UCLA Public Health Magazine - November 2007

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NOVEMBER 2007

UCLA

PUBLIC HEALTH

UCLA

CLIMATE CHANGE and our HEALTH

School of

Public Health

Health care reform is high on the state and national agenda, and the school’s faculty, including Robert Kaplan, are helping to shape the debate.

Nathan Wolfe believes modern research tools could have prevented the HIV pandemic. He’s applying them in an effort to stop the next one.

When she was a baby, Khadeeja Abdullah lived two miles from the Bhopal disaster. Now she is a student studying environmental justice.

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UCLA

PUBLIC HEALTH

Gene Block Ph.D. Chancellor

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

Sarah Anderson Assistant Dean for Communications

John Sonego Assistant Dean for Development and Alumni Relations

features

Dan Gordon Editor and Writer

Martha Widmann Art Director

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

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Roshan Bastani, Ph.D. Professor, Health Services Associate Dean for Research

Thomas R. Belin, Ph.D. 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

Moira Inkelas, Ph.D. Assistant Professor, Health Services

Michael Prelip, D.P.A. Adjunct Associate Professor, Community Health Sciences

Lisa Dooley and Lindsay Gervacio Co-Presidents, Public Health Student Association

Christopher Mardesich, J.D., M.P.H. ’98

UCLA

President, Alumni Association

School of

Public Health

4 Gathering Storm: The Health Effects of Global Climate Change Mounting evidence of the current and potential harmful human impacts associated with the planet’s warming trend calls for public health leadership.

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Nathan Wolfe: “Viral Forecasting” Aims to Prevent the Next Pandemic

Magnetic Forces: SPH Centers Draw Researchers United in Purpose

in every issue 23 RESEARCH

10 Could HIV have been halted before it began its destructive march? He believes it could have been, and is taking steps to ensure it won’t happen again.

Sex differences in diabetes…violence in PG-13 films…bone strength and age-related maculopathy…traffic and poorly controlled asthma…

IMPACT program and prostate cancer quality of life.

18 12

Uncertain Prognosis: Seeking Cures for an Ailing Health Care System Health care reform is back on the agenda, both in California and nationally. As the debate heats up, members of the school’s faculty are playing an important role.

An overview of the 11 interdisciplinary research centers based in the school.

28 STUDENTS 30 NEWS BRIEFS 32 FACULTY

ON THE COVER Global climate change is more than just a weather phenomenon; it is a major public health issue, and strategies to reduce or prevent its effects are taking on greater urgency.

Cover photo illustration: Martha Widmann

PHOTOGRAPHY ASUCLA / p. 8: climate change summit; p. 30 Reed Hutchinson / Cover: Kaplan, Abdullah; TOC: centers; p. 5: Godwin; p. 7: Winer; pp.13-14; p. 15: CHCFC; p. 16: Kaplan; pp. 17, 28-29; p. 31: Ganz, Durkan; p. 33

Yvette Roman Photography / TOC: healthcare; p. 12 Courtesy of Dr. Nathan Wolfe / Cover: Wolfe; TOC: Wolfe; p. 10 Courtesy of UCLA School of Public Health / p. 2; p. 20: genomics; p. 31: Oppenheimer Getty Images © 2007 / Cover: crowd; pp. 6-7: drought field; pp. 8-9: wildfire; p. 15: runner; p. 16: pharmacy; p. 19: health disparities; p. 20: reproductive health; p. 21: environmental health; pp. 22, 25

iStockphoto © 2007 / Cover: tornado/smoke stacks/ earth/mosquito; p. 6: mosquito, New Orleans 9th Ward; p. 9: drainage pipe, car exhaust; p. 17: broken cigarette; p. 19: CHCHC; p. 20: injury prevention; p. 21: Capitol; p. 26 Veer © 2007 / Cover: drought background; pp. 4-5: satellite shot of hurricane; p. 19: mammography; p. 23

School of Public Health Home Page: www.ph.ucla.edu E-mail for Application Requests: info@ph.ucla.edu UCLA Public Health Magazine is published by the UCLA School of Public Health for the alumni, faculty, students, staff and friends of the school. Copyright 2007 by The Regents of the University of California.

Permission to reprint any portion must be obtained from the editor. Contact Editor, UCLA Public Health Magazine, Box 951772, Los Angeles, CA 90095-1772. Phone: (310) 825-6381.

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dean’s message CLIMATE CHANGE has become part of the global vernacular. People take pride in driving alternative fuel vehicles, and corporations think it’s good PR to have lower “carbon footprints.”

Al Gore’s well-earned Nobel Prize is just the latest reminder that environmentalism has gone mainstream. He began talking about climate change long before it had a name and decades before many were convinced it was real. By now, we all know climate change is happening, but the consequences for public health and health research, which are significant, remain largely unappreciated.

According to the World Health Organization, this shift in climate is already responsible for more than 150,000 deaths and millions of illnesses each year, mostly due to a wide array of causes from malnutrition to diarrhea to malaria.

Malaria, for example, is responsible for 1-2 million deaths each year, most of them among children. The mosquitoes that carry the disease, as well as the ticks and fleas that spread other infections, are sensitive to small changes in temperature and humidity. As a result of recent temperature increases, mosquitoes have expanded their range from the tropics to higher elevations. Malaria is now found in the mountains of Ethiopia and in Nairobi, Kenya – high-altitude regions that once were malaria-free. In addition, dengue fever is thriving and heading to less tropical grounds. So far this year nearly 650,000 cases of the disease have been reported across Latin America and the Caribbean. That’s 11 percent more than in all of 2006.

It is my hope that the Nobel win for Al Gore (not long ago an esteemed visiting scholar at our school) will help put public health squarely in the middle of the climate change debate. To that end, the School of Public Health recently hosted the first-of-its-kind summit on the health effects of climate change.

We convened many of the top thinkers and researchers in the world to help us begin a dialogue about threats and decisive actions necessary to begin to address this burgeoning problem. Our cover story (see page 4) takes a deeper look at the issues involved, and the summit, broadcast live via Webcast, is available for viewing at www.ph.ucla.edu/climatechange.

As we learned from our panelists, climate change is another of those issues with an unparalleled impact on poorer, underserved communities. The School of Public Health has made eliminating such differences a top priority by creat-

UCLAPUBLIC HEALTH

ing the Center to Eliminate Health Disparities, which was recently awarded a Centers for Disease Control and Prevention grant and designated a National

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3 2007-2008 DEAN’S A DV I S O RY B OA R D

Center of Excellence in the Elimination of Health Disparities (see page 30).

Through this award, we will expand our ongoing work to address health disparities related to heart disease, stroke and cancer among African Americans, Latinos and Asians at the local, state and national levels.

On the eve of many presidential primaries, it is encouraging to see the amount of attention and thought spent on meaningful health care reform. After witnessing the debacle of the 1994 attempt, most believed another generation would pass before anyone dared to try again. And yet, virtually all of the candidates have some version of what they label health care reform. So what will it take? A feature beginning on page 12 of this issue looks at what our faculty are doing to influence future policy. With California leading the way, and the presidential candidates following suit, we may just find the answer.

Ira R. Alpert * Lester Breslow Sanford R. Climan Edward A. Dauer Martis Davis Michele DiLorenzo (Chair) Robert J. Drabkin Gerald Factor (Vice Chair) Michael R. Gardner Dean Hansell Alan Hopkins * Cindy Harrell Horn Stephen W. Kahane * Carolyn Katzin * Carolbeth Korn * Jacqueline B. Kosecoff Kenneth E. Lee * Richard D. Lipeles * Edward J. O’Neill * Walter Oppenheimer Monica Salinas Fred W. Wasserman * Pamela K. Wasserman * Cynthia Sikes Yorkin

*SPH Alumni

The underlying theme of this issue, of all of public health really, is that there are problems and there is hope. If individuals create change in their lives and demand the same on a larger scale from their state and national elected officials, I believe meaningful reform can and will happen.

Linda Rosenstock, M.D., M.P.H. Dean TOTAL EXPENDITURES Grants and Contracts State-Generated Funds Gifts and Other Fiscal Year 06-07 $53.1 million

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4 M OUNTING EVIDENCE OF THE CURRENT AND POTENTIAL HARMFUL HUMAN IMPACTS ASSOCIATED WITH THE PLANET ’ S WARMING TREND CALLS FOR PUBLIC HEALTH LEADERSHIP.

GATHERING STORM: The Health Effects of Global Climate Change Hurricanes pound the Gulf Coast with

“Global climate change is not just a problem of melting glaciers and drowning polar bears. The human health consequences are significant and underappreciated.”

UCLAPUBLIC HEALTH

— Dr. Linda Rosenstock

unrelenting force. Floods deluge the Midwest. Wildfires rage out of control in California and Florida. A “red tide” blooms off the West Coast, and dengue (“breakbone”) fever spikes in Mexico and looms over the United States. No one can say with certainty that any single one of these events is due to global climate change. But there is little doubt among scientists that these events are on the rise as we are making unprecedented changes to our environment, with grave potential consequences.

“We are conducting an inadvertent experiment by changing the greenhouse gas composition of the atmosphere,” says Dr. Arthur Winer, professor of environmental health sciences at the UCLA School of Public Health. “We can’t know exactly how it’s going to play out, but we can infer there are enormous implications for almost every aspect of human society.”

The world has warmed by approximately 1 degree Fahrenheit since the mid-19th century, when temperature records started being kept, and most of that heating has occurred in the last three decades, coinciding with an exponential increase in burning of fossil fuels. Given the long atmospheric lifetime of

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gases are not controlled soon, the projections are far more sobering.

The school is doing its part to enhance the focus on these concerns. On October 17, just five days after the Nobel Peace Prize was awarded to former Vice President Al Gore and the IPCC for their efforts in raising awareness about man-made climate change and the measures needed to counteract it, the school hosted “Changing Climate/Changing Lives: A Summit on the Public Health Effects of Climate Change.” The summit, the first of its kind, was open to the public and featured an international panel of experts and political leaders, including U.S. Sen. Barbara Boxer (by video). In addition, Rosenstock has formed a search committee to recruit faculty who study the human health impacts of climate change.

“The science is clear that global climate change is not just a problem of melting glaciers and drowning polar bears,” says Rosenstock. “The human health consequences of global climate change are significant and underappreciated, not just in the future but today, and they affect us all.”

“Our challenge in public health is to convey the urgency [of global climate change] while helping people understand that they can have a positive effect and be part of the solution.”

—Dr. Hilary Godwin

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heat-trapping greenhouse gases such as carbon dioxide, methane and nitrous oxide, barring major changes the warming trend is bound to accelerate.

The United Nations’ Intergovernmental Panel on Climate Change (IPCC), a prestigious body of 2,500 scientists, projects an increase in average temperature of 3-10 degrees Fahrenheit by the end of this century. Sea levels are projected to rise between a few inches and more than two feet, putting tens of millions at risk.

Global climate change is more than a weather phenomenon; it is also a major public health issue.

“The environmental threats are increasingly appreciated, but the human health effects have received less attention,” says Dr. Linda Rosenstock, the school’s dean. But the effects – through the intense weather events such as heat waves, wildfires and floods, and indirectly from changes in water, air, agriculture, and infectious disease patterns – are troubling, and already with us. The World Health Organization estimates the shifting climate is now responsible for about 150,000 deaths each year as well as millions of illnesses, many of those from the spread of malaria into new areas where the mosquitoes that carry the disease were once unable to survive. If greenhouse

cover story

RM:

What was once called global warming is increasingly referred to by scientists as global climate change, for a good reason. “Although many areas are warming, some aren’t,” says Dr. Hilary Godwin, chair of the school’s Department of Environmental Health Sciences. “But it’s clear that patterns of weather are changing. There are predicted increases not only in average temperatures, but also in extreme temperatures. In California we will be seeing hotter, drier weather, but other parts of the country may see more precipitation and more severe storms.”

Dr. Jonathan Patz, associate professor of environmental studies at the University of WisconsinMadison and author of more than 50 peer-reviewed scientific papers addressing the health effects of global climate change, notes that studies of temperaturerelated mortality have found that the further temperatures drop from an optimal level, the more the death toll rises; as temperatures increase above the optimal level, though, the mortality increase is much steeper. More than 700 deaths were attributed to the week-long heat wave in Chicago in 1995, and tens of thousands died in the more recent 2003 European heat wave. Extreme heat is also associated with increased emergency room visits and hospitalizations for people with heart disease. The elderly and people with pre-existing cardiovascular and respiratory illness are the most vulnerable, notes Patz, a featured speaker at “Changing Climate/Changing Lives.”

The extreme weather pattern is epitomized by the projection of increases in both droughts and floods. “People ask how you can get more of both,”

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As the insects that carry malaria and other diseases are able to thrive in higher elevations, major population centers are newly at risk.

Low-lying cities face disaster from floods that are expected to become increasingly common, as well as the specter of rising sea levels.

Patz says. “Warmer air temperature evaporates soil moisture quickly, which can contribute to a drought, but it also holds more moisture, so that when it rains it can really rain hard.” As Hurricane Katrina demonstrated, for low-lying areas in Florida and Louisiana, increasingly severe weather is a recipe for disaster.

Higher temperatures indirectly affect health by creating conditions for greater photochemical smog formation, notes Winer, who teaches about the greenhouse effect and its impact on air quality. Hot weather leads to increases in two key ozone precursors: volatile organic compound emissions from fuels, paints and coatings; and nitrogen oxides from spikes in energy usage for cooling. Moreover, at higher temperatures, the chemical reactions producing smog occur more rapidly. Numerous studies have established that higher levels of ground-level ozone and fine particles lead to significant increases in respiratory impact and deaths, Winer notes. Among the most vulnerable are the elderly, children, and people with asthma or other respiratory conditions.

This is a special concern in California, where an estimated 9,000 deaths per year are attributed to what is still considered the nation’s worst air quality. “We’ve made tremendous progress over the last three decades in lowering ozone levels and meeting the air quality standards for pollutants such as carbon monoxide, lead and nitrogen dioxide,” says Winer, a core member of the Environmental Science and Engineering program, based in the school. “Now there is a danger that because of the growth in population and the increasing temperatures, the levels of ozone could begin to rise again.”

California’s air quality concerns are exacerbated by the prospect of an increase in the frequency and severity of wildfires, fueled by drought and higher temperatures. Godwin notes that people with asthma are especially vulnerable to the particulate matter emitted during such events.

Recent studies have also shown that higher levels of carbon dioxide in the atmosphere lead to increased ragweed production – more bad news for people with allergic conditions. Other studies suggest that ozone itself increases sensitivity to airborne allergens. “We’re looking at more days with high smog levels and high pollen counts hitting at the same time in the warm months of the year, and the writing on the wall is pretty clear for that segment of the population,” says Dr. Gina Solomon, a senior scientist at the Natural Resources Defense Council, associate clinical professor of medicine at UC San Francisco and a featured speaker at the recent UCLA School of Public Health summit.

Another concern heightened in California has to do with water – both quantity and quality. The drought-prone state, home to so much of the nation’s agriculture, is already vulnerable to water shortages; with increased temperatures, the forecast is for a higher proportion of future precipitation to come as rain rather than snow. “We have had a free ecosystem service in which snow packs in the Sierras store water that we can use later in the year as it melts,” explains Dr. Richard Ambrose, professor of environmental health sciences and director of the Environmental Science and Engineering program. “If in the future we are getting less precipitation as snow, the water we do get is going to rush out to the ocean in the winter floods and we will lose that service.”

One way to preserve that water is to build new dams, Ambrose says, but that will be costly, both in economic terms and in the negative ecological consequences associated with dams.

Altered rainfall patterns also present water quality issues. For example, much of California’s water comes from the San Joaquin Delta. As levels of fresh water drop, there is increased infiltration from the San Francisco Bay. Sea water contains high concentrations of bromine, which at certain levels can lead to carcinogenic reactions. In addition, Solomon points out that outbreaks of cryptosporidiosis – a persistent problem in drinking-water systems, particularly affecting people with compromised immune systems – have been linked to extreme rainfall, which can wash contaminated soil into lakes and streams, leading to urban water drinking systems that are not effectively treated with standard filtration techniques.

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cover story

The United Nations’ Intergovernmental Panel on Climate Change, a prestigious body of 2,500 scientists, projects an increase in average temperature of 3-10 degrees Fahrenheit by the end of this century.

“We are conducting an inadvertent experiment by changing the greenhouse gas composition of the atmosphere. We can’t know exactly how it’s going to play out, but we can infer there are enormous implications.”

—Dr. Arthur Winer

UCLAPUBLIC HEALTH

Increased malnutrition could be one of the biggest health implications of climate change. Rising temperatures and more severe droughts are likely to result in a migration of where crops can thrive. Dr. Cristina Tirado, a former WHO regional food-safety adviser for Europe and contributor to the health portion of the most recent 2007 IPCC assessment report, says the impacts of climate change on food and water security and safety are a concern particularly for developing countries.

“It is essential to develop health, food and water security adaptation strategies that will protect vulnerable populations,” says Tirado, who has come to the school’s Department of Community Health Sciences from Spain to pursue research on climate change and adaptation strategies for health, as well as health impacts of agricultural policies.

Dr. Matthew Kahn, professor of economics and member of the UCLA Institute of the Environment, cites research suggesting that as weather conditions adversely affect rural farmers’ incomes in developing countries, they move to the cities in search of urban wages. “When millions of these farmers independently make the same rational decision, an unfortunate consequence is that many cities are unprepared and unable to handle the influx and you have increased problems related to congestion, pollution, and disease contagion,” he says.

Many of today’s most problematic infectious diseases, particularly those that are vector- and water-borne, are likely to intensify in their transmission and spread in their geographic distribution, according to the IPCC. Malaria is responsible for 1-2 million deaths each year, most of them children. The mosquitoes that carry the disease, as well as the ticks and fleas that spread other infections, are sensitive to small changes in temperature and humidity. “Malaria is already shifting its range in developing countries,” says Solomon. As the mosquito carrier has become capable of thriving at higher elevations, she notes, major population centers in Zimbabwe and Kenya are newly at risk. Questions are also being raised as to the effect of extreme heat waves and droughts on the dominant mosquito carrier of the West Nile virus, which has moved rapidly through the United States since first arriving in 1999; in hot weather, the virus is produced in the mosquito more

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California’s air quality concerns are exacerbated by the prospect of an increase in the frequency and severity of wildfires, fueled by drought and higher temperatures.

People with asthma are especially vulnerable. quickly and is thus more infectious sooner. The mysterious resurgence of dengue fever in Mexico this year has raised concerns in the United States, where the Asian tiger mosquito capable of carrying the disease has already been found.

Many of these current and potential consequences raise issues of environmental justice. When taken together, the negative impacts of global climate change are expected to be disproportionately felt by poor nations and low-income households, according to the IPCC. “This is an enormous ethical challenge,” says Patz.

“When you place the map of the countries most vulnerable to climate change next to the map showing where the highest proportions of greenhouse gas emissions are coming from, you see a huge imbalance – although in a globalized world, the industrialized countries will also be affected.”

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In October the school hosted “Changing Climate/Changing Lives: A Summit on the Public Health Effects of Climate Change,” featuring an international panel of experts and political leaders. Shown, from left to right: Dr. Gina Solomon, senior scientist, Natural Resources Defense Council; Dr. Nathan Wolfe, professor of epidemiology, UCLA School of Public Health; Dr.Tord Kjellstrom, Australia’s National Centre for Epidemiology; and Dr. J.R. DeShazo, associate professor, UCLA School of Public Affairs.

Since he began teaching at the school nearly two decades ago, Winer has annually provided his students with rankings of the half-dozen or so most important air pollution problems as he sees them. In the 1980s and early 1990s, the accumulation of greenhouse gases and its effect on climate change ranked low in importance relative to issues such as acid rain, photochemical smog, and airborne toxic chemicals. Today, Winer says, climate change has moved to the top of the list, where it will be far more difficult to displace than were the other problems.

“This problem is so enmeshed in the way we have constructed our society,” he says. “You can go down the list – from our energy use to the way we use fertilizers and domesticated herds to feed a population of 6 billion people – and because most of these applications are rising exponentially, so are the greenhouse gas concentrations.” But as great as the challenge may seem, Winer is quick to point out that much can be done. “Given human ingenuity and technology, along with the will to change things, it’s not impossible to reverse course,” he says.

Public health responses to global climate change fall into two categories: mitigation strategies, which seek to prevent, reduce, or delay the climate change impacts; and adaptation strategies, designed to address climate change’s effects to the extent that they are inevitable.

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In California, where water is a major concern, climate change could adversely impact both water quantity and water quality. Concerns about the harmful environmental effects of CO2 emissions from motor vehicles are leading many to turn to greener alternatives.

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On the mitigation side, the most obvious and fundamental steps would be energy policies that reduce the burning of fossil fuels. Beyond government policies and regulations, there are many commercially available mitigation technologies, and more development in this area should be encouraged, says Godwin.

“We can shift the focus of the scientific community toward mitigation technologies in energy and water through the practices of funding agencies and through government incentives for private industry to invest in those technologies,” she explains, noting that the governments of Japan and Germany have advanced development and implementation of new solar energy technologies through incentives to individuals and private companies. Incentives for consumers to purchase hybrid vehicles have already proved effective, Kahn notes.

Among adaptation measures, perhaps the most important strategy in cities prone to heat waves is to assist vulnerable populations, including the elderly and those living in poverty, with access to affordable air conditioning in housing units. In addition, public health departments will need to have plans for heat wave emergencies, floods, and other weather disasters; increased surveillance and infrastructure for water systems; and, in partnership with other agencies, the ability to track patterns of disease to make sure that infectious outbreaks are rapidly detected. “The tools that are the basic foundations of public health will become ever more critical with the changing climate,” says Solomon. “We’re not talking about changing the way we do things in public health; we’re talking about doing more of what we do well.” Public health will

Godwin believes public health should become more active in raising awareness about the likely impacts of global climate change on people’s lives, both to motivate them to make the individual changes that might help to mitigate some of the effects and to mobilize the population to pressure their government to make the broader policy changes that are needed.

“Because the issues tend to be gradual and there is a delay between the actions we take and when we see effects, it’s easy for people to feel as if climate change isn’t as pressing as some of the other concerns we face,” Godwin says. “And when you really impress on people how bad the situation is, you risk overwhelming them to the point that they dissociate themselves from the issue. Our challenge in public health is to convey the urgency while helping people understand that they can have a positive effect and be part of the solution.”

Public health has mostly remained on the sidelines in the ongoing policy debates on reducing greenhouse gas emissions. Rosenstock believes that’s a mistake. “As members of a profession whose goal is to promote population health, when we know from research that reducing greenhouse gases will help to prevent the worst health effects of global climate change it is our responsibility to explain the science and advocate for that policy change,” she says. “In addition, addressing the root causes of global warming has the dual benefit of dealing with the climate change catastrophe unfolding before us and reducing other environmental air pollutants – often generated by the same pollutant sources as greenhouse gases – that are also causing an unacceptable burden of cardiac and respiratory illness and death.”

Patz also envisions additional benefits if the importance of climate change is impressed on the population in a way that leads to a fundamental redesign of American cities. He argues that the epidemic of obesity in the United States is perpetuated by urban designs that are not conducive to exercise; shifting those designs toward better mass transit and greater opportunities to walk and bicycle would address that problem as well. “When you think about this on the scale of moving toward greener cities that are promoting exercise while reducing greenhouse gases and pollution,” Patz says, “this is the most significant public health opportunity we have had in a century.”

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also have an important role to play in educating the population on precautions they should take during extreme weather, she adds.

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10 C OULD HIV HAVE BEEN HALTED BEFORE IT BEGAN ITS DESTRUCTIVE MARCH ?

H E BELIEVES IT COULD HAVE BEEN , AND IS TAKING STEPS TO ENSURE IT WON ’ T HAPPEN AGAIN .

Nathan Wolfe:

“Viral Forecasting” Aims to Prevent the Next Pandemic Nathan Wolfe ventures into parts of the world where few scientists go, for reasons that are at once simple and profound: to find the next major pandemic, and prevent

UCLAPUBLIC HEALTH

it from becoming one.

HIV has infected 25 million people since it was first identified by a UCLA physician in 1981. But the virus’ entry into the human population is now traced by epidemiologists as far back as a half-century earlier, when a Central African hunter is thought to have been infected by blood from his chimpanzee prey. Wolfe believes that with today’s tools and know-how, HIV could have been detected and prevented before it had a chance to begin its destructive march. But the professor of epidemiology, who joined the UCLA School of Public Health faculty in January 2007, laments that virtually all of the effort at controlling emerging infectious diseases is focused on containing outbreaks after they have begun to wreak havoc. He is at the forefront of a growing movement, which he calls “viral forecasting,” that seeks to be much more proactive.

“If you said to your doctor that you were interested in taking steps to prevent a heart attack and he or she told you to just wait until you had heart disease, that would be the end of your relationship with that physician,” Wolfe says. “That’s where cardiology was in the 1950s – just waiting for the heart attack. And that’s where we are today with global disease control. In 100 years, it will be obvious that we were missing the boat in waiting for pandemics to occur and then chasing after them after they were already established.”

There are currently no global monitoring systems to forecast the entry of new diseases into the human population, Wolfe explains. He is doing his part by applying cutting-edge methods from molecular virology, ecology, evolutionary biology and anthropology to study the biology of viral emergence. Wolfe’s venues of choice are places where human populations come into close contact with the blood of animals – from sub-

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sistence hunters in the jungles of Cameroon and the Democratic Republic of Congo (where Wolfe collaborates with UCLA School of Public Health colleague Anne Rimoin) to wet-market workers and restaurant butchers in China, to name a few. “These are populations that act as sentinels for cross-species transmission,” Wolfe explains.

Wolfe’s research group has been instrumental in demonstrating that viral transmissions from animals to humans are more common than was previously believed – these zoonoses are responsible for as many as three-fourths of emerging human diseases.

Publishing in The Lancet in 2004, Wolfe and his colleagues showed for the first time that retroviruses (viruses in the same family as HIV) could cross directly from jungle primates to indigenous hunters.

Last spring, Wolfe teamed with Pulitzer Prize-winning geographer Jared Diamond, another UCLA School of Public Health colleague, on a paper published in the journal Nature that traced five evolutionary stages in a pathogen’s journey from exclusive transmission among animals to exclusive transmission among humans. The review found that animals most closely related to humans, particularly non-human primates such as monkey and apes, are disproportionately responsible for introducing what became some of the most important diseases in human history.

After earning his B.A. in Human Biology from Stanford, Wolfe went on to receive his doctorate in Immunology and Infectious Diseases at Harvard, where he was the recipient of a Fulbright Fellowship.

He was on the faculty at Johns Hopkins University’s Bloomberg School of Public Health before being recruited to the UCLA School of Public Health.

“UCLA has assembled a superb group of people doing field studies in infectious disease,” says Wolfe, who says he was also drawn by the potential he sees in the UCLA High Speed, High Volume Laboratory Network for Infectious Diseases, an initiative the school is spearheading.

While UCLA is his new home base, Wolfe spends close to half of his time on the road, whether it’s helping to run his network’s sites or setting up new projects and establishing new collaborations.

“We know incredibly little about the diversity and nature of viruses on our planet,” he says, “so if you’re a biologist who likes to work in the field and discover new things, there’s nothing better.”

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“In 100 years, it will be obvious that we were missing the boat in waiting for pandemics to occur and then chasing after them after they were already established.”

—Dr. Nathan Wolfe

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In 1999, Wolfe began field work in Cameroon to track “viral chatter” – the regular transmission of viruses from animals to people, usually without further spread among humans. His team of more than a dozen researchers, in collaboration with scientists at the CDC, employed a variety of techniques in their sleuthing efforts – from the collection and analysis of specimens from the Cameroonian hunters and their kills to anthropological surveys and investigations of mysterious die-offs of jungle primates.

By monitoring the habits and the blood pathologies of bushmeat hunters and their prey, Wolfe and his team identified at least three previously unknown retroviruses while also promoting safe practices for handling animals and animal carcasses. “The Cameroon project demonstrated that it’s possible to collect information on viral transmission under very difficult circumstances from these highly exposed people,” Wolfe says.

With Cameroon as a prototype and a $2.5 million National Institutes of Health Pioneer Award as seed money, Wolfe has gone on to create a network of virus forecasting sites that monitor hunters, butchers, and wildlife trade and zoo workers in some of the world’s most remote viral hotspots.

The network of a dozen exotic sites in China,

the Democratic Republic of Congo, Malaysia, Laos, and Madagascar includes source locations for such emerging diseases as SARS, avian flu, Nipah, Ebola and monkeypox. Already, Wolfe notes, the network has proven its ability to detect the entry of new viruses into humans; now, these carriers are being tracked to see whether new diseases appear and the viruses are transmitted.

Wolfe has worked in countries that are considered among the most difficult places in the world for researchers, particularly in biomedical research.

The logistic and political challenges are enormous, and in many cases obvious. “If a researcher from China, Cameroon or Malaysia came to your home asking for blood, you would probably slam the door,” Wolfe says. His strategy in such situations is twofold: Engage and empower the local scientists and infrastructure, and establish a long-term presence. “There is tremendous interest in these issues and substantial expertise in all of these countries,” Wolfe says. “As long as people see that you are looking out for their best interests and that you’re going to stick around, you can work just about anywhere.”

The Pioneer funding has been critical in helping Wolfe to get the sites up and running, but he is now focusing on finding the types of long-term partnerships that will sustain the network well beyond the Pioneer funding period. Establishing a permanent system will require a substantial commitment, but Wolfe is convinced that such an investment is vitally important given the potential reward – stopping the next HIV in its tracks.

faculty profile

ms demic

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12 H EALTH CARE REFORM IS BACK ON THE AGENDA , BOTH IN C ALIFORNIA AND NATIONALLY.

A S THE DEBATE HEATS UP, MEM BERS OF THE SCHOOL’ S FACULTY ARE PLAYING AN IMPORTANT ROLE .

Uncertain Prognosis:

Seeking Cures for an Ailing Health Care System

If the U.S. health care system were a patient, we might describe its condition as serious. The number of uninsured has surpassed 46 million and is continuing to rise as more employers opt out of providing coverage for their workers. For those who do have coverage, benefits are shrinking. Approximately 16 percent of the nation’s GDP is spent on health care, and indications are that we aren’t getting our money’s worth – we receive treatment recommended by evidence-based guidelines only about half the time,

UCLAPUBLIC HEALTH

and each year tens of thousands of hospitalized patients die from medical mistakes.

Is the system beyond repair? Given the considerable obstacles to a major overhaul, some are betting that at the national level, incremental change – the equivalent of administering palliative treatment – is the most realistic goal. Others believe the underlying problems will continue short of major surgery – something like a multi-organ transplant. Everyone agrees the status quo is unacceptable, and as the presidential campaign heats up, with health care as a major topic of discussion, most are optimistic that this is the best opportunity for significant change in years.

How do we get there? As the debate is joined both nationally and in California – where efforts at achieving significant reform are much further along – UCLA School of Public Health faculty are playing an important role through their research, ideas, and consultation.

There are many differences among the competing health care reform proposals that have been crafted in California by state legislators and Gov. Arnold Schwarzenegger, but one thing all of them have in common is their reliance on data from the California Health Interview Survey (CHIS), based in the school’s UCLA

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13 federal poverty level (more than $60,000 for a family of four), a significant portion face high out-ofpocket expenditures – in some cases more than 15 percent of their family income, beyond the cost of insurance premiums – and need protection in the form of a cap on these expenditures, something no one has proposed. In another study, Kominski and colleagues analyzed the amount Californians currently spend on health care, by income level, as a way of identifying an affordability standard that a proposal for reform could use to provide protection for families facing catastrophic expenses.

Kominski has also reviewed previous studies, combined with his own analysis of CHIS data, on the merits of expanding insurance coverage vs. expanding the safety-net services provided by com-

Members of the UCLA Center for Health Policy Research, including (l. to r.) Drs. Ninez Ponce, E. Richard Brown and Gerald F. Kominski, have provided key data and analyses contributing to the health care reform effort in California.

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munity health centers and county clinics to lowincome and uninsured individuals. While confirming the importance of insurance, Kominski also found that safety-net providers perform a critical service by giving low-income families – both insured and uninsured – a usual source of care, or what is also known as a medical home.

“There is mounting literature showing that having a medical home is an important determinant to having adequate access to quality of care, independent of insurance,” Kominski explains. “Our conclusion is that health care reform shouldn’t be a choice between insurance expansion and expansion of direct safety-net services; both components need to be included.” Merely expanding the number of people with insurance coverage would likely increase the demand for services at safety-net clinics, with the potential to tax them beyond their ability to meet

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Center for Health Policy Research. “CHIS has become the common data set that policy makers and advocacy groups use in crafting and discussing health care reform proposals, which means that there is no longer argument over issues such as the number of uninsured people statewide or by subgroup,” says Dr. E. Richard Brown, director of the center, which conducts the survey every two years in collaboration with the California Department of Public Health, the California Department of Health Care Services and the Public Health Institute.

More than supplying the data, the center provides analysis and helps to drive the debate by calling attention to important trends that emerge from the survey, such as the decline in employment-based coverage, the importance of the Medi-Cal and Healthy Families programs in serving as a health insurance “safety net” for children, and issues of health care affordability. Brown and his colleagues at the center have also been called on by state policy makers and advocacy groups to fulfill specific requests for data analysis or provide consultation as they seek a better understanding of particular issues.

Although no action was taken in the last legislative session, health care reform remains high on the state’s agenda. “California has done a lot in the last 10 years to extend coverage for children, and we are close to being able to truly cover every child in the state,” says Brown. “That is the low-hanging fruit on the policy tree, but the higher fruit that we haven’t really begun to reach for is uninsured adults, who are the vast majority of the uninsured population. That’s the issue at the core of the health care reform debate in California today.”

The governor has stated his commitment to universal coverage, and many legislative leaders share that goal, but key issues remain unresolved, Brown notes, highest among them affordability. “Where do we get the funds to provide the subsidies that are needed to help low- and moderate-income workers obtain coverage when nearly two-thirds of the uninsured are below 200% of the poverty level?” he asks.

“That’s a very large number of people we need to help pay for coverage, and that’s the political dilemma.”

Some of the disagreement centers over the level of income at which consumers find health insurance to be affordable. A group headed by Dr. Gerald F. Kominski, professor and associate dean for academic programs at the school and associate director at the UCLA Center for Health Policy Research, has helped to inform that debate with research into what California families currently spend on premiums and out-of-pocket expenditures, by income level, and what they would be able to afford. In one study, Kominski concluded that even when examining families whose incomes are more than three times the

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“Insurers try to cover new drugs by raising premiums, but this drives some people out of the health insurance market. Other insurers impose restrictions.”

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—Dr. Stuart Schweitzer

the needs of the newly insured low-income population that would seek their services, Kominski says.

While extending coverage to people who are uninsured is an important step, it doesn’t guarantee access to care. Dr. Ninez Ponce, associate professor of health services at the school and a senior research scientist at the UCLA Center for Health Policy Research, was the lead researcher on a report that analyzed the composition and potential needs of the newly insured under California’s health care reform proposals. The analysis was funded by The California Endowment and was published by Having Our Say, a statewide coalition working to ensure that health care reform efforts address the needs of communities of color and that solutions provide equal access to coverage and services for all Californians.

“Many of the newly insured will be vulnerable populations who don’t currently have a regular source of care and might have difficulty navigating an HMO system, for example,” says Ponce, who also consulted with aides to the governor on the issue.

“Many of them will be immigrants who will have language-assistance needs that aren’t addressed in most of the proposals. A large proportion will have low income and low education, and will live in underserved communities without much health care infrastructure, making it difficult to find a doctor or community health center. Expanding coverage is very important, but if California isn’t ready to meet the needs of this population, disparities in health care could actually increase.”

As California debates specific proposals for health care reform, the national discussion, at least to this point, has been much less focused. “There isn’t anything approaching the winnowing of options down to a few, as we see in California,” observes Brown.

Although there is a general agreement that employers need to contribute to helping to pay for the cost of coverage, he notes, there are considerable differences about how that should occur. On the subject of what reforms are needed to improve quality of care and control health care spending, there is even less consensus, Brown says. “The one thing everyone agrees on is that we need to move toward electronic medical records,” he notes. “That will facilitate improving quality and will provide some data for efforts to try to control health care costs, but it’s not going to accomplish either goal by itself.”

Among the challenges as the nation grapples with health care reform is what to do about rising costs. Dr. Stuart Schweitzer, professor of health

services and co-director of the school’s Research Program in Pharmaceutical Economics, notes that as technology advances, the costs of drug therapies increase, leading to difficult societal decisions. “Do we raise enough money to pay for these treatments or do we somehow restrict access,” Schweitzer asks.

“Insurers try to cover new drugs by raising premiums, but this drives some people out of the health insurance market. Other insurers impose restrictions, which include encouraging patients to use generic drugs whenever prescriptions are written to allow that.”

If cost-cutting in the health industry becomes overzealous, Schweitzer says, it could lead to reductions in drug companies’ research-and-development investments. “For decades, the U.S. pharmaceutical industry has been the world’s leader in developing new drugs,” he notes. “Other countries, with sharp cost-cutting, have seen the R&D components of their drug industries wither. I don’t think we want to do this, especially as new technologies like biotech and genetics come on line.”

Another issue to address is the balance between access and risk when considering new drugs. “There are numerous reforms that ought to be instituted in the pharmaceutical industry and in medical practice, including increased transparency of studies so that outsiders can review evidence on drug risk before drugs are approved,” Schweitzer says. “But even when more is made known about the results of clinical trials, the fact remains that new drugs are potentially harmful and no clinical trial can uncover all information about dangerous side effects. Consumers should not expect that FDA approval of a new product is equivalent to a magic wand being passed over the product guaranteeing safety.” Moreover, he notes, drugs may confer benefits to patients at the same time they cause dangerous side effects. A better understanding of the trade-offs is needed, Schweitzer argues.

The one specific national health care reform debate that has been engaged has been over the proposed expansion of the decade-old State Children’s Health Insurance Program (SCHIP), which provides coverage for families that can’t afford to buy private insurance but have incomes too high to qualify for Medicaid coverage. Meanwhile, a group of faculty from the UCLA Center for Healthier Children, Families and Communities, based in the school, has been taking steps to broaden the discussion. In “Transforming the U.S. Child Health System,” published in the March/April issue of Health Affairs, Drs. Neal Halfon, Helen DuPlessis and Moira Inkelas called for a more comprehensive approach that would include establishing an entity at the federal level to consolidate funding and planning for children’s health initiatives and organizing local child

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At the school’s Center for Healthier Children, Families and Communities, faculty including Drs. Helen DuPlessis and Neal Halfon have spearheaded efforts to shift the national dialogue toward one that addresses transformative rather than incremental change.

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health development systems to manage the delivery of care, among other things.

“The current system cannot achieve expected performance goals because it is powered by outdated logic, outmoded organization, and inadequate and misaligned finance strategies,” Halfon and colleagues wrote. The article has stimulated a national effort by leading child health policy advocates, along with the UCLA School of Public Health authors, to draft a major child health reform agenda that they hope to make part of the discourse for the 2008 campaign and beyond.

For both children and adults, most health care reform discussions have proposed incremental changes, usually focused on buying more medical care through expanding health insurance. “We’re trying to change this for children so that we’re asking not just about the payment mechanism but how do we redesign the system,” says Halfon, professor of health services at the school and director of the Center for Healthier Children, Families, and Communities. “How do we move prevention and health promotion from the edge into the core of what the system is doing? How do we take a long-term perspective in optimizing health?

How do we make long-term investments in the health capital of the population?

How do we take advantage of the scientific knowledge on health development that shows how much of adult health is determined during childhood? And how can we invest more wisely to get a much bigger bang for the buck?”

The need for transformative change isn’t confined to children, according to Halfon. He points out that by many measures, Americans are less healthy than counterparts in developed countries that spend far less per capita on health care services. The reason, Halfon contends, is that the U.S. system and discussions on improving it are focused too narrowly on medical care rather than on improving health through disease prevention and health promotion strategies such as exercise, diet, and education that more often than not fall outside the purview of the medical care system.

Halfon argues that the current health care system was created during an era dominated by acute and infectious diseases; since then, the nation has moved into an era marked by chronic illnesses, which brought system changes such as prepaid health plan benefits and, most importantly, the passage of Medicare.

Now, he says, a new era is dawning. “We know what it takes to have people live into their 80s and be reasonably healthy, but we don’t have an operating system or the production capacity to make that happen for all people,” he says.

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Critics of the U.S. health care system contend that it focuses too narrowly on medical care rather than on improving health through strategies such as exercise.

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As technology advances, the cost of drug therapies increases. Prescription drug spending grew more than 12% annually between 1990 and 2000.

“We’re spending indiscriminately, without any coordination across our investments toward the goal of enhancing population health. At some point resources are limited and we have to make choices.”

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—Dr. Robert Kaplan

In an effort to foster discussions on fundamental rather than incremental change, Halfon and colleagues, with funding from The California Endowment, launched the Blue Sky Initiative. In September, they hosted a symposium focusing on the organization and financing of a transformed U.S. health care system.

UCLA School of Public Health faculty, including Kominski and Drs. Jonathan Fielding, Tom Rice and Robert Kaplan, were among the national figures presenting and discussing evidence-based options for redesigning the basic architecture of a reformed health system aiming to optimize the health of the population.

“This was an opportunity for us to bring together experts from a variety of disciplines and drill down into specific components of our framework for transforming the U.S. health system and to begin to explore some specific options for reorganizing and financing a new system,” says DuPlessis, a member of the school’s faculty and formerly chief medical officer for L.A. Care Health Plan, which serves Medi-Cal and other low-income patients in Los Angeles as the nation’s largest public health plan.

Kaplan, professor and chair of the school’s Department of Health Services, also believes the focus of the health care reform debate has been misguided. In his book Disease, Diagnoses, and Dollars: Facing the Ever-Expanding Market for Medical Care, scheduled for release in March, he makes the case that Americans have been convinced to want more health care than they need, and that volume, rather than the cost of drugs and services, is driving the health care crisis. Mass markets have been created for preventive medical services such as cancer screening tests and medications to control blood pressure, cholesterol, and glucose; these markets, expanded through guidelines established by respected expert panels, are major contributors to high costs while offering only marginal benefits, Kaplan asserts. The unintended consequence: an increase in the number of uninsured patients and reduced access to more beneficial services.

“As health care costs go up, we pay opportunity costs,” says Kaplan. “Employers are deciding they can’t afford to provide insurance to their employees. We’re spending indiscriminately, without any coordination across our investments toward the goal of enhancing population health. At some point resources are limited and we have to make choices.”

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their relatives or neighbors are sick or poor, they will continue to have access to health care,” Needleman explains. “The challenge is having the social commitment to that kind of subsidy structure.”

Although he notes that this commitment has been demonstrated in the past through the passage of programs such as social security and Medicare, Needleman observes that the United States has recently shown less social solidarity than most, if not all, of its industrialized counterparts. “As long as this issue is lurking in the background without being discussed, it’s hard to move the debate forward,” Needleman says. As the Clinton administration learned during its unsuccessful effort to overhaul the system in 1994, reforms that significantly alter the distribution of services inevitably create financial winners and losers, and thus must overcome the opposition of powerful vested interests.

Nonetheless, Needleman sees signs that the ground is more fertile for change this time around.

“Whenever there is income and insurance insecurity, interest increases,” he says. “As people see the number of uninsured growing, wages going up more slowly, and employers dropping health insurance or demanding increasing shares of the cost of premiums from their employees, they begin thinking more about whether health reform will improve their family’s situation and prospects, not simply those of the poor, uninsured family two towns over.”

Brown agrees. “The pain in the existing system is more widespread,” he says. “There seems to be a wider and deeper understanding of how fundamentally flawed our health care system is, and that it will take very serious reforms to improve the system in a significant way.”

“We used to say that our system had cost and access problems, but at least we provided the best health care in the world.

What we have learned in the last decade is that we have serious quality problems.”

—Dr. Jack Needleman

Preventing people from starting to smoke is one of the most cost-effective health strategies.

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The daunting task of reforming the health care system becomes even more difficult when the issue of quality is added to the mix.

“We used to say that our system had cost and access problems, but at least we provided the best health care in the world,” says Dr. Jack Needleman, an associate professor at the school whose research focuses on the impact of changing markets and public policy on quality and access. “What we have learned in the last decade is that we have serious quality problems that won’t be solved by simply changing the name on the insurance card.”

Needleman, who prior to entering academia worked on health care reform issues at the state and national levels as a senior member of Lewin/ICF, a Washington, D.C., health policy research and consulting firm, believes the sizable barriers to making the fundamental reform that most public health experts believe is necessary are the reason so much of the focus has been on incremental change, such as expansion of SCHIP. Countries that have created successful systems of universal access have all adopted the principle that the amount individuals pay to support insurance coverage is proportionate to their income or wages.

“What that means is that the healthy and wealthy are being asked to pay more than the ‘actuarially fair value’ of the insurance benefits they’re receiving, in exchange for the knowledge that when they or

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Kaplan suggests that while focusing on medical prevention – early identification and treatment of diseases – the health care system pays insufficient attention to primary prevention, or preventing risk factors from developing in the first place. He points to a recent analysis by the U.S. Preventive Services Task Force concluding that in terms of cost-effective strategies, preventing people from starting to smoke is one of the most important efforts we could engage in, yet smoking prevention strategies are among the least-used activities in primary care.

Despite being the largest sector in the world’s biggest economy, the U.S. health care system, unlike other industries, isn’t held accountable for what it produces. “We give treatments that are indicated, but there isn’t any tracking to measure the difference our investments make,” he explains. One of the recommendations he proposes in the book is for a national surveillance system that would enable such estimates. Kaplan also calls for either more regulation or an outright ban on direct-to-consumer advertising of pharmaceuticals, which virtually all other countries do not allow; and a public health infrastructure with a more unified approach to promoting population health.

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MAGNETIC FORCES: SPH Centers Draw Researchers United in Purpose Given that it tackles such a wide range of issues relating to the health of populations, public health is ideally suited to bring together researchers, practitioners and students from disparate fields in a coordinated effort to address important topics. At the UCLA School of Public Health, the 11 interdisciplinary research centers are hubs of exciting research activity, producing new discoveries and benefits that extend well beyond the sum of what individual members could offer on their own.

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: TERS H CEN T L A E H UBLIC L OF P O O H SC ership UCLA Memb y lt u c Fa 12-65 Years Past 5 viewed , s n atio r-re Public 1,500 pee k chapters n a boo th More r books, 57 g u fo , s undin ar ticle ural F rants m a r t /g x acts nt E Curre n 200 contr 0 million a 25 th $ e than Mor more g n li tota es es, Cours ealth cours nts H blic ar tme l of Pu r UCLA dep o o h c 33 S in othe urses o c r u cts fo Other earch proje lubs, s e lc r a r t on journ suppo seminars, t n e d s, • Stu events cturer rous le brown-bag y activities e m u •N nit and ommu rous c ining e m u •N • Tra

“Our centers play a vital role in fulfilling our mission of research, teaching and service,” says Dr. Linda Rosenstock, the school’s dean. “They function ‘without walls,’ which means that faculty who might not otherwise get to know each other – whether from different parts of our school or from different parts of campus – have opportunities to collaborate and exchange ideas. These centers provide a great opportunity for students to work with multiple faculty on their issues of interest, and they bring structure to our efforts at addressing important public health topics.”

The centers are open to all faculty who conduct research on the topic; many are active members of more than one. All of the centers have members from multiple departments, and most also include faculty from other parts of the UCLA campus, as well as collaborators outside of UCLA – from other universities, or from the community.

“Excellence in research is reflected in each of our centers, which serve as laboratories for creating exciting new knowledge in a variety of key areas in public health,” says Associate Dean for Research Roshan Bastani, whose office oversees the school’s research enterprise. “These centers facilitate exchange of views and collaborations among experts in a field, resulting in innovative ideas. They also help to create visibility for important public health topics, because the research being conducted by many different faculty members can be described in a cohesive way.”

Although research is their main mission, the school’s centers also play a significant role in education and training by offering courses, providing opportunities for graduate students and postdoctoral fellows through special training grants, and giving students the chance to gain hands-on experience through participation in studies. In addition, the centers are engaged in significant public service activities to address critical health needs in communities locally, in California, nationally, and internationally.

The following pages offer a glance at the centers that are based solely or jointly in the school.

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THE ISSUE: For nearly every health condition across the lifespan, disparities can be found in who gets sick, the type of care received, and health outcomes. Typically, these differences reflect societal inequities, with historically disadvantaged groups such as communities of color, immigrants, and those with low income and low education on the wrong side of widening gaps.

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CENTER TO ELIMINATE HEALTH DISPARITIES Roshan Bastani and Antronette (Toni) Yancey Co-Directors | Alex Ortega Associate Director www.ph.ucla.edu/cehd

THE CENTER: The Center to Eliminate Health Disparities (CEHD) identifies, investigates and addresses differences in health status and disease burden, with a heavy focus on community-based intervention research to mitigate observed disparities, particularly in Los Angeles County. The center facilitates community and academic partnerships in research, trains new investigators in health disparities research, and assists community partners in implementing effective programs and advocating for effective policies to reduce disparities. CEHD also endeavors to erode the barriers preventing more effective collaboration with local health departments and other key community partners engaged in the practice of public health.

CURRENT EVENT: CEHD was recently designated by the CDC as a Center of Excellence in the Elimination of Health Disparities.

As part of the designation, the center receives a five-year, $4.25 million grant to address obesity-related disparities in diverse populations in Los Angeles and California (see page 30).

CENTER FOR HEALTHIER CHILDREN, FAMILIES AND COMMUNITIES Neal Halfon Director | Todd Franke Associate Director | Moira Inkelas and Alice Kuo Assistant Directors www.healthychild.ucla.edu THE ISSUE: Mounting evidence indicates that physical, cognitive and behavioral factors in early life influence health and well being decades later. But there is a strong sense that children are not being well served by a health care system geared toward treating disease, and that new paradigms are needed as the nation confronts worrisome trends, including increases in childhood obesity, diabetes, asthma and autism.

THE CENTER: The Center for Healthier Children, Families and Communities (CHCFC) aims to optimize children’s life-long health, development and well-being by enhancing knowledge and understanding, and by spreading solutions that improve service systems, environments, and policies. Some of the most challenging health and social problems facing children and families are addressed by a multidisciplinary group of faculty, as well as providers, community agencies, and affiliated institutions.

CURRENT EVENT: CHCFC plays an active role in promoting systems change.Through the Blue Sky Initiative funded by The California Endowment, members of the center’s faculty are convening national experts to work toward transforming the U.S. health system to meet emerging health needs of children. The Blue Sky initiative envisions dramatic changes to the driving principles, organization and financing of the health system toward a more holistic and prevention-oriented approach (see page 16).

DIVISION OF CANCER PREVENTION AND CONTROL RESEARCH Patricia Ganz Director | Roshan Bastani Associate Director www.ph.ucla.edu/hs/prev_control.html THE ISSUE: Cancer is a leading cause of morbidity and mortality in the United States and worldwide. Much of the cancer burden is attributable to our failure to apply, at the population level, what is already known about cancer causes, risk factors, early detection, and treatment. This problem is particularly acute among less-advantaged segments of the population.

CURRENT EVENTS: The UCLA Community Research in Cancer (CORICA) Network seeks solutions to socioeconomic and racial/ethnic disparities in cancer through research that links the university with the community, particularly in underserved areas in Los Angeles. The UCLA-LIVESTRONG Survivorship Center of Excellence addresses the needs of cancer patients and survivors and promotes best practices for survivorship care in the Los Angeles community.

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THE CENTER: The Division of Cancer Prevention and Control Research, the public health arm of the battle against cancer, is jointly housed in the School of Public Health and the Jonsson Comprehensive Cancer Center at UCLA. The center’s Healthy and At-Risk Populations Program focuses on prevention and early detection, including tobacco control, nutrition, physical activity, early screening, control of vaccine-preventable cancers, and predictors of cancer outcomes. The Patients and Survivors Program focuses on reduction in avoidable morbidity and mortality among cancer patients and long-term survivors of cancer, and improving quality of cancer care. The Molecular Epidemiology and Carcinogenesis Program takes a multidisciplinary approach to understanding the interactions between environmental exposures and molecular genetic alterations that affect the risk and progression of cancer and applies this knowledge to improving cancer prevention and control at the population level.

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20 FRED H. BIXBY CENTER FOR POPULATION AND REPRODUCTIVE HEALTH Anne Pebley Director http://bixbyprogram.ph.ucla.edu THE ISSUE: Reproductive health and rights are major concerns both at home and overseas. It is estimated that 2 in 5 births worldwide are unwanted or mistimed, and that 150 million couples have unmet family planning needs. Each year, about 20 million unsafe abortions are performed and 600,000 women die of pregnancy-related causes; 333 million new cases of curable sexually transmitted diseases and 5 million new HIV/AIDS infections are diagnosed; and 2 million girls undergo female genital cutting. To improve reproductive health, service access and quality need to be enhanced, sexuality health education made more comprehensive, and women’s status increased.

THE CENTER: The purpose of the Fred H. Bixby Center for Population and Reproductive Health is to expand the school’s research, training, and service activities in the areas of population, reproductive health, and family planning. The program aims to train a diverse group of future leaders in the area of culturally competent reproductive health, to highlight and address reproductive health disparities, and to conduct research and advocate for policies to improve access to and quality of reproductive health services. The program awards certificates to graduating master’s students who develop expertise in population and reproductive health.

CURRENT EVENT: A Reproductive Health Interest Group (RHIG) within the center provides ongoing opportunities for networking, training, service projects and advocacy for graduate students and faculty, both on campus and in California. The program also maintains a 500-plus member listserv and an RHIG alumni network.

SOUTHERN CALIFORNIA INJURY PREVENTION RESEARCH CENTER Jörn Olsen Director | Abdelmonem A. Afifi Co-Director www.ph.ucla.edu/sciprc THE ISSUE: Once considered inevitable, injuries are now recognized to be a major public health problem that can be addressed through basic research, interventions and evaluations that focus on everything from individual risk factors to the development and evaluation of policy at the national, state and local levels.

THE CENTER: The Southern California Injury Prevention Center (SCIPRC), one of 10 centers funded by the U.S. Centers for Disease Control and Prevention, develops and supports multidisciplinary research and training focused on Southern California.

Master’s and doctoral students receive financial and technical assistance in developing injury-relevant projects, and SCIPRC supports a number of courses in the School of Public Health. Past studies include a definitive evaluation of the California motorcycle helmet law and, in collaboration with the Center for Public Health and Disasters, a series of studies of the mortality, morbidity, and community disruption that occurred following the Northridge earthquake.

CURRENT EVENTS: Ongoing activities include household surveys of preparedness for terrorism and earthquakes; an evaluation of a school-based media violence program; studies of mild brain injury; the UNITY (Urban Networks to Increase Thriving Youth Violence Prevention) project; and support to the Advancement Project Report on Gang Violence Reduction and the Violence Prevention Coalition of Greater Los Angeles.

UCLA CENTER FOR ENVIRONMENTAL GENOMICS Zuo-Feng Zhang and Robert H. Schiestl Co-Directors

UCLAPUBLIC HEALTH

THE ISSUE: Approximately 1.45 million Americans are diagnosed with cancer each year, but a very small percentage of these cancers are related to known genetic mutations; rather, it is believed that most cancers are the result of complex interactions between people’s genes and their environment. The goal for scientists looking to prevent cancer is to discover what specific combination of an individual’s genetics and environmental factors such as diet, air and water pollution, tobacco exposure, and other exposures result in disease.

THE CENTER: The UCLA Center for Environmental Genomics, a partnership between the school and UCLA’s Jonsson Comprehensive Cancer Center, brings together experts from a variety of fields to investigate the molecular mechanisms by which environmental agents such as air pollutants interact with genetic predisposing factors to cause disease. A better understanding of these processes will pave the way not only for targeted drug therapies, but also for targeted public health efforts to reduce environmental exposures in high-risk populations.

CURRENT EVENTS: The Ann Fitzpatrick Alper Program in Environmental Genomics, part of the center, is exploring such issues as interactions between air pollution and genetic factors on risk of lung cancer among non-smokers; interactions between aflatoxin exposure and DNA repair genes on liver cancer; genetic risk factors for esophagus cancer; and the role of inflammation on lung carcinogenesis. The center’s newly established Program on Genomics and Nutrition, headed by Dr. Simin Liu, is working on nutrition and genetic predisposition in the risk of diabetes, heart disease, and cancer.

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UCLA CENTER FOR HEALTH POLICY RESEARCH E. Richard Brown Director | Gerald Kominski, Steven Wallace, and Roberta Wyn Associate Directors www.healthpolicy.ucla.edu

THE CENTER: Since its establishment in 1994, the UCLA Center for Health Policy Research has become one of the nation’s leading health policy research centers and the premier source of information on the health and access to care of Californians. The center seeks to improve the public’s health by advancing health policy through research, public service, community partnership, and education. The center’s data and analysis assists legislators, community-based organizations and advocacy groups in influencing policies for important health-related issues.

The center also offers extensive educational and training opportunities for graduate students and postdoctoral fellows.

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THE ISSUE: For policy makers and community-based organizations at the national, state, and local levels, improving the health status and access to care for their constituents requires reliable data and analysis.

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CURRENT EVENT: One of the center’s most visible and invaluable efforts is the California Health Interview Survey (CHIS), conducted every two years in conjunction with the California Department of Public Health, the California Department of Health Care Services and the Public Health Institute. CHIS is one of the largest health surveys in the nation and the most comprehensive source of health information on Californians. AskCHIS, a free online CHIS data query system, provides a quick and user-friendly way to access data for grant proposals, needs assessments, research, news reporting, and policy making.

UCLA CENTER FOR HUMAN NUTRITION David Heber Director THE ISSUE: The role of foods, nutrients and phytochemicals is the central focus of efforts to prevent and treat common chronic diseases – such as obesity, type 2 diabetes, and certain cancers – through the integration of basic and clinical research and education.

THE CENTER: The UCLA Center for Human Nutrition provides leadership in nutritional sciences by facilitating interdisciplinary research, improving patient care, and creating educational initiatives for health professionals and the public. The center brings together faculty, postdoctoral research fellows, graduate students, and medical students to focus on the roles of nutrition and food in human health and disease. Primary areas of research are in obesity prevention and treatment, and in nutrition and cancer prevention. Programs include basic biological research; nutrition education for various constituencies, including medical, graduate, undergraduate, and postgraduate students; and participation in multi-center clinical trials for primary and secondary disease prevention through dietary intervention.

CURRENT EVENT: Researchers at the center are actively studying the health benefits of phytochemicals in pomegranate products and green tea in cancer prevention.

UCLA CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL HEALTH John Froines Director www.coeh.ucla.edu THE ISSUE: Human activity has transformed environmental health in profound ways; environmental problems are now global and long-lasting. Toxic chemical exposure, global climate change, population growth, habitat destruction, and social/psychosocial factors have produced crises that require long-term social and technical change for their solutions.

THE CENTER: Established by the California Legislature and Executive Branch in 1978, the UCLA Center for Occupational and Environmental Health (COEH) is one of three state-funded programs for research, training, and service in occupational and environmental health, and exercises important political influence on California’s environmental policies. Faculty from the schools of public health, nursing, and medicine train occupational and environmental health professionals and scientists, conduct research, and provide service through consultation, education, and outreach; the academic curriculum of these three schools is enhanced with a multidisciplinary orientation, enabling students to gain a broader view of the tools and techniques available for environmental research and intervention. COEH-affiliated centers include the Southern California Particle Center, Southern California Environmental Health Sciences Center, Southern California NIOSH Education and Research Center, UCLA-Fogarty Training Program in Occupational and Environmental Health, and Southern California Consortium on Asthma and Outdoor Air Quality.

UCLAPUBLIC HEALTH

CURRENT EVENT: COEH is playing a key role in efforts to develop a new UCLA Center for Sustainable Technology, which will focus on the science, policy and economics of reducing or eliminating the use of toxic chemicals in the environment – what is sometimes described as “green chemistry.” Participants include the School of Public Health, Law School, and Anderson School of Management, along with anticipated participation by chemistry and engineering faculty.

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22 UCLA CENTER FOR PUBLIC HEALTH AND DISASTERS Steven Rottman Director | Linda Bourque Associate Director | Kimberly Shoaf Assistant Director www.cphd.ucla.edu THE ISSUE: In this decade, high-profile natural and human-caused disasters – from Hurricane Katrina to the September 11, 2001 attacks and increased specter of bioterrorism – have raised awareness of the necessity for a public health workforce that is well-prepared to take action in such emergencies, in conjunction with other first responders.

THE CENTER: The UCLA Center for Public Health and Disasters (CPHD) promotes interdisciplinary efforts to reduce the health impacts of natural and human-induced disasters, both domestic and international, by facilitating dialogue between public health and fields that include medicine, engineering, physical and social sciences, and emergency management. This philosophy is applied to the education and training of practitioners and researchers, collaborative interdisciplinary research and service to the community.

The center also has an extensive curriculum, and was the first such program in the United States to offer multiple graduate-level courses in emergency public health. CPHD collaborates with state and local public health agencies, community-based organizations, schools, hospitals, and agencies in the public and private sector.

CURRENT EVENT: CPHD is part of a national network of 27 Centers for Public Health Preparedness, funded by the CDC, whose main objective is to strengthen emergency preparedness and response at the front lines by linking academic expertise to state and local public health agency needs.

UCLA/RAND CENTER FOR ADOLESCENT HEALTH PROMOTION Robert Kaplan Director www.rand.org/health/centers/adolescent THE ISSUE: Childhood and adolescence are critical periods for the development of health-related habits whose effects not only have immediate impact but also extend well into adulthood; early adolescence, in particular, is a time in which youth are particularly vulnerable to risky behaviors or environments.

THE CENTER: The UCLA/RAND Center for Adolescent Health Promotion is a Prevention Research Center of the Centers for Disease Control and Prevention whose multidisciplinary faculty, staff, and community partners conduct studies, develop programs, and provide education related to adolescent health promotion, risk reduction, and disease prevention. Major research areas include parent-adolescent communication; physical activity, nutrition, and obesity; sexual health and risk reduction; work-family conflict; substance use; alcohol advertising; health care for children and adolescents; and quality of health care. The center is innovative in its approach, partnering with ethnically and economically diverse communities to conduct community-based participatory research and to provide technical support to community groups for program implementation and assessment. The center also provides training opportunities for School of Public Health students.

UCLAPUBLIC HEALTH

CURRENT EVENT: Community and Youth Advisory Boards hold regular meetings with researchers, providing forums for local partners and teens to help shape the center’s research agenda and to collaboratively develop and conduct projects.

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research

research highlights Findings Shed Light on Sex Differences in Diabetes, Suggest Potential for Earlier Diagnosis and Treatment

The findings could lead to predictive and diagnostic models for diabetes that work far better than the current practice of testing for blood glucose levels.

UCLAPUBLIC HEALTH

DIABETES RESEARCHERS have long observed sex differences in how the disease develops and in its manifestations, particularly with regard to vascular complications. Women bear much of the diabetes risk burden. For example, studies have shown that overweight is a more powerful risk factor for diabetes in women than in men. In addition, type 2 diabetes is a more powerful risk factor for heart disease mortality in women than in men: It increases the risk of heart disease mortality by approximately 250 percent in women, vs. approximately 100 percent in men. But little has been known about the biological reasons for these differences.

Now, a series of 2007 papers published in major peer-reviewed journals by the research group of Dr. Simin Liu, professor in the UCLA School of Public Health, and David Geffen School of Medicine, has shed new light on the biology of the disease, linking three major physiological systems (metabolism, immunity, and reproduction) that contribute to the sex differences in diabetes development. Liu and collaborators assessed these physiological functions across multiple ethnic populations (whites, African Americans, Latinos, and Asians) and identified three sets of biological markers that enabled them to forecast the development of diabetes in apparently healthy women.

The findings suggest the potential for strategies that could lead to a much earlier diagnosis of the disease, which would potentially facilitate interventions at an earlier stage in the disease course, when they might be more likely to succeed. The biological markers identified by Liu’s group could also lead to new prevention and treatment approaches.

Publishing in the journals Diabetes, Archives of Internal Medicine and Diabetologia, Liu and colleagues identified a set of biochemical markers (inflammation and endothelial dysfunction) in women that were highly and significantly predictive of diabetes years ahead of actual disease development. In addition, they reported that these biochemical markers appear to be interacting with sex steroids in determining an individual’s risk of developing diabetes, independent from the traditional risk factors.

The findings, which culminate an eight-year research effort of Liu’s research program, contribute to an improved understanding of the genetic and biochemical roles of sex steroids in the inflammation that occurs not only in the development of type 2 diabetes, but also in heart disease and certain cancers.

“These findings provide some new biological insight in explaining an age-old observation of sex differences in the etiology of diabetes and its vascular complications,” Liu says. “Ultimately, this should allow us to build predictive and diagnostic models for diabetes that will work far better than our conventional practice of testing for blood glucose levels. In addition, the molecules we have identified as biological markers can serve as important targets for improved prevention and treatment of this disease.”

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PG-13 Films Not Safe for Kids?

Distribution of Violent Actions Among PG-13 Films, by Genre

Number (%) of Films with Violence

Number (%) of Violent Actions

Action (n = 13)

13 (16.9)

1,178 (52.3)

Comedy (n = 37)

31 (40.3)

747 (33.2)

Drama and Romance (n = 18)

14 (18.2)

75 (3.3)

Horror, Sci-Fi, Thiller (n = 9)

9 (11.7)

251 (11.2)

Total (n = 77)

67 (87.0)

2,251 (100)

Genre

UCLAPUBLIC HEALTH

* Includes all films in genre, both with and without violence

PG-13 FILMS have lots of “happy violence” – as defined by the late communications theorist George Gerbner, that which is “cool, swift and painless” – without considering the consequences of violent acts, such as injury, death and the shattered lives of the people involved, according to a study by researchers at the school’s Southern California Injury Prevention Research Center.

Homicide is the second leading cause of death among 15- to 24-year-olds in the United States. Media depictions of violence help teach such acts to children, leading to three effects – increased aggression, fear for their own safety, and a desensitization to the pain and suffering of others, according to the study team, which was led by Theresa Webb, a researcher in the Department of Epidemiology and at the center. The study was published in the journal Pediatrics.

In a sample of 77 PG-13 rated films, Webb and her colleagues Average Minimum Maximum Number Number Number recorded a total of 2,251 violent of Acts of Acts of Acts Per Film* Per Film Per Film actions, with almost half resulting in death. Although a small subset of this 6 263 91 content contained violence that was 0 137 20 associated with negative effects such 0 28 4 as pain and suffering, only one film – Pay It Forward, in which the young 2 98 28 hero is stabbed to death – contained 0 263 29 violent acts that would demonstrate to youthful viewers how horrific violence can be.

“Violence permeated nearly 90 percent of the films in this study,” Webb says. “And while the explanations and causes of youth violence are very complex, the evidence is clear that media depictions of violence contribute to the teaching of violence. This is especially true in our society, where the average young person’s engagement with visual media in all its forms can run to as many as eight hours a day.”

The researchers sampled all of the PG-13 rated films from among the 100 top-grossing movies of 1999 and 2000, as established by the Hollywood Reporter. To obtain their results, they coded each act of violence and the context in which it was presented based on features known to put violence in a good or bad light. Such features include the motivation for violence, the presence of weapons, the consequences of violence and the degree of realism.

The findings follow up on a 2005 study the researchers conducted that looked at movie violence in all ratings categories established by the Motion Picture Association of America (MPAA). In that study, they found that parents using the ratings system to gauge movie content receive little meaningful guidance related to violent content.

This time around, the researchers selected the PG-13 category because it has become a repository for action films. “These films are often the largest budgeted ones made by the Hollywood film industry and have also been found to be equally, if not more, violent than R-rated films,” Webb notes.

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GREATER BONE MINERAL DENSITY reduces the risk of age-related maculopathy in elderly women, according to the findings of a research team led by Dr. Anne L. Coleman, professor of epidemiology in the UCLA School of Public Health and professor of ophthalmology at UCLA’s Jules Stein Eye Institute.

Age-related maculopathy (ARM), a leading cause of severe visual impairment among older adults in developed countries, affects the central vision of approximately 9 million people in the United States. “Because we have such a poor understanding of the pathogenesis of ARM and limited available treatment options, identifying prevention strategies is crucial to addressing the burden of this disease,” Coleman says.

In a study published in the Journal of the American Geriatric Society, Coleman reported that greater bone mineral density (BMD) decreased by at least 34% the likelihood of ARM in 1,042 white women aged 75 and older who were enrolled in the multi-center cohort Study of Osteoporotic Fractures.

“To our knowledge, ours is the first study to investigate the association between BMD and ARM, and further research is needed to confirm these results,” says Coleman. “But our findings suggest that maintaining healthy bones, which we already know to be beneficial in preventing osteoporosis, falls and injuries, and cognitive decline, is also beneficial in fighting AMD.” She notes that current prevention strategies for AMD are limited: Intake of antioxidants and zinc has been found to slow the progression of the disease.

The way in which BMD might affect AMD is unknown. One hypothesis is that a higher estrogen level over the course of a woman’s lifetime is what is protective of ARM. “Women with greater exposure to estrogen during their lifetimes tend to have stronger bones,” Coleman says. “Past research has suggested that longer reproductive life, also a marker for higher lifetime estrogen levels, decreases the likelihood of having AMD.” Coleman adds that fruit and vegetable consumption, which has been found to be associated with BMD, is another factor that might have contributed to the findings.

Identifying risk factors associated with AMD is all the more important given the significant financial costs of the disease. In a separate study using data from a random sample of 1995-1999 Medicare beneficiaries, Coleman’s group estimated that the annual cost of treatment of some forms of AMD was $569 million, though the costs might be much greater given that the Medicare database allowed for the inclusion of only reimbursed eye-related professional fees. Nonreimbursed costs that increase the burden from AMD and were unaccounted for in the study include low-vision aids, pharmacy costs, nursing care costs, and indirect care costs in the form of lost productivity.

research

Maintaining Strong Bones May Protect Older Women Against Age-Related Maculopathy

Given the limited treatment options, identifying new prevention strategies is crucial to addressing the burden of age-related maculopathy, a leading cause of visual impairment among older adults.

UCLAPUBLIC HEALTH

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research

Proximity to High Traffic Density, Air Pollution Linked to Poorly Controlled Asthma

UCLAPUBLIC HEALTH

Adults with asthma living in the highest-density traffic areas are twice as likely to have severe asthma as those living in the lowest-density areas.

DESPITE MAJOR ADVANCES in the development of anti-inflammatory medications in the last two decades, many U.S. residents have poorly controlled asthma. In California in 2000, nearly 25 percent of adults diagnosed as having asthma experienced symptoms every day or week, 7 percent reported at least one emergency department visit for asthma, and 2 percent reported they were hospitalized for the condition, according to findings from the 2001 California Health Interview Survey, based in the school’s Center for Health Policy Research. Poorly controlled asthma is difficult to treat and contributes disproportionately to the overall costs associated with the condition, but little is understood about the reasons behind it.

A team of researchers from the UCLA School of Public Health and California Department of Public Health has identified a major factor: traffic and air pollution levels near one’s home. Publishing in the Annals of Allergy, Asthma and Immunology, Dr. Ying-Ying Meng and colleagues reported that adults with asthma living in the highest-density traffic areas are twice as likely to have severe asthma as those living in the lowest traffic density areas, even after adjusting for age, sex, race, and poverty, with the strongest association found among the elderly. Ozone exposures are associated with poorly controlled asthma among elderly adults and men, whereas particulate matter less than 10 μm appears to affect primarily women, even at levels below the U.S. Environmental Protection Agency air quality standard. The varying effects by population group indicate differences in susceptibility to specific pollutants, the researchers noted.

Most previous studies on the subject have focused on the effects of short-term (one- to five-day) pollutant exposures on hospitalizations and emergency care, especially among children; this has left unanswered questions about the potential role air pollution plays in asthma exacerbation among adults and whether certain subpopulations such as elderly adults and women respond to pollutant exposures differently, notes Meng, a senior research scientist at the Center for Health Policy Research. Using 2001 California Health Interview Survey data, Meng and colleagues examined whether exposure to air pollution, measured via traffic density and ambient airmonitoring data near residences, increases the prevalence of poorly controlled asthma among various subpopulations of adults with asthma living in Los Angeles and San Diego counties.

“Our study provides much-needed information on the possible association of long-term exposure – a year or more – to outdoor air pollution and asthma severity in an ethnically diverse adult population,” Meng says. “The findings suggest that more consideration should be given to residential proximity to heavy traffic and outdoor pollutant levels for those adults with poorly controlled asthma.”

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UCLAPUBLIC HEALTH

MEN WHO WERE DENIED ACCESS to California’s public assistance program for prostate cancer during the state’s 2005 fiscal woes experienced significantly more symptom-related distress and less perceived self-efficacy than enrollees in the program, even when comparing individuals with the same disease burden.

These are among the findings of a study headed by Drs. Jennifer Anger, assistant professor of urology in UCLA’s David Geffen School of Medicine, and Dr. Mark S. Litwin, professor of urology in UCLA’s David Geffen School of Medicine and of health services in the UCLA School of Public Health. The findings underscore the importance of the IMPACT program, which has since been made a permanent part of the California Department of Public Health, and which has been headed by Litwin since it was established in 2001.

IMPACT (Improving Access, Counseling and Treatment for Californians with Average Baseline Health-Related Prostate Cancer) is designed to reduce barriers to accessing health care and Quality of Life Scores for Prostate needed psychosocial services among uninsured men with prostate cancer. The Cancer Patients Enrolling in program gives access to providers throughout California – in the individual’s own IMPACT Program vs. Patients community where possible. Besides the direct patient care, IMPACT provides Told They Were Being Waitlisted case and symptom management, culturally and linguistically appropriate patient-education materials, and Difference extensive social-service resources. in Negative Enrolled Waitlisted The program was designed not only Outcome for Patients Patients Waitlisted to remove health-system access barriers faced by uninsured men with 21 24 14% SDS (Symptom Distress Scale)* prostate cancer, but also to diminish health-outcome barriers associated 8.1 10.6 31% PEPPI (Perceived Efficacy in Patient-Physician Interactions)** with minority status, low socioeconomic status, low levels of education * SDS measures the degree of distress perceived by patients for 10 specific cancer symptoms. and health literacy, language, and Responses are scored from 1 to 5 and added together, with higher scores indicating more symptom-related distress. cultural differences. **PEPPI measures patients’ perceived sense of effectiveness in interacting with physicians In February 2005, in the midst of and obtaining needed health care. Responses to each of five items are scored from 1 to 5 a state fiscal crisis, IMPACT enrolland added together, with a higher score reflecting lower self-efficacy. ment was closed; men needing program services were put on a waiting list in the hope that enrollment would reopen in the future. “Suspension of enrollment in IMPACT afforded a unique opportunity to assess the health-related quality of life of a population of men rarely studied,” says Anger. “Health-related quality of life is an important component of treatment decision-making for men with prostate cancer, and researchers have just recently begun to look at how it is affected by access to care.”

Waitlisted men were interviewed every three months until enrollment was reopened and their health-related quality of life was compared with a group of enrolled men matched by disease stage, age and race. In addition to showing significantly more symptom distress and less self-efficacy than the enrolled men, the waitlisted men were significantly less likely to have access to a doctor or other medical treatments and services. Results of the study were published in Public Health Reports.

“The negative impact on health-related quality of life in men with prostate cancer denied access to IMPACT supports the position that ongoing and continuous financial support is crucial for this program,” says Litwin. IMPACT, which has provided prostate cancer treatment to more than 1,000 men, was made permanent with passage by the California Legislature of a bill signed into law by Gov. Schwarzenegger in the fall of 2005 placing the program in the state’s newly formed Department of Public Health. In April 2006, UCLA was awarded the IMPACT administration contract in a new three-year, $9.7 million agreement.

research

Quality of Life Benefits Shown for Patients in Public Assistance Program for Prostate Cancer

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student profiles Supporting a Broader View of Community Health Through Grant-Making for The California Endowment

“This is an organization that acknowledges the impacts that economic viability, availability of education, political will, and social capital have on the health of a community.”

UCLAPUBLIC HEALTH

— Beatriz Solís

BEATRIZ SOLÍS IS RELISHING HER NEW POSITION at The California Endowment – one that allows her to put into practice much of what she learned during separate stints as a master’s and doctoral student at the UCLA School of Public Health.

In March, as she was nearing completion of her Ph.D. in the school’s Department of Community Health Sciences, Solís was hired by the private statewide health foundation as Los Angeles regional senior program officer. In that role, Solís oversees and provides direction for the administrative and grant-making activities of the foundation’s Los Angeles-based program officers, who serve a region that encompasses Los Angeles, Ventura, Riverside and San Bernardino counties. Solís also serves as a member of the foundation’s statewide Community Health and Elimination of Health Disparities Program Team, which seeks to improve the environmental factors that contribute to the poor health status of residents in low-income communities and to reduce the higher rates of health conditions and diseases among racial and ethnic groups.

The California Endowment, whose mission is to expand access to affordable, quality health care for underserved individuals and communities and to promote fundamental improvements in the health status of all Californians, has awarded more than 8,800 grants totaling nearly $1.7 billion since it was established in 1996.

For Solís, the attraction of the job was both in the opportunity to direct the foundation’s resources in ways that can make a significant impact on the health of populations in the region, and to do so in a way that takes a broad view of community health.

“This is cutting-edge philanthropic work that is engaging the community, taking risks, and trying to leverage support on many different levels – not only from the foundation world but from public dollars and the ability to bring together unlikely partners from different sectors,” Solís says. “It’s an organization that acknowledges the social determinants of health, including the impacts that economic viability, availability of education, political will, and social capital have on the health of a community.”

After earning her M.P.H. from the school in 1996, Solís spent five years as a research associate for the UCLA Center for Health Policy Research. From there she went to L.A. Care Health Plan, serving as director of cultural and linguistic services.

There, Solís developed one of the first departments dedicated to cultural and linguistic issues in a managed care setting. Rather than emphasizing health education, her department sought to identify and eliminate health-system barriers to diverse patients receiving the services they needed.

Solís left L.A. Care in 2005 to concentrate on her doctoral studies; for her dissertation, she conducted research on the topic of barriers to care for limited Englishproficient patients among Medi-Cal managed care enrollees. “I am indebted to my professors, who pushed me to challenge myself and think out of the box,” she says.

“They taught me about the importance of looking at the intersections of social determinants of health – understanding the nexus of all of those forces that affect community health, rather than thinking about public health in terms of silos.”

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students

Seeking Environmental Justice After Bhopal Tragedy

“There are underserved communities [with] greater exposure to toxic chemicals.

They don't have a voice.

In some capacity, I would like to serve as that voice for them.”

— Khadeeja Abdullah (with her adviser Dr. William Hinds)

UCLAPUBLIC HEALTH

WHEN KHADEEJA ABDULLAH WAS STILL AN INFANT, her family experienced an environmental tragedy that is, in no small way, responsible for her being at the UCLA School of Public Health today.

Abdullah was born in 1984 in Bhopal, India, two miles from the Union Carbide factory. In the early morning hours of December 3 of that year, her family awakened to the sounds of screaming outside the house. When Abdullah’s uncle went outside he saw chaos – people running in all directions as a thick, musty gas hovered over the city. Dead bodies were strewn on the streets. In one of the world’s worst industrial disasters, 27 tons of deadly methyl isocyanate gas had been released from a holding tank that had overheated at the plant. None of the safety systems built to contain such a leak were operational. Approximately half a million people were exposed, 20,000 died and more than 120,000 continue to suffer the after-effects.

Growing up hearing firsthand accounts of all that went wrong in Bhopal during the disaster and its aftermath convinced Abdullah that she wanted to go into a career in which she could make a difference in protecting communities – particularly the less powerful – from toxic exposures. As a UCLA undergraduate she first considered going into environmental engineering, but her volunteer work at the UMMA (University Muslim Medical Association) Community Clinic – Abdullah was director of volunteers at the clinic, which provides quality health care to an underserved population in Los Angeles regardless of ability to pay – led her to decide she wanted a more direct path combining environmental science and human health.

She is currently in her second year as an M.P.H. student in the school’s Industrial Hygiene Program, with plans to become an environmental scientist who works in the policy arena. Abdullah says her decision to pursue an M.P.H. was reinforced by her belief that preserving health and the environment are important from the perspective of her Muslim faith, and by her desire to promote more awareness in the Muslim community about environmental issues. “Given that much of the developing world is inhabited by Muslims, the impact that could come from these individuals realizing their responsibility from a perspective that is so dear to them – their faith – could substantially improve the fate of subsequent generations,” she says.

Abdullah intends to focus in her professional pursuits on fighting for environmental justice. When she returns to Bhopal to visit relatives, she is reminded that the community has in no way returned to normal: Respiratory illnesses, poor vision, and gynecological complications, among other ailments, continue to be all too common.

New mothers are found to have carcinogenic elements in their breast milk. Ground water around the plant is still contaminated with toxic chemicals. Residents have received minimal financial compensation for their hardship.

While her birthplace is among the most tragic examples, Abdullah believes many less publicized populations in Southern California and beyond need advocates as well. “There are underserved communities that are taken advantage of, even if not intentionally, through greater exposure to toxic chemicals in comparision with affluent communities,” she says. “They don’t have a voice. In some capacity, I would like to serve as that voice for them.”

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news briefs

HEALTH COVERAGE CONCERNS — At a recent news conference on the UCLA campus, results were presented from a UCLA Center for Health Policy Research report showing declining job-based coverage in California.

Pictured (l. to r.) are Dr. E. Richard Brown, professor at the school and director of the center; Dean Linda Rosenstock; and Gov. Arnold Schwarzenegger.

sph a national center of excellence in elimination of health disparities The UCLA School of Public Health has received a Centers for Disease Control and Prevention grant totaling $4.25 million over five years and has been named a national center of excellence to address health disparities related to heart disease, stroke and cancer among African Americans, Latinos and Asians at the local, state and national level. The school will provide technical assistance and training to health and social-service organizations, faith-based groups, schools, and other institutions.

The award will enable the school’s Center to Eliminate Health Disparities (CEHD) to build on more than two decades of work with a large and reputable network of community-based organizations and the Los Angeles County Department of Public Health, one of the largest county health departments in the nation, to improve health by changing physical activity and nutrition norms and practices at key community institutions. Drs. Antronette Yancey and Roshan Bastani, CEHD directors, will co-direct the new Center of Excellence.

The project will focus on changing organizational practices and policies rather than individual behavior. UCLA and L.A. County have pioneered culturally based approaches to increasing physical activity levels and healthy food choices, including incorporating brief dance breaks to music in the workplace.

According to the Agency for Healthcare Research and Quality’s National Healthcare Disparities Report, while health disparities for most U.S. minorities are narrowing compared to the general population, Hispanics/Latinos are falling further behind. Not only do disparities exist between various racial and ethnic groups and whites, but there are also disparities among and within racial and ethnic subgroups.

For more on the CEHD, see page 22 or visit www.ph.ucla.edu/cehd.

UCLAPUBLIC HEALTH

sph center to participate in landmark national study of children’s health The UCLA Center for Healthier Children, Families and Communities (CHCFC), based in the School of Public Health, has been selected as one of 22 new study centers for the National Children’s Study, a nationwide project designed to assess the effects of environmental and genetic factors on children’s health in the United States. The study center will manage local participant recruitment and data collection for the nation’s largest-ever study of child health.

The National Children’s Study is a collaborative effort between the U.S. Environmental Protection Agency and the Department of Health and Human Services (including the National Institute of Child Health and Human Development, the National Institute of Environmental Health Sciences at the National Institutes of Health, and the Centers for Disease Control and Prevention).

“This study is big science and it will be one of the most important generators of new knowledge on child and adult health and development ever attempted,” says Dr. Neal Halfon, director of the UCLA Center for Healthier Children, Families and Communities and principal investigator of the UCLA study center. “It will help children across the U.S. and shape child health guidance, interventions and policy for generations to come.”

The National Children’s Study will eventually follow a representative sample of 100,000 children from before birth to age 21, seeking information that will help prevent and treat some of the nation’s most pressing health problems, including autism, birth defects, diabetes, heart disease and obesity. To better understand the impact of exposures on the developing fetus, infant and child, the study will recruit pregnant women, as well as women who are likely to become pregnant, in order to assess environmental health influence during the pre-pregnancy and prenatal period.

For more information on the CHCFC, see page 19 or visit www.healthychild.ucla.edu.

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Dr. Patricia Ganz, a professor in the schools of public health and medicine, whose research has changed the face of cancer survivorship, has been honored with election to the prestigious Institute of Medicine of the National Academies.

Ganz, director of the Division of Cancer Prevention and Control Research, based in the school and UCLA’s Jonsson Cancer Center (see page 19), is a founding member of the National Coalition of Cancer Survivors and is considered the top national expert on quality of life after breast cancer; her studies have changed the way the medical field views the post-treatment health problems faced by millions of former patients nationwide. Election to the Institute of Medicine is considered one of the highest honors bestowed to professionals in the fields of medicine and health.

news briefs

IOM elects ganz “healthy futures” salon series The school launched a salon series this fall to explore emerging issues in the field of public health. SPH faculty members join alumni, school donors and friends in an intimate setting for a focused discussion around today’s leading public health issues.

Topics slated for discussion in 2007-08 include the cost of health care, cancer survivorship, childhood obesity and infectious diseases.

For more information on this series, or to contribute a suggestion for a salon topic, please email cdifatta@support.ucla.edu.

beverlee a. myers fellowship fund The UCLA School of Public Health is the benefactor of a newly established fellowship fund in honor of Beverlee A. Myers, former head of Health Services at the school, gifted by her widower Duane (Pete) Myers of Santa Fe, N.M. The fellowship will be awarded annually to students in the Department of Health Services. Selection criteria include scholastic excellence, personal integrity and dedication to social justice and equity in health services.

Myers, who died in 1986, was a dedicated and passionate public health professional. She served as an official in the U.S. Public Health Service, rising to become director of planning and evaluation in the office of the assistant secretary for health. Myers served as director of the California Department of Health Services from 1978 to 1983, the first woman and the first non-physician to hold that important post. She was head of Health Services at the school from 1983 until her death in 1986.

remembering walter oppenheimer

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.

UCLAPUBLIC HEALTH

Walter Oppenheimer, a long-time friend of the school and member of the Dean’s Advisory Board, passed away on August 1, 2007, at the age of 92. “Walter was a man of great passion and dedication, and his warm friendship with the school and with me personally is something I will always treasure,” says Dean Linda Rosenstock.

Oppenheimer was a philanthropist and retired fashion industry executive. He and his wife Helga, who died in 2003, owned Helga, Inc., which designed suits, dresses and evening clothes that were sold in speciality stores. Oppenheimer was a generous supporter of the school. Before Helga’s death, the Oppenheimers established two charitable gift annuities to provide funds for student education, and the school’s main lobby was named in their honor. He noted then, “I like the fact that the school trains professionals and scientists who work to benefit the heath of all members of the community, not just individuals.” Oppenheimer remembered the school in his will with a significant gift to endow a professorship in public health.

MATT DURKAN JOINS SPH DEVELOPMENT TEAM — Matt Durkan has joined the school as director of development, with a focus on major donor and corporate support.

Durkan, who will work with Assistant Dean for Development and Alumni Relations John Sonego, brings a wealth of fundraising and development experience to the team, including his most recent work as director of development for HALSA, the HIV-AIDS Legal Services Alliance. Durkan also previously worked at the UCLA Anderson School.

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contracts & grants 2006-07 This section includes new contracts and grants awarded in fiscal year 2006-2007. Due to space limitations, only funds of $50,000 or more are listed, by principal investigator.

SUSAN BABEY Examining Environmental Influences on Child Dietary & Physical Activity Behaviors (Robert Wood Johnson Foundation, $394,182 for 2 years) ROSHAN BASTANI Liver Cancer Control Interventions for Asian Americans Program Project: Increasing Hepatitis B Screening Among Korean Church Attendees (National Cancer Institute & UC Davis Cancer Center, $2,348,597 for 5 years) BARBARA BERMAN Breast Cancer Education for Deaf & Hard-of-Hearing Women (State of California – UC Breast Cancer Research Program, $300,000 for 3 years); A Breast Cancer Education Program for Deaf Women (Susan G. Komen Foundation, $250,000 for 2 years) LINDA BOURQUE A Clearinghouse on Natural Hazards Research & Application Information Center (National Science Foundation & University of Colorado, $226,249); Addendum to NC Start National Household Survey (National Science Foundation, $185,730) E. RICHARD BROWN The California Health Interview Survey (National Cancer Institute, $1,330,146; Blue Shield of California Research & Education Foundation., $450,000 for 3 years; The California Endowment, $2,750,393 for 2 years; California Department of Managed Health Care/Office of the Patient Advocate, $259,800; California Department of Mental Health, $750,000 for 2 years; Robert Wood Johnson Foundation, $1,458,293 for 2 years; LA Care Health Plan, $287,589 for 2 years; California Department of Health Services, $1,855,000); The State of Health Insurance in California Report (SHIC) 20072009 (California Wellness Foundation, $225,000 for 3 years) SUSAN COCHRAN Drug Use, HIV, Morbidity & Other Comorbidities in a Vulnerable Population (National Institute on Drug Abuse, $2,271,766 for 4 years) DOROTA M. DABROWSKA Survival Analysis Methods for Transplantation Studies (National Institute of Allergy and Infectious Diseases, $719,178 for 3 years)

UCLAPUBLIC HEALTH

JONATHAN E. FIELDING Building Capacity Through a Health Impact Assessment Clearinghouse Learning & Information Center (Robert Wood Johnson Foundation, $475,491 for 3 years) JOHN R. FROINES UCLA-Mexico/Colombia Collaborative Training & Research Program (Fogarty International Center, $436,250 for 5 years); Physiochemical & Toxicological Assessment of the Semi-Volatile & Non-Volatile Fractions of PM From Heavy- and Light-Duty Vehicles Operating with and Without Emissions Control Technologists (CA/EPA Air Resources Board & University of Southern California, $67,205 for 4 years)

PATRICIA A. GANZ A Model Clinical/Translational Research Program for Breast Cancer Survivors (The Breast Cancer Research Foundation, $250,000); Cognitive Functioning After Breast Cancer Treatment (National Cancer Institute, $2,270,755 for 5 years) HILARY GODWIN Fluorogenic Methods for the Detection of Lead on Surfaces (Saint Louis University, $89,101 for 2 years) PAMINA M. GORBACH Transmission Behavior in Partnerships of Newly HIV Infected Southern Californians (National Institute on Drug Abuse, $2,621,230 for 5 years) GAIL HARRISON Framework Program for Global Health (Fogarty International Center, $404,864 for 3 years) SYDNEY HARVEY Infectious Disease & Laboratory Development Program (California Department of Health Services, $1,656,029 for 3 years) WILLIAM HINDS Training Program to Increase the Identification Analysis, Remediation & Prevention of Workplace Injuries & Illness Among Uninsured (California Wellness Foundation, $160,000 for 3 years); Proposed Training: Preventing Workplace Injuries & Illness Among Groundskeepers in Tourism Industry (U.S. DOL/Occupational Safety & Health Admin, $188,287) MARTIN IGUCHI Sexual Acquisition & Treatment of HIV Cooperative Agreement Program (National Institute on Drug Abuse & RAND Corporation, $125,124) MARJAN JAVANBAKHT Anal Intercourse, STIs & HIV Among STD Clinic Clients (American Foundation for AIDS Research, $112,193 for 2 years) MARJORIE KAGAWA-SINGER Development of a Toolkit of Guidelines for Culturally Effective Materials & Programs (The California Endowment, $71,300 for 2 years); Increasing Diversity in Cancer Control Research (National Cancer Institute & UC San Francisco, $235,888); Impact of Interpreters on Cancer Care Access & Delivery for Thai & Vietnamese Patients (UC Davis Cancer Center, $144,554 for 2 years) LEEKA I. KHEIFETS Replication of Draper Study of Leukemia, Brain Tumors & Distance to Power Lines in California: Feasibility Study of Exposure Assessment (Electric Power Research Institute, $137,980); The Interplay of Residential Magnetic Fields & Genetic Translocations in the Etiology of Childhood Leukemia (Electric Power Research Institute, $213,815 for 2 years); Update to a Meta-Analysis on Occupational Exposure & Leukemia & Brain Cancer (Electric Power Research Institute, $182,103) GERALD KOMINSKI Medi-Cal Disease Management Evaluation (California Department of Health Services, $1,499,890 for 5 years); California Health Benefits Review Program (UC Office of the President, $214,000 for 3 years)

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SIMIN LIU Magnesium Supplement, Plasma Inflammatory Markers, & Gene Expression in Overweight Individuals with Metabolic Syndrome (General Mills Foundation, $62,500) ANNETTE MAXWELL Liver Cancer Control Interventions for Asian Americans Program Project: Methodology Core (National Cancer Institute & UC Davis Cancer Center, $549,879 for 5 years) WILLIAM J. MCCARTHY Pathways of How Socioeconomic Context Affects Teen Smoking (State of California & UC Tobacco-Related Disease Research Program, $75,000 for 2 years); Surveillance of Lung Cancer Trends in the US With Miscan (National Cancer Institute & RAND Corporation, $125,857 for 4 years) JACK NEEDLEMAN Transforming Care at the Bedside – Phase Three (Robert Wood Johnson Foundation, $1,000,000 for 3 years) ANNE R. PEBLEY Social Disparities in Health Among Latinos (National Institute of Child Health and Human Development, $2,212,767 for 5 years) BEATE R. RITZ California Parkinson’s Disease Registry Pilot Project – Southern California Ascertainment (U.S. Army/Medical Research Acquisition Activity, $342,856 for 2 years); Registry Study of Parkinson’s Disease in Denmark (National Institute of Environmental Health Sciences, $4,575,787 for 5 years) LINDA ROSENSTOCK Diversity in Health Professions 2006-2009 (California Wellness Foundation, $270,000 for 3 years); Traineeships in Underserved Communities 2006-2009 (The California Endowment, $469,750 for 2 years) STEVEN ROTTMAN UCLA Center for Public Health Preparedness (Centers for Disease Control and Prevention, $1,010,340 for 2 years) KIMBERLEY SHOAF Assessing the Public Health Impacts of Hurricane Katrina (National Science Foundation, $92,523); Team Safe-T School Evaluation Plan – Year Two (Team Safe-T [CA Partnership for Safety and Preparedness], $50,000); Pan Flu Regional Training (CA/HHS/Department of Health Services, $91,000); Sphere Evaluation & Tabletop Exercises (Statewide Public Health Emergency Response Exercise, $80,000); Early Warning Infectious Disease Surveillance Program, “USCD Pan Flu Workshop & Tabletop” (UC San Diego, $79,453); Nevada State Health Division Tabletop and Functional Exercise (Nevada State Health Division, $86,981) STEVEN P. WALLACE Healthy Aging Information Project (California Wellness Foundation, $300,000 for 3 years) PHYLLIS B. WEISS Resource Program for Policy Development & Program Evaluation for Violence Prevention Organizations (California Wellness Foundation, $300,000 for 3 years); Support & Enhancement of Urban Networks to Increase Thriving Youth Through Violence Prevention (UNITY) for California (California Wellness Foundation, $75,000 for 3 years)

ROBERTA WYN Women’s Health in California (California Wellness Foundation, $170,000)

new faculty DR. GILBERT GEE has joined the faculty as associate professor in the Department of Community Health Sciences. Gee’s research examines how stressors at multiple levels influence health and health disparities. In particular, he is interested in how racial discrimination and other types of systematic oppression may: (1) contribute to individual and environmental stressors; (2) structure social disadvantage among Asian Americans and other people of color; and (3) lead to health disparities. Gee earned his Ph.D. from the Johns Hopkins School of Hygiene and Public Health and most recently served on the faculty at the University of Michigan.

DR. ANGELA PRESSON has joined the faculty as an adjunct assistant professor in the Department of Biostatistics, with a focus on statistical genetics. Presson was a postdoctoral fellow in the Department of Human Genetics, David Geffen School of Medicine at UCLA and received her Ph.D. in Statistics from UCLA. She was awarded Best Presentation at last year’s Critical Assessment of Microarray Data Analysis (CAMDA) conference.

DR. SHIRA SHAFIR has joined the faculty as an adjunct assistant professor in the Department of Epidemiology, specializing in infectious disease epidemiology with a focus on diagnosis and viability of parasitic diseases.

After earning her Ph.D. at UCLA, she served as a postdoctoral fellow in the School of Public Health’s Global Health Training Program. Shafir continues to administer the NIH-funded training program for students in health disciplines to prepare them for careers in global environmental concerns.

UCLAPUBLIC HEALTH

NATHAN WOLFE NIH Director’s Pioneer Award (NIH Office of the Director, National Institutes of Health, $2,666,722 for 4 years)

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SCOTT P. LAYNE Center for Rapid Influenza Surveillance and Research (CRISAR) (National Institute of Allergy and Infectious Diseases, $18,465,267 for 5 years); UCLA High Speed, High Volume Laboratory Network for Infectious Diseases (U.S. Army/Medical Research Acquisition Activity, $5,327,000)

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