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NOVEMBER 2010
UCLA
PUBLIC HEALTH
A BROADER
VIEW OF HEALTH:
UCLA
Policies in All Sectors Make a Difference
School of
Public Health
Few see dental care as a core public health issue, but access and disparities concerns are great. Ron Andersen is among SPH faculty studying the issue.
Working with local investigators in one of the world’s poorest nations, Anne Rimoin is helping to build an infrastructure that didn’t exist previously.
Myralyn Nartey went to Ghana to play on the national women’s soccer team. Now she is pursuing a Ph.D. to help girls in Africa.
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UCLA
PUBLIC HEALTH
Gene Block, Ph.D. Chancellor
Linda Rosenstock, M.D., M.P.H. Dean,UCLA SchoolofPublicHealth
Sarah Anderson AssistantDeanforCommunications
John Sonego AssistantDeanforDevelopment andAlumniRelations
features
Dan Gordon EditorandWriter
Martha Widmann ArtDirector
E D I TO R I A L B OA R D Richard Ambrose, Ph.D. Professor,EnvironmentalHealthSciences
1
Roshan Bastani, Ph.D. Professor,HealthServices AssociateDeanforResearch
Thomas R. Belin, Ph.D. Professor,Biostatistics
Pamina Gorbach, Dr.P.H. AssociateProfessor,Epidemiology
F. A. Hagigi, Dr.P.H., M.B.A. Professor,HealthServices
Moira Inkelas, Ph.D. AssistantProfessor,HealthServices
Richard Jackson, M.D., M.P.H. ProfessorandChair, EnvironmentalHealthSciences
Michael Prelip, D.P.A. AssociateProfessor, CommunityHealthSciences
Andrew Tsui and Tarah Griep Co-Presidents,PublicHealthStudentAssociation
Christopher Mardesich, J.D., M.P.H. ’98
UCLA
President,AlumniAssociation
School of
Public Health
4 8
WISDOM ON TEETH: A Growing Focus on ANNE RIMOIN: Dental Care Needs Bringing Poor oral health has been called a “silent Emerging epidemic,” with disparities and access problems calling for more attention from public health. Diseases Above the Radar She is working with the Congolese to build a disease surveillance system that has already revealed the surprisingly dramatic growth of human monkeypox.
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A BROADER VIEW OF HEALTH: Policies in All Sectors Make a Difference
HIGHER EDUCATION: New Strategies for Promoting Health
in every issue 23 RESEARCH Monkeypox rising in Africa…children not getting dental care…insurance inequities for same-sex couples…dangerous nanoparticles…home kitchens not making grade…centralized health care fares well.
10 As momentum builds for considering the public health effects of decisions outside health’s traditional purview, SPH faculty are leading the way.
:
28 STUDENTS
16
30 FACULTY
With the one-size-fits-all approach a distant memory, efforts to change health behaviors are relying on better-targeted messages delivered in proactive and innovative ways.
32 NEWS BRIEFS
ON THE COVER A broader view of health takes into account that policies in a wide variety of sectors can directly or indirectly influence the health of populations. Matt LeBarre © 2010
PHOTOGRAPHY Reed Hutchinson / Cover: Nartey; pp. 28-29 Sandra Shagat, UCLA School of Dentistry / TOC: dentistry; p. 6 Todd Cheney, ASUCLA / p. 7: Westwood Predoctoral Dental Clinic J. Rose Photography by Jessica Williams / p. 7: toothbrush learning station Matt LeBarre / Cover: Broader View; TOC: Broader View; pp. 11-12, 14-15 Shoshee Jau, Daily Bruin / p. 32 Courtesy of Anne Rimoin / Cover: Rimoin; TOC: Faculty Profile; pp. 8, 23 Courtesy of Beatriz Solis / p.16: Solis Courtesy of Philip Massey / pp. 16-17 Courtesy of David Gere / TOC: Higher Education; pp. 18-19 Courtesy of Antronette Yancey / p. 20 Courtesy of Roshan Bastani / p. 21 Courtesy of UCLA School of Public Health / Cover: Andersen; TOC: Dentistry; p. 2; p. 4: Andersen; pp. 5-6; p. 7: dentist cleaning teeth; p. 10: Fielding; p. 11: Guerrero; p. 12: Jackson; p. 19: Yancey; pp. 31, 33; back cover iStockphoto © 2010 / Cover; p. 4: teeth; p. 22; pp. 25-26
School of Public Health Home Page: www.ph.ucla.edu E-mail for Application Requests: info@ph.ucla.edu UCLA Public Health Magazine is published by the UCLA School of Public Health for the alumni, faculty, students, staff and friends of the school. Copyright 2010 by The Regents of the University of California. Permission to reprint any portion must be obtained from the editor. Contact Editor, UCLA Public Health Magazine, Box 951772, Los Angeles, CA 90095-1772. Phone: (310) 825-6381.
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dean’s message PUBLIC HEALTH HAS LONG ESPOUSED the role of many factors – such as education, housing, employment and the environment – contributing to overall health status. There is a growing movement to take this broader view of health into all aspects of society. As a result, with leadership from several faculty members at our school, there is a push for policy and decision-makers to utilize the Health Impact Assessment (HIA) when making decisions in any sector. Our cover story takes a look at this innovative approach and how, in addition to our faculty, our students and alumni are working to encourage the use of HIA to evaluate objectively the potential health effects of a project (e.g., a light rail system) or policy (e.g., curbing diesel emissions) before it is built or implemented. They are applying one of the tenets of public health – prevention – not just to individual and community health, but to the policymaking process. We are also taking a broader view when it comes to global health. In addition to activities at the school, faculty and students in a number of UCLA schools and colleges are participating in active global health programs. Crosscampus collaborations in global health are emerging, representing a new frontier of academic opportunity. In order to capitalize on this opportunity the campus is launching a UCLA-wide Global Health Initiative; I have been asked to chair the steering committee. To support the campus-wide effort, in which I expect our school to play a central role, and to further implement one of our school’s strategic goals to build a world-class global health presence, I am pleased to announce the appointment of Dr. Onyebuchi Arah, associate professor in the Department of Epidemiology, as the first associate dean for global health. You can read more about Dr. Arah’s appointment on page 33. Finally, I’m pleased to share that we have an exciting year ahead of us. In 2011, the School of Public Health celebrates its 50th. We plan to spend the year celebrating our past, present and future. Many of us have a vague recollection of what life was like in the early 1960s, and for those who don’t, the TV show Mad Men reminds us of a few
UCLAPUBLIC HEALTH
critical changes we’ve seen since the school was founded in 1961. Long gone
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3 2009-10 DEAN’S A DV I S O RY B OA R D
at the 50th Anniversary Gala, or simply provide your updated information for
Ira R. Alpert * Lester Breslow Sanford R. Climan Edward A. Dauer Deborah Kazenelson Deane* Michele DiLorenzo Samuel Downing* Robert J. Drabkin Gerald Factor (Vice Chair) Jonathan Fielding Dean Hansell (Chair) Cindy Harrell Horn Stephen W. Kahane * Carolyn Katzin * Carolbeth Korn * Jacqueline B. Kosecoff Kenneth E. Lee * Edward J. O’Neill * Thomas Priselac Monica Salinas Fred W. Wasserman * Pamela K. Wasserman * Thomas Weinberger Cynthia Sikes Yorkin
the alumni directory, let us hear from you this year. You are the reason for our
*SPH Alumni
are the days of the three-martini lunch, smoke-filled office and advertising campaigns to convince smokers to keep on puffing. Fifty years ago cars were not required to have seat belts and the notion of a child restraint system was your mother’s arm flung across your chest. It would be 20 years until the first positive case of HIV/AIDS in the United States was reported to the Centers for Disease Control. It was into this environment that the UCLA School of Public Health was born. As part of an institution consistently rated among the top schools of public health in the country, our faculty, students and alumni have led the way in improving the quality of life and longevity for people across the globe. I would like to personally invite all of you – our alumni, friends, faculty, staff and students – to join us in celebrating the enormous contribution we have made, as well as our potential for even greater contributions in the years ahead. Whether you join us online for our new webinar series (see page 32), join us
success, and the key to our ability to continue to make a difference in the health of populations locally and globally. Thank you for being part of something great.
Linda Rosenstock, M.D., M.P.H. Dean
TOTAL REVENUES Grants and Contracts State-Generated Funds Gifts and Other Fiscal Year 09-10 $70.5 million
UCLAPUBLIC HEALTH
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4
P OOR
ORAL
HEALTH HAS BEEN CALLED A
“ SILENT
EPIDEMIC ,” WITH DISPARITIES AND ACCESS PROBLEMS CALLING FOR MORE ATTENTION FROM PUBLIC HEALTH .
WISDOM ON TEETH: A Growing Focus on Dental Care Needs Fewpublichealthissueshave
received
more attention in recent years than lack of access to essential medical services and its disproportionate effect on certain population groups. Meanwhile, a paral-
“Oralhealth issuesfitso closelywith publichealth’s mission,and throughefforts aimedatprevention,educationand addressingaccessissues,wehave thepotentialtogetmoreinreturn fromourinvestmentthanfrom manyotherinvestments.” UCLAPUBLIC HEALTH
—Dr.RonaldAndersen
lel issue has gone relatively unnoticed. “Access problems appear to be considerably greater with respect to oral health services than general health services, and the disparities by income and minority s tatus are probably larger,” says Dr. Ronald Andersen, professor of health services at the UCLA School of Public Health. “But because dental care isn’t associated with saving lives, it hasn’t been emphasized in public health to the extent that it should be.” Overall, oral health has improved dramatically in the United States over the last half-century, thanks in part to public health efforts such as fl uoridation of drinking water and education about the benefits of fluoride toothpaste. It wasn’t long ago that the majority of Americans lost their teeth by middle age; today, most can expect to retain their natural teeth over their lifetimes. But there is significant cause for concern. A decade ago, in the first-ever Surgeon General’s report on oral health, Dr. David Satcher pointed to a “silent epide mic” of dental and oral diseases with “profound disparities that affect those without the knowledge or resources to achieve good oral care.” In addition, although dental care might not seem as critical as medical care, poor oral health can cause significant problems…and can be related to health ailments outside
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The problem of disparities in utilization of dental services – particularly among children – is underscored by a recent study conducted by Dr. Nadereh Pourat, professor of health services and director of research for the Center for Health Policy Research, which is based in the school. Using data from the 2005 California Health Interview Survey, Pourat found that nearly 25 percent of California children ages 11 and under had never seen a dentist, and that among those who had, there were significant differences by race, ethnicity and type of insurance in the amount of time between dental care visits (see page 24). Having any kind of insurance significantly increased the odds that a child would see a dentist on a regular basis, but the type of coverage mattered: 54 percent of privately insured children had seen a dentist within the previous six months, vs. 27 percent of publicly insured children (Medicaid or the Children’s Health Insurance Program) and 12
“Publicprograms aredesignedto improveaccess tocarefor underserved populations, andourstudy showsthatthey aresuccessful indoingso. However, theydon’tclose thegap.” —Dr.NaderehPourat
UCLAPUBLIC HEALTH
Dental public health issues haven’t been ignored at UCLA, where faculty in the School of Public Health and School of Dentistry have worked – often together – to address some of the major concerns. One of the key efforts began in 2001 when The Robert Wood Johnson Foundation provided funding for a national demonstration program aiming to reduce dental-care access disparities. Fifteen dental schools were selected to participate in the Dental Pipeline Program, which would receive additional fu nding from The California Endowment. The program’s national evaluation team was based in the UCLA School of Public Health, with Andersen as the principal investigator and Dr. Pamela Davidson, associate professor of health services at the school, as co-principal investigator. (The original project ended in 2007, but a follow-up study to measure its sustainability is ongoing.) The pipeline program was est ablished in an effort to increase access to dental care in low-income and minority communities by recruiting more students from underrepresented minority groups to dental schools, improving dental school curricula to better prepare students to provide culturally competent care, and providing more clinical practice experiences for students in underserved communities. “If you look at the ethnicity o f dentists compared to the distribution of the population, there are greater differences than in medicine,” Andersen notes. That
5 has contributed in part to the shortage of oral health providers in minority communities, he says. Dental schools have faced significant challenges in their efforts to recruit minority students into dental careers, Andersen notes. For one, the shortage of providers in minority communities means there are few family members or friends serving as role models and mentors. Nonetheless, through steppedup ef forts, including the establishment of pre-dental programs to assist students in meeting prerequisites, the pipeline program schools increased applications from underrepresented minority students by 77 percent from 2003 to 2007, while enrollment of underrepresented minority students increased by 27 percent. Beyond the effort to increase the number of minority dental providers, the pipeline program sought to revamp education and training experiences that would make all students more likely to consider careers in public health and service to underserved communities. While curricula were revised and the number of days senior dental students practiced in underserved communities increased, it’s unclear whether there was a corresponding increase in graduates going on to practice in these communities. Unfortu nately, Andersen notes, dental students tend to enter practice with huge debts; thus, many who want to go into public service positions are deterred by the lower salaries and instead feel compelled to opt for private practice.
feature
the mouth. Untreated, tooth decay (cavities) – the most common chronic disease in children – can cause everything from pain and difficulty eating to lost school and work time. Serious oral disorders can undermine self-esteem, inhibiting children and adults from smiling. Gum disease has recently been linked in studies to increased risk for diabetes, heart disease and stroke. And while much attention has been paid to the proble m of lack of health insurance, the fact that even more are without dental coverage is often overlooked. Although public insurance programs such as Medicaid have increased coverage for children, dental benefits tend to be vulnerable to cuts in tough economic times. By the same token, for many low-income families struggling financially and, in some cases, lacking education about the importance of regular dental visits, dental care may be viewed as optional. “Oral health issues fit so closely with public health’s mission,” observes Andersen, “and through efforts aimed at prevention, education and addressing access issues, we have the potential to get more in return from our investment than from many other investments.”
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6
UCLAPUBLIC HEALTH
An analysis of children who suffer the most from dental disease suggests it’s not only children from low-income families and underserved minority groups, but also those from families with what is referred to as low oral health literacy.
percent of children without any coverage. Even when taking into account only those with public insurance coverage, though, the study found that Latino and African-American children went to the dentist significantly less often than white and Asian-American children. “Public programs are designed to improve access to care for underserved populations, and our study shows that they are successful in doing so,” Pourat says. “However, they don’t close the gap. There is more work to do in addressing disparities in dental care for children.” Pourat suspects a key factor in the persistence of these disparities is that public insurance programs reimburse dentists at a lower level than private insurance. Unlike medical care, in which managed care and group practices encourage more providers to see patients in p ublic programs, dental care is dominated by solo practitioners in private offices – many of whom don’t see patients with public insurance. A study conducted by Pourat and colleagues in 2003 found that only about 40 percent of California dentists accepted public-insurance patients. Coupled with the general shortage of providers in low-income communities, this has posed a major barrier, and may be the reason many families choose to forgo care. Pourat has begun a new study, funded by the National Institute of Dental and Craniofacial Research, to examine the impact of the local supply of oral health providers on access to care. Addressing reimbursement inequities is one of several potential solutions that Pourat and others have proposed. Another is to strengthen the safety-
net system by broadening the types of dental providers – including preparing other licensed professionals, such as hygienists, who can deliver primary pediatric dental care. Pourat notes that many general dentists are uncomfortable delivering care to very young children, an issue that could be addressed in dental school training with more clinical experiences involving young patients. Pourat believes mo re education is needed for all families about the importance of dental visits and preventive oral health care in childhood. “Many parents figure it’s not that important because their children are going to lose their primary teeth anyway,” she says. “But the reality is that when you have a poor oral health environment, the problems are likely to continue when the secondary teeth come in. Teaching chil dren good oral hygiene can have a major impact on their oral health as adults.” An analysis of children who suffer the most from dental disease suggests it’s not only children from low-income families and underserved minority groups, but also those from families with what is referred to as low oral health literacy, says Dr. James Crall, professor and chair of pediatric dentistry in the UCLA School of Den tistry and a faculty member in the UCLA Center for Healthier Children, Families and Communities, based in the School of Public Health. “There are issues of culture, language, nutrition and use of health services that are amenable to public health as well as primary care approaches,” he explains. Crall has been a leader in dental public health for more than a decade. In 1997 he was appointed the first de ntal scholar-in-residence at the Agency for
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Health Care Policy and Research and he has been actively involved in national, state and professional oral health policy development ever since. From 2000 to 2008 he was director of the Health Resources and Services Administration/ Maternal and Child Health Bureau National Oral Health Policy Center, colocated within the Center for Healthier Children, Families and Communities. Crall also directs a pe diatric dentistry leadership training program in collaboration with other members of the center’s faculty. Since 2007 he has been project director of the American Academy of Pediatric Dentistry’s Head Start Dental Home Initiative, which is building networks of providers in every state to improve access to dental services for children in Head Start programs. Crall, who was part of Andersen’s national evaluation team for the Dental Pipeline Program, believes public health efforts to address the current challenges in oral health require a combination of innovative training initiatives and community programs, along with policies that effect change in the practice environment, such as increased reimbursement and other incentives to work with underserved populations. The subspecialty area of dental pu blic health is small, Crall notes; it will take more than dentists to make a difference. “We need to encourage more dentists to go into public health, but we also must find ways to foster collaborations with non-dentists in public health and medicine,” he says. “That’s now occurring at UCLA in a way that we haven’t seen before, and it’s a goal that has gained increasing recognition at the national l evel.”
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feature
M.P.H. Degree Informs Her Effort to Organize American Indian Dentists
Ruth Bol, D.D.S. M.P.H. ’09 UCLAPUBLIC HEALTH
Nowhere are oral health problems more severe than among American Indians. The last survey by the Indian Health Service (IHS), published in 1999, found that 87 percent of American Indian children ages 6-14 and 91 percent of 15-19 year olds had a history of tooth decay. Seventy-eight percent of adults ages 35-44 and 98 percent of those 55 and older had lost at least one tooth because of dental decay, gum disease or oral trauma. Dr. Ruth Bol (M.P.H. ’09), a pediatric dentist in private practice in Menifee, Calif., who is herself American Indian, is drawing on her UCLA School of Public Health education to organize American Indian dentists in response to the problem. Bol worked four years with the IHS (part of the U.S. Public Health Service) and became frustrated with the lack of leadership, which she believed had much to do with the scarcity of American Indians among the dentists practicing on the reservations. So she worked her way up the ranks of the Society of American Indian Dentists (Bol is currently vice president), was elected to the California Dental Association board of directors and became active in the American Dental Association. Realizing the value a public health education could bring, Bol enrolled at UCLA for both her pediatric dentistry residency and M.P.H. from the School of Public Health. With a grant she wrote in one of her School of Public Health courses, Bol secured funding from Delta Dental of California to support the Society of American Indian Dentists’ efforts to mentor American Indians before, during and after dental school. She is currently meeting with other potential funders. “The more I got involved with these big-picture issues, the more I realized there was a lot I didn’t know,” Bol says. “Getting the M.P.H. has given me credibility as well as knowledge on everything from developing and evaluating programs to writing grants. It’s provided me with the tools to work with underserved communities.”
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8 S HE
IS
WORKING WITH THE
C ONGOLESE TO BUILD A DISEASE
SURVEILLANCE SYSTEM THAT HAS ALREADY REVEALED THE SURPRISINGLY DRAMATIC GROWTH OF HUMAN MONKEYPOX .
ANNE RIMOIN:
Bringing Emerging Diseases Above the Radar Althoughherspecificfocusis studying the epidemiology of human
monkeypox in the Democratic Republic of the Congo (DRC), Dr. Anne Rimoin also has an eye on the bigger picture: working with the Congolese government and local investigators to develop an infrastructure that will enable the Central African nation to conduct proper surveillance of all emerging infectious diseases. “To me, if you’re a researcher working in a low-resource setting, you have a moral obligation not just to collect your data and leave, but to build capacity and collaborate with the people who, by their good graces,
UCLAPUBLIC HEALTH
are allowing you to do this work in their country,” she says. Over the last six years, Rimoin, assistant professor of epidemiology at the school, has established a research site in central DRC that now serves as headquarters for a variety of studies of cross-species transmission of disease. Heading an all-Congolese team, Rimoin collaborates closely with the DRC Ministry of Health, the Kinshasa School of Public Health and the National Laboratory to improve disease surveillance capacity in a nation that is one of the world’s poorest, and has been devastated by civil war. “There is a long way to go – what we’ve done so far represents just a drop in the bucket – but I’m pleased just to be able to contribute as I can,” Rimoin says. Already, though, Rimoin and her Congolese collaborators have produced tangible evidence of the critical nature of building a disease surveillance infrastructure. In August, they published the first results of their human monkeypox study in the Proceedings of the National Academy of Science, showing that rates of the disease had increased by an astounding 20-fold in the DRC since 1980.
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Ever since, Rimoin and her team have been training local health workers in identifying and reporting cases as well as interviewing monkeypox patients to learn about their potential exposures. The workers collect biological samples that are transported to the project’s field station and then to Kinshasa, as well as to collaborators in the United States who conduct laboratory analyses and report back to the Congolese field workers. One reason the DRC was in such dire need of a disease surveillance program is that there are tremendous logistical challenges to implementing one. From the beginning, Rimoin’s team has faced problems such as how to collect and preserve biological specimens in settings that often lacked electricity, running water and refrigeration sources. A country of 900,000 square kilometers has only about 300 kilometers worth of roads. Given the expense of gasoline and the DRC’s scarce economic resources, cost is never far from Rimoin’s mind. “Our supervisors have motorcycles, but for day-to-day surveillance we give our health care workers bicycles so they can take supplies from the headquarters to their village,” she says. “That can be as many as 200-300 kilometers away, but it’s a sustainable approach.” At the UCLA School of Public Health, where she has been a member of the faculty since 2004, Rimoin teaches her students the importance of working with local collaborators, understanding the socio-cultural and political context in which problems occur, and designing and implementing interventions that are practical and feasible, particularly in lowresource settings. “Emerging infectious diseases are definitely out there,” she says. “You just need to identify the populations at the highest risk and make sure you’re asking the right questions or you’re going to miss important events that signal the early emergence of a disease.” Rimoin, who spends roughly a third of her time working in the field in the DRC, is committed to being there for the long haul. “My goal is sustainable research,” she says. “I am fully invested in my work in the DRC and intend to have a long relationship with my Congolese collaborators.”
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“Itmade sensetome thatgiven thelackof infrastructure andabsence ofdisease surveillance, iftherewere anysignificant reportsof monkeypox outthereit waslikelya muchbigger problemthan anyonewas anticipating.” —Dr.AnneRimoin
UCLAPUBLIC HEALTH
Growing up in Los Angeles, Rimoin always had positive associations with Africa. In a home adorned with African art, her father would recall fondly his research experiences working with a Pygmy population in the Central African Republic. At Middlebury College in Vermont, Rimoin earned her undergraduate degree in African History. It was only after graduating and going into the Peace Corps that she became interested in science, and particularly epidemiology. In Benin, West Africa, Rimoin spent two years as a volunteer coordinator for the guinea worm eradication effort. “It was a perfect public health program that taught me to do disease surveillance,” she says. “It really brought home the importance of using basic epidemiologic methods to solve a problem.” Upon completing the program, Rimoin enrolled at the UCLA School of Public Health, where she received her M.P.H. in 1996. For her internship she worked in Nepal doing disease surveillance for the World Health Organization’s polio eradication program. Rimoin was then hired by the WHO as a logistics officer, assisting in the expanded polio surveillance and eradication program in Ethiopia and Eretria. She also initiated a collaborative relationship between the WHO and the Peace Corps, including development of a program and training materials for health-oriented Peace Corps volunteers to carry out disease surveillance activities in Africa and Nepal. After completing her Ph.D. at the Johns Hopkins Bloomberg School of Public Health in 2003, Rimoin worked as a program scientist for the National Institute of Child Health and Human Development, coordinating clinical studies in Africa. While at a meeting at the DRC Ministry of Health, she was part of a discussion in which it was noted that there had been an increase in reported cases of human
monkeypox in the country. Rimoin’s interest was piqued. “It made sense to me that given the lack of infrastructure and absence of disease surveillance, if there were any significant reports of monkeypox out there it was likely a much bigger problem than anyone was anticipating,” she says. Rimoin promptly proposed to head the first epidemiologic study assessing the burden of human monkeypox in DRC, and received funding to begin setting up her program in 2004.
faculty profile
Ironically, Rimoin’s group noted, one of public health’s greatest success stories opened the door for the dramatic increase. The eradication of smallpox, announced in 1980, spelled the end of a vaccination program that had also provided protective immunity against monkeypox, a related virus believed to be carried primarily by squirrels and other rodents. (Although generally less lethal than smallpox, monkeypox can cause serious symptoms, including severe eruptions on the skin, fever, headaches, swollen lymph nodes and, in some cases, blindness and death.) Particularly in rural areas, where displaced populations rely to a greater extent on bushmeat, the growing number of unvaccinated individuals over time led to a gradual increase in the rate of infection. But in the absence of any surveillance, Rimoin notes, monkeypox “fell under the radar.” (For more on the study, see page 23.)
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10
A
BROADER Policies in All Sectors Make a Difference Althoughthedetailswere much debated during the AS
MOMENTUM
year-long politicking over health care reform, no one would disagree that there
BUILDS FOR
were major health implications to the bills under consideration – and ultimately
CONSIDERING THE PUBLIC HEALTH EFFECTS OF DECISIONS OUTSIDE HEALTH ’ S TRADITIONAL PURVIEW ,
SPH
FACULTY ARE
UCLAPUBLIC HEALTH
LEADING THE WAY.
to the law passed in Congress and signed by President Obama last March. But what about debates over alternative energy, agricultural subsidies, and even extending the Bush tax cuts? Few would ca ll these health issues…yet their potential impact on health is profound. Similarly, it might seem outside of health’s purview when municipalities consider mass-transit systems or major commercial developments – but whether an urban environment is conducive to safely walking and biking can go a long way toward determining the health of the local population. When public schools face massive budget reduct ions there is concern, rightfully, about the effects on education. But this, too, is a health issue: With physical education and other health-promoting school programs becoming vulnerable, those reductions ultimately affect obesity and children’s health. And formal education is a major determinant of longevity. Dr. Jonathan Fielding, professor of health services at the UCLA School of Public Health and director of the Los Angeles County Department of Public Health, is among the leaders of a growing movement to consider health impacts across a wider range of societal discussions – a movement known as Health in All Policies. “If you look at what determines health in populations, as well as disparities in health between communities, to a considerable extent it has to do with the social and physical en vironment – the societal underpinnings that are typically considered issues of economic development, education, transportation and housing, to name a few, but not health issues,” Fielding says. But Fielding concluded long ago that even prevention-oriented strategies by health departments to reduce health risk factors – though of great importance – fail to address major conditions that affect health in less-than-obvious ways. “We’ve gotten too used to segregating issues by sector,” he says. “We have to do a better job crossing over and working with people in other sectors to help them understand the effects of their decisions – whether it’s decisions on subsidizing high-fructose corn syrup production or decisions on how much is invested in the
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highway system as opposed to bikeable and walkable cities and mass transit-oriented development.” In the same way that Health in All Policies requires educating leaders in non-health agencies about the health consequences of decisions, it also calls for more broadly trained public health professionals, contends Dr. Richard Jackson, chair and professor of environmental health sciences at the school and, like Fielding, a national leader in promoting the Health in All Policies concept. “It’s clear that if you’re graduating from a school of public health, you should have at least a basic familiarity with issues such as housing, engineering and economics,” says Jackson, who has served as California’s state health officer and as director of the National Center for Environmental Health, part of the U.S. C enters for Disease Control and Prevention. With passage of health care reform earlier this year came tangible evidence that the voices of Fielding, Jackson and other public health leaders at UCLA and elsewhere are being heard when it comes to their argument that health impacts should be considered in a broader array of policy decisions. The law created the National Prevention, Health Promotion, and Pub lic Health Council, composed of top government officials, to elevate and coordinate
cover story
VIEW OF HEALTH:
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prevention activities and design a national prevention and health promotion strategy in conjunction with communities across the country. Chaired by the U.S. surgeon general, it includes the secretaries of Agriculture, Labor, Health and Human Services, Education, and Homeland Security; the administrator of the Environm ental Protection Agency; the chair of the Federal Trade Commission; and the director of the National Drug Control Policy, among others. The movement is catching on at the state and local levels as well. In California, the state health department has established a Health in All Policies Task Force as part of the governor’s Strategic Growth Council. In Los Angeles County, Fielding’s department conducted a health impact assessment outlining the potential benefits of a proposed restaurant nutritional menu-labeling law in addressing the obesity epidemic. The assessment is believed to have played a key role in the passage of California’s first-in-the-nation menu-labeling law in 2008, which in turn led to the inclusion of menu labeling in the federal health reform law.
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When public schools face budget reductions, it’s also a health issue: Physical education is jeopardized, and formal education is related to longevity.
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“Ifyoulook atwhat determineshealth inpopulations, toaconsiderable extentithas todowith thesocietal underpinnings thataretypically considered issuesof economic development, education, transportation andhousing, tonameafew, butnothealth issues.”
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—Dr.JonathanFielding
The idea of viewing health more broadly isn’t new – in fact, Fielding notes, in some ways Health in All Policies harkens back to an earlier time for the public health field. “You would see health effects of malnutrition, or of poor housing and inadequate sanitation, and the effects of investments in other sectors on health and health disparities were obvious,” he says. The United States fell behind other parts of the developed world – particularly Europe, which has used the health impact assessment (HIA) as a widespread policy-making tool for some time. But in the last decade, the concept has gained momentum – with the UCLA School of Public Health playing an important leadership role. Jackson, while serving as the director of CDC’s environmental health center in the late 1990s, was a mong the first to advocate for including assessment of health impact in major policy deliberations. He notes that since passage of the National Environmental Policy Act in 1969, major federal projects have required environmental impact assessments; at the state level, the California Environmental Quality Act passed the following year, requiring environmental impact reports for projects with potentially significant environmental effects. Although the environmental studies that take place as part of the state and federal mandates often give a nod toward health impacts, thorough public health assessments for proposed policies are rare. As a result, “you can have a significant project that’s outlining what will happen to endangered species but offering little analysis of what happens to children, old peop le, poor people and everyone
Transportation safety issues are also community health issues: Airports present potential noise and air quality concerns for the local population.
in between,” says Jackson, who is currently chairing an Institute of Medicine committee, “A Framework and Guidance for Health Impact Assessment,” on which Fielding also serves. Recent U.S. history is replete with examples of major undertakings that would have benefited from advance consideration of health impacts, Jackson says, starting with the Interstate Highway System, a n enormous expenditure undertaken by the federal government in the 1950s. “We know the built environment has major health impacts, from respiratory diseases and injuries to obesity and many other chronic diseases,” he says, “and yet transportation and other sister agencies are scarcely aware of them.” In 2001, Fielding brought together a group of UCLA School of Public Health faculty to begin a joint end eavor with the Washington, D.C.-based Partnership for Prevention. With support from the Robert Wood Johnson Foundation, the UCLA Health Impact Assessment Project aimed to assess the feasibility of HIAs and develop prototypes, applied to specific policies. Starting by evaluating the health impacts on the Los Angeles City Living Wage Ordinance, the group crossed traditional boundaries within public health as well as seeking out researchers in other fields. “With a lot of these issues, we don’t start with inherent expertise in the subject matter,” Fielding explains. “We need to partner with experts from other fields and use resources from other disciplines to determine how changes in different sectors positively or negatively affect health.” While the HIA tradition in Europe had emphasized bringing stak eholder communities into the process of decisions with potential health consequences, the UCLA team developed methods that are more quantitative. “We wanted to show through
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For the pediatric residents training at Ronald Reagan UCLA Medical Center, it was an unusual project – but one that reflects a recognition that social and environmental conditions are every bit as important to children’s health as what occurs in a clinical setting. In response to concerns from members of the community surrounding Santa Monica Airport, the 10 pediatric residents – part of the UCLA Community Health and
Community leaders meet with officials to discuss concerns about potential health impacts from Santa Monica Airport.
“Byhaving theresidents reviewthe scienceand engagewith thecommunity onanimportant healthconcern, weare encouraging themtothink outsidethe wallsof theclinic.” —Dr.AlmaGuerrero
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Advocacy Training (CHAT) program – conducted a health impact assessment (HIA) of the Santa Monica Airport to organize, analyze and summarize existing information on the potential health impacts of the airport’s activity related to three issues: air quality, noise and the lack of an airport buffer zone. “Pediatricians increasingly recognize that environmental health is actually closer to pediatrics than it is to adult medicine, and that we need to set environmental standards to protect kids because their exposures are much higher per pound of body weight than adults,” says Dr. Richard Jackson, chair and professor of environmental health sciences at the UCLA School of Public Health and a pediatrician who has specialized in the issue of children and environmental health. Jackson, who was brought in to teach part of the course, is also a longtime proponent of the need to assess proactively the impacts on health of transportation, construction, and other major decisions. The residents conducted what’s known as a rapid non-participatory HIA over two weeks last February. Their analysis was based on reviews of relevant scientific publications; regulations and guidance relevant to airport
planning and health; input from expert consultants; public comment and testimony; and participation in community forums and meetings. The group concluded, among other things, that there has been a rise in the number of jet plane operations in recent decades, potentially increasing the air and noise pollution exposure in the surrounding area. The report noted that the airport’s proximity to schools, daycare centers, parks and residential homes may pose certain health risks for children and families living in the nearby community. The HIA offered recommendations for mitigating the potentially adverse health impacts. Whether the recommendations are acted on remains to be seen, but the effort did not go unnoticed. “It had a huge political impact,” says Ping Ho (M.P.H. ’05), a Santa Monica resident who is a member of Concerned Residents Against Airport Pollution and Friends of Sunset Park Airport Committee, two grassroots groups that have lobbied the City of Santa Monica and airport officials on airport-related concerns. “They showed the community and our elected officials that the problem is of concern to front-line medical professionals, and their summary made it clear that there is sufficient science to justify the concerns of the community.” Drawing on her own education in the school’s M.P.H. for Health Professionals Program in Community Health Sciences, Ho has synthesized scientific studies and written briefings for the communitybased group. “Medical practitioners haven’t been very involved in HIAs to this point,” says Brian Cole (M.P.H. ’90, Dr.P.H. ’03), a researcher at the school who has been a leader in the HIA movement as part of the UCLA HIA Project, and who served as a consultant to the pediatric residents. “It was exciting to see that the pediatric training program recognized the importance of learning about some of the upstream determinants of health problems and using the HIA as a way of addressing that.” Dr. Alma Guerrero (M.P.H. ’08), an assistant clinical professor of pediatrics and CHAT program faculty member, believes the pediatric residents benefited as much as the community. “What we try to instill in the residents is the importance of thinking broadly about health,” she says. “The Santa Monica Airport is near where a lot of our patients live, and it’s easy to take it for granted. By having the residents review the science and engage with the community on an important health concern, we’re encouraging them to think outside the walls of the clinic in how they define their role as physicians.”
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Health Impact Assessment of Santa Monica Airport Teaches UCLA Pediatric Residents to Broaden View of Physician’s Role
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“Weknowthe builtenvironment hasmajorhealth impacts,from respiratory diseasesand injuriestoobesity andmanyother chronicdiseases, andyet transportation andothersister agenciesare scarcelyaware ofthem.”
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—Dr.RichardJackson
our HIAs that a more systematic approach would be a valuable tool in the policy process,” says Dr. Gerald Kominski, professor of health services at the school and a key member of the initial UCLA Health Impact Assessment Project team. “Our goal was to lay out the plausible downstream health effects of a variety of initiatives or laws that might be enacted, casting as broad a net as possible to show t hat virtually all public programs have potential health consequences.” The UCLA group also argued for bringing in an evidence base. “It’s a twostep process,” Kominski explains. “The first is analytical – mapping out the possible pathways by which a policy can affect health. But the second important step is to say whether there is scientific evidence showing that these plausible effects have been me asured. And the answer is that there is a lot of literature out there.” For an HIA of California’s Proposition 49, a successful 2002 ballot initiative to significantly expand state funding of after-school programs, the UCLA researchers found substantial evidence – in the education literature – that providing targeted after-school programs for at-risk children confers secondary health benefits, from incr eased physical activity and improved mental health to lower rates of substance abuse, teen pregnancy and sexually transmitted diseases. Unfortunately, notes Kominski, the initiative wasn’t designed to address the challenges facing these at-risk children. In recent years, one leader in the HIA movement at UCLA and nationally has been Brian Cole (M.P.H. ’90, Dr.P.H. ’03), a researcher in the school’s D epartment of Health Services who was hired as the team’s original project director while he was a doctoral student in the Department of Community Health Sciences. Cole has led the effort to create the HIA Clearinghouse Learning and Information Center (www.hiaguide.org). In addition to providing a single online location for all ongoing and completed HIAs in the United States, the clearinghouse provides links to research used to inform the HIAs and presents different methods for preparing an HIA. “One of our goals is to lower the bar, particularly for smaller agencies, so that they can do these more easily,” Cole explains. Meanwhile, Cole has continued to contract with municipalities and community groups to conduct HIAs. He recently served as a consultant on an HIA of the Santa Monica Airport done by a group of pediatric residents at UCLA’s David Geffen School of Medicine (see the sidebar on page 13). With funding from the
Agricultural policies can affect health by, for instance, subsidizing high-fructose corn syrup – and indirectly fueling the obesity epidemic.
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explains, the HIA as well as other tools can play a broader role by simply educating the public and policy-makers about the connections between decisions that are not primarily about health and their potential public health impacts. Indeed, notes Fielding, the HIA isn’t an end in itself. “The HIA is a tool for operationalizing and concretizing the Health in All Policies concept,” he says. “But it does nothing unless it’s coupled with efforts to use that information to educate those who are making policy about why they should pay more attention to the health impacts of decisions in other sectors.” Kominski points out that the Health in All Polic ies movement is based on a notion that has long been recognized in public health – and championed by UCLA School of Public Health faculty including Dr. Lester Breslow, dean emeritus of the school. “In public health we know that the medical care delivery system is just one determinant of the population’s health – an important component, but a relatively small one, especially when you consider the cost,” Kominski says. “There are also social determinants of health, and we are likely to reap much greater health improvements from investments in those areas than from additional medical care expenditures.” Fielding believes many outside of public health are beginning to come around to that point of view. “When we’re spending 50-100 percent more than our developed-country trading partners and doing worse i n terms of health, it becomes obvious that we can’t just work through the medical care system to improve health,” he says. “We won’t move from being 37th in the world in life expectancy until the determinants of health and health impacts of decisions become a focus of public policy at all levels.”
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Pew Charitable Trust, Cole and his UCLA School of Public Health colleagues are working to ensure that health concerns are addressed in the environmental impact report for the Wilshire Corridor Transit Alternatives – the so-called Subway-to-theSea proposed to be built on Los Angeles’ Westside. Beyond addressing health concerns, Cole says, the UCLA group is seeking to maximize potential health benefits from the development: how, for instance, the system might be able to tap into existing pedestrian and bicycle routes to encourage people to walk and bike more. In addition, with funding from Robert Wood Johnson Active Living Research, the UCLA group is conducting rapid HIAs around physical activity in schools. HIAs related to proposed developments – from a new shopping center to a new highway or subway system – are a natural fit, Cole explains, since they can be coupled with environmental impact assessments. But he and others have also been grappling with the more challenging but no-less-important type of HIA, ones attached to policies that don’t involved bricks-and-mortar projects. “The question is how we get people thinking about the upstream determinants of public health in labor, energy or agri cultural policies, for example,” Cole says. Much of the work of the UCLA HIA project has involved building the tools and evidence base for agencies to apply to these population-level HIAs. In 2008, Cole and Fielding co-wrote a white paper published by the Partnership for Prevention on how Congress and federal agencies could incorporate HIAs into large-scale policy-making (“Building Health Impact Assessm ent Capacity: A Strategy for Congress and Government Agencies”). Beyond the formal processes of analyzing the potential impacts of a project or policy, Cole
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Promoting decent, affordable housing reduces problems associated with allergens, increases community stability and improves mental health, to name a few.
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THE
ONE - SIZE - FITS - ALL APPROACH A DISTANT MEMORY, EFFORTS TO CHANGE HEALTH BEHAVIORS ARE RELYING ON BETTER - TARGETED MESSAGES DELIVERED IN PROACTIVE AND INNOVATIVE WAYS .
Higher Education: In the short video, a young couple has just returned late one evening from a party. Obviously inebriated, they are moving toward a sexual encounter. The scene ends and in the next shot it is morning. The camera zooms in on an unopened condom at the bedside, then shows the nowsober young man and young woman, appearing regretful as they reflect on a missed opportunity.
“There’s an appreciation that we need to challenge our traditional ways of thinking about how to do outreach to populations.” UCLAPUBLIC HEALTH
—Dr. Beatriz Solis
The frankness of the HIV-prevention message targeting youth audiences would be notable anywhere, but what’s particularly striking about this one is that it was produced by high school students for their peers – in the Republic of Senegal, a predominantly Muslim nation in western Africa. Shot using mobile digital technology, it is one of many artistically produced peer-to-peer health messages made widely available to youth in several Senegal high schools and beyond through a specially created website, www.sunukaddu.com (“our voices” in Wolof). The project, which has involved two members of the UCLA School of Public Health faculty and several of their students, is one of many examples, both inside and outside the school, of innovative new approaches to health education. The days of relying on staid, top-down, one-size-fits-all messages are long gone, replaced by more dynamic, interactive communications, delivered in carefully selected settings in ways that resonate with the target audience. It’s a time of opportunity for the field of health education, says Beatriz Solis (M.P.H. ’96, Ph.D. ’07), director of healthy communities for the south
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17 create messages through dramatic video, song, poetry and journalistic approaches. Although the major focus was on issues around HIV (including prevention, testing and stigmatization), students were also able to bring in their own health-related topics. In addition to being posted on the website, the student-created content was entered into a contest in which peers and professional artists serving as judges voted on the winners, which became part of a national campaign. In the urban center of Dakar, the adoption of new media technologies has been rapid. A post-study survey conducted by the UCLA team found that 60 percent of the students reported going online at least once a week – in many cases multiple times a day – and roughly the same proportion said they had easy access to the Internet. Two-thirds had access to mobile devices, including cell phones, and were regularly engaging in text messaging. “West Africans, like most of the developing world, are moving very quickly into these technologies,” says Prelip. “There is a great opportunity to take
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region at The California Endowment. Solis notes, among other things, provisions in the new health care reform law call for increased education and engagement of linguistically diverse populations through community health workers. Funding for prevention that will become available under the new law will help to bolster the population-based perspective, including education. Next year will bring additional dollars to upgrade and expand community health centers and federally qualified health centers, providing new opportunities to reach populations that have traditionally been underserved by the health care system. At the same time, there has been a reexamination of traditional health education efforts. In some cases, Solis says, that has meant capitalizing on new technologies and communication approaches that enable communities to “own” their education – for example, through the use of social media in youth-oriented initiatives. In other cases, it has meant looking more broadly at social determinants of health problems and bringing in experts outside of the health arena to assist in the design and implementation of initiatives.
New Strategies for Promoting Health “We’re seeing much more crossing of traditional silos, as well as the building of relationships with leaders and organizations that have an ‘in’ within communities and can help to build capacity,” Solis observes. “There’s an appreciation that we need to challenge our traditional ways of thinking about how to do outreach to populations.” advantage of their excitement at having access to information – especially by working with young people, who are quick adopters, to influence how they consume information about health.” The project has also provided an opportunity for UCLA School of Public Health students to gain invaluable experience in the field. In 2008, two students then in the M.P.H. program, Philip Massey and Bozena Morawski, went to Dakar to work on the study as summer interns and published a peerreviewed paper on their findings. Another M.P.H. student, Brock Dumville, recently returned after spending 11 weeks in Dakar, working with the youth and collecting research data. “It was such a fulfilling experience,” says Dumville. “It showed
UCLA School of Public Health faculty and students have worked on a project in which students at three high schools in Senegal received content and technology training, then led clubs where peers could create messages through various media approaches. UCLAPUBLIC HEALTH
The Senegal project was the latest in a series of technical assistance and evaluation efforts by two members of the school’s Department of Community Health Sciences, Drs. Deborah Glik and Michael Prelip, to enhance digital and innovative health communication in West Africa. Funded by the Open Society Initiative for West Africa, the project’s research component asked two overarching questions: whether messages generated by youth would be more effective in changing behaviors than the more traditional government-generated messages; and whether the new media technologies currently booming in much of Africa would be effective in facilitating the desired health behavior changes. Students at three high schools in Dakar, Senegal received both content and technology training, then led clubs at their schools where students could
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“If you add creative artists to the mix, you get a jolt of new ideas and innovative communication methods that make everyone’s work stronger.”
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—Dr. David Gere
me that I have the potential to use what I’ve learned in the classroom at UCLA to create a program on the ground.” Massey, now a second-year doctoral student at the school who has remained involved in the study, notes that the intervention had the desired effect. Among his group’s findings: Students in the three participating schools had nearly two times the odds of knowing a place to get tested as students in the control school, where the program was not offered. “Although the actual number of people serving as peer mentors and creating content was small, having the contest and giving students the ability to go to the website and view the entries was hugely successful in creating widespread awareness and interest,” says Massey. Given the project’s success, there is now interest in expanding it throughout Senegal and other parts of West Africa. “For youth audiences in particular, standing up and lecturing to a group isn’t going to be the most effective approach,” says Glik. “It’s important to reach them where they are, and with messages that resonate. Using technology we can reach large numbers of people and provide opportunities for the audience to delve deeper into topics.” In India’s largest government HIV hospital, patients hear seven hours of programming each day over a public address system. The content, cycled over 14 days, is all about HIV/AIDS, but it’s not what you’d
expect. Through a collaboration between the UCLA Art | Global Health Center and a theater troupe in Chennai, where the hospital is located, entertainment programming is used to convey everything from the basics of HIV/AIDS and treatment adherence to psychosocial issues, including coping with deeply ingrained stigma issues associated with HIV. “Are You Well? Arts in Hospitals,” one of several initiatives currently ongoing in India as part of the UCLA center’s Make Art/Stop AIDS Project, started with the theater group putting on short plays as well as epic-style theater performances and grew over several years – to the point that the head of the hospital, which was treating as many as 1,000 patients a day, asked the collaborators to deliver the entire curriculum to patients using their uniquely arts-based presentation. The program has resulted in reductions in stigma as well as improved knowledge and behavior change, including adherence to drug protocols. Another of the center’s projects finds community organizers partnering with multimedia village artists who use scroll painting, poetry and song to deliver HIV education in rural India. Dr. David Gere, associate professor in UCLA’s Department of World Arts and Cultures and founding director of the UCLA Art | Global Health Center – whose mission is “to unleash the transformative power of the arts to advance global health” – has attracted considerable international attention with his approach. Gere regularly teaches UCLA School of Public Health students in his Make Art/Stop AIDS course, which is where many of the project’s idea are born, and has recently begun discussions with the school about conducting collaborative work in India. Gere stresses that public health professionals, physicians and community organizers all play a vital role in fighting the AIDS epidemic. But he started
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feature The UCLA Art | Global Health Center aims to “unleash the transformative power of the arts to advance global health.” Opposite page, left: The “Medicine Man” sculpture was part of the center’s Make Art/Stop AIDS exhibition at the 2010 World AIDS Conference; right: UCLA students in an HIV-education performance for Los Angeles high school students. This page: HIV-related street theater in India. his center out of the conviction that “if you add creative artists to the mix, you get a jolt of new ideas and innovative communication methods that make everyone’s work stronger. A person delivering a lecture in a white coat is not the same as a puppeteer delivering what might be the same message but in a way that is easier to grasp, as well as more memorable and attention grabbing.”
“Jogging alone might be culturally compatible for affluent white men, but often it isn’t for women or ethnic minority communities. On the other hand, moving to music in a group setting tends to appeal to these groups.” —Dr. Antronette Yancey
UCLAPUBLIC HEALTH
In the United States, for all of the messages about the health benefits of regular physical activity and risks of being sedentary, only about 20 percent of adults have made it part of their lives, and an estimated 40 percent are entirely sedentary during their leisure time. Dr. Antronette (Toni) Yancey, professor of health services and co-director of the UCLA Kaiser Permanente Center for Health Equity, based in the school, has begun to popularize a new approach, called Instant Recess breaks. Offered in 10-minute intervals, Instant Recess breaks are incorporated into the routine activities of workplace and other organizations, and are low-impact and moderate enough to engage the entire group rather than only its fittest members. Yancey outlines her approach in a new book, Instant Recess: Building a Fit Nation 10 Minutes at a Time (University of California Press). Grounded in science, the book is written in an engaging, lay-friendly style to reach beyond health professional audiences to decision makers in corporate, education, government, sports and faith-based organizations. “In the past, we have tended to leave behind the most sedentary people,” Yancey explains. “A workplace wellness program might provide a free fitness center or offer incentives for gym membership, but the only ones taking advantage were individuals who probably would have been active regardless. Instant Recess aims to get the most people a little bit of activity rather than getting some people a large amount.” By incorporating exercise into work and organizational settings, the Instant Recess approach seeks to overcome another traditional barrier. “For many people – especially in lower-income communities where park space is scarce and the
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neighborhood might not be safe – the outside environment isn’t always conducive to physical activity,” Yancey explains. “Instant Recess can be done inside, and it doesn’t require a lot of space or a fitness room.” Beyond the commonality of being 10 minutes integrated into an organizational setting and appealing to all levels of fitness, Instant Recess breaks are meant to be adapted to culturally diverse settings. Various programs have been devised with distinct target audiences in mind, featuring different types of music and movement types. In some cases, Yancey has enlisted celebrities with close identification among certain groups to help increase interest. In all cases, the Instant Recess makes exercise a social activity. “Jogging alone might be culturally compatible for affluent white men, but often it isn’t for women or ethnic minority communities,” Yancey says. “On the other hand, moving to music in a group setting tends to appeal to these groups.”
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Dr. Antronette (Toni) Yancey has begun to popularize Instant Recess exercise breaks – offered in 10-minute intervals and incorporated into the routine activities of workplace and other organizations. Delivered in culturally compatible formats, they are designed to appeal to everyone, not merely the fittest.
Health educators have long understood the importance of knowing the target audience and tailoring messages accordingly. But in some cases, efforts haven’t been as well refined as they could be. “When your message is aimed at a population that speaks a different language, it’s not enough just to translate,” says Dr. Roshan Bastani, professor of health services, associate dean for research and codirector of the UCLA Kaiser Permanente Center for Health Equity. “You need to really understand the culture and align the messages with the way people live, their family structure, and other important characteristics.” But even the most well crafted messages won’t make a difference if they don’t reach their intended target. “If you’re putting an ad in the newspaper,” says Bastani, “do you know that the community you’re trying to reach reads that newspaper – or any newspaper?” In preparing for a major study aiming to increase Hepatitis B screening in Los Angeles’ Korean community, Bastani concluded through extensive focus-group research that the best way to engage large groups of Koreans was through churches in Korean neighborhoods. “At least 95 percent of Koreans in Los Angeles regularly attend church, and it’s a major part of the social fabric of the community,” Bastani explains. Bastani and colleagues also learned through the pilot work that the population was interested in receiving health-related programs at church, and was open to discussions of a topic as sensitive as Hepatitis B – a sexually transmitted virus associated with an increased risk of liver cancer. Bastani’s group has implemented a randomized controlled trial of nearly 1,500 people at Korean church sites throughout Los Angeles aiming to reduce the disproportionate burden of Hepatitis B and liver cancer among Korean Americans. The trial is close to completion and preliminary findings indicate that the intervention has had its intended effect of increasing receipt of Hepatitis B testing. The delivery and content of health messages can be critical to their success – and too often, health education efforts have fallen flat in racial/ethnic communities because they have failed to take key cultural factors into account, contends Dr. Marjorie Kagawa-Singer, professor in the School of Public Health and UCLA’s Department of Asian American Studies, whose work focuses on reducing disparities, particularly in cancer, among Asian-Americans and other populations of color. “Different initiatives might have the same goal – such as helping the population get access to health care – but the messages have to be acceptable, understandable and relevant to the particular community, using the appropriate vernacular and metaphors,” she says. As an example of where efforts have gone astray, Kagawa-Singer notes that initiatives aimed at increasing the use of mammography screening among women in the appropriate age groups have tended to emphasize a “take care of
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recent years as a way to assist underserved populations in overcoming barriers to obtaining important health care services. In partnership with organizations working closely with Asian-American immigrant communities, Kagawa-Singer’s group tested a model in which trained members of those communities conduct the outreach and education, and assist women – most of whom are uninsured and non-English speaking – in everything from making and following up on appointments to providing transportation and accompanying the women to the doctor’s office. Navigating and properly using the health care system can be challenging for even the most educated consumers – and, Prelip asserts, the ability to do so has become more important than ever with the passage of health care reform. “If we are increasing people’s access to care, we need to make sure they are utilizing the system appropriately or we aren’t going to be able to pay for it all,” he says. Earlier this year, the U.S. Department of Health and Human Services released the National Action Plan to Improve Health Literacy, aiming to make health information and services easier to understand and use. Now a UCLA School of Public Health research team led by Prelip and Glik, in partnership with Health Net of California, has received funding from the National Institutes of Health to launch an innovative effort that uses a social-media strategy to improve the health literacy of teens. The recently launched project defines health literacy more broadly than in the past, recasting it to include health care literacy. “Rather than focusing
Dr. Roshan Bastani and colleagues have designed and implemented a major study aiming to reduce the disproportionate burden of Hepatitis B and liver cancer among Korean Americans. The educational intervention is being delivered at Korean church sites throughout Los Angeles.
UCLAPUBLIC HEALTH
yourself” message that might resonate among white women but is more likely to fall on deaf ears in other communities, where a more effective approach might emphasize the importance of the woman taking care of herself so that she can fulfill her role as family caretaker. Similarly, Kagawa-Singer notes, among cancer survivors beliefs about pain can be vastly different. While the Western model focuses on relieving suffering, members of some cultures see pain as a necessary repayment for sins, and are thus less likely to seek or want relief. Kagawa-Singer ensures the cultural relevance of her research by closely involving community groups at every stage. As principal investigator of the Los Angeles site of the Asian American Network for Cancer Awareness Research and Training (AANCART), she formed a steering council consisting of representatives from 17 community-based groups serving the diverse Asian-American communities in the Los Angeles area. Kagawa-Singer’s group was recently funded for a third five-year period to continue leading the Los Angeles site of AANCART, the first cancer prevention and control research initiative targeting Asian-Americans. “In the community-based participatory research model, we don’t do anything without the input of our community partners,” Kagawa-Singer explains. “The design and development of the interventions are always conducted with community people who inform us about what’s going to be most helpful and most effective. The process is longer, but it’s been very productive.” Kagawa-Singer also recently completed a project on community navigators for cancer screening. The health navigator concept has gained favor in
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“For youth audiences in particular, standing up and lecturing to a group isn’t going to be the most effective approach. It’s important to reach them where they are, and with messages that resonate.”
UCLAPUBLIC HEALTH
—Dr. Deborah Glik
only on health information, we want our teen members also to know how and when to make appointments and get referrals, as well as their rights to services and confidentiality,” says Nancy Wongvipat Kalev (M.P.H. ’98), director of health education/ cultural and linguistic services for Health Net Inc., and one of five of the school’s alumni at Health Net who are part of the study. (Others are Elaine Robinson-Frank, M.P.H. ’98; Hoa Su, M.P.H. ’98; Vinia Pangan, M.P.H. ’99; and Sharon Nessim, Dr.P.H. ’81.) The study focuses on adolescent Health Net members who are covered through public insurance programs (in California, Medi-Cal or the Healthy Families Program). Many of these teens are the first in their family to have health coverage and may not know who their primary care provider is, much less take the step of making appointments for recommended adolescent well-care visits, Wongvipat Kalev explains. In many cases, she notes, this leads to emergency room visits that could have been prevented. Despite rights to confidentiality about medical care in California, some teens shy away from seeing health care providers for fear that sensitive information, such as reproductive health discussions, will be shared with their parents. The research team has developed an interactive website, www.teen2extreme.com, designed to engage teens on issues about their health as a way to improve their health care literacy. The site employs Facebook-style applications. “There are plenty of fact-laden websites out there,” says Prelip. “We want
this to be interactive and fun. We know that social media has become hugely popular among teens, and we’re excited to find out whether it can be used to have a desired effect on health literacy.” Over the course of a year, a series of health themes will be presented. The site will include quizzes, polls and contests, as well as encouraging participation and interactivity through blogs, live chats and opportunities to ask questions of a nurse. Users will have the opportunity to upload photos and video, and to comment on others’ postings. Embedded in the site will be information about how and when to make appointments. Teens with Health Net coverage through the public programs will be randomly assigned to either the intervention group with access to the social media website, or a control group receiving standard information provided to Health Net members. Participants will be surveyed both before and after the study to determine what effect the intervention had on their health care knowledge and behaviors, and Health Net data will be studied to weigh the intervention’s impact on utilization of services. In some ways, the project illustrates the evolving set of tools available to health educators as they develop new strategies to engage target populations in an effort to improve their health. “We were using computers 10-20 years ago, but it was mostly flat, content-driven websites,” says Glik. “Now we’re able to offer more – links, resources and the ability to interact with people who have similar interests and concerns.”
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research highlights
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research
Virus Related to Smallpox Rising Sharply in Africa
The results were startling, showing a 20-fold increase in human monkeypox in the Democratic Republic of Congo since smallpox vaccinations were ended in 1980.
UCLAPUBLIC HEALTH
In The wInTer OF 1979 the world celebrated the end of smallpox, a highly contagious and often fatal viral infection estimated to have caused between 300and 500 million deaths during the 20th century. Smallpox was defeated through an aggressive worldwide vaccination campaign – a campaign that ended in 1980, with the virus having been eradicated. But a UCLA School of Public healthled research team has found that the elimination of the smallpox vaccine had an unintended side effect. In the Proceedings of the National Academy of Sciences, Dr. Anne rimoin and colleagues reported that 30 years after the mass smallpox vaccination campaign ceased, rates of a related virus known as human monkeypox have increased dramatically in the rural Democratic republic of Congo, with sporadic outbreaks in other African nations and even in the United States. Until 1980, rimoin notes, the smallpox vaccine provided cross-protective immunity against monkeypox, a “zoonotic orthopoxvirus,” meaning it can be passed from animals to humans. Symptoms of monkeypox in humans include severe eruptions on the skin, fever, headaches, swollen lymph nodes, possible blindness and even death. There is no treatment. Once the smallpox vaccination program ended, new generations of people who were “vaccine naïve” were exposed to the monkeypox virus in the Democratic republic of Congo over time, and the number of people who became infected gradually increased. But the increase went unnoticed because the nation has little or no health infrastructure and thus no way to monitor the spread of such diseases. As a result, monkeypox was thought to be very rare. rimoin’s research shows, however, that it has become quite common. rimoin travels frequently to the Democratic republic of Congo (DrC), where she has established a research site to study and track cross-species transmission of the disease (see the profile on page 8). For their recent report, rimoin and her colleagues conducted a population-based surveillance in nine health zones in the central region of the country between 2006 and 2007, gathering epidemiologic data and biological samples obtained from suspected cases. They then compared the current, cumulative incidences of infection with data gathered in similar regions from 1981 to 1986. The results were startling, showing a 20-fold increase in human monkeypox in the DrC since smallpox vaccinations were ended in 1980. Because it is unlikely that smallpox vaccinations would be resumed, rimoin is calling for improved health care education in the Democratic republic of Congo and better disease surveillance. There is an urgent need to develop a strategy for reducing the risk of a wider spread of infections, she says.
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One in Four California Children Has Never Seen a Dentist
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Time Since Last Dental Visit Among California Children Younger than 11 Years of Age
24%
22%
25%
5% 18%
3% 17%
53%
57%
47%
Total
White
African-American
5% 22%
UCLAPUBLIC HEALTH
Had a dental visit within past six months Had last dental visit 6-12 months ago Last dental visit was more than a year ago Never had a dental visit
neArLY 25 PerCenT OF CALIFOrnIA ChILDren have never seen a dentist, and for those who have, disparities exist by race, ethnicity and type of insurance when it comes to the duration between dental care visits, according to the findings of a study by Dr. nadereh Pourat, professor of health services at the UCLA School of Public health and director of research for the Center for health Policy research. For the study, published in the July issue of the journal Health Affairs, Pourat and co-author Dr. Len Finocchio of the California healthCare Foundation examined barriers to dental care in nearly 11,000 California children ages 11 and under using data from the 2005 California health Interview Survey, the nation’s largest state health survey, conducted by the Center for health Policy research. Among their findings: Latino and African-American children with all types of insurance were less likely than Asian-American and white children to have visited the dentist in the previous six months, or even in their entire lifetime. The researchers also found that Latino and African-American children in public insurance programs, including Medicaid and the Children’s health Insurance Program (ChIP), went to the dentist less often than white and AsianAmerican children with the same insurance coverage. Overall, children with private insurance saw a dentist more often than those in Medicaid or ChIP. “Lack of dental care continues to be a significant problem for American children, and our findings suggest that having insurance isn’t always enough,” says Pourat. “we need to address the other barriers that keep children from getting the help they need.” The authors noted that the findings raise concerns about Medicaid’s ability to 26% 22% 27% address disparities in den3% tal care access. Ultimately, 7% 4% 16% they argued, more strategic 18% efforts are necessary to 20% overcome systemic barriers to care, including raising reimbursement rates paid to dentists who serve the 47% 59% 50% Medicaid population and increasing the number of participating Medicaid Latino Asian-American Other providers. Despite the disparities, having any form of dental insurance significantly increased the odds of seeing a dentist on a regular basis – 54 percent of privately insured children and 27 percent of publicly insured children had seen a dentist in the last six months, compared to 12 percent of children without dental coverage. “The data tell us that Medicaid and ChIP have improved children’s ability to get dental care,” says Pourat. “however, both programs need to do more to reduce disparities.” (More on this topic can be found in the article on page 4.)
Same-Sex Couples in California Face Sizable Health Insurance Inequities whILe CALIFOrnIA IS GenerALLY weLCOMInG to individuals of all sexual orientations, employers in the state tend to discriminate when it comes to samesex partners and health care, according to a UCLA School of Public health study. Dr. ninez Ponce and colleagues are the first to show a large gap between employer-sponsored dependent coverage received by heterosexual employees
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Nanoparticles in Common Household Items Cause Genetic Damage in Mice
Partnered gay men living in California are only 42 percent as likely as married heterosexual men to receive employer-sponsored dependent health insurance, while partnered lesbians have an even smaller chance – 28 percent – of getting coverage compared to married heterosexual women.
UCLAPUBLIC HEALTH
TITAnIUM DIOxIDe (TIO2) nAnOPArTICLeS, found in everything from cosmetics and sunscreen to paint and vitamins, cause systemic genetic damage in mice, according to a comprehensive study conducted by researchers at UCLA’s Jonsson Comprehensive Cancer Center and School of Public health. The TiO2 nanoparticles induced single- and double-strand DnA breaks and also caused chromosomal damage as well as inflammation, all of which increase the risk for cancer. The study, published in the journal Cancer Research, was the first to show that the nanoparticles had such an effect, according to Dr. robert Schiestl, a Jonsson Cancer Center scientist and professor in the School of Public health, who was the study’s senior author. Once in the system, the TiO2 nanoparticles accumulate in different organs because the body has no way to eliminate them. And because they are so small, they can go everywhere in the body, even through cells, and may interfere with sub-cellular mechanisms, Schiestl’s team noted. In the past, these TiO2 nanoparticles have been considered non-toxic in that they do not incite a chemical reaction. Instead, it is surface interactions that the nanoparticles have within their environment – in this case, inside a mouse – that is causing the genetic damage, Schiestl says. They wander throughout the body causing oxidative stress, which can lead to cell death. It is a novel mechanism of toxicity, a physicochemical reaction, that these particles cause in comparison to regular chemical toxins, which are the usual subjects of toxicological research. “The novel principle is that titanium by itself is
25
research
and lesbian and gay employees. Their study, whose findings were published in the journal Health Affairs, concludes that sexual-orientation disparities are greater than previously thought. Partnered gay men living in California, for example, are only 42 percent as likely as married heterosexual men to receive employer-sponsored dependent health insurance, while partnered lesbians have an even smaller chance – 28 percent – of getting coverage compared to married heterosexual women. The report used data from the California health Interview Survey. The researchers combined three years of adult surveys: 2001, 2003 and 2005. The final sample included 63,719 women and 46,535 men between the ages of 18 and 64. Of the sample, 51 percent of lesbians and 38 percent of gay men reported being in a partnered or married relationship, compared with 64 percent of female and 64 percent of male heterosexuals. “we found no strong evidence to suggest that California employers are discriminating in providing health insurance to gay and lesbian workers as individuals,” says Ponce, an associate professor at the school. “however, we did find that employers were setting coverage rules for dependents that favored legally and heterosexually married employees.” The authors noted that most of the data were collected before full implementation of the California Insurance equality Act of 2005; they expect that the law, once fully enacted and combined with the federal Patient Protection and Affordable Care Act, may alleviate some of the disparities documented in their study. But they also noted that the way government agencies and employers define dependents, and the federal taxation of health benefits for a same-sex spouse or partner, continue to be “a relevant underlying structural determinant of whether or to what extent sexual-orientation minorities will have more equal access to employer-sponsored insurance.” Achieving universal coverage, Ponce says, "will depend in part on remedying inequalities in state and federal marriagerelated rules."
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chemically inert,” Schiestl explains. “however, when the particles become progressively smaller, their surface, in turn, becomes progressively bigger and in the interaction of this surface with the environment, oxidative stress is induced. Given the growing use of these nanoparticles, these findings raise concern about potential health hazards associated with exposure.” The manufacture of TiO2 nanoparticles is a huge industry, Schiestl notes, with production at about 2 million tons per year. In addition to paint, cosmetics, sunscreen and vitamins, the nanoparticles can be found in toothpaste, food colorants, nutritional supplements and hundreds of other personal care products. “It could be that a certain portion of spontaneous cancers are due to this exposure,” Schiestl says. “And some people could be more sensitive to nanoparticle exposure than others. I believe the toxicity of these nanoparticles has not been studied enough.”
26
Many Home Kitchens Not Making the Food-Safety Grade
UCLAPUBLIC HEALTH
Only 61 percent of home kitchens received scores that would give them an A or B grade, compared to 98 percent of L.A. County restaurants. Twenty-five percent received a C, and 14 percent scored lower than the 70 percent required for a passing grade.
MOST PeOPLe ASSUMe that when they are experiencing food poisoning the culprit is something they ate outside their home. But a study co-authored by a UCLA School of Public health faculty member in his role as director of the Los Angeles County Department of Public health suggests that home kitchens are more prone to causing foodborne infections than most people realize. Publishing in the Morbidity and Mortality Weekly Report of the Centers for Disease Control and Prevention, Dr. Jonathan Fielding and colleagues detailed findings from a study of approximately 13,000 Los Angeles County adults who voluntarily completed an online quiz on their home food-handling and preparation practices. Based on a scoring system adapted from that used for restaurant grading in the county, only 61 percent of home kitchens received scores that would give them an A or B grade, compared to 98 percent of L.A. County restaurants. Twenty-five percent received a C, and 14 percent scored lower than the 70 percent required for a passing grade. “If they got below a C, I’m not sure I’d like them inviting me to dinner,” Fielding says. From 1999 to 2007, foodborne diseases caused a reported 2,590 hospitalizations and 17 deaths in Los Angeles County – numbers that are considered underestimates given that not all foodborne illnesses leading to hospitalization or death are confirmed by laboratory testing. In 1998, under Fielding’s leadership, Los Angeles County established numeric scores for restaurant inspections and posted grades for these inspections publicly. The initiative was credited with helping to reduce the number of hospitalizations for foodborne infections by 13 percent in the first year. In 2006 the county launched the voluntary home Kitchen Self-Inspection Program, which includes a quiz aiming to provide feedback and education that will promote safer food hygiene practices at home. The quiz emphasizes such food handling practices as the need to clean and sanitize cutting boards after handling poultry, the safe handling of raw eggs, and appropriate methods for the refrigeration of cooked and uncooked foods. Fielding’s group noted that the results of the quiz can’t be used to directly compare conditions in homes with those of restaurants, since they are based on self-reports rather than inspections by trained food safety professionals. But given the likelihood that people more interested and conscientious about food
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safety were more apt to take the quiz, the results probably understate the problem. “The findings in this report show that even among interested and motivated persons, food handling and preparation deficiencies occur frequently in the home setting,” Fielding and colleagues wrote.
27
research
Centralized Health Care More Cost-Effective, Offers Better Access to Preventive Services
Preventive Health Care Utilization by Type of Health Care Provider in Mexico
74% 72% 70% 68% 66% 64% 62% 60% Centralized Provider
Decentralized Provider
UCLAPUBLIC HEALTH
FAMILIeS FrOM rUrAL MexICO who receive health care from centralized clinics run by the federal government pay up to 30 percent less in out-of-pocket expenses and utilize preventive services more often than families who access decentralized clinics run by states, according to a study by researchers at the UCLA School of Public health. The findings were published in the September issue of the Journal of Social Science and Medicine. The findings, drawn from a comprehensive survey of 8,889 rural families from seven Mexican states conducted in 2003 by Oportunidades, Mexico's principal anti-poverty program, contradict the widely perceived notion that decentralized systems are superior, since local knowledge and resources can be more effectively used to address local needs. Since the 1990s, centralized and decentralized health care services have co-existed in 17 Mexican states without competing against one another. Because centralized and decentralized organizations rarely operate within the same country during the same time period or cater to comparable populations, Mexico’s health care system provides a rare opportunity to compare the two approaches side by side. In the study, households serviced by decentralized providers repor ted higher out-of-pocket health expenditures and lower utilization of preventive services, spending almost 40 percent more out of pocket and utilizing preventive care 7 percent less than households serviced by centralized providers. The households studied showed no differences in terms of age, years of schooling, family size, insurance status, employment, need and most community infrastructure measures. “The Mexican experience can be useful to other developing countries in Latin America (e.g., Chile or Brazil) and other areas of the developing world (e.g., China, Iran, Turkey) where centralized governments have considered decentralization as a policy mechanism to reform their national health systems," says Dr. Arturo Vargas-Bustamante, the study’s lead investigator and an assistant professor of health services at the UCLA School of Public health. Vargas-Bustamante suggests that the centralized providers have four attributes that may give them an advantage: Type of Service. Because the types of services provided to rural populations do not require a high degree of specialization and are relatively homogeneous and less sensitive to local taste and variation, centralized providers may be able offer these services more efficiently. Quality of Care. Centralized providers have more public resources to provide better services and employ more incentives and monitoring to improve the quality of care. Experience. In the three decades since decentralization began in Mexico centralized providers may have resolved functional issues that decentralized providers may still be tackling. Local Capacity. even if local authorities are closer to their communities and are more familiar with their characteristics and limitations, they still need managerial skills to provide health services that require some level of expertise.
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student profiles For Former Pro Soccer Player, Future Kicks Will Promote Health Among African Girls
“Promoting sports participation in developing countries of Africa could be a great strategy for catalyzing some of the health outcomes we want for young women.”
UCLAPUBLIC HEALTH
— Myralyn "Mimi" Nartey
when She wAS 15, MYRALYN "MIMI" NARTEY ventured far from her family’s home in Arizona to the republic of Ghana, where her father had been raised, to play professional soccer for the Ghanian women’s national team. while there, she contracted malaria. At first the team administrators and medical staff failed to appreciate the magnitude of her illness. when nartey began to deteriorate, she was taken to the nearest hospital, which she barely recognized as a medical care facility. “It felt more like an open-air marketplace,” she recalls. As she waited a seemingly interminable period to be seen, nartey saw frightened-looking women with sick babies on their backs. “They had no idea what was going on, or if they were going to be able to pay for what they needed,” she says. The experience made a huge impression. “here I was, born and raised in the United States with all the resources anyone could have, and commissioned by Ghana to play a sport – yet, I was having problems getting access to health care when I was sick,” nartey says. “It struck me that if I was having a hard time, what about everyone else in this country that was so impoverished?” with that in mind, nartey majored in environmental biology as an undergraduate at Columbia University and went on to do a fellowship in which she conducted research to develop anti-malarial drugs. Ultimately she shifted her focus to policy. She got an M.A. in Climate and Society at Columbia, then came to UCLA, where she is pursuing an M.A. in African Studies and a Ph.D. at the School of Public health as part of a dual-degree program. Since arriving in 2006, nartey has channeled the energy she once used on the soccer field into a myriad of activities: In addition to her studies, she serves as an appointee on the Student health Advisory Committee and is the SPh Diversity Coordination Team co-chair, as well as co-chair of Students of Color for Public health. She also has a daughter, born in February 2009. nartey continues to be interested in malaria – it is an important focus of an undergraduate seminar she has taught the last three years on the dynamics of climate and health in sub-Saharan Africa. But her goals have evolved. After recovering from her bout with malaria, nartey went on to a fruitful career in professional soccer, representing Ghana in the 2002 FIFA African Cup of nations and 2003 FIFA women’s world Cup. now she has her sights set on developing Africa-based programs to promote participation in sports as a way of achieving better health outcomes. “The benefits of sports participation for young women are well documented in the Untied States, including delayed sexual initiation, better ability to negotiate condom use with partners, and reduced risk of gender-related violence and genderrelated medical problems,” nartey notes. reflecting on her own soccer experience, nartey remembers the benefits accrued by her teammates, many of whom were uneducated. “They became much more confident,” she says. “It made me realize that promoting sports participation in developing countries of Africa – and especially soccer, which is so woven into the cultural fabric – could be a great strategy for catalyzing some of the health outcomes we want for young women.”
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students
M.P.H./J.D. Dual Program a Recipe for Policy Influence
“With the entire nation focusing on health care, it’s an exciting time to be studying these issues.” — Eli Tomar
UCLAPUBLIC HEALTH
MOre ThAn MAnY graduate students, ELI TOMAR has spent enough time in the thick of the policy-making process on Capitol hill to know the challenges – and in many cases, frustrations – of passing meaningful health-related legislation. Prior to embarking on his M.P.h./J.D. through a four-year concurrent degree program offered by the UCLA School of Public health and School of Law, Tomar spent several years working in washington, D.C. – as a congressional intern, a government relations aide for the U.S. Soccer Foundation, and a legislative assistant and public policy analyst for two law firms, advocating in Congress as a registered lobb yist. “It’s easy to become disheartened when you see that even getting something passed that everyone agrees on is an uphill battle,” he says. “So often, opposition to a proposal is based on politics, not policy. But it’s important to understand the inertia that exists and learn how to accomplish what you can.” Tomar remains enthusiastic about the opportunity to positively affect people’s lives through legislation. In his workspace he proudly displays a copy of the Medicare Improvements for Patients and Providers Act of 2008, which included provisions to expand coverage for patients with endstage renal disease as well as providing funding for patient education and prevention programs. Tomar had lobbied for the bill as part of a large coalition that included health care providers, dialysis centers and patient groups; it became law after Congress overrode a veto by then-President Bush. “These were relatively uncontroversial provisions, and yet this coalition had been trying to get them for five years,” Tomar says. “I was thrilled to see it pass.” Tomar says he knew he wanted to go to law school well before he considered getting an M.P.h. Although he was exposed to health care policy as a child – his mother served as a policy director for the American hospital Association – it was only after he began working with health care clients as a public policy analyst for the law firm Patton Boggs that he decided to pursue a joint-degree program. Through the M.P.h./J.D. – the first program of its kind west of the Mississippi river – Tomar is gathering credentials that will strengthen his ability to make a difference in the nation’s capital, where he plans to return after completing the four-year program. The M.P.h./ J.D. is designed to prepare students to work in health law, a field that was already growing rapidly but offers even more opportunities since the passage of health care reform. Tomar intends to resume his work in health law and policy; ultimately he would like to help shape policies as part of a think tank or as legal counsel to one of the health-related committees on Capitol hill. “with the entire nation focusing on health care, it’s an exciting time to be studying these issues,” says Tomar, who is in the school’s Department of health Services. “I’m getting a different perspective on policy and a much better grasp of everything from the evaluation of programs to the economic forces behind health care, as well as management-oriented issues such as strategy and marketing. All of this is going to be extremely helpful in my future work.“
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contracts & grants 2009-10 This section includes new contracts and grants awarded in fiscal year 2009-10. Due to space limitations, only funds of $50,000 or more are listed, by principal investigator.
RICHARD AMBROSE Determining Long-Term Changes in Species Abundances and Community Structure in Southern California Rocky Intertidal Habitats (Samueli Institute for Information Biology, $80,000 for 2 years) ONYEBUCHI ARAH Beyond Individual-Level Determinants: The Role of Healthcare System, Socioeconomic, and Environmental Factors in the Global Burden of Chronic Diseases (Netherlands Organisation for Scientific Research & Universiteit Van Amsterdam, $310,489 for 2 years) ROSHAN BASTANI Los Angeles Regional Cancer Prevention and Control Research Network (Centers for Disease Control and Prevention, $1,499,955 for 5 years) RONALD BROOKMEYER Clinical and Pathological Studies in the Oldest Old: Statistical Design & Analysis (National Institute on Aging & UC Irvine, $75,822) E. RICHARD BROWN The 2009 California Health Interview Survey (County of Marin, $200,000 for 2 years; California Children & Families Commission – First 5, $1,500,000 for 2 years; California Department of Managed Health Care – Office of the Patient Advocate, $251,805; The California Endowment, $1,729,643 for 2 years; California Department of Mental Health, $1,568,000; County of San Diego, $394,091 for 2 years; National Cancer Institute, $300,000); The State of Health Insurance in California Report (SHIC) (California Wellness Foundation, $175,000 for 2 years) CATHERINE CRESPI New Methods for the Design of Cancer Studies with Clustered Binary Outcomes (National Cancer Institute, $154,000 for 2 years) ROGER DETELS Multidisciplinary HIV and TB Implementation Sciences Training in China (NIH Fogarty International Center & Chinese Center for Disease Control and Prevention [China], $540,000 for 5 years); Natural History of AIDS in Homosexual Men: ARRA Supplements (National Institute of Allergy and Infectious Diseases, $1,309,694) JONATHAN FIELDING Comprehensive School Physical Activity Opportunities: Using Health Impact Assessment to Develop Accountability and Reporting Systems (Robert Wood Johnson Foundation, $99,850); UCLA/LA County HIA Demonstration and Training Project (Pew Charitable Trusts, $321,580 for 2 years)
UCLAPUBLIC HEALTH
JOHN FROINES Toxicologic Pathways of Rail Yard Emission Exposure on NonCancer Health Impacts (British Petroleum Group, $620,480 for 2 years); International Forum on Disability Management (IFDM) 2010 (California Department of Industrial Relations, $60,600) PATRICIA GANZ A Model Clinical Translational Research Program for Breast Cancer Survivors: A Focus on Cognitive Function after Breast Cancer Treatment (The Breast Cancer Foundation, $198,566); Reducing Breast Cancer Recurrence with Weight Loss: A Vanguard Trial (National Cancer Institute & UC San Diego, $96,417 for 4 years)
BETH GLENN Sun Protection Among Children with a Family History of Melanoma (National Cancer Institute, $154,000 for 2 years) DEBORAH GLIK and MICHAEL PRELIP Adolescent Health Literacy: Improving Use of Preventive Health Services (National Institute of Child Health and Human Development, $1,306,662 for 2 years) HILARY GODWIN Public Health Traineeships (DHHS/Health Resources and Services Administration, $177,392 for 3 years); SARRA – Public Health Traineeship Program (DHHS/Health Resources and Services Administration, $184,319 for 3 years) NEAL HALFON The Interdisciplinary Maternal and Child Health Training Program (DHHS/Health Resources and Services Administration, $1,725,000 for 5 years) GAIL HARRISON Developing the Immigrant Health Component of UCLA’s Center for Global and Immigrant Health (The California Endowment, $76,750) SHEHNAZ HUSSAIN Nucleotide Variation in the Prolactin Receptor and its Agonists and Breast Cancer Risk (Susan G. Komen Breast Cancer Foundation, $299,912 for 2 years); Molecular Epidemiology of B-Cell Activation, DNA Repair & HIV-Associated Lymphoma (National Cancer Institute, $640,376 for 5 years) MARJAN JAVANBAKHT Rectal Transmission of STIS/HIV Among Women (UC California HIV/AIDS Research Program [CHRP], $185,776 for 2 years) ROBERT KAPLAN UCLA/RAND Center for Adolescent Health Promotion – Category 1 (Centers for Disease Control and Prevention, $5,180,000 for 5 years); Women’s Exercise Injuries: Incidence and Risk Factors (National Institute of Arthritis & Musculoskeletal and Skin Diseases & The Cooper Institute, $74,189); Comparative Effectiveness and Outcomes Improvements (CEOI) Center (National, Heart, Lung, and Blood Institute, $3,855,398 for 2 years) LEEKA KHEIFETS Cell Phone Use and the Health of Children in the Danish National Birth 7-1-09 (National Institute of Environmental Health Sciences, $423,500 for 2 years) NOLA KENNEDY Program to Continue Training to Prevent Workplace Injuries and Illness Among Low Wage Workers in Hazardous Jobs (California Wellness Foundation, $200,000 for 3 years) GERALD KOMINSKI Pediatric Palliative Care Waiver Evaluation (CA/HHS/Department of Health Services, $700,000 for 4 years) SIMIN LIU Biochemical Predictors of Type 2 DM in Women (National Institute of Diabetes, Digestive and Kidney Disease, $230,187) CAROLYN MENDEZ-LUCK Elder Caregiving in Los Angeles County: Creating a Profile of Caregiver Health and Health Risks (Kaiser Foundation Research Institute, $150,000 for 2 years)
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ANNE RIMOIN Research and Policy for Infectious Disease Dynamics (RAPIDD) (Fogarty International Center, $81,712 for 2 years); The Emergence of Human Monkeypox in Central Africa (National Institute of Allergy and Infectious Diseases, $88,532); Collaborative Program Development with GVFI (USDS Agency for International Development & Global Viral Forecasting Initiative, $207,587) BEATE RITZ Sunlight Exposure & Vitamin D Metabolic Gene Variations in Parkinson’s Disease (National Institute of Environmental Health Sciences, $154,000 for 2 years); Air Pollution and Childhood Cancers in California (National Institute of Environmental Health Sciences, $423,095 for 2 years) HECTOR RODRIGUEZ Local Health Department Influences on the Health of Older Adults: A Statewide Evaluation (Robert Wood Johnson Foundation, $200,000 for 2 years); The Effect of Differential Item Functioning on the Measurement of Racial and Ethnic Disparities in Patients’ Experiences of Ambulatory Care (Robert Wood Johnson Foundation, $75,000 for 2 years) LINDA ROSENSTOCK Diversity in Health Professions (California Wellness Foundation, $150,000 for 2 years) STEVEN ROTTMAN UCLA Center for Public Health Preparedness (Centers for Disease Control and Prevention, $500,000)
new faculty
faculty
SHANE QUE HEE Whole Glove Permeation/Penetration of Organic Liquids with a Dextrous Robot Hand (Centers for Disease Control and Prevention, $1,060,110 for 3 years)
DR. YIFANG ZHU joins the faculty as assistant professor in the Department of environmental health Sciences. her research focuses on identifying key factors that affect human exposure to ultrafine particles on and near roadways by measuring and modeling their emissions, transport and transformation in the atmosphere, as well as into the in-cabin and indoor environments. Zhu’s studies are supported by two prestigious national awards: the national Science Foundation’s Faculty early Career Development Award and the walter rosenblith new Investigator Award from the health effects Institute. Zhu, who was most recently an assistant professor in the environmental engineering Department at Texas A&M University-Kingsville, received her B.S. in environmental engineering from Tsinghua University in China and her Ph.D. in environmental health Sciences from the UCLA School of Public health. ALSO JOINING THE FACULTY:
BRIAN BRADBURY Assistant Professor, Epidemiology
KIMBERLEY SHOAF Public Health Emergency Management Training and Education Academy (City of Long Beach Department of Health and Human Services, $703,000 for 1.5 years); Preparedness & Emergency Response Research Centers: A Public Health Systems Approach (Centers for Disease Control and Prevention, $4,723,148 for 4 years) PETER SINSHEIMER California Garment Care Technology Demonstration Project, NonToxic Dry Cleaning Incentive Program (California Environmental Protection Agency Air Resources Board, $265,000 for 2 years) STEVEN WALLACE Assessment of Local Environmental Risk Training (ALERT) (National Institute of Environmental Health Sciences, 1,000,000 for 2 years) MAY WANG Stimulus: Agent-Based Model of Individual-Level Food Choice and Physical Activity Behavior (National Institute of Diabetes and Digestive and Kidney Diseases, $860,216 for 2 years) UCLAPUBLIC HEALTH
PHYLLIS WEISS Resource Program for Policy Development and Program Evaluation for Violence Prevention Organizations (California Wellness Foundation, $150,000 for 2 years); Community Gang and Violence Reduction Strategy Planning Project (Centers for Disease Control and Prevention & The Advancement Project, $73,613)
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news briefs SPH hosts lunchtime webinars INTERACT WITH US! You can learn about happenings at the school, participate in discussions on public health topics of the day or reconnect with former classmates and favorite faculty members through the school’s Facebook page, and follow UCLASPH on Twitter for important updates. In addition, alumni are invited to join the UCLA School of Public Health Alumni Network on the professional networking site Linkedin.
Starting in October, the School of Public health began hosting a monthly series of lunchtime webinars. These lunchtime discussions, available through the school’s website, present a valuable opportunity to hear from faculty experts about some of today’s most critical public health issues. Among other things, webinar participants will learn what they can do to create healthier environments in the face of disease and environmental challenges; receive a virtual tour of the new Global Bio Lab at UCLA, a state-of-the-art facility that will vastly increase the rate at which infectious agents are submitted, tested and analyzed; hear how food marketing has vastly altered the culture of food and eating, leading to the current obesity epidemic; and see the role and impact that population health surveys have on implementing health care reform. For a schedule of upcoming webinars and to view previous webinars, please visit http://ph.ucla.edu/.
curbing teen suicide motivates SPH students
UCLAPUBLIC HEALTH
Ashley roberts and Anne Sutkowi, second-year students at the School of Public health, are working with students at Olympic high School in Santa Monica as part of a health promotion and suicide prevention program they created called STrIDeS. The program, inspired by research linking suicide rates and emotional health, promotes physical, mental and emotional well being through physical activity, stress relief and development of a positive self-image. During the 10-week project, roberts and Sutkowi are working at the continuation high school with students who have faced great challenges in their home life and those who know someone who has thought about suicide or committed suicide. Twice a week they lead students in stretches and jogs on campus, hoping to help the students integrate running into their daily lives, since it is an activity that is both an individual and a team sport. Says roberts: “we encourage them to encourage one another, but it's a solitary thing that they can do by themselves for stress relief.” The project culminates in the STrIDeS 5K run/walk at Dockweiler Beach in november. The program was made possible by support from the Albert Schweitzer Fellowship, which assists leaders addressing the needs of underserved communities.
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news briefs
new associate dean for global health
school turning 50 Dr. Onyebuchi Arah, an associate professor in the Department of epidemiology, has been appointed the school’s first associate dean for global health. Arah will help implement one of the school’s strategic goals: building a world-class global health presence. Arah brings a unique perspective in both his training and his experience. A native nigerian, he received much of his advanced academic education in holland. As a pediatrician trained in public health, health services research, health policy and epidemiologic methods, Arah studies issues such as the role of health systems in global health and performance assessment in health care. he has been a member of the school’s faculty since 2006.
special edition of alumni directory A special anniversary edition of the Alumni Directory will be produced to celebrate the School of Public health's 50th Anniversary in 2011. The directory will feature contact information, photos and essays from five decades of distinguished alumni. All alumni will be soon contacted by the vendor harris Connect to gather directory information. You may also visit www.ucla.edu/ sphalumni to ensure the school has up-to-date information about you so that you will be able to reconnect with fellow alumni.
On the eve of the school’s 50th anniversary, preparations are underway for a year of celebrating five decades of innovative and high-impact research, teaching and community service. Beginning with a gala on the evening of February 2, 2011 (more details on the back cover), the school will be hosting numerous events and activities throughout the year to enable all friends and supporters to participate in the celebration. Those not in Los Angeles can join in one of the lunchtime webinars (see previous page). The school will also hold a special celebration for alumni at the annual American Public health Association meeting to be held in San Francisco in november 2011. UCLA’s School of Public health didn’t start out as a graduate school. From 1946 to 1983, UCLA provided undergraduate instruction leading to an advanced degree in public health, which was offered beginning in 1957. It wasn't until 1961 that the University of California regents created an independent School of Public health on the westwood campus. Join us in celebrating the myriad accomplishments of alumni, students and faculty during the past 50 years, and help the school continue on the same trajectory for the next 50.
DID YOU KNOW...
UCLAPUBLIC HEALTH
You are a lifetime member of the UCLA School of Public Health Alumni Association if you are a graduate of the UCLA School of Public Health and its executive programs. If you would like more information about the activities of the Public Health Alumni Association, please call (310) 825-6464 or e-mail phaa@support.ucla.edu.
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UCLA
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School of Public Health Box 951772 405 Hilgard Avenue Los Angeles, California 90095-1772 www.ph.ucla.edu Address Service Requested
The 50th Anniversary Gala of the School of Public Health ATUL GAWANDE, M.A., M.D., M.P.H., distinguished surgeon and bestselling author, is the featured speaker at the school’s 50th Anniversary Gala.
FEBRUARY 2, 2011 at 6 P.M. The Hyatt Regency Century Plaza Los Angeles To purchase tickets and for sponsorship opportunities please visit www.ph.ucla.edu/2011gala or call (310) 825-6464.
