The percentage of Americans under age 65 with employer-sponsored health insurance coverage has dropped to 59.5 percent in 2011, continuing a decade-long decline, finds a new study.

The analysis, led by the State Health Access Data Assistance Center (SHADAC) and funded by the Robert Wood Johnson Foundation, reports that the share of people with employer-based coverage fell from 69.7 percent in 2000 to 59.5 percent in 2011. The drop translates to 11.5 million people who no longer receive health insurance through their jobs or the job of a family member.

A poor economy, with fewer jobs available, is one factor – but the drop in coverage occurred throughout the past decade, not just during the recent recession. Rising premiums have also likely played a role.

From 2000 to 2011 single-employee premiums have gone from an average of $2,490 to $5,081, while family premiums jumped from $6,415 to $14,447. During that same time period, the amount employees contributed toward premiums also skyrocketed, from $435 to $1,056 per year for family coverage.

“Costs for employers and employees have risen steadily and significantly over the past decade,” says Lynn Blewett, SHADAC director and School of Public Health professor. “As a result, employer-sponsored insurance has eroded substantially.”

What’s it mean for ACA?

Even as rates of employer-sponsored insurance continue to drop, the Affordable Care Act (ACA) is estimated to boost coverage by 27 million people in the coming decade. But it is still too early to track the law’s impact on employers. Most of ACA’s provisions don’t take effect until 2014.

So far, ACA’s main effect has been to increase coverage for young adults. The law allows children to stay on a parents’ health plan until age 26, up from age 21 under previous laws.

“As we begin implementing ACA at the federal and state levels, this report will help to establish baseline indicators of coverage and trends,” says Blewett. “It will help to gage the impact of health expansion laws in the coming years and provide context for understanding what is driving future changes.”

Variation in states

The study found that 47 states saw significant coverage declines and that insurance rates varied widely from state to state.

Michigan, Indiana, and South Carolina saw the steepest declines in employer-backed coverage, at about 15 percentage points each. Alaska, Massachusetts, and North Dakota were the only states with stable rates. No state saw an increase in the time studied.

SHADAC researchers report that 80 percent of Minnesotans under age 65 received insurance through an employer in 2000. By 2011 the percentage had dropped to 71.

The average cost of insurance premiums for employee-only coverage in Minnesota more than doubled in the past decade from $2,455 annually to $5,195. Family premiums rose even more from $6,588 in 2000 to $14,721 in 2011.

Access the full report and state-by-state analyses.

Ezra Golberstein

In the first empirical study of the role supplemental insurance coverage might play in Medicare spending growth, researchers at the University of Minnesota School of Public Health and Harvard Medical School found that employer-sponsored and self-purchased supplemental coverage were associated with annual spending growth rates of 7.17 percent and 7.18 percent, respectively, compared to 6.08 percent for beneficiaries without supplemental coverage.

The study, “Supplemental Coverage Associated With More Rapid Spending Growth For Medicare Beneficiaries,” examines trends in Medicare spending. The study, which appears in the May issue of Health Affairs, was led by Ezra Golberstein, Ph.D., assistant professor in the University of Minnesota School of Public Health.

“Medicare spending is growing at a rate that is unsustainable, and this spending growth is the biggest long-term public policy challenge facing the country,” says Golberstein. “In spite of the importance of slowing the rate of spending growth, we lack a solid understanding of what we can do to actually bend the cost curve.”

Golberstein and his collaborators from Harvard Medical School used data from the Medicare Current Beneficiary Survey from 1992 to 2005, before Medicare Part D prescription drug benefits were introduced, and analyzed a sample of 104,365 observations. The researchers found significantly higher rates of spending growth in all supplemental insurance categories compared to the category without supplemental insurance, even while controlling for sociodemographic status, disease, disability, and health behavior characteristics.

“Supplemental coverage reduces cost-sharing for beneficiaries, but we find that it is also associated with higher rates of spending growth for Medicare beneficiaries,” says Golberstein. “These findings suggest that the anticipated declines in employer-sponsored coverage for future retirees and the introduction of policies that would restrict Medicare supplemental coverage may hold the potential to slow rates of spending growth.”

Social Epidemiology launches May 31, 2013.

Understanding how forces of society—from family life to government policies to the global economy—impact health is the focus of one of the first massive online open courses (MOOC) offered by the University of Minnesota.

Some 10,000 students are expected to sign on for Social Epidemiology, one of five free online courses the U developed in partnership with Coursera. The seven-week offering, launching May 31, is drawing about 500 registrants a week, about half of them from outside the United States.

First Social Epi MOOC

Being among the first educators to reach a global audience through the MOOC platform drew SPH associate professor Michael Oakes to the project. Oakes, an award-winning instructor and McKnight Presidential Fellow, also thought the experience would be useful for a book he’s currently writing on the subject.

“I’m excited to be representing the University of Minnesota and the School of Public Health in this mass media-type education,” says Oakes. “This is truly about educating global citizens—in terms of the student base and the subject matter.”

Oakes worked with producers from the University’s media and teaching services—a group he affectionately refers to as “Team Hollywood”—to record the videos that serve as the basis of the course. The lectures will be enhanced with reading materials, quizzes, and group projects. Oakes will hold virtual office hours. Students who complete the course will receive a statement of accomplishment.

The content lends itself well to a global format. Lessons will touch on understanding how race and socioeconomic status affect health, evaluating literature on the so-called fundamental causes of disease, and uncovering why some epidemiological interventions work while others fail.

Challenges & rewards

While the course holds potential to teach tens of thousands of students, it has already helped Oakes learn some important lessons.

“Preparing for this course has taught me so much about teaching,” he says. “It’s been tough to teach to a camera—there’s no immediate student feedback to guide me. But it has helped me to organize my thoughts in new ways.”

The process has also helped him envision new ways to leverage traditional classroom time.

“I’m thinking of moving some lectures for my regular coursework online,” he says. “That will free up class time for discussions, projects, and other sorts of active learning.”

Oakes is not sure how MOOCs will alter higher education but sees this first offering as just the beginning in a field that is sure to change.

“We are in a time of vinyl records but CD-ROMS are just about to be released,” he says with a chuckle. “It’s an exciting time to be a teacher. It will be interesting to see the impact of MOOCs on our school’s enrollment and reputation.”

Learn more about the course

Katy Kozhimannil

United States hospital-based births covered by private insurance are associated with higher rates of obstetric intervention than births paid for by Medicaid, according to new research from the University of Minnesota School of Public Health (SPH). The study appears today in the American Journal of Managed Care.

SPH health policy expert Katy Kozhimannil, who led the study, partnered with fellow SPH researchers Tetyana Shippee and Beth Virnig. SPH student and UCare Minnesota health care analyst Olusola Adegoke was also part of the research team.

The researchers studied the relationship between the primary payer and trends in hospital-based childbirth obstetric procedures, such as cesarean delivery and labor induction. They examined 6,717,486 births across the United States between the years 2002 and 2009.

Though obstetric intervention rates have increased over time for all births, the presence and type of health insurance affected the type of care women received during childbirth.

“After controlling for age, race, clinical conditions, and hospital characteristics, births covered by private insurance had higher odds of cesarean delivery, labor induction, and episiotomy,” says Kozhimannil. “Not only that, but cesarean rates – which were rising nationwide during the time period we examined – increased more quickly among moms with private insurance, compared to those with Medicaid. ”   

Financial implications

Childbirth is the most frequent reason for hospitalization in the United States, and maternity-related expenses including obstetric interventions are substantial expenses among private health insurance plans and Medicaid programs.

Kozhimannil says that had the rate of increase in cesarean deliveries covered by private insurers instead been at the rate seen by Medicaid patients, the difference would have resulted in 41,614 fewer cesarean deliveries in 2009 – a potential savings of nearly a quarter of a million dollars in hospital costs in one year.

“As the number of obstetric interventions goes up, so does the cost to cover them,” says Kozhimannil. “This may ultimately be felt in the form of higher premiums, more expensive copays, or higher deductibles for the privately insured.”

The researchers believe that changes in insurance coverage associated with the implementation of the Affordable Care Act (ACA) could impact the costs and quality of care for women giving birth in U.S. hospitals.

“Through the ACA, increases in private insurance through employer-sponsored coverage or state exchanges could result in unanticipated changes in obstetric care,” says Kozhimannil. “In other words, if women who would have otherwise had Medicaid coverage become eligible for private coverage, they may have higher odds of obstetric interventions.”

The researchers do not know why Medicaid patients are less likely to have certain obstetric procedures. But they offer potential reasons for these differences, including payment rates, hospital policies, clinical decision-making, and patient preferences.

“The changes in the rate of obstetric procedures we uncovered may signal shifts in care or equity concerns, but they may also indicate the potential role that payers can play in shaping health care practices to align with evidence and patient-centeredness, in maternity care and more broadly,” says Kozhimannil.

They’ve also found that current occupational exposure to dust from taconite operations is generally within safe exposure limits.

The updated results come as the Taconite Workers Health Study, a multi-pronged research initiative funded by the state of Minnesota, winds down later this year. The Minnesota Legislature commissioned the $4.9 million project in 2008, after data from the Minnesota Cancer Registry revealed an apparent excess of cases of mesothelioma in Iron Range workers. The mesothelioma deaths only occurred in men working in the taconite industry.

The University of Minnesota School of Public Health partnered with the Medical School and the Natural Resources Research Institute at the University of Minnesota Duluth on the project.  

“This is a landmark study for Minnesota and the Iron Range,” said John Finnegan, Ph.D., dean of the School of Public Health. “Our goal was to begin to answer questions around how mining and taconite processing have impacted the health of Minnesotans. These studies have started to uncover those answers.”

An examination of increased rates of mesothelioma

Mesothelioma, a fatal cancer of the lining of the lung, is mainly caused by prolonged exposure to asbestos particles in the air, linking the disease to occupations that used the material in the past.

The Minnesota Department of Health originally established a relationship between working in the iron mining industry and an increased risk for mesothelioma in the 1990s/early 2000s. Past University of Minnesota research has also reported the risk for mesothelioma in iron mining workers to be around three times higher than in Minnesotans not working in the industry.

As a result, University of Minnesota researchers have looked for explanations for the increase and found that for every year worked, the risk for mesothelioma went up around three percent. Researchers have wanted to determine whether or not cumulative exposure to fiber types within the family of elongated mineral particles (EMPs) present in the dust from taconite operations could account for this increase. The types of EMPs involved in iron ore mining have not been previously linked to increased mesothelioma risk. As these exposures were examined, researchers did identify a potential link between cumulative exposure to workplace EMPs and mesothelioma in taconite workers. However, the link is not felt to be certain.

As a result, the researchers cannot say with assuredness that dust from taconite operations causes mesothelioma.  Further data analysis in this area will continue in the coming months.

“One important finding of the work to date is that the risk of contracting mesothelioma is higher across the entirety of the Range among people who worked longer in the industry, said Jeff Mandel, M.D., M.P.H., a School of Public Health environmental health expert and principal investigator of the study.  “Unfortunately, there is minimal information on exposure to other sources of asbestos, a specific type of EMP known to cause mesothelioma, which they may have experienced outside of iron ore processing. It is something that we want to continue to look at, if at all possible.” 

Taconite worker mortality

In addition to mesothelioma, within the Taconite Workers Health Study researchers researchers assessed causes of death among people born after 1920 who spent time in the iron mining industry in Minnesota. This study includes people working in the taconite industry and the former hematite industry. 

The causes of death in taconite workers (when compared to Minnesota averages) were higher than expected for three important diseases: mesothelioma, lung cancer and heart disease. Causes of deaths from all three were higher than expected across the Iron Range and not in one particular location.

Although working in the taconite industry increases a person’s lifetime risk of mesothelioma, the increase equates to a small risk of actually developing the disease. Mesothelioma is still a very rare disease.

Because taconite workers have higher rates of death than their counterparts for all types of cancer combined and heart disease, it also appears there are other health considerations impacting people living on the Iron Range and lifestyle appears to be an important factor.

Air quality assessment

University researchers can also confirm that air quality in communities surrounding the mines is better than most parts of Minnesota in terms of particulates in the air. Also, researchers found that occupational exposures to dust from taconite operations are, generally, within safe limits. In addition, spouses of taconite industry workers are also at no higher risk of contracting dust-related lung diseases than Minnesota’s broader general public.

“We’re hopeful that the results to date will allay fears that taconite dust has generated broad harm to the general public,” said Mandel. “When employers and employees both take the appropriate safety precautions to curtail dust exposures, potentially harmful effects from the dusts can be eliminated.  

To measure air quality and potential exposure to community residents to dust generated in the mining processing, researchers from the Natural Resources Research Institute at the University of Minnesota Duluth collected and looked at air samples from across the Iron Range. This work confirmed, even though the East and West sides of the range have different geologic characteristics, that there are very low concentrations of EMPs in the air among these communities. 

Challenges and study obstacles

Project researchers did encounter obstacles in this work, as gathering exposure data from within the taconite industry was difficult to secure the further back they tried to go. They were also unable to fully document potential exposure to asbestos products that were used in the industry. Many processing facilities were constructed and maintained in a time period when asbestos was a common building and construction material, but exposures to workers were not regulated or recorded.

As part of their annual legislative report on the Taconite Workers Health Study, University researchers will recommend additional considerations should future investigations be undertaken.

About the Taconite Workers Health Study

The overall objective of the Minnesota Taconite Worker Health Study was to determine whether dust-related lung disease, including mesothelioma, lung cancer and non-malignant respiratory disease, might be related to working in the taconite industry.

The study had five main components, including 1) an occupational exposure assessment, 2) a mortality (cause of death) study, 3) cancer incidence studies of mesothelioma and lung cancer, 4) a respiratory health survey of taconite workers and spouses, assessing non-cancerous respiratory disease and 5) an environmental study of airborne particulates. 

Each study component has utilized an external peer-review process with science advisory boards that have been involved in the projects since the beginning and each of the study’s five components provide a perspective that’s important to the interpretation of the overall health assessment process.

Don Wegmiller

The University of Minnesota has received a gift of $1 million from Master of Healthcare Administration (MHA) alum Don Wegmiller and his wife, Janet, to establish the Wegmiller Professorship in Healthcare Administration. The program is offered by the University of Minnesota School of Public Health.

Wegmiller, a 1962 graduate, credits the MHA program in significantly contributing to the success of his career. He is chair of two health care organizations—C-Suite Resources and the Scottsdale Institute—and was recently inducted into the Health Care Hall of Fame by the publication Modern Healthcare.

“The University of Minnesota has one of the best healthcare administration programs in the country,” says Wegmiller. “It has served as the foundation of my professional and personal life for more than five decades. Janet and I hope that our gift will inspire others to give back to a program that has successfully launched the careers of so many.”

The gift will be used to support the current and future directors of the MHA program and will potentially help to establish discretionary funds for conducting research on emerging issues and recruiting top students and faculty.

“Don has been an innovator in health care for years, and I am grateful for his financial and professional support, says Daniel Zismer, SPH professor and director of the MHA program. Zismer is the first faculty member to hold the endowed professorship.

Minnesota’s MHA program has been ranked second among U.S. healthcare management programs for several years now by U.S. News and World Report.

“On behalf of the school, I offer my sincere thanks to Don and Janet for their role in creating this endowed chair,” says SPH dean John Finnegan. “As we move into a time of enhanced collaboration among public health and health systems, staying connected to industry leaders like Don is key to success for us all.”

Stepan is the quality improvement manager for the cardiovascular service line at University of Minnesota Physicians Heart at Fairview (UMP Heart). She designs and optimizes the plans UMP Heart follows to save costs, improve individual patient quality of life, and streamline the overall process of care for the cardiovascular patient population.

This year, Stepan’s units achieved top results among university-based systems on national measures of clinical care quality and patient satisfaction.

“Academic Health Centers and their affiliate healthcare systems across the country are all working toward meeting these measures. [So] the achievement threshold continues to increase, and we need to constantly innovate and improve.” says Stepan. “When we’re in the top decile, we know that we’re hitting our goal to be a top cardiac care delivery system.”

A strong foundation in leadership

Being part of a successful clinical care team was not a career Stepan anticipated when she began her studies in nutrition and epidemiology at the School of Public Health (SPH). And yet, her work at the school gave her the support, experience, and connections she needed to transition from graduate school to a career in clinical quality improvement.

Stepan can trace her current successes back to hard work, a passion for population health, and the research skills she acquired in school. She cites the importance of the leadership training she received in her Management Essentials class. Her field experience in Costa Rica was another pivotal piece of her graduate training. She describes it as “the perfect opportunity to put into practice what I was learning in the classroom.” Lastly, her leadership fellowship and clinical rotations at Fairview introduced her to quality improvement principles and changed her career path entirely.

Stepan charted some of this path on her own, especially in terms of quality and process improvement education. Since she graduated, the school has launched academic programs that focus on process and quality improvement. This is good thing, says Stepan, because of the growing need for quality improvement professionals with the leadership skills that a public health degree provides.

“I don’t have many people reporting to me directly,” she says, “so I have to work through influence. And I rely on the adaptive leadership skills I’ve learned.”

The impact of ACA

The Patient Protection and Affordable Care Act (ACA) provides professional opportunities and challenges, says Stepan. Keeping up with new, more rigorous quality standards can lead to improved outcomes. But it requires a workforce with strong skills in leadership, analysis, and communications. She cites the complex relationship between curbing costs and improving quality as an example of the new issues professionals like her are addressing.

“The average length of stay for heart failure patients has gone up last year,” says Stepan. “We think that could be an unintended consequence of the patient readmission penalty [under ACA.] We improve costs in one area and it bulges out negatively affecting cost or quality in another.”

But it is the complexity of that dynamic that makes Stepan enthusiastic about her future. She hopes to continue moving into operational or executive leadership roles within health systems and communicating with policymakers about how laws impact clinical practice.

For Stepan, also a lean six sigma black belt, achieving cost savings through process improvement is about more than meeting industry standards and complying with federal regulations. It’s also about building a healthier patient population with a higher quality of life.

“Care delivery systems are shifting from individualistic care to a population health model,” says Stepan. “Basic principles have moved closer to public health goals than where they were ten years ago. It’s an exciting time to be working in this field.”
 

The scramble is on to prepare for January 1, 2014—the day that the Patient Protection and Affordable Care Act (ACA) goes fully into effect. Many of its benefits have been realized already in the three years since President Obama signed it into law on March 23, 2010, but states are still making decisions whether to expand Medicaid benefits. It’s their choice. Others are on the fence about administering the mandatory health insurance marketplaces, also called exchanges, or relying on the federal government to fund and run them. Some are still fighting to nullify the ACA. Currently, there are 270 separate bills to repeal the law, partially or entirely.

For now, the Affordable Care Act is moving forward and significantly transforming the way our country supports the health of its citizens. It will provide unparalleled opportunity for millions more Americans to get affordable health care coverage. As of March 2013, about 49 million U.S. citizens are without health insurance. In 2014, that number is expected to drop to 20 million because of the Medicaid expansion and the exchanges. And the ACA will give us the means and support to stay well. Among its provisions is unprecedented attention to and funding for public health.

A public health act

Public health has not always been so fortunate. According to a report from the Urban Institute Health Policy Center, during the attempt at health insurance reform in the Clinton presidency, “public health advocates were jubilant when they won a simple mention of public health in the…proposal.” Any increase in better options for health coverage and care supports overall public health, yet the ACA goes further to incorporate the basic tenants of the field and provide the means to achieve them.

“It’s quite remarkable how the ACA is, in essence, a public health act,” says SPH dean John Finnegan. “What jumps out at you when you read the law is how the vision and mission of our field—to secure health, well- being, and safety for all populations—runs throughout the entire legislation.”

Nationwide, the attention to preventive care has grown steadily for the past 25 years as we’ve realized the advantages of well- baby visits, immunizations, and screenings for such threats as breast cancer and liver disease. But serious health issues continue to plague us. It’s estimated that more than half of

Americans are living with chronic diseases, most of which could have been prevented. And the specter that our children are in line to have shorter lives than their parents is an unsettling testament to our culture.

Not only do these facts signal reduced quality and quantity of life, they represent a tremendous burden to the health care and health coverage system. According to the American Public Health Association (APHA), we spend “only 3 percent of our health care dollars on preventing diseases, when 75 percent of our health care costs are related to preventable conditions.”

Hand-in-glove

Each of the Affordable Care Act’s nine titles includes enhancements to prevention and public health. Title IV, Prevention of Chronic Disease and Improving Public Health, tar- gets public health needs exclusively and groups them under four areas: community prevention; clinical prevention; public health workforce and infrastructure; and research and tracking. Addressed among these categories are such things as oral healthcare; school-based health centers; barriers to preventive services in Medicare; health disparities; and employer-based wellness programs. Title IV also includes the National Prevention Strategy, a blueprint to create a healthier country.

But it’s with the Prevention and Public Health Fund that the ACA steps up to the plate to pay for initiatives and ongoing pro- grams considered essential, and it marks the first time our country has enacted specific legislation to improve public health. This fund provides $15 billion between fiscal years 2010 and 2019 and $2 billion every year thereafter to give public health efforts the muscle they need to turn our country’s health care focus from illness to wellness.

According to figures gathered by the APHA, if you combine federal, state (Minnesota has received $18 million since 2010), and local programs supported by the Prevention and Public Health Fund in fiscal year 2010-2011:

• more than $385 million (31 percent) went to community-based prevention activities, such as tobacco control efforts.

• more than $220 million (18 percent) supported clinical prevention activities, such as decreasing HIV rates;

• nearly $480 million (38 percent) went toward public health infrastructure and workforce development needs, such as public health training centers; and

• nearly $165 million (13 percent) was spent on research and tracking activities.

Public health needs the funds, support, and clout of the Affordable Care Act to circumvent the growing health problems in our country. The Affordable Care Act needs the all-out effort of the public health field to help Americans lead better, healthier lives. Without a growing body of healthy citizens to bring down health care costs and buy into the insurance exchanges, the ACA can’t survive and its promise of robust preventive care will be deferred.

What the ACA means on the ground: SPH faculty weigh in

In the paragraphs ahead, School of Public Health faculty talk about what the Affordable Care Act (ACA) will mean for the issues they tackle every day and that affect millions of Americans.

Mental health

Ezra Golberstein, assistant professor, Health Policy and Management

The Affordable Care Act has the potential to significantly improve health care for people with mental illness, although some challenges will remain for this vulnerable population. The core features of the ACA are the expansion of the Medicaid program to low-income individuals who were not previously eligible, and the establishment of insurance exchanges with significant subsidies for lower- income individuals.

Because people with mental illness are disproportionately likely to have lower incomes, there is reason to believe that they will benefit significantly by gaining access to health care and the financial protection afforded by health insurance coverage.

The ACA also requires that mental health and substance abuse services be covered by the Medicaid expansion plans and in the health insurance exchanges, and encourages the development of “medical homes,” which may be a promising approach for coordinating the frequently fragmented health services that people with mental illness experience. However, in spite of these potential improvements, access to services may still be limited by existing shortages of mental health treatment resources.

Foodborne disease

Craig Hedberg, professor, Environmental Health Sciences

Reducing the number of Salmonella infections is a target of the ACA’s National Prevention Strategy and the act may help accomplish this through increased health insurance coverage. For example, infected food workers contribute to transmission of Salmonella in restaurant settings. Most food workers do not get health insurance through work and may not seek care when ill. But if food workers do have health insurance and are diagnosed sooner, the risk of Salmonella transmission should go down.

The ACA is also strengthening public health surveillance systems by providing epidemiology and laboratory capacity grants to state health departments and the academic centers that assist them.

Nutrition

Lisa Harnack, professor, Epidemiology and Community Health

The ACA includes a provision that requires restaurants with 20 or more locations to list calorie content information for menu items and on menu boards. Other nutrient information (total fat, saturated fat, cholesterol, sodium, total carbohydrates, sugars, fiber, and total protein) must be available upon request. The ACA also requires vending machine operators with 20 or more machines to disclose calorie content for certain items.

Research suggests that some consumers will use the calorie information to choose lower calorie meals. It’s not clear, though, that consumers at greatest risk for obesity and other diet-related chronic disease will be among those who will use the newly available nutrition information to make better choices. It is possible, however, that all consumers (including those at greater risk for obesity) may benefit if the calorie-labeling mandate motivates restaurants to make changes to their menu offerings. For example, a restaurant may decide to eliminate some higher calorie options and increase offerings of items that are moderate or low in calorie content.

Children’s health care

Pinar Karaca-Mandic, assistant professor, Health Policy and Management

Studies done in the Division of Health Policy and Management suggest that providing insurance coverage and affordable care for the entire family is important for ensuring children’s access to health care. Results showed that for children who do not have special health care needs, higher family out-of-pocket (OOP) expenditures were associated with higher levels of unmet or delayed medical and dental care, regardless of health insurance or socio- economic status.

Provisions in the ACA, such as the expan- sion of Medicaid, premium and cost sharing (copays and deductibles) subsidies, and limits on annual OOP costs, may increase children’s access to health care, support individuals with poor health, and benefit families in which either the children or the adults have substantial health care needs.

Public health dentistry

Sheila Riggs, associate professor, Division of Dental Public Health, School of Dentistry (Riggs is coordinating the new DDS/MPH degree that will launch fall 2013.)

The ACA did not include adult dental care among the essential benefits that must be part of certain coverage plans, and without that inclusion it’s difficult to make a real difference in our country’s dental health needs. However, health coverage under the Medicaid expansion does include dental benefits for adults. What’s more, funds have been allocated for adding dental clinics to federally qualified health centers, or what are called “safety net” clinics, and that is one way to provide access to adults.

The good news is that children’s dental care is covered in the essential benefits package. When it comes to improving public health infrastructure, one of the goals of Title IV, the ACA has allocated, but not yet appropriated, funding to educate mid-level dental care providers. We hope the funds are forthcoming because our country needs more dental practitioners who think along public health lines—about population health—not just about clinical dentistry.

Rural populations

Ira Moscovice, Mayo Professor and division head, Health Policy and Management; Director, Rural Health Research Center

The ACA is likely to have significant impact on rural populations, rural employers, and the health professionals serving rural communities. For individuals living in rural communities, the questions are whether they will be able to afford the costs of having health insurance (particularly an issue for the young and healthy) and will there be social stigma related to signing up for Medicaid eligibility.

Rural employers (many of whom are small) don’t know if they will be able to afford to offer health insurance coverage to their employees and how to best structure their employee pool (i.e. full-time versus contract workers) to take advantage of new health insurance options. Rural health professionals are wondering if they will be able to respond to the increased demand for their services from newly insured individuals and how they will react to the anticipated reduction in unit price reimbursement from public and private payers.

Health of reproductive-age women

Katy Kozhimannil, assistant professor, Health Policy and Management

Twenty-five percent of all reproductive- age women were uninsured at some point in 2009, the year before the ACA was signed into law. Full implementation of the ACA will offer women at or below 400 percent of the federal poverty level expanded access to coverage through state Medicaid programs, health insurance exchanges, and federal subsidies for purchasing coverage.

The ACA also has important implications for those reproductive-age women who do have health insurance, including expanding access to preventive care without cost sharing (copays or deductibles) and requiring that qualified health plans include certain services (such as maternity and newborn care) as essential health benefits.

State Medicaid programs finance nearly half of all births in the United States, and the ACA includes important additions to Medicaid, such as coverage for prenatal smoking cessation support and for childbirth in licensed, freestanding birth centers. New grants to states support home-visiting care programs for pregnant women and new mothers, and also provide services to women who develop postpartum depression.

The ACA also establishes new workplace protections for breastfeeding mothers, requiring employers with 50 or more employees to provide workers with a private place to express breast milk and ample break time to do so.

Illustration by Mark Smith

Don Wegmiller and his wife, Janet, have endowed $1 million for a healthcare administration professorship.

If it’s true, as philanthropist Andrew Carnegie once said, that “it’s more difficult to give money away intelligently than to earn it in the first place,” then Don and Janet Wegmiller’s recent gift to the School of Public Health’s Master of Healthcare Administration (MHA) program would score high with Carnegie.

The couple’s decision to endow $1 million to establish the Wegmiller Professorship in Healthcare Administration, which will be awarded to each director of the MHA program, came from a deep understanding of not only how the program educates, but how it shapes lives.

With their endowment, they want to publicly support what Don Wegmiller calls “the best health care administration program in the country.”

“The MHA program formed not just the basis of our professional lives, but also of our personal lives,” says Wegmiller, who earned his MHA in 1962. “When something like that has been so important to you for over five decades, it becomes a very easy decision to say, ‘This is where we should allocate some of our resources.’”

Wegmiller, chairman of two health care organizations—C-Suite Resources and the Scottsdale Institute—and a recent inductee into the Health Care Hall of Fame, says that Minnesota has long been acknowledged as a leader in producing successful health care executives.

“Alumni of the University’s MHA program are actually known in the industry as ‘the Minnesota Mafia,’ because we’re such a closeknit group,” says Wegmiller, laughing. “The MHA alumni association takes care of itself as a family and supports one another professionally and personally.”

Zismer to hold first professorship

Daniel Zismer, the MHA program’s current director, will be the first person to hold the new professorship.

“Don has been an innovator in health care for the last four decades, and this is his way of helping the program that helped him,” Zismer says. “That’s a longstanding tradition of our MHA program.”

From a strictly pragmatic viewpoint, the endowment means that Zismer, and those who succeed him as director, will have access to discretionary funds to help with such things as supporting emerging research priorities and recruiting top-notch students and faculty.

“But the professorship is about much more than dollars,” Zismer says. “It adds a status to the program that shows the marketplace that we are supported by top industry professionals like Don.”

Wegmiller praises Zismer’s work, believing that he has re-energized and improved an already outstanding program since he was appointed director in early 2010. Wegmiller cites the success of the recently launched Executive MHA program— designed for professionals already working in the health care field—as just one example of Zismer’s contributions so far.

“Today’s MHA students will face daunting challenges as the industry changes from a volume-based to a value-based system, and the program will continue to need support from all of its alumni,” Wegmiller says. “Janet and I hope that one of the results of our gift will be to stimulate others, who’ve had the same benefits we’ve had, to say, ‘Maybe we should do something like this, too.’”

Carnegie would applaud the thought. After all, he was the man who also said, “The best means of benefiting the community with your wealth is to place within its reach the ladders upon which the aspiring can rise.”

Elizabeth "Issie" Karan

“I loved walking across the Mississippi from the Law School to the School of Public Health and taking on a whole new set of challenges,” says Elizabeth Karan (aka Issie) of her years in graduate school earning an MPH in Public Health Administration and Policy and a JD through the University’s Joint Degree Program in Law, Health, and the Life Sciences.

As one of last year’s recipients of the national David A. Winston Health Policy Fellowship, Karan works in Washington, D.C., with the health team of the majority staff of the U. S. Senate Finance Committee. Day­-to-­day, she’s engaged in Medicaid and Children’s Health Insurance Program (CHIP) issues, thinking about big­-picture policy concerns and minute programmatic details.

“Both levels present unique analytical challenges,” Karan says. “I wanted to work on programs that provide medical assistance to some of the neediest and most vulnerable members of society. The committee staff interacts regularly with stakeholder groups who provide insight into programmatic areas, and these sessions are an important reminder of the real­-world impacts of policy.”

Karan credits her time with the Minnesota Department of Human Services for launching her career in public service. She worked there initially through her SPH field experience and then as an Executive Pathways intern, which gave her the chance to learn about large government systems and be part of policy­making decisions.

SPH faculty members Anne Barry, Donna McAlpine, Beth Virnig, and Lynn Blewett, and former faculty member Sharon Long, guided her course selections and volunteer opportunities. The career services office helped her prepare applications, gather materials, and practice interviewing.

“My current work is motivated by opportunities I had as a graduate student to help people,” says Karan. “Whether it was a paper on the inadequate number of mental health providers in rural areas or assisting with applications for asylum, getting my MPH and JD helped me under­ stand the diverse characteristics and needs of underserved populations.”

Karan’s coursework for her degrees was highly interdisciplinary and she broadened her education with a semester studying international law in the Netherlands and traveling through Turkey and Liberia.

“It’s tempting in graduate school to stay in a single department and bang away at required coursework, but the reality is that real­world problems and solutions cut across different disciplines, different agencies, different populations,” she says. “It’s important to begin the collaborative process in graduate school. The University has so many opportunities for joint degrees; I feel lucky every day that I stumbled into such a perfect program.”

By John Finnegan, Dean, University of Minnesota School of Public Health

There are an estimated 310 million guns in private hands in America, that’s 88.8 per 100 people, nearly a quarter of all civilian guns in the world. Our country is awash in firearms.

As of March 15, more than 2,600 people have died of gunshot wounds since the Sandy Hook Elementary School massacre on December 14, 2012. By the end of 2013, more than 30,000 people will be dead from gun-related homicides and suicides. No one of any class, race, or education level is immune to the tragedies related to the gun violence that cuts a wide swath across our country.

As a nation, we know the facts and up until now, they have failed to move us. Yet 20 children and 6 adults dead in three minutes in Newtown woke up our national psyche numbed to violence. That shooting was a tipping point. If we can maintain our moral outrage, we may become a country that has seen too many gun deaths and is finally doing something to stop them.

President Obama’s wise recommendations for a new, stronger ban on assault weapons, a limit on large ammunition magazines, and an increase in background checks for gun purchases are vital steps in reducing gun deaths. Easy access to guns contributes to homicides and suicides, but it’s not the cause. We’ll never decrease gun violence until we address why people pull the trigger in the first place, and how we can help them turn away from making that choice.

OUR PROBLEM, OUR TIME
Since the Newtown shooting, gun violence has been increasingly called a “public health” issue. For the first time, the national conversation is moving beyond seeing the problem in simplistic terms—as a gun control or crime issue—and acknowledging the complex influences that lead to firearm deaths. Over the past decades, our field has helped decrease tobacco use, traffic fatalities, and HIV/AIDS infections, and we are making progress in curbing the obesity epidemic. We have helped people and communities all over the world forge better, healthier futures. I have no doubt that we can bring our expertise, proven methods, and multidisciplinary approach to the intricate problem of gun violence and make a lasting difference.

WHERE TO START
Public health was once a major force in addressing the issue of gun violence in America. The Centers for Disease Control and Prevention (CDC) and smaller agencies, like the Minnesota Department of Health (MDH), produced valuable statistics and research into how, when, why, and by whom guns were used to kill or injure. But in 1996, Congress passed an appropriations bill that banned government funding for any research that could be used to promote gun control.

On January 16, President Obama, by executive order, ended the freeze on gun violence investigations, calling such work “critical public health research.” He went on to allocate $10 million to the CDC and $20 million to expand the National Violent Death Reporting System that collects detailed information and data on gun deaths.

Public health researchers can now use these federal dollars to make up for lost time, gathering information for a serious, educated look at the contributing factors to gun violence the way we have approached other public health threats. Good public policies rely on sound data, and public health researchers play a critical role in providing that information.

BODY, MIND, AND SPIRIT
If we look at gun deaths in street and domestic shootings, mass killings, and suicides, two key factors emerge as major contributors—health disparities and mental health issues.

Communities of color have disproportionate struggles with health, poverty, and education. And it is people from these communities who are most likely to be killed by a gun. For African-American youth, guns are the leading cause of death, and their families and neighbors know this. In a Pew Research study released on December 20, 2012, “African-Americans overwhelmingly say gun control is more important than gun rights (68 percent to 24 percent), while opinion among whites tilts in favor of gun rights (51 percent to 42 percent).” Other minority groups, such as Native American and Hispanic populations, also have above average rates of gun violence.

At our School of Public Health, we have a robust research portfolio of projects that address health disparities, including partnerships with the Medical School and the Office of Minority and Multicultural Health at MDH. In some areas, we’ve seen success in dealing with health disparities, but we, and the entire field of public health, have a long way to go.

We all need to do more to give underserved and poor communities the same opportunities for good prenatal health, parenting skills, sound nutrition, access to health care, and education as those in more affluent populations. We need to work with and learn from these communities to understand their environments and challenges. Giving children a good start in life, helping them stay healthy, and addressing the struggles in their families can eliminate some of the factors contributing to gun violence.

MENTAL HEALTH AS PUBLIC HEALTH
Gun homicides take lives, but suicides using guns take even more. According to the CDC, nearly two-thirds of the gun deaths in 2010 were suicides. Among people younger than age 25 who kill themselves, guns were used nearly 44 percent of the time. We must do more to protect our youth from guns, including giving them the tools to handle the despair that leads to suicide.

In general, our country has done a dismal job when it comes to screening for and helping ameliorate mental illness.

Forty to 45 million people have untreated depression. In our state alone, according to SPH alum Sue Abderholden, executive director of the National Alliance on Mental Illness Minnesota, out of the 21 percent
of children ages 9 to 17 who have mental illness or a substance abuse issue, only 1 in 5 receives treatment.

In the United States, we use a clinical model to address mental health—we wait for people with problems to walk in the door. We need a public health approach to mental health, and we have the potential to move in that direction. Under the Affordable Care Act, heath care providers will be required to adopt population- and community-health methods that will encourage a more involved relationship with neighborhoods and lead to better care overall.

The field of public health itself now needs to add mental health to its areas of expertise and make it part of curricula. Out of the 50 schools of public health in America, only a handful offers advanced degrees or certificates in mental health. We must step up our efforts to make sure public health encompasses this profound challenge to individual health.

GOING FORWARD
At the American Public Health Association (APHA) meeting in December, shortly after the events in Connecticut, leaders from public health schools across the country took up the issue of gun violence and what role we must play. APHA president Adewale Troutman called for a comprehensive approach to gun violence and reinvesting in research on violence in all forms. At our school, the Newtown tragedy has refocused efforts to address gun deaths.

This year, we will again try to establish a University investment in behavioral and mental health promotion from a public health and community approach. Our faculty will use their expertise to make inroads into stopping gun violence. Epidemiology professor Alan Lifson recently testified before the Minnesota State Legislature on universal background checks for all gun purchases. And we have nominated environmental health sciences professor Susan Gerberich to a CDC committee tasked with developing a public health research agenda to reduce gun violence.

Before this day is out, another 80 people will be dead from a firearm. Tragedies as public as Newtown and as private as a suicide will continue to happen, and, as a profession, we have an obligation to make them fewer and farther between. We must take risks, stick our necks out, and work to reverse the roadblocks that the firearms lobby has put in the way of common sense measures to end gun violence.

Persistent gun violence is among our most wicked problems, the kind public health is so perfectly tuned to tackle.

Since Advances launched a decade ago, I have written for the magazine only in this dean’s letter. But I am breaking tradition with this issue, and for good reason. In the months following the tragic shooting in Newtown, Connecticut, our country has renewed its decades-old discussion about gun violence. As we struggle to understand this latest tragedy, we are coming to realize that gun violence is fundamentally a public health issue. At its core are the very concerns to which many of us have devoted our professional lives, including entrenched health disparities among underserved populations. In this issue, I delve further into public health’s relationship to gun violence and challenge our field to make a lasting impact on this persistently wicked problem.

We see extraordinary developments on another front: the rollout of the Patient Protection and Affordable Care Act (ACA). Never before has prevention been so intricately woven into the nation’s delivery and financing of health care. In this issue, we look at how SPH experts are helping to shape this new era. Health policy professors offer their take on Medicaid expansion and opportunities for small businesses. SPH alum April Todd-Malmlov is charged with directing the creation of our own state-run health exchange, and we get her thoughts. Not only are our experts guiding the implementation of the ACA, but they are benefiting from its support of their research. You can read about some of the unexpected and fascinating ways in which the ACA will shape the work of our faculty.

On behalf of the school, I’d like to offer my sincere thanks to Don and Janet Wegmiller for their role in creating an endowed professorship for our Master of Healthcare Administration program. Don, an MHA alum, has a career marked by innovation and accomplishment. Don’s colleagues recently inducted him into Modern Healthcare’s national Health Care Hall of Fame. It’s an honor to have his name attached to this professorship. As we move into a time of enhanced collaboration among public health and health systems, staying connected to industry leaders like Don is a key to success for all of us.

Yours in health,

John R. Finnegan, Jr., PhD
Assistant Vice President for Public Health
Dean and Professor

R.K. Anderson

“Growing up on a dairy farm, we had considerable contact with livestock and wildlife,” wrote R.K. Anderson. “Even though we understood, or perhaps because we understood the primary role of animals in our lives, we were often in a close relationship that gave us a perspective of our interdependence and the nature of life and death in our ecosystem.”

Considered a gentle giant by his colleagues, Anderson died on October 18, 2012. He was the founding director of the veterinary public health program in the School of Public Health, which provided the first opportunity in the country for people to earn an MPH degree in the same four years as their DVM degree.

SPH Dean John Finnegan says that Anderson “understood the breadth and depth of public health and its connection to biologic, economic, and social systems. He was so far ahead of his time in recognizing the interplay of animals and the environment in human health.”

That interplay was a vital concern for Anderson, as he taught public health and veterinary students about such things as zoonotic diseases and how to keep the food supply safe. His belief that we can’t look at animals, humans, and the environment in isolation is an idea we now call “One Health.” Anderson simply said of this relationship, “We are here as one family.”

A deep understanding

Anderson, called R.K. by his friends, may be unknown to most pet and livestock owners, but he fundamentally changed our collective understanding of animal emotions and the human/animal bond. Early in his career as director of the Denver Department of Health and Hospitals, responsible for the city’s animal control facility, Anderson used rewards instead of punishment to modify dog behavior, a method that seemed “soft” at the time.

“I saw that we’d use these harsh methods and the dogs would get worse, becoming more anxious and more afraid,” he said in a 2003 interview. “I decided to try and motivate with food.”

Curious and practical, Anderson drew on his experience, research, and intuition to create the Gentle Leader with colleague Ruth Foster (then president of the National Association of Dog Obedience Instructors). Unlike a traditional collar that puts pressure on a dog’s throat, the Gentle Leader touches the calming points on a dog’s head, removing its natural tendency to pull the leash or engage in anxiety-based behaviors. The Smithsonian has named it among of the world’s best 100 inventions.

“We didn’t use choke chains on horses and cattle, why not use halters on dogs?” wrote Anderson. “I believe we can do a great job of teaching the dog whatever we need to without inflicting pain. After all, don’t they deserve that? We’re supposed to be talking about our best friends.”

Among his many initiatives, Anderson co-founded the Center to Study Human Animal Relationships and Environments (CENSHARE) at the University to investigate the growing understanding of the role animals can play in human health. By studying and encouraging companion animals in care environments and animal-assisted therapy, for example, Anderson believed CENSHARE could improve the quality of life for both humans and animals. He also helped found the Delta Society (renamed Pet Partners), an internationally known non-profit that shares CENSHARE’s mission and provides a forum for pubic policy making.

Leaving a legacy

“I can’t begin to explain how important R.K. was to me in my career,” says Michael Osterholm, SPH professor and director of the Center for Infectious Disease Research and Policy (CIDRAP). “He was one of the greatest teachers. His most profound lesson to me was that nothing matters if you don’t have good science behind it. He requested only that I pay it forward.”

Osterholm shared a personal friendship as well with Anderson, a kind man by any measure. Every year, they had a competition to see who be the first to call the other at Christmas. Anderson, often travelling somewhere in another time zone, usually got the jump on Osterholm, maybe calling in the middle of the night. Osterholm visited Anderson shortly before his death: “The last thing he said to me was, ‘Merry Christmas, forever.’”

Finnegan says of Anderson, “He was a Renaissance man. He was completely focused outside himself and one of the most genuine humans I’ve ever encountered.”

April Todd-Malmlov

Next fall, most Americans and many small business people will sit at their computers searching for the right health care insurance policy. If all goes well, they should be getting more choices in an easy-to-understand format called a health insurance exchange.

“We are planning for [health insurance selection] to be a process that takes less than an hour to complete,” says April Todd- Malmlov, executive director for the Minnesota Health Insurance Exchange and a School of Public Health alum.

The exchanges are meant to be virtual marketplaces where people can comparison shop for health coverage among a variety of insurance plans. There will also be exchanges where businesses with up to 100 employees can buy group coverage.

Insurance exchanges are compulsory for all states and are the lynch pin of the Affordable Care Act (ACA). Whether or not the ACA lives up to its promise of health insurance reform depends in large part on the success of the exchanges.

Each state can decide whether it will establish its own ex-change (referred to as “opting in”), step back and let the federal government establish one for it, or form one in partnership with the federal government.

Double Deadlines for Minnesota

Minnesota has spent more than $100 million to create its own exchange and hopes to have 1.3 million people buying coverage by 2016. Todd-Malmlov has been working feverishly at the legislative level to make sure the plan is in place by October 2013 when enrollment opens.

“We are one of four states out of the 18 that have opted in that does not have legislation or an executive order to run our own exchange,” says Todd-Malmlov. “We need to pass a law giving Minnesota that power by the end of March.”

The bill has to gone through the House and Senate, and is in the hands of conference committees. The final destination is Governor Dayton’s desk.

Three big issues have been up for debate: 1) which carriers may participate in the exchange, 2) how the exchange will be financed, and 3) who is qualified to sit on the exchange board, which will govern the exchange.

In recent votes, the Minnesota House decided to allow 88 insurance providers into the exchange, with minimum requirements. The Senate chose the active-purchaser model, which means that the state must follow strict guidelines and carefully select the providers that can compete.

“When it comes to deciding which providers may participate, some legislators believe there is value in allowing all companies to compete, others say that the state should be involved in selection,” Todd-Malmlov says. “There are strong feelings on both sides.”

Federal grants will fund the exchange for 2014 and the financing going forward has come down to two choices in Minnesota: withholding 3.5 percent from insurance premium fees or using money from the “health impact fee,” also known as the cigarette tax.

When it comes to the powerful exchange board, who should be allowed to participate? Should a position in the health care industry disqualify a potential candidate, or does that make him or her more attractive?

“It’s a big issue,” says Todd-Malmlov. “Some argue that a person’s involvement in the health care industry makes him or her more conversant in the complex issues, others say that individual won’t be able to stay neutral.”

Although the bill is moving swiftly through the legislative process, the provider, funding, and board issues remain unresolved as of March 15. But Minnesota has always been a leader when it comes to health care coverage, so chances are that the exchange will be up and running in October with first-rate choices for consumers.

Jason Champagne

“Healing is the most important ingredient in Native American cooking,” says chef Jason Champagne, a member of the Red Lake Band of Chippewa and current MPH candidate in public health nutrition. “Indigenous foods are a path to health and a way for us to recover our communities.”

At age seven, Champagne taught himself to cook by watching TV chefs after school. By age eight, he would prepare a full dinner and set the table before his parents returned from work. After high school, Champagne started working in construction and saved enough to go to Le Cordon Bleu culinary arts program in Minneapolis. He landed a plum job after graduation with Walt Disney World and was quickly promoted.

“But one night, after a successful 3,000 person steak and lobster dinner, I realized I’d had enough,” Champagne says. “My work was focused on quantity and production, and I realized I’d lost sight of why I’d entered a culinary career—to cook and connect with people. So I decided to finish my education and work in a field where I could do both.” Champagne was awarded a scholarship to the University of North Dakota and graduated with a degree in nutrition and Native American studies.

“Throughout the research I did for my nutrition degree, I kept coming across papers authored by Dr. Mary Story and was captivated by her work in obesity and diabetes,” he says. “So I emailed her and she encouraged me to apply for an MPH.”

Champagne began his MPH studies at the School of Public Health in fall 2011. He is a Shakopee Mdewakanton Sioux Scholar and is a candidate for a Centers for Disease Control and Prevention grant that will help fund his work in diabetes and obesity prevention. This past summer his field experience included an internship with the Chickasaw Nation in Ada, Oklahoma. He consulted with participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), taught nutrition classes, and developed healthy recipes for the Chickasaw Medical Center Cafe.

In November 2012, Champagne was a presenter at the Native American Culinary Association Indigenous Food Culture Conference. “Five-hundred years ago, we Natives were expert farmers, hunters, gatherers, fishermen, and cooks,” Champagne says. “These activities will make us healthy again.”

Champagne is currently teaching nutrition and cooking classes at several Native American outreach organizations and is a volunteer cook for homeless Native Americans at the Minneapolis American Indian Center. “I focus on portion size and whole foods, showing how to make healthy food taste good and look good within a tight budget,” he says.

And this summer, he’ll head the cooking program and work with youth at Dream of Wild Health, a 10 acre, Native-owned organic farm in Hugo, Minnesota.

“I hope that traditional foods will become the everyday foods for Native Americans,” Champagne says. “I dream of having a traditional Native American food truck that serves our ancestors’ food, not the fry-bread and tacos at today’s powows. Why not serve rack bread—a flat bread cooked over an open fire,—bison burgers, wild rice, fresh fried fish? Real foods. Real fun.”
.

The United States has about 49 million people without health insurance, and if the goal of the ACA is to drastically reduce that number—which it is—then small businesses are a good place to start.

Changing the numbers

The ACA has several provisions to help small businesses provide health insurance, according to Jean Abraham, SPH associate professor in the Division of Health Policy and Management. One is the medical loss ratio regulation. Under this rule, health insurers must spend at least 80 percent of small group or individual premiums on clinical benefits, not administrative costs or profits. If they don’t, they must issue rebates to the policyholders. This will help small businesses whose premiums, according to the White House, have up to three times as much administrative cost built into them as plans in the large group market.

“Policymakers have been concerned about the small group market for health insurance for quite some time,” Abraham says. “This market segment has much higher administrative expenses per dollar of benefits than coverage obtained by large employers.”

Abraham served as the senior economist on health issues with the President’s Council of Economic Advisers in Washington, D.C., and she and her colleagues are currently exploring the impact that the ACA will have on employers’ decisions to offer coverage.

If employers do choose to buy insurance for their workers, those premium contributions are tax exempt, as they always have been. But now businesses with up to 25 employees that pay average annual wages below $50,000 may qualify for a small business tax credit of up to 35 percent of the employer’s premium contribution. In 2014, that credit increases to 50 percent and is available for two years.

Finding good, affordable health insurance policies to offer employees is one of the hardest chores of a small business. To address that barrier to coverage, the ACA established exchanges, virtual state marketplaces where individuals and businesses with 100 or fewer employees can choose the best options among a selection of health insurance plans.

Matthew Katz is an SPH alum and executive vice president and CEO of the Connecticut State Medical Society. He’s on the committee of his state’s Small Business Health Options Program (SHOP). SHOP sets many of the parameters and requirements that interested health insurance companies must meet in order to offer plans in the new exchanges.

“In many locations, there were few insurance options for small employers,” Katz says. “They were very expensive or offered such varying and often confusing benefit designs that employers had a hard time selecting options for their employees. SHOP is designed to reduce complexity, reduce confusion, and provide a clear avenue for employers and employees to make the best choices.”

Into the Unknown

The hope is that, with the exchanges and other ACA provisions, employees in small businesses will have the opportunity to obtain affordable health insurance, whether they buy it as individuals or obtain it through their employer’s plan. With tax credits to offset some premium costs, policymakers hope that more small employers will offer health insurance.

But Katz worries that perhaps not enough small businesses will access the exchanges to make them profitable enough for insurance company participation. “The biggest challenge is going to be getting small business owners to use the exchanges,” he says. Among Abraham’s concerns is whether the small business tax credit will be enough of a carrot to get small business owners to offer insurance. “[Since the law went into effect in 2010], relatively few small businesses have taken advantage of the tax credit benefits,” she says.

The Affordable Care Act is an enormous piece of groundbreaking legislation and it will take time for everyone, including small business owners, to understand the law. It may be several years before the country can judge the ACA’s success in bringing better and affordable coverage to more people.

The expansion is designed to provide health care coverage for more low-income families and individuals and is vital to the ACA’s vision of insuring every American. If every state were to participate in the expansion—due to go into effect on January 1, 2014—approximately 17 million more Americans would eventually get health care benefits through Medicaid and the Children’s Health Insurance Program (CHIP), which is the Medicaid program for children. As of March 2013, 24 states have committed to the expansion.

Lynn Blewett, SPH professor in the Division of Health Policy and Management, has been carefully tracking expansion developments. Blewett directs the State Health Access Data Assistance Center (SHADAC). SHADAC supports states in monitoring and evaluating programs to increase health care access and coverage. She shed some light on the Medicaid expansion and what it means.

ADVANCES: First of all, how does Medicaid currently work?

BLEWETT: It’s a combined federal and state program, with each entity paying a percentage of health care costs for people with low incomes who qualify for the program. States run the program and decide who they will cover and how, within federal guidelines. Between Medicaid and CHIP, about 60 million Americans have health care coverage [out of a U.S. population of about 314 million].

ADVANCES: What does it cost states to participate in the Medicaid expansion?

BLEWETT: The Medicaid expansion will add little to what states spend on Medicaid now. The federal government will pay 100 percent of expansion costs, and that will eventually be reduced to 90 percent. Because the expansion will reduce state and local government costs for uncompensated care and other services they provide the uninsured, it is actually a good deal for the states. This is especially the case for a state like Minnesota that has financed similar programs, like MinnesotaCare, with no federal financial support.

ADVANCES: Why then would a state opt out of the expansion?

BLEWETT: There are a lot of politics involved in the choices states are making. And after a few years, states will need to fund 10 percent of the costs of expansion. Many states feel that even 10 percent is too much of a burden for taxpayers.

ADVANCES: When states opt out, what are the consequences for the overall success of the ACA?

BLEWETT: The goal of universal and standardized coverage for the poor will not be achieved, and we will continue to have great variation across states on programs to support access to affordable health care.

ADVANCES: Given the difficulties of the Medicaid expansion, do you still think it was a wise move?

BLEWETT: I would have preferred that it had been simplified and streamlined, and written in a way so that states couldn’t opt out. But the good news is that the law now requires that Medicaid coverage be extended based on income, not based on a category (e.g. pregnant women or the elderly) and the ruling has mandated simplified enrollment procedures. Even so, it’s a complex system and having states opt out adds another layer of complication. But if we waited to figure this all out, nothing might have changed. This is a step in the right direction.

Andrew McCulloch (MHA '80)

By Andrew McCulloch (MHA ’80), president of Kaiser Permanente Northwest

Central to federal health care reform is the need to innovate our systems to deliver higher quality, more affordable care. In my home state of Oregon, we are at the helm of one of the most ambitious reform efforts in the nation. It is focused on reducing costs for Medicaid patients and, eventually, for the entire state.

Under Oregon Governor John Khitzhaber’s leadership, we crafted an innovative approach with federal lawmakers.  They would give the state $1.9 billion over five years, and in return we’d ensure our state Medicaid program would grow at a rate 2 percent less than national trends – restoring $11 billion to state and federal governments over the next 10 years.  

Integrated approach

So how are the health care industry and the State of Oregon fulfilling this promise?  The simple answer: together. 

Our plan aims to provide an integrated package of preventive health care services through local coordinated care organizations (CCOs) with a focus on delivering better, more efficient care, particularly for patients with chronic conditions and frequent emergency room visits.

Using a patient-centered medical home model and a global Medicaid budget, each CCO will be charged with caring for Medicaid patients in a given area and determining the best way to provide comprehensive health care for them. These services include dental and mental health care.

Patient support tools

What we’ve seen is that the success of this collaborative care organization is rooted in some very familiar preventive health practices that Kaiser Permanente, my current employer, has been using in our health care system for more than 65 years.

For instance, we know that by leveraging technology platforms, care delivery systems can improve care for healthy patients as well as those with chronic disease. In conjunction with the electronic medical record, using a platform such as Kaiser Permanente’s Patient Support Tool (PST), health care providers can deliver more of the care they are supposed to receive.

The PST actually monitors recommendations pertaining to medication management and screening for co-morbidities in six chronic conditions: asthma, diabetes, coronary artery disease, heart failure, hypertension and chronic kidney disease. The tool also monitors preventive care measures, such as administering adult immunizations and screening for breast, cervical, and colorectal cancer, as well as hyperlipidemia and osteoporosis. For each care recommendation, the PST indicates what actions need to be taken, if any. It cues the care team to reach out to the patient.

Transforming an industry

Reforming and improving health care is not about tweaking processes. It’s about transforming an entire industry to address large scale economic and health imperatives facing our nation and future generations.  We must do this together through innovation, integration of formerly disaggregated systems, and personal responsibility.   

As the leader of Kaiser Permanente here in the Northwest, I can say without hesitation that this is an exciting time. A lot of the federal reform are aimed at doing what we’ve been doing for years—providing high quality, affordable health care services and improving the health of our entire nation.

I will also say without hesitation that this is also a challenging time. We’ve got to come together , learn from each other, and innovate our systems to expand coverage for millions of Americans while reducing costs.  The result will be providing care that is more affordable for individuals and for our society as a whole.

Katy Kozhimannil

To arrive at their results, School of Public Health researchers examined hospital discharge data from a representative sample of 593 hospitals with at least 100 births in 2009.
 
Cesarean delivery is an important, potentially lifesaving, medical procedure and some variance in hospital rates would be expected based on differences in patient characteristics. In order to address this, researchers also examined cesarean rates among a subgroup of lower-risk patients: mothers whose pregnancies were not preterm, breech, or multiple gestation and who had no history of cesarean delivery.
 
Among this group of women with lower-risk pregnancies, in which more limited variation might be expected, hospital cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent.
 
“We were surprised to find greater variation in hospital cesarean rates among lower-risk women. The variations we uncovered were striking in their magnitude, and were not explained by hospital size, geographic location, or teaching status,” said lead author Katy B. Kozhimannil, Ph.D., assistant professor in the University of Minnesota School of Public Health. “The scale of this variation signals potential quality issues that should be quite alarming to women, clinicians, hospitals and policymakers.”
 
Matter of Policy
 
Childbirth is the most common and most costly reason for hospitalization in the United States. Cesarean births are more expensive than vaginal deliveries, and cesarean rates have increased from 20.7% in 1996 to 32.8% in 2011. Nearly half of all U.S. births are financed by state Medicaid programs. In 2009 alone, public insurance programs paid out more than $3 billion for cesarean deliveries.
 
“Cesarean deliveries save lives, and every woman who needs one should have one,” said Kozhimannil. “The scope of variation in the use of this procedure, especially among low-risk women, is concerning, as  its use also carries known risks compared to vaginal delivery such as higher rates of infection and re-hospitalization, more painful recovery, breastfeeding challenges, and complications in future pregnancies.”
 
Policy recommendations
 
First, women need to be offered the right care for their own pregnancies. Evidence from earlier studies shows women with healthy pregnancies benefit from care provided by midwives, support from trained doulas, and access to care in licensed birth centers. Women with low-risk pregnancies should have access to care options that may benefit them, with strong referral systems and specialized care for complications that may arise.
 
More and better data on the quality of maternity care are needed to support the rapidly advancing clinical evidence base in obstetrics. Clinicians and hospitals cannot improve maternity care, and insurers cannot pay for such improvements, without clear and consistent measures of quality.
 
Tying Medicaid payment policies to quality improvement programs may influence hospital policies and practices and provide incentives and reward hospitals and clinicians for providing consistent, evidence-based care.
 
Information about cesarean rates and maternity care should be more readily available to pregnant women, who have time, motivation, and interest to research their options. However, they lack access to unbiased, publicly-reported information about cesarean delivery rates and other aspects of maternity care.
 
To learn more about Kozhimannil’s passion for understanding and improving care for mothers, visit: http://z.umn.edu/kozhimannil.

The Certificate in Advanced Management Training for Clinician Leaders was designed specifically for clinicians interested in deepening their managerial skills. It was developed with input from clinicians with management positions in integrated health systems and physician organizations.  These professionals include physicians, nurses, pharmacists, and physical therapists. The certificate is offered by the school’s Master of Healthcare Administration and Healthcare Executive Studies programs.

Program Details

The full curriculum (13 credits) is offered over a twelve-month term, most of it online. Students will complete a capstone project developed from their professional experiences with their organization.

Students will have two on-campus experiences: a four-day experience at the beginning of the course of study, and a three-day session at the end. The initial on-campus session will include guest lectures from experts and health system executives. This last on-campus session is dedicated to the presentation of capstone projects.

Coursework between the beginning and ending on-campus sessions will be conducted online through a learning environment that encourages student cohort collaboration. Each twelve-month course of study will begin in the fall of the academic year (the first beginning fall of 2013). Students will conclude their course of study the succeeding fall term.

Between 18 and 20 clinicians will be admitted to each class.

For more information see Certificate in Advanced Management Training for Clinician Leaders. 

Katy Kozhimannil, Ph.D.

The research indicates that policy changes to provide Medicaid coverage for birth doulas may actually decrease costs due to lower rates of cesarean births among Medicaid patients with doula support.  Support during childbirth may be especially important for women with low health literacy or patients whose first language is not English and who may not fully understand all their clinical options during childbirth.

The results are published online today in the American Journal of Public Health.

Better outcomes, lower costs

Currently, taxpayers fund nearly half of all U.S. births through state Medicaid programs, which generally do not cover doula care. A cesarean birth costs almost 50 percent more than a vaginal birth, with the average Medicaid payment of  $9,131 for a vaginal birth and $13,590 for a cesarean delivery.

The study, led by SPH assistant professor Katy Backes Kozhimannil, shows two things: doula support may improve birth outcomes for low-income women; and state Medicaid programs offering coverage for birth doulas could potentially save taxpayer dollars.

“When we compared birth outcomes among culturally-diverse Medicaid recipients who received prenatal education and childbirth support from trained doulas with those from a national population of similar women, we estimated a 40 percent reduction in cesarean rates,” says Kozhimannil. “When you look at the potential cost savings associated with a rate reduction of this magnitude, Medicaid reimbursement for birth doulas could be a case where adding coverage on the front end could ultimately result in real dollars saved.”

Kozhimannil notes that the positive health impacts of continuous labor support are well documented, but this is the first analysis of the potential financial impact of offering insurance coverage for that type of support.

According to the research:
•    Many low-income women are at increased risk for poor birth outcomes
•    Many low-income women are unable to afford the cost of doula services
•    In 2009, Taxpayers funded 45 percent of all U.S. births through state Medicaid programs
•    Medicaid does not typically offer coverage for doula care

Unlike physicians, midwives, and obstetrical nurses who provide medical care, a doula provides support in the nonmedical aspects of labor and delivery. According to the study’s authors, this kind of support can translate directly into fewer cesarean births because more mothers may fully understand their birthing options and have the support they need during challenging aspects of labor and delivery. 

Watch & learn more about Kozhimannil’s work

Improved care for at-risk populations 

“All mothers — but especially those from low-income communities, communities of color, and immigrant communities — stand to benefit from support during childbirth,” Kozhimannil explains. “The doula group we studied made a concerted effort to recruit and train diverse doulas and to match doulas with clients based on language, culture and community.”

In order to recruit doulas from the at-risk communities, broadening the payer base will likely enhance the feasibility and appeal of a doula care business model for a wider range of women.

Increasing financial access by offering coverage of birth doula care would be costly to state Medicaid programs. But these costs may be offset by reductions in hospital payments for cesarean deliveries, should cesarean rates decrease sufficiently.

“In a time of increasing fiscal pressures on health care systems and state Medicaid budgets, the need to stem the rising cost of care is urgent,” says Kozhimannil. “We believe the option of doula support for Medicaid-funded pregnancies would not only be financially beneficial, but may also improve quality and enhance the mother’s birth experience.”

The study is led by Jennifer E. Pelletier, M.P.H., who partnered with University of Minnesota School of Public Health Epidemiology and Community Health researchers Melissa N. Laska, Ph.D., R.D., Dianne Neumark-Sztainer, Ph.D., M.P.H., and Mary Story, Ph.D., R.D. The study appears in the Journal of the Academy of Nutrition and Dietetics. A copy of the article can be found here.

The researchers conducted a cross-sectional study, which examined the characteristics and dietary behaviors of 1,201 students at a two-year community college and a four-year public university in the Minneapolis and St. Paul area. The participants reported low, moderate, or high importance on alternative food production practices.

“Almost half of the young adults placed moderate to high importance on alternative production practices of food,” said Pelletier. “And no differences were found by race/ethnicity or socioeconomic status in this sample.”

Women, young people aged 25 years and older, vegetarians, and those living outside their parent/family home reported the highest importance on alternative production practices.

Compared to those who placed low importance on these practices, those who placed high importance on alternative production practices also consumed:

•    1.3 more servings of fruits and vegetables
•    More dietary fiber, fewer added sugars and less fat
•    Breakfast approximately 1 more day per week
•    Fast food half as often

The study’s findings suggest that nutrition-focused messaging around social and environmental implications of food production practices can be well received by this age group.

“Registered dietitians and other nutrition educators should start incorporating these topics into health-promotion efforts or college health courses,” suggests Pelletier. “We have an opportunity to encourage healthy eating without talking about nutrition directly, but rather by emphasizing alternative production practices to improve overall dietary quality.”

Kelvin Choi

Tobacco companies’ aggressive coupon marketing tactics may reduce the likelihood that current smokers will quit, according to new research published in Tobacco Control, an international peer-reviewed journal.

This report is the first-of-its-kind to illustrate that cigarette coupons have a negative association on smoking cessation.
 
“We know that raising the price of cigarettes encourages smokers to quit. Coupons are a way to bring the price down, and keep people smoking,” says Kelvin Choi, research associate at the University of Minnesota School of Public Health, and lead author of the article. “Smokers who receive these coupons think the tobacco industry cares about their health and well-being, even though industry documents prove that they know their products are addictive and deadly.”
 
Choi analyzed data collected through the Minnesota Adult Tobacco Survey (MATS) Cohort Study, funded by ClearWay Minnesota, which recruited 2,436 participants who were smokers and recent quitters in 2007, and surveyed them between 2008 and 2010.
 
The findings include:
·         Nearly half of smokers reported receiving cigarette coupons.
·         Eighty percent of those who received coupons redeemed them.
·         Women, younger smokers and heavier smokers are disproportionately targeted by coupons.
·         Smokers who use coupons are more likely to believe that tobacco companies care about their
                health, do their best to make cigarettes safe and tell the truth.
·         Smokers who redeem coupons are 84 percent less likely to quit smoking.

Watch a video on tobacco coupons.

Tobacco Still a Problem
Tobacco companies are restricted from using many forms of marketing and advertising. They also know that higher tobacco prices encourage smokers to quit. Cigarette coupons, disseminated through direct mail marketing or other promotional channels, is a legal way for them to reach consumers, counteract rising tobacco prices and keep smokers addicted.

“This research is another reminder that tobacco is still a big problem in Minnesota,” says Molly Moilanen, director of public affairs at ClearWay Minnesota. “Stronger policies can counteract the tobacco companies’ tactics. We know a $1.50 per pack tobacco price increase will help more than 30,000 Minnesota adults quit smoking and prevent thousands of kids from becoming addicted adult smokers.”
 
Currently, New York is the only state that does not allow retailers to use cigarette coupon programs to sell cigarettes under their minimum legal price. There are 25 other states, including Minnesota, that regulate minimum cigarette prices, but they do not prohibit the use of promotional coupon programs. Updating regulations to restrict the use of coupons would further encourage smokers to cut back and quit.

For more information on this research, visit ClearWay Minnesota. 

SPH helps foster a new approach to global health

When the bubonic plague ravaged 14th century Europe, Russia, and Asia, few understood disease vectors or that the tiny flea was the ideal host for Yersinia pesti and rats were the literal jumping off point for human infection.

Animals harbor thousands of viruses— most yet undiscovered—that can potentially infect humans with grave results. We’ve witnessed the damage they can cause in the AIDS epidemic and in the estimated 65,000 deaths each year from rabies.

But a new approach has developed to understand, prevent, and respond to emerging high-impact zoonotic diseases, those that pass from animals to humans. Called One Health, it views animals, people, and the environment as a single system. Doing One Health demands a common strategy and way of thinking that crosses disciplines, national boundaries, and public and private domains.

GLOBAL CONCERNS

Barbara Knust, an epidemiologist at the Centers for Disease Control and Prevention in Atlanta, traveled to Uganda early this summer to help deal with the outbreak of Ebola, an untreatable, deadly zoonotic disease. The past few months, she has been investigating an emergence of hantavirus, which is transmitted by rodents—deer mice, in this instance—to humans, at Yosemite National Park. Out of nine campers sickened, three have died.

Knust received her MPH from the School of Public Health in 2010 after working as a veterinarian for several years. Bringing veterinary expertise together with public health training is an especially useful path for a One Health approach. In the case of hantavirus, the three components of animal health, human health, and the environment must be investigated together.

“We are still studying the effects of climate on the mouse population and hantavirus infection, but we know that the higher the deer mouse population, the more likely humans and mice will come into contact, thereby increasing the risk of a person becoming infected,” says Knust.

FORMALIZING ONE HEALTH

SPH environmental health sciences professor Debra Olson thinks of One Health as “one science, one health, one world.” For her, this phrase emphasizes the notion of dropping the boundaries between science disciplines; between human, animal, and ecosystem health; and between countries and societies. And it is an essential way to approach the multiple layers at play in a disease outbreak. “With the One Health approach, you’re not jumping from one part of the crisis to another, you’re integrating the problem solving,” says Olson.

Just how and how well we solve problems together is Olson’s concern. As associate dean for education, she is helping to facilitate One Health efforts at SPH, the University, and across the globe in two specific ways—one is through the school’s involvement with RESPOND, a component of USAID’s Emerging Pandemic Threats (EPT) program; the other is by engaging with colleagues from the Academic Health Center to create coordinated services in support of global health and social responsibility.

WORKING AS ONE COMMUNITY

The hot spots for emerging zoonotic diseases are the world’s tropical zones, particularly countries in Africa and Asia where relationships between humans, animals, and the environment are always in flux. When land is cleared for farming or roads are cut through rain forests, humans come in contact with more wildlife. Domestic animals often live near wild animals, and many people still kill and butcher “bushmeat,” native animals that can harbor viruses. All this activity raises the stakes for the emergence of novel zoonotic diseases.

SPH is a key player in RESPOND, a highly collaborative project that includes Tufts University. RESPOND brings together faculty from across the health sciences, education, and environmental sciences to build capacity for One Health in universities in 10 countries.

“RESPOND is increasingly focused on the role universities play in supporting One Health,” says Katey Pelican, RESPOND’s University co-lead with John Deen, both in the Department of Veterinary Population Medicine. “Universities can build programs to create a whole different kind of health worker—a One Health worker, who can be comfortable working across disciplines and across public, private, and governmental realms.”

COMMON COMPETENCIES

RESPOND has established a network of schools of public health, medicine, nursing, and veterinary medicine in Central and East Africa (OCHEA) and in Southeast Asia (SEAOHUN) to develop common competencies and a unified, strategic response to global disease threats.

For the past two years, RESPOND has been addressing its capacity- building mandate through small group meetings, international conferences, exchange programs, short courses, and residencies, including those at Makerere University in Uganda and Chaing Mai University in Thailand being modeled on the University of Minnesota Veterinary Public Health Residency.

This summer, RESPOND used a model already in place—SPH’s Public Health Institute—to bring together faculty from Tufts University, OHCEA, and SEAOHUN. The RESPOND team used the three weeks they were together to address cultural barriers with a One Health approach and to begin to devel- op a One Health curriculum for participants to take back to and apply in their respective countries and universities.

REVITALIZING A GLOBAL MISSION

When the University was established as a land-grant institution in 1862, part of its mission was to make knowledge accessible to the world. In the past several decades, the University’s reputation as a health and science educator, leader, and innovator has gone global.

People from multiple disciplines at the University, along with their international colleagues, are addressing the world’s wicked health problems with an increasingly One Health approach. But what the University doesn’t have yet is a coordinated way to bring these efforts together to enhance their reach and impact.

Olson and her fellow Academic Health Center deans have proposed a coordinated infrastructure for global health and social responsibility that would lead, foster, and engage those involved with
One Health activities at the University. It would support colleges, units, and departments from economics to ecology, veterinary medicine to public policy, and technology to agriculture, as they build on their global portfolios that address issues at the intersection of animal, human, and ecosystem health.

Already associate professor Jeff Bender is leading a partnership between the College of Veterinary Medicine and SPH to expand One Health educational opportunities at the University to prepare the next generation to manage the world’s complex health issues.

It’s no surprise that the School of Public Health would be so deeply invested in supporting and nurturing this game-changing approach to global health. The nature of public health professionals is to make human connections, learn as much as they teach, and be aware of and work from an appreciation of the many elements that have an impact on health.

As Barbara Knust says: “One Health is a great term to capture the goal and the concept that has been sought and achieved by public health practitioners for a long time.”

Illustration by Olaf Hajek

CPHEO offers students the chance to gain more knowledge about certain aspects of public health and earn continuing education credits. NGOs (non- governmental organizations) use CPHEO classes to keep their employees up to date on the latest public health issues, as well as to conduct orientation or refresher training on basic public health concepts. CPHEO helps support growing academic programs, such as the Online Executive Program in Public Health Practice and the online program in Maternal and Child Health.

REACHING STUDENTS WHERE THEY ARE

One of the centers’ great advantages is the accessibility of its programming. Nearly a third of the world’s seven billion people have internet access and CPHEO can reach them—and has—in Armenia, Botswana, Australia, and many other countries.

Stanley Blanco lives in La Paz, Bolivia, and is in charge of USAID-funded community health projects in that country. He has an MD and MPH. Two years ago, he was appointed as an assistant mission disaster relief officer.

“I recognized that I needed immediate training on emergencies, risk reduction, and disaster management, so, searching the web looking for reliable universities and courses, I found CPHEO,” says Blanco. For people like Blanco who have limited time, CPHEO’s online courses offer a convenient way to learn. For other students, the classes fill a vital need for the advanced public health training that their countries are lacking.

Anna Guo works for 3M in Shanghai province, China, and manages registered nurses at eight manufacturing sites. She has a bachelor’s degree in prevention medicine and an advanced nursing diploma. Because Chinese schools of public health cannot offer ade- quate advanced training, she says, her U.S. colleagues recommended CPHEO online classes for her career development.

COMING TOGETHER

What’s missing for Guo in her online studies is “schoolmates to exchange learning experiences with.” SPH supplements the online learning available for students via CPHEO with the annual three-week intensive Public Health Institute (PHI) on the Twin Cities campus, which Guo hopes to attend one day. Over the years, SPH has also taken a program modeled on PHI—the Global Health Institute—to places such as Iceland, India, Vietnam, Thailand, and Uganda to address the growing need for coordinated and innovative global public health training.

Offering classes online and at little cost is a rapidly growing phenomenon, and universities across the country are clambering to get on board. CPHEO has more than a decade-old history in delivering first-rate, consistent, and current content to computer screens—and increasingly, mobile phones—all over the world.

ILLUSTRATION BY OLAF HAJEK

Therese Zink

The group of Minnesota college students, all pre-health majors, climbed out of the old yellow school bus. The temperature that January afternoon in Nicaragua registered 35 degrees Celcius (95 Fahrenheit), much warmer than back home. They paired off, linked up with their interpreters, and tromped in different directions down the dirt roads of the village to begin knocking on doors.

The students were spending their J-term with Inter Faith Service to Latin America (ISLA), and I was coordinating their weeklong activity. Thanks to the skills I’d gained through my Master of Public Health program, I suggested that ISLA do a community needs and assets assessment so we could better understand the region’s health issues.

Over and over again that week, people in the village welcomed the students into their homes. One of the important findings from our community assessment was related to asthma. Students noted that locals cooked in kitchens without ventilation. Mothers reported coughing among their children, but were unaware of the relationship between the cooking fumes and their children’s health.

Later, the students and I discussed the findings. We could treat the children’s asthma in the clinic, but addressing the problem from a public health perspective would achieve broader results. Eventually, ISLA identified a Nicaraguan stove with a pipe ventilating to the outside that could be installed in homes for a reasonable price.

The experience also reminded me of why I chose to pursue an MPH after working as a family physician for five years. I wanted a “big picture” perspective and the skills to affect health on a scale broader than one person at a time.

Having an MPH has benefited my work globally and locally. It has helped me address the sources of health problems, as we did with the childhood asthma issue, rather than just treat their symptoms. In my practice in a small rural community in southeastern Minnesota, it is equally important for me to consider health beyond the clinic’s walls.

–Therese Zink , MD, MPH, earned her degree from SPH in 1992.

PHOTO BY PATRICK O’LEARY

“Collaboration is the very nature of our field,” says Debra Olson, SPH associate dean for education, talking about the new public health undergraduate minor. The partnership between the School of Public Health and the College of Liberal Arts in creating the minor “has been one of the greatest successes in the development of the program,” she says.

Its coursework will provide students with a foundation in the language, concepts, and methods used to address individual and population-level health challenges. “Whether a student’s major is pre-med, pre-law, business, or journalism, this minor is relevant and practical,” says Tricia Todd, assistant director of the U’s Health Careers Center and SPH instructor. Offered as an option in the geography and sociology departments, the minor will provide students the tools to work across disciplines.

“It meets both my personal and professional interests,” says Jess Kessler, a senior majoring in biology and environmental sciences who serves as a health advocate for her dorm. Kessler says the minor will help give academic context to the training she received to understand student health issues—physical, mental, emotional, and spiritual. “The holistic approach makes so much sense,” she adds. “The public health classes are taught by graduate-level professors, so this will give me a sense of what the MPH [program] might be like. I am considering applying to SPH, and this is a good way to start to learn more about it.”

Limited to 100 students, the minor drew 97 applicants the first week it was announced.

Graduate Minor – Integrative Leadership

“The Integrative Leadership minor is an astounding collective effort among four professional schools—the School of Public Health, the Carlson School of Management, the Humphrey School of Public Affairs, and the College of Education and Human Development,” says Louis Quast, associate chair of the Department of Organizational Leadership, Policy, and Development in the College of Education and Human Development, the minor’s academic home.

Seminars in the minor will be co-led by two faculty members from different sponsoring professional schools. “Students will develop the leadership skills to create a common vision by drawing from their different areas of expertise,” says Quast. The minor’s mission is to address social, economic, and political change while training future leaders to bridge institutional, geographical, sectoral, and national boundaries.

Open to all University of Minnesota graduate-level students, this new minor is the first of its kind in the country. “When you think about the different systems in our society—health care, political, educational, economic—each may cultivate leaders within its sector, but can those individuals lead across sectors?” says Sandra Potthoff, SPH associate professor. “Solutions to a society’s complex problems that come from an exchange of ideas will be far better than those coming from any one discipline.”

CIDRAP recently issued a major report on the efficacy of seasonal flu vaccines.

Attention-grabbing specters like bubonic plague, Ebola, or the slim possibility of anthrax attacks make for compelling headlines, and the University of Minnesota’s Center for Infectious Disease Research and Policy (CIDRAP) keeps tabs on all of these—along with other nightmarish, if distant, threats.

Recently, CIDRAP has made headlines for its work on a more familiar, yet potentially devastating, peril: influenza. In the past few months, the center has weighed in on the possible dangers of the H5N1 man-made flu virus and investigated the H3N2 swine flu virus. CIDRAP also released a major new report on the efficacy of seasonal flu vaccines and the urgent need to improve them.

Now, thanks to a $1.5 million gift from the Bentson Foundation, CIDRAP will be able to enhance efforts to prevent infectious diseases, whether emerging or familiar.

Proportional response and public outreach

While CIDRAP monitors scores of important issues, from hantavirus to smallpox, its priorities are governed by the principle of proportional response, says Michael Osterholm, CIDRAP director and SPH professor.

“What kills us, versus what hurts us, versus what worries us, versus what scares the hell out of us—often these can all be very different,” says Osterholm. “Our job is to try to make sense out of that, and to try to put the emphasis on what can hurt us or kill us.”

Calling on sound science to educate the public, industry, and policymakers about looming health threats is central to CIDRAP’s mission. That education can take place on the airwaves of national news outlets (Osterholm is a frequently called-upon expert), through CIDRAP-hosted conferences, and in one-on-one discussions with government and business leaders. More than ever, that education is happening online.

Gift to enable website revamp and enhance outreach

The Bentson Foundation gift is targeted broadly to outreach, and “a major component of that is our web presence,” says Aaron Desmond, CIDRAP’s associate director for outreach and development. The gift will enable a revamp and integration of CIDRAP’s websites, whose users work around the globe (a third are from outside the U.S.) in clinical care, academia, the private sector, government agencies, and groups such as the World Health Organization. Each year more than a million pages are accessed on CIDRAP’s sites.

“I’m proud of the work we’ve done to establish CIDRAP as a trusted source for public health reporting throughout the world,” says Osterholm. “Our staff works tirelessly to provide scientifically sound, up-to-the-moment content on critical issues.”

The gift also allows CIDRAP to further develop its use of social media and other online tools for outreach, says Bentson Foundation executive director Judi Dutcher, who notes the possibility of in-person outreach efforts, including summits on topics deemed critical by Osterholm and CIDRAP staff. “We wanted to give them as much flexibility as possible,” Dutcher says.

U graduates Larry and Nancy Bentson formed the Bentson Foundation in 1956 to advance a variety of philanthropic causes. With its history of support for the U, including a recent gift for a new
School of Nursing teaching lab, and its longstanding recognition of Osterholm as an international “thought leader,” the foundation saw CIDRAP as a natural fit, Dutcher says.

“We’re becoming a very close global community . . .the fact that we have this center that is a leader in addressing emerging public health threats is a testament to the University,” she says. “We’re really excited to see what’s going to be accomplished.”

Lizz Hutchinson, center, in Nairobi, Kenya.

In her work for CARE, a leading humanitarian organization fighting global poverty, Lizz Hutchinson travels to more countries in a year than most of us do in a lifetime—Bangladesh, Ghana, India, Malawi, Mali, and Tanzania. In previous assignments, she’s been to Kenya, Mozambique, and South Africa. For fun, Hutchinson and a former MPH classmate, Sarah Sevcik, will head to Panama to sightsee this fall. In just three years of receiving an MPH in Community Health Promotion, Hutchinson is flying high.

Hutchinson’s ease in relating to people has helped her land several positions since graduation, despite a grim job market. In her final semester at the School of Public Health, she requested informational interviews with numerous organizations and individuals. “I listened intently and always asked for other contacts,” she says. “Minnesota is a terrific place for global work. Everyone—professors, my parents’ friends, alumni—provided leads.”

Her current position involves working with one of CARE’s most recent initiatives—Pathways—designed to enable 150,000 women who work small plots of land to develop as farmers, increase their household incomes, and realize a measure of food security. “Alleviating poverty is key to improving public health,” Hutchinson says. “And one of the best ways to do that is by empowering women so they can engage profitably with the markets.” The Pathways program, funded by the Bill and Melinda Gates Foundation, builds on CARE’s established and successful approaches.

Before joining CARE, Hutchinson honed her public health monitoring and evaluation skills at Land O’ Lakes International Development, the University of Minnesota, and WellShare International, formerly Minnesota International Health Volunteers. With her graduate fieldwork in Tanzania and her master’s project in North Minneapolis, she combined academic studies, research skills, intuition, and creativity. In Tanzania, for example, she volunteered with an organization that hosted public health plays performed on the village’s busy market days. For her master’s project, a community needs assessment, she used qualitative interviewing techniques, which encourage open-ended conversations, to discern the neighborhood’s most critical health issues.

Wistful about her time with the School of Public Health, Hutchinson says, “I wish I’d taken advantage of the U’s classes in economics, geography, or perhaps a language.” Given her energy and enthusiasm, it’s likely she will.

John R. Finnegan, Jr.

Dear Friends,

Once again, I’m pleased to present our annual global issue. Its cover story, “Notes from the Field,” gives a glimpse of the hands-on work our students are doing as part of their graduate studies. In summer 2012, they spent time at the World Health Organization in Geneva and the UN’s Food and Agriculture Organization in Rome. Several students worked in isolated areas of Africa, while others headed to Latin America. A special thanks goes to Jennie Meinz, who was in Ecuador, for her photograph on the cover. The picture is a testimony to how the field experience fosters understanding and changes the lives of our students, as well as those they meet along the way.

SPH alumni are also actively involved in international work. One example is Barbara Knust, a 2010 MPH graduate and epidemiologist for the Centers for Disease Control and Prevention, who went to Uganda this summer to investigate the Ebola outbreak. Her work follows the principles of One Health, a public health approach that we embrace and encourage in order to develop a unified, strategic response to global disease threats.

In this issue, you’ll learn more about how our faculty and researchers work with international agencies, organizations, and universities to secure safe blood supplies, stem the tide of malaria, assess the health impacts of gold mining, optimally deliver HIV treatment, and address other public health concerns. And our virtual connection with public health students and professionals all over the world continues to grow via the online courses and programs of SPH’s Centers for Public Health Education and Outreach (CPHEO), which now reach more than 46,500 people.

In closing, I extend my sincere gratitude to the Bentson Foundation for its generous gift to support infectious disease prevention. The Center for Infectious Disease Research and Policy (CIDRAP) will use that gift, in part, to sharpen its ability to communicate effectively using the web, social media, and other online tools. The gift was given especially to support outreach—a land-grant component as essential to the University’s mission today as it was 150 years ago. Thank you, Bentson Foundation.

Yours in health,
John R. Finnegan, Jr., PhD
Assistant Vice President for Public Health
Dean and Professor

BEST TIME FOR TREATMENT
Antiretroviral treatment for people with HIV is costly, not free of toxicities, and lifelong once initiated. When to best start this therapy has been debated for years; finding an answer is critically important. To that end, the International Network for Strategic Initiatives in Global HIV Trials (INSIGHT), led by SPH biostatistics professor Jim Neaton, is conducting a definitive randomized trial. Nearly 4,000 participants will eventually be enrolled at more than 200 sites in 33 countries, including South Africa, Uganda, Nigeria, Mali, and Morocco. In addition to helping researchers discover optimal timing for treatment, many partici­ pants in this global study have enrolled in sub­-studies specifically investigating how HIV and HIV treatments affect neuro-cognitive function, bone health, arterial elasticity, and lung function.

SUPPORT, WHERE YOU LIVE
A major challenge to worldwide efforts in scaling up HIV treatment is that patients often stop going to clinics for care. Many of those who discontinue their clinic visits either die at home or return to the clinic only after their health has significantly deteriorated. In rural southern Ethiopia, SPH epidemiology professor Alan Lifson is conducting a project to improve treatment retention by working with HIV ­infected individuals where they live. The project hired and trained community health workers from the same villages or neighborhoods as their clients. They provide education, counseling, social support, referrals, and linkage to the HIV clinic. The project, which was implemented over a year ago, is currently assessing the impact of this community­ based intervention on client retention rates, knowledge, attitudes, and health status.

TURNING THE TIDE ON MALARIA
Every year, 3.3 billion people—half of the world’s population—are at risk of contracting malaria. The disease affects poor communities most, decreasing the GNP of countries with a high malaria burden by more than 1 percent. But prevention and treatment efforts are paying off. In the past 12 years, malaria mortality rates have fallen by 25 percent globally and 33 percent in Africa. SPH doctoral student John Amuasi is leading an evaluation of a malaria treatment program in his home country Ghana. Funded by the public-­private financing group, the Global Fund, the pilot program subsidizes costly anti­-malaria drugs with the aim of improving accessibility, availability, and affordability. Not only does early treatment save lives and prevent transmission, it reduces the use of less effective treatments to which malaria parasites are becoming increasingly resistant.

GOOD HEALTH CARE EVERYWHERE
Saudi Arabia faces many of the same health care issues we do in the United States, like a growing private health insurance market and the need for efficient, cost­-effective integrated delivery systems. The SPH­ sponsored Executive Master of Healthcare Administration (MHA) program at the King Fahad Medical City in Riyadh will help senior physicians and administrative leaders meet those challenges. The program follows SPH curriculum and allows students to earn a University of Minnesota MHA degree in 25 months. Directed by health policy and management professor Dan Zismer and administrative program director Tom Gilliam, the Saudi Arabia partnership may be the first of many to come to help produce a stronger global medical community.

BANKING SAFE BLOOD
Having a safe, adequate blood supply is something few developing countries have been able to achieve. Afghanistan was one of these countries until 2010, when the Ministry of Public Health chose SPH prof­essor Bill Riley, administrator Terri Konstenius, and the Medical School’s Jeffrey McCullough to assist it in building a national blood supply, including developing screening and collection procedures and systems for recruiting donors. Later that year, this public health and medicine interdisciplinary team began a similar project in Tanzania when the Centers for Disease Control and Prevention selected the University of Minnesota to help the Tanzania/ Zanzibar National Blood Transfusion Service develop a comprehensive donor recruitment program with a goal to double the blood supply in five years.

USING THE INTERNET TO STOP THE SPREAD OF HIV
No one knows yet how well internet-­based education and intervention techniques could lower HIV transmission among high­-risk men in India—methods successful in the United States have never been tried there before. Now a University of Minnesota team has joined a California and India­ based team to collaboratively research that potential in Mumbai. Called ISH Konnect and led by SPH epidemiology research associate Michael Wilkerson, the study will investigate basic issues like internet availability, how the internet is used to connect male sex partners, and whether conducting online focus groups is feasible and culturally acceptable. An online intervention campaign in India has the potential to reach thousands of men, reduce risky beliefs and behaviors, and prevent the spread of HIV.

TOO MUCH FLUORIDE
Fluoride occurs naturally in well water, but when the water table is low, the mineral becomes concentrated. Drinking this water may lead to fluorosis, which can cause teeth enamel to erode and produce pain and damage in bones and joints. As fluorosis becomes more common around Kolar, India, SPH faculty, the Sri Devaraja Urs Medical College (SDUMC), and the Indian Institute of Science at Bangalore are collab­orating to research the issue and design preventive interventions. In the first phase of this effort, SDUMC will conduct a study to estimate fluorosis prevalence in the population. The Indian Institute of Science, because it has the necessary infrastructure, will test local water and soil for fluoride.

GOLD FIELD FALLOUT?
Phased out as a major commercial venture in 2001, the centuries­-old practice of mining gold in India’s Kolar District is suspected of leaving a legacy of occupational diseases and environmental health hazards. Despite possible risks, miners and their kin continue to strive for a revival of gold mining, their only source of employment. An SPH team including, environmental health professors Jeff Mandel, Gurumurthy Ramachandran, and Bill Toscano, has joined with Sri Devaraja Urs Medical College (SDUMC) in Kolar to investigate if mining is truly to blame for many of the region’s health issues—like lung and skin diseases, asthma, and tuberculosis—and to provide solid public health data for the people of Kolar. The long­ term goal of the SPH/SDUMC collaboration is to establish an occupational health program at the college, which has already begun biweekly health fairs where public health information is disseminated and faculty conduct health screenings.

TEACHERS AS GAME-CHANGERS
Bihar is one of India’s poorer states and has extra­ ordinarily high rates of tobacco use, even among adolescents. Epidemiology professor Harry Lando is involved with a study at government schools that focuses on tobacco abstinence among teachers. If the teachers can stop using tobacco, the hope is that they will become role models for students and others in the community, where they tend to be highly respected. After four years of the five­-year project, researchers are surprised by the high numbers of teachers who have quit using tobacco. In another part of the world, Lando is working on an NIH-­funded study to discern the capacity of Tunisia and other low­ resource countries in the region to implement Article 14 of the WHO Framework Convention on Tobacco Control, which calls for measures to reduce tobacco dependence and increase cessation.

CLEANER BURNING STOVES
Burning solid fuels in household stoves for cooking and heating harms health and contributes to carbon emissions and climate change. Environmental health professor Gurumurthy Ramachandran, University of Minnesota civil engineering faculty, and University of British Columbia researchers comprise a team that has completed phase one of a neighborhood­-scale stove replacement program in Karnataka, India. Half the households received cleaner burning stoves after the team collected data related to cardiovascular health, air pollution, and livelihood. The next phase will include collecting post-­intervention data. Team members expect the new stoves will reduce indoor air pollution and improve cardiovascular health.
At the end of the study, all participating households will receive a new stove.

Ramatoulie Jallow returned to her native Gambia to help give girls the education they deserve.

Each one matters
Ramatoulie Jallow, a Community Health Promotion major, returned to her native Gambia to work for Starfish International, a U.S.-based empowerment program for girls in her country. She co-taught a class for young women, covering subjects such as self-care and hygiene, healthy relationships, and preventable diseases, including HIV/AIDS, which are culturally unacceptable for Gambian women to discuss.

“In Gambia, talking about sexual and reproductive health remains taboo,” she says. Jallow’s role was to provide young women with a safe space to discuss these issues and to give them the tools they need to take control of their own health. She used teaching styles she has learned the most from— including games and role-playing—to help the girls understand the material.

“I believe that knowledge is health,” says Jallow. “My greatest accomplishment was that I not only taught the students everything I wish I’d known when I was a high school student in Gambia, but that I was also able to create a safe environment for them. They are so eager to learn and so full of hope for the future.”

Tending to the elders
Que dios le pague. Several times a day, Jennie Meinz would hear this phrase from the elder Ecuadorians at the local community centers. “Roughly translated, it means ‘May God pay you’ or ‘May God bless you,’” says Meinz, a Community Health Promotion major. “Although these seniors have very little, they are extremely grateful for a space to eat and to chat with friends and visitors.”

Meinz spent her global field experience in Pedro Moncayo County, about two hours from Quito, Ecuador. She worked at CECUIDAs (Centro Comunitario de Cuidado Diario del Adulto Mayor), community centers that provide food, health, and social services for senior citizens. “For about $1.50 per day, per person, CECUIDAs feed and care for the senior population and serve approximately 450 people,” says Meinz.

Besides coordinating blood glucose and blood pressure screenings, she talked with older adults about their eating patterns to help them understand the development of chronic diseases. “It was challenging to interview them in Spanish, but after the first few conversations, I started to learn more of the local food vocabulary,” she says.

Autumn Durfey with her host parents, Charles and Eunice.

Africa in an island
Mfangano lies in Lake Tanganyika, about three hours away by boat from the Kenyan mainland. Community Health Promotion major Autumn Durfey spent the summer on the island working on sustainable community health projects and a water treatment study.

The island is a microcosm of the public health challenges seen in the rest of Africa—lung and eye problems from indoor cooking fires, food insecurity, unsafe drinking water, and, most devastating, high rates of HIV (30 percent of the island’s population is infected).

In the struggle to tackle the island’s HIV rate, Durfey saw the effectiveness of community health workers, people especially critical on Mfangano, which has one hospital—albeit without a medically trained doctor—for its 20,000 residents and the citizens on surrounding islands. “Thanks in a big way to their work, HIV is now talked about freely and not tip-toed around as it had been for three decades,” she says.

In her time on Mfangano, Durfey witnessed what so many other SPH students found in their global field experiences: “There is a fine line to tread between instituting Westernized methods and preserving culture and tradition.”

Community care
Andy Tompsett is no stranger to Tanzania. Between college and graduate school, he spent three and a half years in the country as a Peace Corps volunteer. Returning for his field experience, he focused his attention on helping orphans and vulnerable children through a project called Pamoja Tuwalee, which in Swahili, means, roughly, “let’s care for them together.”

“Pamoja Tuwalee is a unique project [in Tanzania] because it increases a community’s capacity to care for children through income-generating projects and small savings and lending groups,” says Tompsett, a Community Health Promotion major.

Tompsett was officially an intern with Africare, which manages the USAID- funded Pamoja Tuwalee and issues subgrants to other organizations to run the programs. His job was evaluating the subgrantees and helping them improve their grant proposals to Africare.

Initially, Tompsett wondered if he’d be prepared to do the kind of work this internship would demand of him. “Most of the courses I took last year at SPH were on domestic public health issues, yet I was amazed how comfortable I felt working alongside my colleagues at Africare,” he says.

Megan Ghai outside the World Health Organization (WHO) in Geneva.

Building relationships
When Megan Ghai first went to Geneva as an intern at the World Health Organization (WHO), it was hard for her to find her place among so many people. But that difficulty didn’t last long.

“Throughout my internship, I was able to develop close relationships with employees at WHO, as well as other interns,” she says “[Making these connections] has been one of the most rewarding components of my time in Geneva.”

Ghai, a Public Health Administration and Policy major, worked in the Department of Pandemic and Epidemic Diseases on a variety of projects related to Yellow Fever and the use of oral cholera vaccines. She quickly discovered that her SPH classes gave her an advantage. “Courses such as International Health Systems and Cost-Effectiveness Analysis provided me with the rhetoric to interact with departments across WHO,” she says.

While Ghai knew that public health efforts are often underfunded at local and state levels, she was surprised to learn that WHO activities also have limited financial support. “I was shocked to see that even on the international level, public health programs that seem indispensable are not impervious to budget cuts,” says Ghai.

Second Time Around
Last summer, Colin Gerber went to Uganda for his field experience. In summer 2012, he was back in Africa serving as a group leader and mentor for American high school students spending five weeks in Ghana.

“I found that my field experience and SPH studies helped me in unanticipated ways,” says Gerber, a Community Health Promotion major. “I could speak with authority about various health and sanitation issues, and I had no problems managing the group budget. I felt prepared and confident, despite the fact that this type of work was new territory for me.”

Hally Turner, left, with a fellow intern and local school children in Namunkesu, Uganda.

Making way for new thinking
In the Ugandan village of Namunkesu, there is no electricity, let alone access to the Internet to search for information. “We were isolated, [but] my studies at SPH helped me design education sessions that were both accurate and culturally appropriate,” says Hally Turner, a Public Health Administration and Policy major.

As an intern with the Uganda Village Project, Turner introduced good health behaviors by discussing such subjects as sanitation and hygiene, eye care, nutrition, HIV/AIDS, sexually transmitted diseases, and family planning. Her biggest hurdle, besides the rainy season, was developing the trust of local people so she could move them beyond traditional beliefs.

“We were not always successful promoting changes in behavior because of deeply rooted cultural practices,” says Turner. “[For example,] one woman explained to me that she would not improve airflow in her kitchen where she cooked with charcoal because witches would watch her through the ventilation holes.”

Megan Peck in Rome on the rooftop balcony of the UN’s Food and Agriculture Organization (FAO).

Finding what works
Like most Westerners, Megan Peck had no idea that rabies was such a scourge in the developing world. An estimated 65,000 people die from the disease each year.

Peck, a Community Health Promotion major, traveled to Rome for her field experience, where she worked at the United Nation’s Food and Agriculture Organization (FAO). There she evaluated rabies prevention and control activities of an FAO- implemented campaign in Kenya.

“Ninety-five percent of rabies deaths occur in developing countries,” she says. “I find this number particularly disturbing because the disease is preventable.” Peck also attended summit meetings of the Codex Alimentarius Commission, created in 1963 by FAO and WHO to establish international standards for safe and equitable food trade. One of the topics was excessive commodities speculation, the effect of which Peck experienced first hand in 2010-11 while living in Kenya.

“When there was even [just]talk of increasing oil prices, the cost of food increased,” she says. “This dynamic leads to a volatile food market, which can have devastating effects on developing countries.”

Toward better beginnings
Ann Marie Castleman headed to Matagalpa, Nicaragua, for her field experience. A Community Health Promotion major, she worked with the Skills to Save Lives Pilot Project, which focuses on reducing maternal and infant mortality. Castleman was in charge of adapting an adolescent sexual health curriculum to be taught by midwives and community health workers in public schools and fine-tuning it for this particular rural Nicaraguan community.

Castleman was struck by the dedication of the midwives, who get no pay for their work. “I learned that many of the midwives walk for hours—across rivers and over mountains—to visit the women they care for,” she
says. “They truly live in a different world than the one I come from.” Castleman writes in her blog about how her time in Nicaragua opened her eyes to the concept of “public health.”

“[For example], a pregnant woman’s health depends on things like her economic stability, education, geographic location, the politics of her government, and priorities set by world health organizations. Public health is complex. That’s the importance of this work.”

Moments of Joy and Sorrow
“Since I started working with African immigrants and refugees 11 years ago, I have wanted to learn to tie a baby to my back. When I arrived in Congo, I told all of the women at my church that I had to learn this one lesson before I left or my trip would not be complete.

“The smallest child was chosen for me, but since babies cannot be tied to the back until they are three months old and she was too young, we had to wait. Just a week before her three-month birthday, she passed away. I knew the statistics on infant mortality in Congo: One in 10 children die before the age of five. But this child was not just a number. She was the little girl who I fell in love with and who was meant to be tied to my back.

“As I finished speaking to the congregation on my last Sunday and church came to an end, my three closest friends, including Kety, the mother of the baby who had died, came up to say that I could not leave yet. Kety picked up her second child and, with tears in all of our eyes and with lots of laughter, too, I learned how to tie a baby to my back.”

— JESSICA LOWE, a Maternal and Child Health major, went to Brazzaville, Congo, to work with the World Health Organization (WHO).