Findings, Love's Touch, Spring 2013

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Love’s Touch Why Our Health Depends on It

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The healing power of human connection p. 14 | A passion for the land p. 20 | Picturing romance p. 32

Ken Orvidas/iSpot.com Mike Savitski

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From the Dean

41 Alumni

What’s Love Got to Do with It?

41 Malaria’s Lessons

42 Report from Eastern Congo

44 Tobacco Wars

45 In Memoriam

46 CareerWatch

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SPH Datebook

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Back cover: In the run-up to Valentine’s Day, the school’s Health Behavior and Health Education Student Association set up shop in the School of Public Health lobby so students could create cards for patients in the University of Michigan’s Comprehensive Cancer Center.

More than 1,000 Valentines, including 100 from SPH, made their way to patients this year as part of the center’s annual “Bag of Cheer” project.

“The handmade cards brighten the day for hundreds of adult patients who are touched to know that others care,” says Mary McCully of the Cancer Center. It’s the third year for the card drive, “which provides stress relief for students and is a great opportunity to do something that also benefits the community,” said Yasmin Mazloomdoost, a second-year HBHE student. Shown here, from left to right: Arielle McInnis, Josillia Johnson, Jessica Lai, Yasmin Mazloomdoost, and Emily Greenberg.

findings Volume 28, Number 2 Spring/Summer 2013

Vivian Stockman/www.ohvec.org

Produced by the U-M SPH Office of Marketing and Communications

20 F e at u r e A r t i c l e s

Love’s Touch 14

Betting on Love A health crisis breaks open the ego— and ushers in compassion.

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Healing Powers When it comes to public health, love plays a vital role.

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Mountains on Her Mind One woman’s single-minded devotion to her land— and its people.

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The Other Side of Paradise In the Caribbean, rates of domestic violence are double the global average.

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Worth a Thousand Words Can images of love help prevent the spread of HIV?

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> FROM THE DEAN

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he English word “love” is one of the most inadequate words in the entire human lexicon. The concept of all-consuming selfless devotion encapsulated in the Greek word agape, for example, lays waste to the simple English phrase “I love.” Never mind storge (Greek for natural affection or familial love), eros (passionate love), and philia (affectionate regard or friendship).

You’ll find each of these in this issue of Findings, which explores the all-embracing concept we know as “love.” From time to time, of course, we all misuse the word to convey affection, affinity, preferences. In its fullest sense, though, love is not the simple romanticism of greeting cards or novels but a complex force that can help heal individuals and communities and compel us to right wrongs, protect the defenseless, improve the environment, and address the structural Martin Philbert impediments to the realization of our full potential as human beings.

It seems as if every day a new study underscores love’s power to restore and improve health, reduce stress, and boost immunity. In our own work at the School of Public Health, we see love at work in many forms—in the joy of discovery, the challenge of solving seemingly intractable problems, the delight that comes in watching a community advocate for resources to improve the health of all. Each of these requires a steadfast devotion to a cause, the unrelenting proposition that as good as things get, they could be better.

In a field where the possibilities for massive financial reward can often be elusive, I have found theoreticians, practitioners, and stakeholders to be deeply passionate about their work in public health and motivated by something far beyond the material benefits of their labors. The engine of that drive is love for persons known or unknown, and is held together by the unifying theorem that there is a lofty estate called health to which

we should not just aspire, but to which we must move individually and collectively.

In my own case, a love of chemistry and biology, and a passion to understand how these come together to affect human health, led me into toxicology—and to research aimed at developing treatments for certain cancers. Because of the nature of my work, I am routinely contacted by people seeking help for loved ones who suffer from cancer, and thus does love inspire multiple facets of my research.

I know I am not alone in this experience.

Then there is the physiological power of love.

We’re learning more and more about the neurochemical and biological processes that love triggers in regions of the brain such as the ventral tegmentum, which affects our sense of satiety and satisfaction.

We’re learning more about the addictive nature of love—that feeling of “I need to see you, I’ve got to see you, I need more of you”—and about the impact of physical affection on human growth.

We know that if newborn babies are to develop empathy and sympathy, early and life-affirming human contact is crucial. We know that infants who are touched gently on a regular basis gain weight, grow at better rates, and have better health outcomes than those who don’t regularly experience

gentle human contact. That’s why programs that bring volunteers into neonatal wards to hold babies close to their skin are so important. And, as research by our own Cleopatra Caldwell shows, positive physical as well as emotional contact between fathers and sons is critical to the well- being of both groups.

People who don’t have enough physical or emotional contact with others tend to overeat or oversleep. Those who are starved of physical contact can be prone to unhealthy excesses that place not just their health but also their lives in jeopardy. All too often, when we misunderstand or pervert the definition of love, the result is domestic violence, risky sexual behaviors, and mental and physical health problems.

So love can bring great pain, but it can also bring great joy. At its best, love inspires us to become our better selves— people willing to do all we can for the benefit of our family, friends, community, and environment. It is this kind of all-encompassing love that drives us each day in our work to be better teachers, researchers, and above all, public servants. <

It seems as if every day a new study underscores love’s power to restore and improve health, reduce stress, and boost immunity.

Martin Philbert

Dean and Professor of Toxicology

Rafael Lopez/iSpot.com

What’s Love Got to Do with It?

> F R O M O U R RE A D ER S

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On Politics, Policy, and Public Health

I

3

was intrigued by Victor Strecher’s essay on

government’s role in a healthy society (“No to a Nanny State,” fall/winter 2012). It reminded me of an idea I developed many living license,” which would require individuals to apply for a license in order to select certain health-related behaviors, such as the right to purchase white bread, sugar-coated cereal, or a burger, fries, and Coke. Applicants for the license would be examined to determine if they possessed the necessary information to make informed choices. If found knowledgeable, they would receive a basic license that could then be supplemented by a series of “mini-licenses” in specific areas such as diet, exercise, sexual activity, etc. People without licenses in regulated areas would be required to follow specified behaviors. People with licenses would be allowed to do as they pleased—including engaging in unhealthy behaviors—as long as these did not adversely affect the individual rights of others.

is lifestyle. And we learned that prevention

Findings (“Divided We

is better and cheaper than cure. So let’s

Stand”) was far and away the

open up preventive care services to the

best I have seen. Great commen-

whole population, and reserve our curative

tary and analysis on public health

resources for those who follow the healthy

issues, Affordable Care Act, and

lifestyle path. There are the “worthy” poor,

many others. Keep it up!!

and there are as well the “worthy” sick.

Al Metz, DVM, MHA ’73

Don’t come crying to me that you need a

Sun Lakes, Arizona

quarter million dollars to treat your head

I

years ago for a “healthful

his most recent issue of

injury because you didn’t feel like wearing a motorcycle helmet that day!

always look forward to receiving my copy of Find-

ings and particularly enjoy Dean Philbert’s insights and comments in “From the Dean.”

Findings is one of the best things I read, and I read a lot besides straight peer-reviewed science. In the fall/winter 2012 issue, I was particularly pleased to see the picture

I have lived in Pakistan, where health

of my dad on page five (“Cross-Cultural Exchange”). He also was pleased to be in

care is fee-for-service–based. I have lived

the magazine and really enjoyed meeting

in Tajikistan where Soviet-style health care

the delegation of health professionals from

has now been converted to fee-for-service.

Taiwan who visited the Chelsea (MI) Retire-

Innovation there runs along the lines of

ment Community, where he lives. By the

breakthroughs like magnetic suppositories. I have lived in Germany, where health care

way, he is 97 and still

is “socialized,” and I highly recommend

going strong.

it over the U.S. model. Back in the U.S.,

Paul F. Hollenberg

my wife was astonished to be billed for a

Maurice H. Seevers

preventive bone scan recommended by

Collegiate Professor

our family physician.

and Chair,

The ACA is grossly imperfect. We

Department of

If found knowledgeable, they would receive a basic license that could then be supplemented by a series of “mini-licenses” in specific areas such as diet, exercise, sexual activity, etc.

The advantages of the system are twofold: first, many people would become

can only hope that, as Jonathan Cohn ob-

Pharmacology

served in his article, lawmakers will even-

University of

tually patch up the holes in the program.

Michigan Ann Arbor,

Jeffrey Paulsen, MPH ’86

Michigan

St. Francis, Kansas

The ACA: Readers Respond [Re: “They Don’t Teach You This in School,” fall/winter 2012]

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Care Act. Aside from millions of new enroll-

ship between lifestyle and health; secondly,

vices, the mandated universal conversion

society would play a greater role in provid-

to electronic health records (EHR) alone

ing for the welfare of its members. While

will cost hundreds of millions, even billions,

it’s admittedly unlikely that such a system

of dollars. I recently went through an EHR

would ever be implemented, the basic

course where the cost for implementa-

ideas behind it—that citizens have an obli-

tion was brushed aside. A chilling footnote

gation to society to live healthfully, that too

did mention the axiom that what can go

many Americans are uninformed about the

wrong, will go wrong. A second reason the

links between lifestyle and health status,

ACA is unaffordable is the cost of harmo-

and that unhealthy behaviors can adversely

nizing IRS taxpayer–income information

affect society at large—seem reasonable

with verification of individual eligibility for

and worthy of further thought.

health care benefits. That will be another

Lynn Deniston, PhD ’75

significant expansion of the role and cost

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to give valuable insight into an incredibly dense issue. As important as health care difficult to cut through the rhetoric—and easy to get frustrated by all the conflict.

Cohn’s insider perspective should make us all a little more realistic—and maybe even a little gracious—about how difficult it is to navigate through the crossfire of political interests. This university and its alumni are involved in many potentially world-changing initiatives. A clearer understanding of the political forces at play would make their success much more likely.

Brad Whitehouse Senior Communications Coordinator,

We all learned early on in our MPH train-

M I C H I G A N

for the excellent article on the Afford-

able Care Act in the fall 2012 issue (“They

reform is for the United States, it gets

of the federal government. ing that the primary determinant of health

y compliments to Findings magazine

Cohn managed in the span of two pages

termed the UCA, the Unaffordable

ees becoming eligible for health care ser-

Briny Breezes, Florida

M

Don’t Teach You This in School”). Jonathan

he ACA should more correctly be

much better informed about the relation-

U-M SPH Associate Professor Emeritus

There are the “worthy” poor, and there are as well the “worthy” sick.

U-M Alumni Association Ann Arbor, Michigan

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FINDINGS

Government’s Role

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n response to both “Hot Buttons” and your story on the recent Institute of Med-

icine report on public health (“In the Spotlight,” fall/winter 2012), I couldn’t help but reflect on my own experience this year as a caregiver and how it relates to Medicare, Medicaid (potentially), and wellness initiatives. As a graduate of the U-M Law School and the Institute of Public Policy Studies (now the Ford School), I would love to see U-M–caliber researchers study and propose ways that high-quality familial care could be safely and effectively supported to reduce the need for high-cost institutional care for the elderly, especially after hospitalizations.

Having learned as a foster parent how other

[Re: “Hot Buttons,” fall/winter 2012]

H

how my father recovered much faster than the doctors thought possible back in his familiar—and naturally stimulating—independent-living apartment (with a small amount

sions, pesticide residues, extraction

byproducts, etc.), which are so pervasive in our environment, have been shown time and again to be a significant cause of serious biological, human health, and genetic impacts, including cancer, birth defects, Parkinson’s and other neurological diseases. Yet legislators and regulators alike refuse to properly address these issues in ways that will prevent debilitating health impacts instead of having to treat disease after the fact. This is a no-brainer. What we need is a proactive approach to prevent the introduction of hazardous substances in our environment in the first place.

Carolyn Poissant

countries support families who serve as foster parents for relatives, and having seen

uman-created toxic substances (emis-

Ann Arbor, Michigan Editor’s note: The writer holds BS and MLArch degrees from the U-M School of Natural Resources and the Environment.

familial TLC), I believe that Medicare and

W

Medicaid could save millions of dollars and

that we educate the public and elected

achieve better results by investing a little

officials about the importance of the work of

more in supporting familial care. They could

the federal statistical agencies. That’s why

do this not by direct subsidy, but by having

Rod Little’s article about the U.S. Census

intermediate options between nursing-

Bureau’s significance to U.S. society and

home and home care—and by dropping the

governance (“It’s Official!” fall/winter 2012)

assumption that if one does go home, one

is such a terrific piece. I hope readers will

needs only seven hours per week of therapy

take a moment to share the article with their

and nursing services combined. I would love

non-statistician friends and elected officials.

of private-duty nursing care, and a large amount of unsubsidized, round-the-clock

to participate in conversations with others to brainstorm and research in this direction.

ith the U.S. House of Representatives’ efforts to eliminate or make voluntary

the American Community Survey, it’s critical

Steve Pierson

R e c ent Aw a r d s Findings magazine won the gold award for Best Specialized or Unit-Level Magazine in the 2012 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.

Findings also won two Silver awards for publication design in the 2012 Addy competition, sponsored by the Greater Flint Ad Club and the American Advertising Federation.

Director of Science Policy

Diane Lehman Wilson

American Statistical Association

Ann Arbor, Michigan

Alexandria, Virginia

This symbol indicates the letter was originally posted to Findings online.

David Perlman Remembered

I

To post your own comment, go to sph.umich.edu/findings/.

t is with great sadness that I write to inform the SPH community of the death of long-time U-M SPH staff member, and my good friend, David Perlman.

David passed away February 8, 2013, at the age of 72. The cause of death was an aggressive form of cancer.

David worked at SPH for almost 30 years. He played a key role in the recruitment and support of students in our On-Job/On-Campus (OJ/OC) programs and

in the overall success of the OJ/OC concept. Two of these programs, Health Management and Policy and Clinical Research Design & Statistical Analysis, are ongoing. David also helped organize the first few iterations of the school’s biennial schoolwide symposium.

After retiring from SPH in 2003, David combined his longstanding interest in mechanical design with his concern for public health to launch a new business, Hamztec, dedicated to developing and manufacturing innovative devices that use micro-sensor technology to address health needs such as Trichotillomania (compulsive hair pulling) and hot flashes due to menopause. There is hope that his colleagues at Hamztec will continue work on those devices and bring some of them to market, thus enabling David’s dreams to be realized.

Richard Lichtenstein, PhD ’81, MPH ’70 S.J. Axelrod Collegiate Professor of Health Management and Policy, U-M SPH

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 734.764.8563. Letters may be edited for length and clarity.

Findings is printed on Rolland Enviro-100, a 100percent post-consumer fiber paper that is manufactured using biogas energy. Findings is printed by an FSC (Forest Stewardship Council)-certified printer using vegetable-based inks that are 91-percent free of volatile organic compounds (VOCs).

> ON THE HEIGHTS

Lobby Day at the Capitol

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Composting at SPH

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Going Glocal

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Point/CounterPoint

Growing Detroit In a gesture reminiscent of British landscape architect Russel Page’s dictum that “to plant trees is to give body and life to one’s dreams of a better world,” members of the SPH Health Behavior and Health Education Student Association planted 172 trees in Detroit last fall in collaboration with the nonprofit Greening of Detroit.

In tribute to U-M SPH, the students named one tree “Philbert”— after Dean Martin Philbert. Shown here, from left to right: Caitlin Buechley, Loan Nguyen, Jessica Roch, Bridgette Ma, Merrybelle Guo, Cary Lentz, Naomi RanzSchleifer, Jillian Reich, Mallory Edgar, and Firas Shalabi.

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> ON THE HEIGHTS

Siobán Harlow, professor of epidemiology, has received a Rackham Distinguished Graduate Mentor Award in recognition of her achievements as a mentor of doctoral students. Good mentors, says Rackham Graduate School’s Pat McCune, “make a difference.

They make themselves available; they give you honest advice; they help you identify the tools you need and develop the talents you have; they recognize that you have the potential to be a future colleague.” n

The University of Michigan is one of ten “innovative universities shaking up education,” according to an article published in January in the online journal edudemic, which noted that in 2012 alone, U-M had 368 new inventions and 101 awarded patents. Among student innovations at U-M, edudemic cited a new fruit and vegetable stand—the brainchild of SPH student Nikki Kasper and other members of the student organization Ann Arbor Student Food Co. Kasper, a PhD candidate in

The SPH Public Health Advocacy Clinic takes the public health message to the Michigan Legislature

Mike Savitski

Drawing on her own medical expertise, Janet Gilsdorf paints a real-life picture of the toll illness takes on families and communities in her new novel, Ten Days, published last fall by Kensington Press. The author of Inside/Outside, a memoir of her experience with breast cancer, Gilsdorf is a professor of epidemiology at SPH, professor of pediatrics and communicable diseases at the U-M Medical School, and co-director of the U-M Center for Molecular and Clinical Epidemiology of Infectious Diseases. n

Lobby Day at the Capitol

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t was late February, and the weather was

SPH students go to Lansing several

the kind that can sap your spirits—gray

times a year to advocate on behalf of pub-

skies, with snow on the ground and more

lic health issues, says Jenifer Martin, U-M

on its way. But for eight first-year SPH

SPH director of government relations and

students who spent the day in Lansing, it

director of the advocacy clinic. “It’s impor-

was a day of hope and high energy. Their

tant for students to engage in real-world

goal: to explain to members of the Michigan

experiential learning, to apply what they’re

House of Representatives—110 in all, 28 of

learning in the classroom while honing

them newly elected—what public health is,

their professional skills in written and oral

how it’s distinct from medicine, and why it’s

communication.” <

critical to Michiganders.

Equipped with talking points and informational packets, the students—all of them first-year health management and policy students and all participants in the school’s new Public Health Advocacy Clinic—spent the day meeting with legislators and staff members, listening to state Medicaid Director Stephen Fitton testify about Medicaid expansion, and absorbing the splendors of

human nutrition, helped develop a weekly on-campus produce stand where U-M students can buy fresh fruits and vegetables at low prices. She and her peers came up with the idea after learning that 52 percent of U-M students have no car and 36 percent are food-insecure. n

the state’s capitol building, built in 1878. “It was,” said Tiffany Huang, who helped coordinate the trip, “an opportunity for us to learn how accessible legislators really are, to learn that they’re actually there to listen to us, and that as students we can help influence policy. It was an opportunity for us to learn not to be afraid to ask for things.”

From left to right: Sarah Mott, Natalie Friess, Colin Yee, Sophia Duong, Sonia Zhang, Tiffany Huang, Kathryn Fischer, and Poorva Gaur. All are members of the Health Policy Student Association.

ON THE HEIGHTS

SPH

Question: If the school’s Glass House Café offers compostable utensils, cups, and containers, why is waste from the café going into a landfill and not to a composting facility?

by the numbers:

Composting at SPH 2

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Allison Aiello, associate professor of epidemiology, speaking to the Boston Globe about the risk of hand-to-hand flu transmission, in a February 17, 2013, article entitled “Do handshakes

make you sick?”

“It’s going to be a much longer journey.”

nswer: Composting is expensive—but not unthinkable. During a four-week trial period this spring,

students in the SPH Public Health Sustainability Initiative (PHSI) piloted a compost program in the Glass House to collect both pre- and post-consumer waste—includ-

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Active SPH students in the Public Health Sustainability Initiative

“some great feedback from students, staff,

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Percentage of overall waste stream at U-M that is compostable

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Percentage of waste tonnage reduction targeted

by U-M by 2025

ing raw fruits and vegetables, sandwiches,

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Total cost, in dollars, of the SPH Compost Pilot

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Gallons of pre- and postconsumer compostable waste collected at SPH from March 11 to April 6

composting facility. The program generated and faculty who want to see a long- term compost at SPH,” says Julia Winfield, a secondyear dual-degree student in public health and public policy who spearheaded the project. She and her PHSI colleagues are also collecting feedback through formal surveys. They hope to implement a permanent SPH composting program next year.

Waste reduction, energy conservation, and alternative transportation are PHSI’s top three priorities, Winfield says. In late April, the group hosted the first-ever endof-year SPH “Stuff Swap.” Next year, in addition to reviving the composting program, they hope to make the school’s Admitted Students Day a zero-waste event.

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Julia Adler-Milstein, assistant professor of health management and policy and assistant professor, U-M School of Information, in a Bloomberg Business Week article (March 4, 2013) about her study showing that most doctors who install electronic medical records systems will lose money in the first five years.

meat, and containers—and haul it to a local

program

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in the media

“As researchers, it’s the million-dollar question.

We really want to know.”

Number of tip carts donated to the SPH Compost Pilot

by U-M’s Ross School of Business

Retail value, in dollars, of 125 BioTuf compostable bags donated to SPH by the Heritage Bag Company

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“When the train comes in Manhattan, the noise is 80 to 85 decibels on average and goes upwards of 95 to 100 decibels for brief periods.”

Richard Neitzel, assistant professor of environmental health sciences, speaking to The Washington Post (April 8, 2013) about his study showing that noise exposure in urban settings can damage hearing.

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“Stakeholders may not like the numbers, but most will acknowledge that Census Bureau data are objective and valid.”

From a Huffington Post blog post (April 9, 2013) on the role of the U.S. Census Bureau, by Roderick Little, the Richard D. Remington Collegiate Professor of Biostatistics, and Tom Louis, professor of biostatistics at the Johns Hopkins Bloomberg School of Public Health.

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Betsy Foxman

In September, the U-M regents named two SPH faculty to university professorships.

Kyle Grazier, chair of the Department of Health Management and Policy, professor of health management and policy, and professor of psychiatry at the U-M Medical School, is the Richard Carl Jelinek Professor. Established in 1992 through a gift from SPH alumnus Richard Jelinek, MHSA ’92, and donations from graduates and friends of HMP, the professorship recognizes “an expert in the field of health services management and policy who will, through teaching and research, strengthen the management of the nation’s hospitals and health care organizations.” Richard Lichtenstein, associate professor of health management and policy and co–principal investigator of the Detroit Community– Academic Urban Research Center, is the S.J. Axelrod Collegiate Professor of Health Management and Policy. The regents established this professorship in 2008 through contributions by individuals wishing to honor Professor Axelrod. n

Going Glocal “Global health and local health are not

MOZAMBIQUE

ZAMBIA

opposites. They’re really part of the same spectrum, and what we learn

ZIMBABWE

abroad can give us lessons right back at home. Sometimes I’ve heard it referred to as ‘glocal’—global and local, if you will. These equal partnerships are the same, and I’ve learned so much by working in the

SOUTH AFRICA

field, shoulder to shoulder, to see how people think differently about exactly the same intervention.

So those equal partnerships are quite critical. …

The scientific frontiers are really global, they’re not local.” —Roger Glass, Director, Fogerty International Center, National Institutes of Health Roger Glass made these remarks at last fall’s schoolwide symposium, “Capacity Building for Global Health.”

Attended by more than 600 SPH students, staff, and faculty, the day-long event included sessions devoted to the many links between global and domestic public health issues and interventions. Says Tom Robins, director of the school’s Global Public Health Initiative, “We structured the symposium to em-

Two new SPH programs have graduated their first students: in December the Health Informatics Certificate Program, launched in 2011, graduated three students, and this spring, the Certificate Program in Health Care Infection Prevention and Control (CHIP) graduated ten students. CHIP director Betsy Foxman, the Hunein F. and Hilda Maassab Professor of Epidemiology, says the program’s internships have been especially successful. Since CHIP’s inception in 2011, 11 students have completed internships in area hospitals, including U-M, the Ann Arbor VA, St. Joseph Mercy, and the Detroit Medical Center. <

TANZANIA

phasize that the United States is very much part of the globe, and that key principles and approaches—such as transparent and coequal partnerships, respect for involved communities, a focus on sustainable capacity building, and the need for highly interdisciplinary methods—apply equally to work with low- and middle-income countries and with disadvantaged communities in the U.S.” Robins terms the symposium a “culmination” of the work achieved during the initiative’s first full year of activity. <

Millennium Promise Scholars Learn and Work at SPH

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ast fall, U-M SPH welcomed 18 Millennium Promise Program Scholars from Mozambique, South Africa, Tanzania, Zambia,

and Zimbabwe. The scholars were funded under a research training grant from the National Institute of Environmental Health Sciences, which enabled them to learn from U-M and SPH faculty for a full semester while furthering their own research.

Each scholar's research involved one of a number of distinct topics surrounding chronic non-communicable lung diseases associated with environmental and occupational exposures.

The scholars—ten doctoral students and eight senior scientists—took part in a variety of courses, including a specially designed mentoring course that “unpacked a variety of topics, including the qualities of a good mentor,” said Joy Kistnasamy, a scholar from South Africa. The two qualities that stood out most for her were empathy and kindness.

The scholars also audited a number of standard public health courses and had the opportunity to learn alongside SPH students.

Many of the scholars said this demanding yet rewarding experience had changed the ways they would conduct their work on environmental health in the future, as well as how they would approach the field of public health at large. < —Danielle Taubman

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Nkosana Jafta, University of KwaZulu-Natal, South Africa

Many of the scholars said this demanding yet rewarding experience had changed the ways they would conduct their work on environmental health in the future.

Julita Maradzika, University of Zimbabwe, College of Health Sciences

“I was prepared for the fast life in the U.S., but Ann Arbor is much laid back, and it’s easy to get on with what you want to do.”

“How do you put in place a workplace program? How do you motivate workers to take care of their health?

Coming here to me is part of strengthening our capacity to teach and to interact with other people.”

Focus: The association between tuberculosis and indoor air pollution

Focus: Occupational health promotion

Simon Mamuya, University of Muhimbili, Tanzania “I enjoyed the writing course here—writing is part and parcel of my life. The mentoring course was also very important.”

Patrick Hayumbu, Copper Belt University, Zambia “Here I can see the ways we can help improve the respiratory health of miners in Zambia.”

Hussein Mwanga, Tanzania; University of Capetown, South Africa “There are a lot of academic resources in the U.S. I’m learning a lot.”

Focus: Respiratory diseases in Zambian copper miners

Focus: Pneumoconiosis among workers in Zimbabwe

Focus: Work-related asthma among health care workers

Paulino Chamba, Mozambique “Ann Arbor is calm and tranquil. There is a good ambience—but it’s cold!”

Focus: Work-related asthma among workers in the woodprocessing industry

Focus: Indoor air pollution, especially cook stoves and women and children’s health; exposure and respiratory health problems among Tanzanian workers

Camillo Fungai Chinamasa, Department of Community Medicine, College of Health Sciences, University of Zimbabwe “Being away from my usual routine has been very constructive. The daily routine does not give you enough time to stand back and reflect. I call this a retreat— it has allowed me to recast what I’ve been doing and project forward what I would like to be doing.”

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Jose Mirembo, Mozambique

Emmy Nkhama, Chainama College of Health Sciences, Zambia “I’ve received a lot of positive input on my research project.”

“It’s my first time here, and I’m learning a new style of academic living and teaching methodology. It’s really a good thing to be here—we are getting a lot of improvement.”

Focus: Respiratory diseases among farmworkers

Focus: Cement dust exposure and respiratory health

Scholar portrait photos: Peter Smith

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Point:

by Sharon K ardia

Why I Love Big Numbers

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love big numbers in so many ways. In public health genetics we deeply need to accumulate information on the lived experience of millions of people to best predict what can happen to a single individual. There are 25,000 genes and millions of mutations.

To sort out what is causing what, we need a really large databases of people’s health experiences. For example, babies with rare genetic mutations or abnormalities occur in approximately one in 10,000 births. Every baby in the country is screened so those with the rare diseases can be identified and treated. Newborn screening programs worldwide then pool together information on the new cases to help companies develop and test new drugs. Without really large efforts like millions of babies being tested every year, we couldn’t save the lives of those one in 10,000 infants.

Here is another way I love big numbers: the genome is big, really big. It is approximately three billion DNA base pairs large, and I share 99.9 percent of those base pairs with every other human on the planet. So, in one way, I have seven billion brothers and sisters—that’s a big family. However, the 0.1 percent difference in our genomes means that we are each different by approximately three to six million mutations. It is the perfect paradox: we are simultaneously all the same while being completely unique.

Very little of the genome can be used to predict without knowing a person’s context.

Large population studies are the key to understanding which things in the genome have predictive power and which do not.

There are great studies of bacteria and mice where scientists have systematically deleted an entire gene to see what happens.

Essentially, those studies show that some 50 percent of our genes are “not essential.”

Our bodies are set up to have a lot of redundancy and back-up systems so that most mutations don’t have catastrophic effects.

That’s why we need large numbers, so that we can understand how a given individual’s genome is likely to play out in different environments or over a lifetime.

As we move closer to the time when major medical systems (including U-M) start to incorporate genetic sequencing and other genomic technologies into clinical practice, we face a huge paradox: we’ll be able to sequence people’s big genomes cheaply, and we’ll find thousands of rare or “private” mutations, but we won’t know how to interpret those mutations unless we have huge data sets to find other people with those same rare mutations. The more ways we can learn from the health experience

2 Our genetic systems are set up to have a lot of redundancy so that mutations don't have catastrophic effects. of others (entire populations) the better we will be able to serve each individual in our society. For example, I have loved ones who are allergic to sulfa drugs, but they only learned this after being given sulfa drugs. It might have been nice to have had that information beforehand so that they didn’t have to learn through trial and error. The type of genetic epidemiology we do here at U-M SPH uses large populations to discover the genes and the mutations that make people sick.

There is some really great work being done by our health informatics program to develop a prototype for a regional or national Learning Health System that can integrate every conceivable type of health information—across counties and states, including data from primary and emergency care, Medicare, and Medicaid—so that we can learn how to better care for people. This system would also revolutionize public health, since it would give us real-time health data about the health of our communities and help us improve health outcomes in those communities. It is a great way to merge individual benefit with public health values.

The most personal way I love big numbers is the mind-boggling mega-relationship between me and my genome. My body (and everyone else’s body) is an entire world made up of the grass-roots, autonomous action of bazillions of molecules.

For example, I am about ten to 20 trillion cells large (not counting my 100-trillion microbial inhabitants), and each cell has two copies of an entire genome (three billion base pairs from my mom and three billion base pairs from my dad). Through the miracle of meiosis, which happens each generation, the DNA in my cells is the DNA of thousands of my ancestors. For example, I can trace my family line back 250 years— and at 25 years per generation that means about ten generations—so through that lens, my genome can be traced back to 210 genomes (which is 1,024 people). The whole mega-collection of genomic worlds within my cells works together, moment by moment, to process information about where I am, what I am eating and doing to adapt and optimize my health. I couldn’t be here without large numbers. < Sharon Kardia is the U-M SPH senior associate dean for administration and a professor of epidemiology, whose research focuses on the genetic epidemiology of common chronic diseases. She directs the U-M Life Sciences and Society Program.

ON THE HEIGHTS

CounterPoint:

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By Bhramar Mukherjee

Why I Love Small Numbers

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n the public health and medical research studies I’m involved with as a biostatistician, my collaborators are happy if their findings reach statistical significance, and that comes with what we call “small P-values.” P-values are a measure of evidence— a way of determining whether your data is compatible with the baseline, or “null,” hypothesis that’s under consideration.

The null hypothesis usually indicates that not much is happening with an intervention, or there is no evidence of association.

As a researcher, you often want to refute the null and establish an “alternative hypothesis,” which means that something is actually going on in your study—for example, your intervention has an effect, or a new drug is better than an existing therapy, or a set of genetic markers is indeed associated with a particular disease. To quantify the strength of that finding you need a measure of evidence, and P-values are the most commonly used measures for this purpose, with P<0.05 considered to be a statistically significant finding. Researchers want tiny P-values—in fact whenever my analysis leads to large P-values, my collaborators become sad because it means their study doesn’t show much. This obsession with tiny P-values has generated considerable publication bias. As a statistician, I am bothered by this obsession, but I can’t avoid it.

I’m currently working with a large consortium, funded by the National Cancer Institute, that’s exploring gene-environment interactions related to colorectal cancer.

We’ve put together various study cohorts from all over the world and are trying to understand the extent to which genes modify risk due to environmental factors such as high red-meat intake or lack of physical exercise. We’re studying millions of genes and about a dozen established environmental factors for colorectal cancer, and our work is giving rise to many gene-by-environment interaction tests. As the number of potential hypotheses that we are testing increases, we need even tinier P-values—say, of the order of 10-8. On the other hand, larger

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sample sizes lead to a greater probability of statistically significant results with small P-values, and thus large and small numbers play a very important dual role in all this.

When it comes to public health, particularly genomics, little numbers can add up to big differences. In risk prediction models, one individual gene may not confer much risk, but if you have an ensemble of genes, each with modest relative risk, they can contribute collectively to disease risk in a significant way.

When it comes to public health, particularly genomics, little numbers can add up to big differences.

As we move closer to the era of personalized medicine, we’re paying more attention to the potential collective significance of individual genes with tiny effects.

Scientists are trying to create composite cancer risk scores, for example, for people who have a number of cancer genes, each with a tiny elevated risk. Such scores can be used for risk prediction as well as for defining subgroups of patients who might benefit from a particular treatment regimen.

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On the other hand, just as little effects can add up to big differences, little errors can add up to big problems. When you are conducting studies with a large number of tests, small violations from classical assumptions can lead to trouble. In the modern era, scientists are confronted with zillions of tests, and even minute departures in the distribution of a test statistic—say, a violation of normality—can substantially inflate your false discovery rate. We need to pay more attention to the behavior of the extremes—or “tails”—of the distribution of these test statistics than we did in classical statistical inference.

I’ve always been fascinated by the duality between small and large numbers. In our theoretical statistics courses, we teach about limiting behaviors, and we speak of things “tending to infinity” or “becoming infinitesimally close to zero” in very similar ways.

Ultimately it’s all relative. Take a small number, and its reciprocal is large. Take a big number, put a minus sign in front of it, and it becomes small. As a culture, we want some numbers to be small (the unemployment rate, price inflation) and some numbers to be large (the gross domestic product of a country, per capita income). One thing I can tell you for sure is that I do not like small numbers for my teaching evaluations or my salary! < Bhramar Mukherjee is an associate professor of biostatics at U-M SPH, whose principal research interests are Bayesian methods in epidemiology and studies of gene-environment interaction. She is a co-investigator in several studies led by faculty in the U-M Departments of Epidemiology, Environment Health Sciences, and Internal Medicine.

Illustration: Dan Page c/o the iSpot.com

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Overlapping Pa s s i o n s

Peter Smith

Peter Smith

These members of the SPH community exemplify the fine art of the work-life balance.

Student: Amanda Eccleston

Faculty: Mousumi Banerjee

Staff: Vlad Wielbut

First-year MPH student in epidemiology (global health certificate); member, U-M women’s varsity cross-country and track teams

U-M research professor, biostatistics; director of biostatistics, Center for Healthcare Outcomes & Policy; member, U-M Comprehensive Cancer Center

Director, U-M SPH Informatics and Computing Services; co-organizer and host, Ann Arbor Polish Film Festival; member, U-M Collaborative Domain Group

Running and public health draw similar types of people. If you want to get involved in running, become passionate about it. People who go into public health are also very passionate. It’s not a field you go into just to make money or have a job—it’s a field you go into because you really care about it. Success in both is long-term. There’s no instant gratification. With running there can be years and years of training. Public health can also take years of work, research, negotiation, and program implementation to achieve results.

I have a very deep love and affection for the arts, particularly music and poetry. They counterbalance my work as a scientist. As it happens, I did my training as a statistician at the same time I was studying Indian music—specifically Rabindrasangeet, or songs written by the Bengali poet Rabindranath Tagore. What I love most about this genre is that I can find a song for any mood that I’m experiencing.

I have always been fascinated by how people communicate.

When I was a kid growing up in Poland, my grandmother would take me to the village where she was born. I would listen to the peculiar dialect these people spoke, and after a couple of weeks I would talk like them.

Running and public health both require teamwork. Last fall, I got about halfway through the Big 10 championship cross-country race and then fell off the lead pack. One of my teammates caught up to me, and for the second half of the race we ran every step together. Together we were able to get through the race—and Michigan won the Big 10 championship! In public health also, it’s about collaborating with people and organizations.

Running and public health both require teamwork.

I’ve been reading lately about the United Nations Millennium Development goals related to immunization, and about how much international cooperation this takes. These are things you can’t do alone. You can’t win a national championship as a team alone, and you can’t cure diseases and solve public health problems by yourself.

To me, data and music both hold mysteries.

Music helps me feel the human link for my work as a scientist doing statistical modeling for cancer. It’s important to have that connection—to realize that there is a human face on the other side of the data. To me, data and music both hold mysteries—whether it’s about an underlying biological mechanism, or patterns of disease in a population, or connections to one’s deep inner self. You just have to know how to unravel these mysteries.

I enjoy making sense of data, using statistics to learn important stories and discover interesting phenomena. Music gives me similar joy, because through music I discover myself.

There is a level of abstraction in both statistics and music, which I love. Both fields are all about patterns and rhythms.

W Hear Mousumi Banerjee sing Indian classical songs at sph.umich.edu/findings.

In school, we all had to learn Russian. It was a language of the Soviet oppressor, but I enjoyed it so much that I wrote poetry in it. After high school I wanted to learn English, so I bought a textbook and went to see American movies. That helped a lot when my wife and I left Poland in 1987 and spent two years in Germany waiting for our visas to the U.S. I of course wanted to learn the language, so I studied German literature.

Now I carry a small library on my Kindle.

When we came to America, I found a wholly different set of languages, which allowed me to communicate with a machine, so I studied computer science. Once I wrote my first program, I was hooked. I “spoke” with a machine and we “understood” each other.

Underlying all this is my love of learning. I think I inherited it from my grandmother, who had only a fifth-grade education but was always surrounded by books. When I lived in Warsaw, I always had a book with me. Now I carry a small library on my Kindle. <

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Love’s Touch A Public Health Sonnet

How do love and health connect? Let us count the ways.

When, for instance, parents and children bond, Stress goes down and resilience up, and kids respond By eating less and telling us they feel safe.

When communities come together to say They love the land and want to keep its hills and ponds Free of contaminants, because their health depends On a clean environment, we see love’s sway.

Love, we know, is linked to hormones that improve mood, Lower blood pressure and help us endure, boost our immunity and heal deep wounds.

Love brings hope and meaning; it makes us more Inclined to exercise and eat good food— Proof enough, some would say, that love’s the cure.

— Leslie Stainton —

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Betting on Love

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A health crisis yields unexpected gifts.

by Madeline Strong Diehl

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ver the past couple of decades, medical researchers have started to confirm what writers, poets, and philosophers have known for thousands of years—love heals.

“Love is among the most important factors that contribute to health,” explains Cleopatra Caldwell, associate professor at the University of Michigan School of Public Health. “By this I mean feelings of affect, warmth. It gives meaning to life ... when we are touched, there are positive physiological reactions that can be measured.”

It’s not so hard to believe that love can decrease stress, depression, neurodegeneration, and anxiety, or that it can improve cardiovascular function, immune defense, memory, and feelings of pleasure and an overall sense of well-being—all of which can be found in the literature. But for various reasons, many people hold themselves back from giving and receiving love—or they just don’t know how.

Our culture teaches us self-reliance is a virtue. But in reality, it doesn’t take too long for most adults to run into a crisis that they can’t handle on their own. It takes a great deal of humility to reach out in such times, but I have learned that these crises can become gifts in breaking through our ego so that we can allow the love and care of other people in.

For some people, the myth of total self-reliance melts away gradually. For me, I can tell you the exact date and time on which I met my emotional Waterloo: it happened at two minutes before midnight on New Year’s Eve, in 1994. That’s when my daughter, Amelia, died right after she was born—then came back to life again.

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I’ll spare you the technical details of the rare medical condition (velamentous placenta) that was responsible for Amelia’s traumatic birth. Instead, I’ll cut to the quick: Amelia’s brain had been deprived of oxygen for some time, and tests showed signs of significant damage. The doctors at the University of Chicago Hospitals didn’t tell us this at first—no doubt because they were so busy just keeping Amelia alive. None of her major organs were working on their own, so her body was covered by tubes, wires, and monitors.

I’ll never forget the immense joy and sadness when a kind nurse allowed me to hold Amelia for the first time. The nurse carefully bundled up all the wires from the monitors and gently, reverently placed my daughter in my arms. Of course I felt the joy that she was alive, and fighting so hard for us. But my heart also felt great sadness, because I realized, in the three days I had been camping out in the neonatal intensive care unit, I had yet to see her eyes open. Was this, then, to be my future, looking always into the face of a child who could never look back?

All the doctors and nurses said they were astonished by Amelia’s progress as, each day, another organ came on line; another tube was removed. “A miracle baby!” they declared, and they praised my strength, too, as I sat next to Amelia’s incubator, hour after hour, so I could be there when she finally woke up. But she never woke up, and she never cried, and she never moved—was this, then, to be my future?

I never let my husband—or anyone— know what I was feeling. If I cried at all, I cried alone; I was taught to be strong, after all, and very self-reliant.

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n the day of Amelia’s release from the hospital, a doctor showed us the results of EEG tests that revealed the extent of the damage to her brain. He proclaimed that Amelia did not have much chance of ever living a normal life. We were instructed to give her anti-seizure medicine because she had had one seizure shortly after birth, probably due to trauma. But my mind couldn’t take in anything past the “no normal life” part. Because I knew it wasn’t just Amelia’s life that wouldn’t be normal.

was this , then , to be my future , loo k ing always into the face of a child who could never loo k bac k ?

It was mine; my husband’s; our two-anda-half-year-old son, Zach’s. My brain was repeating the doctor’s words as my husband put Amelia’s sedated body in the car seat for what should have been her triumphant first ride home. When we got home, I finally allowed myself to collapse, sobbing, into the arms of my big sister Peg, who had come from a thousand miles away to help for a whole month. “But remember, she’s a miracle baby!” Peg reminded me. “Maybe Amelia isn’t finished surprising you yet!”

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Peg spent her days trying to keep Zach out of trouble, and I fed and stood watch over Amelia, wanting to be sure I was there when she opened her eyes. But the days passed into weeks, and weeks passed into months, and Amelia never woke up.

Because I was so sleep-deprived and distraught when Amelia was discharged from the hospital, I did not hear, understand, or remember how important it was for her to stay on her medicine, and so one day, when she was about three months old, I tried an experiment and skipped a dose. I wanted to see how much of her lack of consciousness was a side effect. Now I know I was wrong—I do not recommend that any parent change or stop a child’s medication without consulting a doctor first—but at the time, I didn’t see how her brain could possibly heal unless we had a chance to bond with each other.

Within hours I was gratified to see a glimpse of her brown eyes, which locked into mine. Every day she spent more and more hours awake, studying our faces, taking in the shapes of furniture, curtains, clothing, and stretching her arm towards the light streaming in through the window.

When I took Amelia in for her biweekly EEG test and evaluation with Dr. H, the pediatric neurologist, the nurse noticed the change in both Amelia and me right away.

But when I told her I had stopped Amelia’s medicine, she was upset, and left to make her report to Dr. H. A supportive, warm, wise doc in his seventies, Dr. H was not wearing his usual smile when he entered the room about ten minutes later, and I feared the worst. He bent over the day’s test results, then watched Amelia, who had completely transformed since her last visit, and now gurgled and happily lunged at my nose. When Dr. H took both of Amelia’s hands in his, Amelia suddenly turned towards him and shot him an irresistible smile.

Almost despite himself, Dr. H smiled back, then seemed to be struggling with himself.

Finally he said to me: “You did the right thing. Amelia’s brain has healed.”

Dr . H was ta k ing a bet on the healing power of bonding.

A nd by affirming me as a mother , he was ta k ing a bet on love .

I took this to mean that Amelia’s test results finally showed no damage. In fact, I learned later that Amelia’s brain had—and still has—the same damage as when she was born. But I think, when Dr. H used the word “healed,” he was drawing on years of experience seeing patients’ brains recover from trauma. Also, seeing Amelia and me relating so well together, he was taking a bet on the healing power of bonding. And by affirming me as a mother, he was taking a bet on love.

Dr. H told me to come right in again if we ever needed him, but added that he doubted we’d have to. For two days I was elated, and then the strangest part of this story happened. For the next six weeks, I was plunged into the deepest, darkest despair, diagnosed with post-partum, and placed in an outpatient program.

I think I’d stayed strong because I had to, and when a doc told me Amelia was okay, I gave myself permission to let go. At the time, it was humiliating, but now I see that period as a great gift. People who had been casual friends in our Quaker Meeting brought us casseroles, held me when I cried, and became close friends. During my days in the outpatient program I made friends whom I would never have met otherwise.

The hospital was located in a primarily African-American neighborhood, and we shared an intimacy in group therapy that people normally don’t share—especially not across racial lines. My ego was broken, and I say this in a positive way. I believe unless and until our ego is broken, we cannot be free of our cultural myth of total self-reliance—and we cannot benefit fully from the sublime pleasure and pain of love in community.

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melia is 18 years old now, and if you were to look at her and talk with her for any amount of time, you would never guess she died when she was born. She plays ice hockey, writes plays and poems, and plans to change the world.

She’s a straight-A student and already has scholarship offers from four colleges. And I know, on that bittersweet moment when I drop off Amelia at college next fall, I will have many, many people to thank. It takes a village to save a baby who has only the wisp of a chance of a normal life—and I also know that village saved me and our whole family. <

Madeline Strong Diehl is a freelance writer based in Ann Arbor.

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When Society Bets on Love

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s medical researchers cover new ground in confirming and measuring the benefits of love, public health researchers like U-M SPH Associate Professor Cleopatra Caldwell and her associates are finding ways to apply this knowledge to society. Caldwell’s seminal 2004 project in Flint, a community-based participatory research collaboration, shed light on how improving the communication and parenting skills of nonresident fathers in the African-American community positively affected their own health while significantly strengthening the social safety net for their sons.

“This is not rocket science,” said Caldwell, who plans to expand her research by studying nonresident fathers and their sons in a Chicago neighborhood, and eventually to include daughters and mothers.

Caldwell’s Flint study revealed that appropriate expressions of love reinforce and benefit the health and well-being of both fathers and sons, and that there are many ways that father-son relationships can be supported by the community. Many men grow up in a culture where fatherhood is defined as being the provider, explains Caldwell, and this can leave unemployed nonresident fathers without a

way to feel involved—unless they learn that there’s a lot more to fathering than a paycheck.

“We saw grown men crying in our sessions,” Caldwell recalls. “Some told us they didn’t understand how much their sons needed them.”

Among the 332 nonresident African-American fathers who participated in Caldwell’s study, those who reported a good relationship with their sons drank less alcohol and reported fewer symptoms of depression. Fathers with drinking problems requested help after the men realized how impor-

tant they were to their sons. It is also possible, says Caldwell, that their sons may make better health choices because they had the counsel of their fathers, and they felt loved. Contrary to the “deadbeat dads” stereotype, current research is finding that nonresident African-American fathers are more likely than the nonresident fathers of other ethnic groups to be actively involved in the lives of their children. So Caldwell’s work can have great impact in the African-American community as a whole.

It seems logical that love impacts health on a community level as well as on a personal level, and Caldwell and her associates are trying to discover where and how community agencies, hospitals, and other key social resources can develop scientifically based interventions to help family members learn how to nurture and communicate love. “This kind of heart-to-heart communication between fathers and sons needs to happen in a safe place, and we work with our community partners to find and create that space,” she says. “By engaging nonresident fathers, we fill a gap that can make a big difference in a young boy’s life—and his father’s as well.” < — MSD

The Physician’s Art of Compassion

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ecent survey data show that while 75 percent of physicians believe they provide “compassionate care” to their patients, fewer than 50 percent of patients say they receive such care from their doctors.

And that’s a problem, says physician Joel Howell, who defines “compassionate care” as care that takes into consideration a patient’s family and overall situation. “How do you get doctors to understand their patients not simply as biological entities with a disease,” Howell asks, “but as human beings with families, emotions, and lives outside of what can be captured with a CAT scan or DNA analysis?”

One way, he suggests, may be the arts.

“You can understand what it means to be human by studying biochemical pathways and anatomical relationships and cost-benefit analyses of the human body,” says Howell, a professor in the U-M School of Public Health; Medical School; and College of Literature, Science, and the Arts. “On the other hand, if you want to understand what it means to love, to experience the depths of despair or joy, the great artists are another way of trying to understand that.”

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For the past four years, Howell and his colleague Sanjay Saint, professor of internal medicine, have been exploring art’s power to help doctors prepare for a profession where choices are often complex and “tolerance for ambiguity” is a critical skill. Howell and Saint co-direct U-M’s Medical Arts Program, which partners with the University Musical Society and other area arts organizations to introduce some 120 medical students and residents a year to concerts, art exhibitions, dance performances, plays, works of literature, and behind-the-scenes discussions with artists and arts experts.

The aim is to help young physicians deepen both their compassion and their tolerance for ambiguity by addressing issues that don’t always get addressed “as effectively as possible elsewhere in the curriculum,” says Howell. “Such as how to understand death, how to be comfortable reveling in ambiguity when you don’t know what to do and yet you have to make decisions. Textbook science draws nice graphs and charts and says, ‘This is

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what you do next.’ The real world is not like that.

Real medicine is not like that.”

Ashley Dehudy, a 2009 SPH graduate and fourth-year U-M medical student, says the program has been eye-opening. “It’s very easy to read textbooks and publications and discuss disease in a matter-of-fact sort of way, but learning how to think about the gravity of an illness, and how it impacts the many facets of an individual’s life and his or her well-being, is a more difficult process. I think we are helped in that process by attending events that are often inspired by the same gamut of emotions that surround health care, from joy to despair.” Dehudy also believes the program has improved her observational skills.

Howell and Saint are studying the program’s impact and expect to publish their findings in 2013. <

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For more on U-M’s Medical Arts Program

visit http://themedicalarts.med.umich.edu/.

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Love can help reduce stress, lower blood pressure, and improve mood.

It can also transform the practice of public health.

Ken Orvidas/iSpot.com

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by Allison Nye O’Donnell

s a Peace Corps volunteer in Honduras, I worked with a group of inmates in the local prison. My friends and family would ask me, “Aren’t you scared to work in the prison?” The Peace Corps country director even asked me to write a statement detailing how I would guarantee my safety while working there.

I posed the question to the group of prisoners.

In all seriousness, one of the leaders said, “Allison, we guarantee your safety.” I trusted him completely and wasn’t scared, because I was working with a group of men who had love at the center of their hearts.

They did not have a good life by our standards. They lived in dormitories of 50 men with bunks stacked four high; the conditions were filthy, and some had no hopes of ever leaving. Yet not once did I see a trace of anger among those men, because their hearts were filled with love. Love of God, love for their families, and love for one another. They served their fellow inmates as teachers and leaders, while at the same time working to further their own educations. Their willingness to collaborate with me voluntarily, their unabashed religious faith, their genuine smiles, and their gratitude for my service and friendship showed me that it was love that motivated their actions. Their ability to love and serve others, despite their situation, humbled and inspired me. Their ability to love—despite their histories, which included everything from petty theft to murder—convinced me that love can heal deep wounds.

It helped me see that true happiness comes from within, and loving and serving others can develop that happiness. If those men could live happy lives, full of love, so could I.

In a sermon he wrote while in a Georgia jail, Martin Luther King Jr. shared his insight that love should not be confused with some sentimental outpouring; love is much deeper than that. He spoke about an overflowing love that seeks nothing in return, the love of God operating in the human heart. I’ve come to believe this is the kind of love that can solve the most fundamental barriers to optimal health and wellness.

Studies have shown that giving reduces mortality later in life and increases longevity, that social relationships and connectedness improve health.

As public health practitioners, we fight battles that are often contentious and divisive. We fight against enemies rich and powerful, seen and unseen. We make decisions based on what we think is best for the public’s health, even when those decisions are not popular. I believe that we need to keep love and service to others at the center of those decisions. In fact we need to keep love at the center of everything we do—not just to guide our decisions, but also to bolster our resilience in the face of adversity.

Love is not only about service to others. Love also serves ourselves. In fact, the research on the causal links between love and health is convincing and growing. The Institute for Research on Unlimited Love was founded with grant money from the John Templeton Foundation to fund studies

on unlimited love. The institute defines unlimited love as to affectively affirm as well as to gratefully delight in the well-being of others, and to engage in acts of care and service on their behalf. Unlimited Love extends to all people without exception, in an enduring and unconditional manner.

The institute highlights studies that have shown that giving reduces mortality later in life, and increases longevity (Oman).

That social relationships and connectedness improve health (Holt-Lunstad). That love and affection are linked to hormones that help us reduce stress, lower blood pressure, and improve mood (NIH). They also highlight research from U-M SPH Professor Neal Krause that finds that supporting others actually improves our own well-being.

Rumi, the Sufi poet, knew this long before scientists started investigating it.

He wrote that Love is the cure, for your pain will keep giving birth to more pain until your eyes constantly exhale love as effortlessly as your body yields its scent.

I am convinced that love is the answer.

My life experiences have shown me this, and current research supports it. The hard part is knowing how to cultivate and spread love in a world that often doesn’t support it. Serving others seems to be a good start. Looks like public health professionals are on the right track. < Allison Nye O’Donnell recently finished a health policy internship in the U.S. Senate and is now working in advocacy at the Campaign for Tobacco-Free Kids. She received her MPH from U-M SPH in 2012.

Sources

Julianne Holt-Lunstad, Timothy B. Smith, and J. Bradley Layton, “Social Relationships and Mortality Risk: A Meta-analytic Review,” PLOS Medicine (July 2010).

Doug Oman, Carl E. Thoresen, and Kay McMahon, “Volunteerism and Mortality among the Community-dwelling Elderly,” Journal of Health Psychology (May 1999).

Martin Luther King Jr., Strength to Love (ca. 1963; repr., Minneapolis: Fortress Press, 1977).

org/mission (accessed January 6, 2013).

The Institute for Research on Unlimited Love, unlimitedloveinstitute.

Neal Krause, A. Regula Herzog, and Elizabeth Baker, “Providing Support to Others and Well-Being in Later Life,” Journals of Gerontology, Series B: Psychological Sciences and Social Science (September 1992).

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“The Power of Love: Hugs and Cuddles Have Long-Term Effects,” NIH News in Health (February 2007).

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FINDINGS

Jarrell’ s Ce m e t ery

One woman’s fight to protect the land she loves—and the people who live there.

Mountains

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by Leslie Stainton

Leslie Stainton

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hen she takes a visitor to see the land her ancestors settled in the early 19th century in Boone County, West Virginia, Maria Gunnoe drives out along a rutted two-lane highway, beneath softly wooded hills and rippling brooks, to the base of a mountain, and points to a small mound at its peak. “That’s Jarrell’s Cemetery,” she says. “We used to camp up there a lot when I was growing up.” The tiny graveyard dates back to Civil War times. Some of Gunnoe’s forebears are buried here.

Jarrell’s Cemetery once occupied a slope leading up to the mountain’s summit, but in recent years the graveyard has become the summit itself, as coal workers have systematically destroyed the earth around it in their pursuit of the black rock that fuels the light bulbs and cell phones and air-conditioning units that make 21st-century-American life possible. The only reason the cemetery still stands, in fact, is because Gunnoe and others like her fought to save it.

Even though its graves are sinking and many of its headstones missing or shattered, and even though the land around it is a moonscape, Gunnoe, a lean woman in her forties, with long black hair and the watchful eyes of a hawk, periodically visits the place where her ancestors lie buried.

It’s not an easy trip. She has to go through worksite-safety training, wear a hard hat and steel-toe boots, limit her visit to two hours, and keep a coal-company escort with her. But she does it, “just to remind them that we care about the people that’s in the cemetery.” Once there, Gunnoe says, her eyes narrowing, “you’re in the midst of just sheer devastation.

I’ve explained it as feeling like a newborn baby lying in the middle of a mountain of rolling rock.”

Aerial photo: Vivian Stockman / www.ohvec.org. Flyover courtesy of SouthWings.org

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The Wallenberg Award First given in 1985, the University of Michigan’s Raoul Wallenberg Award honors “individuals, organizations and communities that reflect Raoul Wallenberg’s humanitarian spirit, personal courage and nonviolent action in the face of enormous odds.” A 1935 graduate of U-M, the Swedish-born Wallenberg saved tens of thousands of Hungarian Jews near the end of World War II. In choosing Maria Gunnoe as the 2012 recipient of its award, the Wallenberg Committee wrote, “She is in the vanguard of activists who recognize that environmental justice is critical for the survival of small rural communities that face powerful political and economic interests.”

Peter Smith

Most of the homes in Lindytown were bought and destroyed in 2009 by Massey Energy so the company could mine the mountain overhead.

While in Ann Arbor to accept the 2012 Wallenberg Award, Maria Gunnoe spent time at the School of Public Health discussing the health impacts of mountaintop removal.

The mountain on which Jarrell’s Cemetery perches is one of more than 500 peaks environmental advocates say the coal industry has flattened through mountaintop removal, a process in which miners use explosives to rip off the tops of hills and mountains to get at underlying coal seams.

For the past 18 years, Gunnoe has been battling the practice, which is destroying the land her elders taught her to cherish and damaging the health of its residents.

Her actions have brought her honor— most recently the University of Michigan’s Wallenberg Award—and peril. The pale green one-story house where she lives with her husband, the house her grandfather built in 1951 at the base of a hollow near the lyrically named town of Bob White, is surrounded by a chain-link fence and under 24-hour video surveillance. A few years ago, after she received death threats and heard gunfire over her home, Gunnoe began wearing a bulletproof vest to mow her lawn.

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amily legend has it that when Gunnoe’s Cherokee ancestors fled Georgia in the 1830s during the Trail of Tears, Maria’s great-great-great grandmother cast her eyes into West Virginia’s undulating hills and announced, “These hollows will protect us.”

And so they did. Growing up, Maria learned from her mother, father, and grandfather how to forage in the mountains for berries and wild onions, how to prepare medicinal teas from native plants like sassafras and ginseng. She hunted for arrowheads in the caves that lace the ridgelines of Boone County’s mountains.

Home to the largest unbroken forest east of the Mississippi and to one of the world’s most biodiverse ecosystems, this isolated part of America is also home to some of the nation’s most lucrative coal deposits. Gunnoe, the daughter, granddaughter, sister, and mother of miners, is the first to declare her support for “underground, responsible, union coal miners.”

But not mountaintop removal. It’s the predominant form of strip mining in the U.S., and since 1970 it has destroyed more than 1.5 million acres in West Virginia, Kentucky, and Virginia, and buried or severely degraded over 3,000 miles of streams, according to mine safety and health and environmental expert Jack Spadaro, who often testifies in cases related to mining accidents and environmental damage.

Gunnoe spent ten years listening to the mountaintop that sits 3,500 feet above her house gradually give way to rubble as miners systematically drilled down into its bedrock, packed it with chemical compounds, and “exploded the mountain. They were drilling, pushing rock, or blasting, all day long, six days a week, and sometimes seven, usually twice a day,” she remembers. Blasting is so routine in this part of Appalachia that local newspapers regulary print notices announcing when and where it will occur.

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Dust from the operation drifted down into the hollow where Gunnoe lives and in the winter nestled against the ground like fog and stayed for days. Her teenage son once came back from jogging with black goo inside his eyelids.

Chemical fallout from mountaintop removal penetrates not only the air but the waterways that course through Boone County and feed into the Ohio River system. Sludge left over after coal is cleaned for shipment is pumped underground, often into abandoned mines, and winds up in the aquifer. Mountain debris is dumped into valleys, where it buries and contaminates headwater streams, and sprayed with grass seed to create “valley fill,” an unstable substance prone to flooding. Gunnoe estimates she’s experienced nine major floods on her property in the past decade.

Two years ago a study in the journal Science reported that mountaintop-mining removal and valley fill produce “serious environmental impacts,” including the permanent loss of ecosystems critical to the food chain, a loss of vegetation and topsoil, alterations in topography, greater storm runoff, and increased frequency and magnitude of downstream flooding. The impact on human health is equally dire, researchers said. In streams beneath valley fills, scientists found elevated concentrations of sulfate, calcium, magnesium, bicarbonate ions, and selenium, which bioaccumulates and can disrupt human endocrine function.

Leslie Stainton

What frightens her most today is not the threat of violence but the more than 20 peerreviewed studies that have come out in the past five years showing the grave dangers of mountaintop removal to human health.

An eerily blue stream flows at the base of the Twilight Surface Mine, not far from Maria Gunnoe’s home.

Boone County resident Jennifer HallMassey, who lives a dozen miles from Gunnoe, told the New York Times in 2009 that tests of the water in her home showed toxic amounts of lead, manganese, barium, and other metals.

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FINDINGS

Quote/Unquote

Common Ground?

Founded in 2004, the interdisciplinary U-M Risk Science Center supports science-informed decision-making on existing and emergent human health risks. Andrew Maynard, director of the center and NSF International Chair of Environmental Health Sciences, suggests ways the center—and risk science in general—can help communities address contentious issues like mountaintop removal: “Mountaintop removal is a classic case of a situation where you’ve got significant health, environmental, and economic impacts vying with each other, and people desperately looking for answers, but little clarity as to what’s right or wrong. And what happens is that people end up arguing from a position of gut instinct and fear—fear of losing their business, or their livelihood, or their lives.

Evidence and science can help establish a meaningful dialogue between different stakeholders. But evidence in complex situations like this is almost never conclusive. I see the role of risk science as not dictating what’s right or wrong, but making evidence more understandable and accessible, and giving people on both sides of the debate a common basis from which to find solutions that work for everybody.

What happens is that people end up arguing from a position of gut instinct and fear.

“Our planet is going to change more radically over the next 30 years than it has in the past 200 years, and if we want to sustain both local and global communities, we’ve got to re-energize dialogues that are often bogged down in entrenched positions and assumed risks—because the world is quickly becoming smaller, more crowded, and more complex, and we have to work together to protect our planet. You just need to look at the exponential growth in energy demands and at the growth in human population, which is heading toward nine billion people in a decade or so. As a society, we need to find common ground about what is acceptable and what is not acceptable. Again, there are no right or wrong answers—but if the decisions we make together are divorced from the science that dictates how things behave, the only certainty is that we’ll end up in a mess.”

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For more on the U-M Risk Science Center, visit sph.umich.edu/riskcenter.

Like most of her neighbors, Gunnoe uses bottled water for drinking and cooking.

When her two grandsons were born, she bathed them in bottled water for months.

“It takes three gallons,” she says. Rashes, tooth decay, gall bladder diseases, miscarriages, kidney and thyroid issues are common in the region, and the incidence of health problems is unusually high, say medical professionals. Gunnoe’s 19-yearold daughter, Chrystal, has lost three young friends to cancer. Earlier this year, a fourth was diagnosed. “Cancer’s as common as a cold here anymore,” Gunnoe sighs.

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s she pilots her dust-encrusted Ford along a two-lane road underneath the Twilight Surface Mine, Gunnoe points to the ways mountaintop removal has altered the life she knew as a kid: an empty storefront that used to be a busy café, an eerily fluorescent-blue stream, a grassy hillside where there was once a valley. The community of Lindytown, formerly home to some 40 families, now consists of four homes and an abandoned union hall. The rest of its homes were bought up and destroyed in 2009 by Massey Energy, and their inhabitants relocated, so the company could mine the mountain overhead. “The church sat right there on the corner,” Gunnoe says as she pulls up beside a patch of weedy land.

“Right here used to be flower gardens, sidewalks, a set of steps.”

She drives on, along a road scarred from use by 18-wheelers trundling in loads of ammonium nitrate and diesel fuel for blasting. “A wreck or a spark could cause a massive explosion,” Gunnoe says. Not long ago, her sister-in-law died in a collision with a truck whose driver had been sent out to patch leaks on a sludge dam. Gunnoe is now raising her eight-year-old nephew, who survived the crash.

In 1998, Gunnoe’s father was out collecting wild onions in an all-terrain vehicle when he lost traction on a gravelly patch of land the coal industry had reclaimed after mountaintop removal. The ATV flipped over and killed him. He was 51. “That’s something that’s very difficult for me to talk about,” Maria whispers, her voice cracking. “But yeah, I feel like

this industry murdered my father.” She falls silent, looks out at the hills, rubs her hand across her eyes. “My dad was the reason that I love these mountains so much. That’s where I spent my time with him.”

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he dislikes the term “environmentalist,” often used to describe the work she and her colleagues do, educating neighbors about the health and environmental impacts of mountaintop removal and building citizen advocacy. “People try to divide us by calling us environmentalists, but we’re really people that are trying their best to protect our community and our lives.”

In the 25 years they’ve collectively been battling mountaintop removal, Gunnoe and the organization she works for, the Ohio Valley Environmental Coalition (OVEC), have had their share of successes, including blockage of a valley fill in 2007 and the permanent preservation of land near Bob White, West Virginia, formerly slated for destruction. OVEC recently bought a small house in the town of Twilight, and their presence means it’ll be harder for the coal industry to purchase rights to destroy the mountain above them. “The fact that we own property here now is one of the reasons that you’re looking around and you still see homes here,” Gunnoe says proudly.

In January, OVEC joined a coalition of groups urging passage of federal legislation (acheact.org) to impose an immediate moratorium on all surface mining permits until further health impact studies are done.

Gunnoe believes her work helped inspire an op-ed by the late U.S. Senator Robert Byrd (D-WV), which came out shortly before his death in 2010. A long-time proponent of the coal industry, Byrd stunned constituents when he wrote, “If the process of mining destroys nearby wells and foundations, if blasting and digging and relocating streams unearths harmful elements and releases them into the environment causing illness and death, that process should be halted and the resulting hazards to the community abated.”

Equally stunning was a statement by outgoing U.S. Senator Jay Rockefeller (D-WV) last year in which he urged the coal industry to “listen to what markets are saying about

Mario Tama/Getty Images

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Fro m the A rch i v e s

Black Lung

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ontroversy over the health impacts of coal mining is nothing new. The issue took center stage at the School of Public Health on April 3, 1974, when SPH students convened a conference to refute claims made at the University of Michigan by Keith Morgan, then director of the Appalachian Laboratory for Occupational Respiratory Disease, that cigarette smoking posed a greater health risk to miners than coal dust.

The students summoned two experts—Donald Rasmussen, MD, a pulmonary disease specialist in West Virginia’s Appalachian Regional Hospital, and M.H. Ross of the United Mine Workers Clinic—to counter Morgan’s statement.

(Arnold Miller, then president of the United Mine Workers President and himself a victim of black lung disease, was also invited but could not attend.)

Ross criticized Morgan’s statement as an “insensitive attack on coal miners’ benefits. For years,” he went on, “most doctors were assuring miners that coal dust was among the least harmful dust while miners were hardly unaware of shortness of breath, black spittle, and miners’ asthma.” Ross reminded the SPH audience that miners are “human beings who dig for their living underground to provide air conditioning and heating for Americans.”

UMW President Miller cabled his support for the conference. “It is vitally important that students of public health hear what Dr. Rasmussen and Ross have to say, particularly now when other physicians are attempting to minimize the significance of this disease.”

Miller died in 1985 and Ross in 1987, but Rasmussen, 84, remembers the SPH conference vividly. “At that time there was a big deal of controversy about the existence and characteristics of black lung,” Rasmussen told Findings by phone earlier this year. “There are no such differences now.”

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he late Ian Higgins (1919–2006), professor emeritus of epidemiology and environmental and industrial health at U-M SPH, devoted much of his career to investigating the health of coal miners. His exhaustive studies of both chronic respiratory disease and coronary heart disease in coal-mining communities in West Virginia helped confirm the prevalence of A West Virginia miner is coal-worker’s pneumoconiosis, or black lung tested for black lung in 1974. disease, in miners and contributed to new federal policies requiring periodic screenings for early detection of the disease and preventive measures to reduce exposure to coal mine dust. Higgins’s work on miners’ health was part of a broader examination of exposures to hazardous substances, including asbestos exposure among taconite miners in Minnesota.

He also studied the health impacts of smoking.

SPH alumnus David Musch, MPH ’78, PhD ’81, completed a dissertation on chronic respiratory disease epidemiology under Higgins’s guidance. “I spent three years poring over reports by expert readers of chest radiographs from miners,” Musch remembers. “Our goal was to help to ensure the reliability of the process that leads to a miner’s being certified as having pneumoconiosis.”

Musch’s work helped inform government policy on disability compensation for miners who suffered from black lung.

Blasting is so routine in this part of Appalachia that local newspapers regularly print notices announcing when and where it will occur.

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Adapted from graphic created by Appalachian Voices for iLoveMountains.org

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Kent Kessinger/Appalachian Voices; flyover: Southwings.org

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Top: Pickering Knob mountaintop removal site in West Virginia. Valley fill is at bottom right.

Above: The 10,000-acre Hobet Mining site in West Virginia (shown in red) would cover most of Manhattan Island (dark grey) in New York City.

Left: Runoff from a valley fill in eastern Kentucky.

Below left: The Brushy Fork sludge impoundment in West Virginia holds eight billion tons of coal sludge.

Giles Ashford/Appalachian Mountain Advocates/www.appalmad.org

Vivian Stockman/OVEC; flyover: SouthWings.org

Below right: Valley fills like this example in West Virginia bury and contaminate headwater streams and exacerbate flooding problems.

greenhouse gases and other environmental concerns, to what West Virginians are saying about their water and air, their health, and the cost of caring for seniors and children who are most susceptible to pollution.”

Despite her support of underground miners, Gunnoe knows that Boone County—like the rest of the U.S.—must wean itself from dependence on fossil fuels. “The reality is we’re running out of coal. I think we’re coming to a point, globally, that we have to … treat responsible coal mining as a transition fuel into a renewable energy future.”

As for the charge that she and her fellow activists are destroying jobs, Gunnoe notes that mountaintop removal itself replaces workers because it’s less labor-intensive than underground mining. Records show that between 1979 and 2010, West Virginia’s coal workforce dropped from 62,500 to around 22,000. Retired miner and United Mine Workers of America member Terry Steele told the New Republic in 2010, “I don’t even like to compare what they’re doing to what we’re doing.”

Gunnoe likes to think she’s no longer in the danger she was when she first started her advocacy work. In fact what frightens her most today is not the threat of violence but the more than 20 peer-reviewed studies that have come out in the past five years showing the grave dangers of mountaintop removal to human health.

On a late afternoon in January, Gunnoe sits on a wooden swing on the front porch of her house in Bob White and looks out at the chickadees and nuthatches crowding her birdfeeder, and at the mountains in the distance where her ancestors took refuge nearly 200 years ago, and where many of them lie buried. This is her favorite spot in the world, she says, and if she has to risk her life to stay here, she will. “They tried everything to scare me off, thinking I would just pack and leave,” she nods. “But I made a promise to my grandfather and my father, and ultimately I’ll keep that promise. And the promise was that I would take care of their property and see to it that it carried on into the future, and that’s what I’ve done.” <

W To see video footage of Maria Gunnoe in Boone County, visit sph.umich.edu/findings.

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As more than one U-M SPH research study makes clear, we pay a price when we cut into the earth’s surface.

Mining’s Global Toll

Reuters/Hereward Holland

Gold Larry Gibson’s cabin once nestled at the base of West Virginia’s Kayford Mountain. Today Gibson’s cabin occupies the highest point in the landscape. Gibson died last fall, but his cabin—the centerpiece of a tract of land acquired by his forebears in the 18th century and razed by the coal industry in the 1980s and 1990s—stands as a poignant and powerful symbol of the devastation that accompanies the mining practice known as mountaintop removal.

Rachel Long first saw the Gibson cabin in 2009, and the experience shocked her. Then a student in U-M’s Program in the Environment, Long promptly joined a grass-roots campaign to end mountaintopremoval mining, a practice that has led to the destruction of more than 500 mountaintops in Appalachia.

Today she’s focused on a different kind of mining. As project manager for the U-M–based Integrated Assessment of Small-Scale Gold Mining, Long is working with U-M School of Public Health Assistant Professor Nil Basu and a team of researchers to assess and understand the health impacts of small-scale gold mining in Ghana.

In addition to contributing to deforestation and land-use change, gold mining in Ghana poses serious health risks to the men, women, and children who live near the country’s gold deposits. “There’s no boundary between the workplace and where people live,” says Tom Robins, professor of environmental health sciences and a member of Basu’s research team. The process of extracting gold releases heavy metals, including mercury and arsenic, and other undesirable U N I V E R S I T Y

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pollutants—including particulate matter, arsenic, and so-called “acid gases”—emitted by coal-fired power plants. Coal generates approximately 40 percent of the electricity used in the United States and is the country’s single largest source of mercury pollution.

Studies show that individuals exposed to high levels of air pollution experience higher rates of morbidity, says Lynam, who received her PhD in environmental health sciences from SPH in 2003. “New studies also show that in addition to respiratory dysfunction as a result of air pollution, there’s cardiac dysfunction associated with exposure to particulate matter.”

compounds, such as silica, into the air, and researchers believe Ghanaians are inhaling these materials as dust or ingesting them through water. “You can see very high levels of ore dust exposures,” says Robins.

Basu’s group is also studying the health impacts of the mercury used to process gold. During processing, gold ore is ground to a powder, washed, and ultimately blended with mercury, which is then vaporized and inhaled by workers.

“That’s a pretty high dose of mercury if you’re standing right over it,” Long notes.

Vaporized mercury also enters the air and is eventually deposited in both soil and water, where bacteria convert it into an organic form that’s ingested by fish, and in turn by both animals and humans.

For more on U-M’s Integrated Assessment of Small-Scale Gold Mining visit http://sitemaker.umich.edu/smallscale miners/home.

Gold mining in Ghana poses serious health risks to the men, women, and children who live near the country’s gold deposits.

Mercury

When she heard that Maria Gunnoe was coming to U-M to accept the 2012 Wallenberg Award, Mary Lynam, a researcher with the SPH-based U-M Air Quality Laboratory, knew it would benefit SPH students, faculty, and staff to hear Gunnoe’s story firsthand, and so Lynam arranged for Gunnoe to visit the school.

“The real cost of producing electricity is not understood by most people,” Lynam says. “The real cost is air and water pollution—that’s Maria Gunnoe’s message.”

For more than two decades, Lynam and her colleagues in the Air Quality Laboratory have been studying the environmental impact of mercury and other atmospheric

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Mercury released into the air from coal-fired power plants makes its way into the food chain, where it is converted into an even more potent toxin known as methylmercury. Fish, which reside near the top of the food chain, can contain high levels of mercury and pose a particular risk to women of childbearing age, young children, and so-called “subsistence” fishers. The Environmental Protection Agency has issued at least one fish-consumption advisory in every state in the U.S., Lynam notes. Commercial fish are also susceptible to mercury emitted from both U.S. and Chinese coal-fired power plants.

Research from the Air Quality Lab, founded in 1990 by the late Gerald Keeler, has been instrumental in helping to shape U.S. mercury-emissions-control policy. But as long as humans continue to rely on coal for electricity generation, mercury and other toxic emissions will persist. “That’s what’s so important about Maria’s work,” says Lynam. “She teaches us that although we might not live in an area where mountaintop mining is being carried out, we are P U B L I C

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intimately involved with this process every time we turn on a light.”

Copper

SPH Professor Tom Robins has devoted much of his career to studying respiratory diseases associated with underground mining. His work on pneumoconiosis—black lung disease—has helped strengthen regulatory standards in the coal industry in both the U.S. and South Africa.

Robins is now studying the pulmonary health of miners in Zambia, where copper is a major export. The critical issue with copper mining, Robins says, is the high concentration of crystalline silica in the ore. Exposure to silica can lead to silicosis, a non-malignant but often lethal lung disease that “has probably killed more people than any other type of occupational lung disease in the world,” Robins says.

Silicosis—and even silica exposure itself—can compromise the human immune system and heighten the risk for tuberculosis, now endemic in Zambia. The country also has some of the world’s highest rates of HIV/ AIDS—another factor in increased risk for TB. Robins and his research team have found substantial exposures to silica in Zambia’s copper mines—in many cases, he says, “well above international standards.”

Better enforcement of safety regulations is a must. Robins and his colleagues are already presenting data to officials in Zambia’s Ministry of Health and Ministry of Labor. “People are quite interested,” he notes. “They’ll be very interested, I think, when we make our final presentations.” < S P H . U M I C H . E D U

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the other side of paradise

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What happens when love becomes an excuse for violence?

By Leslie Stainton

Renowned for its spice trade, Grenada is the world’s second-largest grower of nutmeg, normally producing 20 percent of the annual world harvest. Already harmed by the global economic slowdown after 9/11, however, the country’s economy was brought to a near standstill in September 2004

by Hurricane Ivan, which damaged or destroyed many of the country’s buildings. Ten months later, Hurricane Emily struck just as Grenada was recovering from Ivan. Besides negative impacts on the tourism industry, the two devastating hurricanes destroyed or significantly damaged a large percentage of Grenada’s tree crops, including nutmeg, which may take years to recover.

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T H E O T H ER S I D E O F P A R A D I S E

SPH alumnus and Paul B. Cornely post-

But there are signs of hope. Jeremiah

North American winter, and you can

doctoral fellow Rohan Jeremiah, PhD, MPH

has been evaluating a United Nations pro-

be forgiven for thinking you’ve landed

ly down to Grenada in the depths of a

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’06, has spent years working to understand

gram called Partnership for Peace (PFP), the

in a sliver of heaven. Blue seas, blindingly

and reduce the high rates of domestic

first comprehensive domestic-violence inter-

white beaches, bougainvillea dripping

abuse in the Caribbean, with a focus on

vention in the English-speaking Caribbean.

from doorways and walls. No wonder the

Grenada. His research points to multiple

Launched in the wake of Hurricanes Ivan

Minister of Tourism calls this three-island

contributing factors: high unemployment,

(2004) and Emily (2005), which destroyed

Caribbean nation of just over 110,000 “our

inequalities in education, religious strictures

or damaged 90 percent of Grenada’s infra-

little paradise.”

against divorce, the brutal legacy of two

structure, the volunteer program provides

centuries of slavery, long-held cultural norms

behavior therapy for men charged with

about gender roles, and social taboos that

domestic abuse under Grenada’s Domestic

effectively silence victims.

Violence Act of 1999—itself a sign of change.

Since its inception, PFP has enrolled

By the time most Grenadian boys in lower socioeconomic families reach ado-

more than 200 men, and its success in

lescence they’re expected to contribute to

reducing recidivism has led seven additional

household incomes, Jeremiah reports, and

Caribbean nations to adopt the program.

they typically forego school. Girls, by con-

Jeremiah believes that in conjunction with

trast, are encouraged to complete secondary

elevated law enforcement in rural communi-

school, even though it costs money, because

ties, new measures to address education and

families tend to think it will make them more

employment disparities, widespread dissemi-

marriageable. It also makes them more

nation of violence-prevention programs and

employable—which can breed resentment

communications, and greater engagement by

in a nation where male unemployment

church and community groups, PFP can do

approaches 50 percent in some areas.

much to reduce the prevalence of domestic violence in the Caribbean.

Jeremiah has found that Grenadian

Increasingly, Grenadians are speaking

men who abuse women often share the same story. “They’re unemployed, they

out against gender-based abuse—in person,

can’t take it anymore, and they snap.”

through letters to the editor and Facebook

Love itself can be a factor. “It seems

pages, in schools and community groups,

there is no specific process by which children

and here on these pages. The profiles that

Grenada is part of a sobering trend in a

are told what love is and is not,” Jeremiah

follow are drawn from focus groups con-

corner of the world where rates of domestic

says. Sadly, many wind up mistaking abuse

ducted in Grenada in March 2013 by Rohan

violence are double the global average. The

for affection. One woman told Jeremiah

Jeremiah, Jicinta Alexis, and Findings editor

World Bank terms gender-based violence

that when her partner doesn’t hit her, she

Leslie Stainton. The names of the individuals

in the Caribbean “not only a serious public

wonders if he still loves her.

have been changed to ensure privacy.

Grenada’s colonial past has helped

health problem and a violation of women’s human rights,” but also an economic burden

engender a culture where men routinely

“affecting productivity, earnings, and taxing

express their masculine identities by taking

health care and judicial systems.”

multiple partners and/or using verbal, physi-

Between 60 and 78 percent of all

Leslie Stainton

But there’s another side to paradise.

cal, and sexual violence to exert power and

female homicides in the region occur within

control. (Women also occasionally engage in

the victim’s home and are committed by a

violence, but chiefly in response to assaults

male partner, relative, or ex-partner. Last

from men.) Few Grenadians speak up for fear

summer, in a single horrifying week, three

of intruding on others’ privacy or courting

Grenadian women were hacked to death by

trouble, says Jicinta Alexis, a social research

their male companions. In the wake of the

consultant in Grenada who collaborates with

murders, the Ministry of Social Development

Jeremiah. Many Grenadians view domestic

issued a statement urging Grenadians “to

violence as “a societal thing, something that

avoid sullying the reputation of the dead

happens among ‘the other people,’ the lower

women, or even blaming them, as though

socioeconomic classes,” she adds. Wealthy

they were somehow responsible for the

Grenadians who suffer abuse often leave the

actions of their killers.”

island rather than risk the social stigma that

This slave bell (above left) is a reminder of Grenada’s history of colonial rule. Coupled with current unemployment rates as high as 50 percent for Grenadian men, the legacy of slavery contributes to a culture of domestic abuse on the island.

comes with admitting to difficulties.

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Few Grenadians speak up for fear of intruding on others’ privacy or courting trouble.

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Alicia: The System is Flawed A thirty-something police officer in Grenada, Alicia says she responds to a domestic violence call at least once a week, often more. She’s seen incidents of abuse where outsiders have intervened and called the police, only to have the victim—usually female—then turn against the person or persons who tried to help her. Sometimes a victim will try to convince the police that the person who phoned for help is in fact the one who caused, or even committed, the abuse. As a result, says Alicia, “persons refuse to help because they realize that it becomes a game.” Or they call the police but refuse to divulge their identity.

Once a domestic abuse case enters the legal system, there are other problems, like corruption. If a legislator or highly placed government official is charged with domestic violence, for example, “they keep it at a hush-hush.”

But what really “kills the system,” Alicia says, are the magistrates. “The police will do what they have to do, social services will do what they have to do, but the magistrates do not enforce it. On many occasions, the magistrate will say, ‘Is he a good boy? Ever been charged? Is he a businessman? Come from a good family?’” The law is crafted in such a way that magistrates have discretion in determining the length of a sentence for someone convicted of domestic violence.

Often magistrates will elect to give the minimum sentence because of some special circumstance. “So then, you train the constable, you train the cop, you train the social worker, [but] you don’t train the magistrate!

We have female magistrates who are even worse than the men.”

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Jason: it happens in Broad Daylight

Uel: Some See Abuse as Survival

to accept it. Men will be unfaithful to a

A teacher with more than seven years’ exper-

Uel is in his twenties and has a background

woman, and vice versa, and we’ll come up

ience in the classroom, Jason has worked with

in media and business. He is eager to find

with the most philosophical, the simplest

young people in business, social, and religious

ways to reduce domestic violence in Gre-

reason.” Only a very few people are rational

settings and is currently involved with a pro-

nada but is unsure how to change prevail-

enough to say, “Even though this is the

gram to end violence against women.

ing attitudes and behaviors. In rural areas,

case, it is wrong.”

“One of the sad parts is it stems from our

As a society, she believes, “we’ve grown

he’s aware of “parents who encourage their

Recently, Chandra went shopping for

heritage with slavery,” he says of Grenada’s

young daughters into relationships with

clothing and tried on a dress that was too

high rates of domestic abuse. “It stems

older men.” It doesn’t happen often, he

short for her. A female customer in the store

from that heritage where female slaves

admits, “but it happens. Some people see it

told her, “Buy it. If you don’t buy it, you will

were victimized sexually by both the planter

as a way of survival.”

cause your husband to look at younger girls

class and their male slave counterparts.”

Women grow up believing physical violence is normal, “and then they find a man who would treat them just the same way, and it’s a vicious cycle, and it keeps going on and on and on.”

Four years ago Jason was in Grenada’s capital city, St. George’s, at a busy intersection, when he spotted a mini-bus with a male driver and a woman in the passenger seat.

A child was sitting between them. The woman was talking to the man when

in shorter dresses and leave you.” Chandra

One woman told Jeremiah that when her partner doesn’t hit her, she wonders if he still loves her.

did not respond to the woman.

“I think we’re beginning to correct some of our mistakes,” she says. “All of the schools now have a counselor or two.

Women in Grenada—I’m so proud of us these days—we’re career-oriented rather than divorce-oriented. So women are studying, women are holding powerful positions.”

Even though social status can still be an impediment, upper-class and educated women are beginning to report incidents of abuse. “We’re getting there. I am hopeful

suddenly “the guy literally took his fist and socked her a couple of times across the child

One woman told him she can only

to get her calmed down. And I was shocked.

afford to send her kids to secondary school

I was, like, really? That just happened in the

because her young daughters have relation-

middle of town, in the middle of the day,

ships with older men, who in turn provide

in bright sunlight? And it’s, like, nobody’s

funds to the family. “You see it especially

business. She settled down. She got quiet.”

in the rural parts,” Uel says. “A woman has

that we’re going to get there, and not too

by the numbers:

three daughters, and she doesn’t want to

Gender-based violence

work, and they might send the daughters

Karim: There’s a Lot of Fighting

for a visiting relationship with an older man, knowing that the guy would approach the

A twenty-something unmarried man who

girls sexually and expect the girls to provide.”

has worked in the media and with youth

Uel notes that according to published

groups, Karim grew up witnessing domestic

reports, the average age for initial sexual

violence “without knowing what it was.

experiences in Grenada is 11. “For both girls

There’s a lot of fighting in the community,

and boys.”

violent with her. He told her, “It can’t work

Chandra: Attitudes Need to Change

because I’m not that type of person.” But

A high-school guidance counselor, Chandra

she saw his response “as me being soft, or

talks “all the time” to students who’ve wit-

probably me not being a man or something.

nessed abuse or experienced it themselves.

That just is not my mentality, not my de-

Some are as young as 11 years old.

who expected—even wanted—him to be

violence. “My father used to beat Mommy.

claimed she could not get sexually aroused

For the life of me I couldn’t figure what she

“if he don’t slap her or hit her or tell her

was doing wrong.” One day Chandra asked

something bad, demean her, things like that.

her father why he hit her mother. He told

And it was shocking. And I was, like, yeah,

her the other men in the village were doing

well, it happens.”

it, and he didn’t want to appear “soft.”

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30% 25% 29% 70%

Antigua and Barbuda, Barbados Guyana

British Virgin Islands, Trinidad and Tobago

Suriname

As a child, Chandra herself witnessed

meanor.” Karim broke off the relationship.

One of his friends had a girlfriend who

Although the precise level of domestic violence in Grenada is unknown, rates across the Caribbean region suggest the gravity of the problem:

boyfriend and girlfriend, husband and wife.”

Not long ago, Karim dated a woman

very long from now.” <

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Source: Clarke, R., and Sealy-Burke, J. (2005) Eliminating gender-based violence, ensuring equality: UNIFEM/ECLAC regional assessment of actions to end violence against women in the Caribbean. Bridgetown, Barbados: United Nations Development Fund for Women.

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FINDINGS

The collages shown here were created by participants in the Photolove study (2010–2012). The accompanying captions are excerpted from comments they made about their work. For more information visit

“For me, my entire goal in life is to start a family, no matter what it takes.”

sph.umich.edu/findings.

by Rachael Strecher

Worth a Images of love inspire a new approach to sexual health.

ove and art have no business in the world of hard science, some believe.

And yet love plays a crucial role in sexual and emotional safety, as studies by the University of Michigan Center for Sexuality & Health Disparities (SexLab) have indicated. The lab’s findings, in fact, suggest that love may be a critical factor in both the emotional well-being and sexual health of certain population groups.

To further examine the role of love in preventing disease, researchers in the Center for Sexuality & Health Disparities recently undertook a 24-month “Photolove” study using a Photovoice-inspired methodology developed by former U-M SPH faculty mem-

ber Carolyn Wang. Wang developed Photovoice in the 1990s as a community-based participatory research and empowerment methodology through which participants create their own images and discuss them with each other and with researchers. The technique allows researchers to delve deeper into a topic than they’re able to do with alternative methods, such as in-depth interviews.

As a first-year MPH student working in the SexLab, I designed the Photolove study starting in September 2010 with the help of Jose Bauermeister, director of the lab and an assistant professor of health behavior and health education at U-M SPH. Our hope was to collect qualitative data to bet-

ter understand some of the lab’s previous findings about sexual and partner-seeking behaviors among young men who have sex with men (YMSM). In one earlier study, for example, researchers found that YMSM who could envision a future with a committed, loving relationship—love—reported fewer sexual partners with whom they had unprotected sex. These data suggested a need to understand what romantic love meant to these men.

When we asked them in earlier studies how they defined romantic love, the young men we interviewed were often understandably baffled. Providing language to explain the concept of love is something

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“I am really proud of myself, and I don’t care what people think or say.”

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“Love is when you make the decision to support a person so completely that you would be willing to mount any level of resources and sacrifice anything in your life for their well-being.”

WorDS

poets, storytellers and songwriters have been attempting for hundreds of years, often with poor results.

Given these challenges, we sought through Photolove to give our study population the opportunity to explain their perspectives on love, using both words and images. If they met the study requirements (between the ages of 18 and 24 and identifying as gay, bisexual, queer, or questioning), participants could choose either to create a collage or take photographs that represented their conception of romantic love. Once they sent us the creative portion of their project, we scheduled an in-depth interview.

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For the majority of the men interviewed, love followed a traditional, Western, heteronormative trajectory of dating, marriage, children, and growing old together.

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So what is love according to 17 YMSM in the Ann Arbor and Detroit Metro areas?

As you might imagine, love is an amalgam of experiences. To one participant, whose collage included an image of a field filled with hundreds of candles, love was romance. To another participant, a recent immigrant from Mexico, love was acceptance of his sexuality—by himself and by others.

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FINDINGS

For the majority of the men interviewed, love followed a traditional, Western, heteronormative trajectory of dating, marriage, children, and growing old together. While sex was an important component of love—a component that many of our interviewees highlighted—it wasn’t the only element, and was often far down on their list of important relationship aspirations, if not absent entirely.

We can show young people images of death and disease, implore them to use condoms at all times, and— most ineffectually— tell them to abstain from sex until marriage all we want, but it won’t work.

So how do these conceptions of love play out in the sexual behaviors of young men who have sex with men, and how can such conceptions contribute to HIV/AIDS prevention? As any good public health student will tell you, our sample was small and not representative of any broader population, but the depth of insight we gained through the study was profound in a way that surveying thousands of the same population about condom use would not be. We found that our study participants faced the same web of complications and insecurities that most young people deal with in the realm of love and sex, and that this web was even more complicated in the face of expectations from inside and outside the gay community about how they, as YMSM, should act.

“Everything in the middle is something I would look for in the beginning of a relationship."

"Love should be fun."

“The last row was, sort of, I saw the progression of a relationship, ideally.”

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Dreaming of Tomorrow Research shows that when young gay men envision a future for themselves, they take better care of their bodies.

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n public health, we too often focus on disease prevention rather than on the promotion of health and well-being.

But this is gradually changing. In 2012, the United Nations placed “happiness” on the global agenda, and economists like Jeffrey Sachs and Joseph Stiglitz are now talking more about a country’s “happiness indicators” than its GDP. These ideas have been brewing in our culture for a long time, as indicated by the World Health Organization’s 1948 definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Yet the (admittedly crucial) process of vaccinating people, for example, can be easier than creating the conditions for health as defined by WHO, and such obvious interventions are often promoted over deep environmental and cultural changes that can/could lead to better health.

As Professor Bauermeister points out, we can show young people images of death and disease, implore them to use condoms at all times, and—most ineffectually—tell them to abstain from sex until marriage all we want, but it won’t work, and hasn’t worked. Is it time for a paradigm shift? It might be more useful to understand YMSM as complex beings navigating a challenging environment of lust, love, discrimination, self-image, and other cultural and personal expectations for how to be a “gay man.”

Our hope is that public health policies will shift to promote commitment and love between same-sex couples, and to develop programs that will allow YMSM to have the skills and self-acceptance to navigate relationships in a way that is safe, both emotionally and physically, whether they are looking for romantic love or not. <

H

Rachael Strecher, MPH ’12, is a program associate in the Global Health and Development Department of the Aspen Institute and a former health communications fellow at the National Cancer Institute.

public health professionals is keep talking about using condoms, we’ll fail,” Bauer-

IV infection rates in the United States have stabilized in every population group except one: young men who have sex with men. In the Detroit Metro

area, for example, young men between the ages of 20 and 29 account for 16 percent of all new HIV cases in Michigan. “If you include younger adolescents, the number is even larger,” says SPH Assistant Professor Jose Bauermeister, director of the U-M Center for Sexuality & Health Disparities.

Bauermeister is trying to identify the behavioral patterns that may underlie the relatively high rates of HIV transmission in this population. Through a series of studies on “virtual love,” begun in 2009, he and his research team are working to understand what happens when 18-to-24-yearold gay and bisexual men go online to meet partners and date, and how that information can help health professionals design and implement effective safesex interventions.

Health professionals have tended to focus more on risk factors associated with HIV transmission than on healthy behaviors, Bauermeister says, and he thinks that’s a mistake. “From a public health standpoint, if we’re always measuring risk, we miss the opportunity of increasing what works for people. In the context of HIV, I can talk to young men about condom use until I lose my voice, or I can understand that they’re looking for love and equip them with tools that can help them negotiate condoms with their partners.”

Through their Virtual Love project, Bauermeister and his team are using surveys, interviews, and Photovoice methodology to learn how young gay and bisexual men conceptualize love and dating—including things like how they distinguish between a hookup and a date, how they know when they’re falling in love, and how they characterize and define love. Having recently concluded a pilot Photolove study (see pages 33–34) in southeastern Michigan, Bauermeister and his colleagues are now embarking on a nationwide survey of 1,500 to 2,000 young men who have sex with men. The aim, Bauermeister explains, is to understand the romantic desires of this population and how those desires can either protect young men or put them at risk for HIV and other sexually transmitted infections. “A lot of what we’re doing is finding out how love protects kids. When they can envision a future for themselves, for example, they tend to take better care of their bodies.”

Key findings from Bauermeister’s research are: > Among young men who have sex with men, sex is tied to intimacy, and therefore the act of foregoing a condom is often a nonverbal expression of interest in a partner. > Youth who are able to envision a committed relationship in the future report fewer unprotected sex partners in the present. > Youth who experience “romantic obsession” can be so thirsty for love that it overruns their safer-sex decision-making, and so love isn’t always a good thing.

The public health implications of such findings are significant. “If all we do as meister says. “The literature has been very clear that condom use is partner-dependent. The way someone negotiates condoms with a casual partner is very different from a partner with a romantic interest. If we don’t understand how people process love or romance, how can we build interventions for them?” < For more visit sexlab.sph.umich.edu.

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> RESEARCH NEWS

Whether it’s end-of-life decision-making or start-of-life nutrition— or any of the myriad stages of human existence between those two extremes—love plays an important role in our health and well-being, as new studies by SPH researchers confirm.

The Love Hormone and Childhood Obesity

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f parents bond more closely with their kids, is it possible those children will eat less? That’s the question behind a study

by SPH Assistant Research Professor Alison Miller, who’s testing oxytocin levels in low-income moms and their preschool children to see if the so-called “love” hormone may have an impact on eating behaviors.

Scientists know there’s Miller a link between high levels of the hormone oxytocin in humans and lower levels of stress, and they also know that less sensitive parenting has been associated with higher levels of obesity. In animals, higher oxytocin levels are associated with

a lower intake of high-carbohydrate and sugary foods. So what Miller and her colleagues want to learn is whether oxytocin— a hormone that increases when we connect with people we love—may have an impact on a child’s chances of becoming obese.

In animals, higher oxytocin levels have been associated with a lower intake of highcarbohydrate and sugary foods.

Using what they call a “cuddle-promoting” study protocol, Miller and her colleagues are trying to find out whether

oxytocin levels increase when mothers and their children play games that foster positive physical contact like high-fives and hugs. And if oxytocin levels increase in those children, will they eat less when offered unlimited snacks for a short period of time?

The researchers hope to have results by this fall. Miller, a psychologist, believes the study may shed light on the potential for behavioral interventions to help reduce childhood obesity, especially in populations with higher-than-average levels of stress, such as low-income groups. <

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Letting Go—or Not— at the End of Life

What You Can Do Now Darin Zahuranec, MD, MS ’09, offers these recommendations for

At some point, many of us will find ourselves in a position to make decisions for a loved one facing a serious life-threatening illness—or we’ll need someone to be in that position for us.

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edical treatments in the weeks and days before death consume a disproportionate amount of health care spending, and can often lead to unnecessary suffering and unwanted medical interventions. But a myriad of factors makes it difficult for both practitioners and loved ones to respect patient autonomy and treatment preferences at the end of life.

“Matching our treatment goals to the values and preferences of the individual is a key part of ethically sound practice,” says SPH alumnus Darin Zahuranec, MD, MS ’09, an assistant professor of neurology in the U-M Health System who studies end-oflife decision-making.

Zahuranec notes that even when people attempt to give specific instructions to those who may actually make life-or-death decisions on their behalf—as with advance directives—evidence shows that such instructions typically do not account for all of the treatment decisions that may arise.

Further, different health conditions present different challenges. Patients facing a terminal illness, such as cancer, may have opportunities to discuss end-of-life treatment preferences with their families and doctors. But when a sudden unexpected illness, like a stroke, occurs, many patients and families are unprepared—especially as decisions often need to be made quickly, and the patient may be unable to communicate. This is particularly true with acute brain hemorrhage, a type of stroke with very high rates of early mortality. In about 70 percent of cases of acute brain hemorrhage, the withdrawal of life-sustaining treatment (e.g., a ventilator) precedes death. In such cases, family members are often placed in a position of making life-and-death decisions about treatment.

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In a new study funded by the National Institutes of Health, Zahuranec and his team are exploring the decision-making processes that family members of people with brain hemorrhages undergo when considering treatment options. “In many cases, doctors and family members face a tradeoff between the possibility of death or survival with some disability, but our ability as practitioners to predict the impact of this disability on someone’s quality of life is imperfect,” Zahuranec says. “ We’re learning more about just how difficult this is for people, and we hope to be able to improve this process in the future.”

Zahuranec’s research is a powerful reminder that, while no advance decisionmaking can guarantee what happens near the end of a patient’s life, if loved ones and practitioners address these issues ahead of time, they may find it easier to make sound treatment decisions for—and respect the autonomy of—the patient. < —Jillian Murphy, MPH ’09, Project Manager, U-M Stroke Program

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end-of-life planning:

> Consider your values and what is important to you. We are all going to die; how we die remains uncertain. It is fair to expect that our self-determination and autonomy as individuals be respected in all our medical treatment.

> Talk to your loved ones and doctors about your various treatment preferences, and continue to have these conversations as your health status changes.

> Take the time to formally grant durable power of attorney (DPOA) for health care to someone you trust so that person can make medical decisions for you in the event you are unable to speak for yourself.

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For more information,

visit Caring Connections (caringinfo.org), a program of the National Hospice and Palliative Care Organization. (Click on “Planning Ahead” for additional resources).

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R E S E A R C H D IG E ST

The Troubled State of American Health On average, Americans die sooner and experience higher rates of disease and injury than people in other high-income countries, according to a recent report from the National Research Council and Institute of Medicine. The report found that this health disadvantage exists at all ages from birth to age 75, and that even advantaged Americans—those who have health insurance, college educations, higher incomes, and healthy behaviors—appear to be sicker than their peers in other rich nations. U-M SPH Professor Ana Diez-Roux, chair of the Department of Epidemiology, served on the panel that wrote the report.

What Happens after Sex —and Why It Matters T

he time partners spend together after sex is markedly important for bonding as a couple. According to Daniel Kruger, research assistant

professor at U-M SPH, understanding new ways to encourage relationship commitment and stability has implications for promoting sexual and emotional health—and for preventing the spread of sexually transmitted infections (STIs). Two recent studies by Kruger and his colleague Susan Hughes of Albright College suggest that couples should use the so-called “post-coital time interval” (PCTI) to strengthen their attachment to one

Kruger

another. “Our research shows that expressions of love and commitment are especially important in this time span, because people are experiencing a cascade of emotions and hormonal activity,” says Kruger.

Couples who want to establish a long-term relationship should use the PCTI as an opportunity for bonding.

The first of the studies by Kruger and Hughes examines how gender differences affect people’s PCTI experiences. The second study demonstrates that individuals with partners who tend to fall asleep first after sex have a greater desire for partner expressions of emotional bonding, physical affection, and communication, which can in turn affect relationship commitment.

“The systemic nature of the problem was surprising to the committee, and suggests that a number of interrelated environmental and policy factors may be playing an important role,” Diez-Roux said.

The report is the first comprehensive look at multiple diseases, injuries, and behaviors across the entire life span, comparing the United States with 16 peer nations—affluent democracies that include Australia, Canada, Japan, and many western European countries. Among Diez-Roux these countries, the U.S. is at or near the bottom in nine key areas of health: infant mortality and low birth weight; injuries and homicides; teenage pregnancies and sexually transmitted infections; prevalence of HIV and AIDS; drug-related deaths; obesity and diabetes; heart disease; chronic lung disease; and disability. This health disadvantage exists even though the U.S. spends more per capita on health care than any other nation. To learn more: sph.umich.edu/ findings. < —U-M News Service

The significance of the post-coital time interval may be most relevant when there is ambiguity as to whether the relationship is long-term and exclusive. In particular, says Kruger, “couples who want to establish a long-term relationship should use the PCTI as an opportunity for bonding.”

It’s an important public health issue, Kruger adds. If people switch partners less frequently, it can reduce their risk of STI transmission. He explains, “People these days have a casual relationship with sex—despite the fact that one act of sex could change your life.” —Danielle Taubman, MPH ’13

<

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Personality and Heart Disease:

What the Genes Reveal S tudies show that personality measures—including traits such as patience and aggression—can predict both heart disease risk and a person’s overall prospects for healthy

aging. And that’s got biostatistician Goncalo Abecasis wondering whether he and his

research team can find specific genes capable of predicting personality or changing heart disease risk factors. “The idea would be that once you’ve found a specific gene, you could try to design a drug that either copies or blocks its effect, depending on the outcome you’re after,” says Abecasis, the Felix E. Moore Collegiate Professor of Biostatistics.

But it’s much more difficult to identify genes associated with personality than it is to find genes linked to more physical measures like cholesterol and blood pressure levels—which Abecasis has had considerable success doing. That’s because when it comes to personality, he says, more genes are likely to be involved, and so the

“It’s very clear that genes and genetic variants contribute to personality.”

impact of any one specific gene will be smaller. In an effort to disentangle the mystery, he and his team have devised new and better ways to sequence the human genome and are using that methodology to parse the genomes of 1,000 individuals. They hope to learn more about human personality and how such information can be used to reduce the risk of heart disease. The cohort is a subset of a larger genetic study focused on aging.

“It’s very clear that genes and genetic variants contribute to personality,” Abecasis says. “But it seems like most of them only make very small contributions, so it’s hard to

pinpoint something and say, ‘Aha! This variant makes you more agreeable or more neurotic, and therefore at a lower or higher risk for heart disease.’”

One finding to have emerged from their work is that genetic factors that change good cholesterol (HDL) have no impact on the risk of heart disease.

Abecasis

“So HDL is probably not directly linked to heart disease,” Abecasis says. The findings shed light on why drugs that have been developed to alter HDL have not worked especially well. <

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Since the early 1980s, Medicare has paid for kidney dialysis for any American who needs it, regardless of age. But because until recently Medicare paid a flat rate for basic dialysis treatment and associated tests and drugs, and a separate fee-forservice rate for additional medications and lab tests, costs kept going up. So Congress ordered the Centers for Medicare & Medicaid Services (CMS) to come up with a new bundled-payment system that would allow Medicare to pay a flat rate for dialysis, medications, and tests. CMS in turn asked the U-M Kidney Epidemiology and Cost Center (KECC) to develop the system.

“We looked at multiple years of claims data to determine what drugs and tests should be in the system, and we built a case-mix adjustment model as well,” says Richard Hirth, associate director of KECC and professor and associate chair in the Department of Health Management Hirth and Policy. The goal was to build a cost-effective system that would provide equal access to all patients, regardless of how expensive their treatments were.

CMS implemented the new dialysis-payment system in 2011, and since then the use of injectable medications has dropped by approximately 25 percent, and Medicare payments for dialysis have gone down by two percent—or about $225 million per year. Dialysis facilities themselves are profiting because their costs have dropped by as much as ten percent. It’s therefore expected that CMS will be able to reduce payments even further in the future. The new system also makes it easier for patients to receive dialysis in their homes. Hirth says the dialysis-payment system is the latest in a long-standing movement toward bundled-payment systems by both public and private payers. For more visit sph.umich. edu/kecc. <

H E A L T H

S P H . U M I C H . E D U

R E S E A R C H D IG E ST

U-M–Developed System Yields Millions in Medicare Savings

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FINDINGS

At the launch of the new U-M Momentum Center, a campus-wide research collaborative aimed at ending childhood obesity, chef, author, and National Geographic Fellow Barton Seaver told listeners, “Childhood obesity is a representation of a complete societal failure to create a human environment that is purposed to sustain life.” Seaver also runs the Harvard School of Public Health’s Healthy and Sustainable Food Program.

Tales of Resiliency E

Peter Smith

R E S E A R C H D IG E ST

In the News: Two New U-M Centers

Barton Seaver with SPH Dean Martin Philbert.

Directed by U-M SPH Professor Karen Peterson, U-M’s Momentum Center has already forged partnerships with ten different U-M units spanning a range of disciplines— from health sciences to architecture, design, and business—and is expected to expand its reach. “Momentum is focused on the U.S., but clearly the long-range aim has to be global,” says SPH Dean Martin Philbert.

In response to the growing complexity of cancer research—and the increasing need for advanced statistical analysis of data—U-M Taylor SPH has established a new Center for Cancer Biostatistics. Directed

by Jeremy Taylor, the Pharmacia Research Professor of Biostatistics at SPH and professor of radiation oncology and professor of computational medicine and bioinformatics in the U-M Medical School, the center will foster collaborations between SPH faculty, staff, and students, and the U-M Comprehensive Cancer Center. <

conomically disadvantaged cities like Flint, Michigan, with high unemployment and restricted mobility, often provide a backdrop for personal struggle. People in such settings must often do much more to succeed than those from more affluent areas. And yet many young residents in Flint manage to thrive. In an effort to understand why, U-M SPH researchers are actively listening to their stories.

Emily Pingel, project director of the Flint Adolescent Study, part of the U-M SPH Prevention Research Center (PRC), has interviewed 15 young African-American adults who grew up in Flint and still live in the city. The interviews were designed to explore how structural factors shape their lives and health. Ideally, the study’s qualitative approach will yield insights into residents’ lives and health that complement existing quantitative research.

Pingel says she’s struck by the fact that participants in the study have encountered so much adversity and have nevertheless remained focused on accomplishing what they set out to do—and on helping others at the same time. Participants have told her that to maintain their sense of individual resiliency and become successful, they’ve found it important to volunteer, strengthen community bonds, and support fellow members of their community. “Here are people who have challenging lives in terms of interpersonal struggles, barriers to access, and constraining structural inequalities, yet they never stop believing in their ability to succeed,” she says.

People in such settings must often do much more to succeed than those from more affluent areas.

This attitude may reflect the phenomenon of “John Henryism,” commonly understood as a psychological strategy for coping with prolonged exposure to high levels of stress. Because such high-effort coping wears on people over time, John Henryism has been used to explain a variety of poor health outcomes among African Americans.

Research from the PRC and other studies makes it clear that structural inequalities can constrain people in ways that create significant stress and contribute to racial health disparities. Pingel and her colleagues hope that by developing a better appreciation of how people make sense of their lives and contend with struggle, the researchers can develop evidence-based structural interventions to improve individual health outcomes and reduce health disparities. < —Danielle Taubman, MPH ’13

> A L U M N I N E T W OR K

41

Q UO T E / UN Q UO T E

Malaria’s Lessons

A grave illness teaches the power of love.

I

n May 2012, eight years after completing

by Varsha Mathrani, MPH ’04

By the Numbers: Malaria’s Global Toll

4

noble intention of serving as a Peace Corps

Ugandan family treated me as one of their

Volunteer. After ten weeks of training, and

own and later e-mailed me from across the

getting sworn in as a community health vol-

miles. In Kampala, a Canadian neighbor at

unteer, I moved to the small town of Bugiri

a guesthouse where I stayed bought me

to start life with a new community for two

yogurt while I was sick, as my medication

years. Within a week of arriving, I fell sick

needed to be taken with fatty food. I am

with malaria. After three days of being nearly

touched by the prayers and wishes of

bed-ridden in Bugiri and a week of medical

fellow volunteer friends in my training

treatment in Kampala, I

Number of parasite species that cause malaria in humans.

resigned from the Peace Corps and flew home to the United States to recover. I felt like I’d had

65

a brush with death.

Approximate percentage of global malaria fatalities that occur in children under 15 years old.

I did not imagine the toll disease would take on my body—nor did I imagine how much

90

it would teach me. As

Percentage of all malaria deaths that occur in Africa.

Charles Fritz notes in

660,000

Mental Health, “Disasters

his book Disasters and provide a temporary lib-

Estimated number of deaths worldwide from malaria in 2010.

eration from the worries, inhibitions, and anxieties associated with the past

66,000,000

Estimated number of long-lasting insecticidal nets (LLIN) delivered to endemic countries in sub-Saharan Africa in 2012, down from a peak of 145 million nets in 2010. A decrease in LLIN coverage is likely to lead to major resurgences in the disease.

219,000,000

Estimated number of cases of malaria worldwide in 2010.

Varsha Mathrani (second from right) with community health workers in Bugiri, Uganda.

and future, because they force people to

class, including some nurses whose skills

concentrate their full attention on immedi-

and compassion helped play a part in the

ate, moment-to-moment, day-to-day needs

healing process.

At one point, I wished that life could

within the context of the present realities.”

Later I realized I didn’t need such loving, attentive care all the time, because it is always implicitly there.

always be like this. But later I realized I didn’t need such loving, attentive care all the time, because it is always implicitly there in society at large—not all the time, but in very important ways.

As my illness faded, I found that it had made me fiercer—less willing to waste my time and more urgent about what mattered. I know that despite pain and

5.1 billion

So does illness. It was a challenging

Estimated dollar amount needed every year between 2011 and 2020 to achieve universal access to malaria interventions.

Source: WHO World Malaria Report 2012

U N I V E R S I T Y

I am touched by the many kindnesses I received from “strangers.” In Bugiri, my

my MPH, I traveled to Uganda with the

O F

hardship, I have grown spiritually and men-

and humbling experience to face the sim-

tally from this experience. I’m learning to

ple and raw truth of mortality, to feel fear

recognize and appreciate those who have

and doubt, to accept both my strengths

created pathways where I can learn in my

and weaknesses. I now know the feeling

life. As an African proverb says, “He who

and can identify with others who face—

learns, teaches; he who teaches, learns.” <

and have faced—this disease.

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S C H O O L

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FINDINGS

Q UO T E / UN Q UO T E

Report from Eastern Congo:

Research Builds Hope

L

ast October, Congolese physician and human rights advocate Denis Mukwege narrowly escaped death when gunmen attacked him and killed one of his security guards outside Mukwege’s home in Bukavu. Lisa Peters, MPH ’08, says the attack “underscores the importance of Dr. Mukwege’s work, the impact he is having in the region, and the desperate need for the international community to come together for his cause.”

Peters speaks from first-hand experience. She met Mukwege in Ann Arbor in 2010, when he came to campus to accept

the University of Michigan’s prestigious Wallenberg Award for his work treating the victims of sexual violence in war-torn eastern Congo. Peters asked Mukwege, the medical director of Congo’s Panzi Hospital, how the University of Michigan could help. He said Panzi needed U-M’s research expertise.

Since that conversation, Peters has spent more than eight months in Congo working with Mukwege and his colleagues at Panzi to systematize and expand the hospital’s research agenda and begin implementation of a cervical cancer screening

program. In collaboration with U-M faculty members Jane Hassinger, Janis Miller, and Paul Clyde, Peters and the Panzi staff are also developing a training program in mental health for local nurses. Many of the women who come to Panzi need psychosocial support, Peters notes, and there’s a critical need to build local capacity for trauma care in rural areas.

Despite the violence that plagues eastern Congo—and nearly claimed Mukwege’s life— Peters believes the region can emerge from its present crisis. A sound and robust research agenda, she adds, is crucial to that process:

Denis Mukwege (left) on the grounds of Panzi Hospital; below left, Lisa Peters (right) with Panzi’s Betoko London; above, social assistant Sifa Chitera Rose provides counseling to a patient.

Also shown on these pages: scenes from Panzi Hospital, including Denis Mukwege performing surgery, and women patients attending classes in sewing, knitting, and literacy.

Photos: Panzi Hospital Communications Department

A LUM A RNT II CNLE ETW T IOR T LE K

E

veryone goes to Panzi Hospital for data, so making sure the numbers are accurate is of the utmost importance.

If you can’t answer questions about how many people are there, and why, and what support they receive, you can’t get funding.

Are things working? Where do we need to focus next? None of this can happen without having numbers to support what you’re doing.

“What we do here at the University of Michigan and the U-M School of Public Health is exactly what they need—we solve problems by getting data and then apply-

ing it to make things better. Panzi needs to develop an infrastructure and format for research. Eastern Congo receives millions of dollars in humanitarian aid every year. The projects those dollars fund are incredibly important—emergency food and medicine—but people are so focused on the immediate crisis they’re missing a critical training and education component. It’s changing, though. The physicians and staff at Panzi are starting to see the importance of research, evaluation, and training, and they’re teaching people to think through projects on their own.

43

“Eastern Congo is an incredibly hopeful place. Many of the doctors there trained abroad and could go somewhere else like Belgium or France, but they are amazingly dedicated, and they stay there. That’s why I keep going back. If I didn’t think it was possible for things to change, I wouldn’t be there. You can see it. And Dr. Mukwege has inspired that vision in his whole staff. <

W Denis Mukwege was featured in the spring/summer 2011 issue of Findings, which is available online at sph.umich.edu/ findings.

“If I didn’t think it was possible for things to change, I wouldn’t be there.

You can see it.”

U N I V E R S I T Y

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FINDINGS

C L A SS NO T ES

M A K I N G A D I F F E R EN C E

1960s

In recognition of his contributions to public health during the past seven decades, the Oral Health Section of the American Public Health Association has awarded Jay W. Friedman, DDS, MPH ’62, the 2012 John W. Knutson Distinguished Service Award in Dental Public Health. 

Warden has been a key figure in the IOM for more than 25 years.

On the Front Lines of the Tobacco Wars C

1980s

America Bracho, MPH ’88, is the executive

director of Latino Health Access, a center for health promotion and disease prevention in Santa Ana, California. The center was created under Bracho’s leadership to assist with the health needs of Latinos in Orange County.  Patrick T. Dowling, MD, MPH ’86, is professor and chair of the Department of Family Medicine and the Kaiser Endowed Chair of Community Medicine at the David Geffen School of Medicine at UCLA. His key research, clinical, and teaching interests are prevention and lifestyle conditions that contribute to type 2 diabetes, high blood pressure, and elevated cholesterol levels.  The American Heart Association has awarded its 2012 Population Research Prize to Aaron Folsom, MD, MPH ’80, professor of epidemiology and community health at the University of Minnesota School of Public Health. Folsom has contributed to more than 750 scientific publications on risk factors for heart attack, stroke, venous thrombosis, and cancer. continued on p. 45

onsider the numbers: 1,200 deaths a day in the U.S. from smoking-related causes; 4,000 kids a day who try their first cigarette.

But what Meg Riordan, MPH ’02, finds most compelling are the stories: the young woman in North Carolina who is raising her son by herself because his father died from a smoking-related disease; the grandmother in California who cares for her grandson because the boy’s mother— her daughter—died from smoking.

“It’s mind-blowing when you know the numbers of people and families affected by tobacco use,” says Riordan, director of policy research for the Washington, D.C.–based Campaign for Tobacco-Free Kids.

Even though her office is charged with being the “number crunchers, responsible for all of the data that we use in our advocacy and communication efforts,” Riordan says she’s ever mindful that the work she and her colleagues do “is real stuff that can impact people’s lives. Public health matters.”

Key moments during her ten years with the campaign include passage of the Affordable Care Act—which requires coverage for treatment to help smokers quit and provides funding for tobaccoprevention programs—and passage of legislation in 2009 giving the Food and Drug Administration authority to regulate tobacco products. The second

effort, Riordan remembers, took years of “blood sweat, and tears, but has the potential to be a major, major game-changer in driving down tobacco use.”

Riordan got interested in politics as an undergraduate, but it was a class on Medicare, Medicaid, and the U.S. health system that led her into public health. “I thought, this is real. This is a real public policy issue.”

What does she hope to achieve through her work with the tobaccofree campaign? “Before Last fall, Meg Riordan, MPH ’02, visited SPH I hang up my boots, I’d and met with students love to see the smoking in HMP 618, “Tobacco: rate in this country fall From Seedling to Social below ten percent for Policy,” taught by both adults and young Clifford Douglas. people. We’ve made a lot of progress, but smoking rates are still way too high. People want to quit. It’s a disease. A lot of people—especially people who’ve never smoked— don’t understand how addictive this product is.”

For more on the Campaign for Tobacco-Free Kids visit tobaccofreekids.org.

Peter Smith

Last fall, the Institute of Medicine awarded SPH professor and alumnus Gail Warden, MHA ’62, the Adam Yarmolinsky Medal for outstanding service to the IOM. Warden has been a key figure in the IOM for more than 25 years, serving as a member of the IOM Council, as a reviewer of multiple reports, and as chair of several committees.

A LUM N I N E T W OR K

45

I N MEMO R I A M continued from p. 44

1990s

Sylvia Hacker

Henry Ford Wyandotte (MI) Hospital has named Denise Brooks-Williams, MHSA ’91, its new president and chief executive officer. Brooks-Williams is a graduate of the U-M SPH Summer Enrichment Program and a member of the Department of Health Management and Policy Alumni Board.  As associate executive director of the National Association of City & County Health Officials, David Dyjack, DrPH ’96, oversees the following programs: environmental health, preparedness, infrastructure, systems, chronic disease, infectious disease, and maternal and child health/injury prevention.  The readers of DBusiness included nutrition expert Stacy Goldberg, MPH ’99, RN, BSN, in the magazine’s 2012 “30 in Their Thirties” list of regional professionals who are advancing their companies, industries, and communities. Goldberg is the founder and CEO of Savorfull (Savorfull.com), a Detroit-based company.  Charles Holmes, MD, MPH ’94, recently left his position in Washington as Chief Medical Officer for the President’s Emergency Plan for AIDS Relief (PEPFAR) and Deputy U.S. Global AIDS Coordinator to become the new director of the Centre for Infectious Disease Research in Zambia. “I wanted to be part of an organization that was involved in improving health every day and doing cutting-edge research to improve programs,” Holmes says.  Jennifer Kolker, MPH ’92, is the new associate dean for public health practice at Drexel University School of Public Health. An associate professor in the school’s Department of Health Management and Policy, Kolker also directs, in collaboration with the Graduate School of Public Health at the University of Pittsburgh, the Pennsylvania Public Health Training Center.  Alisa Koval, MHSA ’98, provides monthly asbestos-related health screenings and chronic asbestos disease management for patients at the Center for Asbestos-Related Disease in Libby, Montana. She also participates in the Libby Epidemiological Research Program.  Clif McClellan, MS ’97, is vice president of NSF International’s Global Water Division.

Previously he was the company’s director of U N I V E R S I T Y

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toxicology.  Scott Nordlund, MHSA ’90, is the new executive vice president for enterprise strategy and innovation development at Trinity Health, based in Livonia, Michigan.

Previously he was senior vice president for strategic growth, network, and new venture development at Dignity Health.  A professor of clinical practice in the U-M School of Kinesiology, Michael P. O’Donnell, PhD ’94, directs the U-M Health Management Research Center, which helps employers measure the health risks of employees and analyze the relationship between health risks, medical costs, and productivity.

O’Donnell is also editor-in-chief of the American Journal of Health Promotion, which he launched in 1986.

2000s

Philip Mataverde, DO, MPH ’01, a

neurologist at Lake Regional Neurology in Osage Beach, Missouri, has been boardcertified in neurology by the American Osteopathic Association.  During a two-year global pediatric fellowship in health service delivery through Harvard University, Boston Children’s Hospital, and Partners in Health, Leana May, DO, MPH ’08, is working as both a hospitalist in Boston Children’s Hospital and a pediatrician in Rwanda, and is also furthering Partners in Health research initiatives.  Jamaican-born Yanique Redwood, MPH ’00, is the new president and CEO of the Consumer Health Foundation, which seeks to achieve health justice in the Washington, D.C., region through activities that advance the health and well-being of historically underserved communities. Previously Redwood was senior associate for health and mental health at the Annie E. Casey Foundation.  Shannon N. Zenk, RN, PhD ’04, has received the 2012 School of Nursing Distinguished Alumna Award from Illinois Wesleyan University. Zenk, an associate professor at the University of Illinois, Chicago, studies obesity and the environmental and socioeconomic factors that contribute to obesity. <

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P U B L I C

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n January 13, 2013, Sylvia Sukoff Hacker, Associate Professor Emerita of Population Planning and International Health and Associate Professor Emerita of Nursing, died peacefully in her sleep at her apartment in Lawrence, Kansas.

Born October 19, 1922, in New York City, Hacker earned a BS in biology from Brooklyn College and an MA from SUNY– Cortland.

At age 53 she received her PhD from the University of Michigan.

She subsequently taught at Michigan for 16 years, holding a dual appointment in the U-M School of Nursing and School of Public Health, where she taught courses in human sexuality. She produced her own TV show, “Sexy Minutes,” and appeared on both the Phil Donahue and Montel Williams shows, and with her daughter Randi Hacker, she coauthored What Every Teenager Really Wants to Know about Sex: The Startling New Information Every Parent Should Read.

Sylvia Hacker received a number of awards from the Michigan Department of Public Health, Mensa, and lesbian and gay civil rights groups.

Fond of the statement “human beings are highly overrated,” Hacker collected jokes and appreciated humor of all types.

Perhaps her greatest gift, writes her daughter Randi Hacker, “was her cheerful willingness to adjust, and adjust well, to whatever situation she was dropped into, and there is little doubt that she will use this gift wherever she is now.” Hacker is survived by two daughters, Randi Hacker and Avry Budka; a granddaughter, Juliana Hacker; a sister, Sunnie Kurtzman; and a brother, Shel Sukoff. Her husband, Charles Hacker, died in 1978. A memorial service for Sylvia’s friends and family will take place at U-M SPH on May 19, 2013, starting at one p.m. <

H E A L T H

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FINDINGS

CareerWatch: The Nonprofit Sector

I N MEMO R I A M

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

Overview

Skill Set

1920s & 1930s

There are numerous public health jobs avail-

Nonprofit work entails a wide variety of

Syed F. Husain-Khan, MSPH ’28; DPH 1933

able in the nonprofit sector—both domesti-

skills. Basic computer skills—including

cally, at the local, state, and national levels,

social media, databases, and electronic

1940s

and globally. Most jobs in the nonprofit

recordkeeping—are essential, as are basic

Walter G. Bigler, MPH ’43

sector are about the good of the population

research and evaluation skills. Both writ-

you’re working with and not for the benefit

ten and verbal communication skills and

1950s

of a company. If a nonprofit agency does

a grasp of finances and budgeting are

happen to make a profit, it goes right back

crucial. You need to be a good manager,

into the agency. Some nonprofits pay good

to be able to supervise people, including

salaries, but not all. Even with nonprofits

volunteers. Interpersonal skills are huge, as

that pay well, staff members often work be-

nonprofit work tends to be highly team-

cause of love, not money. Often, the bigger

oriented, and collaboration is essential.

the agency, the better the salary, and the

Cultural competence is very important,

more stable the job.

especially when it comes to community

In Practice

partnerships. Many nonprofits deal with controversial issues like birth control and

The nonprofit sector is highly action-orient-

sexually transmitted diseases, so you need

ed—you get hands-on experience in making

to understand different kinds of cultures—

a difference. Frequently you have to wear

not just racial and sexual, but religious,

multiple hats: fundraiser, manager, grant

socioeconomic, political, and generational.

writer, volunteer coordinator, etc. In general, nonprofit jobs aren’t nine-to-five—your job doesn’t necessarily end when you walk out the door. But that’s also part of doing what you love. As with any job, the higher your rank, the more you can dictate your own schedule, and the more hours you put in above and beyond the scheduled work week. For the most part, full-time jobs in the nonprofit world come with benefits, but those can be limited, and increasingly you

Takeaway Quote

“The goal of public health is to make the world as healthy as possible, and to me, nonprofit work is really about making the world a better place, and about making sure that everyone has opportunities.”

you to stay true to your core values.

Job Opportunities Job possibilities include health educators, executive directors, program directors, grant writers, data coordinators, volunteer coordinators, general educators, and COOs. There are ample opportunities in development and public relations. Some nonprofit jobs involve conducting university-based research that’s linked to, or in partnership with, community-based organizations.

Service on boards of directors is a huge part of nonprofit work, and not remunerative. When it comes to boards, don’t take on more than you can do, because it’s not helpful to the nonprofits or to yourself.

’95, Executive Director, Peter Smith

can be low, nonprofit work in general allows

October 24, 2012

October 24, 2012

Robert K. Anderson, MPH ’50  October 18, 2012 B.G. Garrison, MPH ’52  January 3, 2013 James D. Sorley, MPH ’56  November 27, 2012 Gloria R. Smith, MPH ’59  January 14, 2013

1960s Chin-Un (Kimma) Chang, MHA ’65  November 12, 2012 Vito M. Logrillo, MPH ’66  December 14, 2012

1970s JoAnn H. Yatabe-Kuntz, MPH ’70  March 21, 2012 Shirley A. Keating, MPH ’71  January 1, 2013 Patricia H. Parkerton, MPH ’72; PhD ’00  October 26, 2012 Daryl F. Patterson, MS ’72  September 17, 2012 Leon A. Shepard, MPH ’74  June 23, 2012 Deborah L. Ebers, MHSA ’76  September 3, 2012 John H. Nichols, MPH ’79  November 11, 2012

1980s Nina Poppelsdorf, MPH ’82



November 22, 2012

K EE P I N T OU C H

—Nicole Adelman, MPH

have to help pay for them. Few nonprofits match retirement savings. Although the pay





Nicole Adelman

Interfaith Hospitality Network of Washtenaw County (MI); former Vice President of

Education, Training and Outreach, Planned Parenthood, Mid and South Michigan; Director of Prevention Programs, HIV/AIDS Resource Center, Ypsilanti, MI; Health Educator, The Corner Health Center, Ypsilanti, MI

To Learn More: new.org mnaonline.org nonprofit.umich.edu

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

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> SPH Career Connection matches SPH students and grads with companies and agencies.

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> Update your SPH contact info from our home page at sph. umich.edu. Or indicate changes on the address label and mail to the address on the back cover.

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> S P H D AT EBOO K

New on the Web Public Health in Action

July 7–26, 2013

Graduate Summer Session in Epidemiology Now in its 48th year, this internationally recognized program provides instruction in the principles, methods, and applications of epidemiology.

A certificate program as well as online and e-learning courses are available. For more visit umich.edu/epid/GSS.

August 2013

Executive Master’s Program in Health Management and Policy The Department of Health Management and Policy launches the newest cohort in its two-year Executive Master’s Program. For more information, or to apply, visit um-execmasters.org.

Through SPH Frontlines, a blog about public health practice in the field, you can relive the experiences of students in the SPH Public Health Action Support Team who traveled to Grenada and Texas over spring break to conduct public health research on chronic disease, health care access, sickle cell anemia, and other issues of concern to local communities. Check back often, as students add to the blog from other public health frontlines. umsphfrontlines.org

Catch Up on Your Watching September 26, 2013

Why Is It Hard to Pivot Based on Science?

U-M Palmer Commons, Great Lakes Room, 2-4 pm The 2013 Bernstein Symposium examines the tension between personal convictions and scientific evidence, with a keynote address by Mark Lynas, author of The God Species: How the Planet Can Survive the Age of Humans. Open to the public; advanced registration required at umriskcenter.org.

October 2013

On Job/On Campus Program in Clinical Research Design and Statistical Analysis The U-M SPH Departments of Biostatistics and Epidemiology begin a new cohort in their two-year On Job/On Campus program in clinical research design and statistical analysis.

Applications accepted until program is full; for more, visit sph.umich.edu/biostat/ programs/clinical-stat/.

Risky Business

October 18-19, 2013

Leadership and Change Management: Improving the Health of Our Communities Sheraton Ann Arbor Learn, reconnect, and build new connections during this year’s symposium and football weekend sponsored by the Griffith Leadership Center in health management and policy.

For more visit sph.umich.edu/glc.

November 2–6, 2013

APHA Annual Meeting, Boston, MA Even if you’re not registered for APHA, alumni and their guests are invited to Michigan’s Keep-In-Touch reception, Monday, November 4, 6:30 to 8 pm. For more information contact sph.keepintouch@umich.edu or 734.764.8093.

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Learn about health risks — and how to avoid them—in accessible bite-sized videos from Andrew Maynard, chair of the Department of Environmental Health Sciences and director of the U-M Risk Science Center. More than 1,000 subscribers follow Maynard’s weekly insights into the science behind how we understand and make sense of risk—you can join them! youtube.com/riskbites

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

For details on these and other UM SPH events, visit sph.umich.edu.

U N I V E R S I T Y

Wish you could sit in on one of the scores of presentations by faculty and guest lecturers that make SPH such a vital place to be? Now you can. On our YouTube page you’ll find lectures by former SPH Dean Kenneth Warner on why public health is contentious, Professor Karen Peterson on how to reduce obesity rates, Professor Vic Strecher and colleagues on how to design narratives for health behavior change, and more. youtube.com/sphweb

P U B L I C

H E A L T H

S P H . U M I C H . E D U

> M Y S PAC E

With Professor A. Mark Fendrick, right, in the Center for Value-Based Insurance Design, U-M North Campus Research Complex, Ann Arbor “Since coming to the School of Public Health in 2012, I’ve worked with the U-M Center for Value-Based Insurance Design, or V-BID, and its director, Mark Fendrick.

My biggest concern about returning to school was the fear of taking a vacation from the ‘real world,’ and from the realworld issues that matter to people outside the ivory tower. V-BID has given me a truly special opportunity to stay grounded in conversations around rethinking ‘business as usual’ in health care.

In February, Mark was asked to testify before the House Ways and Means Subcommittee on Health on reforming the Medicare benefit package. I helped Mark draft his testimony and then flew to Washington for the hearing. Given the substantial differences that generally divide Democrats and Republicans on health care reform, there seemed to be an unusual level of bipartisan openness to setting cost-sharing in accordance with clinical value. It was especially exciting to help educate members of Congress on an issue where meaningful progress is possible.”

—Jason Buxbaum, first-year student, Master of Health Services Administration program, Department of Health Management and Policy; research assistant (2009–2011) and policy analyst (2011–2012), National Acad-

Peter Smith

emy for State Health Policy, Portland, Maine

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 Web Editor Mari Ellis Art Direction/Design Hammond Design

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. ©2013, University of Michigan

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

IN THEIR WORDS:

SCHOLARSHIPS MAKE THE DIFFERENCE

In fields as diverse as human nutrition, hospital administration, cancer prevention, vaccine development, and health communications, graduates of the University of Michigan School of Public Health are transforming our world.

“Thanks to scholarship funding, I was able to start my own business in Detroit in 2011, during my last semester at SPH. We now have 25 stores across the city. We work with corner store gas stations and small-scale retailers to develop a sustainable distribution model that can continually increase access to quality healthy food in Detroit. The best comment I’ve gotten from a customer was the 70-year-old man who told me, ‘I tried your chicken caesar sandwich the other day and realized I’ve been eating wrong my entire life.’ That totally made my day.”

NOAM KIMELMAN, MPH ’12 Co-founder and owner, Fresh Corner Café, Detroit, Michigan Recipient, S.J. Axelrod/Eugene Feingold Memorial Scholarship, U-M SPH

To find out how you can help make the difference for an SPH student, contact Gail McCulloch, Development & Alumni Relations, at 734.764.8093, or visit sph.umich.edu/giving, where you’ll find more scholarship stories.

Office of Marketing and Communications 1415 Washington Heights, Ann Arbor, MI 48109-2029

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Peter Smith

University of Michigan School of Public Health