealth Group Inc.’s Optum subsidiary.  Gwen Sandefur, MHSA ’94, is the new COO of Spectrum Health in Grand Rapids, Michigan. She was previously executive vice president and COO of St. Mary’s Health in Evansville, Indiana.

ou may not need a passport to get there, but for Vance Farrow, MPH ’94, Nevada definitely posed “a bit of a culture change.” The Detroit native moved to Las Vegas in 2012 after 12 years in Washington, D.C., as chief of the Bureau of Cancer and Chronic Disease with the District of Columbia Department of Health. In Nevada, he’s an industry specialist in the governor’s economic development office, charged with strengthening health and health education resources and boosting the number of health professionals in the chronically underserved state. After four years, Farrow says, “I absolutely love it here.” He spoke to Findings about his work: What sets Nevada apart from a place like Detroit, where you grew up, or Washington, D.C., where you used to work?

I’d never been in an environment before where you had to take into account a rural presence, and the technical and connectivity and access issues that come with that. You don’t have to drive far out of Las Vegas before it starts looking like a desert. Those folks—mostly ranchers, people in retirement communities— shouldn’t have to drive 100 miles or so just to get good health care. So we’re working with federal and rural hospital partners to try to create satellite clinics.

It almost sounds like global public health work.

When you think about it, the differences between one community and the next can be as great as between countries. In some areas of Nevada, people don’t even have drinking

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water—they have to get it from a well. We have a Desert Resource Institute that’s helping communities get access to clean water.

“I tell people all the time, you can’t even fathom the way things are going to go.”

That’s something we could take to any climate that suffers the same kind of environment that we have. Global health is about taking your blinders off and thinking peripherally about how to solve problems. It’s about taking what you’ve been able to perfect in one place and re-creating it in another situation where you have like needs.

Did you ever imagine yourself doing this kind of work?

I tell people all the time, you can’t even fathom the way things are going to go. That’s the beauty of it. I studied health behavior and health education at SPH. And now in one aspect I’m in sales, and in another I’m in higher education, and in another area I’m in policy, and in another aspect I’m helping businesses to grow and expand. It’s a rainbow of things, and I feel like every bit of experience I’ve gotten over my career has positioned me to do this job well. <

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inda Schultz, MPH ’12, always wanted to do work with a global focus.

She just didn’t imagine she’d be doing it in Washington, D.C.—where, as a consultant with the World Bank, specializing in health and education, she’s a critical part of a global campaign to eliminate river blindness and control other neglected tropical diseases.

A former elementary schoolteacher, Schultz was attracted to the job because of the World Bank’s emphasis on school-based health programs. As she explains, “schools are an important entry point to deliver simple health interventions to a subset of the population that is often poorly served by traditional health systems.”

“To me, health is an equally important part of the World Bank’s effort to end poverty.”

Common infections like schistosomiasis and hookworm are highly prevalent in children in developing countries and can cause kids to miss school. So at 50 cents per child per year, deworming is one of the most cost-effective ways to ensure that kids keep coming to school. And because parasites feed on nutrients, children who are regularly dewormed have better nutrition and are more likely to perform well in school and achieve their potential outside the classroom.

Schultz also contributes to efforts to wipe out devastating diseases like onchocerciasis, or river blindness, which is transmitted through the bite of

infected black flies that breed in rapidly flowing bodies of water. River blindness causes severe itching, and, in the worst cases, blindness. But despite the widespread and devastating impact of the disease, global resources have traditionally been directed toward life-threatening diseases—hence the World Health Organization’s classification of river blindness as a “neglected tropical disease.”

Before beginning her job in 2013, Schulz knew little about river blindness. But now she’s part of a global public-private partnership that’s charting a new course for people at risk. Since 1987, thanks to the drug ivermectin, health ministries in affected countries have made massive inroads against river blindness. Schultz supports a World Bank–managed trust fund that finances the distribution of ivermectin.

In areas where regular treatment is available, blindness from onchocerciasis no longer occurs, and both the labor force and land use have expanded. “It’s widely considered one of the most effective public health achievements of recent decades in Africa,” Schultz says.

Experts hope that most of Africa will be rid of river blindness by 2020.

Her work at the World Bank has taught Schultz to appreciate the value of understanding and communicating health through an economic lens. “With a lot of the work we do, the strongest arguments are ones that frame the costs of intervention as investments,” she says.

Besides directly improving lives and livelihoods, Schultz is helping to reduce poverty. “To me, health is an equally important part of the World Bank’s effort to end poverty,” she says, “because countries can only thrive if they have healthy citizens who can lead fruitful lives.” <

Olivier Asselin

Samuel Nicol, who suffers from onchocerciasis, walks with assistance through the village of Gbonjeima, Sierra Leone.

Alumni Network

CL A SS NOTES continued from page 43

2000s

Djenaba Joseph, MD, MPH ’04, is a commander in the Commissioned Corps of the U.S. Public Health Service and medical director of the U.S. Centers for Disease Control and Prevention’s Colorectal Cancer Screening Program. From 2005 to 2007, she was an officer with the CDC’s Epidemic Intelligence Service.  Ikenna “Ike” Mmeje, MHSA ’07, is the new chief executive officer of Doctors Hospital of Manteca in San Luis Obispo, California.  Ka’imi Sinclair, PhD ’05, is an assistant professor at Washington State University’s Spokane Health Sciences campus, with a focus on culturally adapting health programs to be more accessible to underserved populations.  As head of the Intellectual Capital (IC) Accelerator team within Mercer’s new Health Innovation Team, Renya Spak, MPH ’03, works with field consultants to identify, capture, and codify new IC opportunities.  In her efforts to reduce motor-vehicle crashes, Deborah Trombley, MPH ’01, senior program manager, transportation, for the National Safety Council, has worked on cell phone–distracted driving, teen driving, alcohol-impaired driving, child-passenger safety, and other issues related to motor-vehicle behavior and policies.  Lansing (Michigan)–based Deidra Wilson, MPH ’03, is vice president of government relations for McLaren Health Care Corporation.

She joins McLaren after 11 years at Blue Cross Blue Shield of Michigan.

2010s

IN MEMORI A M

Kieran O’Brien, MPH ’12, is working with epidemiologists and ophthalmologists on clinical trials examining the prevention and treatment of corneal ulcers in India and Nepal, as well as a cohort study of CMV retinitis treatment and disease progression in Thailand.  A former program officer for adolescent health at the Pan American Health Organization/World Health Organization, Meaghan Quinlan-Davidson, MPH ’10, is now working with the World Bank Group on adolescent sexual and reproductive health issues.  As a senior program officer with the Kresge Foundation’s Environment Program, Jalonne L. White-Newsome, PhD ’11, leads the foundation’s work on the intersection of climate change and public health and manages a grant portfolio addressing sustainable water-resources management in a changing climate. Grist magazine recently named White-Newsome “One of the 50 People You’ll be Talking about in 2016.” <

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February 3, 2016

1950s Albert H. Brunwasser, MPH ’52  November 9, 2015 Donald W. Marshall, MPH ’53  January 26, 2016 William C. Wilson, MPH ’53  May 6, 2015 Darrell W. Brock, MPH ’55  September 29, 2015

1960s Rose M. Williams, BSPHN ’60  September 30, 2015 Adelene L. Darr, MPH ’61  October 10, 2015 M.H. Floyd, MPH ’61  December 6, 2015 Ellen C. Johnson, BSPHN ’61  February 1, 2016 Donald C. Tavano, MPH ’63  October 30, 2015 Betty J. Wolfe, MPH ’63  October 11, 2015 Thomas R. Holleran, MPH ’64  November 18, 2015 Ernest M. Hammel, MPH ’66; PhD ’76  November 16, 2015 Edward L. DeMeritt, MS ’67  August 26, 2015 Florence A. Smith, MPH ’67  September 30, 2015 Lee Holder, PhD ’68  January 30, 2016

1970s Edward S. Thomas, MHA ’70  September 19, 2015 James A. Buford, MPH ’72  January 27, 2016 David R. Mann, MPH ’73  February 2, 2016 Nancy G. Kinney, MPH ’77  September 11, 2015 Jo Anne H. Magee, MHSA ’78  September 1, 2015 Ray A. Flanders, MPH ’79  January 15, 2016

Keep in Touch

Forbes has named Noam Kimelman, MPH ’12, to its 2016 list of “30 Social Entrepeneurs Under 30,” a group that is “combining their range of skills in technology, engineering, science and business with their hunger to solve the world’s problems.” Kimelman is the cofounder and owner of Fresh Corner Café, which delivers healthy food to small-scale retailers throughout Detroit.  As a research coordinator with the F.I. Proctor Foundation at the University of California, San Francisco,

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> Update your SPH

contact info at leadersandbest.umich. edu/alumni_update/.

Or indicate changes on the address label and mail to the address on the back cover.

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1980s Steven M. Li, MPH ’80  November 3, 2015 Steven P. Singleton, MPH ’80  December 31, 2015 Patricia N. Meyer, MPH ’81  September 20, 2015 Barry E. Smith, MPH ’82  November 18, 2015 2000s Melva F. Hardy, MHSA ’00

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February 11, 2016

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FINDINGS

“Roadblocks with hand-washing stations and fever checks had become routine.”

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n December 21, 2014, Jodi Vanden Eng, MS ’04, a research mathematical statistician with the Center for Global Health at the U.S. Centers for Disease Control and Prevention, flew to Sierra Leone to begin a sixweek deployment in Freetown.

The Ebola epidemic was at its peak, with some 500 new cases being reported weekly.

Although Vanden Eng had been to Sierra Leone four times before to work on malaria prevention, nothing prepared her for what she found when she landed. As Vanden Eng recalls: “Instead of people holding hands and hugging in general social situations, there were nods and faint smiles. Curfews at night prevented social gatherings. Roadblocks with hand-washing stations and fever checks had become routine. And drivers yielded to ambulances and any vehicle with EBOLA RESPONDER on the windshield.

A colleague and I were given the task of assessing the surveillance process and data flow

for the country’s Ebola response. This seemed insurmountable. How do you describe the surveillance and information systems of a newly introduced disease for an entire country? How do you account for the variation between districts, partners, and nongovernmental organizations? But it had to be done, so we developed a small standardized set of questions.

We visited Ebola response centers in several districts and assessed the data flow from beginning to end from the patient’s perspective, including alerts, ambulances, case management, labs, quarantine, holding and treatment centers, contact tracing, and burials.

We assessed information technology infrastructure and resources.

I sometimes had mixed feelings about my work. When people are dying, data collection is often an extremely low priority—and rightfully so. Nonetheless, real-time data are invaluable for coordinating response efforts. Not only do data describe the epidemiology of the disease, but they also identify areas with the greatest needs and allow donors to direct aid and resources efficiently and cost-effectively.

Working on data assessment allowed me to see the big picture of the outbreak. I saw public health workers tirelessly visiting every health center to train and retrain staff on standard infection-control procedures.

I saw survivors who stayed on at treatment centers to provide care for other patients. I saw people hold special, unplanned meetings to figure out where to place newly orphaned children, or how to care for a pregnant woman going into labor while in quarantine.

I saw a volunteer set up a village hotline to enable families to get feedback about their ill loved ones. Although these types of efforts could not be measured with data, they were crucial to the response.

Nearly one year after my deployment and two years from the start of the outbreak, it felt really gratifying to hear the World Health Organization declare Sierra Leone Ebola-free on November 7, 2015. It was especially gratifying to know that the efforts of so many people who tried to prevent the disease from spreading—including those who lost their lives—were not in vain.” <

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Michael Budros at Simien Mountains National Park in northern Ethiopia

Our Students Are

on Top of the World

An SPH scholarship sent Michael Budros to Ethiopia, where a summer internship gave him a profound new perspective on his public health career. He could not have done it without the support of SPH donors Natalie and Jack Blumenthal, who believe in the power of doing good. For our students, nothing compares to real-world experience.

Our students are doing a world of good in a world of ways.

Victors for Michigan.

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Challenges Having worked as an English teacher in a Chinese village prior to beginning graduate school at SPH, Kristin Maurer was acutely aware of the health care issues rural Chinese residents face. Through a summer internship in Beijing, at the George Institute for Global Health at Peking University Health Science Center, Maurer learned firsthand how rural hospitals operate. The George Institute is a global health research organization that works to identify effective and affordable strategies to prevent and treat the leading causes of illness and injuries worldwide.

Maurer took part in a project focused on improving the quality of care and health outcomes among patients with limited resources who were admitted to rural Chinese hospitals with acute coronary syndrome, or ACS. “Many people who seek care for ACS at rural hospitals in China don’t receive recommended treatments,” says Maurer. “The project I worked on attempted to address disparities in the quality of care by increasing the capacity of hospitals with limited resources.”

A second-year MPH student, Maurer analyzed hospitals’ quality improvement initiatives—but she quickly discovered that recognizing those factors that contribute to inadequate health care was only a small step toward addressing disparities in care. The greater challenges were agreeing on an intervention, implementing that intervention, and evaluating the results. Maurer discovered it’s often necessary to approach an issue in myriad ways, and that processes have to evolve with the needs of the project.

“The greatest take-away from my internship was the importance of working with a crossdisciplinary team to evaluate and implement public health programs.”

Her 12 weeks in China gave Maurer invaluable experience in the field of international health care—and the opportunity to apply her knowledge and skills to real-world problem-solving.

“The greatest take-away from my internship,” she says, “was the importance of working with a cross-disciplinary team to evaluate and implement public health programs.”

For a video on SPH student Sarah Bassiouni’s internship in Malawi: sph.umich.edu/findings.

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Choices During her 11-week internship in Addis Ababa, Nagpal worked with St. Paul’s Hospital Millennium Medical College, a teaching hospital that provides lowincome families with the health care they need. As part of a project she helped create, Nagpal interviewed women about family planning choices and other reproductive issues and met with top officials from the Ministry of Health to learn about factors that contribute to women’s choices. She discovered that donor funding has an impact on the availability of family- planning resources across the country.

Her summer in Ethiopia gave Nagpal new insight into how cultural dynamics influence health care.

The best part of her experience, Nagpal says, was “understanding what the people of Ethiopia face every day, and seeing firsthand what their lives are like.” Her summer in Ethiopia gave Nagpal new insight into how cultural dynamics influence health care and solidified her intent to pursue a career in international development.

Although Ethiopia has experienced success in family planning in recent years, having decreased the fertility rate per woman, Divya Nagpal, a second-year MPH student, was curious about the challenges Ethiopian women face when it comes to family planning.

The Dynamics of

Change

During his eight-week internship in Addis Ababa, SPH student Michael Budros worked for the KNCV Tuberculosis Foundation, a partner organization of the United States Agency for International Development (USAID) and the lead partner in Challenge TB, the world’s largest TB control and surveillance program. Budros helped develop new data collection and quality assurance tools and contributed to a report on the state of TB data in Ethiopia and recommendations for next phases of Challenge TB.

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Field visits in Addis Ababa and rural Ethiopia provided Budros with the basis of his research data and gave him incredible insight into the availability of TB programs in those areas. He also took part in high-level government meetings on barriers to providing TB services and possible solutions to those barriers.

Budros came away with a new understanding of the intricacies of health care policy change in a developing country and “unique insight into the challenges and methods of collaborating with host country governments to improve existing systems,” he says. s

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The internships featured here would not have existed without support from Natalie and Jack Blumenthal and Rich Rogel. Support a scholarship fund and help give an SPH student the experience of a lifetime!

“What motivates us to contribute to SPH is our need to give back to Michigan in thanks for the gifts of education our family has received from U-M over three generations.

We’re especially happy to provide support for students to serve in global settings. Our daughter Sara, an SPH graduate (MPH/MPP ’12), and her sister, Elizabeth, a physician, have grown as professionals and personally as a result of internships in Africa, so this is our way of paying it forward.”—Natalie and Jack (AB ’65) Blumenthal “Wherever I travel in the developing world, I hear about the amazing work that is being done

by SPH. That is why Susan and I decided to provide scholarship support to master’s students at SPH.” —Rich Rogel (BBA ’70, LLD Hon ’09)

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$47,431.

Thank you for being a victor for public health!

Doing a

World of Good

Progress toward $100 million SPH campaign goal

$30 million

Your support makes it possible for SPH students to gain invaluable global experience in their field of interest.

contributions pledged to date:

By supporting an SPH scholarship, you help SPH students do a world of good. The possibilities are endless.

goal remaining:

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sph.umich.edu/giving Or call 734.764.8093

What do you love about U-M SPH?

New on the web online at sph . u m ich . e d u

> Spring Break

on the Frontlines

SPH turns 75 this year! Our alumni

Students on the school’s Public Health Action Support Team, or PHAST, help health departments and community organizations with public health projects. This year, PHAST students spent their spring break volunteering in Grenada and Texas. They chronicle their experiences on the Frontlines blog: umsphfrontlines.wordpress.com.

hold many of the memories that make our history real. Maybe it’s a milestone moment, or a personal epiphany, or a particular place or

> Innovation

faculty member or classroom

in Action

Innovation in Action harnesses the talents of U-M students to address real-world problems. Wrapping up its third year, the competition has expanded from its original public health focus to include a new education track. Meet the winning teams and see their innovations at innovationinaction.umich.edu.

and Resources

sph.findings@umich.edu.

July 10– 29 , 2016

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

pay it

forwar d Want to share your real-world knowledge and experience with current or prospective students? Need a job or have

one to fill?

> SPH Career Connection 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 or mentor a

student, please send an email to sph.inquiries@umich.edu.

S C H O O L

We’ll publish your answers online and

visit sph.umich.edu/75 or e-mail

> Something to Say?

M I C H I G A N

it is, we want to hear about it.

of Findings this fall. To submit your story

Go beyond the headlines and learn about the Zika outbreak from a team of SPH experts: sph.umich.edu/zika.

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experience you cherish. Whatever

in a special 75th-anniversary edition

> Zika: Info

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Graduate Summer Session in Epidemiology Now in its 51st year, this internationally recognized program provides instruction in the principles, methods, and applications of epidemiology. A certificate program as well as online courses are available.

For more information visit SummerEpi.org.

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FINDINGS

h e my global l The realities of international work t seldom meet expectations. h Often that’s a good thing.

Leaving Home

by Sarah Gutin In 2005, when I was 25, I moved to South Africa for two years to do my MPH at the University of Cape Town. My parents—especially my father—thought this was a distinctly bad idea. A lot of that came from a place of fear—the fact that I was moving to a country I had never been to, a country with a very high HIV rate, which was also known not to be the safest of places. I had never been to Cape Town or South Africa, never been on the African continent. But I took this leap of faith and said, “I want to do HIV and I had never been reproductive health work, this is a fascinatto Cape Town ing place, and this is or South Africa, where I want to go.”

never been on the

I was one of the youngAfrican continent. est people in my program. Almost everyone But I took this leap else was from South of faith.

Africa or sub-Saharan Africa, and they were being sent by ministries of health or by NGOs, and they brought an amazing wealth of experience. That was part of what made the program so challenging and enriching. Also, I had the opportunity to get out into some of Cape Town’s townships and do community health outreach, and I was able to conduct research about a reintroduction of the IUD into the contraceptive-method mix in South Africa.

I sent regular e-mails home to a wide listserv I’d created.

A few months after being there, my father sent me an e-mail that came from a colleague of his. He had forwarded one of my e-mails to this colleague, and the colleague had written back, “What a wonderful e-mail. You must be so proud of her. What amazing things she’s getting to do!” And my father forwarded it to me, and above it he wrote two words: “I agree.” I realized that was my father’s way of saying, “I’m proud of you, and I think you made the right choice.” Since then, my father has been exceptionally supportive of my global health research and career. <

Ken Orvidas/iSpot

Sarah Gutin received her MPH from the University of Cape Town in 2007. She is a PhD student in the Department of Health Behavior and Health Education at U-M SPH, specializing in the intersection of reproductive health and HIV care.

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Finding a Family

by Sarah Ketchen Lipson From July 2009 through June 2010, I lived in the Republic of the Marshall Islands, a Micronesian atoll nation about halfway between Hawaii and Australia. When I first arrived, I was scared. I was constantly on the brink of tears.

Mostly I missed having people who really cared about me, and I wondered if I would find that sense of connection so far from home.

Though my immersion into Marshallese life was subtle, there were certain turning points. One occurred on a weekday afternoon in December. I was walking home from the high school where I worked, when a dog ran up behind me and clenched its teeth into the back of my left knee. I fought back as best I could, and the dog eventually released its grip and retreated. As I limped to find help, blood dripping down the back of my leg towards my ankle, I felt defeated—like somehow this stray dog knew that I was weak, that I was running on empty and had been for quite some time. I had been living on a That night as I lay tiny island with intermittent electricity in my cockroachand a sporadic supply of running water, infested makeshift and my head was crawling with lice (which I had for eight months total). That hut, my knee night as I lay in my cockroach-infested bandaged to the makeshift hut, my knee bandaged to the best of my ability, best of my ability, I thought, “I don’t know I thought, “I don’t how much more I can take.”

know how much The next day, I was awoken by a young Marshallese boy. I recognized him from more I can take.” the village but didn’t know his name. As he walked towards my bed, I sat up, startled. He smiled and extended his hand expectantly. I hesitantly received his hand and allowed him to escort me silently through the neighborhood. I followed in a daze, focused primarily on protecting my wounded knee from branches that came across our path. After about five minutes, we came to a house that backed up against the lagoon. There, a group of women were meticulously setting up what looked like a séance. One woman motioned for me to lie down. So I did. Lying on my stomach, face down on a mat of woven coconut husks, I could hear all sorts of commotion above me. Then another woman knelt down beside me and, in broken English, told me that she and her family would be caring for my injured leg. They—and most of the island, I would soon realize—had heard about the dog attack. That morning, and every morning thereafter for the next week, the same young boy, Ayden, would escort me through the village to his family’s home, where they would treat my wound and feed me breakfast. By the time I was fully healed, I had found myself a Marshallese family. Sometime in February I moved out of my vermin-infested hut and into their home by the lagoon. <

Brian Stauffer/iSpot

Sarah Ketchen Lipson is a joint-degree doctoral candidate at U-M, studying health management and policy at SPH and higher education at the School of Education. She is also assistant director of the Healthy Minds Network for Research on Adolescent and Young Adult Mental Health. She holds a master’s in education from Harvard University and is a former Fulbright scholar.

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