UCLA Public Health Magazine - November 2004

Nov04.cvrs

11/10/04

10:59 PM

Page 2

NOVEMBER 2004

UCLA

PUBLIC HEALTH

We’re getting

OLDER

UCLA

Will we be ready?

School of

Public Health

William Hinds trains individuals who promote the health and safety of U.S. workers — a group that is challenged by long hours and new threats.

In linking exposures with disease risk, Beate Ritz has pointed to the dangers of air pollution and workplace radiation. Not everyone has been pleased.

The school and its supporters are investing in the future of public health by providing financial support to talented students such as Kristin E. Yarris.

SPHmag.Nov04.2-13

11/10/04

11:35 PM

Page 1

UCLA

PUBLIC HEALTH

Albert Carnesale, Ph.D. Chancellor

Linda Rosenstock, M.D., M.P.H. Dean, UCLA School of Public Health

Sarah Anderson Assistant Dean for Communications

Dan Gordon Editor and Writer

fe a t u r e s

Martha Widmann Art Director

E D I TO R I A L B OA R D Richard Ambrose, Ph.D. Associate Professor, Environmental Health Sciences

Thomas R. Belin, Ph.D. Associate Professor, Biostatistics

Ralph Frerichs, D.V.M., Dr.P.H. Professor, Epidemiology

F. A. Hagigi, Dr.P.H., M.B.A. Associate Professor, Health Services

William Hinds, Ph.D. Professor, Environmental Health Sciences

Michael Prelip, D.P.A. Assistant Professor, Community Health Sciences

Susan B. Sorenson, Ph.D. Professor, Community Health Sciences

Richard Hector, Eric Lai Co-Presidents, Public Health Student Association

Joyce A. Page, M.S.P.H., J.D.

UCLA

Past President, Alumni Association

School of

Public Health

4

Beate Ritz: Epidemiological Sleuth on the Case for Prevention In the complex patterns of health and disease, the faculty member and alum of the school makes connections that can be used to improve health.

6 We’re Getting Older...Will We Be Ready?

In seven years, the first baby boomers turn 65. The challenge of promoting healthy aging while tending to the ailments of a fastgrowing elderly population looms large.

SPHmag.Nov04.2-13

11/10/04

11:35 PM

Page 2

Investing in Their Future – and Ours

14

in every issue 23 RESEARCH Co-payments and prescription drug use...school-based peer education on HIV... sedentary in L.A....Hispanics and HAART...antioxidant as cancer fighter...community health centers and access.

28 18 With the cost of pursuing a graduate degree on the rise, SPH steps up efforts to assist talented candidates.

28 STUDENTS

Getting Wise About Workers

30 FACULTY 32 NEWS BRIEFS

U.S. workers are toiling longer hours with less security. Economic shifts are creating new concerns as old ones persist. Through research and education, the school seeks to keep workers well.

ON THE COVER As a society, we can no longer hide the gray. How prepared are we to accommodate 70 million seniors by 2030 – roughly double the number we have today? There is much work ahead.

Cover photo: 2004 © Getty Images.

PHOTOGRAPHY Reed Hutchinson / Cover: Hinds, Ritz,Yarris; TOC: Ritz, Investing; pp. 2, 4; p. 7: Wallace; pp. 8, 11-12, 14, 16-17, 19; p. 21: Rosenstock; pp. 29, 31-32

Courtesy of William Hinds / TOC: workers; pp. 18, 20; p. 21: facility tour; p. 22: facility tour Courtesy of Sarah Rothenberg / TOC: students; p. 31 Courtesy of the UCLA School of Public Health / p. 22: Needleman Getty Images © 2004 / Cover; TOC: elderly; pp. 6-7, 9-10, 13, 25

School of Public Health Home Page: www.ph.ucla.edu E-mail for Application Requests: app-request@admin.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 2004 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.

SPHmag.Nov04.2-13

11/10/04

11:35 PM

Page 3

2

dean’s message IT’S NO COINCIDENCE that of the 16 ballot measures that California voters faced in November, five dealt with health care: improved mental health programs, more funds for emergency rooms, construction of children’s hospital facilities, stem cell research, plus a law requiring employers to provide health insurance to their workers.

A large share of the state’s problems, and of the nation’s problems, are related to the escalating costs of health care and the shrinking access that many people – and not just the poor – have to medical services.

In national polls relevant to the November election, health care ranked among the top issues of concern. Depending on the poll, health care often rated as more important than the war in Iraq – competing with the economy and homeland security. The voters most concerned about health care were, not surprisingly, seniors.

One of the successes of public health is a population that is living longer and better. The elderly are at high risk for illness and disability, and they are the heaviest users of health services. Over the next 30 years the number of older persons in the United States will double, intensifying the importance of healthy public policy for older persons.

The school’s work on the elderly, highlighted in the cover story (page 6), contributes knowledge and data to inform key policies for the older population in several areas, including improving access to acute and long-term care, enhancing the quality of medical care and prevention, and improving the efficiency and effectiveness of financing care for older persons. California has the most diverse older population in the nation, and our efforts at the school place a special focus on policy-relevant issues for racial and ethnic minority communities as well as immigrant communities. In this area, as well as many others, we are fulfilling the school’s mission of translating research into policy and practice.

Another of our missions is to enhance the public’s health by training future leaders and health professionals from diverse backgrounds. In one of the most diverse schools of public health in the country, admission continues to become more competitive, with applications up 10 percent for the third year in a row. In the face of state budget cuts and rising tuition, we are able to continue to recruit and retain the best and brightest by providing merit- and need-based support to

UCLAPUBLIC HEALTH

more than 80 percent of our students.

SPHmag.Nov04.2-13

11/10/04

11:35 PM

Page 4

3

As you’ll read in the article on student support (page 14), funding comes from many sources, including foundations and generous individuals. Cumulative gifts to the school during the ongoing UCLA Campaign total nearly $40 million, almost tripling our original goal, and this year receipts to our Annual Fund nearly doubled. Once again we see an impressive increase in faculty research productivity, as measured by contracts and grants (see chart below), with state support now only about 20% of our total annual budget. And finally, the school recently received a bestowed trust from a former faculty member in honor of another faculty member. Professor Carl Hopkins’ gift honoring Professor Milton Roemer pays tribute to both of their innumerable contributions to the field of public health, and will enable us to ensure that their legacies continue.

As we start the new school year, faculty and staff are buoyed by the enthusiasm of our talented students. And in looking at the prominence of health in the recent election, we are reminded of our role in ensuring that our future public health workforce is ready.

Linda Rosenstock, M.D., M.P.H. Dean

$43.0 M $37.5 M $34.1 M

CONTRACTS & GRANTS: A GROWING SOURCE OF SUPPORT

$28.6 M

$21.3 M $18.0 M

1997-98

1998-99

1999-00

2000-01

Contracts and Grants Direct Cost Indirect Cost Recovery State

2001-02

2002-03

2003-04

UCLAPUBLIC HEALTH

$17.5 M

SPHmag.Nov04.2-13

11/10/04

11:36 PM

Page 5

4 IN

THE COMPLEX PATTERNS OF HEALTH AND DISEASE , THE FACULTY MEMBER AND ALUM OF THE

SCHOOL MAKES CONNECTIONS THAT CAN BE USED TO IMPROVE HEALTH .

BEATE RITZ:

Epidemiological Sleuth On the Case for Prevention As a medical student at the University of Hamburg, Germany, Dr. Beate Ritz quickly realized that clinical work wasn’t for her. “I was less interested in taking care of sick patients than in learning why they had become sick in the first place,” she says, “and I knew it would frustrate me enormously to have to treat someone when I might have prevented the disease.” She also discovered she had a gift for the detective work and analysis of complex patterns of population health and disease that defines

UCLAPUBLIC HEALTH

the field of epidemiology.

In becoming an occupational and environmental epidemiologist, Ritz found the perfect marriage of her skills and her bent toward prevention. “If you find a genetic factor that puts people at risk for a disease, there’s not always a lot people can do with that information,” says Ritz, who got her M.P.H. and Ph.D. from the UCLA School of Public Health before joining the Department of Epidemiology faculty in 1995. “On the other hand, any disease caused by an occupational or environmental factor is potentially preventable by taking that factor out of the workplace or general environment.” But in choosing to explore connections between exposures and increased disease risk for certain workers and communities, Ritz frequently courts controversy. “These are often politically high-stakes kinds of questions in which you have people on both sides who are very interested in our findings,” she says. “There’s almost always somebody who doesn’t like what I’m doing.”

SPHmag.Nov04.2-13

11/10/04

11:36 PM

Page 6

More recently, when Ritz wanted to investigate a possible link between air pollution and adverse birth outcomes, the controversy concerned her decision to even study pregnancy in that context. “No one would fund it, because everyone figured that fetuses in the womb don’t breathe, and reasoned that for air pollution to have an effect you have to inhale,” she recalls.

Undaunted, Ritz proceeded without funding, using public databases on birth outcomes and air pollution monitoring to produce the first compelling evidence that air pollutants, even at the levels currently found in Los Angeles, can contribute not only to asthma and other respiratory illnesses, but also birth defects.

She found that when exposed early in their term, pregnant Los Angeles-area women living in regions with higher levels of ozone and carbon monoxide pollution were as much as three times as likely as women in areas with the cleanest air to give birth to infants who suffered serious heart problems.

While these findings await confirmation by other studies, researchers all over the world have employed similiar databases to corroborate other results initially reported by Ritz, including as associ-

A positive finding on the relationship between pesticides and Parkinson’s would be certain to make headlines, something Ritz recognizes as coming with the turf – even if it’s not something she relishes.

“It’s difficult, because people are always trying to pull you one way or the other, and often that means they want you to say something that the science hasn’t arrived at yet,” she says. “But I do feel an obligation not just to let others interpret my data, so I will respond to media requests and I’m always happy to answer questions from members of the communities that are affected.”

More enjoyable, she says, is the process of discovery, particularly when she’s sharing it with students. “It’s a lot of work to train and re-train students, particularly at the master’s level, since they often will only be around for a year or two,” she says.

“But I believe the research experience is valuable to them, and they bring such great enthusiasm to the studies. That’s what I enjoy about what I do.”

She pauses, smiling. “The media and professional attention, which a lot of people assume are so glamorous, I see as necessary but somewhat stressful.”

5

“These are politically high-stakes kinds of questions in which you have people on both sides who are very interested in our findings.

There’s almost always somebody who doesn’t like what I’m doing.”

—Dr. Beate Ritz

UCLAPUBLIC HEALTH

ation between air pollution and low birth weight and preterm birth. Ritz is now investigating the relationship between exposure to air pollutants and asthma in Los Angeles and San Diego counties, using detailed information on traffic density, an extensive air monitoring network, and data from the 2001 California Health Interview Survey, based in the school’s Center for Health Policy Research.

In 1999, Ritz ventured in a new direction with research examining the impact of exposure to pesticides suspected of increasing the risk of certain neurological disorders. She now co-directs UCLA’s Center for Gene-Environment Studies in Parkinson’s Disease, funded by the National Institute of Environmental Health Sciences to study the interplay between pesticides and “candidate” genes that could leave certain people susceptible to Parkinson’s when exposed to the toxins. As part of the center, Ritz heads a study testing the gene-environment interaction hypothesis for Parkinson’s by conducting a population-based case-control study of newly diagnosed patients in three rural California counties. The study takes advantage of more than three decades of data collected as part of California’s mandate on reporting commercial and agricultural pesticide use.

“With technology that allows researchers to inexpensively and efficiently conduct genetic screens on large numbers of samples, we’ve seen an explosion of genetic knowledge,” Ritz says. “As a result, we can now begin to go out into the field and apply those laboratory findings to populations.”

faculty profile

That message was delivered resoundingly in the first few years of Ritz’s faculty career, when highly publicized findings from studies she and her colleagues conducted of cancer risk for radiationexposed workers at Rocketdyne’s Santa Susana Field Laboratory drew a harsh rebuke from the company, which is now owned by Boeing.

With funding from the U.S. Department of Energy, Ritz’s group reviewed medical and personnel records for 4,563 employees monitored for radiation between 1950 and 1993 at the facility (located near Simi Valley, Calif.), and found that workers exposed to low doses of radiation had a cancer risk that was at least 6-8 times greater than previous studies had reported. The increased risk was found at exposure levels far lower than prior research had shown. In addition, the rocket fuel hydrazine was, for the first time, identified as a human lung carcinogen.

Ritz believes the company, fearful of potential lawsuits, calculated it would be much cheaper to hire its own panel of scientists to poke holes in the researchers’ methods.

“Epidemiology isn’t exposing rats to a certain amount of chemicals in a controlled setting,” Ritz notes. “When there are humans involved, there is a lot of potential for error. But it’s still the scientific method. One study can be only so certain with its results, but in the context of the larger science, you draw your conclusions. And when the vested interests don’t like your conclusions, they will always be able to find people willing to question them.”

SPHmag.Nov04.2-13

11/10/04

11:37 PM

Page 7

6

IN

SEVEN YEARS ,

THE FIRST BABY BOOMERS TURN

T HE

65.

CHALLENGE

OF PROMOTING HEALTHY AGING WHILE TENDING TO THE AILMENTS OF A FAST- GROWING ELDERLY POPULATION LOOMS LARGE .

We’re Getting

OLDER...

Will We Be Ready?

One of the best measures of public health’s success in the United States over the last century also presents one if its greatest challenges, now and in the decades ahead.

UCLAPUBLIC HEALTH

We’re getting older.

Thanks to a variety of factors, not least of which is public health’s impact in areas ranging from sanitation and infectious disease control to the promotion of healthy lifestyles, people in this country are living longer, generally healthier lives. But since advancing age continues to be a key risk factor for the most common causes of death and disability, the challenge presented by the sheer demographics of an aging society looms large.

Within seven years, the first baby boomers will turn 65; barely two decades after that, the number of U.S. residents 65 and older is expected to reach 70 million – roughly double what it is now. The trend begs a simple question: If our system of tending to the health needs of society’s elders shows considerable strains today, how will it hold up as the ranks of older people swell?

On the positive side, the next generation of elderly people could be healthier than the current one, which is healthier than prior generations as measured

SPHmag.Nov04.2-13

11/10/04

11:37 PM

Page 8

7

“Given our current system, you would expect that a doubling of the Medicare population would significantly push up our total health expenditures.”

— Dr. Steven P. Wallace

UCLAPUBLIC HEALTH

by declining rates of disability and nursing home admissions. With rising education levels and more information on ways to promote health through such strategies as diet, exercise and not smoking, successful aging is more within the control of populations than ever before. On the other hand, the epidemic of obesity and sedentary lifestyles, with the inevitable impact it has on chronic conditions such as diabetes, cardiovascular disease and cancer, suggests that education and information aren’t always sufficient.

It’s also true that countries such as Japan, France, Spain, Italy, Germany and the United Kingdom, all with significantly higher proportions of elderly, spend much less on health care as a percentage of GDP than the United States. That merely suggests that, despite the fact that health costs of older individuals are considerably higher than those of younger ones in any country, other factors, including the unique characteristics of the health care system, may be even more important.

“We spend more than other countries on hightech medicine and invasive procedures, and hospital costs are a major driver of health care spending,”

cover story

says Dr. Steven P. Wallace, professor of community health sciences and associate director of the schoolbased Center for Health Policy Research, who studies issues related to the elderly and health. “And the United States, unlike those other countries, has this patchwork quilt of health insurance, which has enormous overhead expenses. Given our current system, you would expect that a doubling of the Medicare population would significantly push up our total health expenditures.”

Medicare, originally conceived as a first step toward a national health insurance system, will, by current estimates, cover more than one-fifth of the U.S. population in 20 years. With most politicians reluctant to either raise taxes or reduce benefits in a substantial way, it would seem as if a day of reckoning is unavoidable. Current debates on Medicare reform focus on increasing the reliance on managed care or privatizing the system. But, Wallace argues, managed care hasn’t substantially slowed the rise of costs, and privatizing Medicare in the hope that competition will drive down prices introduces costs related to administrative overhead and marketing.

In fact, Wallace notes, “Compared to the alternatives, Medicare is the most administratively efficient system in the country.”

SPHmag.Nov04.2-13

11/10/04

11:37 PM

Page 9

8 As policy-makers grapple with Medicare’s soaring tab, beneficiaries have struggled with outof-pocket costs. Growing concerns about the affordability of prescription drugs led to passage of the Medicare Modernization Act, signed into law by President Bush in 2003 and scheduled to take effect, following a transition phase, in January 2006. But the benefit’s so-called doughnut-hole structure has been criticized. For a premium estimated to start at $35 per month, purchased through private insurers, beneficiaries will receive 75% coverage for the first $2,000 they spend after a $250 deductible. After that, they receive no coverage for the next $2,850 spent, before coverage is reinstated at a rate of 95%.

Approximately one in five beneficiaries are expected to have yearly prescription drug bills that will force them to pay the $2,850 out-of-pocket expenses before the 95% coverage kicks in. “If you spend $5,100 a year on drugs, you would pay $3,600 out of your own pocket under this system,” says Dr. Tom Rice, professor of health services at the school. “It’s a very incomplete benefit.”

“We should be helping the elderly to assess their needs and prioritize their health strategies, taking a more global approach rather than just focusing on our area of expertise.”

UCLAPUBLIC HEALTH

— Dr. Roshan Bastani

Rice notes that poor and near-poor people would qualify for substantial government subsidies, paying only $1-$2 per prescription for generic drugs and $2-$5 for brand-name drugs. But to qualify, beneficiaries must have not only low income, but also assets below $10,000 for individuals and $20,000 for couples. “On the one hand, we encourage seniors to save, but on the other hand, if lowincome seniors have saved, we’re telling them they’re not eligible for these subsidies,” Rice says.

With funding from the Kaiser Family Foundation, he is currently conducting a study to determine the number and characteristics of people who will be excluded from this benefit based on the assets test.

Wallace points to other potential weaknesses.

“The new law does nothing to promote alternatives to drug therapy, or to deal with rising drug prices, and because the premium is tied to total spending on drugs, it will go up as drug costs go up,” he says.

“This is a political issue that won’t go away any time soon.”

While prescription drugs have consumed the bulk of policy-makers’ attention in recent years, long-term care has been like the elephant in the room that few have wanted to mention. Promoting healthier aging could reduce the nation’s bill for long-term care by lowering disability rates, but no one expects the problem to go away. Nursing homes cost tens of thousands of dollars a year, and the current reality for many disabled elderly is that they exhaust their life savings before qualifying for Medicaid coverage. “It’s not a rational or desirable way of financing long-term care,” says Wallace. He notes that while many begin setting money aside far in advance for their children’s college education, few think about how they might be able to afford long-term care until they are faced with a crisis, by which time it’s often too late.

Financing isn’t the only issue. As families search for alternatives to nursing-home care, particularly in cases where round-the-clock medical supervision isn’t needed, board-and-care, assisted living and other community-based options have grown dramatically. But concerns about quality of care in nursing homes aren’t eased by these new settings, where it’s far more difficult to supervise and monitor the care provided. “Most elderly people would prefer to stay in their homes, or at least in assisted living settings, rather than going into a nursing home,” says Wallace, who has studied disparities by race and ethnicity in the use of and preferences regarding long-term care

SPHmag.Nov04.2-13

11/10/04

11:37 PM

Page 10

Mary Ellen KullmanCourtright,

9

Medicare, already showing signs of strain, will cover more than one-fifth of the population in 20 years. services. “But we are still trying to determine how to ensure quality and affordability in these settings.”

Maxine Weiner Marcus, M.P.H. ’97 As a health educator for the County of Orange, Calif., Office on Aging (OoA), Marcus seeks to optimize the health of more than 400,000 people ages 60 and older.

It’s no small task: “Every city has significant numbers of older adults – many of whom are low-income immigrants who speak little or no English,” Marcus notes. To meet the challenge, she partners with dozens of stakeholders – senior centers, health care agencies, faithbased organizations, governmental agencies, social service providers, hospitals, HMOs, colleges, health charities, parks and recreational centers, senior residences, and ethnic service agencies – to plan and implement programs that help seniors engage in healthy lifestyles.

Last year, funded by a state grant, Marcus’s Active Aging Coalition trained 50 exercise instructors who then taught 5,000 seniors how to strengthen their bones and muscles so that they would reduce their risk of injury due to falls. Marcus also uses a health promotion outreach strategy: Seniors are encouraged, through local media, to call OoA’s Information and Assistance department for referral to senior exercise classes, health fairs, clinics, classes/lectures, and materials that teach them how to manage their health.

UCLAPUBLIC HEALTH

Financial considerations and personal preferences, combined with the growing elderly population and the rising incidence of dementia – for which advancing age is by far the leading risk factor – ensure that family caregivers will assume increasing responsibility, and in many cases suffer hardships and considerable emotional stress as they balance care for their family member with other obligations.

Dr. Carol Aneshensel, professor of community health sciences at the school, recently completed a large study of more than 500 family caregivers of people with dementia, interviewing them annually for five years and continuing to track them after their loved one was placed in a nursing home and following the family member’s death. Aneshensel and colleagues found that a caregiver’s disposition about nursing homes at the start of the caregiving process had no bearing on the likelihood and timing of placement of their relative in such a facility. “The imperatives of the disease are so strong that they override people’s intentions,” she explains. “People who initially said that they would never institutionalize their spouse or parent were no less likely to institutionalize them than those who said they could see themselves doing so.”

For the most part, Aneshensel says, family members continued providing care long after it would have been in their best interest to turn the job over to professionals – an average of eight-and-a-half years from the point where they first recognized something was wrong. “It’s a great myth that people are anxious to institutionalize their relatives and then abandon them,” she says. “The care-

Kullman-Courtright’s interest in public health and aging was sparked by her advisor and mentor at the school, the late Ruth F. Richards.

Richards introduced her to the Arthritis Foundation, where Kullman-Courtright spent six years as a staff member developing community-based programs and working in grants administration. For the last nine years, she has developed funding initiatives and overseen the grants and programs as vice president of the Long Beach, Calif.-based Archstone Foundation, a nonprofit foundation that provides $4-$5 million per year in grants and program support in aging and elder care. “So often when we think of aging, we consider the issues around intensive medical care rather than the other determinants of health as we age,” KullmanCourtright says. “Our view at the foundation includes the broad determinants of health including housing, economic security, social support, transportation, accessibility, mental health, primary prevention, access to appropriate care and medications.” The foundation’s grants provide direct service, education of the broad range of professionals and lay caregivers who work with the elderly, and work that supports the development of policy and planning, demonstration projects, conferences and dissemination of best practices. Among the Archstone Foundation’s major current initiatives are one focused on prevention of falls in the elderly and another on elder abuse and neglect.

cover story

M.P.H. ’83

SPHmag.Nov04.2-13

11/10/04

11:37 PM

Page 11

10

Janet C. Frank, M.S., Dr.P.H. ’94

Soonim Huh, M.P.H.

UCLAPUBLIC HEALTH

The rapid growth of prescription drug expenditures and inadequate coverage for the elderly have drawn national attention in recent years to the concept of universal prescription drug coverage under the Medicare program. The recent Medicare Prescription Drug Improvement and Modernization Act is expected to provide the largest benefit expansion for Medicare recipients – but with drug benefits determined largely by budget constraints and the structure relying on private plans, there are concerns that some beneficiaries will still not be sufficiently covered. Huh, a doctoral candidate in the Department of Health Services, is interested in the effect of prescription drug coverage on the elderly’s overall drug utilization, access to essential medications for specific conditions, and appropriate use of medications. “Optimal use of prescription drugs is critical for treating diseases for which long-term pharmacotherapy may be especially effective in improving health outcomes, and the elderly are more dependent on prescription drugs than other groups,’’ says Huh, who ultimately hopes to evaluate the impact of drug policies such as cost-sharing and formularies on access to optimal medications and health outcomes.

While completing her doctoral studies and working in geriatric medicine at UCLA, Frank began to carve out a niche by bridging the areas of public health, geriatric medicine and gerontology.

In 1990, she was appointed assistant director for academic programs for the UCLA Multicampus Program in Geriatric Medicine and Gerontology. She is also currently director of the California Geriatric Education Center, an interdisciplinary statewide training center funded by the Bureau of Health Professions, HRSA; administrator for the UCLA Older Americans’ Independence Center; director of the National Institute on Aging-funded coordinating center for the Resource Centers for Minority Aging Research; and director of the UCLA Alzheimer’s Disease Center’s Education and Information Transfer Core, as well as an adjunct assistant professor in the UCLA School of Public Health. She explains that work within each of these projects provides opportunities for bestpractice applications of the strong public health foundation she gained as a student at the school. “In geriatrics, most interventions have multiple targets: the individual, the family, the social context, providers of care, and medical and social systems,” Frank says.

“Issues of the aging population are a relatively new area within the field of public health, so there is lots of work to be done.

I tell my public health students, ‘There’s a future in aging!’”

Issues of financing and quality of long-term care options remain unsettled. Family caregivers often bear a huge burden. givers in our study were extremely reluctant to do so, and even after their family member was placed in a nursing home they continued to visit quite regularly and stay involved in the person’s care.”

Aneshensel found that for many caregivers, the physical demands of assisting their loved one were compounded by secondary stressors, including financial burdens and less time to spend with friends or involved in activities they enjoyed. Often, the caregiver’s own physical health suffered. Social and psychological factors – including a sense of feeling overwhelmed by their role – were more influential in the decision to institutionalize the family member than actual tasks such as feeding and dressing the person. The caregivers who were best at coping with the stress were those who showed the greatest sense of what the researchers defined as a “mastery” or self-efficacy – the belief that they could control important things in their lives. This self-efficacy was most likely to be found in caregivers who were well educated and financially secure.

Overall, Aneshensel believes her group’s findings point to the need to provide better support to caregivers. “These families are bearing a huge financial burden that limits their ability to deal with the problems that arise,” she says.

“They are providing a great service to society – if all of the persons who were being cared for by families had to be institutionalized, the formal care system would be overrun. Given that, they deserve more support.”

The elderly population is not only growing larger; it’s becoming more diverse.

“Most policies and discussions of the elderly assume that it’s a homogeneous group,” says Wallace. “To the contrary, although it lags behind in terms of the trend, the elderly population is following the younger age groups in becoming increasingly diverse, and there are large differences involving culture and language that, if not considered, tend to result in doing a disservice to the most vulnerable groups.”

SPHmag.Nov04.2-13

11/10/04

11:37 PM

Page 12

11 still does not cover the costs of interpreters or related services. Ponce found that those with limited English proficiency were the least likely to have a usual source of care or to see a private physician, and the most likely to use a safety-net provider.

Overall, they reported being in significantly poorer physical and mental health than their counterparts who were bilingual or English-only. “Medicare reimbursement for interpreter services could reduce barriers that lead to these disparities,” Ponce says.

Even when they speak English, many seniors face other barriers to services, particularly those designed to keep them healthy. “They’ll go to the doctor when they’re sick, but often the elderly will have transportation or other problems that cause them to postpone getting preventive health care,” says Dr. Roshan Bastani, professor and associate dean for research in the school and associate director of the UCLA Jonsson Cancer Center’s Division of Cancer Prevention and Control Research. She and her colleagues recently tested an intervention designed to remove such barriers by bringing a mobile mammography unit to senior centers and

— Dr. Teresa Seeman

UCLAPUBLIC HEALTH

“What’s most exciting is how much of an improvement people in their 70s and 80s can get with just a little more physical activity.

The biggest benefit comes when you go from doing nothing to doing something, even if it’s just a modest amount.”

cover story

Dr. Marjorie Kagawa-Singer, associate professor of community health sciences, considers cross-cultural aspects of palliative and end-of-life care. Her work investigates how differing concepts of suffering can influence the appropriateness of interventions.

“Members of certain cultural groups may feel their disease is a punishment from God, and that they need to bear the pain and suffering in order to pay penance,” she says. Differences also exist across groups on the question of when to take heroic measures to keep patients alive, even when there appears to be little hope for survival or for restoring any semblance of quality of life.

There are also cross-cultural differences in the value placed on truth-telling, Kagawa-Singer notes.

Until the mid-1970s in the United States, for example, it generally wasn’t considered appropriate or ethical for a clinician to discuss a diagnosis of cancer with a patient; that has changed, but not among all groups or nations. For example, the diagnosis of cancer is not routinely told to patients in France or Italy. Kagawa-Singer is currently studying cultural expressions of bioethical behavior in an effort to develop appropriate strategies to guide clinicians in discussing bad news with patients from cultures different than their own.

Health-related disparities in aging are being addressed by UCLA’s Center for Health Improvement in Minority Elders, funded by the National Institute on Aging. As director of the center’s Investigator Development Core, Dr. William Cunningham, professor in the schools of public health and medicine, is helping to promote the development of minority junior faculty who are conducting community-based participatory research that addresses disparities in areas ranging from access and use of preventive services to prevalence of lifestyle-related conditions such as diabetes, cardiovascular disease and cancer.

“Our goal is to develop projects that do something about the problem rather than simply understanding it, because in many of these areas the disparities are well documented,” Cunningham explains.

One of the pilot projects from Cunningham’s core is led by Dr. Ninez Ponce, assistant professor of health services at the school, who used data from the UCLA Center for Health Policy Researchbased California Health Interview Survey to examine differences in health care access among Medicare seniors with varying levels of English proficiency.

Despite government guidelines that require health care providers receiving federal funds to make interpretation services available when needed, Medicare

SPHmag.Nov04.2-13

11/10/04

11:37 PM

Page 13

12 “The system is stretched to its limits and we are spending considerable resources on some interventions that have little benefit while ignoring other treatable problems.

Further, as health care costs increase, so does the number of employers who decide not to offer health insurance.”

— Dr. Robert Kaplan

Lené Levy-Storms,

UCLAPUBLIC HEALTH

M.P.H. ’92, Ph.D. ’98 “When I realized how essential social relationships are to healthy aging, I found my passion,” says LevyStorms, now an assistant professor of social welfare and medicine at UCLA. In 2003, she received a fiveyear National Institute on Aging career development award in which she is using survey and digital video methods to define and measure how mostly minority nursing aides communicate with mostly Caucasian older adults during nursing home care. Using edited video footage of nursing aides, Levy-Storms is evaluating a peer-based training program to improve the nursing aides’ communication with residents. “Nursing aides do not talk enough to nursing home residents, and when they do they lack an emotional connection with them,” LevyStorms says. “By seeing themselves on video and receiving constructive feedback from their peers, the nursing aides will, ideally, learn how to optimize that relationship by using both verbal and non-verbal ways to positively connect with residents during care.”

meal sites. Study subjects in the control group received the same information and education about mammography screening as those in the intervention group, but without access to the mobile van they were much less likely to get screened. “Many services – including flu shots and promotion of healthy nutrition and physical activity – could be made more readily available by going to the sites where elders congregate,” Bastani says.

In fact, often overlooked amid the legitimate concerns about how best to address the health care needs of an aging population are strategies for promoting healthy aging. Dr. Teresa Seeman, professor in the schools of medicine and public health, has contributed to a growing body of knowledge on how social relationships and other lifestyle behaviors influence health and aging through biological pathways. Seeman has published data on the benefits of increased physical activity by elderly persons, even when it comes in the form of increased walking. “What’s most exciting to me is how much of an improvement people in their 70s and 80s can get with just a little more physical activity,” she says. “There’s a misconception among a lot of older adults that you have to do a lot for it to make a difference. But the biggest benefit comes when you go from doing nothing to doing something, even if it’s just a modest amount.”

Equally encouraging are Seeman’s findings that a strong social support network increases longevity by affecting a wide range of biological systems known to have an impact on health – including lower blood pressure, lower levels of stress

hormones and reduced levels of inflammation. “As people get older, they retire from work and their social interactions are often reduced,” Seeman notes.

“Our findings suggest that we need to be aware of the importance of facilitating ongoing social engagement by older adults, which can improve not only their mental health, but also, we’re learning, their physical health.”

Bastani suggests that public health could do a better job of communicating messages about healthy aging. “Training in the special issues that are important to the elderly isn’t routinely provided in public health education,” she says. “We need to better understand the aging process and be more sensitive to their needs.” For example, she explains, prevention messages might need to be modified when being delivered to older adults with multiple conditions, or those who have just gotten out of the hospital.

“We should be helping the elderly to assess their needs and prioritize their health strategies, taking a more global approach rather than just focusing on our specific area of expertise,” she says.

When it comes to allocation of the U.S. health care system’s limited resources, rational prioritizing has not always been the order of the day. Dr. Robert Kaplan, recently recruited to the school as chair of the Department of Health Services (see page 31), has been interested in how best to optimize health care spending to manage populations, including the elderly. Through his studies, he has developed a “disease reservoir hypothesis” – the idea that for conditions common to older people, much of what is found through more vigilant detection efforts is disease that is not likely to have an impact on health outcomes, or for which treatment may produce down sides at least as great as the benefits.

SPHmag.Nov04.2-13

11/10/04

11:37 PM

Page 14

13

A growing body of evidence indicates that social engagement and physical activity are key components of healthy aging.

Linda Delp, M.P.H. ’84 California’s In-Home Supportive Services program enables more than 300,000 low-income elderly and disabled to stay in their homes and to live independently in the community. It is the largest such program in the country and uniquely structured to allow both consumers and workers to have a voice in the system.

Consumers can hire their own home care providers, including family members if they choose to do so; workers are represented by a union, the result of many years of organizing for better wages and benefits. Delp, a doctoral candidate in the Department of Community Health Sciences, is examining the working conditions for California’s 200,000 home care workers. “The historically low wages and lack of benefits for this primarily female and ethnically diverse workforce has created a field plagued by high turnover and a worker shortage,” she notes. Her dissertation is part of a multi-county, 2,500-worker study to examine the role of wages, benefits, working conditions and caregiving relationships as determinants of job satisfaction and workers’ intent to continue providing home care. Delp plans to analyze differences between low-wage and high-wage counties, across ethnicities, and between family and non-family providers.

Sandra Maldague,

cover story

“Approximately 3% of men die of prostate cancer, but as many as 60% of older men will have it if you look hard enough,” says Kaplan. “For an elderly person, the cancer is not likely to change life expectancy, and sometimes people end up worse off if they are aggressively treated.” Similarly, he has studied the concept as it pertains to breast cancer screening. More recently, Kaplan has been examining the impact of lowered thresholds for putting older persons on medication when they have elevated blood pressure, cholesterol, or blood sugar levels.

“A lot of patients are unaware that these are controversial issues among public health and medical researchers,” says Kaplan. He has promoted the concept of shared medical decision-making, in which clinicians present both sides of controversial issues and involve patients to a greater extent in the course of their care.

“The consequence of increased detection of chronic conditions is that health care has become much more expensive,” Kaplan says. “The system is stretched to its limits and we are spending considerable resources on some interventions that have little benefit while ignoring other treatable problems. Further, as health care costs increase, so does the number of employers who decide not to offer health insurance. It’s making society less capable of properly prioritizing the problems, as well as contributing to the number of uninsured.”

Those in public health who, like Kaplan, are looking at the big picture of how to optimize health among an aging population agree that important decisions must be confronted. “The incentives in the health care system favor hightech and invasive treatments, when a lot of the conditions that have the most dramatic effect on older people’s quality of life are more amenable to low technology and less expensive interventions,” says Wallace. “We will need to reassess our priorities to focus on what’s in the best interest of the elderly population.”

M.P.H. ’99

UCLAPUBLIC HEALTH

Maldague’s interest in the concept of healthy aging was sparked when, at 18, she spent a summer taking care of her great-grandparents in France. “While they suffered from many chronic conditions, they were in generally good health, going on hourlong walks every day, keeping up their friendships, playing Scrabble, staying informed of current events, and serving as the focal point for a large family,” Maldague recalls. “Eating well was a big part of their life – they had 20-year relationships with local shopkeepers and knew where to go for the best products.” Through her studies at UCLA and her subsequent work at the American Society on Aging, Maldague has come to realize how unusual her experience with older adults had been, and grew motivated to help more people have better experiences of aging. At the American Society on Aging, Maldague has learned about the variety of professionals who promote the health of older adults, supporting them in conducting health promotion program planning and evaluations.

“The vision of healthy aging that I learned early on, the diversity of the field, and the challenge of enabling all people to achieve a healthy, active old age keep me fascinated and engaged,” she says.

SPHmag.Nov04.14-35

11/10/04

14

W ITH

THE COST

11:26 PM

Page 1

Investing in Their Future – and Ours

OF PURSUING A GRADUATE DEGREE ON THE RISE ,

SPH

STEPS UP

EFFORTS TO ASSIST TALENTED CANDIDATES .

The Smart Money Is Supporting the School’s Students The generosity and vision of two people she never knew gave Kristin Elizabeth Yarris (above) the impetus to pursue her Ph.D. in the

UCLAPUBLIC HEALTH

UCLA School of Public Health’s Department of Community Health Sciences.

Yarris, who completed her M.P.H. at the school and M.A. in Latin American Studies last spring, was nominated for and awarded a fellowship from the Bette and Hans Lorenz Endowment Fund. The financial support was instrumental in her decision to enroll in the school’s Ph.D. program. Once she has completed her required coursework, Yarris, who has spent the last three summers working with non-governmental health organizations in Central America and Brazil, plans to conduct her field research in Latin America, seeking to better understand how community-based organizations respond to health problems using community organization- and popular education-based approaches.

At a time of escalating costs and intense competition from other public health schools and other professions for the top students, Yarris provides one of many illustrations of the importance of financial support in attracting the best candidates to the UCLA School of Public Health’s graduate programs.

“I had always intended to pursue an M.S.W. degree and become a licensed social worker,” says Yarris, who entered the M.P.H. program with an eight-year

SPHmag.Nov04.14-35

11/10/04

11:26 PM

Page 2

15 ects, students can apply to one of several internship programs offered through gifts from private donors, including the Max Factor Foundation, Wilshire Foundation, and Monica Salinas programs.

As of 2002-03, nearly three-fifths of the school’s students – 58% – were receiving merit-based aid, with an average award of $17,331 per year. When factoring in need-based financial aid, more than fourfifths – 83% – were receiving some form of support, at an average annual level of $24,117. While the proportion getting some type of aid has remained steady in recent years, the amount of funding per student has risen considerably.

“We’re doing increasingly well, particularly over the last few years,” says Kominski. “But with fees set to go up rapidly, we face growing challenges and we’re going to have to work even harder to continue meeting our students’ needs.”

RUTH FARNAN RICHARDS, a long-time member of the school’s Department of Community Health Sciences and the namesake of a scholarship for students, died in September at the age of 87. As a public health educator, Richards educated civilians and physicians in India, Yugoslavia, and South America through the World Health Organization. She was active in the Society for Public Health Education, serving as its president in 1984. The Ruth F. Richards Outstanding Student Award is given at the school each year in her honor.

SCHOOL OF PUBLIC HEALTH TOTAL FINANCIAL AID, 2002-03 $12,878,218

Total Merit-Based $6,533,946 Total Need-Based $6,344,272 UCLAPUBLIC HEALTH

Constance Gewa became interested in the school’s doctoral program when, while working toward her master’s degree in applied nutrition at the University of Nairobi in Kenya, she met Dr. Charlotte Neumann, a professor who has conducted nutrition-related research in Kenya for more than two decades. Gewa worked on Neumann’s study of the effects of animalsource foods on the growth and cognitive development of children and realized that a doctorate from the UCLA School of Public Health could give her tools to better address nutritional problems in her native country. She applied and was accepted to the school’s doctoral program, but knew that without financial support, the dream would be unobtainable: Gewa lacked adequate funds to cover tuition, outof-state-fees, and living costs.

Thanks to the support she received through the Eleanor J. De Benedictis Fellowship in Nutrition, Gewa is at the school, focusing on international health with a special interest in human nutrition.

“I really appreciate the support I’ve gotten from this fellowship,” she says. “It has covered my out-of-state fees and helped me to be able to afford the costs of childcare services for my young daughter so that I can enroll in courses and have time for studying.”

UCLA’s Graduate Division estimates that in 2002-03, the cost of attending graduate school at UCLA for California residents was $23,000 per year.

For non-residents like Gewa, it was nearly $38,000.

Tuition, fees and books are only a small part of those figures, which also include living expenses in a city in which housing costs are high. Moreover, these figures don’t take into account full-time work

feature

professional background working with communitybased nonprofit organizations in health and social services. “But I was drawn to public health because I believe the field provides the tools to address some of the underlying causes of ill health and other social problems. Receiving the Lorenz fellowship has in large part made possible the first year of my Ph.D. program.”

“Ensuring that we continue to be able to enroll the best students in the country has always been a high priority for our school, but it’s even more important now in light of rising tuition costs and the inability of the state government to provide support at the levels people had come to expect in the past,” says Dr. Linda Rosenstock, dean of the UCLA School of Public Health. “It’s very difficult for most students to make it through school without financial support, and we want to be there to help them.”

In recent years, the school’s efforts in this area have paid off: Financial support has increased at a rate that has surpassed students’ rising costs. In particular, merit-based support has gone up substantially, as federal funding, private donations and grant support for graduate student researchers and teaching assistants have boosted the school’s efforts to attract and retain the most talented students.

Support for UCLA School of Public Health students comes from a wide variety of sources – from individual faculty members, from the school’s five departments, and school-wide through the Dean’s Office. Approximately half of the school’s total support is need-based, in the form of employment, loans and financial aid, awarded based on economic considerations. The other half is merit-based, a category that includes private awards; research and teaching assistantships, including those from contracts and grants awarded to faculty; UCLA Graduate Division support; and federal funding in the form of traineeship programs, including the UCLA-Fogarty AIDS International Training and Research Program, the Southern California NIOSH Education and Research Center, the UCLA/RAND Health Services Research Training Program, Biostatistics Training for AIDS Research, the Interdisciplinary Maternal and Child Health Training Program, the Pacific Public Health Training Center, and others.

“Most forms of support available to students come with some type of work- or service-related expectation,” says Dr. Gerald F. Kominski, the school’s associate dean for academic programs, “but the great thing about this arrangement is that while students are receiving assistance that helps them get through school, they’re also typically working on a project related to their field of interest. It’s a win-win situation.” In addition to the federally funded traineeships and opportunities to work on faculty research proj-

SPHmag.Nov04.14-35

11/10/04

11:26 PM

Page 3

16

Kynna Wright (r.) is supported by a California Endowment fellowship in her research on disparities in access and use of services among children with asthma.

income that many students sacrifice in order to dedicate themselves to their studies.

To ease these burdens, the school has stepped up its efforts to gain additional support for students through foundations and the generosity of private donors. In addition, Rosenstock has identified student support as a priority for donations to the school’s Annual Fund. And finally, a sharp rise in faculty research productivity has brought in critical support

for students who can work as paid researchers through grants. Since 1996, the school’s support for graduate student researchers has increased by 62%.

“The net effect is that we are supporting students at unprecedented levels,” Rosenstock says.

Rosenstock is the principal investigator on two major grants for student support that have come from The California Endowment and California Wellness Foundation, and oversees students whose internships are funded through a gift from Dr. Monica Salinas.

In different ways, all three programs not only support students, but strengthen the school’s capacity to address health disparities among underserved communities and bring greater diversity to the public health profession.

“My scholarship is directed toward students who are interested in learning about how public health issues are managed within minority communities and in Latin America. I believe that my contribution helps them acquire valuable information that they can then incorporate into their work and research,” says Salinas, who received the Dean’s Award last June in recognition of her sustained and generous support for students. “Providing support to UCLA School of Public Health students is extremely rewarding,” she adds. “Students receive the best education possible to prepare them to make tangible and lasting contributions to improve the health of our community, country and world.”

A California Wellness Foundation fellowship made a major positive impact on the educational experience for Ignacio Ferry (M.P.H. ’04, M.A.),

SCHOOL OF PUBLIC HEALTH PER CAPITA FINANCIAL AID, 1996-2003

Per Capita Support

Per Capita Merit-Based Support

$30,000 $24,117

$25,000 $17,331

$20,000

$18,891

$15,000 $11,605

$10,000

In 2002-03, 58.3% received merit-based aid, and 83.3% received any support.

2002-03

2001-02

2000-01

1999-00

1998-99

1997-98

$0

1996-97

2002-03

2001-02

2000-01

1999-00

1998-99

1997-98

1996-97

UCLAPUBLIC HEALTH

$5,000

SPHmag.Nov04.14-35

11/10/04

11:26 PM

Page 4

17

feature

EXAMPLES OF PRIVATE SOURCES OF STUDENT SUPPORT, 2003-04* ABDELMONEM A. AFIFI STUDENT FELLOWSHIP FRED H. BIXBY SUMMER INTERNSHIPS CELIA AND JOSEPH BLANN FELLOWSHIP THE CALIFORNIA ENDOWMENT CALIFORNIA WELLNESS FOUNDATION ELEANOR J. DE BENEDICTIS ENDOWMENT FELLOWSHIP IN NUTRITION who, while pursuing joint master’s degrees in public The Eleanor J. De Benedictis Fellowship health and Latin American studies, was also working in Nutrition enabled part-time and tending to his obligations as a husband Constance Gewa (above and father of two children, both born while he was right) to come to the in graduate school. school from Kenya for “Because of the fellowship, I could be less focused her doctoral education. on financial constraints and was able to devote time to organizing events through my involvement with the Students of Color for Public Health,” says Ferry, 2003-04 co-chair of the group, which provides social, academic and professional support to the school’s students and alumni of color. Among other things, Ferry helped to put together activities focused on encouraging high school and undergraduate students to consider public health careers, as well as forums to raise issues of concern specific to underserved populations. He is now working in adolescent health and youth development with the Restorative Justice Program of the Bill Wilson Center, a nonprofit organization in the San Francisco Bay area whose mission is to support and strengthen the community by serving youth and families through counseling, housing, education and advocacy.

For Kynna Wright, The California Endowment fellowship has been critical to her ability to focus on her doctoral studies, in which she is exploring disparities in access and utilization of health care services among children with asthma.

“Without this funding, I would have had to work a lot more, and it would have slowed the process down considerably,” says Wright, whose future plans include political advocacy and policy development addressing health problems facing women and children of color.

NEUMANN-DRABKIN INTERNATIONAL FIELD FELLOWSHIPS MAX FACTOR FAMILY FOUNDATION INTERNSHIP PROGRAM LENOR GOERKE AWARD FOR GENERAL EXCELLENCE RAYMOND GOODMAN SCHOLARSHIP BETTE AND HANS LORENZ ENDOWMENT FUND TONY NORTON MEMORIAL FELLOWSHIP ANN G. QUEALY MEMORIAL FELLOWSHIP ENDOWMENT MONICA SALINAS INTERNSHIP IN LATINO AND LATIN AMERICAN HEALTH SCHOOL OF PUBLIC HEALTH ALUMNI ASSOCIATION RUTH F. RICHARDS OUTSTANDING STUDENT AWARD JUNEAL MARIE SMITH FELLOWSHIP IN INTERNATIONAL NUTRITION STEP UP AWARDS (LEGACY/ASPH) THAI HEALTH OUTREACH WAYNE SOOHOO SCHOLARSHIP SAMUEL J. TIBBITTS FELLOWSHIP BETTY S. WILLIAMS SCHOLARSHIP WILSHIRE FOUNDATION ENDOWMENT INTERNSHIP PROGRAM IN GERIATRIC MEDICINE AND LONG-TERM CARE *There are many other forms of support available to UCLA School of Public Health students, including support from the school’s departments and from individual faculty members through contracts and grants.

UCLAPUBLIC HEALTH

Despite the many forms of support now available to students, there is no room for complacency, says Natasha Brown Levy, the school’s manager of student affairs. “With tuition and fees expected to go up dramatically in the next few years, our students will continue to face hardships in their efforts to get the education that will help them become our future public health leaders,” she notes. “Our ability to stay ahead of the curve in terms of the level of support we can provide will go a long way toward ensuring that the UCLA School of Public Health remains able to attract the quality of students that its reputation as a nationally renowned school warrants.”

“Student support will continue to be one of our school’s highest priorities,” says Rosenstock. “Now more than ever, we are looking to our alumni and friends to continue helping us as we strive to maintain what we believe to be the best caliber of students of any public health school.”

DEAN'S OUTSTANDING STUDENT AWARD

SPHmag.Nov04.14-35

11/10/04

11:27 PM

Page 5

Getting Wise About Workers

18

U.S.

WORKERS

ARE TOILING LONGER HOURS WITH LESS SECU RITY.

E CONOMIC

SHIFTS ARE CREAT ING NEW CONCERNS AS OLD ONES PERSIST.

T HROUGH

RESEARCH AND EDUCATION , THE SCHOOL SEEKS TO KEEP WORKERS WELL .

We All Gain from Promoting the Health of Employees

UCLAPUBLIC HEALTH

Jeff Birkner has been an industrial hygienist for two decades Above: Students who take the “Health Hazards of Industrial Processes” course offered by the school’s NIOSH Education and Research Center tour a different type of industrial facility each week to learn about the health and safety challenges associated with various processes.

and is vice president of technical services for a major respirator manufacturer. But he couldn’t have possibly appreciated the scope of worker health and safety issues arising from different industrial processes until, as a doctoral student at the UCLA School of Public Health, he was given the ultimate tour.

Through “Health Hazards of Industrial Processes,” offered every Winter Quarter, Birkner and other students – both doctoral and master’s – at the schoolbased Southern California NIOSH Education and Research Center (ERC) piled into a van and journeyed to a different type of industrial facility each week, surveying the plant and talking with management and workers before writing a report on the health hazards and how they are handled.

A surface mining operation in Boron, Calif. A secondary smelter that recycles batteries into metallic lead. An electroplating shop. A petroleum refinery. A manufacturer of roof shingles. A food-processing facility. A maker of bathtubs and

SPHmag.Nov04.14-35

11/10/04

11:27 PM

Page 6

19 Each day, an average of 9,000 U.S. workers sustain disabling injuries on the job, 16 die from an injury suffered at work, and 137 die from workrelated diseases. Moreover, even as the traditional focus of injuries and illnesses from workplace exposures remains as important as ever, occupational health and safety experts in the ERC, elsewhere in the school and throughout the country believe the proper approach to promoting the health of workers also takes into account other concerns.

“We’ve learned to look at health and safety more broadly,” says Dr. Linda Rosenstock, who was director of NIOSH before becoming dean of the UCLA School of Public Health, and whose Textbook of Clinical Occupational and Environmental Medicine (Elsevier Science, Second Edition) was released in October. “We have a better understanding that worker health is related to such factors as employment security, uninsurance, appropriateness of work settings, and job-related stress. We have had great success dealing with traditional problems like chemical hazards and lead exposure, but with the shifts in the workforce and the nature of work, other health issues are emerging.”

In particular, Rosenstock notes, changes in work organization raise new concerns. U.S. workers are putting in longer hours than they did 20 years ago – 47 hours a week on average. Thirteen percent have two jobs. Workers in the United States lead the world in the number of hours clocked per year – more on average than Japanese workers, and 350 hours (about nine work weeks) more than Europeans. Not coincidentally, workplace stress is a growing problem. An estimated 13% of U.S. worker compensation claims

feature

“There is a lot of good research that’s been done, but there is still uncertainty, and a good deal of judgment that goes into making decisions concerning these exposures.”

—Dr. William Hinds

UCLAPUBLIC HEALTH

shower enclosures. An iron foundry. Some are union shops, others are not. Some are large corporations with thousands of employees and nationwide facilities, others are mom-and-pop operations. It’s the full spectrum of manufacturing facilities encountered in the occupational health and safety field, with challenges ranging from a variety of potential chemical and environmental exposures to the gamut of safety and ergonomic issues.

“We’re in the middle of California’s manufacturing base, which provides an ideal laboratory for students that we are able to take advantage of,” says Dr. William Hinds, professor at the school and director of the ERC, one of 16 multidisciplinary centers across the country supported by the National Institute for Occupational Safety and Health for education and research in occupational health.

Students appreciate the hands-on experience.

“The ERC program provides a strong foundation in the theory so that we are better able to solve problems on our own, and that course was great practice for industrial hygiene work – an excellent overview of the types of hazards that are out there,” says Samantha Yaussy Chua, who received her M.S. from the program last spring and now works as technical lead – taking and analyzing samples at workplaces and homes – for an environmental consulting company.

Health Hazards of Industrial Processes, a teamtaught course led by Dr. Nola Kennedy, adjunct assistant professor at the school, is the capstone of the Southern California NIOSH ERC, which offers degrees in occupational medicine and occupational health nursing as well as industrial hygiene. Approximately 40 students are supported through a training grant that the school has received since 1983. The funding – renewed for another five years effective last July – also supports a continuing education and outreach program as well as training for hazardous waste workers.

Part of the job of many of the environmental specialists trained in the school’s Industrial Hygiene Program is to interpret the toxicological research on health hazards and use that information to evaluate and control exposure to potentially dangerous chemical agents. “There is a lot of good research that’s been done, but there is still uncertainty, and a good deal of judgment that goes into making decisions concerning these exposures,” says Hinds. “These chemicals are mostly invisible – you typically can’t sense them – and they cause disease over a long period of time, so you don’t get much feedback that people are being overexposed. You have to understand the nature of these risks, and that requires special training that we provide in our programs.”

SPHmag.Nov04.14-35

11/10/04

11:27 PM

Page 7

20

UCLAPUBLIC HEALTH

ERC students tour the parts area at a Metropolitan Transportation Authority facility in Los Angeles, where buses are repaired and engines rebuilt or refitted for changing to compressed natural gas. are for stress-related disorders. Twenty-seven percent of U.S. workers report their jobs are their greatest single source of stress. Additionally, 46% frequently worry about being laid off – a proportion that has more than doubled in the last 20 years. One in four U.S. workers is in a non-traditional employment situation – including temporary or contingent work and self-employment – often not by choice. And of the 45 million Americans who have no health insurance, more than 80% are in working families, with the burden falling disproportionately on younger workers, minority workers, and those with less education.

Addressing such concerns benefits not only the workers who bear these burdens, but also U.S. businesses, Rosenstock points out. “People often miss the fact that investing in worker health and safety can improve a company’s bottom line,” she says. “For example, we have known for a long time that doing so in the car manufacturing process decreases the cost of health-related illness and increases economic productivity, and is also linked to improving the quality of the products. People questioned whether this could be generalized to other industries, and we now have evidence that, in fact, the same is true when it comes to investing in the health and safety of the health care workforce.”

That evidence comes in part from a study by Dr. Jack Needleman, who was at Harvard at the time and is now an associate professor at the UCLA School of Public Health. In 2002, Needleman reported in the New England Journal of Medicine results of the first large study drawing a connection between inadequate nursing staff levels and poorer patient outcomes. “When nurses are overworked, they

cannot do the same job of monitoring patient conditions that they can when nurse staffing is better,” Needleman explains.

Health care is one of the fastest growing work sectors – and one in which there are lingering concerns. Stresses on the system include a severe nursing shortage and an aging population that ensures increasing demands on health care personnel, particularly low-paid home-care workers. While rates of all workplace injuries and illnesses are declining, rates for health care workers – now 8% of the U.S. workforce – are on the rise. They face risks from lifting, stress, assaults, blood-borne and respiratory infections, and latex allergy from the use of protective gloves, to name a few.

In addition to the potential for allergic reaction, gloves and other items meant to protect workers in certain industries are not always as effective as they might appear. Dr. Shane Que Hee, professor of environmental health sciences at the school, has conducted studies of the amount and characteristics of chemicals that pass through “protective” materials.

He and his students have found that when complex mixtures such as pesticides and metal-working fluids permeate gloves, what gets through is often significantly different from the original chemical composition. “That means you can’t necessarily look at the dominant compounds in a mixture and say that a glove will be permeable or not,” he explains.

“You have to do the experiments to know for sure.”

The wearing of protective materials often provides a false sense of security for workers, Que Hee says, because workplace conditions don’t necessarily mimic conditions used by government regulators to certify them. “The highest concentrations of expo-

SPHmag.Nov04.14-35

11/10/04

11:27 PM

Page 8

21

feature

sures typically occur in the workplace, where you have closed conditions, ventilation can be poor, and workers are often in close proximity to the source of exposure,” he says. In the same manner, wearing a respirator does not necessarily protect a worker. Que Hee has developed technology to sample the air inside a respirator to measure what gets through the filters and methods to detect whether this material is toxic if the exposing agent is unknown.

Dr. Wendie Robbins, an associate professor in the UCLA School of Public Health and School of Nursing and director of the ERC’s Occupational and Environmental Health Nursing Program – in which future occupational and environmental health nurses take public health as well as nursing courses to learn more about high-risk worker populations – is heading a NIOSH-funded team examining the reproductive effects of occupational exposure to boron in male workers who mine the element in Liaoning Province, China. Robbins is conducting the study in China because the exposure levels are significantly greater at the plant there than in the mining plant in Boron, Calif., toured by the ERC students – the only such plant in the United States – rendering it more likely that her group will be able to detect levels at which the element causes risk.

On the other hand, perhaps as a byproduct of Robbins’ research, worker health and safety measures at the plants being studied in China have recently improved. “It makes it more difficult to conduct the study, but it is very gratifying to me that we seem to be having this positive impact on worker health and safety,” she says.

Back in Los Angeles, Dr. Beate Ritz, in collaboration with ergonomics researchers at UC San Francisco and UC Berkeley, is addressing another pervasive problem. Her study of more than 300 garment workers recruited from shops in Chinatown and El Monte tests the impact of redesigned work stations and ergonomic chairs on prevention of pain and musculoskeletal disorders. Job-related musculoskeletal disorders such as low-back pain, tendonitis, and carpal tunnel syndrome account for much of the cost of work-related illnesses and injuries in the United States, amounting to an estimated $13-$54 billion in annual treatment costs.

“We’ve learned to look at health and safety more broadly. We have a better understanding that worker health is related to such factors as employment security, uninsurance, appropriateness of work settings, and job-related stress.” —Dr. Linda Rosenstock

Certain settings place workers at higher risk for violence, notes Dr. Jess Kraus, professor of epidemiology and director of the school-based Southern California Injury Prevention Research Center. These include small businesses – such as

ERC students tour the US Borax mine facility, where boron is processed.

UCLAPUBLIC HEALTH

SPHmag.Nov04.14-35

11/10/04

11:27 PM

Page 9

22 At LASCO in Anaheim, Calif., ERC students view a shower stall mold and learn how shower enclosures are coated with fiberglass and other resins by a spray-on process.

“When nurses are overworked, they cannot do the same job of monitoring patient conditions that they can when nurse staffing is better.”

UCLAPUBLIC HEALTH

—Dr. Jack Needleman

liquor stores, gas stations, bars, fast food restaurants, and taxi driving – where there are late-night hours and money is exchanged. “A proportion of the workforce is in settings where security measures can be taken,” says Kraus, “but it’s not as feasible to offer protective services to a small liquor store, for example. In such cases, there is constant exposure to risk.”

Differentiating violence that is work-related from that which is not can be difficult. Sometimes, work just happens to be the setting for a violent act committed by a perpetrator who knows that is where he or she can find the victim. Kraus is currently completing a study seeking to improve the classification of suicide at work.

In examining California coroner records, he found that because suicides are classified based on where they occur – without regard to the motivation behind them – many are mislabeled. “If we want to look at risk factors for suicide at work so that we can prevent it, we need to improve the way suicides are classified,” he says.

At the UCLA Labor Occupational Safety and Health (UCLA-LOSH) Program, part of the School of Public Health-based Centers for Environmental Quality and Health, there is a focus on two populations that are particularly vulnerable to work-related injuries and illnesses: immigrants and the youngest workers. “These are two groups that are more likely to take whatever job they can get, without training on the health and safety issues they will face, and that are often unaware of their rights as workers or afraid to voice concerns or report injuries for fear of losing their jobs,” says Linda Delp, UCLA-LOSH’s director effective in January 2005, replacing Marianne Brown, who retired as director earlier this year.

UCLA-LOSH has targeted both immigrant workers and high school students with education and training initiatives. The program is also the lead agency in a National Institute of Environmental Health Sciences-funded consortium to train workers who clean up hazardous waste sites, and is participating in health and safety training for port workers along the West Coast.

It is the working poor and working middle class who disproportionately bear the burden of workplace illness and injury as well as uninsurance, notes Rosenstock. By compiling evidence of what causes problems in health status for workers and which interventions are effective in addressing these problems, public health can make a significant difference in the lives of workers – a population that, after all, includes almost all adults at one time or another.

SPHmag.Nov04.14-35

11/10/04

11:28 PM

Page 10

23

research

research highlights Patients with Chronic Conditions Reduce Their Use of Prescribed Drugs When Co-Payments Double

Condition

WHEN THE COST OF PRESCRIPTION DRUG co-payments doubles, patients cut their use of common drugs for chronic diseases such as diabetes, asthma and gastric acid ailments by as much as 23 percent, a UCLA School of Public Health and RAND research team has found.

In the study, published in the Journal of the American Medical Association, Predicted Change in Drug Use people being treated for diabetes cut back on anti-diabetes drugs other than When Co-Payments Are Doubled insulin by 23 percent when co-payments doubled, while those treated for asthma for the Chronically Ill reduced anti-asthmatic drug use by 22 percent.

People with gastric disorders cut use of related drugs by 17 percent.

“We don’t have enough information to know if 31 Allergic rhinitis this is having an impact on people’s health, but 27 Arthritis now we know the groups that are most at risk,” says lead author Dr. Dana Goldman, adjunct 23 Diabetes associate professor at the school and director of 22 Asthma health economics at RAND. “These findings show us where health problems may arise. Raising co17 Gastric acid disorder payments is a blunt tool for changing people’s use 10 of prescription medicine. If we want to change the Elevated cholesterol patterns of drug use so that we don’t adversely 10 Hypertension affect patients’ health, that will require more sophisticated benefit designs.”

8 Depression The researchers found preliminary evidence that patient health suffers as patients with some 30 5 0 10 20 25 15 chronic illnesses cut back on their medicines. % Reduction in Days of Drugs Consumed For example, as the use of prescription drugs When Co-Payments Double dropped, visits to hospital emergency rooms increased 17 percent and hospital stays rose by 10 percent among patients with diabetes, asthma and gastric acid diseases.

Goldman’s group studied the experiences of nearly 530,000 privately insured non-elderly adults from 1997 to 2000, examining how the use of eight therapeutic classes of drugs changed when co-payments for prescription medicines doubled. The drugs involved treat high blood pressure, elevated cholesterol, depression, arthritis, asthma, allergies, diabetes and gastric acid disorders, including ulcers.

Use of all of the drugs dropped, particularly for medications that have close over-the-counter substitutes. “We see significant price sensitivity, but most people do not change their use of prescription drugs indiscriminately,” says Dr. Geoffrey Joyce, a RAND economist and assistant visiting professor at the school who was the study’s other principal investigator. “Some changes may be appropriate by reducing overuse of certain medications, particularly drugs that treat symptoms rather than the underlying disease.”

Patients generally were less likely to reduce use of a drug if they were receiving ongoing care from a physician for the disorder.

35

UCLAPUBLIC HEALTH

SPHmag.Nov04.14-35

11/10/04

11:28 PM

Page 11

24

School-Based Peer Education Program Effective in Promoting Condom Use to Reduce Spread of HIV IN A COUNTRY WHERE RISING HIV/AIDS RATES among adolescents is a great concern, a school-based peer education program can be effective in changing attitudes and behaviors related to condom use, a research team of UCLA School of Public Health faculty and students has concluded.

The study by Dr. Janni Kinsler (M.P.H. ’98, Ph.D. ’02), her faculty advisor Dr. Mean Scores for Condom Use, Donald Morisky and Carl Sneed and Alfonso Ang, assistant researchers in the Attitudes, and Intentions Among school’s Department of Community Health Sciences, evaluated the impact of a Student Receiving Peer-Group cognitive-behavioral, peer-facilitated, school-based HIV/AIDS education proIntervention gram on the knowledge, attitudes and behavior of primary and secondary students in Belize – the country with the highest HIV prevalence rate in Central America, and where concern is particularly focused on Pre-Intervention adolescents and young adults. As of 1999, the HIV Post-Intervention prevalence rate among the 15-24 population in Belize 5.0 was 1.75 per 1,000, with 2.59 of every 1,000 males 4.84 4.79 infected. Approximately 30% of the country’s HIV infections are in people ages 15-24.

4.0 For their study, published in Health Education 4.00 Research, the researchers recruited 150 students from six schools in Belize City, with half receiving a three3.34 3.0 month-long intervention consisting of seven weekly 2.91 two-hour sessions conducted by peer educators. The sessions sought to increase HIV/AIDS-related knowl2.0 edge, positive attitudes toward condom use, perceived 1.86 susceptibility to contracting HIV, self-efficacy, intention of using condoms, and condom use. All activities in the 1.0 educational sessions were interactive and included role-playing exercises, role-model testimonials, skillsbuilding activities, and other strategies tailored to the 0 concerns of the youth population in Belize.

Condom Condom Condom At the follow-up assessment, members of the interUse Attitudes Intentions vention group showed higher HIV knowledge, were more likely to report condom use, had more positive attitudes toward condoms, and were more likely to indicate future intentions to use condoms than the students in the control group.

“Our results suggest that using peer educators with whom the study population could relate leads to a supportive and non-threatening environment and ultimately to sex-related behavior change, such as using condoms, to prevent the spread of HIV,” says Kinsler.

The researchers hope additional studies will provide further insight on issues not addressed in this study, including the impact on HIV risk of cultural stigmas associated with homosexuality and bisexuality, gender issues such as machismo and marianismo, and perceptions on sex and AIDS in Belizean culture.

UCLAPUBLIC HEALTH

Two in Five Los Angeles County Residents Exercise Fewer Than 10 Minutes Per Week FORTY-ONE PERCENT OF LOS ANGELES COUNTY RESIDENTS say they get no more than 10 minutes of continuous physical activity per week, according to a UCLA School of Public Health study headed by Dr. Antronette Yancey, associate professor of health services.

Reporting in the American Journal of Preventive Medicine, Yancey’s group found that women were almost twice as likely as men to be physically inactive.

SPHmag.Nov04.14-35

11/10/04

11:28 PM

Page 12

25

research

Older and less educated residents, along with those born outside the United States, were also more apt to be sedentary.

The study, supported by the California Department of Health Services, the Los Angeles County Department of Health Services, and the Los Angeles County Medicaid Demonstration Project, used data from a 1999-2000 random telephone survey of 8,353 Los Angeles County adults. The survey participants were interviewed in English, Spanish, Cantonese, Mandarin, Korean and Vietnamese.

Sedentary behavior – defined as less than 10 minutes of continuous physical activity per week – was more prevalent among those who said they were depressed or in poor health, the researchers found. Yancey and colleagues also found that perceiving oneself to be overweight was a better predictor of physical inactivity than actual measures of overweight such as body mass indices.

More “screen time” was associated with less exercise: County residents who spent three or more hours a day watching television or using a computer in their leisure time reported the highest levels of physical inactivity.

“While much attention in advertising and the media has been devoted to the obesity epidemic, it may also be important to promote physical activity independent of weight loss,” Yancey says.

She and her colleagues on the study – including Drs. Jonathan Fielding and William McCarthy from the School of Public Health – contend that government agencies could promote more exercise among residents by becoming activityfriendly workplaces themselves.

“Sedentary, overweight and diverse captive audiences of adults can be engaged in physical activity during the routine conduct of business,” Yancey says. “Society must share with its members some of the ‘cost’ of adopting and maintaining an active lifestyle.”

The findings are not unlike those of other studies, which suggest that 30% of Americans get little or no regular weekly exercise.

“Similar to the challenge of minimizing tobacco smoke exposure two decades ago, the U.S. epidemic of obesity and sedentariness is now of sufficient social magnitude and cost that increasing physical activity participation can no longer be treated as solely an individual responsibility,” Yancey says.

Physical Activity Levels in L.A. County Adults, 1999

District

% Sedentary (<10 min/wk)

County

41

Compton

45

South

50

Inglewood

46

Long Beach

37

West

31

Hispanic Women with HIV Are Less Likely to Receive State-of-the-Art HAART Therapy than Hispanic Men

UCLAPUBLIC HEALTH

AMONG HISPANICS WITH HIV, women are far less likely to receive highly active antiretroviral therapy (HAART) than men, researchers from the UCLA schools of public health and medicine have reported.

Analyzing survey results from a nationally representative sample of adult HIV patients – part of the HIV Cost and Services Utilization Study – the research group built on its previous findings that Hispanics with HIV are less likely than whites with HIV to receive appropriate treatment, and explored whether important differences exist among Hispanic subgroups.

Most strikingly, Hispanic women with HIV had less than half the likelihood of Hispanic men with HIV of being on HAART, which has been shown to reduce HIV-related morbidity and mortality. This was the case despite the fact that by certain measures, Hispanic women with HIV had better access to care: For example, they were three times as likely as their male counterparts to have a usual source of care at the time of HIV diagnosis. On the other hand, female HIV patients were less than half as likely as male patients to have gone for the rec-

SPHmag.Nov04.14-35

11/10/04

11:28 PM

Page 13

26

Oxidative DNA Damage

research

ommended three ambulatory care visits in the previous six months, and had made nearly three times as many emergency department visits without an associated hospital stay – an indicator of sub-optimal care.

The reasons for women’s poorer access to appropriate care compared to men among Hispanic HIV patients could not be determined by this study, but previous research has suggested that women’s traditional care-giving role can create barriers to their receiving the health services they need, notes Dr. William E. Cunningham, professor of public health and medicine and a co-leader of the analysis, which was published in the American Journal of Public Health.

The study found other differences in access among subgroups of Hispanic HIV patients. Those exposed to HIV by drug use and heterosexual sex were at increased risk for not having had a usual source of care at HIV diagnosis – suggesting another target for tailored interventions, Cunningham notes.

“It’s very important not just to target Hispanics as a monolithic group in efforts to improve their access to HIV care,” Cunningham says. “This is a heterogeneous population, and that needs to be recognized when researchers and policy-makers are developing programs.”

Antioxidant Could Have Cancer-Fighting Effects for People with Genetic Disease

40 30 20 10 0 WT (normal)

ATM (abnormal gene)

ATM+NAC (abnormal gene + drug)

WT (normal)

ATM (abnormal gene)

ATM+NAC (abnormal gene + drug)

7

Loss of Genetic Material

6 5 4 3 2 1 0

UCLAPUBLIC HEALTH

NAC therapy reduces oxidative DNA damage and loss of genetic material in ATM deficient mice.

HIGHER ANTIOXIDANT INTAKE MIGHT BENEFIT INDIVIDUALS with ataxia telangiectasia, a rare genetic disease that causes progressive loss of motor control, cancer and immune system problems, according to research conducted in the laboratory of Dr. Robert Schiestl, a professor in the school.

One in five ataxia telangiectasia (A-T) patients are eventually diagnosed with cancer, most frequently acute lymphocytic leukemia or lymphoma. In addition, the tendency to develop a weakened immune system makes them susceptible to recurrent respiratory infections. There is no cure or effective treatment for slowing progression of the disease, nor is there any known strategy for prevention. Most of those who have A-T die in their teens or early 20s.

Schiestl, director of the Center for Environmental Genomics (based in the school), studied the effect of the antioxidant N-acetylcysteine (NAC) in mice with mutations in the ATM gene, which has been found to be altered in A-T patients. “ATM-deficient mice provide a good model to study the human A-T disease,” says Schiestl, who carried out the work with Dr. Ramune Reliene, a researcher in his laboratory. “They show symptoms similar to those of A-T patients, including high cancer risk, neurological deficits, high levels of loss of genetic material and oxidative stress. Elevated oxidative stress and appearance of certain genetic alterations – including loss of genetic material – are among the known factors that predispose humans to cancer.”

Schiestl found that administering the antioxidant reduced oxidative damage and prevented the loss of genetic material in the ATMdeficient mice; in fact, mice that were given the antioxidant showed levels of oxidative DNA damage and loss of genetic material similar to what was found in mice without A-T. The antioxidant produced no side effects – a finding that was expected, Schiestl notes, given that it has been successfully used in pharmaceutical form to treat broncho-pulmonary diseases for four decades. The findings were reported in the journal Cancer Research.

“If oxidative damage and loss of genetic material in A-T patients is what is increasing their susceptibility to cancer, it appears that higher antioxidant intake might be beneficial for these patients, and that we should move toward clinical

SPHmag.Nov04.14-35

11/10/04

11:28 PM

Page 14

27

research

trials with human subjects,” Schiestl says. On the heels of Schiestl’s report, one such clinical trial, in which the NAC antioxidant will be administered to A-T patients, is being planned. Meanwhile, Schiestl and colleagues are continuing to investigate the effects of NAC on the cancer frequency of ATM-deficient mice, and are planning to examine the effects of other nutritional supplements such as green tea, grape powder and lycopene for their anti-cancer effects in these and other mouse models of human cancer-prone diseases.

Community Health Centers Improve Access, but Over Reliance on Safety-Net Providers Has Down Side

UCLAPUBLIC HEALTH

LIVING IN AN URBAN AREA that has more community health centers increases the chances that lower-income adults – both with and without health insurance – Characteristics of Low- and will visit a physician during the year, according to researchers at the UCLA Center Moderate-Income Adults vs. All for Health Policy Research, based in the school.

Adults Ages 19-64 in 54 But the research team, headed by Dr. E. Richard Brown, the center’s direcMetropolitan Areas, 1995-96 tor and a professor of community health sciences at the school, also found that living in an area with a large population that depends on safety-net providers 80% reduces the chances that a lower-income resident will have a usual source of care – an indicator of how con73.5 70% 69.2 nected a person is to the health care system.

“Areas that have more low-income residents, 60% especially those who are uninsured, increase the Low- and Moderate-Income Adults financial burden on safety-net providers and thus may Adults at All Income Levels 50% make it more difficult for these community clinics and public hospitals to establish connections with adults in the community,” Brown explains.

40% The analysis, which examined access to care in 54 metropolitan areas, looked at the effects of com30% 32.6 munity factors that reflect the supply of health care 25.1 services, support for the safety-net system, and the 24.1 20% wider health care market. It advances previous 17.8 16.9 16.7 research that primarily has investigated characteristics 10% of the vulnerable population in relation to access to care. The study was funded by a grant from the Robert Wood Johnson Foundation.

0% The researchers found that the probability of havReporting Uninsured No Usual At Least Health Problems Source of Care One Doctor Visit ing seen a physician during the past year was greater During Year for both insured and uninsured lower-income adults in areas that have more federally qualified health centers – facilities whose main purpose is to serve low-income people. In urban areas with more safety-net support – specifically, higher Medicaid payments for providers – the lower-income uninsured were more likely to report having a regular source of care and the insured more likely to report a physician visit sometime in the past year. Increased competition among HMOs in a health market appeared to have no effect on access of lower-income adults, regardless of insurance status; living in an area with greater HMO penetration, however, was found to benefit only adults with insurance.

“Our findings confirm that public policies and community environment have measurable and substantial impacts on access to care,” Brown says. “Expanded public resources, such as increased Medicaid payments, extended public health coverage and more community health centers, can improve access to care for vulnerable populations in large urban areas.”

SPHmag.Nov04.14-35

28

11/10/04

11:29 PM

Page 15

student profiles Warming to the Environmental Science

“I had been looking for some way to use my interest in math, and at that moment I knew that applying it to environmental issues would be a great way for me to go.”

UCLAPUBLIC HEALTH

— Sarah Rothenberg (second from left)

SARAH ROTHENBERG WAS IN WASHINGTON D.C., in the summer of 1998 when she had an experience that set her on the path she continues to follow today.

Then an undergraduate on her way to a bachelor of science in applied mathematics, Rothenberg was spending the summer working as a congressional intern.

One day she attended a committee hearing on global warming. At a time when Congress was preparing for a potential vote on the Kyoto Protocol, the agreement reached by 160 nations on limiting greenhouse gas emissions, Rothenberg watched as the legislators heard testimony on the legitimacy of an issue that the vast majority of the scientific community view as settled.

“It was stunning for me to see so many conservative legislators question the hypothesis of global warming,” she says. “I had been looking for some way to use my interest in math, and at that moment I knew that applying it to environmental issues would be a great way for me to go.”

Rothenberg, who spent nine years working in the film industry as a sound editor for feature films before starting as an undergraduate at age 33, went on to earn her master’s degree in statistics before enrolling in UCLA’s interdisciplinary Environmental Science and Engineering (ESE) program, based in the School of Public Health. She is now in her third year in the doctoral program, which trains environmental scientists, engineers and policymakers for environmental leadership positions.

For her dissertation, Rothenberg will be researching numeric targets for a total maximum daily load (TMDL) for mercury in Ventura County, Calif. As part of the Clean Water Act, TMDLs are established by the U.S. Environmental Protection Agency to specify the amount of pollutant a water body can absorb while continuing to meet state water quality standards. Mercury is a potent neurotoxin that can travel long distances and be deposited in otherwise pristine environments. Studies showing the potential for human health problems from consumption of mercury-containing fish have raised concerns worldwide.

Rothenberg, who recently began an internship with the U.S. Army Corps of Engineers’ Ventura County field office, spent last summer in Beijing, China conducting an investigation on terrestrial mercury contamination. Her internship was sponsored by the East Asia and Pacific Summer Institutes, a National Science Foundation program in which U.S. graduate students in the sciences and engineering spend eight weeks gaining firsthand laboratory experience working with researchers in China, Japan, Korea, Taiwan, or Australia. In 2002, Rothenberg was in Japan under the same program, researching residential water usage in eight Japanese cities, an extension of her master’s thesis on water consumption in Kobe, Japan.

As she spent last year interviewing for internship positions, Rothenberg was reminded how valuable her education will be in opening up future options. “On a wide variety of subjects that came up at these interviews, I already had some knowledge of the problems, and employers at agencies and nonprofit organizations appreciate that,” she says. “The ESE program gives you broad-based education so you are conversant in almost any environmental topic. You have a 360-degree scope of environmental problems in the world, which enables you to get in the door almost anywhere.”

SPHmag.Nov04.14-35

11/10/04

11:29 PM

Page 16

29

students

Students in Family and Sexual Violence Course Moved to Action After Visit to Women’s Prison

“They were so sad that they had to leave their children and didn’t know where they were. Our feeling was that their children shouldn’t be made to suffer any more than they already had.”

— Armine Kourouyan (right)

UCLAPUBLIC HEALTH

STUDENTS IN THE FAMILY AND SEXUAL VIOLENCE course taught by Dr. Susan Sorenson, professor of community health sciences, had learned about the consequences of domestic violence and how the violence sometimes becomes lethal.

But a field trip to a women’s prison brought the classroom discussions home – and moved many of the students to action.

Sorenson has arranged to have students in her Family and Sexual Violence course visit the California Institute for Women each year since 1992 to attend a meeting of Convicted Women Against Abuse, which was started by women convicted of killing their abuser. Last spring, for the first time, members of Sorenson’s class received a tour of the Corona, Calif., prison before breaking into small groups and spending time talking with the imprisoned women.

“It was an eye-opening experience,” says Marcia Suzuki, who graduated with her M.P.H. and is now a program officer for First 5 LA. “They described in graphic detail the abuse they had faced in their lives. You could tell they had given a lot of thought to the factors that had brought them to this point.”

Once they returned to UCLA, the students, deeply moved, gathered to discuss what they had just experienced, and decided they wanted to follow up with assistance.

One of the things they had learned was that the inmates went through lengthy periods without access to notary services – and that when they did have access, many lacked the means to pay the $10 fee.

This was a particular problem for the women who wanted to have a say in what would happen to their children, since notary services are required for certain forms, particularly those pertaining to custody.

“They kept referring over and over again to their children,” says Armine Kourouyan, a second-year M.P.H. student. “They were so sad that they had to leave their children and didn’t know where they were.

Our feeling was that their children shouldn’t be made to suffer any more than they already had.”

So the students began collecting donations for notary services, and several – led by Kourouyan, Talia Baruth and Ingrid Dries-Dafner – initiated contacts with legislative offices in an effort to effect policy changes.

In the meantime, Suzuki began training as a notary with plans to volunteer her services where possible.

Three other students, Bridget Brownell, Mel Sage and Lidia Carlton, coordinated a book drive, collecting both from students at the school and through a larger drive at Taft High School in Woodland Hills, Calif., where Brownell teaches health.

More than 200 books and approximately 75 CDs and cassette tapes were donated to the prison library, which has been unable to purchase many new items due to budget cuts.

“It’s one thing to read about the situation these women find themselves in, but it’s another to have a woman sitting in front of you telling you these things herself – how she had gone to the police for help on several occasions and nothing had changed,” says Brownell. “This experience brought the textbook to life.”

SPHmag.Nov04.14-35

11/10/04

11:30 PM

Page 17

30

contracts & grants 2003-04 This section includes new contracts and grants awarded in fiscal year 2003-04. Due to space limitations, only funds of $50,000 or more are listed, by principal investigator.

RICHARD F. AMBROSE Success of Wetland Mitigation Sites in Los Angeles and Ventura Counties, California (CA/Water Resources Control Board, $85,454); Assessment of Water Quality Loadings from Natural Landscapes (Southern California Coastal Water Research Project, $102,940) RONALD M. ANDERSEN California Dental Pipeline Program Evaluation (The California Endowment, $482,609 for 3 years) ROSHAN BASTANI Informed Decision Making Regarding PSA Screening (NIH/National Cancer Institute, $1,145,422 for 4 years) BARBARA A. BERMAN School-Based Tobacco Control Programming for Deaf/HH Youth (UC Tobacco-Related Disease Research Program, $510,000 for 3 years) E. RICHARD BROWN California Health Interview Survey (CHIS) (NIH/National Cancer Institute, $719,253; CA/HHS/Department of Health Services, 2,893,458 for 2 years; Robert Wood Johnson Foundation, $1,009,797 for 2 years; Alameda County Health Care Services Agency, $350,309 for 18 months; LA Care Health Plan, $200,000); SHADAC-CHIS Medicaid Undercount Project (University of Minnesota, $214,660); The State of Health Insurance in California Report (SHIC) (The California Wellness Foundation, $130,435 for 3 years); The Health of California's Young Children: Findings from the 2001 California Health Interview Survey (First 5 California, $78,723); "Spillover Effect" of County Child Health Insurance Expansion Initiatives on Publicly Funded Program Enrollment (UC/California Policy Research Center, $50,496) ROGER DETELS Fogarty International Training Grant in Epidemiology Related to AIDS (Fogarty International Center, $5,466,575 for 4 years); Risk Assessment and the Development of the Environmental Health Criteria (Royal Adelaide Hospital, $200,000) PATRICIA A. GANZ Development of a Computerized Tool to Assess Cognitive Functioning of Breast Cancer Patients in the Clinic (The Breast Cancer Research Foundation, $148,078)

UCLAPUBLIC HEALTH

BETH GLENN Interplay of Family Context and Ethnicity in BRCA 1/2 TEST (UC/Breast Cancer Research Program, $80,000 for 2 years) DEBORAH C. GLIK Technical Assistance to California Department of Health Services Immunization Program (CA/HHS/Department of Health Services, $243,761)

AN-FU HSIAO CAM Use and Access to Care by Asian Pacific Islanders (NIH/National Center for Complementary & Alternative Medicine, $180,000 for 2 years) MARJORIE KAGAWA-SINGER California AAPI 5-a-Day Campaign (Public Health Institute, $108,776) LEEKA KHEIFETS Joint WHO/EPRI Workshop on EMF and Children (Electric Power Research Institute, $50,000) GERALD F. KOMINSKI Measuring Access for Managed Care Enrollees in the 2003 California Health Interview Survey: Collecting Data for a New Managed Care Report Card (Department of Managed Health Care, $317,980); California Health Benefits Review Program (UC Office of the President, $327,569 for 2 years) ANNETTE E. MAXWELL Increasing Repeat Mammography Screening Among LowIncome Filipino American Women (Susan G. Komen Breast Cancer Foundation, $200,000 for 2 years); Increasing Adherence to Follow-Up of Breast Abnormalities in LowIncome Korean American Women: A Randomized Controlled Trial (US Army Medical Research and Material Command, $625,000 for 4 years); Understanding Tobacco Use and Correlates Among Filipino Men (Cancer Research Foundation of America, $70,000 for 2 years) YING-YING MENG Center for Excellence for Environmental Public Health Tracking (University of California, Berkeley, $370,167 for 2 years) JACK NEEDLEMAN Hospital Nurses' Working Conditions and Patient Outcomes (Harvard University/Harvard Medical School, $102,990); The Future of Public Hospitals and Clinics (Robert Wood Johnson Foundation, $107,331) NADEREH POURAT Determining the Impact of Health System Navigation Skills Among Asian Americans on Breast Cancer Screening (Susan G. Komen Breast Cancer Foundation, $206,859 for 2 years) STEVEN J. ROTTMAN Bioterrorism Training and Curriculum Development Program (DHHS/HRSA, $607,187 for 2 years) DELIGHT SATTER American Indian Breast Cancer Prevention: Turning Knowledge Into Action (Susan G. Komen Breast Cancer Foundation, $199,953 for 2 years)

SPHmag.Nov04.14-35

11/10/04

11:30 PM

Page 18

new faculty

31

DR. ROBERT KAPLAN, an internationally renowned scholar known for his groundbreaking work in quality of life and health outcomes assessment, has been appointed to the school as chair of the Department of Health Services.

Kaplan has contributed widely to health literature, authoring more than 350 original scientific articles and 15 books. He is currently editor-in-chief of the Annals of Behavioral Medicine. Kaplan has been honored by many organizations, including being two-time recipient of the Annual Award for Outstanding Scientific Contributions from the Division of Health Psychology of the American Psychological Association (in 1987 for Junior Investigator and in 2001 for Senior Investigator).

His interest in measuring functional and quality of life outcomes has led to an increased focus in recent years in issues of cost-effectiveness and resource allocation – particularly questions of how to optimize the use of health care dollars to manage the health of populations.

Kaplan, who has a Ph.D. in psychology from UC Riverside, most recently served as professor and chair of the Department of Family and Preventive Medicine in the School of Medicine at UC San Diego. “I have spent most of my career working in a medical school, but have always been interested in public health and wanted to immerse myself more in the public health sciences,” he says, “and in my field of health services research, I felt that there was more of a concentration of talented people in West Los Angeles than just about anywhere in the world. This is where I wanted to be.”

KIMBERLY I. SHOAF Training Needs Assessment for Bioterrorism Preparedness (CA/HHS/Department of Health Services, $123,890); Public Health Response to Disasters (County of Los Angeles/ Department of Health Services, $161,878)

ROBERTA WYN Health D.A.T.A. (Data for Advocacy and Technical Assistance) (The California Endowment, $270,068 for 18 months)

DR. ALEXANDER ORTEGA (Health Services) has joined the school as associate professor, with a special focus in child and family health policy. From 2003 to 2004, Ortega served as associate professor of health behavior and health promotion in the School of Public Health at Ohio State University, and from 1998 to 2003 he was an assistant professor of health policy and administration at Yale University. Ortega’s research expertise includes medical care disparities and children’s health services research. He serves on several federal advisory boards, including the National Latino & Asian American Study (NLAAS) and the Health Systems Research study section of the Agency for Healthcare Research & Quality.

ANTRONETTE K.YANCEY School Physical Activity/Physical Education Assessment (The California Endowment, $184,057) ZUO-FENG ZHANG Prostate Cancer Molecular Epidemiology - Retinoid Receptors (NIH/National Cancer Institute, $588,750 for 4 years) UCLAPUBLIC HEALTH

FRANK J. SORVILLO B. Procyonis: Epidemiology, Diagnosis, and Bioterrorism (Association of Schools of Public Health, $60,590)

faculty

DR. MARTIN Y. IGUCHI (Community Health Sciences) most recently served as senior behavioral scientist and director of the Drug Policy Research Center at RAND. Known for his expertise in drug policy research and analyses, Iguchi’s work examines the application of behavioral principles in drug abuse treatment and prevention, as well as the role of drug use and related risk behaviors in the transmission of HIV. He is a fellow of the American Psychological Association, a member of the National Institute on Drug Abuse’s Center Grant Research Review Committee and on the Board of Directors of the College on Problems of Drug Dependence.

SPHmag.Nov04.14-35

32

11/10/04

11:31 PM

Page 19

news briefs DID YOU KNOW...

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.

• If you are not already receiving and would like to receive SPH ALUMNI e-NEWS, which brings information on events and people of special interest to alumni three times a year, please send your e-mail address with your name and current home and business addresses to publichealth@support.ucla.edu.

long-time faculty member bestowed part of family trust The UCLA School of Public Health will receive more than $300,000 from the family trust of Dr. Carl Hopkins, a long-time faculty member who died in 2002. Hopkins, a biostatistician and medical-care scholar, was a professor of public health and health services at the school from 1964 to 1980, serving as chair and associate dean from 1971 to 1974. He was a highly regarded statistical consultant on many medical studies and engaged in research on the organization, financing and evaluation of health services.

The Hopkins gift was generously given “in grateful memory of Professor Milton Roemer,” a pioneering health services researcher and teacher in the school. In addition to his 38 years on the faculty, Roemer served at all levels of health administration – county, state, national and international. Says Dr. Ruth Roemer, professor emerita of health services and Milton’s widow: “Carl Hopkins was an inspiring colleague and dear friend. I am deeply touched that his generous gift honors Milton’s legacy.”

school’s annual fund grows at record-setting pace ANNUAL FUND $140,000 $120,000 $100,000 $80,000 $60,000 UCLAPUBLIC HEALTH

$40,000 $20,000 $0 Fiscal Year 2003

Fiscal Year 2004

Contributions to the school’s Annual Fund, which generates flexible, unrestricted revenue to meet immediate school needs, rose 80% in the last year. A small but critical piece of the school’s development efforts, the Annual Fund provides key support for a variety of faculty and studentrelated activities. For more information on resources available to students and how the school is addressing these challenges, please see the article on student aid beginning on page 14.

NEW EXECUTIVE DIRECTOR FOR DEVELOPMENT

ANITA M. MERMEL will join the school as executive director for development.

Mermel has held a variety of administrative positions at UCLA over the past decade.

Most recently, she was assistant dean at UCLA’s School of Public Policy and Social Research, where she successfully built the decade-old school’s development and external relations infrastructure.

Prior to coming to UCLA, Mermel was in the field of international urban, economic, and community development, having worked for the United Nations Development Programme, among other international agencies and nonprofit organizations.

Mermel earned her BA. cum laude in political science and her M.A. in urban planning at UCLA.

SPHmag.Nov04.14-35

11/10/04

11:31 PM

Page 20

33

news briefs

PREP program will help prepare underrepresented minorities for public health success A Post-baccalaureate Research Education Program (PREP) grant from the National Institutes of Health (NIH) will help the school prepare underrepresented minority baccalaureate recipients for successful careers in public health and other careers in the biomedical sciences.

Under the PREP program, which is funded by the NIH’s National Institute of General Medical Sciences, underrepresented minority baccalaureate recipients benefit from a combined academic and research experience – free from financial worries – to prepare emotionally and academically for success in graduate school. The UCLA PREP program, which also includes participation by other units on campus, is designed to recognize the needs of these students and to provide individually designed activities appropriate for each PREP scholar.

The program’s objectives include: • heightening scholars’ interest in careers in biomedical research; • ensuring their academic preparation for entry and success in graduate school; • enhancing their performance on standardized tests; • enhancing their academic skills essential for success in graduate programs; and • developing research skills necessary for success in graduate school and a research career.

Each PREP student interested in public health will be paired with a faculty member who has a track record of successfully mentoring minority students and whose research is of interest to the student. The student will be integrated into the faculty member’s research program, taking responsibility for a significant aspect of the studies. Students will also be encouraged to attend writing workshops, symposia and courses throughout the program.

C A M PA I G N U C L A S C H O O L O F P U B L I C H E A LT H Cumulative Progress Through Fiscal Year 2003-04 $37,969,674 $35,000,000 $33,029,500 30,000,000 25,000,000 $23,336,915 20,000,000

$18,852,239

15,000,000

5,000,000

$ 4,453,851 $ 1,969,479

0 FY 95-96 FY 96-97 FY 97-98 FY 98-99 FY 99-00 FY 00-01 FY 01-02 FY 02-03 FY 03-04

UCLAPUBLIC HEALTH

$12,364,174 $10,037,344 $ 8,165,239

10,000,000

Nov04.cvrs

11/10/04

10:59 PM

Page 1

UCLA

UCLA

PUBLIC HEALTH School of

Public Health

School of Public Health Box 951772 Los Angeles, California 90095-1772 www.ph.ucla.edu Address Service Requested

Nonprofit Org. U.S. Postage PAID

UCLA