Drawing a link between cancer and cause may seem a far cry from mapping forest cover in northern Minnesota. But a computer application commonly used for that and a spectrum of other land use analyses is now finding its place in the world of public health sleuthing.
Known as geographic information systems, or GIS, the tool offers simultaneous views of a variety of traits of a neighborhood, a state, or even a country in a map format. Since it was developed in the 1970s, it has been applied to everything from protecting endangered species to siting fast-food restaurants. Today it's being explored as a way of answering, or at least more appropriately posing, research questions that relate to the spatial distribution of health-related variables.
"The idea of using maps is not all that new," says Lance Waller, an SPH biostatistician who is at the leading edge of efforts to increase the usefulness of GIS as a public health tool. What GIS does bring to the table, he says, is the ability to intertwine data gathered from a variety of sources. With GIS, census reports, weather maps, groundwater flow diagrams, and a whole host of other data sources can be combined.
"It allows you to pull in a lot of types of information," Waller says.
At first glance, the resulting multilayer display may seem an epidemiologist's dream. But as Waller points out, the ability to combine so many data from so many sources is both good news and bad news.
"You can pull in a lot of data you haven't collected yourself, [so] you don't know all the nuances and quirks of it," he says. If any of the inputs are inaccurate, the final product is, too. As a result, Waller says, GIS today "is more a data management and display tool than a data analysis tool."
Is that inevitable? Waller thinks not. This past summer he received a grant from the National Institutes of Health to help forge statistical tools that allow epidemiologists to draw valid conclusions from GIS results while taking into account the limitations of the layered data. Such tools would open the door for the application of GIS to discern relationships between pollution sources and health problems, support or refute claims of environmental racism, and resolve countless other public health issues.
Despite the tremendous appeal of the technology, Waller is quick to point out that it has limits. Like any compilation of data, it's only as good as its least accurate component. It leans heavily upon the notoriously weak link between exposure and proximity to a health risk. Results can vary substantially depending on how units of space are defined - for example, whether data are broken down by census tracts or ZIP codes. Multiple factors are invariably interwoven. The displays it creates are deceptively user-friendly, so there is a strong temptation to infer far more from them than is warranted.
Still, Waller sees the approach as a powerful application in the right circumstances.
"GIS-based study is not going to replace traditional epidemiological studies. But these can be expensive, so you want to use them in places of greatest concern and places where you're expecting tangible results," he says. "[GIS] helps you prioritize where you might do some of your studies."
You wouldn't exactly expect competing businesses to work together to decrease demand for their services. But that's just what's happening this fall at Andersen Elementary Community School in Minneapolis. There, with the encouragement of SPH adjunct faculty member Nicole Lurie and others, four Twin Cities health maintenance organizations have worked with school groups, community agencies, and city-wide organiza tions to create an innovative clinic aimed at improving student health and decreasing school days lost to illness.
Jointly funded by Allina Health System, HealthPartners, Metropolitan Health Plan, and UCare Minnesota, the clinic was created in response to concerns of parents, teachers, and others about the high rate of certain illnesses and absenteeism among students who attend Andersen. It will offer on-site diagnosis and care for acute problems such as earaches and strep throat as well as coordination of care for chronic problems such as asthma and attention deficit hyperactivity disorder (ADHD). Prevention services such as sports physicals, immunizations, and health education are also part of the picture, as is an emphasis on creating and maintaining links with other health care providers and community services. The hope is that with a facility for preventing, detecting, and resolving health problems right at the school, illness among Andersen students can be significantly reduced.
"This is a true public health model," says project coordinator Joanne Mooney. "It's weaving together services to children with providers that haven't worked together before. We are building upon existing models and adding programmatic and staff support that we think will be very powerful and effective."
Unprecedented Cooperation
The fact that the new health services are on school grounds is far from revolutionary; after all, school-based clinics have been around for years. What is novel in the Andersen project is the unprecedented degree of cooperation among competing HMOs.
"There are a lot of school-based clinics, and the odd health plan around is doing something in schools, but this is the first time that plans have actually exercised joint responsibilities," Lurie says.
A health policy analyst, Lurie was largely the catalyst for this cooperation. She first heard of the Andersen situation in early 1995, when she was working with the Allina Foundation on a study of how health plans could extend their health improvement efforts beyond the immediate sphere of their own enrollees. Lurie immediately saw the potential for collaborations that would benefit both students and the HMOs that covered them by nipping health problems in the bud.
"I became aware of what an incredibly unique situation it is there," she says, adding that Andersen presented a perfect opportunity to test "whether health plans can work together to improve the health of a population, not just who's in what plan."
Lurie began talking to representatives of the HMOs that served Andersen families. Aware that reducing frequency and severity of health problems made sense from both fiscal and humani tarian perspectives, the organizations worked out a way to pool funding to cover start-up costs. They are working to establish a mechanism to continue covering the operating cost of the clinic; details of sharing costs over the long term are now being ironed out.
Though the mechanism itself is novel, participants agree that the outcome is clearly in line with organizational goals and approaches.
"Health care plans have a commitment to keep members healthy - that's how we make money," says Rob Jeddeloh, associate medical director and director of clinical health improvement with Allina. "We need to go where people are. Kids are in schools, so we need to go to the schools."
But Does It Work?
The fact that HMOs are working together on the Andersen project
is a huge accomplishment in itself. However, the ultimate test of success will come in the impact on children's lives.
To measure that impact, Lurie collected baseline data on variables such as student health, absenteeism, and health care costs before the clinic opened. Those data will be compared with numbers gathered at intervals throughout the first year of operation to delineate if and how the clinic is making a real-world difference to Andersen students. Though it will still be some time before the jury is in, Lurie knows what she'd like to find.
"My ideal outcome is that the kids are healthy, they are in school more, and that the parts of health care utilization that are avoidable are avoided; that health plans will understand that there are things in the community they all have to work together on," she says. If that happens, she adds, the project could become "a template for other organizational arrangements," helping children elsewhere find better health through HMO collaboration, too.
A major report released this past summer by the surgeon general's office encouraging healthier exercise habits among Americans contained key input from School of Public Health faculty.
Aaron Folsom, professor in the Division of Epidemiology, was a member of the editorial committee for the report, Physical Activity and Health: A Report of the Surgeon General. He also worked with former SPH postdoctoral fellow Carl Caspersen to evaluate surveys to delineate current patterns of exercise in Americans. The two wrote Chapter 5 of the report, "Patterns and Trends in Physical Activity."
Arthur Leon, an adjunct faculty member of the division, cowrote two chapters of the report, one on exercise physiology, the other on the benefits of exercise relative to various disorders. His coauthor on the latter was SPH alumna Marty Slattery (M.P.H., public health nutrition, 1974).
The report, published in July by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, underscored the value of exercise to cardiovascular health and encouraged Americans to make physical activity a bigger part of their daily lives.
"Americans are not achieving the level of physical activity recommended for health," says Folsom, adding that the report was an attempt to remedy this situation.
How can small wood products manufacturers reduce workers' risk of health problems due to wood dust? That's the question occupational health experts at the Minnesota Department of Health (MDH) and the University of Minnesota hope to answer in a four-year intervention project that got under way this past summer.
The study, funded by the National Institute for Occupational Safety and Health (NIOSH), seeks to identify simple, affordable ways in which cabinetmakers, furniture crafters, and others who work with wood in small-business settings can reduce their exposure to wood dust. Wood dust has long been associated with a spectrum of health problems, from eye irritation to bronchitis and asthma. Two years ago it earned the title of a Group 1 (proven) human carcinogen because of its link to a form of nasal cancer.
According to SPH faculty member Lisa Brosseau, who is a coinvestigator on the project along with MDH's David Parker and DeAnn Lazovich of the Division of Epidemiology, some 15,000 Minnesotans work in the wood products industry. Many of these are employed in small businesses that, although interested in keeping workers safe, "have almost no access to information or know much about health and safety," Brosseau says. The goal of this project, she says, is to prove that education and technical assistance can help small businesses overcome this knowledge gap and make changes that increase the safety of their employees' work environment.
The intervention effort began last summer with a pilot study of five wood products manufacturers employing 25 or fewer people. Information gathered from those businesses will give the research team some concrete ideas for practices and technologies they could recommend to reduce wood-dust exposure - anything from using a vacuum cleaner instead of a broom to installing a central dust-collection system.
During the course of the main study, which begins in spring 1997, up to 60 wood products shops will be randomly assigned intervention has made a difference. Once they know what works best, they'll share their recommendations with others so they can be applied throughout Minnesota's wood products industry.
"The ideal outcome would be, number one, that we can get good access into these places, that the industry's cooperative; number two, that we can develop interventions that are efficacious and cost-efficient; number three, that we can implement those interventions and measure a decrease in worker exposures; and fourth, that we can piggyback onto this [for further studies]," Parker says.
Study team member Tom Milton, from the University's Department of Wood and Paper Science, says that whatever the specific findings, the study will have done a good part of its job just by raising the issue of health and wood dust. "It creates a higher level of awareness of concern, it raises their thoughts about what wood dust is, that it can be controlled and that it can be monitored," he says. "They're learning . . . that even the simple things - the techniques that they use, or their habits - can have an effect on what their wood dust levels are."
Researchers with the wood dust intervention project are focusing their attention for now on a relatively specific subject - wood products workers exposed to wood dust. Their true agenda, however, is much larger: boosting health and safety in all small businesses.
"I'm one of those people always interested in the underdog, those who don't have much support," Lisa Brosseau explains. Employees of small businesses make up about 40 percent of the total work force, she says, yet they draw little attention from those working to improve occupational health and safety. Not only that, because they're inundated with requirements ranging from fire codes to environmental regulations to hiring and firing mandates, small businesses owners often have little time or energy for dealing with issues such as wood dust exposure. Brosseau and David Parker are out to change that.
"What we bring to small business is a level of expertise that they can draw on, and a tremendous savings in what it costs to implement programs with regard to prevention, worker safety, and health," Parker says. "The [wood dust] project is part of a larger concept. Our overall goal is to develop programs to work with and assist small business establishments with regard to safety and health issues."
In Pursuit of Better Rural Health Practice. Physicians and public health professionals from more than two dozen countries got ideas for improving rural health practice when Ira Moscovice offered the keynote presentation at the First International Conference on Rural Medicine in Shanghai, China, in May. Moscovice, a professor in the Health Services Research and Policy Division, presented a set of underlying principles that can be used to support the choice of appropriate strategies to improve rural health practice. Among them: rural communities need leadership and empowerment; rural health depends on generalists; rural health systems tend to be unstable due to the ebb and flow of government attention; and rural health care infrastructure must be strengthened.
"These principles are relevant for the large majority of rural health environments throughout the world," Moscovice notes.
Snapshots From a Sabbatical. Sabbatical leaves offer faculty a chance to broaden their horizons, share their expertise, and gain fresh perspectives on their work. Biostatistics professor and head Thomas Louis made the most of his sabbatical when he spent eight months as a visiting professor at the University of Leiden, the Netherlands.
"Major activities included a general catching-up on reading, development of new statistical procedures, preparation of the final report of the IOM [Institute of Medicine] Committee to Assess the Health Consequences of Service During the Persian Gulf War, and visits to several groups in Europe," he reports. Louis shared insights on Gulf War health problems with Dutch researchers, gave talks around the Netherlands on statistical topics, and observed firsthand the do's and don't's of crisis management when he visited England during the peak of "mad-cow disease mania." In Denmark he learned that the government is investing heavily in efforts to begin M.P.H. programs at two universities.
"A sabbatical has the benefit of getting away from the usual routine and context," he says. "I returned a bit refreshed, with good progress on various research projects and a better understanding of issues in European universities and agencies. Some of this will make it into the classroom, much will play a role in my research, and some will surface in division head and policy council meetings."
Growing Old in Latin America. It's common knowledge that Americans as a society are getting older. But we're not the only ones. "The developing world now has more older persons than the developed world and is growing much faster," says Robert Kane, Health Services Research and Policy (HSRP) Division professor and Minnesota Chair in Long-term Care and Aging. "They will have to contend with this demographic challenge with far fewer resources. At the same time, there is evidence that many of their social structures, including the family, are under great strain." At a World Health Organization symposium in Brazil this summer, Kane and HSRP professor Rosalie Kane worked with other experts on aging from around the world to help develop a plan for managing aging in developing countries. The primary result, Robert Kane says, was a declaration drafted and signed by participants indicating the need for nations around the world to pay attention to the emerging problem and to "begin now the necessary social planning to maintain and support the social structures that will be needed."
Leonard M. Schuman, professor emeritus of epidemiology and Mayo professor emeritus of public health, has been named by the American Public Health Association (APHA) as the 1996 recipient of the Sedgwick Memorial Medal for Distinguished Service in Public Health. The prestigious honor recognizes the numerous contributions Schuman has made to the public health field.
"Your distinguished career in public health has spanned over 50 years during which you have made extensive national and international contributions to the study and application of epidemiological principles through your research, practice, and your unique teaching ability. . . . APHA is pleased to express its gratitude for your many significant contributions to public health by adding your name to the lustrous list of Sedgwick awardees," association executive director Fernando Trevi–o wrote to Schuman in announcing the award.
Schuman joined the School of Public Health in 1954 as an associate professor. He established the first Ph.D. program in epidemiology and the first summer epidemiology continuing education program in the nation. He served as head of epidemiology from 1954 to 1983. In 1955 he discovered the cause of silo-filler's disease. He served on more than 40 national committees and advisory boards during his career, including the surgeon general's advisory committee that issued the 1964 landmark report implicating tobacco in lung cancer and other diseases. In 1983 he was named Mayo professor of public health, and his exceptional teaching abilities were acknowledged with the creation of the Leonard M. Schuman Excellence in Teaching Award. Although he retired in 1983, he remains active in research and in professional associations.
In supporting Schuman's nomination, former surgeon general C. Everett Koop noted his many contributions to diverse areas of research. "Dr. Schuman has also left his mark as an educator in public health, as a member of the Illinois Department of Public Health, as a member of innumerable national committees and advisory boards in reference to public health and epidemiology. . . . He is as deserving a candidate for the Sedg-wick Award as I can think of," Koop wrote.
Schuman will be presented with the Sedgwick award at the leadership banquet held in conjunction with the APHA annual meeting November 17-21 in New York City.
I am honored to have the opportunity to serve as president of the School of Public Health Alumni Society this year. This task would appear overwhelming if it weren't for the volunteers working with me as board members and for the staff support from the University of Minnesota Alumni Association. To tap into the vast knowledge of this group of SPH graduates, the board held a strategic planning meeting in August for all board members and past presidents. The meeting gave us the opportunity to review some of the key challenges facing us, to define who we are and what our organization would like to be in the future, and to set a plan to lead us into the 21st century.
There are close to 6,000 SPH graduates, many of whom live in Minne-sota. Over the last 20 years, a number have served on the SPHAS board. The boards have consistently received recognition for their valuable work, including creating a curriculum survey, advocating for School programs, supporting the School during times of reorganization and dean searches, and developing and providing student scholarships.
The same challenges that affect many today - limited resources and limited time - affect the SPHAS board. The board is all-volunteer, and as everyone who is an active volunteer recognizes, volunteerism is a dying art - not because people are less willing to volunteer, but because there are so many good reasons to volunteer that the competition for time and loyalty is intense. We recognized those challenges, and chose to undergo a strategic planning process to help us identify some clear goals that will guide us as a board and a society.
To accomplish these goals, we must have active alumni who recognize the essential role of a dynamic and established School of Public Health in Minnesota. The School, in turn, has the responsibility to provide an outstanding education that produces qualified public health professionals who interact with graduates throughout their professional lives and provide firm support for the principles of public health and clear contributions to the public health profession.
The new SPHAS strategic plan describes how we will go about achieving our goals. We invite all alumni interested in having a voice in this process to contact Carmela Kranz at 612-626-4707 or me at 612-296-9107 to obtain a copy of the plan, then offer comments or join us for discussion at any of our board meetings.
Your voice is our greatest asset. Please use it. My five-year-old daughter, after watching "The Little Mermaid," informed me, "She did a lot without her voice, Mom, but to get what she wanted, she really needed her voice." We need and appreciate your voice.
Robert Anderson, professor emeritus of the School of Public Health and the College of Veterinary Medicine, was named 1996 honor alumnus of Colorado State University's College of Veterinary Medicine and Biomedical Sciences. A 1944 Colorado State graduate, Anderson was cited for his work in establishing animal behavior and the human-animal bond as an integral part of veterinary medical training.
Bradley Carlin, associate professor, and Thomas Louis, professor and head of the Division of Biostatistics, are authors of a new textbook, Bayes and Empirical Bayes Methods for Data Analysis (London: Chapman & Hall, 1996). They will teach a one-day course based on the book at the International Biometric Society spring regional meeting in Memphis, Tennessee, in March.
Patricia Grambsch, associate professor in the Division of Biostatistics, has been elected a fellow of the American Statistical Association. This award is reserved for association members who have made special contributions to the field of statistics.
Marcus Kjelsberg, associate dean for administration, will be honored for 40 years of membership in the American Public Health Association at the group's annual meeting in November.
Cheryl Perry, professor in the Division of Epidemiology, has been named to receive the American Association for Health Education Scholar Award for 1997. The award is given to a person who has a long-standing record of scholarly work in health, contributes to health education, and is a good communicator.
Peter Hannan, chief consulting statistician in the Division of Epidemi-ology, has been named a 1996 recipient of a University of Minnesota Academic Staff Award.
A member of the division since 1977, Hannan has contributed to the success of countless research projects over the years. Faculty, staff, and students alike recommended him for the award, citing his talent for explaining complex principles, his generosity in sharing time and expertise, and his exemplary dedication to scientific research.
"Peter should be called the 'statistician's statistician'," wrote epidemiology faculty member Richard Crow in supporting the nomination. "His in-depth knowledge of statistics provides a reference standard for other statisticians, and at the same time he is able to discuss complex issues, develop hypotheses, and design analysis with the non-statistician."
"He is a great teacher and is always willing to share," added student Mahesh Deshpande. "He is patient and very clear in expressing what needs to be done."
The Academic Staff Award is given annually to a select number of University staff for their outstanding achievements and contributions.
A thorough grasp of complex subject matter, an engaging teaching style, and a sense of humor
have earned faculty member Paul McGovern special recognition as one of the School of Public Health's outstanding teachers.
An associate professor in
the Division of Epidemiology, McGovern was presented the Leonard M. Schuman Award for Excellence in Teaching at a combined faculty and school assembly meeting in June. He was chosen at the recommendation of numerous students, former students, and colleagues, who consistently commented on his rapport with students and his ability to make complex subjects interesting and comprehensible.
"He is a serious researcher, teacher, and scientist, but he never forgets to laugh," wrote Ph.D. student Celine Vachon in support of McGovern's nomination. "His good nature and positive attitude create an ideal learning and working environment."
"His infectious enthusiasm, love for what he does, and incredible mastery of so many content areas stimulated me to push myself and develop skills way beyond what I ever thought possible," wrote former student Steven Kelder, now an associate professor at the University of Texas.
"There is no question in my mind that Dr. McGovern is a stellar teacher," added colleague and former student Eyal Shahar. "One sometimes encounters teachers of great ability in one main domain, but less frequently a teacher who draws upon and synthesizes concepts from several disciplines. Dr. McGovern has that unique quality."
The Leonard M. Schuman Award for Excellence in Teaching is awarded to full-time SPH faculty who have demonstrated excellence in the classroom for five or more years. It is given in recognition of the superior teaching of Leonard Schuman, a member of the SPH faculty from 1954 until his retirement in 1983.
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Of maps and maladies: Geographic computer tool finds niche in public health
HMOs team up for in-school care
Faculty make mark with surgeon general's report
Small businesses get boost in reducing wood dust hazard
A sampler of ways in which the School contributes to public health on the international front
Schuman to receive prestigious Sedgwick medal
Challenge
Editor: Mary Hoff
Editorial Consultant: Judy Peterson