ColoradoSPH 10th Anniversary Magazine by Amanda Kujawa

10th Anniversary Edition Colorado School of Public Health

University of Colorado Anschutz

Colorado State University

Charting new paths for a healthier future

University of Northern Colorado

10th Anniversary 2008â&#x20AC;&#x201C;2018

Dean’s Note Colleagues, Students and Alumni, and Friends, This magazine, our first, tells the story of the Colorado School of Public Health over its initial decade. The stories are about the research accomplishments of the faculty and students, the school’s engagement with the state through education and training, practice and translation, and the impact of our alumni. Above all, this magazine documents how the school and its many public health and community partners have contributed to advancing health in Colorado—the over-riding goal a decade ago when ColoradoSPH was established and the Colorado Public Health Act of 2008 was passed. I was fortunate to join ColoradoSPH after the hard work of establishing it was completed. For this, I credit our first Dean, Dick Hamman, and others with having the vision and persistence to negotiate the challenging path to an accredited three-university school of public health, a model that is unique but tailored to the state of Colorado. As described in the stories in this magazine, ColoradoSPH advances health in the Rocky Mountain West in many ways: training and education, research, testing and implementing interventions to advance health, and consultation and advice.

2 | ColoradoSPH 10th Anniversary

Of course, a school of public health has education and training as an ongoing core activity. The numbers document impact—more than 2,000 graduates, 600 enrolled MPH and other graduate students, and a shared undergraduate program at the University of Colorado Denver campus with more than 500 public health majors. The successes of graduates and their stories in this magazine—Barbara Martin, Katie O’Connor, and Saskia Bunge-Montes from our CU Anschutz programs, Rachel Freeman from our UNC program, and Ben White from ColoradoSPH at CSU— are compelling. But our impact is even broader as our Center for Public Health Practice reaches thousands of practitioners throughout the state. One story describes how the Centers for American Indian and Alaska Native Health used telemedicine to reach remote reservation sites to address the tragic mental health problems of Native Americans.

“

And, as always, there is much more to come. Colorado is facing some of the same public health challenges as other states: diabetes, epidemic opioid abuse, mental and behavioral health challenges, tobacco, and environmental pollution, as examples. For diabetes, our approach is comprehensive and spans the full lifespan through the work of Dana Dabelea and others at the Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center. We have learned that risk of diabetes as an adult begins to be set during gestation and childhood. Through a comprehensive epidemiological research program, the LEAD Center is exploring how risk evolves across the lifecourse with an eye towards finding the critical events that can be reversed. ColoradoSPH has responded to the behavioral and mental health crises with new educational programs, including a new certificate and concentration within the MPH degree developed with leadership from Jenn Leiferman. Our Center for Health, Work and Environment, led by Lee Newman, engages workplaces and workers in its Total Worker Health® program and training to reduce opioid use. There is long-standing emphasis on advancing child health as well with statewide initiatives through the Rocky Mountain Prevention Research Center and a specific focus on the communities of Colorado’s San Luis Valley. A planned initiative there will address the emerging topic of adverse childhood experiences, or ACES, which have lasting consequences. Colorado has a booming oil and natural gas industry centered in Weld County, which has the majority of the state’s wells. ColoradoSPH is well positioned to tackle the related environmental and public health concerns, given the needed expertise among our faculty and our neutral position as an academic institution. Work done by Lisa McKenzie, John Adgate, and others has used the methods of environmental sciences to estimate the risk to health from the wells, a needed first step in managing any risk from this industry. Our programs at the University of Northern Colorado are integrated throughout Weld County as well, with faculty, students, and alumni working to combat health issues related to tobacco control and the built environment as northeast Colorado experiences a population boom related to a

resurgence in job growth from the developing oil and natural gas industry, construction, agriculture and agriculture-related businesses and technology, health care, education, and government. And several unique programs at Colorado State University are rooted in “one health,” the concept that the health of all people is connected to the health of animals and the environment, stemming from CSU’s strengths in environmental health, animal and farm medicine, and foodborne pathogens. Public health, like other fields of health, has been transformed by the ever-increasing capacity to generate, store, and analyze data—sometimes simplified as “big data”. Our scientists in biostatistics and informatics are developing methods to tease signals from large bodies of data, as illustrated by the story on analysis of images of cancerous tissues. Through the Center for Innovative Design and Analysis, we are helping researchers across the University of Colorado Anschutz Medical Campus as they grapple with the challenge of ever-larger data sets. And the magazine covers many more initiatives of ColoradoSPH: the Latino Policy and Research Center, the Program for Injury Prevention, Education and Research (PIPER), the Colorado Integrated Food Safety Center of Excellence, and others. Support from donors has had enormous benefits for the school from the “Founding Funders” to the Hoffman Endowment Fund for Public Health Scholarships and the new Judson Endowed Fund for Impact on Public Health Policy, both stemming from donations by committed friends of the school, Richard Hoffman and Frank Judson, respectively. We could only capture a part of our story in these pages and I encourage you to read this magazine as an introduction to what we do on our three campuses and across the state of Colorado and in the Rocky Mountain Region. And, as always, there is much more to come. Warm regards,

Jonathan Samet, M.D., M.S. Dean and Professor

Photo by Nikki A. Rae 10th Anniversary ColoradoSPH |3

Table of contents

4 | ColoradoSPH 10th Anniversary

Public Health Pioneers 10 years of progress

Shaping Public Health in Colorado Two 10-year milestones

Telemedicine Pioneers The Centers for American Indian and Alaska Native Health

Charting New Paths A 40-year legacy of diabetes research

Supporting Student Success Richard Hoffman, MD, MPH

Student Voices Why did you choose to pursue a career in public health?

Breaking the Cycle 23 The LEAD Center seeks to stop the cycle of diabetes in families

A Data Democracy Leading the field in data imaging

ColoradoSPH by the Numbers Then & now | 2008â&#x20AC;&#x201C;2018

Mining for Gold A complex world of data

Helping Colorado Kids Live Healthier Lives Innovative health programs in school districts statewide

Creating a Safer World Maternal & child health promotion

40 Healthy Babies, Strong Families Joining forces to address African-American infant mortality

Extending Reach to Rural Guatemala Promoting health & saving lives

Latino Research & Policy Center Taking education, prevention to the community

Public Health Warriors Waging the battle against cancer

Meeting the Opioid Epidemic Up River A course that goes to the source

Addressing an Epidemic Countering pain & opioid use in women

Health Linksâ&#x201E;˘ Promoting a culture of workplace safety & well-being

Shaping Healthy Hospitals Caring for employees, patients & community

Fostering Public Health Practice Building the capacity of the public health workforce

Tackling Tobacco in Weld County Serving & protecting a diverse community

Breaking Ground 72 Understanding the health implications of oil & gas development

Mental Health Policy Reducing stigma & breaking down barriers

Improving the Safety of Our Food

Crunching the Numbers The value of evaluation in public health initiatives

Charting a Path of Purpose ColoradoSPHâ&#x20AC;&#x2122;s first MPH graduate at CSU

Investing in Top Talent Frank Judson, MD

Building capacity to investigate & respond to foodborne outbreaks

10th Anniversary ColoradoSPH | 5

Public Health Pioneers 10 years of progress

hen they met in the mid-1980s, they had no idea their paths would ultimately cross again— at an institution where both would lead. This 10th anniversary year of the Colorado School of Public Health, founding dean Richard Hamman, MD, DrPH, and current dean Jonathan M. Samet, MD, MS, sat down to reflect on the school’s decade-long history and look ahead to what is next in public health. Prior to becoming part of ColoradoSPH, Hamman and Samet shared similarities as pioneers in the field. At the time they met, there were parallels in their work: Hamman was focused on Hispanic populations in Southern Colorado, and Samet on Hispanic and Native American health in New Mexico, including studies of uranium miners. Both driven to find solutions to the difficult challenges facing these communities, Hamman and Samet were well-prepared to confront complex public health issues in Colorado and the Rocky Mountain West as leaders of ColoradoSPH. 6 | ColoradoSPH 10th Anniversary

Building From the Ground Up

In the late 1970s, Hamman moved to Colorado to address health disparities and lack of access to care. Over the next two decades, he became deeply involved in conversations around the future of public health in the state. “Ten years ago, the landscape of public health was in disarray,” said Hamman. “The scope of public health was smaller and less emergent, and the state was rife with challenges.” In the late 2000s, the tides began to turn when the Colorado Legislature launched initiatives to expand public health awareness, and mobilize and train health workers. Momentum quickened as a task force of public health practitioners, academics, and business leaders partnered to create the first and only collaborative school of public health in the region, drawing upon the collective strength of the University of Colorado, Colorado State University, and the University of Northern Colorado. With the investments of several local philanthropic foundations—Kaiser Permanente Colorado, Caring for Colorado, The

Colorado Trust, The Colorado Health Foundation, and Rose Community Foundation—their vision was realized in 2008. “We are where we are with ColoradoSPH because the Founding Funders helped us get our start,” said Hamman, appointed inaugural dean before the school opened in July 2008. “We cannot thank them enough for their generous support during the school’s most formative years.” In just a decade, ColoradoSPH has achieved widespread recognition, making incredible progress in fulfilling its commitment to protect and promote health across the state and the world. To accomplish that goal, ColoradoSPH is engaged in multidisciplinary research and education programs that are making a tangible impact—addressing issues spanning countries and cultures.

Charting New Paths in Public Health

ColoradoSPH is working with impoverished communities throughout the world for better health and a better future.

Richard Hamman & Jonathan Samet

In Guatemala, the school is implementing prevention strategies for sugarcane workers amid a kidney disease epidemic. In collaboration with multinational organizations, ColoradoSPH is helping to develop an international training program addressing the psychological needs of refugees, displaced populations and children in high-conflict areas. Here at home, ColoradoSPH is helping to address the state’s most pressing health issues—combatting the growing opioid crisis, obesity and diabetes, health care delivery, and access to care in rural areas, among others. There was no more fitting time for a renowned leader to take the helm than as ColoradoSPH approached its 10th anniversary. Following the departure of second dean, David C. Goff, Jr., MD, PhD, to join the National Institutes of Health, eminent public health leader Jonathan M. Samet, MD, MS, joined ColoradoSPH as its third dean. “I was honored by being selected as the third dean of the Colorado School of Public Health,” Samet said. “A key goal will be to enhance the school’s impact on public health in the state and region through our research and training activities.” Samet has a proven track record, with over 40 years of experience in health care, education, and research. By translating that research into action, his efforts have led to advancing tobacco control nationally and around the world, tightening air quality regulations, and winning compensation for uranium miners suffering health problems. With his first year in office complete, Samet has spent his time deepening his understanding of Colorado’s public health challenges. He believes it is important to elevate the visibility of ColoradoSPH and expand its reach across Colorado and beyond. “Now is the right time to establish who we are and what we do,” said Samet. “We must work hard to find new and innovative ways to broaden our impact, build our partnerships, and better disseminate our research into practice, our communities, and beyond. With our eyes set on these aims, we will achieve the goal of a healthier region and world.” While neither can predict with certainty what the next 10 years have in store for public health, both Hamman and Samet agree that ColoradoSPH is poised to tackle some of the most complex challenges facing the state—today, and in the decades to come. — CK

“

words from past, our Founding Funders present & future

The school of public health went from an idea, and perseverance and collaboration by a number of individuals and institutions, to come out of three universities to become a school that really has no peer in the public health world. — Chris Wiant, Caring for Colorado Foundation

“

We are lucky to be residents in a state with a group of funders, like the Founding Funders, who share a vision for all Coloradans to have the resources they need to live healthy lives, and are able to make investments that yield impact for the state. — Amy Latham, The Colorado Health Foundation

“

Those who pulled together this school after years of commitment recognized that the Rocky Mountain region had a gap—an important gap to fill. This led to our audacious goal of bringing together not one or two institutions, but three large, impactful institutions to make it happen. — Whitney Connor, Rose Community Foundation

“

I express my love of public health and the importance that it has played in saving lives—in moving humanity and the planet forward—and more importantly, what awaits us in terms of the increasing importance of public health as we start to think more deeply and start doing things to improve the quality, the care experience, and the affordability of health care in this world... — Jandel Allen-Davis, Kaiser Permanente Colorado

“

I started working on the school of public health years ago in the planning and early implementation phases of the school. It was John Moran, one of my predecessors at The Colorado Trust, whose vision included what a robust school of public health would mean to the state of Colorado. It was easy when I came to the Trust to participate in a funding collaborative to ensure that the great trajectory of this regional school of public health continued. — Ned Calonge, The Colorado Trust

10th Anniversary ColoradoSPH | 7

looking back

Shaping Public Health in Colorado Two 10-year milestones

ny discussion of the history of public health in Colorado leads to Florence Sabin. A Colorado native, doctor, researcher, and public health leader, she was one of 14 women in a class of 45 to attend Johns Hopkins School of Medicine in 1896 where she later became the first female medical professor and the first female member of the National Academy of Sciences. Her career and research focused on tuberculosis, and while her work didn’t produce a cure, it advanced knowledge of the disease and of the immune system. When Sabin retired in 1938, she made her way home to Colorado where she was asked to help teach people about prevention of tuberculosis and tapped by the Governor to lead the State Health Committee. Her efforts in community health education led to the passage of eight health bills, known as the “Sabin bills.” By 1948, thanks to the infrastructure provided by Sabin’s bills, eight health units existed in the State of Colorado to provide basic public health services to 18 of Colorado’s 64 counties. Fast forward to the early 2000s, and 15 “organized health departments” covered 24 counties and 85 percent of the

8 | ColoradoSPH 10th Anniversary

residents in Colorado, providing a wide range of services. The other 40 counties, however—where staff might include one physician and a county commissioner— were only able to provide the limited public health services that were deemed necessary by a local board of health. The fast-growing population of Colorado may largely be positive about the public health system in place today, having enjoyed the results of major public health successes in battling teen pregnancy, tobacco addiction, air pollution, foodborne illnesses, immunizations, and more. They forget, or don’t realize, that it wasn’t always so. The atmosphere leading up to the launch of the Colorado School of Public Health in 2008 and passage of the Public Health Act was one of urgency and motivation to finally bring Colorado forward in public health, more than a century after people started moving to the arid Rocky Mountains for a tuberculosis cure. “It was a patchwork quilt of public health in Colorado,” said Mark Johnson, MD, executive director of the Jefferson County Department of Public Health. There was no statewide standard at the time of what it meant to guarantee public

health safety, and some counties had no ability to do much more than run a home health nursing service for needy residents. “Every citizen was paying taxes for public health, so every citizen should at least have a basic level of public health in their counties. And we couldn’t guarantee that at the time,” he said. “There was a feeling that perhaps we needed to put billboards up as you come into some of these counties, ‘We can’t guarantee the safety of these restaurants,’ because the counties weren’t doing inspections and it fell to the state, it fell to the counties, and they didn’t always have the resources to do them.” At the turn of the 21st century, with news of pandemics, natural disasters, and bioterrorism on the rise, it became clear to public health and legislative leaders in the state—the state’s public health infrastructure was in need of major reform to ensure that core public health services would be available to every person in Colorado, regardless of where they live, and with a consistent standard of quality. Reform would come via a coordinated effort to pass the Colorado Public Health Act in 2008; but, to truly inform the infrastructure, Colorado would also need a developing public health workforce. More than half of Colorado’s public health workers at that time

looking back

To faithfully reform public health services in Colorado, both legislation and a school of public health had to flourish at the same time. had not had any formal public health training, and many who had received advanced training were nearing retirement. There wasn’t a school of public health in the nine-state Rocky Mountain Region— the closest schools of public health were in Arizona or Texas. To faithfully reform public health services in Colorado, both legislation and a school of public health would have to flourish at the same time. Preparations to launch a school of public health in Colorado had long been underway. Richard Hamman, MD, DrPH, the first dean of the Colorado School of Public Health, likes to point out that a state blue ribbon commission was calling for a unified school of public health in the early 1980s. Johnson does him a few decades better. He notes that an assessment from the national association of public health first recommended such a school as early as 1946. Over the intervening decades, there were many thorny issues to sort out before consensus could develop on having a school. As the blue ribbon commission started to meet in earnest, the closest thing to a public health school at the University of Colorado was the School of Medicine’s Department of Preventive Medicine and Biometrics, formed

after World War II. That’s where Hamman began his career, as a new MD and doctor of public health. Other leading institutions along Colorado’s Front Range also each brought something to the discussion: Colorado State University had expertise in environmental health, animal and farm medicine, and foodborne pathogens. The University of Northern Colorado had a fledgling MPH program of its own, along with education programs that produced thousands of qualified teachers and nurses. All three universities were already offering courses in public health. It became clear that a collaborative school would combine their efforts while also allowing a Colorado school of public health to have more depth and breadth in academic offerings, and in attracting research dollars to public health, than each university might offer as a standalone school or program. Key leaders at CU, CSU and UNC joined with Colorado’s growing philanthropic foundations to issue a 2001 report formally calling for a unified school. “The timing of it was really ideal for everybody,” said Lorann Stallones, director of Colorado State University’s component of the Colorado School of Public Health. “For the state, what we needed was more

trained people to work in local and state health departments, who were trained in Colorado and were familiar with Colorado issues.” Serious work began on the tricky questions of campus location, curriculum and faculty. Answers were getting hammered out just when state economic recessions hit, tightening budgets at every university. The advocates persisted, and were boosted by major foundations: Caring for Colorado, The Colorado Health Foundation, The Colorado Trust, Rose Community Foundation, and Kaiser Permanente Colorado—a group of foundations that the Colorado School of Public Health affectionately refers to as its “Founding Funders,” and recognized during its 10th anniversary year with the Dean’s Recognition Award. There were still a few last-minute questions. “Who gives out the diplomas?” Hamman laughed, recalling one of them. CU, CSU and UNC eventually agreed that the ColoradoSPH graduates from each of the three campuses would all get the same diploma “because it doesn’t matter where you go to school,” Hamman said. “So I sat down at my computer and pulled down the seals from the three

10th Anniversary ColoradoSPH | 9

249

2008 enrollment

universities and mocked one up.” Between the chancellors and the deans at all three universities, Hamman said, “it’s probably the most highly-signed diploma in the United States.” Hamman was appointed the founding dean in mid-2007, and was given a year to organize space at the burgeoning CU Anschutz Medical Campus in Aurora, Colorado, and to be ready for fall classes in 2008. The Colorado School of Public Health today remains the only school of public health in a nine-state region, and is also the only state-designated workforce training center in the Rocky Mountain West that is funded by the federal Health Resources and Services Administration. That first fall semester of classes, 249 students were enrolled in classes, including 95 newly enrolled students and 154 who were previously enrolled in the MSPH program in the prior Department of Preventive Medicine and Biometrics. Enrollment has climbed in the decade since, with a current student enrollment of 674 across the school’s MPH, MS, PhD, DrPH, and certificate programs. The school’s first MPH graduates had their eyes on diplomas in the spring of 2010, just when Hamman and other staff were finishing the 2,000th page of accreditation materials to win approval from the Council on Education for Public Health (CEPH). Today, the school has more than 2,000 alumni. In just 10 years, the Colorado School of Public Health has contributed state and local research and trained students and public health professionals in tobacco control, cancer prevention, deadly foodborne illness outbreaks, policy and community education for marijuana, controlling HIV, and has contributed to the state’s remarkable success in reducing teen pregnancy. The critical mass of educational institutions, financial resources, and growing population that prepared the way for ColoradoSPH’s establishment did not

10 | ColoradoSPH 10th Anniversary

674

2018 enrollment

dissolve the big city-small town feel that marks Front Range life for so many. More than 700,000 new residents have joined the state since the first ColoradoSPH class met in 2008, most anticipating their new state would have a well-organized and efficient public health system. While launching the region’s only school of public health was a feat, the 2008 Public Health Act was the largest reorganization of state health services for decades. The Act set uniform public health services that each county must provide, or contract to provide; set minimum standards for local health directors and medical officers; required statewide public health improvement plans; and required counties to regularly assess local needs and create strategic plans to meet those needs.

Connections Abound

With many ColoradoSPH graduates who are now dispersed across the state in local health departments and other community institutions, connections that started through the 2008 launch of the school and the Public Health Act continue to grow. Johnson notes a recent national movement to offer accreditation to local health departments, which boosts their chances of receiving federal funding and other research grants. “The work Colorado did with the 2008 Act and creating the school has aligned many counties and the state to be ready for that,” he said. “There are always new public health threats emerging,” said CSU’s Stallones. “The kind of training we’re doing with our students in the school provides them with the skills they need to adapt to whatever is coming down the road—whether it be an outbreak of Lyme disease, new cases of tuberculosis, or all the issues surrounding fracking. We’re really building capacity in the state to address whatever the issues are.” — TE & MB

“

There are always new public health threats emerging... We’re really building capacity in the state to address whatever the issues are. — Lorann Stallones

10th Anniversary ColoradoSPH | 11

looking back

Telemedicine Pioneers The Centers for American Indian and Alaska Native Health

“

It’s incredibly rewarding work. We get to help communities that have been marginalized and have not gotten a lot of support. It always feels like we’re making a difference and that makes the work a lot of fun, and very meaningful. — Doug Novins

12 | ColoradoSPH 10th Anniversary

Nighthorse Campbell Native Health Building

research

fter decades of pioneering work proving the efficacy of telehealth services for remote American Indian and Alaska Native communities, Spero Manson, PhD, can paint any number of illustrations to make a point about reaching those in need. For now, the director of the Centers for American Indian and Alaska Native Health (CAIANH) draws two. Manson recalls walking the grounds of the Northern Navajo Medical Center in Shiprock, New Mexico, talking with a Navajo former U.S. Marine. The hospital grounds were modern and wellkept. A veteran soldier talked about being haunted by memories of service in Vietnam, and then pointed to the hospital’s mental health program— back then, a double-wide trailer parked on weedstrewn ground. Not only would everybody in the community see him walk down that sidewalk to the trailer for an appointment, but at the reception desk he might run into a family member. “I’d rather be thought drunk than crazy,” the Marine told Manson. Manson’s other portrait of the urgent need for more telehealth is from a point Western health leaders made to the Department of Veterans Affairs (VA). They invited VA officials considering telehealth programs to visit Canyon de Chelly in Arizona, a significant tribal center. Then they asked those officials to find transportation to the nearest VA facility, as local tribal members would be forced to do. Hitchhiking, waiting for a bus, walking and then driving back made for an 8-hour day, for one appointment. Point taken. Since coming under the aegis of ColoradoSPH at the school’s creation in 2008, the Centers for American Indian and Alaska Native Health have further cemented the role of telehealth in the care of veterans nationally, and in expanding mental health services for remote tribal areas reporting high levels of substance use and trauma. CAIANH now offers 12 telehealth psychiatry clinics across the U.S. heartland, reaching residential substance abuse treatment centers in Alaska, primary care programs, and a wide range of researchers on the University of Colorado’s Anschutz Medical Campus and elsewhere. The VA has endorsed CAIANH’s groundbreaking research by paying for innovative treatment models such as tribal ceremonies offered before and after military service, which CAIANH researchers proved could minimize veterans’ experience of PTSD. Study after study has backed the effectiveness and cost-savings of telehealth through the VA and Indian Health Service. Moreover, the center and ColoradoSPH have trained 52 Alaska Native and American Indian

MDs and PhDs “to replace us aging folks” in leadership, Manson said, smiling. “It’s incredibly rewarding work,” said Doug Novins, MD, associate director of CAIANH, professor of psychiatry at the CU School of Medicine, and chair of the Pediatric Mental Health Institute at Children’s Hospital Colorado. “We get to help communities that have been marginalized and have not gotten a lot of support. It always feels like we’re making a difference and that makes the work a lot of fun, and very meaningful.” Like other research and practice hubs based in ColoradoSPH, such as the Center for Global Health or the Latino Research and Policy Center, CAIANH provides a wide array of academic resources for the CU Anschutz Medical Campus. From its quiet headquarters in the artistic showcase of the Nighthorse Campbell Native Health Building, CAIANH encompasses dozens of professors teaching courses and conducting research on key tribal and societal questions. But the emphasis on telehealth makes CAIANH unique in that it hosts psychiatrists and other professionals using telehealth hookups inside the building to conduct long-distance patient assessments, prescribe medicines, supervise cases and offer other technical assistance. For hours of the day, it’s a working clinic, with the twist that clients may be speaking from Anchorage, Alaska, or northwestern New Mexico. The faculty and collaborators’ published research has helped spread the integration of mental health and substance use treatment with primary medical care. Tribal-wide screenings for depression symptoms have helped lead states to broaden insurance payments for mental health treatment. And research into best standards for PTSD treatment is ongoing, with military veterans sometimes making up as much as 40 percent of the population on reservations. “There are a lot of examples where our work has made a substantial difference,” Manson said. CAIANH has been a natural fit with ColoradoSPH in part because the typical tribal approach to health has always been a community-wide practice, Novins said. Tribal health officials “think first about the health of the community overall, and what to do in their services to support healthy child development or good parenting, how to prevent diabetes and other prevalent disease,” Novins said. “It’s not that they don’t want good clinical services— they do—but what they really prefer is robust prevention and surveillance programs. “Work with tribal communities fits incredibly well with the mission and values of the Colorado School of Public Health.” — MB

10th Anniversary ColoradoSPH | 13

looking back

Charting New Paths A 40-year legacy of diabetes research

14 | ColoradoSPH 10th Anniversary

looking back

hen Dana Dabelea, MD, PhD, was considering a move from Romania toStock work inphoto diabetes research in the United States, she was drawn to the work of Richard Hamman, MD, DrPH, saying she was “inspired by his vision and the opportunities he created for diabetes research.” Jill Norris, PhD, MPH, considers Hamman, the founding dean of the Colorado School of Public Health, “a mentor, who was always collaborative and encouraged people to work with him.” Today, Dabelea is a professor of epidemiology and pediatrics and directs the Lifecourse Epidemiology of Adiposity and Diabetes Center at CU Anschutz, while Norris is a professor and chair of the Colorado School of Public Health’s Department of Epidemiology. The two of them and their colleagues are doing innovative and ground-breaking diabetes research, that is built on the studies Hamman started decades ago. When looking back on his 40-year career at the University of Colorado, and the 10-year anniversary of ColoradoSPH, Hamman is more modest about his achievements. “I get way too much credit as the founding dean,” he says. “It’s something we talked about for a very long time—you go from a department of preventive medicine and grow it into a school of public health. I thought if it happened across the country, why couldn’t we do it here? There were so many people who worked so hard. It was a wonderful group effort.” He stepped down as dean of ColoradoSPH in 2010 and continued to teach and do research in the epidemiology department until he retired in 2013, but he still works on research grants even today.

At the Beginning

Hamman moved to Colorado in January 1979 after completing his doctorate in epidemiology at the Johns Hopkins School of Hygiene and Public Health (now the Johns Hopkins Bloomberg School of Public Health). He had been a staff fellow with the National Institutes of Health field study branch, doing research and providing clinical care to the Pima Indians living south of Phoenix. “The Pima Indians have the highest rates of diabetes in the world,” he says. “That’s where I got my main interest in diabetes and cardiovascular disease.” Hamman continued that interest at the University of Colorado, where he embarked on a series of studies in the San Luis Valley, a rural community with a large Hispanic population in South Central Colorado. The first funded study started in 1984, focusing on the prevalence of type 2 diabetes in adults. “It was the launching pad for a lot of type 2 studies in insulin resistance, obesity and physical activity,” he says. “And it was the start for the Rocky Mountain Prevention Research Center, which has done a lot of policy and school-based work in improving diet quality and physical activity in schools.” The NIH and the Colorado Department of Public Health and Environment (CDPHE) also funded Hamman to develop a registry for type 1 diabetes to identify and track people with the disease. It was one of the first efforts nationwide to create a registry that was geographically based, rather than location based, as in a hospital. The grant allowed Hamman and his team to identify all children with type 1 diabetes in Colorado. The registry began in 1984 and the data were collected through 1996.

10th Anniversary ColoradoSPH | 15

looking back

“

...some people believe there’s nothing you can do because every member of their family has diabetes. And that message is wrong. There’s a lot you can do. — Richard Hamman

16 | ColoradoSPH 10th Anniversary

looking back

“It was also aimed at understanding the ethnic difference in type 1 diabetes and we were able to show that non-Hispanic white children had more type 1 diabetes than Hispanic children, the reverse of type 2,” he says. “And we are still part of the national SEARCH for Diabetes in Youth registry study, which is really a long-term continuation of the registry we started in Colorado.”

The SEARCH for Diabetes in Youth

Dabelea, who had also studied the Pima Indians while doing postdoctoral studies at the National Institute of Diabetes and Digestive Kidney Disease (NIDDK), found her work there piqued her interest in studying type 2 diabetes in youth. She joined CU’s Department of Preventive Medicine and Biometrics in 2001 (the department that would later help form the Colorado School of Public Health) and three years later, she took over the local leadership of SEARCH, becoming the principal investigator. In 2005, she became a national co-chair of the study, which is still ongoing. SEARCH is one of the most comprehensive projects looking at type 1 and type 2 diabetes. Researchers have studied approximately 9,000 children with diabetes in six geographic centers, including Colorado. The study has a registry component, tracking pediatric diabetes, and also endeavors to determine diabetes risk factors and barriers to quality health care for children. “It’s not often you have an NIH study that is funded for 17 years,” says Dabelea, adding that their landmark work “has changed the face of diabetes.” She adds, “We understand type 1 and type 2 diabetes are distinct diseases

that come with different risk factors and exposure. We know more about what we need to do to prevent complications.”

Working to prevent diabetes

The Diabetes Prevention Program (DPP) study, also initiated by Hamman and Dabelea, has helped researchers better understand the importance of lifestyle changes that can help adults and children prevent or delay the development of diabetes. “We’ve participated in studies that have changed not just our knowledge about diabetes about both kids and adults, but have changed the lives of people who are at risk or who have diabetes,” Dabelea says. Hamman says he’s especially proud of the work he and his team did with the DPP, an NIH study conducted at clinical centers nationwide from 1996 to 2001. The trial included 3,234 participants who were at high risk for type 2 diabetes. Researchers assigned DPP participants to three random groups: one that provided intensive training in lifestyle changes, such as diet, weight loss, and exercise; one that received the drug metformin; and a third that received a placebo. “We were able to win one of those grants and became one of the 27 centers across the country,” Hamman says. “The initial trial ended early because the results were so successful.” Both weight loss and metformin helped delay the onset of type 2 diabetes in overweight or obese adults, according to the study. If an individual was able to lose 7 percent of his body weight, the risk of type 2 diabetes dropped by 58 percent. The drug metformin helped

reduce the risk of type 2 diabetes onset by 32 percent. “From a research standpoint, the DPP has been crucial and has shown us that changes in lifestyle can reduce your risk,” says Hamman, adding that for every one percent of body weight lost, the risk of type 2 diabetes is reduced by 16 percent. “That gives people hope, especially for people in Native American and Hispanic communities where some people believe there’s nothing you can do because every member of their family has diabetes,” he says. “And that message is wrong. There’s a lot you can do.” Researchers have continued to follow up with most DPP participants since 2002. The studies found that participants, who have undergone lifestyle changes or have taken metformin, have been able to delay or prevent type 2 diabetes for at least 15 years. As participants age, the researchers also are monitoring their other health problems, including cardiovascular diseases, cancer, nerve damage, kidney and eye diseases. Dabelea, who is now the principal investigator of the Diabetes Prevention Program Outcomes Study (DPPOS), says the studies originated by Hamman have had both national and international impact as ColoradoSPH researchers continue their work in a variety of multi-center studies. And that’s part of Hamman’s legacy, she adds. “We’ve expanded our collaborations in diabetes research, not only in the United States but we’re also leaders in international global health studies,” she says. “Nobody overlooks Colorado when talking about diabetes.”

10th Anniversary ColoradoSPH | 17

looking back

Richard Hamman

Expanding diabetes research

In 1990, Jill Norris joined Hamman’s team after completing her MPH and PhD at the University of Pittsburgh Graduate School of Public Health to work with the Colorado type 1 diabetes registry that he started in 1984. Since then, her studies of the registry participants as well as the San Luis Valley populations have involved genetics and gene-environment interactions in both type 1 and type 2 diabetes. Norris is involved in a number of studies associated with type 1 diabetes and autoimmune diseases that grew out of the registry. The Diabetes AutoImmunity Study in the Young (DAISY), funded by the NIH, began in 1993 to study how genes and the environment interact to cause type 1 diabetes. The study follows more than 2,500 children who have a parent or sibling with diabetes as well as children who don’t have a relative with diabetes but have a high genetic risk of getting the disease. They’ve screened more than 31,000 Denver newborn babies, and as a result, researchers have been able to identify children who likely will have an onset of diabetes in five to 10 years by comparing diets, genes, infections, and immunological markers with healthy youth. The NIH also funded The Environmental Determinants of Diabetes in the Young (TEDDY), a study that screened 424,000 children in the U.S. and Europe looking at what causes type 1 diabetes in children. The Barbara Davis Center for Childhood Diabetes at the CU Anschutz Medical Campus is one of six clinical centers worldwide participating in this study. Norris also collaborates with the Barbara Davis Center researchers and its executive director, Marian Rewers, MD, PhD, who also was recruited by Hamman to work on the San Luis Valley studies. Hamman’s mentorship and encouragement has helped many researchers as they’ve moved forward in their careers, she says. Today, a number of studies have also grown out of those initial efforts in the San Luis Valley, she says. Norris tapped the Valley population for the Insulin Resistance Atherosclerosis Study (IRAS) Family Study, which evolved into nationwide, multi-center research exploring the genetics of obesity and insulin resistance that lead to diabetes. “We studied the genetics in the population of the San Luis Valley with regard to diabetes and insulin resistance,” she says. “It was a great population—they are primarily Hispanic, which was one of the ethnic groups that the NIH and the American Diabetes Association wanted to study, but what was more unique is that it is a rural population.” “I have fond memories of doing research in the San Luis Valley and much of that was working with Dick Hamman,” she says. “He and his colleagues modeled respect in their interactions with the community and that’s why it was so successful. They brought the personality of the community into the research and people stayed in the study because we included them.” — KB

18 | ColoradoSPH 10th Anniversary

education

Supporting Student Success Richard Hoffman, MD, MPH

“

financial resources for masters and doctoral students showing high potential to excel in public health careers, including epidemiology and communicable disease control. “I received a scholarship when I was studying for my MPH degree, and I was grateful for it,” Hoffman said. “That was the impetus for establishing the endowed public health scholarship fund at the school. We want to help attract the best students to the Colorado School of Public Health and give them support for their studies. With that boost, we hope they will become public health leaders in Colorado or wherever they choose to live and practice.” With his generous investment in future generations, Dr. Hoffman is ensuring that ColoradoSPH attracts highly qualified applicants, and that students have the resources they need to make the most of their education and graduate ready to join the workforce as highly capable leaders. — CK

Richard & Molly Hoffman

longtime benefactor and early advocate for the Colorado School of Public Health, Richard Hoffman, MD, MPH, has demonstrated a profound dedication to the success of the school and the careers of public health students. A distinguished scholar in public health, Hoffman has spent the majority of his career in leadership positions at the Colorado Department of Public Health and Environment, and the Centers for Disease Control and Prevention. He serves as an adjunct associate professor of epidemiology at ColoradoSPH. A decade ago, Hoffman helped set the stage for ColoradoSPH—the first and only collaborative public health school in the region. After providing initial philanthropic support for ColoradoSPH, he felt there was a pressing need for scholarships and established the HammanHoffman Scholarship, named in honor of ColoradoSPH’s founding dean Richard Hamman, MD, DrPH, to support graduate students showing high potential to excel in epidemiology. He also established a scholarship supporting students with creative ideas for addressing health disparities. In 2016, Hoffman established the Richard E. Hoffman, MD, MPH, Endowment Fund for Public Health Scholarships, which provides critical

We want to help attract the best students to the Colorado School of Public Health and give them support for their studies. With that boost, we hope they will become public health leaders in Colorado or wherever they choose to live and practice. — Richard Hoffman

10th Anniversary ColoradoSPH | 19

why did you choose to pursue a career in public health?

Student Voices University of Colorado Anschutz Medical Campus Cynthia Hazel | Community & Behavioral Health DrPH While in Ghana, I was the program coordinator for a faith-based medical missions project that recruited physicians and pharmaceutical companies to provide medical services and drugs to vulnerable communities. I had the opportunity to witness firsthand how this program brought relief to ailing people who had limited resources to access health care. We organized the program twice a year, but soon I began to question if there was a better way to make health care more accessible to these people. This is what started my interest and journey in public health.

Johnny Williams | Health Systems, Management & Policy MPH I chose to pursue a career in public health after participating in a Future Public Health Leaders Program at the University of Michigan. It gave me the opportunity to work hands-on in various public health areas from food security all the way to delivering water in Flint. It also allowed me to travel to the CDC in Atlanta to network with public health professionals who showed me that the way to truly make the change I wanted to make was at the grassroots level and could not be prescribed away. After graduation, I plan to work in reducing chronic disease disparities and hope to run my own community center one day to ensure my interventions are sustainable.

Venice Williams | Health Services Research PhD I chose to pursue a career in public health because, as clichĂŠ as it sounds, I wanted to make a difference in my community. I was always interested in health and well-being and a career in public health was the perfect combination for me to learn from people, apply rigorous research into practice, and work together to achieve a common goal.

20 | ColoradoSPH 10th Anniversary

why did you choose to pursue a career in public health?

Student Voices Colorado State University Rachel Sauer | Health Communication MPH I’m a career changer, and my previous experience was as a newspaper reporter. It was work that I loved, but I also saw firsthand the impacts that things like inequity of access to health care, lack of education, and lack of funding can have on individuals and communities. As a journalist I reported on these things and hoped that somebody would do something about them, but as a public health practitioner I can be the one who’s taking action. So, I changed direction and charted my course to public health.

Beth Stewart | Global Health & Health Disparities MPH I’m choosing to pursue a career in public health because I appreciate how it encompasses the science and social parts of life. I love science, but I also love interacting with people, hearing their stories, and finding ways to integrate science to help people be successful and find their own adventures in life.

“

I love how I can mold my education and really get what I want out of my time here. — Beth Stewart, MPH student

10th Anniversary ColoradoSPH | 21

why did you choose to pursue a career in public health?

Student Voices University of Northern Colorado Sara Dasugo | Community Health Education MPH I always knew that I wanted to do something in the health field. Originally, I thought I wanted to be a clinician, working directly with patients. After taking a few community health classes in my undergrad, I discovered that it is very expensive and inefficient to treat people after the onset of disease, so I got really interested in prevention. Specifically working with at-risk populations in primary prevention, preventing the onset of illness rather than treating the illness after it occurs through the medical approach.

Derrick Bomar | Community Health Education MPH My path to pursuing a career in public health was not straightforward, but took some great advice and insight to where I wanted to see myself in the future. Throughout my undergraduate career, I was set on a career in counseling. This all changed after taking a undergraduate course that focused on the core concepts of public health and meeting with faculty within the Colorado School of Public Health. I realized that I wanted to work at the community level, because I felt that I could make a stronger impact through a career focusing in this area.

â&#x20AC;&#x153;

I was inspired to continue my education with these exceptional teachers because they believed in me and the impact that I could have in public health. â&#x20AC;&#x201D; Sara Dasugo, MPH student

22 | ColoradoSPH 10th Anniversary

research

Breaking the Cycle The LEAD Center seeks to stop the cycle of diabetes in families

or Mariah Maestas, diabetes has always been a part of life. At age 21, she has struggled with the disease for more than a decade. “Everybody in my family has diabetes—my mom and all her sisters, my grandma and all her sisters,” she says. “My mom’s brother recently had to go on dialysis because he wasn’t taking care of his diabetes.” Maestas is not alone. Obesity in the United States has risen steadily since the 1960s and researchers have found a rising frequency of type 2 diabetes in youth at increasingly younger ages. Nearly 20 percent of youth ages six to 19 are obese and type 2 diabetes increased 30 percent in youth from 2001-2009, across all ages, genders, and ethnicities. “Our research focuses on this vicious cycle of obesity and diabetes in families,” says Dana Dabelea, MD, PhD, the Conrad Riley Endowed Professor in epidemiology at ColoradoSPH. “Type 2 diabetes used to be present only in adults 20 or 30 years ago, and now we’re seeing it increase in kids.” Dabelea directs the Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, a collaboration among the Colorado School of Public Health, the CU School of Medicine and its Department of Pediatrics, and Children’s Hospital Colorado. Within the Center, she leads a multi-disciplinary team of approximately 30 physicians, scientists, and staff in a variety of specialties including pediatrics, nutrition, epidemiology, biostatistics, environmental health, and obstetrics and gynecology. The LEAD team currently conducts research funded with 19 grants (most have five-year cycles) totaling $7.6 million annually. Established in 2015, the LEAD Center’s mission is to examine the complex relationship between environmental and biological factors over the lifetimes of communities, families, and individuals— factors increasing the risk of obesity and diabetes. The goal of the research is to prevent these diseases, while training

future generations of researchers and clinicians to better understand the root causes and provide effective treatments. “Our focus is on the entire lifecourse— not just children, not just pregnant women or the elderly—and this is what sets us apart,” says Dabelea, adding that the LEAD Center does a combination of observational and interventional research. “We use a multi-disciplinary approach that combines the study of biology, the environment, and behavioral and social exposures. We also pay particular attention to high-risk populations, like Native Americans. Our studies look at why obesity and diabetes develop and how we can prevent them in the future.”

Dedicated to the Study of Diabetes

Dabelea trained as a physician specializing in diabetes in her native Romania and also earned a PhD in clinical science. She continued her post-doctoral studies at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in Phoenix. “It was the 1990s when I first started studying an isolated Native American community in Southern Arizona—and it had the highest rates of type 2 diabetes in the world,” she says. “And to our surprise, we found type 2 diabetes in children.” During her time in Arizona, Dabelea

saw the progression of diabetes in children as they grew into young adults and developed complications from the disease, including chronic kidney disease and renal failure, amputations and blindness. Some had even died in their 20s or 30s. “Above and beyond obesity, a sedentary lifestyle, poor diet, and socioeconomic issues, we also saw biological implications—first in this population and later in other populations,” she says.

A Family Pattern of Diabetes

Doctors diagnosed Maestas, of Denver, with type 2 diabetes at age 11 when she enrolled in SEARCH for Diabetes in Youth, a national study designed to understand diabetes in youth and young adults in the United States. Dabelea is the principal investigator of the Colorado portion of the study, working in collaboration with the Centers for Disease Control and Prevention (CDC) and the NIDDK. “I was in fifth grade when I found out I had diabetes,” Maestas says. “When I got diagnosed, I knew what was coming. I lived with my grandmother until she died and saw her go on dialysis and lose her sight because of diabetes. When I was 12, I had to pre-fill her insulin syringes and give her insulin.” At first her grandmother encouraged

Dana Dabelea with participants in a LEAD Center study

10th Anniversary ColoradoSPH | 23

Maestas to test her blood sugars and helped her keep on track with her diabetes. “At first it was her watching over me, but as time went on, I was the one watching her,” Maestas says. “I’d say, ‘Grandma, have you taken your medicine, are you testing your sugars, did you eat today?’”

diabetes and weight gain, maternal diet and smoking during pregnancy. “We’re able to link these epigenetic changes to a variety of childhood outcomes, obesity, diabetes, allergen disease, and all sorts of things that happen later in life,” she says.

What Sets the Cycle in Motion

Optimistic for the Future

Dabelea and her colleagues found that the likelihood for children to develop type 2 diabetes could be traced back to their “intrauterine environment” before they even were born. “A particular intrauterine environment conferred increased risk for diabetes later in life for children born to mothers who had diabetes or were obese,” she says. “They would transfer their own nutrients from the intrauterine environment to the baby. That over-nutrition sets a vicious cycle in motion.” Their research found that babies born to these mothers tended to be heavier at birth and gained weight easily throughout their childhoods. These children were at high risk of developing obesity and diabetes, and girls had a tendency to perpetuate the cycle when they grew up and became mothers themselves. “Many studies have replicated these findings, but we are also starting to look at the biological mechanisms that set this cycle in motion,” Dabelea says. “We realized that it’s not just obesity and diabetes that starts the cycle, but also maternal diet, exposure to smoking and chemicals, air pollution—all the things the mother is exposed to during the sensitive period when the fetus develops.” Dabelea and her team also have studied epigenetic changes—the expression of certain genes in a newborn—based on intrauterine exposure. “For example, hyperglycemia in a pregnant woman due to diabetes may trigger certain genes to be over- or under-expressed in her offspring, changing their risk factors for diabetes,” Dabelea says. “Her offspring may then have a different satiety point or a lower number of pancreatic beta cells, increasing their risk of obesity.” In Healthy Start, a pre-birth study, and EPOCH, a historical perspective study of children later in life, LEAD researchers collected blood samples to look for epigenetic changes, based on subjects’ exposure to a variety of factors—such as maternal gestational

Dabelea, who was honored last year with the American Diabetes Association’s prestigious Kelly West Award for outstanding achievement in epidemiology, is as enthused as ever about the LEAD Center’s work. She has seen that lifestyle interventions— educating patients about healthy diet and exercise—from the Diabetes Prevention Program (DPP) study that she led, has helped delay and prevent type 2 diabetes in adults. The health care giant, Kaiser Permanente, has adopted and implemented these interventions for their patients. “We’re seeing some plateauing and even a downward trend of type 2 diabetes in adults, which is great,” says Dabelea, adding that for the first time in 20 years, the annual rate of diabetes development in U.S. adults has decreased. “I think we’re doing well with adults, but we should definitely focus our attention on this vicious cycle because if our kids are going to be an obese or diabetic generation, we will be back where we were.” Dabelea is hopeful that LEAD Center research will ultimately discover the root causes for type 1 and type 2 diabetes, resulting in future innovations and interventions in prevention and treatment. “We hope that through our studies we will be able to develop programs that once implemented will lead to a healthier young generation, who will make our nation healthier for years to come,” said Dabelea.

Living a Kid’s Life

Maestas, who has a four-year-old daughter, is determined to break the cycle of diabetes in her own life. She’s working at losing weight and keeping it off and wants to be a good example to her daughter, so she will have a healthy childhood free of diabetes. “I want her to be able to have a kid’s life,” says Maestas. “Because of diabetes, I didn’t get to live one.” – KB

research

â&#x20AC;&#x153;

We hope that through our studies we will be able to develop programs that once implemented will lead to a healthier young generation, who will make our nation healthier for years to come. â&#x20AC;&#x201D; Dana Dabelea

10th Anniversary ColoradoSPH | 25

A Data Democracy Leading the field in data imaging

Debashis Ghosh

f data were a traded commodity like corn and soybeans, its market price would be sky-high. Worldwide appetite for it is keen in every business sector and promises only to accelerate. The health care world is no exception. Data is the foundation of evidence-based medicine and clinical research. So it surely follows that when it comes to advancing health care, preventing disease, and addressing public health issues, the more data we have, the better off we are. Not so fast. Ever-deepening stores of data aren’t assets without efficient ways to access and analyze the information accurately. That requires harnessing technology that digs meaningful nuggets from mountains of data—helping clinicians make better-informed decisions about patients they treat, and assisting researchers investigating complex problems of disease and treatment, for example. Those challenges are top of mind in the Department of Biostatistics and Informatics at ColoradoSPH. The department focuses on providing analytical and study design support for a wide range of medical and public health research. One key area is imaging

26 | ColoradoSPH 10th Anniversary

analysis, said Debashis Ghosh, PhD, chair of the department. “Every imaging modality—MRIs, CTs, PET scans—generates rich data,” Ghosh said. Rich, yes, but also raw, he added, and filled with “noise”: data that is not relevant to the researcher working on distinguishing lung nodules from healthy tissue, for example. Biostatisticians can offer help with software designed to visually enhance the relevant portions of an image—such as diseased tissue. “That information can be used to compare groups of people with and without disease,” Ghosh said. Sarah Ryan, a PhD student in the biostatistics and informatics program, works with Lisa Maier, MD, MSPH, a pulmonologist and chief of the Division of Environmental and Occupational Health Sciences at National Jewish Health, to improve diagnosis of pulmonary sarcoidosis, a disease that inflames and scars the delicate tissues of the lungs. “Pulmonary sarcoidosis is considered underrecognized,” Ryan said. Ryan set out with Maier to find ways to help radiologists find signs of the disease in lung images and make clinical judgments about it. That meant identifying the specific features of abnormal lung tissue and using software to highlight those visual clues in chest CT scans. “The challenge is all about how we can quantify disease and find its location on the lungs using objective methods,” Ryan said. That work resulted in her master’s thesis, which addressed using the image features of pulmonary sarcoidosis to differentiate abnormal and healthy lung tissue. With Ghosh’s help, Ryan then went on to work with an imaging group at the Johns Hopkins Bloomberg School of Public Health on a new problem: creating a pipeline for analyzing lung images. They did this by developing user-friendly software that segments lung images into pictures of the left and right side, and registers, or aligns,

images into the same coordinate space so they can be analyzed more easily across people. The software includes a third element: a 3D image of an “average” lung shape based on high-resolution CTs from healthy control individuals enrolled in the COPDGene Study. Together, the package helps researchers compare images from study subjects to the average lung, Ryan said.

A CT scan image of the density of lung tissue in the disease, sarcoidosis. The red is fibrotic tissue and the turquoise is potentially disease nodules.

The tool is free and all the code and data is available publicly—a boon to research. “Being open-source advances science more quickly,” Ryan said. “By collaborating with others, we can make advances more quickly across universities.” “Democratizing” access to data and code for image analysis is a goal that Ghosh stresses, said Pam Russell, MA, a research instructor with the biostatistics and informatics department. Russell explained that getting underlying information from imaging studies about data sources and methodology can be difficult, in part because of patient privacy concerns. In a bid for greater openness, she developed a program called TCIApathfinder that enables individuals to navigate more easily The Cancer Image Archive, a database of some 30,000 deidentified images of varieties of cancer. The archive, Russell said, is hard to navigate for someone pointing and clicking at a computer in an effort to tap its

research

“

By collaborating with others, we can make advances more quickly across universities. rich resources. “Issues of access are the bottlenecks to research,” Russell said. To address that, TCIApathfinder allows researchers to write lines of code in R, a free programming language frequently used by statisticians, to plumb the database. That makes it relatively easy to search for all data sets related to, say, stomach cancer. In addition, TCIApathfinder saves the commands that led to the relevant data, creating “a history of everything you’ve done in a script instead of having to do ad hoc work,” Russell explained. The upshot for researchers is greater speed and efficiency and the ability to write shareable scripts that reproduce their work. “R is the common language of biostatisticians,” Russell said. “We’ve made a program that is accessible to a wider range of people who are interested in large-scale data analysis.” Russell published her work in the August 2018 issue of Cancer Research. It’s been downloaded more than 1,000 times from the CRAN (Comprehensive R Archive Network) and has received favorable comments from the National Cancer Institute.

Machine “Deep Learning”

The challenges confronting clinicians and public health researchers in a data-rich world are also evident in the task of analyzing resected pancreatic tissue for signs of neuroendocrine tumors. Today, pathologists microscopically examine a field of at least 500 cells. They look for areas with high levels of mitosis, or cell division, signaled by the presence of a protein that is a marker for unchecked cell growth. The pathologist then counts the number of tumor cells in the sample that express the protein (immunopositive) and those that do not (immunonegative). They use the percentage of immunopositive cells in the entire sample to grade the tumor: 2 percent or fewer is grade 1; 3 percent to 20 percent is grade 2; and anything above 20 percent is grade 3, or a neuroendocrine carcinoma, the

— Sarah Ryan

most serious form with the most dismal prognosis. The accuracy of the count and the grading is very important, said Toby Cornish, MD, PhD, a pathologist with University of Colorado Hospital, because it establishes the prognosis a surgeon presents to a patient. The estimated fiveyear survival rate declines dramatically with a diagnosis of a grade 2 tumor as opposed to a grade 1 or a grade 3 as opposed to a grade 2. “We’re most concerned about percentages at the fringes,” Cornish said. Can the “gold standard” of counting by a highly trained specialist be improved? Cornish wants to find out in a collaboration with Fuyong Xing, PhD, assistant professor in biostatistics and informatics. The idea: program computers to identify cells in a neuroendocrine tumor tissue sample (distinguishing both immunopositive from immunonegative or tumor from non-tumor) and grade the tumor. That could produce a more reliable result in a shorter amount of time—potentially seconds as compared to hours, Xing said. “Doing the count manually takes a lot of time and effort and can result in significant variations between pathologists,” Xing added. Cornish and Xing are trialing a form of machine learning dubbed “deep learning” to teach computers to pick through arrays of tissue cells and finger the tumor-causing rogues. Programmers give the system no predefined features. They present the objects—in this case, the various kinds of tumor and non-tumor cells—and the system proceeds through a series of algorithms to “teach itself” the differences between them. It’s more nuanced than traditional machine learning, in which the programmer pre-defines the features to look for and asks the computer to distinguish between them. Properly instructed, the learning system can identify the differences between a pen and a pencil or things far more complex. Xing said he’s completed preliminary testing of the deep-learning model on

sample tissue images with encouraging results, but there is still much work to be done. One essential point: the work requires annotating slides that accurately identify each type of cell in the sample. “It’s a lot of effort, and you have to have a trained pathologist to do it,” Cornish said. “If you don’t, all you’ve done is train a computer to reproduce what a non-pathologist would do.”

Two examples of pancreatic neuroendocrine tumor images. The goal is to develop a deep learning-based imaging informatics system to automatically count different types of cells to better grade the seriousness of a tumor.

The work also relies on graphic processing unit circuitry capable of producing images rapidly. “We’re figuring out how to use powerful technology to tackle medical problems,” Xing added. Cornish said he’s grateful for his partnership with Xing and to Ghosh’s team in public health. “There are very few people in the country who have the deep-learning experience, specifically in histopathology, [Xing] has. I am impressed with the Colorado School of Public Health and that they are working in the area of machine learning. The fact that they are branching into these new computational areas with people who are at the forefront of computation and medicine speaks volumes to their foresight about where medicine and prevention is going.” — TS

10th Anniversary ColoradoSPH | 27

data

ColoradoSPH By the numbers: then & now

CU Anschutz Medical Campus

28 | ColoradoSPH 10th Anniversary

2008 | 2018

data

U.S. News & World Report Best Graduate Schools of Public Health

97% in giving then

in giving now

600+

peer-reviewed articles annually

249 674

students now

students employed full-time or pursuing advanced education within one year of graduation

$174K $7.6M

students then

faculty then

$900,000 FY18 scholarships

$33M

annual research funding

11 then 21 MPH concentrations now

Degrees: MPH, MS, PhD, DrPH

41 then 132 courses now 2 then 8 dual degrees now

64 176

faculty now & 124 staff

alumni then

357 2,217 alumni now

1 then 7 certificate programs now 10th Anniversary ColoradoSPH | 29

research

Mining for Gold A complex world of data

30 | ColoradoSPH 10th Anniversary

Nichole Carlson

or many men and women on the University of Colorado Anschutz Medical Campus, each day is a search. Their quarry is the signals in data: information necessary to answer an endless array of questions about the complex world of public health and medicine. But for any researcher, it’s not enough to simply amass data. That’s akin to hauling piles of dirt and rock from the earth and walking away. Just as the art of refining ore lies in extracting usable metal from raw ore, careful research requires a plan to mine reservoirs of data for the nuggets that reveal patterns, and increase our understanding of the world. That’s a heavy lift, but many researchers on campus and in its surrounding communities turn to the Center for Innovative Design and Analysis (CIDA) for help. The center, which is part of both the Colorado School of Public Health and the CU School of Medicine, draws on the expertise of biostatisticians, data scientists, and health economists united by a passion for the pursuit of data, said CIDA Director and Professor Nichole Carlson, PhD. “In society, data is everywhere,” Carlson said. “As the Department of Biostatistics and Informatics and as a center, we collaborate to make data more accessible and to turn it into knowledge.” An important part of that work is helping researchers refine their questions, whether they be about treatment outcomes, immune response, cancer risk, the microbiome, or subjects that range far beyond the medical realm. “We work from beginning to end with researchers to identify the scientific questions they are trying to understand,” Carlson said, “and to find what is answerable with the data sources that we have.” The world of data gathering and analysis may conjure images of pallid stats geeks peering into computer screens, cloistered from the world. But that’s far from the world CIDA inhabits, said Assistant Director Miranda Kroehl, PhD. For example, CIDA graduate research assistants head clinics that provide one-on-one consultation with medical and public health students working on research projects. The students also

provide free statistical analysis for community organizations, Kroehl noted. The goal is to develop professionals with statistical skills who are comfortable collaborating with researchers, she said. “As an academic program, we are unique in that we’re strong in developing students with applied skills who are workforce ready,” she said. And as a 2014 graduate of ColoradoSPH’s PhD program in in Biostatistics, she knows those strengths well. A short list of CIDA projects also shows the department’s immersion in the real world of patient care, Kroehl noted. Among many others, these include mining electronic health record data to identify patients who respond especially well to chemotherapy and using the findings to predict those likely to respond well before starting therapy; evaluating the effects of maternal obesity and pre-gestational diabetes on infants; and evaluating efforts to reduce prescribing of opioids to patients after they are discharged from the hospital. Another important example of CIDA collaboration is its ongoing work with the Colorado Department of Health and Environment (CDPHE) to assess and predict the risk of acute hepatitis C (HCV) and HIV outbreaks linked to injection drug use in the state on a county-by-county basis. The effort followed a study and report by the Centers for Disease Control and Prevention (CDC) that pinpointed the 220 U.S. counties “most vulnerable to rapid dissemination of HCV/HIV infections among persons who inject drugs.” That work, in turn, was spurred by an HIV outbreak in 2015 in Indiana that was powerfully linked to intravenous drug users. The CDC report, released in 2016, relied on data encompassing some 15 variables— from race, poverty, income, and education to drug overdose deaths and prescription opioid sales—collected from a host of federal sources. The 220-county list represented those in the top 5th percentile of risk, said Daniel Shodell, MD, MPH, deputy and medical director for the CDPHE’s Division of Disease Control and Environmental Epidemiology. The idea was to help public health officials in Colorado and other states “get ahead of

research

the curve in figuring out [how] to prevent outbreaks like the one that occurred in Indiana,” Shodell said. However, the list included Crowley County in southeast Colorado. That raised eyebrows at the CDPHE. “That surprised us because of our own anecdotal evidence,” Shodell said. “We thought of other counties that might be of similar or even higher risk.” To test that idea, the CDPHE enlisted the help of CIDA and Bryan McNair, MS, a researcher instructor and also an alum of ColoradoSPH. The goal: break down the CDC’s methodology for calculating the risk of HCV/HIV outbreaks among injection drug users, then figure out if the methodology could be applied using county-level data from Colorado. McNair mastered the CDC methodology, which used national data, but when he and his CDPHE colleagues inserted Colorado-specific data built from a composite of variables, the risk findings changed. They used the new model to produce a risk-ranking of all 64 Colorado counties. Crowley County, though still at higher than average risk, was not among the highest-risk group. The conclusion is not that the CDC risk model is flawed, emphasized McNair, who worked closely with CDC statisticians. It used national data to model county risk in the average state, a valid approach. The Colorado model changed the equation, reasoning that no state is “average,” but instead has unique demographic and health resource characteristics that affect risk on a county and statewide basis. Shodell noted, for example, that emergency department visits for drug overdoses—not included in the CDC data—“had a statistically significant and high magnitude risk ratio for acute hepatitis C” in Colorado. The upshot: the Colorado risk-ranking provides a powerful tool to help CDPHE decide how best to reduce injection drug use and prevent acute HCV and HIV outbreaks. “It’s a critical point of information in deciding where to go with resources,” Shodell said. “Do you go to places where there are the most cases, or do you go to the places with the highest rates [of disease] and therefore the greatest risk?” He added that the risk profiles for HCV and HIV outbreaks often differed by county, another useful point to consider in allocating resources.

“

We work from beginning to end with researchers to identify the scientific questions they are trying to understand... — Nichole Carlson

10th Anniversary ColoradoSPH | 31

research

“

The CDPHE collaboration notwithstanding, the Center for Innovative Design and Analysis (CIDA) forges collaborations with a host of community partners pursuing all kinds of interesting questions. To wit: what kinds of beers pair best with what kinds of foods? McNair also got involved with that one, which was the brainchild of Nicole Garneau, PhD, chair of the Department of Health Sciences at the Denver Museum of Nature and Science (DMNS). She’s also principal investigator of the museum’s Genetics of Taste Lab. Garneau is an enthusiastic advocate for building people’s interest in science by involving them rather than lecturing them. The Genetics of Taste Lab, for example, designs studies that “connect to real life” by exploring questions such as how sour flavors can intensify umami (savory) flavors, she noted. The research includes getting a DNA swab from participants before they take a series of taste tests. Back to the beer: Garneau designed a study aimed at investigating how beers with varying degrees of malt roast affect how people perceive the intensity of the food they taste. The study involved some 200 people who attended a tasting at DMNS in 2017. The participants rated the taste of the beers and a series of three dishes, individually and together, and voted on their preferences. The immediate goal was to engage audiences, Garneau said, but the longer-range purpose was to help restaurants make better-informed choices about beer pairings—serious stuff in a highly competitive business. McNair did not design the study, but crunched the data Garneau gathered. A key challenge: how to evaluate the intensity of, say, umami, since there is no measurement standard for it. “We could still do the data analysis, but we couldn’t measure the magnitude of the change,” McNair said. Instead, he developed a statistical framework that showed the probability of the flavor intensity of a particular dish increasing, decreasing or staying the same when paired with a particular beer. Garneau’s study, still to be published, aptly underscores Carlson’s observation that CIDA strives to “distill science to what can be digested” — Nichole Carlson by the consumer of data. “We work from beginning to end to help people with the scientific questions they are trying to understand,” Carlson said. “We are helping to train biostatisticians who can consult and collaborate and use their skills to communicate with others.”

...we collaborate to make data more accessible and to turn it into knowledge.

— TS

32 | ColoradoSPH 10th Anniversary

Helping Colorado Kids Live Healthier Lives Innovative health programs impact school districts statewide

t takes four hours and 20 minutes for Jenn Leiferman, PhD, and Jini Puma, PhD, to drive to the San Luis Valley from central Denver. When faculty and staff from the Colorado School of Public Health get to this rural community in Southern Colorado, they’re often greeted by their first name and a hug. They know the school well here. Leiferman directs ColoradoSPH’s Rocky Mountain Prevention Research Center (RMPRC) and she and Associate Director Puma, as well as other center personnel, travel to the San Luis Valley monthly to check in with community partners, schools, teachers, and students. “We have such an amazing partnership with the San Luis Valley that has grown over the past two decades,” said Leiferman. “There is so much opportunity to bridge research to public health practice and have a significant impact on the health and well-being of the community.” The Rocky Mountain Prevention Research Center celebrates 20 years of working with Colorado communities this year and predates the Colorado School of Public Health. Richard Hamman, MD, DrPH, founding Dean of ColoradoSPH and Julie Marshall, PhD, started the Center in 1998, working out of the Department of Preventive Medicine and Biometrics in

the CU School of Medicine. The longtime associate director of the Center, Elaine Belansky, PhD, took on the director role in 2015 when Marshall retired, and Belansky passed the lead to Leiferman when she left CU earlier this year. “Initially, the Center was largely focused on physical health, particularly obesity and type 2 diabetes, and over the last 20 years, that focus has expanded to a much broader definition of health that includes mental and emotional well-being, as well as physical health,” said Leiferman. Much of the original research and programming started in Colorado’s San Luis Valley, a low-income community with a high prevalence of obesity, in an effort to understand the root causes of diabetes. The Rocky Mountain Prevention Research Center established a partnership with community leaders and began the translation of research to interventions that prevent disease. Leiferman and other team members meet with the San Luis Valley’s Community Advisory Board monthly to discuss programs and plans. Former Center Director, Belansky, calls the board “critical consumers,” who evaluate potential research projects to determine if they meet their community’s principles and

values. “I went there every month for almost 20 years,” Belansky says. “When you go that often it’s to the point where the host at a restaurant recognizes you and gives you a handshake or a hug.”

Promoting Healthy Partnerships

Lauren Sheldrake, a special education teacher for the K-12 Creede School District, has lived 30 years in the San Luis Valley and has worked with the Rocky Mountain Prevention Research Center from the beginning. A career educator, Sheldrake has served as a teacher, superintendent and principal in three of the school districts there. The Center’s programs have been invaluable assets for San Luis Valley students, school staff, and parents, she says. “I think I’ve been involved in all of them,” she says. “Every time they come up with a new project, I make sure it happens wherever I am. It’s just a no fail opportunity. Wherever I am I always say, ‘Whatever they offer, we’re doing that.’” Most of the Rocky Mountain Prevention Research Center programs are based on AIM (Assess. Identify. Make it happen.), a strategic planning process originated in the Center that helps school districts identify and use evidence-based practices

10th Anniversary ColoradoSPH | 33

$ 2.7 million

The Colorado Health Foundation provided $2.7 million in grant funding to support schools in working on health and wellness.

that support student health. Since 2005, more than 500 evidence-based strategies have been implemented. In addition to programs in the San Luis Valley, ColoradoSPH and the Rocky Mountain Prevention Research Center’s programs have reached additional communities statewide.

A Culture of Wellness in Preschools

Jini Puma

The Culture of Wellness in Preschools (COWP) is one of the Center’s signature programs and received its first planning grant in June 2010. COWP is aimed at increasing healthy eating and activity among preschool children, their parents, and staff. The program has five components, which bring classroom-based nutrition education, physical activity, and staff and parent education to preschools, and it also uses the AIM process to make evidence-based policy and environment changes in the preschool setting. “Early intervention is critical because one in six preschool-age children is obese,” says Jini Puma, PhD, the Center’s associate director and COWP principal investigator. “Once they’re obese, it’s hard to bring them back.” COWP started in Denver’s Great Kids Head Start, Denver’s largest Head Start agency, and has since been im-

34 | ColoradoSPH 10th Anniversary

plemented in 125 pre-schools in 12 counties statewide, meeting the needs of more than 32,500 children, preschool staff members, and parents over the years. Data from the Colorado Department of Public Health and Environment (CDPHE) show a downward trend in early childhood obesity over the last three years for children ages two to four, who participate in the Women, Children and Infants Nutrition Program. Although the CDPHE program is not affiliated with COWP, their participants are the same demographic, leading Puma to see a positive correlation between the Center’s programs and the drop in early childhood obesity. “It’s super exciting,” Puma says. “We are just one part of the solution, but it’s encouraging to see positive trends in the data.” Last February, The Colorado Health Foundation awarded the Rocky Mountain Prevention Research Center with an additional two-year $865,000 grant to expand its work in preschools. “The grant was made for us to adapt COWP to be more intentional about not only increasing children’s physical development, but also focusing on their cognitive, language, social and emotional development,” Puma says.

Other School-Based Wellness Initiatives

Puma also runs the Center’s Integrated Nutrition Education Program (INEP), which helps elementary schools, children, and families eat well and be active. Children get hands-on experience in food preparation and learn about nutrition. More than 46 schools and 11,000 students participate in the INEP program annually. The Colorado Health Foundation has a long history of supporting the Colorado School of Public Health and its Rocky Mountain Prevention Research Center. In 2016, the Center received funds from The Colorado Health Foundation to create the Working to Improve School Health (WISH)

project. One of the goals of the project was to provide grant-writing assistance to small rural school districts in the San Luis Valley and southeast Colorado that didn’t have the capacity to create a grant application. “Often these districts don’t have a grant writer and can’t pull a lengthy proposal together so the Rocky Mountain Prevention Research Center connects with districts that might never come to us for funding,” says Dara Hessee, a senior program officer at the Foundation. “But they’re exactly the communities and organizations we want to support—so it’s a win for us too.” More than 36 rural school districts serving 44,364 students in the San Luis Valley and southeastern Colorado benefited from grant-writing assistance and were able to access “Creating Healthy Schools” funds from The Colorado Health Foundation. “What impresses me is the ability of the Rocky Mountain Prevention Research Center to build strong relationships with communities and their partners,” Hessee says. “They demonstrate authentic and deep community engagement, which is fantastic for us. When I’ve met with preschools and school districts, they are always quick to comment on how impressed they are with RMPRC and how they’re physically present and spend a considerable amount of time working with schools and districts to support them.” As a result of providing grant-writing assistance to rural districts, The Colorado Health Foundation provided $2.7 million in grant funding to support schools in working on health and wellness. The Rocky Mountain Prevention Research Center facilitates those districts through AIM XL, which is designed to address “whole child” needs, including social, emotional, and psychological. School districts who go through the AIM XL process

collaboration

will develop comprehensive health and wellness plans based on community data and input and evidence-based practices. Since 2016, the Foundation has made grants to RMPRC totaling $4.7 million. Sheldrake’s San Luis Valley students have participated in many of the Center’s programs, including the Physical Education (PE) Academy, a program to increase the quality of PE instruction to engage students in lifelong physical activity. She also served on the HELM (Healthy Eaters, Lifelong Movers) steering committee, has implemented AIM projects, and is currently working on an AIM XL wellness plan in her district. The Creede School District, which has only 90 students in its K-12 school, is uniquely positioned to benefit from creating a health and wellness plan, says Sheldrake, adding that a task force of 15 currently is collecting data on what’s needed. “Everyone is very excited about the potential of what we’re going to be able to do,” she says. “There are always people with ideas who want to do great things,

but the Rocky Mountain Prevention Research Center provides training, professional development, and funding to make sure it actually happens.” The community is very concerned that children are educated about drug, alcohol, and tobacco prevention. Creede is a historic silver mining town with an elevation of 8,854 feet, located in an area that is 96 percent wilderness. Only 500 people live there year-round. “One of our challenges is that kids have opportunities to be exposed to different kinds of foods and activities that are healthy for them,” she says. “And because we’re small, we have to be very particular that the money entrusted to us is spent appropriately and is going to have an impact.” The impact of this work has been worth the four hour and 20 minute drive each way, each month, for Center staff to visit the San Luis Valley over the last 20 years. “The ability to be known in a small community brings a lot of good things with it,” former director Belansky says.

“

People care about each other and are willing to create partnerships to make their resources go further. And that’s what the work of the Rocky Mountain Prevention Research Center is all about. — Elaine Belansky

— KB

10th Anniversary ColoradoSPH | 35

education

Creating a Safer World Maternal & child health promotion

36 | ColoradoSPH 10th Anniversary

n a world of constant change and growing complexity, the link between mother and child seems a reassuring sign of stability. In fact, maternal-child bonds are as vulnerable to fraying as other relationships. Many mothers, children, and families face poverty, social isolation, and trauma—realities that disrupt and damage their lives. Left unaddressed, the stresses spawn public health problems, including substance use disorders, domestic abuse, and chronic physical and mental health issues, that affect generations. Attacking a multi-layered problem demands resources on more than one front, as the efforts of ColoradoSPH’s Department of Community and Behavioral Health demonstrate. Their work includes educating maternal and child health professionals, bolstering public health resources in local communities, reducing stress in both moms and kids, encouraging moms to make healthy lifestyle changes, closing gaps in mental health care, and more. It is vital that ColoradoSPH addresses the needs of local public health professionals, particularly those in thinly populated areas, said Carol Kaufman, professor and interim chair of the Department of Community and Behavioral Health. “Our hallmark is community engagement,” Kaufman said. “We work to figure out where public health professionals are [in their work] and meet them there. In remote, isolated communities, there is usually a vibrant set of relationships,” she added. “We try to open up opportunities for people there to learn, but also to understand what they have to offer, and to leverage what they have to remedy gaps.” That’s the approach of MCH-Link, a ColoradoSPH program launched in 2014 through a five-year grant from the federal Health Resources and Services Administration’s Maternal and Child Health Bureau. MCH-Link provides

education

bachelor’s degree in 2000. Working in a remote area, she found the online learning opportunity appealing, and the content “thoroughly enjoyable” and relevant to her job. “The ACEs material really hit home because of what the tribe and the nation have been through for years and years and how it has affected their health overall,” Henson said. “The course opened my eyes and helped me have more empathy.” The nutrition course encouraged Henson to introduce healthy alternatives—like fresh fruits and vegetables— to mothers and children used to canned or processed foods. She also joins with community organizations to promote exercise, healthy pregnancy, breastfeeding, and other keys to avoiding illnesses like diabetes, reducing stress, and improving kids’ health. “We try to change people’s attitudes and show that you don’t have to accept what you can’t change. It’s a new day, and you can move on to healthier choices,” Henson said. “We’re chipping away in ways that make a difference in their lives.” The painful history of physical displacement and cultural disenfranchisement endured by American Indian and Alaska Native populations continues to take a powerful toll, said Michelle Sarche, tribal liaison for MCH-Link and principal investigator with ColoradoSPH’s Centers for American Indian and Alaska Native Health, as well as associate professor of community and behavioral health. “In general, they are more likely to experience a host of physical and mental health disparities, including trauma, violence, and disrupted family situations,” Sarche said. Sarche led a 2011-2016 study aimed at buffering young American Indian children from “toxic stress,” described by the Center on the Developing Child at Harvard University as the physiological toll taken on the body as a result of

“strong, frequent and prolonged adversity”—think chronic abuse and neglect and exposure to violence—“without adequate adult support.” Sarche’s study included measuring hair samples in children and their parents for cortisol, a hormone released in stressful situations. The study recruited 100 parents and children in Early Head Start. Given the importance of early relationships for helping children manage stress, researchers and staff used Parent-Child Interaction Therapy (PCIT), a 16-week intervention to help parents build connections and warmth with their children and learn how to set appropriate and effective limits that build structure, Sarche explained. Recognizing that it is often difficult for parents to arrange transportation, child support and time off work to participate in therapy sessions in person, Sarche is also at work on mobile health programs to distill the core ingredients of PCIT and deliver them through text messages and videos. “We realized we’re not reaching as many parents as we could and that we can increase access,” Sarche said. “The question is how to use new technologies as a bridge to resources for tribal communities.” Sarche and Kaufman partnered to lead another study, launched this August, that centers on reaching young American Indian and Alaska Native women Carol Kaufman

scholarships for online and conference-based graduate-level courses to maternal and child health professionals living and working in underserved rural and tribal areas, said Elizabeth Greenwell, assistant professor of community and behavioral health, and principal investigator and program evaluator for MCHLink. The program has awarded scholarships to more than 75 maternal and child health professionals in the Rocky Mountain Region since the program began, as well as other ColoradoSPH students, Greenwell said. “These are people who live and breathe maternal and child health on a daily basis,” Greenwell said. Yet many have not been able to attain public health graduate education beyond their bachelor’s degree due to a combination of geographic isolation, financial challenges, and heavy work and family responsibilities. The professionals receive academic credit for courses covering maternal and child nutrition, intimate partner violence, early childhood and adolescent health, sexual and reproductive health, and more, Greenwell said, and receive the latest knowledge on many other topics, including screening children for signs of debilitating stress. In turn, they are prepared to directly apply their education and training in their current jobs and in the communities they serve. Jane Henson, a public health nurse who works on the Southern Ute Reservation in Ignacio, Colorado, has taken two MCH-Link courses covering nutrition and Adverse Childhood Experiences (ACEs), which are identified by the federal government as stressful events, such as abuse and neglect, that are strongly linked to substance use disorders and other health problems later in life. Henson, who began work on the reservation a year ago after serving high-risk mothers and infants through the NurseFamily Partnership, said she got her

10th Anniversary ColoradoSPH | 37

Michelle Sarche

Mental health issues and substance use disorders have long been shrouded in stigma... through social media to prevent alcohol-exposed pregnancies. This innovative work focuses on those living in urban areas. The fiveyear, $2.96 million grant from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) will focus on preventing or modifying risky behaviors, including unprotected sex and alcohol use, in young women. The vehicle is a culturally adapted evidence-based program, delivered electronically, Kaufman said. “The intervention aims to reach those at high risk for early sexual activity, risky sex, and drug and alcohol use,” she noted. “This combination can increase the likelihood of alcohol-exposed pregnancy with grave consequences to mother, baby, and community. Prevention is critical.” The ColoradoSPH mHealth Impact Laboratory, led by Professor Sheana Bull, PhD, develops mobile technology to promote health and is a close collaborator on the project, Kaufman said. In addition, American Indian and Alaska Native representatives serve on an advisory board to ensure the content is culturally relevant and accessible. Another important bridge to improve maternal and child health is access to mental health and wellness services, said Jenn Leiferman, PhD, associate professor of community and behavioral health and director of ColoradoSPH’s Rocky Mountain Prevention Research Center. Leiferman, who has done extensive work developing programs and mobile applications to help women improve their prenatal and postnatal mental health and well-being, heads C o l o r a d o S P H ’s Population Mental Health and WellBeing program,

38 | ColoradoSPH 10th Anniversary

which aims to make ColoradoSPH a national leader in the fledgling field. The program “aligns well with one of Chancellor [Don] Elliman’s goals to make mental health a top priority at the University of Colorado Anschutz Medical Campus,” Leiferman said. The program, she noted, has four prongs: developing a strong research portfolio; offering unique educational programs; training the current and future workforce; and bridging research and practice communities. Through this comprehensive approach, Leiferman hopes to transform the public health landscape to promote well-being and prevent mental health and substance use conditions, as well as revolutionize their treatment. For example, an important training aim is to help professionals—physicians, midwives, nurse practitioners, and social workers, among others—identify people in need of mental health services and refer them to mental health care and resources. This kind of screening and linkage to care is especially important for women who are pregnant and for those in between pregnancies, Leiferman said. Women who struggle with mental distress before or during pregnancy are more likely to eat poorly, gain weight, smoke and use substances, thereby increasing their risk of future adverse birth outcomes. Mental health issues and substance use disorders have long been shrouded in stigma and left out of crucial conversations about how we treat and pay for whole-person health. But as they continue to drive up health care costs in the United States, citizens and policymakers alike will increasingly recognize that early intervention and treatment of mental health and substance use disorders is not only humane but also cost-effective, Leiferman predicted. “We can provide both cost savings and better care for people.” — TS

Population Mental Health & Well-Being New certificate & MPH

y 2020, mental and substance use disorders will surpass all physical diseases as a major cause of disability worldwide. Colorado fares particularly poorly on many measures of mental well-being: a 2017 report by Mental Health America which looked at things like suicide rates, prevalence of mental illness and substance use disorders, and access to care, ranked Colorado 43rd among U.S. states and the District of Columbia. The Colorado School of Public Health recognizes mental health and substance use as issues of rising importance in public health on local, national, and global levels, and is dedicated to expanding and investing in research, education, and partnership with practitioners in this burgeoning field. The Population Mental Health and Well-Being program was founded by ColoradoSPH faculty, with the support of Dean Emeritus Dr. David Goff, to unite and expand the work of ColoradoSPH in the area of mental health. The vision of this program is that the Colorado School of Public Health will become a national leader at the intersection of behavioral health and public health by developing cutting-edge research, informing practice and policy, and strengthening the public health workforce and the communities they serve. To this end, ColoradoSPH introduced a graduate certificate program in 2018 for current students and practitioners alike to build their expertise in the area. In 2019, the school will accept its first students into a new Master of Public Health concentration in Population Mental Health and WellBeing. One of the first programs of its kind in the country, this MPH concentration will arm students with public health competencies and the specific skills and knowledge to apply those competencies to the promotion of mental wellness, access to care, and innovative, large-scale prevention and treatment efforts in behavioral health. â&#x20AC;&#x201D; CB

10th Anniversary ColoradoSPH | 39

collaboration

Healthy Babies, Strong Families Joining forces to address African-American infant mortality

t’s a heartbreaking statistic: AfricanAmerican/black infants in Colorado are two-and-a-half times more likely to die before their first birthday than white infants. The number frames two complicated questions: why the disparity and how to eliminate it? For the past three-plus years, ColoradoSPH’s Center for Public Health Practice—whose mission is to support public health programs and to develop and strengthen workforce training for them—has worked to find answers by joining forces with state and local agencies, including the Colorado Department of Public Health and Environment, the

2.5x

African-American infants in Colorado are two-and-ahalf times more likely to die before their first birthday than white infants. 40 | ColoradoSPH 10th Anniversary

Tri-County Health Department, and Denver Public Health. The effort has its roots in the communities of northeast Aurora and Denver. In 2014, the Families Forward Resource Center (FFRC), a long-established organization that offers families a wide variety of services, secured a federal grant from the Healthy Start initiative, which aims to reduce African-American infant mortality nationally. The grant funded the Healthy Babies, Strong Families program, which targets the problem locally. The Healthy Start grant provided valuable financial support for the program, noted Cerise Hunt, MSW, director of the

ColoradoSPH Center for Public Health Practice. But stakeholders recognized that meaningful progress required collaboration between local public health agencies and the people they serve, she added. “We saw building engagement at the community level as the best investment of our resources,” Hunt said. “It was important for us to walk that walk as dedicated staff engaged in endeavors to eliminate disparities, advance health equity, and promote health and wellness.” Following that lead, the FFRC, the Center for Public Health Practice, and other agency leaders created the Community

We united around the issue of infant mortality and how to use our shared knowledge to tackle it. Action Network (CAN), reasoning that collaboration was the best approach for addressing a daunting problem. “We united around the issue of infant mortality and how to use our shared knowledge to tackle it,” said Virginia Visconti, PhD, community practice specialist with the Center. Visconti served for 14 months in 2014 and 2015 as collective impact coordinator for the CAN (she continues to serve on the group’s steering committee and contributes to one of its work groups). As the collective impact coordinator, Visconti brought partners together to discuss and agree to developing strategies for meeting their common goals and measuring success; sharing data; communicating regularly; and maintaining momentum for their work. The groundwork Visconti laid was “invaluable,” said Nathifa Miller, JD. Miller succeeded Visconti’s role at the CAN and now serves as workforce development senior specialist with the school’s Center for Public Health Practice. “Virginia developed an infrastructure for the CAN, which was required for the network to be successful,” Miller said. “The CAN is in and of itself a movement. It is where change began.” During her tenure, Miller broadened the CAN, bringing in representatives from the legal community, an AfricanAmerican sorority, and the 9HealthFair. She also strengthened an existing relationship with the March of Dimes. The CAN identified three key factors driving the shockingly high AfricanAmerican infant mortality rate (10.3 deaths per 1,000 births versus 4.0 for white non-Hispanic infants), most often because of premature birth: • Racism and unjust systems • Social isolation • Health care, including disparities in access and a lack of “cultural competency” among medical providers

In June 2015, ColoradoSPH and the CAN broadened their work by convening the African-American/Black Infant Mortality Summit. The event introduced the CAN to the public and presented the results of the group’s root cause analysis. “We wanted to see if our analysis resonated with community members,” Visconti said. “The summit was an opportunity to catalyze interest in this issue.” The Infant Mortality Summit spawned a compelling short film, “Precious Loss,” which aired in February 2016 on Rocky Mountain PBS. ColoradoSPH sponsored the film, and the school joined with the Center for Public Health Practice to host a screening and panel discussion that spring. Starting in 2017, the CAN kept the spotlight on the issue with additional film screenings for local audiences. “Precious Loss” explored the possible factors contributing to the high rate of infant mortality among blacks. It featured interviews of African-American women who had suffered early loss of their infants and comments from health care professionals. One finding, which has support from medical literature: African-Americans contend with chronic stress, which is reflected in hair samples that show elevated levels of the hormone cortisol. That stress has many contributors, including a lack of access to health care and racism. The filmmakers suggest this may explain why the infant mortality rate among African-American women is higher than those in other groups, regardless of education, income, and social status. In speaking to women, members of the CAN found another troubling source of stress: a general distrust of the providers who deliver care. A path to addressing that problem opened in the spring of 2016 when students from the University of Colorado School of Medicine expressed interest in joining the initiative

to reduce African-American infant mortality. Visconti and Hunt encouraged the students to attend the CAN meetings, listen to community members, and learn ways to improve their practice. Among the newcomers were sisters Megan and Kathryn Kalata, both med students at the CU Anschutz Medical Campus. Megan is also working toward a master’s degree in public health from ColoradoSPH. The sisters attended the CAN meetings and helped with two screenings of “Precious Loss.” In a separate project, they facilitated focus groups with African-American mothers to listen to them speak of their needs, concerns, and fears as patients. The women provided “the wisdom” that drove the meetings, Kathryn said. “We weren’t coming to drop in, provide some education, and leave. And we weren’t telling [the mothers], ‘Here’s what you need to do to change.’” The meetings convinced the Kalatas that many providers need to reevaluate their practice and shift from simply dispensing instructions. Instead, it is important to listen non-judgmentally to patients and avoid questions that may engender mistrust— was the pregnancy intended or will

Virginia Visconti

— Virginia Visconti

factors for women and combating providers’ implicit biases.” Meanwhile, the CAN continues its work on many fronts. Goals for the coming year, Visconti said, include building a data dashboard that all members can use to track key measures, such as clinics’ use of screenings, prescribing of hormones to help women stay pregnant, family-friendly policies, and attention to signs of cardiovascular health. Another aim is to create toolkits to help physicians, nurses, and other providers engage patients and build trusting relationships with them.

We can mitigate stress by making patients more comfortable with their providers.

— Megan Kalata

ColoradoSPH’s Center for Public Health Practice will continue to be an essential part of that work, Miller added. “The Center for Public Health Practice will identify voices that need to be heard as part of community relations and identify the roles they can play with the CAN,” she said. “We need to continue to find strong stakeholders in the process.” For her part, Hunt stressed that the size of the problem can never be an excuse for inaction. “We won’t eliminate the disparity if we don’t tackle it,” she said. “The CAN is thriving and showing it is a good model of translating theory to action.” From a strict financial standpoint, society stands to save billions of dollars in medical care by helping African-American women have healthy pregnancies. But Hunt said the CAN’s calculus is more basic. “Our return on investment is more first birthdays,” she said. –TS

42 | ColoradoSPH 10th Anniversary

— Cerise Hunt

the father be involved in caring for the child, for example. “These aren’t questions that are explicitly racist,” Megan said, “but they can negatively impact women. We can mitigate stress by making patients more comfortable with their providers.” An environment that invites trust would encourage more women to go to the clinic for prenatal care, medications, and other services that keep them and their infants healthy. Hunt said the Center for Public Health Practice also works with clinics to help them understand the importance of creating environments that welcome all patients. Team members use “cultural competency training” to assess staff’s awareness of how important it is to patients that clinics are “diverse and inclusive,” she said. “Through training, a workforce can build proficiency to authentically engage patients,” Hunt said. That includes health care organizations increasing the diversity of their providers and staff, but even short of that, she added, “health care providers must be able to address the cultural and linguistic needs of the individuals they serve, making sure their promotional materials, programs, and interventions are culturally responsive.” The competency training also aims to ensure that clinic providers and staff are sensitive to the issues and challenges that African-American women may face, such as shortages of housing, healthy food sources, transportation, and other social determinants of health, Hunt noted. The responsibility for changing that is in the hands of a new generation, Kathryn Kalata said. “We are uniquely situated as health care students to work on the provider aspect of the problem,” she said. “It’s not about changing women, it’s about helping to inform the medical community about how to mitigate the risk

Our return on investment is more first birthdays.

collaboration

alumni

Extending Reach to Rural Guatemala Promoting health & saving lives

n a typical scorching hot day in the rural Trifinio region of Guatemala, you might find Saskia Bunge-Montes, MD, MPH, checking a child for malnutrition or monitoring a pregnant woman. Or she might be traveling dusty dirt roads in a motorized three-wheel tuk tuk to meet members of the community. Or she could be skyping with her colleagues at the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus. For Bunge-Montes, a 2016 graduate of ColoradoSPH, the best part of a typical day is that it’s not typical at all. “I can’t describe a typical day because no two days are the same,” she says. Bunge-Montes is Director of Community Programs and Education for the school’s Center for Global Health and their Center for Human Development, the

University of Colorado’s first international public-private partnership in collaboration with ColoradoSPH and other schools of health on the CU Anschutz Medical Campus, Children’s Hospital Colorado, and AgroAmerica. A Guatemalan native, Bunge-Montes earned a Doctor of Medicine degree at Universidad Francisco Marroquin in 2015, then came to ColoradoSPH to complete a certificate in Global Public Health in 2015, and a Master of Public Health in 2016 with a focus in maternal and child health. She was one of the first recipients of the Celgene Global Health Fellowship in ColoradoSPH’s Center for Global Health, which is designed to fund international students in low- to middle-income countries who come to the United States for public health training. “The Celgene fellowship is specifically

for capacity building and it was made for people from countries like Guatemala, who were very adamant that they wanted to go back to their country of origin,” she says. “What sometimes happens is that people come to the U.S. to get trained in higher education and there’s a brain drain on their country of origin because they want to stay. They were looking for candidates who were very willing to go back and share their knowledge in their home countries.” For Bunge-Montes, there was no question she would return to Guatemala. A daughter of an educator mother and a pediatrician father, she has strong ties to her country. She is part of a large family, including 23 first cousins, who live close to each other in Guatemala City. “Growing up, I had a very fortunate childhood in that my dad was a

Saskia Bunge-Montes is an alumna and director of Community Programs and Education for the Center for Human Development in Guatemala.

10th Anniversary ColoradoSPH | 43

professional and I lived in the city,” she says. “But I got a lot of exposure to Guatemala itself because the city is like a bubble. If you only live in the city and don’t look around, it can be a very developed place, but once you leave the confines of the city and spread out, you see you’re in a developing country.” She said her parents exposed her to the less affluent parts of Guatemala by taking her and her siblings to community centers and through the outreach work her dad did as a physician. “It’s such a vibrant and culturally rich country,” she says. “You have 23 different languages in a country that’s a fourth the size of Colorado.” But it was also frustrating for Bunge-Montes as a medical student. She saw how a lack of services, education, and clean water negatively affected the health of Guatemalans who were treated for medical problems that could have been prevented. “In Guatemala, it’s all about curing people with different sicknesses, but it’s never about preventive health or education—that’s why I decided to focus on public health,” she says.

A Journey to Rural Guatemala

When Bunge-Montes returned to Guatemala, she went to work at the Center for Human Development operated by the school’s Center for Global Health on a banana plantation in rural Guatemala. Work on the center began in 2011 with a $1 million grant from the Jose Fernando Bolaños Foundation, run by the owners of AgroAmerica, a major Guatemala banana grower, along with financial support from Children’s Hospital Colorado. The goal of the center was to provide health care services for the 3,000 plantation employees, as well as the more than 20,0000 residents of the local community. These families often face diseases, malnutrition, maternal pregnancy complications, and other issues related to poverty, poor sanitation, and a lack of health care services. Three years later, the clinic opened

44 | ColoradoSPH 10th Anniversary

a family clinic and a community prenatal nursing program. The program paired traditional birth attendants with nurses, so deliveries can be shifted from the home to the local hospital. A birth center recently became operational. In addition to the birth center, Bunge-Montes has supervised a community-based program that focuses on mothers, pregnant women, and children. Nurses enroll women early in pregnancy and follow them through birth and the first three years of the child’s life, providing health, development, nutrition, and hygiene education. Bunge-Montes “is incredibly dedicated to the public health mission” and she’s been able to take the knowledge and experience that she gained in the Colorado School of Public Health back to her home country, says Stephen Berman, MD, FAAP, director of the Center for Global Health. “Because of her interpersonal skills and her ability to relate to the staff and community people and the Ministry of Health, she has been incredibly productive in building sustainable systems. She’s really been essential to our success there.” Berman says the providers there have made childbirth safer, by treating mothers with complications and getting them to the hospital. They’ve also made strides in successfully treating infections in children and reducing neonatal mortality. “It’s been very personally gratifying to see the community engagement and how the Guatemalan staff has taken ownership and leadership in the whole process,” he says. “It’s not our project, it’s their project and that’s the goal.” The biggest challenge is how to expand what we have learned in the Trifinio clinic that would allow other communities to benefit, he says. “We know how to train people, but we need to establish more of an integrated collaborative relationship with the Ministry of Health and local universities to take what we’ve learned to scale,” he says.

alumni

“

In Guatemala, it’s all about curing people with different sicknesses, but it’s never about preventive health or education — that’s why I decided to focus on public health. — Saskia Bunge-Montes

10th Anniversary ColoradoSPH | 45

alumni

4,500

home visits

GIS Mapping to an NIH-Funded Zika Study

Bunge-Montes used her public health training to carry out geographic information system (GIS) mapping of the area. She recruited a local pastor and four students to help her interview the area residents to get a picture of who they were and how they lived. Although they had collected good data from clinic patients, they had never done an overall study of the people who lived in the area. Many were migrants, who came to work in the banana or palm oil plantations. “We had been working in Trifinio for about three years without really knowing how many people were there and their ages,” says Bunge-Montes, adding that her interviewers visited 4,500 homes and had 97 percent participation from area residents. “We were getting not just the physical location of the people, but also what types of food they had access to, what they drank, what type of sanitation services they had, and how many kids were in each house,” she says. They found households with up to 12 people living there. Fewer than 50 percent of those interviewed had access to clean water and many lived with uncovered latrines, a breeding ground for disease. Teen-age pregnancy was also a big problem. Based on the data, Bunge-Montes and her team looked at a variety of interventions to improve the health of Trifinio residents. They implemented a sex-education course called Big Decisions, based on a Texas program, and tweaked it to fit the cultural needs of Guatemalan teens. “We trained a local teacher, creating

46 | ColoradoSPH 10th Anniversary

97%

participation from residents

capacity in local schools,” she says. “In terms of sex education, these kids didn’t know anything. And the parents wanted to know what we were teaching their kids and that helped us educate them on family planning methods and STDs.” Her mapping research on area families also helped obtain approval of a National Institutes of Health study, in which researchers at ColoradoSPH, the CU Anschutz Medical Campus, and the Baylor College of Medicine will work with Guatemalan investigators examining the long-term brain development of children infected with the Zika virus. The mapping project identified that there were more than 500 newborns in the area—enough babies to complete the study on the three-year timeline. Researchers will also look at the effects of the dengue and chikungunya viruses, also transmitted by the mosquito that carries the Zika virus. “Saskia’s work and documentation were instrumental in showing the NIH we could enroll enough participants to do the study,” says Berman, adding that recruitment will take place through the Center for Human Development. “This is a very complicated project that has many blood draws and follows patients very closely,” Berman says. “The fact that our mapping project had a 97 percent participation demonstrated to the NIH that our community engagement process was very successful and our relationships were such that we would be able to carry out the study.”

Overcoming Barriers to Care

Bunge-Montes finds that her patients often face tough barriers to getting the health care they need. Even though their

clinic costs between a dollar and $1.50 for an appointment, money can be an issue for patients. They also struggle to afford prescriptions—even though they are necessary. Finding transportation to the clinic can also be a problem for residents who live on the outskirts of the area. “Recognizing when they need to seek care—we teach that a lot,” she says. “We show women what is normal and what isn’t normal in their pregnancy and with their baby, so they know when to come to the clinic. We don’t want moms to wait too long before they seek care.” Educating the community has worked. When Bunge-Montes first started working in the clinic in 2014, she saw one or two patients each day. Today, 2530 patients seek care on a daily basis. Says Bunge-Montes, “It was really cool to see that transition from being unknown and outside the community to trusted providers today.” She’s reminded of a 42-year-old patient who gave birth to her tenth child at the clinic. Her younger children were small and malnourished, giving providers an opportunity to help the mom learn about the importance of good nutrition. The mom also was grateful to learn about an implanted birth control device because it was dangerous for her health to have additional children. “We were there at the right moment to deliver her baby and get to know the rest of the family,” she says. “It was a precarious situation, but now months later the younger kids are doing well and the nurses are following up with them. We were able to avert a crisis because of our great system.” — KB

Center for Global Health The Center for Global Health is a multidisciplinary center of the Colorado School of Public Health that engages faculty, fellows, residents and students from the University of Colorado Anschutz Medical Campusâ&#x20AC;&#x2122; schools of public health, medicine, dental medicine, nursing, and pharmacy, as well as other schools in the University of Colorado system including business, engineering, architecture, liberal arts, and more to collaborate in the development of transformative interventions for global health problems.

10th Anniversary ColoradoSPH | 47

48 | ColoradoSPH 10th Anniversary

research

Latino Research & Policy Center Taking education, prevention to the community

n a bright day in early October, people filled the Terrace Room in the University of Colorado Denver’s downtown offices. The occasion: an open house hosted by the Colorado School of Public Health’s Latino Research and Policy Center. Minglers feasted on empanadas, along with news and information about an institution with an impressive pedigree and plenty of plans for the future. Why a get-to-know-you event? After all, the Center was founded more than 20 years ago and has been part of the school’s Department of Community and Behavioral Health for just shy of a decade. On the other hand, the Latino Research and Policy Center is the only ColoradoSPH program located on CU’s downtown Denver campus. That can make for a low profile, even with plenty of CU Denver neighbors nearby, said Kisori Thomas, projects management coordinator for the Center. There was plenty of news to spread. For starters, ColoradoSPH is the only public health school in the country to offer a certificate program in Latino Health. “This open house is a chance to share with others what we are doing and also attract new students to the certificate program,” she said. Thomas is also helping to get the word out about a new study the Center is leading around health disparities and exposure to indoor allergens for people living along East Colfax Avenue and in surrounding neighborhoods of the CU Anschutz Medical Campus in Aurora, Colorado, where ColoradoSPH is primarily located. The study idea sprang primarily

from two sources: frequent emergency department visits and hospitalizations of youngsters on the medical campus at Children’s Hospital Colorado for respiratory problems, and concerns expressed by local residents about the condition of living spaces near the campus. “People from community organizations contacted us with pictures that depicted some of the potentially unhealthy conditions,” Thomas said. Children’s Colorado is a partner with the Center and is funding the pilot, which is just underway. The plan is to collect dust from homes; analyze it for allergens like mold, bed bugs, and pet dander; and assess the incidence of respiratory diseases like asthma and skin conditions such as eczema in residents. The research team will go to the field for study recruits. Those recruited will complete a questionnaire at the nearby office of Aurora Warms the Night, a provider of shelter and services to the homeless. They will get a spirometry test and a vacuum cleaner—which they can keep if they choose—fitted with a special filter to collect dust samples. The Colfax study and other initiatives from the Latino Research and Policy Center could ultimately lead to policy changes that address the social inequities that often drive health problems, said Fernando Holguin, MD, a practicing pulmonologist who leads the Colfax study and directs the Center. “The true challenge is to understand why these disparities still exist and to define the problems and move forward,” he said. “We are trying to

create an environment in which we gather the evidence that moves to action.” Holguin said the Colfax study illustrates the importance of research finding inspiration from those in the community. “They were concerned about the health of children in the neighborhood,” he said. “Kids are sick. We said, ‘Let’s do an assessment and evaluate and strategize.’” Asked if the study could help to strengthen relationships between the campus and the community, he said, “Let’s hope trust is the fall-out.” Meanwhile, the Center will expand a program launched in 2015 to increase the number of young Latina women who complete the three-shot vaccination regimen to prevent human papillomavirus (HPV or VPH in Spanish). HPV is “at the root” of cervical cancer and affects Latinas disproportionately, said the Center’s Associate Director for Research, Evelinn Borrayo, PhD. The 2015 grant from the Colorado Department of Public Health and Environment (CDPHE) provided $750,000 to identify Latina women ages 19 to 26 who either had never started or never completed their HPV vaccinations (ideally, girls and boys should receive the vaccinations between the ages of 11 and 12). The pilot targeted women in this group who received care at Denver Health and included a “patient navigator” who helped make appointments for the women at risk, Borrayo said. The funds also paid for an eight-minute YouTube video texted to targeted women’s phones that dramatized the experience of a woman

10th Anniversary ColoradoSPH | 49

research

whose sister died of cervical cancer. At the conclusion of the video, women were asked to answer questions about what they had learned. More than 90 percent who responded identified HPV as the root of cervical cancer. Most encouraging were the results of the pilot. Baseline data showed that 43 percent of Latinas in the targeted age group at Denver Health completed their three-dose HPV vaccinations. The pilot set 58 percent as the compliance rate goal; the final tally was 66 percent, Borrayo noted. That success helped to win a new threeyear CDPHE grant that will target underserved women of all ethnicities in the vulnerable age group. Borrayo said the Latino Research and Policy Center, in collaboration with the Colorado Community Health Network, will expand the program to about 20 clinics in Colorado associated with three Community Health Centers: Denver Health, Metro Community Provider Network, and the Lamar-based High Plains Community Health Center, which serves women in rural southeastern Colorado communities. Community engagement is the common denominator for all of the work carried out by the Latino Research and Policy Center, said Kisori Thomas. “We want to be consistent in our relationships with people,” she said. “We want to show we are there not just to collect data, but to make an impact on their lives.”

The New Latino Health Certificate The Latino/a population currently makes up 17 percent of the U.S. population, 21 percent of Colorado’s population, and 32 percent of the residents in metro Denver, making it the largest and fastest growing ethnicity in this country. Significant disparities in Latino health are seen throughout the nation resulting from challenges such as insufficient educational attainment, high poverty, and high rates of being uninsured. The ColoradoSPH certificate in Latino Health is currently the only graduate Public Health Certificate in the country devoted to preparing a sector of the public health workforce to address this need. “The Latino Health Certificate will provide scholars with the necessary tools and experience to strategically and effectively implement research or service programs to improve the lives of Latino communities in Colorado and beyond,” said Fernando Holguin, MD, MPH, director of ColoradoSPH’s Latino Research and Policy Center.

— TS

21%

50 | ColoradoSPH 10th Anniversary

Evelinn Borrayo

of Colorado’s population is Latino/a

research

Public Health Warriors Waging the battle against cancer

ccording to the National Cancer Institute, more than 15 million people in the United States were cancer survivors in 2016. The number testifies to the rapid development of new treatments for the disease and improvements in techniques for managing it. However, there are also 1.7 million new cancer cases each year. Another 600,000 Americans are projected to lose their lives to cancer in 2018, never to join the survivorship ranks. These numbers raise important questions for public health experts. What can medical providers, businesses, and government do to construct a society that allows individuals not only to survive but also to thrive? And what more can be done to prevent cancer in the first place? The search for answers continues at the Colorado School of Public Health and the University of Colorado Cancer Center on the University of Colorado Anschutz Medical Campus. Their efforts cover closing access-to-care gaps, building regional collaboratives, expanding disease prevention programs, and improving workplace accommodations. A common desire drives the public health mission, said ColoradoSPH Associate Dean for Research Cathy Bradley, PhD. “Our goal is to decrease the burden of cancer in Colorado,” she said. Cancer is the leading cause of death in Colorado, and about 50 percent of men and 40 percent of women in the state will be diagnosed with the disease at least once, Bradley said. But the burden does not fall equally across Colorado communities. That was revealed in Bradley’s work with Marcelo Perraillon, PhD, assistant professor with ColoradoSPH’s Department of Health Systems, Management and Policy, and other colleagues on a pilot with the Colorado Department of Public Health and Environment (CDPHE). The project linked CDPHE’s Central Cancer Registry with the Colorado All

Payer Claims Database, which provides information on people covered by commercial, Medicare, and Medicaid insurance. The result: a more complete picture of cancer’s impact on Colorado. The data showed, for example, fewer newly approved, high-cost tumor-fighting agents are used in low-income areas. The divide falls roughly along rural and urban lines, Bradley noted, in large part because the state’s sparsely populated areas lack comprehensive cancer care services. “From a health care perspective, Colorado is divided,” Bradley said. “One area, along the Front Range, is more affluent and care is accessible, while in rural areas across the state, disparities are stark and the sojourn for care can be lengthy and treacherous.”

600,000 Americans are projected to lose their lives to cancer in 2018. She is working to broaden the cancer-care perspective by helping to convene leaders in cancer control and prevention from the NCI-designated Comprehensive Cancer Centers in each of the Four Corners states: Colorado, New Mexico, Utah, and Arizona. The first conference and summit are slated for December 2018. The summit will encourage leaders to share data and ideas that help bolster prevention and early detection of cancer, particularly to underserved populations, and broaden access to treatments that decrease mortality and improve quality of life, Bradley said. “So far we have had fragmented efforts on these initiatives,” she said. “We want to try to equalize care throughout the four-state collaborative.” The CU Cancer Center and ColoradoSPH, likewise, collaborate extensively to prevent new cases of cancer

and improve the lives of survivors. The Colorado Cancer Screening Program offers a prime example. Funded by grants from the Cancer, Cardiovascular and Chronic Pulmonary Disease program in the CDPHE, the program initially aimed to increase colorectal cancer screenings at three health systems that treat large numbers of underserved patients. Nearly a decade later, the program includes 25 health systems with some 100 individual clinic sites that serve 88 percent of Colorado counties, said Andrea (Andi) Dwyer, director of the Cancer Center’s screening program and research assistant in ColoradoSPH’s Department of Community and Behavioral Health. The linchpins of the approach are patient navigators who are community members employed by the clinics. Many of them receive training from the school’s Patient Navigator Training Collaborative in its Center for Public Health Practice. The navigators work to overcome structural barriers to care, such as a lack of access to transportation or child care. They also deliver education about the importance of disease prevention, and reduce anxiety about colonoscopies, an unfamiliar procedure for many, Dwyer said. “The navigators help to form a better connection with the patients,” she said, adding that they free nurses and physicians to concentrate on clinical care. Those efficiencies have helped to prevent an estimated 500 cancers and saved the health care system “conservatively” $12 million—the difference between the cost of cancer treatment and the cost of the program. ColoradoSPH’s Department of Community and Behavioral Health also contributed to the success of the program as a site from 2009 to 2014 in the multi-state Cancer Prevention and Control Research Network (CPCRN), said Associate Professor Betsy Risendal, PhD, who served as principal investigator.

10th Anniversary ColoradoSPH | 51

research

Cancer is the leading cause of death in Colorado. The CPCRN, which is funded by the National Cancer Institute and the Centers for Disease Control and Prevention, worked with the clinics in the Colorado Cancer Screening Program to find “ways to advance the delivery and uptake of colon cancer screening,” Risendal said. She cited strong clinic leadership and feedback as keys to successfully implementing the program, while burdensome electronic health record systems and poor data were barriers to care. “These findings suggest that colon cancer screening implementation remains challenging, but also highlights some ways to target resources toward improving program implementation,” Risendal said. The life-saving work continues. Last spring, Dwyer co-authored an article in the journal Cancer that recommends new guidelines for colorectal cancer screenings, specifically lowering the age to 45, down from the previous recommendation of 50 set by the American Cancer Society and the U.S. Preventive Services Task Force. The reason: an increase in the incidence of colorectal cancer among young adults. Dwyer and her colleagues based their recommendation on MISCAN-Colon, a

52 | ColoradoSPH 10th Anniversary

mathematical tool that models the benefits and risks of screening. They concluded that starting screenings at age 45 and repeating them every 10 years to age 75 is likely to yield the greatest benefit in terms of saving and extending lives while making the most efficient use of available resources. On a separate prevention front, Arnold Levinson, PhD, associate professor in community and behavioral health, is project leader on an initiative of the National Cancer Institute’s Cancer Moonshot program that aims to drive down smoking rates among cancer patients. The Cancer Center was one of 22 NCIdesignated centers selected early in 2018 to share $10 million in two-year grant funds to develop smoking cessation programs to help cancer patients kick the habit. The NCI also wants the centers to show that they can sustain their tobacco treatment programs after the funding period. To that end, the Cancer Center has worked closely with UCHealth University of Colorado Hospital, which has a well-established inpatient smoking cessation program, to develop a strategy to reach tobacco-using cancer patients, regardless of where they receive their

cancer therapy. “At the core of it all, we want to find a way to link all our cancer patients who smoke with treatment for cessation,” Levinson said.

Cancer Survivors in the Workplace

Meanwhile, millions of cancer survivors continue to work, another long-running interest for Bradley. She is collaborating with Lee Newman, MD, MA, director of ColoradoSPH’s Center for Health, Work and Environment, on finding ways to help employers develop policies and a culture that address the needs of cancer survivors in the workplace. The two are co-authors, along with several other University of Colorado, ColoradoSPH, and Kaiser Permanente colleagues, of an upcoming commentary in the Journal of the National Cancer Institute on issues of cancer survivorship and employment. “We’re doing better in terms of curing cancer and having people survive longer, which means there are many more of us in the workplace,” said Newman. But focus group discussions with a dozen or so employers about how well they understand the issues of cancer survivors in the workplace exposed gaps, Newman said.

No single approach will be sufficient to turn the tide against cancer. A successful public health initiative requires attention to discovering new treatments, improving health care delivery, investigating the roots of the disease and, not least, addressing the disparities that make some more vulnerable to cancer’s ravages than others.

“People assume that employers know what to do” about providing accommodations for survivors, he said. “In fact, managers and bosses often don’t have a clear idea. What one cancer patient needs versus another in the workplace will vary widely by not only the type of cancer but also how aggressive it is and what kind of treatment is needed and at what point in time.” For example, a bilateral radical mastectomy imposes significant physical limitations, while chemotherapy can cloud cognition. These and other differences in cancer treatment require that employers have direct conversations with employees that respect confidentiality and reduce stigma, Newman said. Doing so will help businesses analyze the accommodations they can reasonably offer, explain the benefits available to employees with various work arrangements, and create a culture of open communication. Newman also stressed that oncologists and their teams should ask their patients what kind of work they do. “They need to understand the context of what survivors can and can’t do when they go back to work and write a set of recommendations for employers that specify the restrictions.” No single approach will be sufficient to turn the tide against cancer. A successful public health initiative requires attention to discovering new treatments, improving health care delivery, investigating the roots of the disease and, not least, addressing the disparities that make some more vulnerable to cancer’s ravages than others. “We will need a synergistic approach if we are to decrease the burden of cancer,” Bradley concludes.

Cathy Bradley

research

— TS

10th Anniversary ColoradoSPH | 53

Meeting the Opioid Epidemic Up River

A course that goes to the source

Lili Tenney & Lee Newman

n 2011, Lee Newman sat down to what he thought was an ordinary breakfast. It turned out instead to be the opening chapter in what he now calls a “case study in public-private partnership.” Newman, founding director of the Center for Health, Work and Environment (CHWE) in ColoradoSPH, dined that morning with the then-CEO of Pinnacol Assurance, the longtime workers’ compensation provider for Colorado companies. A crisis was brewing in the state, he told Newman. “He said, ‘If workers’ compensation carriers don’t address opioids, it will be a disaster for the insurance industry,’” Newman recalled. The words surprised Newman, a physician whose training includes pulmonary and critical care medicine and epidemiology. The mission of CHWE is to protect workers through education, research, and occupational health policy and practice. The Center has long focused on preventing injuries and illnesses in the workplace, and what Newman heard that day was that prescription painkillers had become a new kind of threat to workers and employers. “That hadn’t been on my radar at all,” said Newman, but he quickly got up to speed. By 2011, the number of drug

54 | ColoradoSPH 10th Anniversary

overdose deaths attributable to prescription painkillers had been on the rise for nearly two decades, driven in large part by a national shift in medical practice to use these medications for managing pain, particularly for patients in chronic discomfort from injuries. Newman spoke to others knowledgeable about the problem, including Kathryn Mueller, MD, MPH, a professor in the ColoradoSPH Department of Environmental and Occupational Health, the Department of Physical Medicine and Rehabilitation in the CU School of Medicine, and medical director for Colorado’s Division of Workers’ Compensation. Mueller had recently convened representatives from the state, insurers, and academia to overhaul the division’s guidelines for treating chronic pain in non-cancer patients. Providers seeking reaccreditation to handle workers’ compensation cases would get information on effective but sometimes overlooked non-opioid pain management options, like acupuncture, physical therapy, and cognitive-behavioral techniques. However, a big gap needed to be addressed, said Lili Tenney, MPH, a ColoradoSPH graduate, CHWE’s associate director for outreach, and a senior instructor in the school. The new

“

We need all prescribers to be able to appropriately manage chronic pain. — Lee Newman

education

“

We get stuck in our own fields and treatments and when you have continuing research that is coming out, it’s helpful. — Messina Michalsky

guidelines lay buried on a state website, unlikely to be discovered unless a provider was up for reaccreditation. How to get information about managing chronic pain to as many providers as possible—and change their thinking about treatment? An unrestricted grant from Pinnacol helped CHWE develop and launch an online training course aimed at just that in 2012. It provides information on the best available methods of pain relief, and offers best practices for assessing patients’ pain, developing treatment plans, and monitoring their progress. An online toolkit includes examples of patient provider contracts and screening assessments to help identify abberrant behavior and establish accountability that reduces abuse. Pinnacol made the course a requirement for providers in its network, and several other organizations endorsed the training for providers across the state. Awareness of the opioid abuse problem heightened further in 2013, when Governor John Hickenlooper launched the Colorado Consortium for Prescription Drug Abuse Prevention, a coordinated, statewide attack on the epidemic that CHWE joined. That year, opioids killed 295 Coloradans. “We realized we needed not just to train providers taking care of injured workers,” Newman said. “We need all prescribers to be able to appropriately manage chronic pain.” Tenney marshalled reinforcements: key health care stakeholders—including

the Centers for Medicare and Medicaid Services; the medical liability insurance provider, COPIC; and the state’s Department of Regulatory Agencies. They spread the message that confronting the deadliest public health scourge of the century required educating the providers who prescribe the drugs about their dangers. Five years later, nearly 3,000 providers from around the state have completed the course, with some 80 percent reporting that they use the information to “actively manage” their chronic pain patients, Tenney said. In addition to physicians, nurses, and pharmacists, dentists and veterinarians began receiving training in 2015. The course is not aimed at demonizing opioids or the relief they give some patients with debilitating pain, she emphasized. The course points providers toward evaluating their patients comprehensively, with a focus on improving function with evidence-based guidelines and using the state’s Prescription Drug Monitoring Program (PDMP) to discourage abuse and diversion. CHWE’s online course has been instrumental in expanding provider education about alternatives to long-term opioid regimens, said Robert Valuck, PhD, RPh, professor of clinical pharmacy with the Skaggs School of Pharmacy and Pharmaceutical Sciences and epidemiology with ColoradoSPH on the CU Anschutz Medical Campus.

Valuck chairs the coordinating center for the Colorado Consortium for Prescription Drug Abuse Prevention, a hub for 10 work groups chaired by government, public health, academic, and community volunteers. The groups tackle drug abuse-prevention issues spanning treatment, recovery, safe medication, public awareness, and more. CHWE’s work has given providers a different way to get resources for using non-opioid treatments in chronic pain management, Valuck said. He noted the Consortium also provides a variety of educational options, including remote video conferencing. He believes trained providers can, in turn, “seed and plant” others with a greater awareness of an epidemic many years in the making. That work is underway at Grand River Health Clinic in Rifle, Colorado, said Messina Michalsky, APRN, an advanced practice psychiatric nurse who treats patients with substance use disorders. Michalsky took the CHWE training through Pinnacol in 2017 as part of her credentialing. Michalsky estimated that she’s treated eight new opioid-addicted patients in the last three months—a significant number in a mostly rural community. That includes heroin users, a number that is growing, ironically, as more vigilant primary care physicians prescribe opioids for pain less frequently, Michalsky said. “The heroin epidemic is huge; it’s all over,” she said. 10th Anniversary ColoradoSPH | 55

education

While Michalsky isn’t herself a prescriber, she said she found the online course useful, in part because it helps providers who treat chronic pain patients “understand the red flags” of addiction. “For me, that was great because I’m on the other end”—treating patients addicted to the painkillers. The opioid epidemic and growing awareness of it have forced policy changes at Grand River Hospital, Michalsky said, including limiting the number of pain pills for patients visiting the emergency room, eliminating chronic pain treatment in the ER, imposing mandatory drug urinalysis for patients prescribed opioids, and having providers regularly check the PDMP. The hospital’s pain specialist now also recommends that all providers who prescribe opioid painkillers also prescribe Naloxone, the overdose antidote drug. Many of these steps aim to make providers accountable as well as patients, Michalsky said. She credited the CHWE course for focusing on objectively describing the behaviors that accompany opioid misuse. “It’s not about a blame game and shaming,” she said, noting that it is often difficult to explain to a patient who has relied on opioids for years why limiting them and finding alternatives, like opioid receptor blockers, can lessen their cravings and ultimately make them feel better. The course was valuable for giving providers a more complete view of patients facing the physical and mental health strains of chronic pain—“the whole person,” as Michalsky put it. These often are individuals with complicated issues like PTSD, child abuse, and anxiety. “We get stuck in our own fields and

treatments and when you have continuing research that is coming out, it’s helpful,” she said. Now Michalsky, the hospital’s only psychiatric nurse practitioner, says she is a member of a “wrap-around team,” serving as a resource for physicians and other providers with questions about medications and treatments that reduce the risk of abuse and addiction. The work to help providers like Michalsky in traditionally underserved communities continues. Tenney said CHWE and the Colorado Consortium for Prescription Drug Abuse recently updated the course, adding material on best treatment practices for new and expectant mothers and guidelines for safely using, storing and disposing of prescription medications. For his part, Valuck leavens hope for improvement with a realistic assessment of a country still awash in opioids, both prescribed and illicit. “We’re bending the curve on the provider side,” he said. “But there is still a lot of public awareness work to do.” He notes that 10 billion prescription tablets a year go to medicine cabinets. “Seventy percent of people addicted to opioids started out on pills that were left over—their own or someone else’s.” It’s a sign of a broken system, Tenney agreed, but one CHWE continues to help repair. “We’ve come to the table to say this is our responsibility and we need to change,” she said. “We are playing a role in educating providers. And the providers who have taken the time and made the effort to change their practice deserve credit. They have made a huge commitment and have done good work to decrease the use and misuse of these medications.” — TS

56 | ColoradoSPH 10th Anniversary

research

Addressing an Epidemic Countering pain & opioid use in women

hen it comes to the opioid epidemic and helping the more than one-third of women in the United States who suffer from chronic pain, what are the alternatives? Where is the relief? To date, opioids are the most common form of pain management, but that comes with substantial risks. Research conducted in part by Dani Brittain, PhD, associate professor of community health education and director of the Colorado School of Public Health at the University of Northern Colorado, points to physical activity as a possible answer. Physical activity can improve physical functioning and fitness levels, benefiting overall health, but it also can alleviate pain, disabilities, and depression. “Reducing the need for pharmacologic pain relief should be one

of the strategies for addressing the opioid crisis,” says Brittain. “A better understanding of how women can use physical activity to manage chronic pain may both reduce the demand for opioids and improve quality of life.” Overall, data show that women are less likely to engage in physical activity for relief. Fatigue and pain, and social barriers such as unsupportive friends or family members, and environmental barriers such as unsafe neighborhoods, can make it difficult to utilize physical activity as an alternative pain management strategy. Additionally, due to inadequate knowledge about chronic pain and pain management strategies, it can be difficult for health care providers to deliver care to those with chronic pain.

To increase knowledge, Brittain and her colleagues developed and pilot tested a program to educate and train exercise providers to work with their clients who have chronic pain. During a three-hour in person training course, exercise providers learned how to educate their clients on pain and exercise, and to enhance psychological skills to adhere to exercise plans. “Research studies are finding that health care providers tend to have inaccurate beliefs that physical activity is harmful to people with chronic pain, and they are reluctant to prescribe physical activity as a pain management strategy,” Brittain said. “We need to identify evidence-based strategies that will help women living with chronic pain be more active.” — TE & KP

A better understanding of how women can use physical activity to manage chronic pain may both reduce the demand for opioids and improve quality of life.

Danielle Brittain

“

—Dani Brittain

10th Anniversary ColoradoSPH | 57

Health Links™ Promoting a culture of safety & well-being

hen Anna Stout became executive director of the RoiceHurst Humane Society in Grand Junction, Colorado, in 2015, she stepped into an environment she described as “toxic.” The workplace wasn’t literally poisonous, although working with chemicals, leaky water hoses, and traumatized animals makes any humane society a “massive study in risk,” both physically and emotionally, Stout said. Equally dangerous was a culture of blame, judgment, and distrust between employees. The result: high turnover, injuries, and harm and death to the animals the organization was sworn to protect. The problems culminated shortly before Stout arrived in a serious dog bite that required euthanizing the animal. The incident wasn’t a one-off, Stout said. “It was common for us to have injuries to workers, volunteers, and the public,” Stout said. “We had no culture of safety.” The number and severity of claims meant Roice-Hurst faced non-renewal of its general liability insurance policy. Discussions began about how to dissolve the organization, a community fixture since 1962. It’s still around and a far safer and healthier place today, as evidenced by the organization earning the Director’s Award given last August at the annual Health Links™ event, Celebrating Colorado’s Healthiest Places to Work. Health Links, a signature program of the Center for Health, Work and Environment (CHWE) at ColoradoSPH, works with organizations of all types to create workplaces that promote both safety and wellness for their employees. Health Links launched in 2013 with a pilot program in Pueblo, Colorado, funded by a grant from Pinnacol Assurance, the workers’ compensation provider for the state. The goal was to launch a community-based initiative to help small businesses improve worker health and safety. The project wedded the interests of public health and business, said Lee Newman, MD, MA, CHWE’s founding director. “Business people have the same

58 | ColoradoSPH 10th Anniversary

concerns as those of us in public health,” Newman said. “Chronic disease, stress, and unhealthy behaviors among workers affect productivity.” Health Links bridges the daily demands of businesses and professionals with the priorities of public health, Newman said. “We are distillers and translators,” he said, describing CHWE’s work with businesses as “pracademic.” For CHWE’s Health Links program, that meant using evidence-based benchmarks adopted from the Centers for Disease Control and Prevention (CDC) and from the National Institute for Occupational Safety and Health (NIOSH) to create the Healthy Workplace Assessment™, a tool that helps organizations evaluate their health and safety culture. Based on the results of that evaluation, they advise employers on how they can improve their health and safety outcomes, even with limited resources. “We wanted a scalable program with boots on the ground,” said Lili Tenney, MPH, director of Health Links. A team of trained “local ambassadors” helped businesses to set goals and stay connected, she added. Five years later, Health Links has worked with more than 400 organizations spanning private business, not-for-profits, local governments, schools, and hospitals in 21 Colorado counties. It reaches more than 90,000 employees. It piloted expansion programs in Manatee County, Florida in 2015 and in Oregon in 2017. This year, the program has gone national. Roice-Hurst Humane Society is one of the organizations supported by Health Links. “The program has helped us to measure and quantify the impact of the work we do,” Stout said. The tools include staff surveys, connections to like-minded businesses, and leadership training. These support cultural changes that Stout said she recognized the organization needed to make in 2015 if it was to survive. The work began modestly, with weekly staff meetings that focused on wellness topics like the importance of sleep and hydration to maintaining cognition—vital to preventing injuries to both humans

and animals. The meetings, which revolve around a 52-week calendar of wellness topics, also aimed to foster cooperation and communication between staff and to move from a culture of judgment to one of empathy, Stout said. “We needed to communicate to employees that we care about them,” Stout said. “That was a big culture shift for us.” Other seemingly small but meaningful steps included asking staff to express things they are grateful for, verbally and in journals; distributing packets of seeds for gardening, a stress-taming activity; and encouraging mindfulness and meditation. Stout stressed the positive results of the changes. The hard physical and emotional work of a humane society means there will always be turnover, she said. But those who leave now do so on good terms, the leadership team is committed and intact, and the quality of job candidates is vastly improved. “Our culture has become a major recruitment tool,” Stout said. CHWE is now one of six centers in the United States designated by the National Institute of Occupational Safety and Health (NIOSH) as a Center of Excellence for Total Worker Health®—a concept defined by the CDC as “policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being.” A five-year, $1.2 million award from NIOSH to CHWE funds research to implement those goals. “We are a center that is predicated on public health practice,” Newman said. “That means that we take the existing best evidence and translate it to the community. We take what we know is effective today, put it into practice, and learn from our partners.” That approach, with its emphasis on listening, learning and mentoring, and a commitment to assisting small businesses—often overlooked in discussions of improving workplace wellness—sets CHWE apart in an emerging field. — TS

“

[Health Links] has helped us to measure and quantify the impact of the work we do. —Anna Stout

Anna Stout, executive director of the Roice-Hurst Humane Society, Health Links Certified Healthy Workplace™ Partner

10th Anniversary ColoradoSPH | 59

Shaping Healthy Hospitals Caring for employees, patients & community

Rayna Hetlage & Katie O’Connor

he idea of an initiative to make hospitals healthy sounds like a no-brainer. People go to hospitals to regain their health. But it turns out hospitals haven’t always been in the vanguard of promoting and encouraging healthy behaviors for those who work in them, those they care for, or those who live in the communities around them. Think about hospital cafeterias that offer patients, visitors, and employees ready access to sugary drinks and fatty foods, but may not have many leaner opportunities like fresh fruits and vegetables. In 2014, the Colorado Department of Public Health and Environment (CDPHE) set out to encourage the state’s hospitals to make their facilities heavy on nutritious food and drink options and lighter on junk food and soft drink favorites. Children’s Hospital Colorado was an early adopter of the statewide initiative, dubbed the Colorado Healthy Hospital Compact. The Children’s Colorado effort had an enthusiastic advocate in Katie O’Connor, MPH, a 2013 graduate of the Colorado School of Public Health. As part of her MPH degree, O’Connor completed her practicum and capstone projects at the hospital and then stayed on as an employee. She’s managed the Healthy Hospital Program since early 2016, but has focused throughout on making Children’s

60 | ColoradoSPH 10th Anniversary

Colorado a model and advocate for the importance of keeping body, spirit, and mind healthy. Much has changed on the food front since O’Connor began work at the hospital. “In 2013, there were not a lot of healthy items in our cafeteria,” she said. As a member of the Healthy Hospital Committee, she worked on an exhaustive inventory of all the items the food service had on hand. That led to labeling packaged items as green, yellow, or red— green being the healthy options, red the items to avoid. Getting more green into the array of meal choices didn’t mean the hospital had to make a complete overhaul of its vendor relationships. Stocking low-fat Doritos instead of the traditional salty, fatty favorites, for example, offered a gentle push in the right direction without shaking a scolding finger in the face of people looking for a quick snack. “You have to meet people where they’re at,” O’Connor said. Children’s Colorado stopped offering sugar-sweetened drinks altogether in 2016 and increased the number of daily healthy entrée options they offer. One major impetus for the change: the growing problem of childhood obesity, which drives health problems for kids now and later in life. “We saw that we as a hospital needed to model the behavior

“

I saw that nutrition is something that all people can have access to, regardless of their social status and background. — Rachel Bernhardt

students & alumni

Children’s Hospital Colorado community garden

that we advocate,” O’Connor said. “We could tell kids not to drink sugary beverages, but if we’re downstairs selling it, we’re sending the wrong message.” The same idea applied to reshaping the cafeteria menus for employees and visitors, O’Connor said. “We have people who eat here every day,” she said. “We should also be a model for healthy eating.” That didn’t mean putting out “salad and water” and expecting happy customers, O’Connor added. The hospital worked with the kitchen team to develop flavorful dishes with more plant-based options that used fresh, local produce. That produce will soon come from a very local source: the hospital’s own garden, which officially opened with a ribbon-cutting ceremony on a plot of land east of the building in late September. It was designed and will be tended to by an urban farmer from the Denver area. Youngsters will be welcome in the space, O’Connor said. “We’re trying to instill or reverse lifelong [nutritional] behaviors in kids,” she explained. “They will have a chance in the garden to see, touch, and feel food and understand where it comes from.” It’s not easy to get a hospital garden in the ground or off the ground, O’Connor said. She noted the importance of working with hospital leadership, facilities management, and epidemiologists to ensure the new addition was safe for patients and operationally sound. In this, she enlisted the help of a

ColoradoSPH student intern, Rachel Bernhardt, MPH, who earned her degree in May. Describing herself as “definitely a Diet Coke a day person” for most of her life, Bernhardt said O’Connor helped to spark an interest in the importance of nutrition to improving public health. “The more I studied, the more intrigued I became about nutrition and what it can do to help individuals and the community,” Bernhardt said. “I thought about ways we can utilize the resources we already have to help with that. I saw that nutrition is something that all people can have access to, regardless of their social status and background.” Bernhardt did basic research necessary to build a proposal for the Children’s Colorado garden. She contacted people familiar with the challenges—including the Master Gardener Program at Colorado State University—to learn about garden layout, produce choices, who might care for it, and so on. “It wasn’t necessarily an area that I anticipated enjoying learning about,” Bernhardt admitted. But that changed. “The project taught me a lot as far as how research goes into project proposals so you’re not redoing labor-intensive work.” With O’Connor’s encouragement, Bernhardt went on to wrap up her MPH degree work with a capstone project that examined the costs and potential benefits of transitioning the hospital’s meat purchases to antibiotic-free products. Sometime next year, the hospital also

plans to use produce from the garden to stock a farm cart and farmers market for staff and community members. Rayna Hetlage, a current ColoradoSPH student who plans to finish her degree next spring, said a partnership with LiveWell Colorado’s Double Up Food Bucks program will allow people in the Supplemental Nutrition Assistance Program (SNAP) to get one dollar of free produce for every dollar they purchase on their SNAP card. Hetlage also interns with O’Connor. For her program practicum, she researched the steps needed to set up the farm cart. The key considerations included ensuring the operation followed the hospital’s epidemiological guidelines to protect patients’ health and safety and determining culturally relevant food choices for the very diverse community in Aurora, Colorado. “We wanted to be sure on this project that we were aware of what people are eating in different cultures rather than only a mainstream American diet,” Hetlage said. The cart also aims to close a critical health gap, she noted. “Healthy foods are more expensive and difficult to obtain,” Hetlage said. “So we hope the cart will make [those foods] more accessible to the families of the communities that we see on campus.” As her capstone project, Hetlage is working with O’Connor on a different effort and health equity issue. The Employee Wellness program at Children’s Colorado provides a $600 reduction in 10th Anniversary ColoradoSPH | 61

annual health premiums to employees who hit specific marks, such as filling out a health metrics survey, staying tobacco free, or entering a cessation program. The task: identify the employees or groups of employees who are not participating, discover the possible reasons, and quantify the consequences of not using the program. Hetlage’s project underscores O’Connor’s belief that nutrition is just one piece of the larger health care puzzle at Children’s Colorado. A hospital-paid weight management program launched this year after many employees cited the need for it in an online wellness survey, but O’Connor said the organization’s goals go beyond checking boxes and calling it good. “We genuinely see ourselves in a customer-service role—providing healthy options that are relevant, accessible and useful,” she said, adding that she supports strengthening “the social aspects of wellness” for employees: building teams, encouraging volunteer service, and destigmatizing mental and behavioral health issues. All of these translate to better patient care and healthier communities. “We’re ingraining the concept of healthy teams into our culture,” O’Connor said. That idea is gaining strength beyond Children’s Colorado, added Cristina Lever, MPH, a 2017 ColoradoSPH grad who also interned with O’Connor. Lever completed a first-ever assessment of the food options at Children’s Colorado’s South Campus as her capstone project. More businesses, Lever noted, are implementing other measures that reflect concern for their workers’ overall health: building green space, installing lactation rooms, creating workspaces with natural light, planning spaces with walking and bike paths, and so on. “We’re beginning to think of health more structurally,” said Lever. Children’s Colorado is a leader in that movement. It is one of four platinum-level facilities—the highest designation given by CDPHE—in the Healthy Hospital Compact. O’Connor was on hand recently to receive awards on behalf of the hospital from Health Links, a signature program of the Center for Health, Work and Environment at ColoradoSPH that is dedicated to working with businesses to create workplaces that promote both safety and wellness for their employees. O’Connor’s influence also extends to the interns she has mentored. “It was eye-opening to see how basic public health principles could be pushed at Children’s Colorado and to see how we could support employees as well as the entire community,” said Bernhardt, who is now looking for a job in a hospital or clinic where she can continue that kind of work. “It can be difficult to get things done in a larger organization like a hospital,” Hetlage added. “I learned from Katie that it’s about relationship building. Relationships are the key to getting things done.” — TS

62 | ColoradoSPH 10th Anniversary

“

students & alumni

We’re trying to instill or reverse lifelong [nutritional] behaviors in kids. They will have a chance in the garden to see, touch, and feel food and understand where it comes from. — Katie O’Connor

10th Anniversary | 63 Children’s Hospital ColoradoColoradoSPH community garden

collaboration

Fostering Public Health Practice Building the capacity of the public health workforce

Cerise Hunt

successful public health school spreading tobacco cessation skills, We’re on the ground listening to our pubneeds to take on the health crises the Center for Public Health Practice lic health practitioners, our local health and policy concerns of the day, takes the three-campus knowledge agencies, state health leaders, commuwhile also reaching out into the com- of ColoradoSPH to every corner of nity partners—anyone who is promotmunity to listen, partnering with local Colorado, as well as the six-state re- ing health and wellness. We listen to see experts on public health issues, and then gion making up the U.S. Department of how we, as a center, can help them do returning to campus with curriculum- Health and Human Services’ Region 8: their work better.” and research-shaping ideas. Students’ firsthand The Center for experience Public Health Practice The Center for Public at ColoradoSPH has Health Practice and its been doing exactly hubs are one of the prithat since the school’s mary ways for current inception in 2008, with ColoradoSPH students every tool from bootsto get out into the on-the-ground comcommunity and expemunity health assessrience public health ments at the behest of research and policy rural entities like Bent firsthand. The Bent County, to convening County Community leaders and researchHealth Assessment ers to collaborate in is one example, Hunt fighting obesity, adsaid. “I co-teach the dressing emerging community health issues like legalized assessment course,” The six-state region making up the U.S. Department of Health and Human Services’ marijuana, or leading Hunt said. “Every seRegion 8: Colorado, Montana, North and South Dakota, Utah, and Wyoming. remote online trainings mester, the students with rural communities get to support health on public health topics like transgender Colorado, Montana, North and South partners around the state.” health. Dakota, Utah, and Wyoming. Bent County is a community of Through a handful of statewide and As one of only 10 public health schools about 5,800 people in far southeastern regional hubs promoting anything from in the nation with a federally-funded Colorado, marked by a strong farming training patient public health training center—the Rocky history, a county seat in Las Animas, n a v i ga - Mountain Public Health Training Center and the Arkansas River flowing through. tors to (RMPHTC)—ColoradoSPH and the ColoradoSPH students in Hunt’s classes Center’s affiliated education hubs make gain practice-based experience through up one of the nation’s most comprehen- conducting capacity assessments. The sive sources of training and develop- students in Hunt’s course this fall will ment for the public health workforce. take what they’ve learned to develop Just as important, the Center fosters communication materials for the local those crucial interactions when working health department to share with their public health professionals to bring re- community partners. al-world experience and insight back to In the past, student community asits students and leadership. sessment teams have also worked with “Our mission is excellence in public Jefferson, Las Animas, and Huerfano health practice,” said Cerise Hunt, di- Counties, among others. rector of the Center for Public Health “People see us in communities, and Practice. “We support the work we’re listening,” Hunt said. that’s being done at the local level.

collaboration

222 9,549

trainings in 2018

Building peer networks

A key goal of the Center’s work, said Elaine Scallan, PhD, associate professor of epidemiology and director of the RMPHTC, is to “provide training to public health professionals, connect them with their peers, and reduce professional isolation” in states where one county’s public health leader might be a two-hour drive from colleagues. “Many public health leaders live in rural areas where they may be the only professional working in their area,” Scallan said. “Through the regional training center, we work to provide relevant, engaging, online training opportunities that use bi-directional video. We connect them to subject matter experts and to peers around the state. Building these peer networks is key to reducing professional isolation. We hear from professionals that they can now pick up the phone and know who to call.” RMPHTC accomplishes this by offering carefully-planned, highly-engaging, live learning sessions, including its ECHO series developed with the Colorado ECHO (Extension for Community Health Outcomes) program on the University of Colorado Anschutz Medical Campus. These are not one-way webinars that the distance learner can ignore while still “checking the box” of continuing education. They are highly interactive peer sessions that use bi-directional video, where working professionals and community health workers share stories, experiences, and tips. The format “allows everyone to get into the same ‘room’ through technology,” even across the six-state mass of

people trained in 2018

the federal Region 8, said Jen Anderson, clinical quality improvement director for the Community Health Association of the Mountain/Plains States (CHAMPS). “The series is people talking to each other and making connections: ‘How exactly did you pay for this program?’ ‘We went after this grant, and here’s another one . . .’ They are able to work through problems on the ground.” CHAMPS has worked with RMPHTC on topics such as diabetes case management and colorectal cancer screening, Anderson said, bringing together questions and answers from across a region that includes Colorado, Wyoming, Montana, North Dakota, South Dakota, and Utah. “They are fantastic partners,” Anderson said. “It’s a type of work we just wouldn’t be able to do without their support. We don’t have the capacity to do it on our own.” The RMPHTC also utilizes bi-directional video in an online course, in which participants read and watch information on their own and then come together for discussion via video once a week as a learning cohort. One recent online course was on the topic of LGBTQ health. The series covered health disparities within that group, the limits of current data, diversity in age and urban and rural settings, workplace barriers, and conscious or unconscious bias, said Sarah Davis, associate director of RMPHTC. One participant wrote in the course evaluation, “Since I am new to all of this, and having my first transgender patient, I found all the coursework helpful,

especially the terms. I had absolutely no idea that there were so many terms and how much pronouns matter.” One lesson the Center’s hubs have learned in recent years is that when it comes to online and distance learning, partners demand and appreciate depth of information over most other factors, Scallan said. “There’s a lot of stuff available out there online that people can look to for best practices. Where we heard the gap and real need was the chance to delve into a topic more deeply,” Scallan said. That was reflected in the Region 8 experience with a series on care coordination strategies in diabetes management, Anderson said. It was initially a new experience to focus on care coordination for a specific disease, but it produced wide acclaim from the participants. Each of the states involved is now drilling deeper into diabetes management based on the topics shared. CHAMPS and RMPHTC made a presentation on the series to the American Public Health Association this year. “So the net keeps getting wider and wider, if you will,” Anderson said. The overarching goal, Hunt said, is to maintain the Center for Public Health Practice’s partnerships and to be a source for the exchange of valuable information about public health practice. “We try to be authentic,” she said. “We don’t ever try to promise the world. We know our niche. We’re always willing to take risks, to have those crucial conversations that need to take place to promote health equity.” — MB

10th Anniversary ColoradoSPH | 65

collaboration

“

We’re always willing to take risks, to have those crucial conversations that need to take place to promote health equity. — Cerise Hunt

66 | ColoradoSPH 10th Anniversary

Center for Public Health Practice Rocky Mountain Public Health Training Center (RMPHTC) Developing the latest in online learning techniques for topics ranging from care coordination to leading effective coalitions to foodborne illness outbreaks. Patient Navigator Training Collaborative (PNTC) Offering a full curriculum to build patient navigator skills and knowledge, and also a network enabling navigators to connect with colleagues around the nation. Tobacco Control Training and Technical Assistance Team Working with the Colorado Department of Public Health and Environment to create and deliver both in-person and online tobacco control training programs. Topics include insights into tobacco industry marketing strategies, cessation best practices, and public policy development and legal guidance. Community Engaged Practice The team builds communitybased partnerships designed to strengthen population health and promote health equity, through training, consultation, and technical assistance. Partners include Families Forward Resource Center Health Babies, Aurora Health Access, and more.

10th Anniversary ColoradoSPH | 67

Tackling Tobacco in Weld County Serving & protecting a diverse community

achel Freeman grew up in Greeley, Colorado, and remembers a time when corn, hay, and alfalfa fields surrounded her neighborhood. It wasn’t unusual to see a tractor lumber through the main thoroughfare. It was a small farming town. But as the rural Weld County’s population soared to more than 300,000 people with a third of its residents in Greeley, Freeman, now tobacco control supervisor for the Weld County Department of Public Health and Environment, finds herself dealing with urban problems. “I love Greeley—the city has changed a lot and the population has exploded,” she says. “I feel lucky I get to work in a county where I grew up and that gives me a deeper connection to the community I serve.” A 2014 graduate of ColoradoSPH at the

68 | ColoradoSPH 10th Anniversary

University of Northern Colorado, Freeman earned a Master of Public Health degree with a concentration in community health education. She says the classes she took and the school’s practical approach to gaining experience through community outreach practica and her final capstone project was invaluable in helping her engage in evidence-based, tobacco policy change strategies in her current position with the Weld County Tobacco Control Program. In partnership with the TobaccoFree Coalition of Weld County, the Weld County Tobacco Control Program works to reduce and prevent tobacco use among adults and youth. The agency develops and identifies services to help people quit using tobacco and also works with lawmakers to create policies to protect

people from secondhand smoke. “We still see quite a bit of tobacco use in Weld County, but we’re seeing it with populations that are lower income, who use tobacco and other substances,” she says. “These people tend to have low socioeconomic status, low educational attainment, and it really is a huge equity issue.” A 2016 Community Health Survey found that one in six Weld County residents used tobacco (17 percent). Smoking was more prevalent in lower income residents—31 percent of those whose household income was less than $16,000 a year smoked cigarettes. In one outreach effort, Freeman and her team worked with the Weld County Food Bank to target food bank clients who came in for emergency food boxes. Food

Rachel Freeman

The “Protect Your Future” mural in downtown Greeley, Colorado was designed to raise awareness about the consequences of tobacco use.

alumni bank staff screened their clients for tobacco use and referred them to the Colorado Quitline, a statewide program that offers free coaching calls and nicotine replacement therapy. Between February 2017 and March 2018, the food bank found that 2,770 clients used tobacco. Of those, 818 clients were referred to the Quitline. “We try to integrate tobacco cessation resources in the locations individuals are already going to—such as the food bank or Department of Human Services,” Freeman says. “The more times a person hears the message about the dangers of smoking the more likely they are going to think about quitting or try to quit. And that’s exactly what we want.”

Reaching Youth

In addition to adult programs to target tobacco use, a youth movement in Weld County, Preventing Addiction Caused by Tobacco (PACT) works to prevent tobacco use in schools. Students work together to discuss tobacco-related issues and make their environment safer. More than 17 percent of Weld County high school students say they have smoked cigarettes and nearly half of Colorado youth have tried an e-cigarette, according to the 2015 Healthy Kids Colorado Survey from the Colorado Department of Public Health and Environment (CDPHE) and led by ColoradoSPH faculty and researchers. Health Department staff, PACT youth, and local artist and UNC graduate Armando Silva, collaborated on a downtown Greeley mural, which portrayed the message, “protect your future,” from tobacco and secondhand smoke. The mural was designed to raise awareness about the consequences of tobacco use and vaping. “The mural has been really well received and has been a great opportunity for the Tobacco Control Program and the Health Department to develop new relationships with non-traditional partners,” Freeman says.

Keeping the Environment Smoke Free

Greeley has been in the forefront in Colorado and national efforts to stop the exposure of second-hand smoke in public areas. 2018 will mark the fifteenth year since Greeley enacted a public smoking ban, one of only five Colorado municipalities to enact the law before it went statewide three years later. In 2015, the Greeley City Council voted to treat e-cigarettes like traditional cigarettes and included them in the city’s current public smoking ban. This year, the City Council is currently considering whether to ban smoking in public parks, trails, and open spaces. “We’ve focused a lot of attention and work on environmental change strategies,” says Freeman, adding that Greeley city officials requested technical assistance from the Weld County Department of Public Health and Environment to make these changes. “This allows us to impact the health of a very broad population.” Since ColoradoSPH’s inception 10 years ago, the UNC program has grown to offer three options for a Master of Public Health degree: Community Health Education; Healthy Aging and Community Health Education; and Global Health and Community Health Education. ColoradoSPH at UNC also offers a Certificate in Public Health Sciences. These specific degree concentrations, along with community experience in practicum and capstone courses, give ColoradoSPH students valuable experience working with diverse communities as they prepare for jobs in the real world, says Teresa Sharp, MEd, PhD, associate professor for the Colorado School of Public Health at UNC. Practicums are “high-level internships” and the capstone course is “a culmination experience, using all the information they gained in their degree program,” says Sharp, adding that examples of capstone programs include developing curriculums, writing a grant or guide book, doing needs assessment, among other outreach efforts. “These practicum and capstone courses involve students going out and working in the community with organizations and agencies that have a need and interest in public health initiatives,” she says. “We always say that ‘public health is everything

“

I feel lucky I get to work in a county where I grew up and that gives me a deeper connection to the community I serve. — Rachel Freeman

10th Anniversary ColoradoSPH | 69

“

I’m just so proud to see there are so many places where and everything is public health’ so the projects are as broad as you can imagine.” The relationships between former and current students are “mutually beneficial opportunities that benefit the agency or organization while also benefiting the student—allowing them to operationalize the things they learn in the classroom,” Sharp says. Some students will work for the Weld County Department of Public Health and Environment or other local non-profits and agencies to get their experience. Others will travel internationally. It all depends on students’ interests and passions. Freeman’s capstone project involved the development of a guide used by local public health agencies considering the implementation of the Healthy Corner Store Initiative. “The experience was valuable in that I

70 | ColoradoSPH 10th Anniversary

was able to work with health department staff members that I don’t usually interact with on a day-to-day basis,” Freeman says. “It was interesting to develop relationships with small business owners in Weld County and to work in healthy eating and active living, a program area that was new to me.” Our students are incredibly passionate and creative about identifying ways to enhance and support public health needs. — Teresa Sharp

Freeman is one of many alumni who work with current public health students from ColoradoSPH at UNC. She is a preceptor for the school’s Weld County practicum site and supervised two students who have since completed their MPH degrees. The ColoradoSPH students

assisted Freeman in coordinating Kick Butts Day, a national day of action, where students speak out against tobacco. “These students were able to gain knowledge and skills in youth engagement, health education and communication, and tobacco addiction treatment,” Freeman says. Freeman’s project is just one of many that ColoradoSPH students experience during their time at the school. “Our students are incredibly passionate and creative about identifying ways to enhance and support public health needs,” Sharp says. “Across the board, our students are doing everything they can to find ways to reduce health inequities.”

Partnering to Improve Health

ColoradoSPH programs at UNC are a “unique model” because they give

alumni

we have an impact. — Mark Wallace

students the opportunity to serve their school’s community, says Mark Wallace, MD, MPH, executive director and chief health officer for the Weld County Department of Public Health and Environment and co-founder, CEO and CMO of the North Colorado Health Alliance. “I wanted to be certain that the school was practice- and community-based, not just an ivory tower approach to getting an education,” says Wallace, who helped plan the UNC public health program and has taught classes there. “And now having seen the school in action, I’m particularly proud of the community engagement opportunities for the students, particularly on the UNC campus.” As head of the Weld County Department of Public Health and Environment, Wallace appreciates being

able to tap into the expertise brought by ColoradoSPH students, both for internships and as a highly qualified workforce after graduation. “We’ve got this ability to have students right nearby, offer them opportunities, work alongside them, and bring them on board,” he says. “When you look at my team, a lot of them have graduated from the Colorado School of Public Health—especially from the UNC campus.” UNC also has been an active partner of the North Colorado Health Alliance, which serves as an “incubator of best practices” to improve public health, Wallace says. “People are surprised when we describe our partners because they think it’s going to include traditional hospital systems, behavioral health and community health providers, but we very deliberately at the beginning wanted UNC at the table

to be one of our key partner agencies,” he says. It’s challenging work, given that Weld County is made up of 32 municipalities, all with different government officials, goals and priorities. The region is also projected to grow to more than a million people by 2035. Partnering with UNC has given the coalition the capacity to do more outreach with students’ help, as well as being able to use the university’s expertise to measure and evaluate if programs are effective. “We see UNC having an very important role in turning data into actionable information,” he says. “That will help us understand if we’re really making a difference as our communities continue to grow. I’m just so proud to see there are so many places where we have an impact.” —KB

The completed “Protect Your Future” mural in downtown Greeley, Colorado

10th Anniversary ColoradoSPH | 71

research

Breaking Ground Understanding the health implications of oil & gas development

John Adgate

o publish research on the envi- well—far from it.” sudden spikes in population in homes ronmental impact of Colorado’s Coloradans have been drilling for oil and schools, perceptions of living in an oil and gas industry is to resign products since the 1860s. Yet, not until industrialized zone, and more. yourself to pleasing some and not others. the 21st century did environmental health The oil and gas studies serve as a primLisa McKenzie, PhD, MPH, and John researchers begin in earnest to study the er in public health research, because Adgate, PhD, MSPH, are both faculty in potential impacts of drilling operations Adgate and McKenzie are meticulous in environmental and occupational health on humans who live nearby. The advent pointing out both the solid conclusions at the Colorado School of Public Health, of hydraulic fracturing spurred demands and the remaining gaps to be filled by and have long since given up the fantasy for more research, as new extraction tech- more research. For example, what the that their research will be greeted with niques brought drilling to petroleum-rich Garfield County study specifically did not universal celebration of the scientific fields close to major population centers do was put a cost or a public policy value method. They’ve chosen to investigate in states like Pennsylvania and Colorado. on managing the risks they had pointed the oil and gas industry because it is a The Colorado School of Public Health out. fascinating and important intersection first got involved with research in the inMcKenzie and Adgate say they were of public policy, public health, and one dustry in 2008 with a white paper writ- told by Garfield County to not consider of the fastest-growing industries the feasibility of the interventions in Colorado. What could be more the report listed. We publish so people can talk about relevant? “We got accused of overstepping,” our results and critique them—that’s Siting oil and gas operations in Adgate said. “The goalposts were some of the most beautiful placthe way the scientific process works. moved.” es in Colorado creates “complex “It became clear that the oil and — John Adgate problems with no easy answers,” gas industry was expecting complete said Adgate, professor and chair of ten by Roxana Witter, MD, MSPH, MS, Lee vindication, and citizen opponents of the Department of Environmental and Newman, MD, MA, and colleagues. Adgate drilling were expecting it would support a Occupational Health. “Our faculty are joined the faculty in 2010 as an exposure total ban on drilling,” Adgate said. “So, no complex problem junkies.” scientist interested in both chemical and one was happy.” And it shows. Their team gets credit nonchemical stressors on human health. While political turmoil resulted in from national environmental health ex- McKenzie has a chemistry PhD and came Garfield County, the researchers learned perts for their willingness to tackle ques- to ColoradoSPH for an MPH. During her valuable lessons and received nationtions on oil and gas and health, and to studies she joined a new effort to assess al attention that led to funding for more seek out useful data without overstating oil and gas impacts in Garfield County in work. Adgate was invited to present at results. 2011. a National Research Council forum on “They’ve responded very effectively,” The Western Slope study was origi- shale gas risks and governance. McKenzie said Bernard Goldstein, MD, professor nally commissioned as a Health Impact communicated research findings in exemeritus and for- Assessment for the county, which has pert testimony to the U.S. House of mer dean of the long been one of the hotbeds for drilling Representatives Committee on Natural University of (Weld County on the Front Range is now Resources’ Subcommittee on Energy. P i t t s b u r g h the state’s production leader, by far). The ColoradoSPH startup funds to the G r a d u a t e study looked at potential environmental Department of Environmental and School of and personal health impacts in proposed Occupational Health supported a study Public Health. gas drilling areas on Battlement Mesa in published in 2014, using existing data Pennsylvania Garfield County. sources such as birth records to look for has had its own The assessment concluded there were any connections between birth outcomes fracking con- likely impacts on people from drilling-re- and proximity to oil and gas development. troversies, with lated air emissions, especially within a As the researchers describe it, it’s neia revival of the half-mile of well sites. They also found ther a correlation paper nor a causation drilling industry that the population would be adverse- paper, but an “odds” paper—the study there. “Not all the ly affected by dangers and stress from found that children with congenital heart schools in all the industrial traffic, and that there were defects were more likely to be born to a states with fracking possible health impacts from changes mother who was living in the densest arhave responded as to the “normal way of life,” including eas of oil and gas development.

378,000

Coloradans live within a mile of at least one oil or gas well

Well site in Greeley, Colorado

What the paper did not try to say is why—there could be a number of factors about moms living near oil and gas wells that are different than other groups of moms, including rate of smoking, age, socio-economic status, and more. McKenzie calls her next paper an environmental justice paper that found home values were lower closer to wells, and that people living closest to the development hadn’t been informed of any potential health risks. The paper concluded that 378,000 Coloradans live within a mile of at least one oil or gas well. While that paper did not stir as much controversy as their earlier work, two papers in 2017 did. A workshop two years earlier had brought together researchers, industry, and health department officials to talk about what was known on emissions of benzene and cancer risk. McKenzie sought funding from the University of Colorado Cancer Center at CU Anschutz to cull through existing data in the state cancer registry. McKenzie and her team found that children diagnosed with leukemia were about four times more likely to be living in the highest-density oil and gas developments

of Colorado. The Colorado Department of Public Health and Environment (CDPHE) cast doubt on the study’s significance, citing the small sample size and other issues. Advocacy groups again turned to the study as a good argument for a drilling ban. A second paper that year had a timely landing: A home explosion from an improperly capped branch line in Firestone, Colorado killed two people, right when the research team was preparing to publish a study comparing accident rates in Utah and Colorado. The study found a major gap in accident rate reporting between the two states. And most recently, a paper this year estimated far higher lifetime excess cancer risks, as was well as other health risks, for residents living closest to oil and gas sites, based on results from an extensive air sampling campaign conducted by the CDPHE, the National Oceanic and Atmospheric Administration (NOAA), the National Center for Atmospheric Research (NCAR), and the National Aeronautics and Space Administration (NASA) in the summer of 2014. Adgate remembers losing sleep before the first of the series of papers landed in

2012, but has since become used to the ritual controversies. “I think we’re doing the best science that we can around this, and we’re doing our studies and writing them for peer review, making it as rigorous as we can given the data we have,” he said. “We publish so people can talk about our results and critique them—that’s the way the scientific process works.” The researchers have changed a few things along the way. They help write the press releases that accompany their work, to launch results with the most accurate claims. They speak at scientific venues and, when invited, to communities and government representatives, but not to industry forums or advocacy meetings, or protests on the State Capitol lawn. “We believe that is important to communicate our results to regulators and community members and engage in discussion on the implications of our results,” McKenzie said. Other public health schools in fracking states would do well to expand on the Colorado research, said Pitt’s Goldstein, “because they’ve been a leader.” — MB

10th Anniversary ColoradoSPH | 73

alumni are all working until July 2019 to meet this goal. The new model has helped providers transition from “fee for service” care, in which providers are paid for each service performed, to an emphasis on treating patients with evidence-based, quality care supported by value-based payment. This is a difficult transition, requiring partnership between practices and payers to better meet the needs of Coloradans. “It’s a movement away from how we currently pay for health care, which is volume over value,” Martin says. “We are really working hard with our practices and the health plans (payers) to drive towards value and a shared understanding of what outcomes we want to see in Colorado.” SIM is also taking a statewide approach to population health, to improve the health of Coloradans with preventive care and screenings, connecting patients to the resources they need, and tracking these efforts over time. “We’re also thinking about how our work is impacting our overall population health outcomes, including suicide rates, chronic disease, hospital utilization, and cost of care,” she says. “These population metrics can take some time to change, but the foundation we’re laying in communities and systems will impact those measures in the next five to 10 years.” After more than 11 years working as a clinician, Martin enrolled in the Colorado School of Public Health in 2011 to earn her master’s degree with a concentration in Health Systems, Management and Policy. It was an important step in learning how to change the health care system and improve the health of more patients in the process. “I saw how sometimes the systems are stacked against patients and that’s what led me to look for solutions and back to school to get my MPH,” she says. Richard Lindrooth, PhD, interim chair of the Department of Health Systems, Management and Policy, recalls Martin as a “fantastic student,” a clinician whose questions and comments greatly

Mental Health Policy

Reducing stigma & breaking down barriers

s a cardiology nurse practitioner in Chicago, Barbara Martin often asked her patients if they had chest pain walking up a flight of stairs. At Valley View Hospital on the western slope of Colorado, she might ask her patients about their stamina during hunting season. The patients she worked with had heart problems. But for Martin, RN, MSNACNP, MPH, her approach to talking to her patients differed to fit their environment, and that made all the difference in how she worked to coordinate their care. “It’s important to understand the opportunities and limitations available for patients and help coordinate their care accordingly,” Martin says. “I’ve always been passionate about how we best use our resources to help our patients.” Today, as director of the Colorado State Innovation Model (SIM), a sweeping and ambitious $65 million initiative that seeks to transform the Colorado health care system with better quality care at lower costs, Martin and her team are working to lay the groundwork for individual and population-based advancements in treating the “whole person,” which includes behavioral and physical health. For SIM, the term behavioral health includes mental health, substance use disorders and healthy behaviors. SIM currently works with 325 primary care practices and more than 2,000 providers statewide with a goal to influence the care of 80 percent of all Coloradans. With the progress made with practices, community mental health centers, local public health agencies, behavioral health transformation collaboratives, and through regional health connectors, they are well on their way. Martin oversees a team of 16, along with dozens of consultants, vendors, and other agencies that

74 | ColoradoSPH 10th Anniversary

enhanced classroom discussions of the finance coursework he taught. “These classes are designed to give students the skills to understand the financial and reimbursement system within which public health organizations operate, so they can work within the system to the best of their abilities,” he says. In economics courses, students learn how health care funding works and the role of government in that process. Students also learn how to do a cost-benefit analysis to determine how to make the best use of limited resources and they have courses that focus on how to influence health policies and how they are implemented, primarily on state and county levels. Martin was one of many public health students with clinical backgrounds to bring real-world perspective to Lindrooth’s classes. “There were times she would stump me and I would have think about it, figure it out and get back to her,” he says. “That really made it a pleasure to have her in the program—her questions and comments improved the course for other students and for me as well.” Martin was in school during the passage of the Affordable Care Act, an exciting time to be a student, she says. “Learning about how it affected delivery systems in real time provided me a rich context and also a different perspective than the clinical lens, which was a fascinating evolution for me,” she says. “It was foundational to how I think today.” As she finalized her MPH, Martin helped assemble a proposal in 2013 as part of an initial SIM planning grant that the state was awarded. “It was a daunting and amazing experience, where I was able to bridge between school and moving into the professional realm,” Martin says. “I met a lot of state leaders, who were innovative and committed to driving value in the health delivery system.” The group reached out to experts statewide to get the best ideas possible while building support for the project. The team held meetings, both large and small, to tap the interests and viewpoints of more than 150 stakeholders statewide.

46%

of adults will experience mental illness or a substance abuse disorder

67%

of adults with a behavioral health disorder donâ&#x20AC;&#x2122;t get the care they need

20%

of primary care visits are mental-health related

10th Anniversary ColoradoSPH | 75

alumni

Barbara Martin

Martin transitioned to the Colorado Department of Public Health and Environment (CDPHE) at the end of the planning grant and worked as Health Systems Unit Director when the full SIM initiative was awarded to Colorado by the Centers for Medicare and Medicaid Services (CMS) in 2015. Her work on the planning team has paid off as the SIM team continues to partner with seven workgroups to ensure that all stakeholder perspectives— including public health, children and youth, and provider/workplace—are included in and addressed by in the initiative. A steering committee and advisory board made up of stakeholders representing consumers, providers, insurers, agencies, academia, technology, business, and behavioral health, provide additional feedback. In 2015, she became director of the Transforming Clinical Practices initiative (TCPi), a CMS-funded initiative that is managed by the SIM team, to help clinicians and medical practices transition into new care delivery and payment systems. She was named SIM interim director in March 2016 and was made director six months later. During her first year with SIM, Martin made important changes to the initiative that helped SIM practices show how their work to integrate care improves patient health and reduces or avoids unnecessary health care costs. This is key to success with alternative payment models, which is a key piece of SIM’s purview.

Tackling Systemic Change with SIM

From 2015 to January 2019, the SIM team has been tasked to improve the health of Coloradans by: • Coordinating community systems to better integrate physical and behavioral health in

76 | ColoradoSPH 10th Anniversary

•

• •

primary care settings and improve patient access. Applying payment structures that include quality of care measurements to ensure value for patients. Expanding information technology statewide, including telehealth. Establishing a state plan to implement and improve population health.

Integrating Mental Health

Studies nationwide have shown 46 percent of adults will experience mental illness or a substance abuse disorder at some point in their lives, and 20 percent of primary care visits are mental-health related. Yet 67 percent of adults with a behavioral health disorder don’t get the care they need, according to a New England Journal of Medicine study. Championed by Colorado Governor John Hickenlooper’s administration, SIM’s goal is to integrate physical and behavioral health services in coordinated systems. Moving behavioral health professionals into the primary care setting is key to making treatment more accessible to patients. “We need to better screen, but we also know our systems will be stronger if they connect to communities at the patient and the system levels,” Martin says. “We need to understand the barriers and the stigmas surrounding mental health. We’ve made great inroads, but there’s a lot of work to do.” Continuity of care will improve for patients who have integrated mental and physical health care, Lindrooth says. “If you can have a situation in which a patient can walk down the hall and have an appointment for physical health care where they’re already comfortable with their behavioral care, you will improve access and opportunities for the joint management of chronic conditions,” he says. “You can improve health outcomes for individuals and potentially save on

“

We need to understand the barriers and the stigmas surrounding mental health. — Barbara Martin

costs because untreated physical health can manifest itself into more expensive conditions.” Leilani Russell, MPH, SIM’s lead data coordinator/analyst and a 2016 epidemiology alumna of the Colorado School of Public Health, initially enrolled in ColoradoSPH to get a certificate in public health sciences. After completing that program, she returned to earn her Master of Public Health degree. “The Colorado School of Public Health required me as a student to take a bigger perspective and I found that really valuable,” she says. “It couldn’t just be about science, understanding co-morbidities or why some people have better health outcomes than others, but really looking at everything that’s involved—changes in health systems, patient empowerment to make healthy choices and community engagement.” ColoradoSPH’s core courses in epidemiology, biostatistics, health systems, community and behavioral health, among others, have helped Russell prepare for SIM and its challenges. “The work can be a little daunting at times, but I feel so glad to be able to tackle the challenges of health care access at a system level,” she says. “I came into public health with a science and community-based perspective, but the more I

attended classes and did research I realized you can’t do everything at the community level.” Russell’s says her work at the system level within SIM helped her see the needs of individual communities that also must be considered. “I feel like SIM has so much of both and it’s been rewarding and challenging,” she says. “It’s been great that there are so many amazing people to work with, including stakeholders and colleagues.” The opportunity to work with Russell, a fellow ColoradoSPH alumna, has been invaluable, says Martin, adding that the “sense of a shared commitment to improving the health of Coloradans is strong.” “It would be great to continue to identify opportunities for the Colorado School of Public Health to continue to be a leader both academically as well as in this messy world of program implementation,” she says. “We appreciate the opportunity to work together, grounded by a strong academic foundation. It really does feel like a community. I have reached out to Dr. Lindrooth, as well as other faculty and staff, when I am stuck on a policy problem or trying to get my head around a complex data question—the broad expertise of faculty, students, and alumni provides an ample pool of resources to draw upon.” — KB

10th Anniversary ColoradoSPH | 77

Improving the Safety of Our Food Building capacity to investigate & respond to foodborne outbreaks

t is sometimes difficult to find rays of hope in a public health crisis like a listeria outbreak in Colorado, until the outbreak is solved and contained through the joint efforts of local and national public health experts. In 2011, a bacterium contaminated cantaloupes grown on a farm in the southeastern part of the state and wreaked havoc, eventually killing 33 people and sickening about 150 others across the nation. It was the deadliest foodborne illness outbreak in the United States since 1924. The crisis helped to heighten awareness of the constant vigilance required to protect the food supply in the state and nation. Soon after the first reports of people falling ill and signs pointing to Colorado cantaloupe as the culprit, the Colorado Department of Public Health and Environment (CDPHE) began trying to understand how the cantaloupe became contaminated. CDPHE epidemiologist Alicia Cronquist turned to Elaine Scallan, PhD, associate professor in ColoradoSPH’s Department of Epidemiology at the CU Anschutz Medical Campus for help finding an expert in cantaloupe production. Scallan, in turn, reached out to Marisa Bunning, PhD, a food safety expert who is an associate professor for ColoradoSPH at Colorado State University (CSU) and in CSU’s College of Health and Human Nutrition. Then Bunning pulled in Mike Bartolo, a horticultural expert with CSU’s agriculture extension office in Rocky Ford, Colorado, the heart of cantaloupe country. The fundamental question: How could the outbreak have occurred? Bartolo provided a crash course covering cantaloupe production, including typical growing habitat, how growers pack and ship the fruit in Colorado, and other vital details. His agricultural expertise gave public health professionals a better understanding of the cantaloupe industry in Colorado.

78 | ColoradoSPH 10th Anniversary

“It was a moment in time when public health and epidemiology needed agricultural production information,” Bunning recalled. Eventually, the contamination was traced back to a farm in Holly, Colorado, where investigators found evidence that the melons likely were contaminated in the farm’s packing house because of dirty water on the floor and old, hard-to-clean equipment.

The Colorado Integrated Food Safety Center of Excellence

The call from the CDPHE did more than help with the Listeria outbreak investigation; it also laid the groundwork for the development of an important resource for Colorado and ColoradoSPH. In January 2011, President Barack Obama had signed into law the Food Safety Modernization Act. It created new rules to protect the nation’s food supply by directing states to build their capacity to respond quickly to foodborne illness outbreaks and develop preventive measures. In addition, the Centers for Disease Control and Prevention (CDC) announced its intention to form six regional Integrated Food Safety Centers of Excellence that would focus on improving food safety by increasing educational resources and providing additional public health training. In 2012, the Colorado Integrated Food Safety Center of Excellence (CoE)—a partnership between ColoradoSPH at CU Anschutz, CSU and the CDPHE—became one of the six CDC designees, with responsibility for an 11-state region running through the West from Montana to Texas. “As a land grant university, CSU could bring information about food production to the table,” Bunning said, in a format that could be readily accessible to public health professionals. Colorado was well situated to meet the requirements for a

CoE, Scallan added. First, the CDC wanted its safety centers to have partnerships between public health departments and academic centers—an ingredient ColoradoSPH and the University of Colorado Anschutz Medical Campus provide. Added to that, “The CDPHE has a strong reputation for responding to outbreaks, and CSU has long had a focus on food safety,” CoE co-director Scallan said. “We have a hotbed of people with expertise.” Education, professional support, and teamwork have been major pillars of the CoE mission since its inception. One early example: Bunning and Scallan worked with James Peth, a ColoradoSPH public health PhD candidate at CSU, who developed the Food Source Information Wiki, an interactive online site for public health professionals interested in learning how various foods are grown and produced, as well as researching reported disease outbreaks and food recalls. Peth earned the Colorado Public Health Association’s 2014 Award for Technical Innovation in Public Health for his Wiki work. The site continues to grow as students and experts from other regions contribute new articles to the site for food groups from other regions, like shellfish, peanuts, and citrus fruits, Bunning said. For students, the CoE emphasizes interactive education as an important supplement to didactic work. “Public health work is incredibly practice-based,” said Rachel Jervis, MPH, an epidemiologist with CDPHE and co-director of the CoE. “You can’t learn everything in the classroom.” To address that, the CoE runs annual outbreak response training exercises on the CSU and CU Anschutz campuses. ColoradoSPH students get a scenario based on a real-life foodborne illness outbreak, then work with partners to respond to it, including conducting interviews with

collaboration collaboration

“

Public health work is incredibly practice-based. You can’t learn everything in the classroom. — Rachel Jervis

10th Anniversary ColoradoSPH | 79

Elaine Scallan

other students playing the roles of people being interviewed as part of the outbreak response. The case interview training was very important, said Leslee Warren, MPH, a ColoradoSPH graduate who is now an epidemiologist with the Tri-County Health Department (serving Adams, Arapahoe and Douglas counties). “It was one of the most practical things I participated in,” Warren said. “One of the biggest challenges is being comfortable and being confident in asking questions.” An interviewer must often glean sensitive information, she explained, including health-protected details, demographics, and addresses. “You learn how to establish rapport and work through individual challenges with people. It’s hard to just jump into it,” Warren said. Students also get real-world experience during outbreaks, said Jervis, who ticked off recent examples of E. coli detected at a sandwich shop and salmonella found in ground beef. She sends out emails requesting students to work four-hour shifts for phone interviews and to sit in on conference calls with public health officials responding to the outbreak. Warren, who moved on to a stint as an interim epidemiologist with the CoE at CDPHE after working as a graduate student assistant, said the networking opportunities afforded by the CoE aided her career development. “Communicating and meeting with all aspects of public health—state, federal, and professional organizations—was invaluable,” she said. The CoE provides resources and support for established public health officials, many of whom work in sprawling rural areas. Tiffany Greenlee, MPH, for example, who graduated from the ColoradoSPH program at CSU, is the sole epidemiologist for the Wyoming Department of Health. The state covers close to 100,000 square miles but has fewer than

600,000 residents. Greenlee is responsible for all interviews for foodborne disease cases. On one occasion, CoE sent staff to Wyoming to help Greenlee train environmental health specialists on interviewing skills. She said she often calls on the CoE for help with questions about cases she encounters. “If I have an interesting outbreak I can call them and say, ‘Hey, have you encountered this before? What did you do? Are there any resources?’ They have been great at helping connect me with other peers.” Greenlee has also taken advantage of CoE’s “Live Learning Series,” which offers online courses using bi-directional video on a range of topics for public health officials in far-flung locales. One series she attended brought together representatives from several state health departments via the Colorado ECHO (Extension for Community Health Outcomes) platform and in collaboration with ColoradoSPH’s Rocky Mountain Public Health Training Center. The live learning series looked at what colleagues in other states do to investigate and respond to food-borne illness outbreaks, Greenlee said. “Since no two outbreaks are the same, this training was beneficial for me because I learned how other states approach outbreak investigation through applicable examples and made connections with them for the future.” Scallan said such opportunities are one example of how “people working on food-borne illness are more connected now. Six years ago, someone in a public health department looking for resources didn’t find a lot out there.” The connections continue to grow, she added. “We have the capacity and infrastructure to do more,” she said, pointing to work the CoE is doing with colleagues on the CSU campus to better understand how veterinarians are using antibiotics in animals and how we can work together to mitigate the rise of antimicrobial resistant pathogen— an important threat to human health. Jervis said the CoE is also working to strengthen ties between epidemiologists and laboratory professionals who are interested in using whole genome sequencing technology to more precisely identify how outbreak-causing bacteria are related. For her part, Warren credits ColoradoSPH and the CoE for building her confidence to move forward into these and other new areas of learning. “The CoE provided unique training and opportunities for me to hone my skills,” she said. “It was hands down the best foundation for me as a brand-new public health professional.” — TS

80 | ColoradoSPH 10th Anniversary

collaboration

Constant vigilance [is] required to protect the food supply in the state & nation.

10th Anniversary ColoradoSPH | 81

Crunching the Numbers The value of evaluation in public health initiatives

ot many people can say they are doing exactly what they want in their career. Ashley Brooks-Russell however, is. “I have my dream job,” she admitted. “I’m very fortunate to say that.” Brooks-Russell, PhD, MPH, who is an assistant professor in ColoradoSPH’s Department of Community and Behavioral Health, attended Eaglecrest High School in Centennial, Colorado, and went on to Case Western Reserve University in Ohio where she earned her bachelor’s degree in Anthropology and Master in Public Health degree. She also holds a PhD from the University of North Carolina and did two years of post-doctoral work at the National Institutes of Health in Bethesda, Maryland. When the opportunity to come back to Colorado arose, Brooks-Russell jumped at it. She started her “dream job” at ColoradoSPH in January 2014, where she has been able to combine her passion for both teaching and conducting research. “I would be lying if I didn’t say part of it was the appeal of coming home, just how much I love Denver and Colorado,” she acknowledged. “But I also knew that my ideal academic home would be a school of public health. There’s a lot of activity, synergy, and collaboration in this world. We just have such a rich research environment across so many topics with all these different departments doing public health research.” She also notes that one of her former professors at the University of North Carolina, Carol Runyan, PhD, is

82 | ColoradoSPH 10th Anniversary

now a professor of epidemiology at ColoradoSPH, and helped lead the hiring process and ultimately recruited her ex-student. Brooks-Russell says she was very excited to work with Runyan and be part of a growing team of injury researchers. Brooks-Russell currently teaches three courses at ColoradoSPH—Intimate Partner Violence, Adolescent Health, and Methods in Research and Evaluation— but spends the bulk of her time doing research on major initiatives for the Colorado Department of Public Health and Environment (CDPHE). Current and recent projects include marijuana messaging and evaluation of the state’s Good to Know campaign; as well as the department’s Healthy Kids Colorado Survey.

Good to Know

The “Good to Know” campaign launched in early 2015, one year after the start of legal marijuana retail sales in Colorado. Brooks-Russell has been conducting research and evaluating results of the Good to Know campaign since its inception and also did pre-testing in the fall of 2014 before the inaugural survey. During that time, the CDPHE was tasked with creating statewide campaigns via TV, radio, billboards, and other mediums to educate Coloradans about safe, legal, and responsible marijuana use. Brooks-Russell along with ColoradoSPH colleagues including Sheana Bull, PhD, MPH, Arnold Levinson, PhD, and Elizabeth Brooks, PhD, surveyed roughly 1,000 Colorado adults before and after the ads went live to see

how their knowledge of marijuana laws had changed, as well as their perception of risk and personal use. The sixth and final survey of the Good to Know campaign wrapped up in June 2018. Overall, Brooks-Russell is pleased with the outcome of the project and feels it’s essential for public health practitioners to take an interest in evaluating interventions. “If you spend millions of dollars on an ad campaign for example, you want to know if it affected people’s beliefs or behaviors,” she explained. “I really applaud the health department for partnering with the school and experts here to evaluate their efforts. I take away a reinforced view that evaluation is really critical. We can’t learn how to do things better if we don’t know if it works or not.” Brooks-Russell says it’s also important to have realistic expectations for what a campaign like this can do. We live in this world (public health) where we do small doses of things for a large number of people,” she said. “A little change for a lot of people is still a big change, but it’s an equation we always have to keep our eye on.” Ali Maffey, program manager for the CDPHE’s Retail Marijuana Education Program, has contracted with BrooksRussell to oversee their program evaluation. In addition, the women were formerly on the state’s Marijuana Education Oversight Committee together, and both currently sit on the Healthy Kids Colorado Survey Steering Committee. Maffey has nothing but high praise

2.5x

research

Of those who were surveyed and said that they saw the campaign ads, they reported they were 2.5 times as likely to now know the laws around marijuana use in Colorado.

“

for Brooks-Russell and admires her dedication and determination. “Ashley is so passionate about social impact research and problem solving,” said Maffey. “I have always known she is passionate in helping our programs access the data we need to ask and answer important questions about public health in this state. (She is)

...it is so rewarding to work with a team that is passionate about the work we are doing and the public health solutions we are creating. — Ashley Brooks-Russell

Ashley Brooks-Russell

even keel, not easily flustered, passionate about problem-solving, supportive, adaptable, kind, and wicked smart.”

Healthy Kids Colorado Survey

As for the survey, the CDPHE contracts with Brooks-Russell and her team in the school’s Community Epidemiology and Program Evaluation Group to understand the behaviors of Colorado youth and what factors support them to make healthy choices. She’s worked on both the 2015 and 2017 surveys, taking over as the principal investigator last year. A lot goes into conducting these surveys, says Brooks-Russell, including recruiting schools, working out logistics, distributing materials, and scanning, cleaning,

and analyzing the data. Around 80,000 students across the state participate in the voluntary, anonymous survey. It’s administered every other year, from September through early January, and results are typically available within the same school year. Working on the Healthy Kids Colorado Survey allows BrooksRussell to keep her finger on the pulse of what’s happening with teens in Colorado, especially as it relates to e-cigarettes and marijuana use. “We’re ahead of the curve and have added questions that perhaps no other state is asking because of legalized marijuana. It’s fun to be at the vanguard of how the change in policy is affecting youth.” Up next, Brooks-Russell is spearheading an observational study on the effects of marijuana-impaired driving. It kicked off in June and she hopes to be finished with data collection by the end of 2019. “I just can’t wait to find out the answers to all these questions,” BrooksRussell said. “I’ve been fortunate to work with very dedicated, hard-working staff, and when you have this dream of what you can do in a grant proposal or a contract, it is so rewarding to work with a team that is passionate about the work we are doing and the public health solutions we are creating.” With projects like the Good to Know campaign and the Healthy Kids Colorado Survey in her portfolio—and new ones on the horizon—Brooks-Russell is certainly making a name for herself in the public health sector. And she’s not slowing down anytime soon. — VH

10th Anniversary ColoradoSPH | 83

Charting a Path of Purpose ColoradoSPH’s first MPH graduate at CSU

his year, the Colorado School of Public Health has more than 600 graduate students with an alumni base of more than 2,000, most of whom reside in Colorado. When Ben White enrolled in 2008, he was one of four in the school’s first cohort in the MPH program at Colorado State University. A year and a half later he earned his MPH and was the school’s first graduate at CSU. Some may think it’s a risk to enroll in a brand-new graduate program, preferring to take classes at a more established school with all the kinks ironed out. But the newness of ColoradoSPH was one of the things that appealed to White. “I think because I was new to public health and the school was new; I thought they might be more open to diverse backgrounds like mine. I was learning about public health at the same time the school was developing, so it seemed like a good fit,” White said. He first came to Colorado State University to pursue a graduate degree in anthropology after graduating from Wisconsin’s Marquette University, where

84 | ColoradoSPH 10th Anniversary

he majored in anthropology and minored in broadcasting communications. He had heard the Colorado School of Public Health was forming there and had an inkling that he would switch over. “Archaeology is definitely my first love, but I felt that my skills would be better suited to influencing the health of living people as opposed to analyzing deceased populations,” he explained. White initially wanted to pursue an interdisciplinary certificate in GIS (geospatial information science), which was offered at Colorado State University and which he also completed in conjunction with his MPH. So, with a partially completed degree in anthropology, he applied and got into the school of public health—and he never looked back. “I wanted to have a greater purpose,” he says of why he pursued an MPH. Back when White was taking classes, the ColoradoSPH staff and administrators wore many hats. Lorann Stallones, PhD, MPH, director of ColoradoSPH at Colorado State University, was his faculty advisor and instructor. “Ben was very enthusiastic, wildly creative, and really willing to help us with the launch [of the school] where we had to be innovative to make it work,” Stallones recalled.

His capstone project showcased his creativeness and willingness to be innovative. Not surprisingly, since White was in the first cohort of the school, the capstone project process was not well established at the time. He took it upon himself to forge ahead by cold calling and cold emailing numerous public health programs and officials in the surrounding area and basically asked them for an internship. Boulder County Public Health responded. He worked with a variety of departments during his time in Boulder, including the zoonotic team, the environmental health division, and communicable disease control. His capstone was a Knowledge, Attitudes, and Practices (KAP) survey for their mosquito control district, which is the unincorporated area in Boulder County. This experience and the people he worked with laid the groundwork for future employment. While Stallones was his advisor during his time at ColoradoSPH, White considers Ann Magennis, PhD, a now-retired CSU anthropology and public health professor, his mentor. She was his advisor as a graduate student in anthropology, and he also served as her teaching assistant. Magennis helped him through the transition to public health and, as a

alumni

professor in ColoradoSPH, she still advised him after he switched programs. They become close and, in fact, still keep in touch a decade later. Magennis said that knowing what she knew about White’s skills and interests, his switch to public health was the right move for him. “He and I talked about it a lot. Knowing his interest, at the time, in tracking infectious diseases and GIS, I thought the MPH was the right way to go for him. A PhD in anthropology would’ve taken 10 to 12 years, and he really wanted to get to work.” Immediately after graduation White diligently sent out resumes looking for meaningful full-time work while working part-time at the CSU Forestry Department. Within a couple of months, and based on the connections he’d made while completing his capstone project, Boulder County Public Health was able to offer him a part-time temporary job as a disease reporting technician. With his growing network within the field of public health, he learned about a long-term part-time position at the

Colorado Department of Public Health and Environment (CDPHE). He made the switch in August 2010 and soon became a full-time employee. At the CDPHE White has been fortunate enough to work in different departments focusing on a variety of different projects. He first worked as an emerging infections program epidemiologist, reviewing hospital charts and looking at the database of reportable conditions. He moved on from there to look at foodborne outbreak data and waterborne diseases. He also did some GIS and health communications work during the Ebola scare. “My role continued to expand over the years as [the CDPHE] utilized more of my skills,” White said. His wide-ranging responsibilities and exposure to different projects suited his learning style and career interests and helped him prepare for his current position as a GIS Health Analyst in CDPHE’s Center for Health and Environmental Data (CHED). At CHED, he consults with all divisions including the Divisions of Air Quality, Water Quality,

Prevention Services, Disease Control, and more. He maps health surveys and fluctuations in outbreaks, air quality, and health access. “Anything that has a spatial component, I map. I’m sort of a map and spatial data steward for the health department,” White explains. “I like the versatility of what I do. I like how every week it tends to be a new project. I’ve really expanded my skills and knowledge base of public health action.” White said the broad scope of classes he took at ColoradoSPH were “incredibly eye-opening” and taught him many of the skills that he still uses today in his job. He shares that what he learned in class has helped him in real life applications when he occasionally guest lectures at ColoradoSPH on both the CSU and CU Anschutz campuses. As for White’s future in the public health field, the options are endless. “I’m one of those people who doesn’t think of work as a linear trajectory,” he says. “I abide by the principles that I want to make a difference and feel like I’m helping people, and I want always to be learning.”

“

I wanted to have a greater purpose. — Ben White

Ben White

— JK

10th Anniversary ColoradoSPH | 85

education

Investing in Top Talent Frank Judson, MD

“

These public health leaders are working to transform the health of communities across Colorado and beyond... — Frank Judson

ith more than four decades of leadership in public health teaching, research and policy work, Franklyn Judson, MD, is deeply committed to advancing the field. After joining the University of Colorado in 1974, Judson served on the CU School of Medicine faculty for more than 30 years in the Division of Infectious Diseases in the Department of Medicine, as well as in the Department of Preventive Medicine and Biometrics (the predecessor program to the Colorado School of Public Health). He has been a professor at ColoradoSPH since its establishment a decade ago, and served as director of Denver Public Health for nearly 20 years. Throughout his career, Judson has demonstrated a passion for ensuring that bold ideas developed in academic and research environments are translated into public health practice, advancing the field and informing policy that impacts lives. In addition to investing his expertise and passion in ColoradoSPH, Dr. Judson has made philanthropic gifts to further accelerate progress. In 2017, he established the Franklyn N. Judson, MD, Endowed Fund for Impact on Public Health Policy. This fund provides flexible support to enhance strategic initiatives, address public health policy, and translate public health evidence into practice. “It is an honor to invest in the future successes of faculty and students at the Colorado School of Public Health,” said Judson. “These public health leaders are working to transform the health of communities across Colorado and beyond, and it is my hope that my contributions continue to move the field forward.”

Frank Judson

— CK

86 | ColoradoSPH 10th Anniversary

Dean Jonathan Samet Director of Communications Tonya Ewers Contributing Writers Chloe Bennion Kathleen Bohland Michael Booth Tonya Ewers Vanessa Hughes Courtney Keener Joelle Klein Katherine Phillips Tyler Smith Principal Designer Amanda Kujawa This magazine celebrates the first 10 years of the Colorado School of Public Health. We look forward to what is to come.

10th Anniversary ColoradoSPH | 87

coloradosph.ucdenver.edu

@ColoradoSPH

@Colorado.SPH