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U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H

FINDINGS

V o l u m e 2 5 , N u m b e r 2 S P R I N G / S U M M E R 2 0 1 0

T H E H E A L T H O F O U R C H I L D R E N

INSIDE > A pediatric hospital for the 21st century | High-tech routes to healthy kids | When I grow up | For runaways, dreams and despair


32

12

Soccer photos by Peter Smith

Brian Stauffer c/o theispot.com

34

116

11

14

Ken Orvidas c/o theispot.com

W On the Web

Whenever you see this symbol, it

means you can check out additional,

exclusive content on this topic online

at www.sph.umich.edu/findings.

The fall issue of Findings

will feature a special

section on SPH alumni

who’ve volunteered

for the Peace Corps.

To share your Peace

Corps story, visit

wwwpeacecorps.umich.edu or

e-mail sph.alumni@umich.edu.

Findings is printed on Rolland Enviro-

100, a 100-percent post-consumer

fiber paper that is manufactured using

biogas energy. This means we’ve saved

the equivalent of 92 trees, reduced

solid waste by over 5,800 pounds,

conserved over 55 thousand gallons

of water, and reduced air emissions by

over 12 thousand pounds compared to

printing on virgin pulp paper. Findings

is printed by an FSC (Forest Stewardship

Council)–certified printer using

vegetable-based inks that are

91-percent free of volatile organic

compounds (VOCs).

2 From the Dean

44 Alumni Network

Our Debt to Our Children

44 The Peace Corps at 50

3 From Our Readers

5 On the Heights

32 Research News

32 The Whole Child

35 Special Section:

Doing Battle With Bugs

38 Special Section: Childhood Obesity

44 Class Notes

45 The Best Care Possible

46 Bright Smiles

48 Research for Kids’ Sake

50 In Memoriam

50 A Son of Ghana Returns Home

51 SPH Datebook

51 New on the Web

52 Snapshot

On the back cover: Epidemiology postdoctoral fellow Malavika

Subramanyam, in pink, leads a Bollywood dance class inside

the School of Public Health. A native of Mysore, India, who has

taught Bollywood dancing for 20 years, Subramanyam sent

an e-mail at the start of the winter term offering free biweekly

classes, and around 25 students signed up. As someone new to SPH,

she says, “it’s a nice way to meet people and to work out.”

F I N D I N G S W W W . S P H . U M I C H . E D U S P R I N G / S U M M E R 2 0 1 0


A R T I C L E T I T L E 1

f i n dings

Volume 25, Number 2 Spring/Summer 2010

Produced by the UM SPH Office of Communications

20

F e at u r e A r t i c l e s

The Health of Our Children

14 Pathways of Enlightenment

Could public health be the secret to improving America’s schools?

20 Voices in the Night

For young transgender runaways in Detroit, life on the streets is perilous.

26 Our Children, Our Future

The many ways SPH is working to protect the world’s most vulnerable citizens.

28 Turning the Technology Around

The good news about electronic media and kids’ health.

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


F R O M T H E D E A N

Our Debt to Our Children

One of the sacred duties of every

generation is to ensure that their

children, and their children’s children,

will inherit a world better than the one they

were bequeathed by their parents. On this,

in many ways we have failed.

“The Greatest Generation”—my parents’

generation—did their job. They helped save

us from Hitler’s grotesque ambitions and

paved the way toward an unprecedented

path of global economic growth. Yet they

left us with a legacy that is itself far from

perfect. We struggle today with the immense

challenge of global warming, a byproduct of

that phenomenal run

of economic growth

that, unfortunately,

all too few of us anticipated,

and that all

too few today seem

willing to confront.

One of the Greatest

Generation’s greatest

contributions, Medicare

and Medicaid,

Kenneth E. Warner

along with the major

contribution of their parents’ generation,

Social Security, imperils the solvency of the

nation. But it is my generation that has failed

to deal with the challenges created by these

cornerstones of our society.

Older Americans vote in far larger

numbers than do young Americans; and

the youngest Americans—those under age

18—have no vote. Our self-protection mode

translates into congressional dread about

addressing the financial stability of Social

Security and Medicare. In a world of

me-first politics, the situation will only

worsen as the baby-boom generation

reaches retirement age. Today, 13 percent of

the United States population is 65 or older.

By 2030 one in five Americans will be a

senior citizen. Our failure to bequeath our

kids a reasonable level of national debt and

a plan for ensuring the future of Social

Security, Medicare, and Medicaid places

them in an untenable, and possibly

unsalvageable, situation. How will they pay

the public’s bills—our bills—and manage

to cover their own at the same time? Our

recent struggle to come together to finally

realize health care reform in this country—

while a great victory—vividly illustrates our

inability to work productively across party

lines to address our most difficult challenges.

Will we leave our children with a series

of eventually intractable problems? The

epidemic of childhood obesity, spawned by

an admixture of basic genetics, the physical

inactivity of modern life, and the rapacious

needs of the fast-food industry, threatens to

make our children the first generation to live

fewer years than their

parents. Inadequate

education, a lack of

permanent housing,

abusive or absent

parents, a myriad

of preventable emotional

and behavioral

disorders—all these

constitute serious

challenges to the

health and wellbeing

of all too

many of our kids.

And what of

children outside the

developed nations?

Ten million kids still

die annually, the

vast majority from

utterly preventable

conditions. Diarrhea

claims the lives of two million children

each year. Measles—a vaccine-preventable

condition—still kills nearly 200,000 children

annually. In sub-Saharan Africa alone, 11.6

million children have been orphaned by HIV/

AIDS, and many of them will succumb to

complications of the disease. In a world

increasingly plagued with over-nutrition,

under-nutrition continues to exact a price for

millions of kids living in the world’s poorest

nations. This was brought very close to home

earlier this year in the heartbreaking pictures

of the often emaciated orphans of Haiti.

If you have read this far, I fear that I have

left you depressed and/or angry. The picture

How will they pay

the public’s bills

—our bills—and

cover their own at

the same time?

is definitely gloomy, but it is not hopeless.

The horror stories in the preceding paragraph

must be contrasted with the good

news: Worldwide, despite an increasing

population, the child death toll today is

literally half that of just a few years ago.

Deaths from vaccine-preventable diseases

have plummeted. Led by both the U.S.

government and major private organizations,

like the Gates Foundation, resources

are flowing into global health at an unprecedented

rate. With a few notable exceptions,

low- and middle-income countries are

experiencing

substantial decreases

Michael McGowan

in infant mortality

and, associated with

that, fertility rates,

as well as rapid

increases in adult

life expectancy.

In the U.S., the

nation’s premier

foundation devoted

exclusively to health,

the Robert Wood

Johnson Foundation,

has made childhood

obesity one of its

principal programmatic

targets. Health

and education are

focal points of the

current administration

in Washington,

as witnessed by First Lady Michelle Obama’s

campaign to improve children’s eating and

exercise habits. And scientists are producing

new knowledge that will undoubtedly

improve the health and well-being of children

in America and around the world. The

present issue of Findings reports on many

such exciting efforts here in your University

of Michigan School of Public Health. Dr.

Warner prescribes a thorough reading of the

issue to cure the depression with which he

may have afflicted you.

Now, when will Congress ever get the

backbone to deal with Social Security,

Medicare, and Medicaid? <

F I N D I N G S W W W . S P H . U M I C H . E D U S P R I N G / S U M M E R 2 0 1 0


F R O M O U R R E A D E R S

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FINDINGS

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H

V O L U M E 2 5 , N U M B E R 1 F A L L / W I N T E R 2 0 0 9

Kudos on Findings

Belated congratulations on the spring/

summer 2009 (“Food for the 21st

Century”) issue of Findings. This was the

best issue of a school magazine I have ever

read. The issue was packed with fascinating

stories about important health and

scientific issues and passionate, interesting

people who are doing important, meaningful

work. Each of the stories was well

written. Many were highlighted with wellcomposed,

informative photos and colorful,

creative graphics. I feel very informed

on public health issues but learned a lot

from this issue. I also felt a sense of pride

learning about the dedicated and smart

students and faculty.

Michael P. O’Donnell, PhD ’94

Editor-in-Chief

American Journal of Health Promotion

Bratenahl, Ohio

While in Ann Arbor recently, I was

introduced to a couple issues of

Findings magazine. Though I am not an

SPH alumnus, I thoroughly enjoyed the

informative articles and the variety of

interesting content. Along with the copywriting,

I was very impressed with the overall

design and supportive illustrations and

photography. Your editorial and design

personnel are masterful—I am keeping my

issues just for inspiration!

Clark Most

Midland, Michigan

I

American Dreams

INSIDE > Marian Wright Edelman on our children’s future | The state of the state of Michigan | Health care at 30,000 feet

just have to drop you a line to let you

know what a magnificent issue the fall/

winter 2009 (“American Dreams”) issue of

Findings is. I picked it up this morning and

couldn’t put it down. It covers so many of

the great public health issues of today,

starting with Dean Warner’s message that

“Dreams Come True.” Yes, we have made

some progress on ending racism, but there

is still so far

to go. And

yes, Ken,

since you

sent your

message,

Michigan has

finally passed

our own public/private

clean indoor-air

bill, and I will

attend the Governor’s

bill-signing ceremony. Then on to

Marian Wright Edelman’s sage observation

that we states spend three times more on

our prisoners than we do on teaching our

students. She admonishes us to work harder

in public health to create the political and

spiritual will to build communities that produce

healthy and hopeful children. I especially

appreciated Leslie Stainton’s article

“Hour-Glass Nation,” giving us George

Kaplan’s take on our public health responsibilities

to describe the impact of social and

health inequity. We are currently developing

an approach for these same issues here at

the Michigan Department of Community

Health. Then on to the very interesting

pieces on the Michigan experience, tobacco,

and H1N1. Findings is always good, but this

one is special. It is so on the mark.

Jean C. Chabut, BSN, MPH ’68

Deputy Director for Public Health

Michigan Department of Community Health

Lansing, Michigan

Karina Rodriguez, who is featured

on the front cover of the fall/winter

2009 issue of Findings, is one of our

migrant students. She is very focused on

what she wants for her future, and we are

very proud of her accomplishments.

Deborah L. Dominguez

Migrant Clerk

Rivera High School

Brownsville, Texas

A Smoke-Free Michigan

(Campus and State)

Congratulations to SPH Dean Kenneth

Warner for his key role in encouraging

Michigan’s state legislature to finally

adopt a comprehensive smoke-free workplace

law, and kudos also to UM for going

smoke-free in 2011 (“Dreams Come True”

and “Vanishing Act,” fall/winter 2009 Findings).

I share Dr. Warner’s passion (if not

his level of success) for tobacco control,

having labored in the “trenches” for nearly

35 years. Beginning with a futile attempt

in 1974 to get Michigan State University’s

trustees to ban smoking in the classrooms,

I eventually had some significant success

during a decade-long battle to control

smoking in West Virginia in the 1990s, and

I later helped four northern Michigan counties

adopt a comprehensive smoke-free

workplace regulation in 2005. In addition,

I am intellectually indebted to Dr. Warner

for his pioneering publications on global

tobacco control. His work greatly influenced

my academic work as a medical

anthropologist, where I focused on tobacco

issues in Latin America, including the efforts

of transnational cigarette companies to

“make a killing” in countries like Mexico,

Guatemala, Ecuador, Peru, Chile, and Argentina.

Here’s wishing UM SPH continued

success in its many important endeavors!

Kenyon Stebbins, PhD

Chair of the Tobacco Control Coalition

of the Northwest Michigan Community

Health Agency (covering Emmet,

Charlevoix, Otsego, and Antrim Counties)

Harbor Springs, Michigan

Editor’s note: On December 10, 2009,

the Michigan Senate passed legislation

(HB 4377) that bans smoking in all workplaces—including

bars and restaurants—

with the exception of cigar bars, tobacco

shops, and non-tribal casinos. The bill was

amended to be named in statute after the

late Ronald M. Davis, MD, a member of the

UM SPH faculty, a past president of the

American Medical Association, and a longtime

advocate for smoke-free air. Governor

Jennifer Granholm signed the legislation

on December 18, and the ban took effect

on May 1, 2010. Michigan is the 38th state

to limit smoking in public places.

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


Myra Klarman

4 F I N D I N G S

> F R O M O U R R E A D E R S continued

The UM SPH community experienced two grievous

losses earlier this year. In tribute to these wonderful

young women, the families and friends of Kamilah

Neighbors and Julia Strecher have established a

pair of programs that will extend their legacies for

decades to come.

The Kamilah Neighbors

Internship in Child Mental

Health Services

To honor SPH alumna and doctoral

student Kamilah Neighbors, MHSA

’01, who died suddenly on March 4,

2010, the school has created a fund

to support the Kamilah Neighbors

Internship in Child Mental Health

Services. The fund will help Summer Enrichment

Program students and SPH degree students secure

internship placements in research, policy, and

public health–practice environments that are

focused on reducing racial/ethnic disparities in

child mental health services.

The daughter of UM SPH Professor Harold

“Woody” Neighbors and his wife, Bonita, Kamilah

was working on a doctorate in health services

organization and policy at SPH, where she founded

the school’s Graduate Student Health Research

Symposium and helped found the SPhDs (Doctoral

Students of SPH). Before embarking on her doctorate,

Kamilah worked as a hospital administrator at

Children’s Memorial Hospital in Chicago. She created

the hospital’s Summer Internship Program. To contribute

to the Kamiliah Neighbors Internship fund,

visit www.sph.umich.edu/alumni/allfunds.html.

The Julia Strecher Organ

Donor Registration Drive

A recipient of two heart transplants,

19-year-old Julia Strecher knew what

it meant to survive in the face of a

dire prognosis. Determined to help

others do the same, she enrolled in

the UM School of Nursing and was

completing her freshman year when she died on

March 2, 2010. In her memory, her friends and

family have launched an organ-donor-registration

drive. Julia’s two transplants “gave her 18

years of life that she otherwise would never have

experienced,” they write on their Facebook page.

“They gave us all 18 beautiful years with her.”

Registration takes 10 minutes, they note, and

“could save multiple lives and grant precious time

to the families and friends in similar situations to

our own.” To register to become an organ donor,

visit www.giftoflifemichigan.org/go/julia. Julia is

the daughter of UM SPH Professor Vic Strecher

and his wife, Jeri.

Sexuality and

Health Research

at SPH

I

read with great

interest the

article mentioning

the school’s

new Sexuality and

Health Research

Lab (“The Other

Side of the Dream,”

fall/winter 2009

Findings). Having

worked in STD and

HIV epidemiology for the past seven

years, I greatly understand the need for

innovative behavioral, cultural, and riskfactor

research to aid in STD prevention.

I’m very proud of SPH for dedicating

resources to this very prevalent health

issue. I can only hope the research lab

can collaborate across all disciplines

at SPH and incorporate epidemiology,

policy, health disparities, and health

behavior and health education.

Kathryn Macomber, MPH ’02

Michigan Department of

Community Health

Lansing, Michigan (From a comment

posted to Findings online)

Correction/Notes

An article in the fall/winter 2009 issue

of Findings neglected to mention that

SPH alumna Christy Zalewski, MPH ’04,

coauthored a report questioning the role

of obesity in severe H1N1 infections. The

report appeared on July 10, 2009, in a

special dispatch in the U.S. Centers for

Disease Control and Prevention’s Morbidity

and Mortality Weekly Report.

Our thanks to the reader who called to

point out that the illustration for

the article “H1N1 Surveillance

in Michigan” on

page 38 of the

fall/winter 2009

issue of Findings

represented Michigan

without

including

the Upper

Peninsula.

Recent

Awards

The 2009 spring/summer

and fall/winter issues of

Findings received Gold

Addy awards in the 2010

Ann Arbor Ad Club Addy

competition, sponsored by

the American Advertising

Federation. The spring/

summer (“Food for the 21st

Century”) issue also received

the competition’s Best of

Show award. In addition,

the fall/winter issue received

a Silver Addy Award in the

district-level competition,

which encompasses Michigan,

Indiana, and Illinois.

We love hearing from you!

Send your letters to Findings,

University of Michigan

School of Public Health,

1415 Washington Heights,

Ann Arbor, MI 48109-2029;

fax 734.763.5455; e-mail

sph.findings@umich.edu;

or post online comments.

Letters may be edited for

length and clarity. Please

include an address and

daytime phone number.

F I N D I N G S W W W . S P H . U M I C H . E D U S P R I N G / S U M M E R 2 0 1 0


O N T H E H E I G H T S

5

The Michigan BioTrust 6

Reactions to Health Care Reform 7

The Resilience of Children 8

From the Archives 8

When I Grow Up 9

Haitian Earthquake Relief 10

A World of Experience 1 1

Soccer Magic 12

U.S. Senator Debbie Stabenow

(D-Michigan) visited the School of

Public Health on April 5 to talk about

the health reform bill that President

Obama signed into law in March.

She noted that two provisions in the

bill—value-based insurance design and

a nationwide network of depression

centers—stemmed directly from University

of Michigan research initiatives.

She also noted that the bill benefits

young Americans, in part by extending

the Children’s Health Insurance

Program and by immediately stopping

insurance companies from denying

children coverage because of preexisting

conditions.

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H

Peter Smith


O N T H E H E I G H T S

SPH DIGEST

> Avatars aren’t

just on the

screen these

days—

they’re

in public

health.

Second-year

MPH student

Honor Potvin and a team of UM School of

Information students have designed a robot

avatar named mibo (from “my robot”)

that appears on a user’s mobile phone and

uses GPS and accelerometer technologies

to track walking activity and to show

progress on weekly walking goals. Potvin

and her colleagues made it into the final

round of the Computer Human Interaction

2010 Student Design Competition with

their paper “mibo: A Mobile Application to

Encourage Walking.” They presented their

application to a panel of judges at the premier

international conference in the field

of human-computer interaction in Atlanta,

Georgia, in April. •

> Technology was also

the focus of Sex:Tech, a

conference in February in

San Francisco examining

the interplay between

sexual education and

technology among youth

in the U.S.

At the conference,

SPH students Emily Pingel,

Michelle Marie Johns, and Anna Eisenberg

received the ISIS Award for Young

Researchers in recognition of their work

with Research Assistant Professor Jose

Bauermeister’s SexLab project at SPH.

Through their work with young men who

have sex with men, conference organizers

said, the SPH students had dispelled

negative stereotypes about men’s behaviors

online and instead shown how the Internet

is shaping young men’s sexual identities,

sexuality, and sexual maturation. •

Your Blood, Your Kids’ Blood,

and the Michigan BioTrust

Under Michigan’s Mandatory Newborn

Screening Program, a blood sample is

taken from every infant born in the state

and tested for 49 genetic disorders. Completed

test samples are stripped of identification

and stored in a temperature-controlled facility

managed by Wayne State University’s Biobanking

Center of Excellence. Health officials

estimate that in its 25

years of existence, the

screening program has

prevented disabilities

and saved the lives

of more than 4,000

Michigan babies.

Now the Michigan

Department of

Community Health

(MDCH) is moving

ahead with plans to

make the leftover

dried blood samples

more readily available

to scientists for medical

and public health

research through an

initiative called the

Michigan BioTrust for

Health—an initiative

that SPH epidemiologist

Sharon Kardia

says she is “cautiously”

helping to develop.

Kardia, who directs

the SPH Public

Health Genetics Program and co-directs

the UM Life Sciences and Society Program,

says the BioTrust represents “a wonderful

research resource. But I want to be sure it’s

not used inappropriately. Right now, for

example, it’s not clear what the limits on

research will be, or whether there are strong

enough safeguards to keep data from being

turned over to the criminal justice system.”

“I want the governance

of the BioTrust

to reflect the values

of our communities—

not just scientists

and ethicists.”

To help ensure that the citizens of

Michigan are fully aware “that their

blood or their kids’ blood” is in the

BioTrust, Kardia and her colleagues in

the Life Sciences and Society Program

have secured a challenge grant that’s enabling

them to develop an informational

website and hold town meetings in each

of Michigan’s five

geographic areas.

They’re funneling

information from

both initiatives to

MDCH and Michigan

legislators.

Kardia notes

that while every

state in the country

collects newborn

blood samples,

only Michigan is

trying to make the

residual samples

widely available for

research. The potential

health benefits

are enormous,

but so are the potential

“unintended

consequences,”

she says.

“I have enormous

respect

for the BioTrust

initiative, but if

it isn’t going to benefit and protect the

citizens of Michigan, then we are in effect

gambling with the public’s trust in the

name of science,” Kardia says. “I want

Michigan’s citizens to be informed, and

I want the governance of the BioTrust to

reflect the values of our communities—

not just scientists and ethicists.” <

Brian Stauffer c/o theispot.com

continued on p.8

F I N D I N G S W W W . S P H . U M I C H . E D U S P R I N G / S U M M E R 2 0 1 0


In March, President Obama signed

legislation to overhaul the nation’s health care

system and provide medical insurance to an

estimated 30 million Americans who currently lack

coverage. UM SPH faculty and extended community

members had these reactions:

For more SPH reactions to the health reform bill, visit www.sph.umich.edu/findings/.

The ramifications of health reform for environmental

health will be as great as they are for any other aspect of

public health and medicine. Removing barriers to

seek advice, evaluation and management

of occupational and environmental disease

risks will improve lives while enabling our economy

and industries to recover in a sustainable way.

Howard Hu, NSF International Chair of Environmental Health

Sciences; Professor of Environmental Health Sciences, Epidemiology,

and Internal Medicine

Rarely do we get a

chance to see our place in

historical time, to be part

of a movement that will

so clearly affect millions,

and to witness the collective

power of people

dedicated to raising the

bar for human equity.

It was a proud day to be

an American celebrating

the most fundamental of

public health values.

Sharon Kardia, Chair, Epidemiology;

Director, Public Health Genetics and

Life Sciences and Society programs

Little appreciated is that

the developers of Medicare

and Medicaid saw those

programs as desirable

primarily because they would be a ‘foot in the door’ of

national health insurance covering all Americans. Some

45 years and eight administrations later, the door has

been shoved open. This is an occasion for public health

celebration.

Kenneth E. Warner, Dean

The bill is a

starting point and

a foundation. There will

be a lot more to unfold over the next

several years—but now is time for

celebration and hope that we will

finally achieve universal access to

care for all Americans.

Marianne Udow-Phillips, MHSA ’78

Director, Center for Healthcare

Research and Transformation

So glad to see the U.S. is moving forward in health care reform. As we devote efforts in

public health to prevention as well as the management of chronic disease, it is wonderful

to know the bill allows people with pre-existing conditions greater possibilities for

affordable insurance. Nancy Janz, Professor and Associate Chair, Health Behavior and Health Education;

Associate Director, Center for Managing Chronic Disease

The passage of this legislation

represents the culmination

of decades of work by

public health professionals

and progressive government

officials. Like the mythical Sisyphus,

who was condemned eternally to repeat the

task of rolling a boulder up a steep hill, only

to have it roll back down before he reached

the summit, health care advocates have

been thwarted, time after time, in their quest

to achieve universal health coverage for the

U.S. On March 21, 2010, President Obama,

the Democratic Party, and the millions of

Americans who have fought courageously

for health reform got that boulder over the

top of the hill, and now the American people

are going to enjoy the benefits of reaching

the other side.

Richard Lichtenstein, Associate Professor; Director, Summer

Enrichment Program in Health Management and Policy

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H

From a public health perspective, we should celebrate that an estimated 32 million

more Americans will have health insurance coverage as a result of this legislation.

However, we know that simply having health insurance does not

ensure access to quality clinical services in a timely manner.

We also know that health insurance reform is not the same thing as ‘health reform,’

because medical care is only one of the many things that creates healthy individuals

in healthy communities. As such, we need to celebrate this historic expansion of

health insurance coverage, and to use it as a catalyst towards additional reforms that

are needed to realize actual improvements in population health.

Paula Lantz, Chair and S.J. Axelrod Collegiate Professor of Health Management and Policy

It is terrific that we have embarked on this journey, despite severe opposition

and misinformation. However, there is a long road ahead. We have

to contain our health care costs and change our

spending with more emphasis on preventive

services. We also need good data series to monitor and analyze our

health care expenditures. Federal agencies such as the Agency for Healthcare

Research and Quality and the National Center for Health Statistics should be

asked to develop national data collection series to allow for dissection of our

spending, and the corresponding benefits, to make informed policy decisions.

Trivellore Raghunathan, Chair and Professor, Biostatistics


8

F I N D I N G S

SPH DIGEST

continued from p.6

> Michael Boehnke spoke about

diabetes and his efforts to identify its

genetic underpinnings during a February

lecture celebrating his Distinguished

University Professorship—the highest

academic title UM confers. Earlier in the

year, the American Association for the

Advancement of Science named Boehnke,

the Richard G. Cornell Distinguished

University Professor of Biostatistics,

to its newest class of fellows. •

> For their role in helping to establish UM as

a world-renowned research center in the

area of microelectromechanical systems

and integrated microsystems, Ted Zellers,

professor of environmental health sciences,

and a team of College of

Engineering collaborators

have received the

Ted Kennedy Family

Team Excellence

Award. Zellers and

his colleagues have

focused on two testbed

microsystems.

The first is a family of

implantable neural prostheses for disorders

such as deafness, paralysis, epilepsy,

and Parkinson’s disease. The second is a

wristwatch-size environmental monitor

capable of gauging pressure, temperature,

humidity, radiation level, and air quality. •

> On yet another tech note, Vic Strecher

has been named the UM Distinguished

University Innovator for 2010. Strecher, a

professor of health behavior and health

education at SPH and a successful entrepreneur,

has conducted

breakthrough research

leading to a fundamental

shift in how

technology is adapted

to support preventative

health behaviors. An

expert in “tailoring,” he uses digital technologies

to assess specific health needs and

then creates tailor-made plans that help

people make better decisions and improve

health-related behaviors. •

continued on p. 10

The Resilience of Children

Kids aren’t the first thing most people

think of when they hear the words

“hospice care,” but in fact, says Ed

Goldman, an adjunct faculty member in

health management and policy at SPH,

southeastern Michigan’s Arbor Hospice

serves ten pediatric patients a

day and provides grief counseling to

more than 200 children a year.

Goldman, who serves on the

organization’s governing board (together

with board chair and SPH

alumna Pat Warner, MPH ’77), calls

hospice a vital part of the “whole

continuum” of health care and says

the key challenge of pediatric hospice

care is figuring out “how best to help

people come to grips with something

that no one should have to come to grips

with.” Whether it’s end-of-life care for a dying

child or counseling for a grief-stricken

“Kids are

smarter

than

we give

them

credit for.”

sibling or parent, hospice workers and volunteers—including

nurses, social workers,

spiritual advisors, and grief counselors—

must find the right approach for each family.

Time and again, Goldman’s work with

Arbor Hospice has shown him how

resilient human beings are—especially

children, both those who are

receiving care and those who are

grieving for loved ones. “Kids are

smarter than we give them credit

for,” he says. “It’s amazing how they

can cope with terrible tragedy, how

interested they are in getting accurate

information, and not saying,

‘I don’t want to know, don’t tell me.’

And how sophisticated they are at

taking the information and understanding

what it means.”

For more on Arbor Hospice, visit www.

arborhospice.org. <

f r o m t h e a r c h i v e s

When Pearl Kendrick and Grace Eldering began collecting b. pertussis specimens in 1928, they came face to face

with the bleak realities of whooping cough. “We collected specimens by the light of kerosene lamps, from

whooping, vomiting, strangling children,” Eldering would remember. “We saw what the disease could do.”

What the disease did was kill. In the late 1920s, pertussis, or whooping cough, claimed an average of 6,000 lives

a year in the U.S., nearly all of them children under five. Although scientists had identified the causative organism

of pertussis in 1906, there was as yet no effective, readily available vaccine to prevent the disease.

In the late 1920s,

pertussis, or

whooping cough,

claimed an average

of 6,000 lives

a year in the U.S.

Kendrick, a Grand Rapids–born bacteriologist who served as chief of the Western Michigan Branch Laboratory of

the Michigan Department of Health, set out to find one. She enlisted the help of Eldering, a fellow bacteriologist, and

together the two women developed a program of research, performed lab experiments, conducted field tests, and

ultimately succeeded in growing pertussis in sheep’s blood.

In 1934, they began inoculating children in a vast and complex clinical trial in Grand Rapids. That Kendrick could

assemble the people and money needed for such a trial in the midst of the Great Depression is a testament to her character,

as is her determination to know whether her vaccine truly worked. Kendrick not only welcomed scrutiny, she courted it.

In the end, the vaccine did work, and in 1940 the state of Michigan began producing and distributing it, all but

ending the scourge of whooping cough deaths. Kendrick and Eldering later combined shots for diphtheria,

whooping cough, and tetanus into the single DPT shot children routinely receive today.

Following her retirement from the Michigan Department of Public Health in 1951, Kendrick joined the faculty of

the Department of Epidemiology at UM, where she remained until her second retirement in 1960. She died in 1980.

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O N T H E H E I G H T S

9

2

2. First Black Woman

Supreme Court Justice

I’ve always had a passion for human rights.

In school I was the playground defense

attorney—I was always looking out for the

underdog.

4. Schoolteacher

and Librarian

I did, in fact, get my

teaching certificate and

started on a master’s in

library science.

4

1

1. Doctor, Lawyer, Professor

As I now look back on three decades at SPH,

I realize that public health and our school have

enabled me to combine all of these earlier desires

and interests in a wonderfully harmonious way.

3

3. Veterinarian

When I learned about dissecting cats and frogs,

that was the end of my vet dreams. I turned to

math, where the numbers are “clean.”

13

When I Grow Up

Sometimes there’s a clear path between

what we dream of being as children and

what we become as adults. And sometimes,

as these revelations from members of

the SPH community suggest, there’s

little rhyme or reason to the trajectory.

(Not sure who’s who? See the key below.)

5

5. Tree-hugger

My activist days came and

went when I realized I could

have a greater effect as a

teacher and a researcher.

6

6. Veterinarian

I really wanted to talk to the

animals, like Dr. Doolittle.

13. Professional Baseball Player

I wanted to play center field for the New York Mets.

Oh well, it would have been fun.

12. Anything

but Math

Imagine my surprise

when I found out I liked

math when I took biostatistics.

I guess I’m a

case study in keeping

an open mind—or in

stubborn personalities.

12

7

7. Oceanographer

Although I didn’t become an

oceanographer, I take what

small steps I can to help

preserve our environment—

I’m an avid recycler, I use my

own grocery bags at the

store, and I drive a hybrid.

8

11

11. Wife

and Mother

Growing up in North

Dakota, I expected to be

a wife and mother like my

mother and every female

neighbor and relative I

encountered. But through

school and books, I learned

to love science and

decided to go to medical

school. In the end, I

became a scientist and a

wife and mother.

10

10. Rancher

Still hoping to do it.

8. Marine Biologist

Having grown up near the Pacific

Ocean, I thought for sure that I’d be a

marine biologist or conservationist.

9

9. Doctor

I found out later I

was a pretty allergic

kid, as was my

sister. I now work on

food allergies in

schools and on

asthma in China.

1. Toby Citrin Adjunct Professor, Department of Health Management and Policy; Director, Center for Public Health and Community Genomics; Co-Director, UM Life Sciences and Society Program 2. Tesenga Sha’ Duncan Smith

Diversity Officer 3. Cathie Spino Research Associate Professor of Biostatistics 4. David Hunsche Academic Technology Coordinator 5. Nil Basu Assistant Professor, Department of Environmental Health Sciences

6. Susan Morrel-Samuels Managing Director, Prevention Research Center of Michigan 7. Shelagh Saenz Career Service Coordinator 8. Dana Dolinoy Assistant Professor, Department of Environmental Health Sciences

9. Harvey Leo Assistant Research Scientist, Center for Managing Chronic Disease 10. Melissa Valerio Assistant Professor, Health Behavior and Health Education 11. Janet Gilsdorf Professor of Epidemiology; Professor

of Pediatrics and Communicable Diseases 12. Laura Rozek Assistant Professor, Department of Environmental Health Sciences 13. Marc Zimmerman Professor and Chair, Health Behavior and Health Education


10

F I N D I N G S

SPH DIGEST

Peter Smith

continued from p.8

> As co-chairs of the Health Behavior and

Health Education Student Association, SPH

students Benita Sinnarajah and Sarah

Tersegno helped coordinate the association’s

two-week Winter Warmth Drive, during

which HBHE faculty, staff, and students

donated enough coats, scarves, sweaters,

hats, and gloves to fill a pickup truck. On

a frigid December night, Sinnarajah and

Tersegno took the donated clothes to a

group of homeless men and women living on

Ann Arbor’s south side at a site called Camp

Take Notice. The camp is a grass-roots tent

community whose mission is to create a safe,

sober, drug-free environment where members

of Ann Arbor’s homeless population can

receive not

only food

and shelter

but also

“a genuine

sense of

community,”

says Caleb

Poirier, a

resident of

the camp.

People like

Sinnarajah

and Tersegno, he adds, play a vital role in

building relationships “between homeless

and home-full people.” For more information

visit http://tentcitymichigan.org/.•

> As the first-ever SPH Michigan Apprentice,

health behavior and health education

student Doug Roehler won an all-expensepaid

job-shadowing opportunity with SPH

alumnus Grant Baldwin, director of the

Division of Unintentional Injury Prevention

at the National Center for Injury Prevention

and Control in Atlanta. Baldwin’s office is

dedicated to reducing the number and

severity of unintentional injuries through

science-based programs and applied

research. Roehler was chosen by the UM

Alumni Association and the SPH Career

Services Offices. This marked the first

year the Alumni Association extended its

apprentice program to graduate-level

students at SPH. •

B y t h e N u m b e r s :

Haitian Earthquake Relief

In the aftermath of the catastrophic earthquake that struck Haiti on January 12, members

of the UM and SPH community sprang into action. Here’s a glance at their work:

8,378

Unique visits to UM’s Haiti blog, www.umhaitirelief.org, since the blog launched

on January 22. The blog includes at least 25 events through which UM students,

faculty, and staff have raised over $12,000 towards Haitian relief.

Dollars collected at SPH during a lunchtime drive conducted by Public Health

$1,201

Students of African Descent and the Public Health Student Assembly:

All proceeds went to Partners in Health, which has worked in Haiti for 20 years.

816 Bottles of hand sanitizer sent to Haiti in January from Allison Aiello,

the John G. Searle Assistant Professor of Epidemiology, who studies the

efficacy of hand sanitizers.

138 People who registered for a free online

“Coping with Disasters” course through the SPH

Office of Public Health Practice between January 12

and April 30.

100

Boxes of food & clothing collected through the

UM campus-wide program “Let’s Do It for Haiti!”

60

UM students, staff, and faculty who

formed “Tet Ansamn Ak Ayiti” (United

with Haiti), a volunteer group dedicated to partnering with

agencies in Haiti to rebuild the country’s infrastructure and

respond to immediate needs. SPH Research Associate

Armando Matiz Reyes facilitates the group.

Minutes after which student and graduate nurses at the Faculté des Sciences

30

Infirmières d’Leogane (FSIL) began providing emergency care to people

in Leogane, near the quake’s epicenter. SPH alumna Rosemarie Rowney is

president of the Haiti Nursing Foundation, which supports FSIL.

16 UM medical students who traveled to World Medical Relief’s

Detroit headquarters in February to help organize two large cargo

shipments of donated medical supplies for Haiti.

UM Health System employees

deployed to Haiti in February.

10

Further south: UM students, staff, and faculty are working with

Armando Matiz Reyes, SPH research associate and director

of the school’s Field Experience Office, and the Universidad

Católica de Chile in Santiago to collect food, medicine, and winter

clothing for victims of the February 27 earthquake in Chile.

UMHS registered nurse Keenan

Stonebraker with two Haitian

patients on the U.S. Navy

hospital ship Comfort.

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O N T H E H E I G H T S

11

Questions for Stephannie Moore

A World of Experience

The staff coordinator of the SPH Global Health Program talks about kids in need, life overseas,

and the orphanage she helped found in Tibetan China.

What drew you to Tibetan China?

I’ve studied and translated Tibetan for about a decade. In 2005 I

went to an extremely poor part of Tibetan China known to Tibetans

as Golog to study with Buddhist scholars as part of a cultural

preservation initiative. In Golog I met a Tibetan named Dockpo,

who wanted to start a home for orphaned girls, but he had no idea

how to do such a thing.

So you got involved. How?

First I worked out a budget. Then I began massive fundraising and

helped Dockpo convert an unfinished building he’d used as a

medical clinic into girls’ dorms. Then we drove around from village

to village and found about 30 girls whom we’d heard were abandoned

or came from families who couldn’t support

them. In one family, the mother and father both had

cancer and no money for treatment, and six children to

support. Every girl’s story was like this. It was just

heartbreaking.

Why so many orphans in the area?

Maternal mortality is a huge reason. The rates in Tibetan communities

are out of this world. A friend of mine who runs a woman’s

health NGO in Tibet often says, “The rates wouldn’t be worse if the

women were giving birth on hot coals.”

How did the girls adapt to life in the orphanage?

We raised enough money so they could all go to school and have

private instruction, even some Buddhist training, which girls

usually don’t have access to. They learned traditional arts like

dancing and painting. They loved going to school. With better

nutrition, the weaker ones gained weight and began looking healthy

and vibrant. It was obvious the girls were thriving.

You left China in 2006. What happened to the orphanage?

It still exists, and it’s doing great. They have a fair number of Chinese

donors, and they’ve gotten a grant from Sony to build a library.

In one family, the mother and

father both had cancer and no

money for treatment, and six

children to support. Every girl’s

story was like this.

In your job with the SPH Office of Academic Affairs, you

oversee several student programs, including global health.

Your own experience abroad must play a role in your work.

The part I’m most passionate about is helping students prepare for

that global experience, which, best-case scenario, can be incredibly

enriching and life-changing. There’s a level of humility and flexibility

that often doesn’t develop until you force yourself to be in a

situation that’s really different, even uncomfortable, particularly in

places that are really poor. It forces you to look outside your limited

culture and self-interest. < Photos courtesy of the Sengcham Drukmo Girls Home, except as noted.

Stephannie Moore


12

F I N D I N G S

M a g

i c

o f

a

S o c c e r

B a

T h e

l

l

The simple act of kicking a soccer ball—a pleasure most kids take for

granted—can be a rare gift for a child with special needs. Ask Scott White,

whose daughter, Lauren, has “just blossomed” in the four years she’s

been involved with TOPSoccer, a nationwide program that gives disabled

children the chance to play soccer at levels consistent with their skills. In Ann

Arbor, where Lauren plays, the program serves more than 25 special-needs

kids and their families.

White says TOPSoccer is both a welcome source of physical activity for his

daughter, who has Williams syndrome, a genetic condition similar to Down’s

syndrome, and an important social outlet. The Ann Arbor program offers 15

sessions a year, during which Lauren gets to work closely with college and

high-school athletes and coaches to learn basic soccer skills. “She looks forward

to seeing the other kids there, and to seeing the volunteers and coaches,” her

dad says. “She’s gotten to know a lot of them on a first-name basis.”

A collaborative effort by UM, the Ann Arbor Public Schools, and Ann

Arbor’s Rec & Ed program, TOPSoccer “is a model for how universities can

work with communities,” says Siobán Harlow, a professor of epidemiology

at SPH, who’s been a volunteer coordinator for the program for the past two

years. “It’s a few people putting in a little bit of effort, and it makes a huge

difference.” Harlow, whose sons both play soccer, sees her work with the

program as part of her contribution to the university and “to the linkage

between the university and the town.”

Steve Burns, head coach of the UM men’s soccer team and a driving force

behind the program, notes that TOPSoccer benefits not only kids like Lauren

but also the high-school and college athletes who volunteer for the project.

“It’s easy for players to lose perspective,” Burns says. “A program like this

reminds them of how their work resonates with the larger community.” <

Soccer photos by Peter Smith

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T H E H E A L T H O F O U R C H I L D R E N 13

T H E H E A L T H O F

O U R C H I L D R E N

They come in multiple heights, widths, hues, and shapes.

They live in deserts and on mountains, inside brick

houses and cardboard shacks, near rivers and airports

and factories and swamps. Their names are Chris, Naida,

Ethan, Ranjit, Li Mei, Jennifer, Pilar, Tanisha. They arrive

on earth programmed to play, eat, weep, laugh, and grow.

Some do these things more readily than others, and

some cannot do them at all. Most harbor hopes, fears,

questions, appetites, fantasies, dreams, and desires we

cannot begin to fathom. Each is a complex machine,

miraculous in its ability to accommodate a world where

love and compassion are often in short supply, and

basic needs too frequently go unmet. They are our

precious resource and grave responsibility—a measure,

as Dietrich Bonhoeffer said, of our moral worth as a

society—and in their stories we are reminded of the

children we all were once upon a time.

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


14

F I N D I N G S

Pathways of

Enlightenment

For schools to work, James Comer believes they must

address all of a child’s developmental needs.

by Leslie Stainton

Ken Orvidas c/o theispot.com

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P A T H W A Y S O F E N L I G H T E N M E N T

15

T H E H E A L T H O F

O U R C H I L D R E N

t’s 9:30 in the morning at

I

Davis Street 21st Century

Magnet School in New

Haven, Connecticut, and

Gail DeBlasio is starting

her sixth-graders’ morning.

She gathers the class in a circle and talks

to them quietly about what’s on the day’s

agenda. Then she asks kids to share. Five students

every day. They know who they are and

when their day is, and they know the rules.

You have to talk about yourself—not about

something you saw on TV or read in a book.

Each kid talks for a couple of minutes. Then

it’s time to address problems and concerns.

Family issues, playground spats, disagreements

with friends—it’s all fodder for discussion.

By 10 o’clock the students are ready to

begin learning.

Kids do better when their minds are

cleared, DeBlasio says.

Down the hall, Waltrina Kirkland-

Mullins begins her third-graders’ day by asking

what’s up. Their language skills may not be as

advanced as DeBlasio’s sixth-graders, but they

know the drill. One day last fall a girl said she

was being teased. The class talked it over, and

the boy who was doing the teasing apologized,

and the two patched things up.

Children aren’t statistics, says Kirkland-

Mullins. They’re human beings “who have

feelings, who need to be nurtured, who need

to be met where they are developmentally.”

DeBlasio and Kirkland-Mullins are

rarities in the American school system. They

teach in a school where the focus is not just

on cognitive learning but on the overall

development of children—a “Comer school.”

The term is shorthand for a research-based,

comprehensive K-12 education-reform

program pioneered by Yale child psychiatrist

James P. Comer. Since its introduction in 1968

in two low-achieving schools in New Haven,

Comer’s program has been implemented

in more than 20 states and the District of

Columbia as well as overseas.

Step into a school like Davis Street, and

you feel the difference. Kids walk peacefully

through the halls. Teachers are affectionate.

Peter Smith

There are signs on the walls reminding everyone

to respect one another. And it’s not just

window dressing—the good feelings generated

inside Davis Street, as in other Comer

schools, translate into higher-than-average

scores on standardized tests.

DeBlasio thinks her kids perform better

because they aren’t afraid of failure. “They

know they’re going to be built up by the rest

of the class and not be humiliated.” That’s

how the Comer process works. Years after

they leave Davis Street, students tell DeBlasio

and Kirkland-Mullins how much they miss

the school and how grateful they are for what

it gave them.

Of the man behind the Comer process,

Kirkland-Mullins says quietly, “I’m blessed to

have known him in his lifetime.”

Seventy-five years old, dapper and compact,

James P. Comer, MD, MPH ’64,

has a way of smiling that lights up his whole

face. It’s easy to imagine children warming to

him. He is courteous and soft-spoken, a gentle

man in every sense of the word. In an era of

T-shirts and casual Fridays, he wears neatly

pressed suits and ties, and he insists on holding

the door open for others.

Although he’s reached an age when he

could be spending his time traveling or

listening to jazz or visiting with his grandchildren,

most days Comer goes to work. He’s the

Maurice Falk Professor of Child Psychiatry at

Yale University, and from his book-lined

office on the second floor of the Yale Child

Study Center he oversees the dissemination

and implementation of the school-reform

program he’s spent a lifetime refining.

It’s a big operation. Besides the many

staff members who work directly on the

program at Yale, nearly a dozen schools and

school districts across the country currently

use Comer’s School Development Program

(SDP), as it’s officially known. Comer and

his staff also collaborate with universities,

state departments of education, and regional

training centers.

Perhaps the best way to understand SDP

is to think of it as a multifaceted intervention

aimed at preventing the social, physical, and

psychological problems that can arise when

The way kids

develop as social

beings has everything

to do with how

they perform in

school. This is a

lesson that Comer

first learned from

his mother and

father.

children don’t get the right start in life. Where

traditional school programs focus primarily

on cognitive development, SDP guides children

along six connected developmental

pathways: physical, psychological, social,

ethical, linguistic, and cognitive (see sidebar,

page 19). The program is especially well

suited to low-income kids in urban schools,

but it also works in rural and suburban

settings. Its core principles are collaboration,

consensus, team-building, and no-fault

problem-solving.

The program’s underlying assumption is

that the way kids develop as social beings—

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


16

F I N D I N G S

The family’s

income may have

been low, but

expectations were

high. Between

them, James and

his four brothers

and sisters would

earn 13 advanced

degrees.

Comer during medical school

at Howard University in 1959.

how they deal with personal problems and

interact with others—has everything to do

with how they perform in school. This is a

lesson Comer first learned 70 years ago from

his mother and father.

He has written at length about both

parents—most memorably his mother,

whose story is the subject of Comer’s 1988

book, Maggie’s American Dream, a work

Henry Louis Gates Jr. says “has helped

hundreds, perhaps thousands, of students

understand the sacrifices and motivations

of an earlier generation, the importance of

education, and the crucial role played by

family and community in achieving that

education.” Born into a family of Mississippi

sharecroppers, Maggie Comer finished just

two years of formal schooling and made her

living as a domestic in East Chicago, Indiana.

She believed education was the key to a better

life, and she passed that insight on to her

children—as did her husband, a steelworker

and descendant of slaves who had fewer than

eight years of schooling himself.

The family’s income may have been low,

but expectations were high. Between them,

James and his four brothers and sisters would

earn 13 advanced degrees.

“We were poor but we weren’t really that

poor,” Comer says today. “We had a very rich

home and church and community experience.”

Hugh and Maggie Comer took their kids to

museums and the zoo. They encouraged spirited

conversations around the dinner table.

Such things made a difference, Comer

saw. Boyhood friends who were just as bright

as he was, who played in the same East Chicago

neighborhoods and attended the same

schools, later succumbed to depression, drugs,

and crime. Why did they sink while he thrived?

And what could he do to help prevent other

young men and women from going downhill?

His first instinct was to become a doctor,

but while getting his MD from Howard

University in 1960, Comer came to realize he

was more of a “social-problem person” than

a physician. One of his teachers at Howard,

Paul Cornely, a three-time graduate of the

University of Michigan (AB ’28, MD ’31,

DPH ’34), with a doctorate from the School

of Public Health, pointed out to him that

public health and prevention had done more

to improve human health than “the entire

medical profession. I think I resented that

remark as a soon-to-be-physician,” Comer

has written, “but I remembered his claim.”

Keen to know more, he enrolled in

Cornely’s alma mater. “In a way,” Comer

admits, “going to Michigan was buying time,

but it was also a way to learn about prevention.”

He and his wife and infant son arrived

in Ann Arbor in August 1963, two days before

Martin Luther King’s march on Washington.

Comer listened to King’s “I Have a Dream”

speech on the radio while unpacking boxes.

“You tell ’em, Martin!” he cheered. The

following spring Lyndon Johnson gave the

commencement address at Michigan. The

new president called on Comer and his fellow

graduates to use their skills and knowledge to

help build a “great society” for all Americans,

and Comer was riveted.

“I had already decided I needed to know

more about people,” he remembers. But it

was Johnson’s charge to “do something”

that really fired him up. A year later Comer

embarked on a residency program in psychiatry

at Yale Medical School, and in 1968 he

joined the faculty of the Yale Child Study

Center. His task: To spearhead a new initiative

bridging child psychiatry and education.

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P A T H W A Y S O F E N L I G H T E N M E N T 17

During his year at Michigan, Comer had

learned valuable organizational and management

skills. He’d studied epidemiology and

environmental ecology and become fascinated

by the parallels between these and what

he called “human ecology, the study of how

policies and institutions interact with families

and children.” He’d written a term paper in

which he argued that schools were the only

organizations strategically positioned to help

all children grow—and to compensate for the

difficult conditions that too often interfere

with their growth.

Schools, in other words, were vital to the

public’s health. It was a melding of his disparate

interests and the first major step toward

what would become his life’s work. To this

day, Comer says he thinks of himself not as an

educator but as “a public health physician—

a child psychiatrist who practices prevention.”

t Yale, Comer and his colleagues

at the Child Study Center were

A asked to develop a strategy for

turning around two of New

Haven’s most troubled elementary schools,

Simeon Baldwin and Martin Luther King Jr.

The two schools were predominantly African-

American and low-income and had the worst

attendance records and standardized-test

scores in the city. At Baldwin, Comer found

playgrounds strewn with glass and kids

running wild in the halls. One teacher

grabbed him by the arm and cried, “Help me!

Help me!” King was only slightly better.

“We had to overcome deep-seated distrust

and limited relationship skills among

all involved,” Comer recalls. Slowly, painstakingly,

he and his colleagues worked with

faculty, staff, parents, social workers, and

psychologists from the two schools to map

out a holistic process of educational reform

that could address the schools’ problems.

They called their initiative the School

Development Program. Central to the program

were relationships—among teachers

and children, parents and teachers, staff and

community, kids and their peers. “When

relationships improve in the schools,” Comer

would write, “the children themselves

become the carriers of desirable values.”

In effect, SDP sought to replicate the

close-knit support system Comer had enjoyed

as a boy growing up in East Chicago.

“This is Comer’s great achievement,”

Henry Louis Gates Jr. has said. “To realize

that the public school is just another aspect

of child development and that the learning

process is infinitely more complex than

amassing a body of facts outside of this selfreinforcing

network of nurture, psychological

support, concern, care, affection,

ego gratification, and mentorship. Schools

are an extension of the family structure.”

Paul Bass/New Haven Independent

Through SDP, Baldwin and King each

set up a governance and management

team headed by the school principal and

composed of teachers, staff, and parents.

Each school instituted a mental-health team,

a parents’ program, teaching programs, and

a curriculum based not just on cognitive

learning but on the six interlinked pathways

of childhood development.

President Johnson’s 1964 commencement address

calling on graduates to help build a “great society”

riveted Comer.

Schools, in other

words, were vital to

the public’s health.

It was a melding

of his disparate

interests and the

first major step

toward what

would become

his life’s work.

The good feelings generated inside Davis Street

Magnet School often translate into higher-thanaverage

scores on standardized tests.

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


18

F I N D I N G S

Things began to change. One day at

the start of the fourth year of the program,

someone stepped on the foot of a transfer

student at King, and the student put up his

fists to fight. A classmate intervened.

“Hey man,” he said, “we don’t do that in

this school.”

Five years into the project, as part of a

neighborhood rehabilitation effort, the school

district closed a much-improved Baldwin,

Scores of schools

and school districts

have proven that

SDP works, and

Comer is determined

to push for its widespread

adoption.

“I feel like I have the

cure for cancer,”

he says.

and a similar low-income, low-achieving

school, Katherine Brennan, took its place in

the program. By 1978, attendance at both

Brennan and King had risen, serious behavior

problems had all but vanished, and reading

and math scores on standardized achievement

tests were soaring. Follow-up studies would

show that three years after the Yale team

left the schools, kids who’d attended either

Brennan or King were two years ahead of

their peers in language arts and more than

a year ahead in math.

It was the breakthrough Comer had

dreamt about as a young man. In the next

decades, he and his colleagues would hone

their methodology and, with funding from

the Rockefeller Foundation and other

sources, disseminate SDP to hundreds of

schools and school districts at home and

abroad. Time and again, their preventionbased

program changed lives and boosted

academic performance.

Comer himself began publishing books

(nine by 2005) and contributing a monthly

column to Parents magazine. He became

a consultant to the Children’s Television

Network, producer of Sesame Street.

Honorary degrees and awards piled up,

among them the UM SPH Alumni Society’s

John H. Romani Award. President Bill

Clinton reportedly considered Comer for

Secretary of Education.

Peter Smith

Paul Bass/New Haven Independent

Gail DeBlasio and students at Davis Street School.

In 2002, a team of researchers from the

University of Wisconsin–Madison conducted

a meta-analysis of the 29 most widely used

comprehensive school-reform programs in

the U.S. The researchers found that of the 29,

only three programs could be expected to

improve students’ test scores. One of those

was SDP.

Today Comer is working to persuade

federal and state policymakers to implement

SDP in schools and school districts throughout

the U.S. Doing so, he knows, will require

changes in the way teachers are trained,

changes in the way schools of education

are run, and changes in the way beginning

teachers are supervised—but scores of

schools and school districts have proven that

SDP works, and Comer is determined to

push for its widespread adoption.

“I feel like I have the cure for cancer,”

he says.

A life-long football fan, he insists he’d

rather have time run out on him on the two

yard line than on the 50. “You never know

where the miracle is going to come from.”

ack at the Davis Street Magnet

School in New Haven, Gail

B DeBlasio is talking to her

students about how the Comer

process has helped them this year. Hands

waggle in the air.

“I’ve seen more behavior, less calling out,”

a girl volunteers.

A classmate chimes in. “I was on the out a

lot this year, because I used to be getting into

a lot of trouble, but then when I learned the

Comer pathways I kind of changed a little.”

Pressed to explain how he’s changed, the

boy says, “I learned to think before I act.”

DeBlasio reminds her students that

what they’re doing is an important part of

learning to be good friends and responsible

citizens. As the discussion winds down,

she gently steers the children back to their

desks, and they plunge into a quiet session of

reading. Later that afternoon, she’ll post their

most recent standardized test scores on an

overhead projector. Once again, her kids have

matched—and in some cases exceeded—

statewide averages, and DeBlasio wants them

to be proud.

What amazes her is that every school in

America isn’t a Comer school. If it were, she

believes, the country would be a different and

much better place. “At some point,” she says,

“we have to break the mold.” <

F I N D I N G S W W W . S P H . U M I C H . E D U S P R I N G / S U M M E R 2 0 1 0


P A T H W A Y S O F E N L I G H T E N M E N T

19

Nurturing the Child

One of the first things kids in a Comer school learn is to

cultivate the six developmental pathways—social, psychological,

physical, ethical, cognitive, and language. Even

young kids get it, says Mary Patterson, who teaches first

and second grades at South Lexington School in Lexington,

North Carolina, a Comer school since 2002. When students

in Patterson’s class misbehave, she talks to them about

which pathways they’re neglecting and need to start using.

“Usually they take that pretty well,” she says.

Students at South Lexington keep records of how they’re

doing on each of the pathways. They’re given cards to help

them track how much they’ve walked in a day, and they’re

encouraged to eat a balanced breakfast and lunch. Both

are important parts of the physical pathway. Through the

“ Are they getting

enough sleep

at night? Have

they eaten

breakfast?”

language pathway, the

students learn to express

themselves in complete

sentences and to be

good listeners. Through

the social pathway they

learn how to establish

and maintain friendships

and to be courteous citizens. The psychological pathway

helps them understand their emotions and develop

self-confidence, and the ethical pathway stresses the

difference between right and wrong and suggests ways

of dealing with the consequences of wrong choices. The

cognitive pathway emphasizes not only academic learning

but also critical thinking and problem-solving.

“When we first heard it, it was like, this makes complete

sense,” says South Lexington teacher Sue Vivacqua Grubb.

Especially at South Lexington, where a majority of students

are low-income, and “you have to think of so many things

other than can they add two plus two. Are they getting

enough sleep at night? Have they eaten breakfast? You’re

not going to get your best out of anybody if all of their

needs aren’t met.” <

Comer’s Career

at a Glance

1964 – Graduates from UM SPH

with an MPH

1967 – Joins the faculty at the Yale Center

for the Child

1968 – Embarks on a

school-reform initiative

in New Haven that will

become known as the

School Development

Program (SDP)

1972 – Publishes

Beyond Black and White

1978 – Begins writing a monthly column

for Parents magazine

1980 – Publishes School Power:

Implications of an Intervention Project

1988 – Publishes Maggie’s American

Dream: The Life and Times of a Black Family

1992 – Is said to be on the short list for

U.S. Secretary of Education

25

1993 – Bill Cosby

speaks at the

25th anniversary

celebration of SDP

1997 – Publishes

Waiting for a Miracle:

Why Schools Can’t

Solve Our Problems,

and How We Can

1998 – Hillary Clinton speaks at the 30th

anniversary celebration of SDP

2004 – Publishes Leave No Child Behind:

Preparing Today’s Youth for Tomorrow’s World

2009 – Receives the John H. Romani

Award from UM SPH

W James Comer discusses his work at www.

youtube.com/comersdp.

For more on the Comer School Development

Program visit http://medicine.yale.edu/

childstudy/comer.

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


20 F I N D I N G S

T H E H E A L T H O F

O U R C H I L D R E N

Voices in

the Night

For young transgender runaways in Detroit,

sex buys both survival and despair.

By Laura Bailey

F I N D I N G S W W W . S P H . U M I C H . E D U S P R I N G / S U M M E R 2 0 1 0


V O I C E S I N T H E N I G H T 21

In a quadrant of Detroit

near Six Mile and

Woodward, which is known for

gay prostitution, one crumbling, filthy

motel in particular houses a number of

transgender sex workers, most of them in

their teens and early 20s. They have one

thing in common: They all use the Ruth

Ellis Center in nearby Highland Park for

some type of refuge. For some, it’s their

only refuge.

The Ruth Ellis Center is the only center

in the Midwest dedicated to serving the

physical and mental health needs of lesbian,

gay, bisexual, transgender, and questioning

(LGBTQ) youth (see sidebar, page 25).

The sex workers at the motel near Six

Mile and Woodward have, in some ways,

disappeared from the rolls, having fallen

through every safety net for runaway youth.

Not all are homeless now, but many are or

are “couch surfing,” which is just one locked

door away from homeless. Others live and

work right at the hotel as prostitutes.

While this quadrant of Detroit may seem

like a small corner of the city—a place where

most of us will never venture—these runaways

represent a significant public health

challenge. Nationwide, some 1.7 million

people experience at least one night of

homelessness every year. Of those, an

estimated 40 percent are LGBTQ. This

often-overlooked population, says Ruth

Ellis Center Director and SPH alumna

Laura Hughes, MPH ‘04, is “very much at

the intersection of race, gender, poverty,

and sex.” Homeless youth who identify as

LGBTQ have little access to health care

and health-related resources, including

prevention services. “Where do they go to

get primary care or to prevent sexually

transmitted diseases?” Hughes asks.

Many of the kids who work at the motel

were born with male genitals, but they

identify as women (and are therefore

referred to as women throughout this

article). When these transgender youth

finally get the nerve to come out as transgender

and dress as women (a double

whammy), employers and even foster care

providers often force them to head straight

back into the closet by making them dress

and act as men. They feel that the only way

left for them to earn money, while at the

same time staying true to their own female

identity, is prostitution. Also, for some of

these women, it’s the first time they’ve ever

felt attractive to a member of the opposite

sex. Ever.

Cars drive in past a Plexiglas money

booth which sells items for criminally high

markups—for example, condoms at $1.25

each. The narrow drive opens into a courtyard/parking

lot with the motel rooms

facing into the courtyard. At night the

prostitutes stand in the lighted windows

trying to lure clients.

Around 3:30 p.m., a client arrives, a

professional-looking man looking out of

place in a crew sweater and thick, sideparted

silver hair. He heads toward a room

at the end of the courtyard, where he’s

greeted by one of the girls. Another worker

spies him and comes out of her room to

compete for him. This is a violation of

etiquette, says April Summers, a street

outreach worker for the Ruth Ellis Center.

For some of

these women,

it’s the first time

they’ve ever felt

attractive to

a member of the

opposite sex. Ever.

Summers keeps an eye on as many of

the girls as she can. She routinely visits,

bringing food, condoms, safe-sex kits—

anything that will help make their very

lonely, dangerous existence more livable.

Below are profiles of five gay black

males who identify as women. Those who

can afford it take female hormones, and all

dress full-time as women. They all use the

motel as a home base for prostitution.

All of them hate the life, and all of them

feel helpless and trapped into staying.

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22

F I N D I N G S

Kelly At 27, Kelly, of

Detroit, says she had a solid

family and church upbringing.

“I got started (prostituting)

late,” she says. “Growing up I

did kid things. I had a mother

and father who loved me

dearly.” She kept a 3.2 grade

point, sang in choir, played

three sports.

“I’m very intelligent,” she says matterof-factly.

In the beginning, prostitution was

fun: Money, parties, men liking her for the

first time, being surrounded by others like

her. But “the life I thought I wanted to be a

part of has now become a way of life.” And

she hates it.

Says Kelly: “I lost a lot.” She’s hoping

to save for an apartment because

“stability is key.”

Like all the girls, her earliest memories

are of questions and confusion, denial and

rejection. Why do I feel like a girl when I

have boy genitals? Am I the only one like

this? Why do I want soft skin, feminine

clothes?

“I knew I

wanted to

be a girl,

but being raised in

the church, I tried

to make myself

believe that things

would change.”

“I knew I felt different,” says Kelly,

who at 6’2” isn’t “passable” like some of

the others, though her face is soft and

feminine. Like all the girls, she lights up at

any compliment about her womanhood or

femininity.

“I knew I wanted to be a girl, but

being raised in the church, I tried to make

myself believe that things would change.”

Things did change—they got worse.

As a boy, she was effeminate and

teased constantly. “I wanted to be a

cheerleader but they didn’t have a place

for me.” Her dad forced her to play high

school football, and she became a coach.

Miserable, she graduated from

Detroit’s McKinley High School and

attended college in South Dakota, as a

man, on a football and cheerleading

scholarship. Word got out she was

sleeping with her male teammates and all

hell broke loose, so she transferred to a

university in Chicago.

There her eyes opened: Transvestites

and drag queens paraded openly, and she

tried it. Dressing and acting as a woman

was a liberation.

“Finally how I acted, my feelings and

emotions and how I carried myself,

matched up with how I felt,” she recalls,

her face shining. “I kinda went stone

cold crazy.”

Now revulsion has replaced the thrill,

but she believes it’s the only employment

open to her.

She starts her shift at 6 or 7 p.m., and

her quota is $200 a night. Kelly glances at

the window; the slice of sky visible from

the room has started to dim. It’s almost

time to go to work. The manager comes

and orders the shades down—he says he

doesn’t want anyone driving through to

know what happens in the rooms.

Donna “I hate it. I hate it.

I want to be a girl but I hate

prostituting,” says Donna, 22,

of Detroit, who’s been at the

motel for two months. Her voice

is the kind of hopelessness for

which there’s no response.

Donna’s situation is particularly difficult

because she dropped out of high school,

so even if she weren’t dressing as a woman

it would be impossible to find employment

without a diploma, she says.

“I have to find someone who will accept

me for who I am and give me a job,” she says.

“I was an effeminate gay boy and had plenty

of jobs, but as soon as you put the hair and

the makeup on it’s like … the only place that

will hire someone like that is a hair salon, and

not everyone can work there.”

Donna came out at 15. Her dad was

hostile, and despite her mother’s support,

Donna ran away at 16 and started dressing

as a woman. Without a job or money, she

began stealing. She bounced between Flint

and Detroit, then settled permanently in

Detroit. At some point she began making

money by placing ads for sex on the Internet

or in the Metro Times and dressing as a

woman full-time.

“It started like that,” she says of the

ads. “And then everybody knows about Six

Mile and Woodward”—the quadrant known

for gay prostitution.

“At the beginning of the month you can

make up to $800 (a night) but then it slows

down,” as the pay checks dry up, Donna

says. But it’s dangerous work, and her

stress and anxiety make her appear eggshell

frail. “I worry every day about my

health. I actually have clients try to pay me

not to use a condom.”

The rooms in the hotel are horrible,

Donna says. None of the girls can have

company unless it’s a client, the heat hardly

works, the rooms are filthy and don’t have

mirrors.

During the day Donna wakes around

10 a.m. and leaves the motel until 8 p.m. or

so, when she starts working again.

“I’ll be here the rest of the night, or

walking around,” she says. On a decent

night she might be up all night, seeing five

to ten clients. “You work until you can’t

take it or you feel like you’ve made

enough,” she says.

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V O I C E S I N T H E N I G H T

23

Kim Everything about Kim,

19, is quiet and reserved and

controlled. She’s petite and

feminine. It’s obvious she’s

been “moaning”—taking

hormones either from a doctor

or purchased on the street—

for a while.

Kim was born and raised in Detroit and

has been on her own since about age 13,

when she “really became flamboyant.”

Like the rest, she didn’t have much

choice. Neither her stepfather nor her real

father—who had just gotten out of prison—

could handle her sexuality, so she left home.

She says she met some folks from Saginaw

on the Internet through a chat room aimed

at gay blacks. They drove to get her, and

she stayed at one of their homes for a while,

learning about the gay life.

After a couple months she returned to

Detroit and put herself back in school.

“Education is key,” says Kim firmly. She

says she’s in school during the day and

works at night.

“When I wake up I have to be ready

to hit the streets to make enough money to

survive,” she says. Clients can be anyone—

married, professional, white, black, male,

female—but there’s one constant: When

any of the girls picks up a client, there’s the

constant terror of how that client will react

when they find out she has male genitals,

Kim says. Even though this part of Detroit

is known for gay sex, you cannot assume

clients know that under the female hair and

makeup is male anatomy. Kim says she is

feminine and petite enough to be able to

undress in front of a man without him

knowing. “I get in and I get out.”

“It’s all about the money,” says Kim.

“Our main focus is to get the money.”

Kim doesn’t live at the motel but rents

a place outside Detroit. She says she can

make a few thousand a week. Some of her

family knows, and some don’t. When she

was about 17, Kim started to reunite with

her family. She wound up in the hospital

one night, and her mom turned up at her

side, seeing her for the first time as a girl,

Kim chuckles.

“My mother told me no one would ever

love you like your mother.” Kim told her

mother she didn’t want to go back “out

there” to prostituting, and her mother

invited her home. It lasted two months

before the fighting with her mother got so

bad Kim left again. They love each other,

but can’t live together.

“I went straight to Woodward and

got me some deals and got me a room,”

she recalls. You develop a sixth sense, but

not armor. Once she got into a car, and a

man crawled out from the back seat,

clocked her in the head, and robbed her of

at least $600, plus a new purse. “It’s not

my type of life,” Kim says. “I was raised in a

nice home, in a nice environment.”

Her rent is $650 a month, plus the $45

she has to give the motel per night, which

comes to about $900 a month on top of

the $650. Her car is broken, so she takes a

cab to the motel. She hopes to become an

accountant one day.

Neither her

stepfather

nor her real

father—

who had just gotten out

of prison—could

handle her sexuality,

so she left home.

Steve Read

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


24

F I N D I N G S

© Brooklyn Production/CORBI

“A man

pulled

up on me

and said

‘I’ve got

$60,

what’s

your

name?’”

She gave him the

first female name

that came to her.

Karyn Karyn, 21, hasn’t

seen her extended family since

she began her life as a girl

four years ago. She came out at

14 and stayed at home, though

the situation wasn’t great. “My

mother didn’t put me out, but

she never let me go anywhere,”

she says.

Karyn spent time at Palmer Park,

which was like a “little gay park,” she

recalls. She moved out at 18 and met and

befriended an older transgender girl.

Karyn says she was staying at a Motel Six

on 14 and John R when the woman insisted

on doing her hair and makeup.

When they’d finished, Karyn looked in

the mirror and felt as if she’d finally come

home. “I felt like a different person. I

thought, what am I supposed to do now?

Where can I go, what can I say?”

Where they went was out on the strip

to pick up clients, but Karyn had no idea

what she was in for. The girl gave her a few

quick instructions, then left.

“A man pulled up on me and said ‘I’ve

got $60, what’s your name?’” She gave him

the first female name that came to her. “I

got in. I kind of knew that I was going to be

OK. Now when I think about it, it’s scary,”

Karyn says. “I’ve been out of town and

everything.” In fact, Karyn is planning to

leave soon for a few weeks to make enough

money to save for an apartment. Traveling

to other cities is a good way to make money

fast, if you know someone with a car, Karyn

says. “You go where they haven’t seen you,

and you are the new face.”

Unlike many of the girls, she has a

great relationship with her mother, and

they talk daily. Rarely do any of the girls

mention fathers, including Karyn.

Her dream? Social work, some kind of

mentoring. Like all of them, her dream is

anything but this. Yet Karyn hasn’t

graduated from high school either, and it

seems that prostituting is a sure way to

make money in the foreseeable future.

She desperately wants to avoid “oldtimer”

status. “I don’t want to be one of the

girls who the younger girls come to ask,

‘Where do I go to make the most money?’”

F I N D I N G S W W W . S P H . U M I C H . E D U S P R I N G / S U M M E R 2 0 1 0


Jeremy Whiting

V O I C E S I N T H E N I G H T

25

Danielle

“I think

there’s something about us in a

dress—they just say, ‘I don’t

want that in my house,’” says

Danielle, 25, whose mother

caught her sneaking into the

house in girls’ clothes one

night in 2002. Danielle left

the next day and moved to

Southfield with her best friend

and another woman, who took

Danielle under her wing.

Danielle quit her job as a

janitor and started prostituting.

She didn’t speak to her

mother for two years.

“I was so surprised,” says Danielle, who

assumed her mother would understand,

because Danielle was already so feminine.

“I’d wanted to be a girl since I was in third

grade.” She is very feminine and pays for

hormones.

Danielle was still in high school when

she started prostituting.

“I was so scared, I would try to basically

follow what the other girls were doing but

once you get approached, it’s up to you.

You go with your instincts. Then after so

long you learn the ropes.”

She too hates the life. “When I first

started coming out, I didn’t go home with

less than $300. They didn’t tell me it wasn’t

going to last. I don’t want to be a prostitute

for the rest of my life,” says Danielle, who

says she once attended what is now the

College for Creative Studies. “Eventually I

want to have my own fashion company—

that and do makeup. I love to do makeup.”

She reconnected with her family when a

sibling called and invited Danielle to a

holiday dinner, and she went. She and her

mother chatted as if nothing had happened.

That’s how it happens sometimes, love

overrules pride and disappointment.

She doesn’t like it. “It’s always a

possibility I’ll end up in jail,” Danielle says.

“I didn’t even want to tell her, but I’ve seen

so much bad stuff happen to girls where

they couldn’t even identify the body. If

anything were to happen to me, I don’t

want her to be surprised.” <

Comment on this article at

www.sph.umich.edu/findings/.

A Refuge from

the Streets

Laura Hughes, MPH ’04, executive director of the Ruth Ellis Center, says she knows you

can teach safe-sex interventions all day long, but if a kid is broke and starving, they

won’t wear a condom if it means they’ll earn more money without one.

Sometimes it takes working in the trenches to understand the gulf between health

and behavior theory and gritty reality, says Hughes,

who took the executive director position in August

2009. In some ways the job couldn’t be further from

where she thought she’d end up. In other ways, it is

the essence of public health and defines why she

entered the field.

Ruth Ellis is the only center in the Midwest

dedicated to serving the lesbian, gay, bisexual,

transgender, and questioning (LGBTQ) youth

population. Named for the late Ruth Ellis—a Detroit

resident who opened her home as a safe space for the

city’s gay African-American community—the center

runs three programs: Street outreach and a drop-in

center for kids 14–24, and two residential programs.

Sometimes it

takes working

in the trenches

to understand

the gulf

between health

and behavior

theory and

gritty reality.

Nationally, 40 percent of the nation’s runaway or homeless youth identify as LGBTQ,

and the center estimates that 800 homeless LGBTQ youth are struggling to survive in

Detroit daily.

Anecdotally, about half the kids served at Ruth Ellis are HIV-positive, and 97

percent are black, hailing mainly from Detroit, Highland Park, or surrounding areas.

Hughes and her staff provide AIDS-awareness and HIV-prevention programs and help

HIV-positive kids get treatment and navigate the health system. Hughes says it’s a

powerful experience “working with our youth, meeting them where they are at and

working to improve their health outcomes.”

Her job is not an easy one, and it’s made tougher by program cuts. The need is

overwhelming—11,000 requests for assistance in 2008 on a $900,000 budget. Despite

strong support from several large donors in the community, the center must raise

$300,000 annually for the drop-in program alone—the lifeblood of the center. Drop-in

provides meals, computers, recreation space, counseling, clothing (including interview

suits), small housewares, showers, safe-sex kits, and other necessities. The goal is for

kids to make contact with staff through drop-in, and then transition off the streets and

into a residential facility or program, with Ruth Ellis or a referred program that staffers

know understands LGBTQ issues.

Hughes counts her experience at SPH among the best in her life, and keeps close

contact with her graduating class. The difference now is that her academic-heavy world

view has veered toward the pragmatic. “If you don’t have a place to stay,” she says, “it’s

going to have an impact on the decisions you make, and no health behavior theory is

going to change that.”

For more on the Ruth Ellis Center visit www.ruthelliscenter.com/index.htm.

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


26

F I N D I N G S

Our Children, Our Future

by Sally Pobojewski

2

Prenatal Lead Exposure

Mexico City, Mexico

3

Toxic Metals

Mexico City, Mexico

6

5

Childhood Vaccines

EURO region

Maternal Mortality

Ghana and Haiti

8

7

Brain Tumors

Casablanca and Rabat, Morocco

9

Adolescents and Risk

Warsaw, Poland

Breast Cancer

Gharbiah Province, Egypt

16

14 Polio

Northern India

Asthma

Beijing and Tianjin, China

17 Measles

Tianjin, China

1 Preterm Birth

Mexico City, Mexico

4 Nutrition

Bogotá, Colombia

10

Lead and Malaria

Nigeria

15 Lead

Chennai, India

1. Preterm birth rates are rising worldwide and many

scientists suspect that air pollution is one of the causes. With

funding from the U.S. National Institute for Environmental

Health Sciences, SPH investigator Marie O’Neill and colleagues

are studying 1,000 pregnant women in Mexico City to learn

whether inflammatory responses to air pollution can affect

the outcome of pregnancy.

12

HIV and AIDS

Western Cape, South Africa

11 Malaria

Blantyre, Malawi

13

Air Pollution

Durban, South Africa

T H E H E A L T H O F

O U R C H I L D R E N

2. It’s well known that exposure to lead is dangerous for young children, but less

is known about the long-lasting effects of fetal lead exposure on older children and

adolescents. In a pilot study of 200 mothers and children, SPH researchers Karen

Peterson, Dana Dolinoy, and Brisa Sanchez want to learn whether women with high

lead levels during pregnancy are more likely to have children who are overweight or

whose physical maturation lags behind their peers.

Pb

82

207.2

3. SPH environmental health scientist Howard Hu and

colleagues at Harvard University and the National Institute of

Public Health in Mexico are continuing a 17-year-long study to

determine how fetal exposure to toxic metals, especially lead, affects a child’s future

health, behavior, and ability to learn. The investigators want to understand how

individual differences in gene activity, diet, and lifestyle make some children more

susceptible than others to the effects—like aggression, ADHD, and learning disorders—

of toxic metal exposure.

According to the World Health Organization, more than 10 million

children under the age of five die every year. All children are susceptible to the

effects of poor nutrition, environmental pollution, injuries, and natural disasters—but most of the world’s

most vulnerable citizens die from illnesses that can easily be prevented or treated. To learn why so

many children fall victim to these and other debilitating conditions, and to find ways of preventing

further suffering and death, researchers in the School of Public Health are working around the globe.

W Visit www.sph.umich.edu/findings/ for more information about these and other

UM SPH research projects.

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O U R C H I L D R E N A, ROT UI CR L FE U TI UT RL E27E 27

4. Inadequate nutrition is a growing public health threat with long-lasting

consequences for children in developed and developing countries. In ongoing

research with thousands of Colombian schoolchildren, SPH investigators

Eduardo Villamor and Ana Baylin are studying how a poor

diet makes children more susceptible to disease and affects their

growth and development.

5. In some

African countries, women have a one in

18 lifetime risk of dying during pregnancy.

Pregnant women in Haiti have the highest

mortality rates in the western hemisphere.

SPH researcher Frank Anderson is working

with universities and the Ministries of

Health in Ghana and Haiti to improve the

odds of surviving pregnancy and childbirth

by helping physicians in local communities

and hospitals learn how to identify and

treat emergency obstetric conditions.

6. In a study for the World Health Organization’s EURO region, SPH policy expert

Gary Freed and colleagues surveyed immunization program managers in 53 member

states in Europe, Eastern Europe and the former Soviet Union to determine how the decision

to approve a new childhood vaccine was made and factors that influenced these

decisions—especially for hepatitis B and haemophilus influenza, type b (Hib) vaccines.

7. Part of growing up is learning how to manage serious risks associated with

drinking, drugs, sex and violence. SPH faculty member Marc Zimmerman studies

protective factors in families, schools and communities that help teenagers avoid

bad outcomes from risky behavior. In a three-year study of middle school students,

Zimmerman and his colleagues found that parental support is a major factor

shielding teens from risk in Poland, just as it is in the U.S. Determining which factors

are most important will help countries develop effective programs to support

adolescents in their transition to adulthood.

8. In one of the first epidemiology studies of

pediatric brain tumors to be conducted in Africa, SPH

epidemiologist Amr Soliman, MPH student Leana May,

and colleagues from Morocco reviewed medical records

of 542 children diagnosed with primary brain tumors

from 2003 through 2007 at hospitals and clinics in the

two largest cities in Morocco. Medulloblastoma was

the most common type of tumor documented in the

study, with brain tumors in general being slightly more

common in boys than in girls.

9. Can childhood exposure to chemicals found in plastics—like BPA and

phthalates—alter normal gene activity and increase the risk for breast cancer

later in life? To find the answer, SPH faculty members Dana Dolinoy, Laura

Rozek, Maureen Sartor, and Amr Soliman are studying girls in Gharbiah,

Egypt, where breast cancer is three to four times more common in urban

women than in rural women.

10. Children in Nigerian cities have the highest rates of malaria and

lead poisoning in Africa. In a recent study, SPH investigator Jerome Nriagu

found an intriguing association between high blood levels of lead and fewer

bouts of malaria in Nigerian children. Researchers know that children with sickle cell

disease are less likely to get malaria. Could lead’s damaging effects on red blood cells

somehow be protecting these children against malaria parasites as well?

11. Malaria kills at least one million people

every year–the vast majority of them in Africa

and primarily children under age five.

In their survey of Malawi households,

SPH epidemiologists Mark Wilson

and Don Mathanga found that using insecticidetreated

bed nets reduced by 50 percent episodes of malaria in young children. They also

found that children in households with the lowest incomes were least likely to use bed

nets and most likely to have anemia and malaria parasites in their blood. The researchers

affirmed that providing free nets to poor families could help reduce the epidemic of

childhood malaria in Africa. In Malawi, all mothers who attend antenatal clinics now

receive free bed nets, along with instructions for their use.

12. In 2005, 11.2 percent of sexually active 15–24-year-olds in the Western

Cape province of South Africa tested positive for HIV, the virus that causes AIDS. To

understand what motivates young people to seek HIV testing, SPH researcher Rachel

Snow and colleagues examined data from the Cape Area Panel Study. They learned

that women were far more likely than men to be tested for HIV, especially if they

have been pregnant. To slow the spread of the HIV virus in South Africa, the study

concludes it is important to increase rates of HIV testing in young men and young

women who have never been pregnant.

13. Since 2001, SPH environmental health scientists

Tom Robins and Stuart Batterman with partners at the

University of KwaZulu-Natal have conducted extensive

research with South African schoolchildren to study

the effects of ambient air pollution. Early research in

Durban—one of South Africa’s most industrialized and

polluted cities—found that children living in highly industrialized parts of the city were

more likely to have decreased lung function and asthma. Currently, the researchers are

starting a new study of Durban children with specific genetic variations that increase

their sensitivity to air pollution.

14. Vaccines have eradicated polio in most parts

of the world, but not in parts of northern India where

more than 733 new cases were diagnosed in 2009.

In a study to inform the World Health Organization,

SPH epidemiologist Jim Koopman is modeling the

dynamics of transmission in this part of India to

learn why current vaccination programs aimed at

children under age five have failed to stop the spread

of disease. His conclusion: Transmission is so high in

this region that in order to stop polio from spreading,

some adults should be vaccinated.

15. Exposure to lead is a serious environmental

health problem in India, where

lead is commonly used in manufacturing

and was still added to gasoline until 2001.

SPH Professor Howard Hu and colleagues in

Chennai are studying elementary schoolchildren

to determine how lead exposure is

related to IQ, behavior, and brain development. This project is the first formal study of

the impact of lead toxicity on children to be conducted in India.

16. There’s no cure for

asthma—a chronic and potentially

life-threatening disease

that affects 300 million people

worldwide and often develops

during childhood. Health

behavior and health education

faculty Noreen Clark and Molly

Gong developed and tested the

Open Airways self-management

program to help children learn

how to avoid disease triggers

and prevent asthma attacks and hospitalizations. The Open Airways program has

been adapted for use in schools around the world—most recently in Beijing and

Tianjin, China.

17. Public health officials in China are worried about recent outbreaks of measles,

especially in major cities like Tianjin. More than 100,000 cases were diagnosed

nationally in 2008, many in children under one. Working with the Tianjin CDC, SPH

epidemiologist Matthew Boulton and colleagues hope to organize and direct largescale

case-control studies to identify segments of the Tianjin population most at risk

for infection. A successful control effort in Tianjin will help the national Chinese CDC

learn how to manage outbreaks of measles nationwide.

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28

Turning THE

Technology

Around

by Mary Beth Lewis

Smart

interventions

help kids

chat, text,

and game

their way to

better health

At the annual meeting of the American Public Health Association

last fall in Philadelphia, crowds gathered around hawkers

peddling the latest in “amazing” new inventions like:

> The “revolutionary” ActiFry® hot air cooker that repeatedly churned out a

pound of crisp French fries with just 2 tablespoons of oil (also great for granola)

> The “breakthrough” big beige LouseBuster TM scalp vacuum

> “Risk-minimizing” acrylic (rather than metal) tongue barbells, heralded

by the Association of Professional Piercers to prevent damage to teeth

Other intriguing tech-based innovations were discussed more quietly.

In backroom academic sessions, with minimal hardware hoopla, public

health presentations heralded technology that has been used for years—

and increasingly abused, some might say.

When was the last time you heard anything but complaints about kids

playing video games, texting, and spending time on Facebook or MySpace?

Adults are worried, understandably, about the links between violent video

games and aggressive behavior, the dangers of “sexting” (texting sexual

content), and privacy protection in the era of social networking. They’re also

concerned about physical inactivity due to kids’ obsession with electronic

media. According to a recent Kaiser Family Foundation report on juvenile use of

entertainment media, average screen time for kids now exceeds seven hours a day!

But the news is not all bad on the kid-tech front. Awareness is growing

about how adults can manage, and even take advantage of, electronic media

to ensure the well-being of the world’s first-ever generation of digital natives.

Kathryn Montgomery, a communication professor at American University and

author of the book Generation Digital, says being a kid today means never

having known a time without “constant connectivity.” This is a generation that

considers e-mail an archaic and slow form of communication, according to the

PBS Frontline report on “Growing Up Online.”

“Viral” has a new definition for effective health educators. Communicating

with kids increasingly means getting on their screens—literally, the little ones

they’re holding in their hands or on their laps. It’s happening already, and

University of Michigan faculty and staff are part of public health’s push toward

positive apps.

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T U R N I N G T H E T E C H N O L O G Y A R O U N D

29

T H E H E A L T H O F

O U R C H I L D R E N

HOPE

Alison Grodzinski was among the

information specialists at the 2009

APHA annual meeting presenting on

Web 2.0 interactive platforms in public health.

Twelve years as a health librarian has convinced

Grodzinski of interactive technology’s “enormous

potential to revolutionize ways in which public

health workers reach their target populations and

improve communication.” Who wouldn’t want to

use a collaborative platform that breaks down

geographic and logistic barriers, boosts communication

skills, and can be, for the sake of total

convenience, both “live” synchronous or “on your

own time” asynchronous?

At the UM School of Public Health, Grodzinski

is the communications coordinator on the core

project of the Prevention Research Center (PRC)

of Michigan for 2010 to 2014, which is using education

and online social networking to fight the

spread of sexually transmitted infections (STIs)

in a mid-Michigan area that has experienced

elevated rates of HIV and STIs, including a recent

syphilis outbreak. The idea is to keep teens and

young adults thinking and talking about safe sex

on their time and their networks, long after inperson

education sessions have passed.

More than 19 million new cases of STIs occur

each year, and almost half occur in teens and

young adults. In Flint, Michigan, the rates of STIs

for African-American residents aged 18–24 are

high, but testing rates need improvement. The

PRC wants to build a buzz around best practices

and prevention. Its CDC–funded project is officially

called “HOPE: HIV/STI Outreach and Prevention

Education.” The HOPE concept was developed

by YOUR Center, the lead community organization

for the project. The intervention will begin this

summer with face-to-face get-togethers focused

on healthy-sexuality education in two Michigan

counties, Saginaw and Genesee. Along with

refreshments, attendees at these parties will get

education in STI-prevention methods, condom

negotiation, and communication skills. They’ll

make plans to reduce their risk. The intervention in

Genesee County will add the social technology

component. Participants will be invited to utilize

blogs, sexual health podcasts, and social

networking sites on an ongoing basis, to expand

educational opportunities and enhance peer

mentoring. PRC researchers and their community

partners will analyze responses and outcomes

among the two groups.

Marc Zimmerman, chair of SPH’s Department

of Health Behavior and Health Education and

principal investigator on the HOPE project, says

the PRC partnership came up with this model for

positive health messages as a way to use “what’s

already out there.” With about three-quarters of

teenagers now using social media, “natural

networks are now online,” Zimmerman says.

Social media and online peer networking are

in focus elsewhere at UM as well. Some sample

projects:

>UM medical students working on the Social

Media Research Project are surveying what the

public—including potential patients—think of

physicians-in-training who turn up in unflattering

photos or questionable public contexts online.

Coordinator Anuja Jain says the goal is “to create

policies related to professionalism.”

>The UM Health Sciences Library recently went

into several Ann Arbor public schools to “teach

teachers” about online health resources, including

wikis and resource-sharing tools.

>The 2010 annual Depression on College Campuses

conference on central campus in March had a

session focusing on how technology and online

networks can support student mental health.

Meanwhile, the CDC has come aboard the

wave as more than a funder: It launched a new

website in early 2010 offering best practices for

online communication tools, stating, “The use of

social media tools is a powerful channel to reach

target audiences with strategic, effective and

user-centric health interventions.”

The idea is to keep

teens and young

adults thinking and

talking about safe

sex on their time

and their networks,

long after inperson

education

sessions have

passed.

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


30

F I N D I N G S

>HAITI 90999 $10.00

Dawning Day

4 Mobile Health

Social networking health interventions are

more promising in the U.S. than other

places in the world because the Internet is

so accessible in this country (about three-quarters

of American teenagers use online social networks

frequently). But there’s a downside to our networked

status: Many other countries skipped ahead of us

to build wireless infrastructures that allow great

flexibility in the communication of health information.

“The creativity and energy that goes into the

Internet here goes into mobile in other countries,”

said Paul Meyer of the technology firm Voxiva (a

Washington, D.C.–based consulting company that

provides interactive mobile health information

services). He was speaking at one of the many 2009

APHA sessions on mobile health, which is a catchall

term (along with mHealth) for any health-related

technology that involves cell phones or any wireless

data transmissions.

“The U.S. has to catch up to places like

Rwanda in mobile health,” Meyer said. And he

wasn’t just throwing out the name of a developing

country: Rwanda actually has a public-private

partnership which uses computers and mobile

phones in a national electronic reporting system

that eases delivery of public health care at the

village level. Similarly, programs addressing 1.2

million TB and HIV patients in Malawi and Uganda,

run on a shoestring by FrontlineSMS:Medic, are

showing that text messages and cheap mobile

phones can extend the reach of community health

workers (each installation of their open-source

network also requires a laptop and GSM modem).

FrontLineSMS:Medic also helped set up a

bandwidth-light text-messaging “distress line” in

Haiti in the days after the January 12 earthquake;

it received 18,000 requests for food, water, and

other forms of help in about a month. (And few

people could have missed hearing that the Red

Cross texting-based fundraising effort raised

more than $32 million in a month for Haiti.)

Imagine if American kids just the age to be

obsessed with texting were regularly managing

chronic conditions like diabetes by sending glucose

readings and photos of what they’re eating for

lunch to caseworkers in real time. Electronic

medical records could be managed wirelessly,

along with operational communications for other

population health issues. Attractive scenarios,

but there’s a problem in the U.S.: Our

mobile communication industry model

involves numerous carriers charging

independently for data transmission,

adding complexity for large-scale

health interventions.

One reason to be hopeful about

the future of mobile health in the

U.S. is the new Text4Baby® maternal

and infant health initiative. Sponsored

by numerous private and public partners,

the nationwide program could never have gotten

off the ground without “free messaging services

generously provided by participating wireless

service providers,” according to the website of

the sponsoring National Healthy Mothers, Healthy

Babies Coalition. Text4Baby® provides pregnant

women and new moms with broadcasts of up

to three text messages a week about nutrition,

immunization, prenatal care, mental health, car-seat

safety, breastfeeding, and more. Expectant parents

simply text the word BABY (or BEBE for Spanish)

to 511411 and enter their due date. Though not

personalized, the messages are timed to coordinate

with appropriate prenatal, postpartum, and infantcare

milestones through the child’s first birthday.

Closer to home, on a smaller scale but

with greater personalization, UM SPH alumna

Susan Woolford, MD, MPH ’06, is incorporating

tailored motivational text messages into her work

with overweight youth in the federally funded

MPOWERed Messages project. “It’s all about

healthy messages geared to keeping healthy

choices at the forefront of their minds,” she says.

As medical director of the UM Health System’s

Pediatric Comprehensive Weight Management

Center, Woolford has patients who live hours

away. Because she believes in the importance

of provider-patient communication related to

behavior change, she’s turned to electronic

messaging to extend contact, boost impact, and

bridge geographical distances. She ran a pilot

project last year to see if, in between visits, her

teen patients would be responsive to receiving

text-message reminders to help them keep on

track with healthy behaviors and goals. “A large

majority enjoyed participating,” she said. “I see it

as an adjunct to face-to-face work we do.”

Imagine if American kids were

regularly managing diabetes

by sending glucose readings

and photos of what they’re

eating to caseworkers.

As with the PRC’s social media project,

outcomes will be compared from equal-sized groups

that do and do not receive the text messages.

“Focus groups help us develop messages that are

salient to adolescents,” Woolford explained. She’s

working with the Ann Arbor–based Center for Health

Communications Research to refine participant

surveys of their food preferences and habits. Such

“tailoring” helps recipients feel that each message

was written just for them, even if it was generated by

a computer, Woolford believes.

Further down the line, Woolford would love to

start using Internet conferencing to communicate

with patients. “We need to interact frequently

with the young people we’re working with,” she

said. “Weight management is a chronic problem

for many adolescents. We need to do everything

we can for them.”

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T U R N I N G T H E T E C H N O L O G Y A R O U N D

31

Getting in the Game

In the gym affiliated with the UM Pediatric

Comprehensive Weight Management

Center is something Woolford calls

“spectacular.” Several sessions at the APHA

annual meeting were devoted to what this

spectacular innovation represents.

The trend is “exergames” that get young people

off their duffs and moving. Most popular is the

Wii Fitness suite of active video games, which are

inspired by sports as diverse as snowboarding and

tennis. Judging from the amount of enthusiasm kids

show playing Wii Fitness games, Woolford says she

wishes all her patients could afford to have their own.

“I love the goals part of the programs,” she says.

“Young people step up and enter their weight into

the system, and the Wii comes up with an avatar.

They see it and say, ‘That is not how I want to look.’

It can be very motivating.”

It can also be a lot of fun. Whether it’s Dance,

Dance Revolution, or the virtual reality workouts

catalogued in a lengthy Wikipedia entry on

“exergames,” it’s a trend that public health can’t

afford to ignore. Can there be a better way for kids to

spend their daily screen-time limits?

Actually, additional types of “Games for Health”

shared the bill at the January 2010 conference

of the same name in New York sponsored by the

Robert Wood Johnson Foundation and the Serious

Games Initiative. Dedicated to “advancing the

role of videogames in health and health care,”

the conference showcased antismoking games,

nutrition and healthy-eating programs, and even

games designed around “beating” particular juvenile

diseases like diabetes and other chronic conditions.

An Apps for Healthy Kids competition (part of

Michelle Obama’s Let’s Move! campaign to end

childhood obesity) challenges software developers,

game designers, and other innovators to develop fun

tools that drive children to eat better and be more

physically active. The USDA nutrition data set will be

the basis of the games.

An award-winning Warner Brothers–built

video game called Pamoja Mtaani is at the center

of a public-private partnership to fight HIV/AIDS

in Africa. With the support of the U.S. President’s

Emergency Plan for AIDS Relief (PEPFAR), this game

aims to really turn tables by empowering people with

the idea that HIV/AIDS can be the disease of their

Peter Smith

parents’ generation—assuming young people can

stop the spread with safe practices like delaying sex,

using condoms, getting tested, and more.

The Facebook page for the American Legacy

Foundation’s truth® campaign, along with providing

a fearless forum for people to rail out for and

against smoking, occasionally links to custom-made

video games like Addictor Click and Type or Die. It’s

a strategy that fits with the initiative’s mandate to

allow teens “to make their own informed choices

about tobacco use,” without preaching and judging.

Meanwhile the role of games in education

continues to grow. A New York City charter school

has been structured completely around educational

gaming. Inexpensive iPhone apps help you eat

healthier (fish and local food) and demystify the

human brain for fun and enlightenment. Scientific

American recently quoted astrophysicists at

prominent universities who were intrigued by the

way newly launched Mass Effect 2 incorporated the

concept of dark energy into the action of the game.

One role of video games is to stretch what we know

about science by using the imagination, they said,

heralding tremendous untapped potential in games

for incorporating cool science.

Perhaps this kind of attitude is what it’s

going to take to meet tomorrow’s adults—today’s

e-savvy digital natives—on their own playing field.

At the same time we’re selling them on lowercalorie

junk food, kinder body art, safer sex, and

games that challenge more than their eyes and

thumbs, we could probably learn a thing or two

from them about the positive potential of another

brave new world. <

Comment on this article at

www.sph.umich.edu/findings.

Learn More

Social Media & Health

> PBS Frontline’s “Growing Up Online: http://

www.pbs.org/wgbh/pages/frontline/kidsonline/

> Centers for Disease Control Best Practices for

Social Media: http://www.cdc.gov/SocialMedia/

> Health 2.0: http://www.health2con.com/

Mobile Health

> Text4Baby®: http://www.text4baby.org/about.

html

> FrontLineSMS:Medic: http://medic.frontlinesms.

com/

> MPOWERed Messages 2 (Center for Health

Communications Research Center): http://chcr.

umich.edu/projects_list

Video Games

> The Partnership for an HIV-free Generation’s

Pamoja Mtaani game: http://hivfreegeneration.

warnerbros.com/

> Robert Wood Johnson Foundation Games for

Health: http://www.gamesforhealth.org/

> Truth® and the American Legacy Foundation:

http://www.legacyforhealth.org/28.aspx

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


R E S E A R C H N E W S

T H E H E A L T H O F

O U R C H I L D R E N

The Whole Child

Last year in a speech at the University of Michigan, Marian Wright Edelman,

founder of the Children’s Defense Fund, called on the public health community

to invest in “the whole child, and not just our piece of a child.” Collectively,

School of Public Health researchers are doing just that. Through a vast body of work

aimed at making kids everywhere healthy, SPH faculty, students, staff, and alumni

are reducing—and in some cases eliminating—the dangers that threaten the

young, and helping to restore the magic and hope we associate with that strange,

miraculous, all-too-fleeting place called childhood.

P O L I C Y

M A T T E R S

What’s a Child’s Life Worth?

Recent research finds that when it comes to money allocated for

health care, most Americans prefer to distribute resources to

save life-years earlier in life rather than later. Daniel Eisenberg,

assistant professor of health management and policy, has been working

with faculty in the UM Department

of Pediatrics to understand

why—and what it means for our

health care system.

In a nationally representative

survey of over 2,000 participants,

Eisenberg and his colleagues asked

respondents to select an imaginary

government program that would

either save the lives of 100 ten-yearolds

or a randomly selected number

of 60-year-olds. Seventy percent of

the respondents chose the program

that would save 100 children—even

when the alternative program would

save up to 1,000 60-year-old adults.

This was the case both for respondents

who were parents of children

under 18 and for nonparent respondents over the age of 50, and for

all ethnic groups and socioeconomic backgrounds represented in the

survey. The preference for children also held when the researchers

asked people about programs to prevent nonfatal illnesses.

In other words, American adults, regardless of age, socioeconomics,

race and other demographics, largely preferred to prevent

both deaths and nonfatal illnesses among children as compared to

older adults. The findings, says Eisenberg, imply the existence of “age

weights.” That is, the survey respondents

seemed to place greater emphasis,

or weight, on quality-adjusted

life-years for children versus adults.

Seventy percent of the

respondents chose the

program that would

save 100 children—

even when the alternative

program would

save up to 1,000

60-year-old adults.

One of the respondents on the

survey commented, “Let us hope we

must never make decisions such as

these.” Yet while questions about the

allocation of health care resources by age are uncomfortable to

answer, Eisenberg notes, they are important for policymakers to

consider as they try to contain health care spending—especially in

a world where people are living longer lives. —Valentina Stackl <

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R E S E A R C H N E W S 33

Chemicals in Consumer Products Linked to Preterm Births

A study of expectant mothers suggests that a

group of common environmental contaminants

called phthalates, which are present in many

industrial and consumer

products—including

everyday personal care

items—may be contributing to an alarming rise in

premature births in the U.S. SPH researchers have

found that women who deliver prematurely have,

on average, up to three times the phthalate level in

their urine compared to women who carry to term.

Premature

birth accounts

for one-third

of infant deaths

in the U.S.

John Meeker, Rita Loch-Caruso, and

Howard Hu of the Department of Environmental

Health Sciences and collaborators from the National

Institute of Public Health in Mexico and the U.S.

Centers for Disease Control and Prevention

analyzed data from 60 women—30

who carried to term and 30 who

delivered prematurely (defined as fewer

than 37 weeks gestation). They

found significantly higher levels of

phthalate metabolites in the urine of

women who delivered prematurely.

Premature birth accounts for

one-third of infant deaths in the U.S., says Meeker,

making it the leading cause of neonatal mortality.

Being born too early can also lead to chronic

health problems such as blindness, deafness, cerebral

palsy, and low IQ. Since 1981, premature

births have increased by more than 30 percent

in the U.S.

Phthalates are commonly used compounds in

plastics, personal care products,

home furnishings, and many

other consumer and industrial

products. Past studies

show that several

phthalates cause

reproductive and

developmental toxicity

in animals. This is the

first known study to look at the

relationship between phthalates

and premature births.

—Laura Bailey <

Each Pound at Birth

Lowers TB Risk

Just one more pound may help a newborn avoid tuberculosis later in life. In a

new study, Eduardo Villamor, associate professor of environmental health

sciences and epidemiology at SPH, looked at how much protection additional

birth weight added against developing the disease years later and found that

every 1.1 pounds of birth weight decreases the risk of developing TB later by

46 percent among identical twins.

The association between birth weight and developing tuberculosis is

much stronger for males than females, says Villamor, who collaborated on the

study with colleagues

at the Karolinska

Institute in Sweden

and began the

research while at

Harvard.

The findings are

important because

TB infects about

one-third of the

planet’s population

and is second only to HIV in deaths caused by a single infection. Low birth

weight of babies is a larger problem in developing countries, but it occurs

everywhere, he says.

It’s too early to say if insufficient prenatal growth causes clinical

tuberculosis, but the findings suggest that may be the case. “Prenatal

exposure to environmental insults, including maternal malnutrition, could

program what happens later on in terms of our immune responses to

infection, possibly through programming of the immune system,”

Villamor says. “This study is an example of that.” —Laura Bailey <

Whether Too Little or Too Much,

Iron May Affect Cognition

Evidence suggests that children born to women who don’t get

enough iron during pregnancy suffer cognitive and behavioral

impairment in their early years and into adolescence.

Both animal and human studies indicate that at the age of one or

two, the offspring of iron-deficient mothers have problems with

memory formation, spatial coordination, and alertness, says SPH

Searle Assistant Professor Dana Dolinoy, who is trying to

understand the mechanism

behind the phenomenon.

Dolinoy is working with

human nutrition doctoral

student (and SPH alumna)

Olivia Anderson, MPH ’09, and

scientists in the UM Center for

Human Growth and Development

to see whether the cause is

epigenetic—that is, whether the

damage to cognition stems not directly from the DNA sequence

“but from the software that encodes our genome,” Dolinoy says.

The epigenome—the layer of molecules that sits on top of the

genome and, like a dimmer switch, regulates the degree to which

individual genes are turned on or off—is particularly vulnerable

during the early stages of pregnancy, she adds.

The offspring of mothers who get too much iron—rather

than too little—may also show epigenetic changes, and Dolinoy

and her colleagues are conducting additional research aimed at

finding out whether an iron-zinc interaction may be the culprit.

In the end, says Dolinoy, “it’s very much about balance: not too

much, not too little.” <

Jon Krause c/o theispot.com

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34

F I N D I N G S

Daniel Nevins c/o theispot.com

P O L I C Y

M A T T E R S

Moms, Kids, and Care

Are there enough public health workers

to provide the maternal and child health

care services Detroit residents need?

Thanks to a $300,000 grant from the

Kresge Foundation, the SPH Center of

Excellence in Public Health Workforce

Studies is about to find out. Over the

next two years, the center will survey

the city’s community-based organizations

to determine their contribution

to the delivery of maternal and child

health services in Detroit. The results

will characterize the composition of

this important segment of the public

health workforce, which plays a critical

role in ensuring that mothers and

children get such vital services

as pre- and postnatal care,

nutrition counseling, and

childhood immunizations.

Established in 2009 with

the aim of assessing public

health workforce capacity,

Michigan’s Center of Excellence

is one of only two such

centers in the nation. <

When Parents

Go to Jail

Eleven years ago, Shirley Cochran decided to

give Christmas presents to a group of children

in Flint whose mothers were in jail. That simple

gesture turned into a long-term commitment when

Cochran founded Motherly Intercession, a nonprofit,

community-based program whose mission is to

break the cycle of intergenerational incarceration

and help kids cope when a parent goes to jail.

Kids whose mothers

and fathers are

incarcerated are

emotionally at risk,

and their caregivers

are often burdened.

Today, Cochran and her staff not only

distribute holiday gifts, they provide after-school

tutoring in reading and math, monitor children’s

progress in school, support caregivers by providing

kids with transportation to tutoring sessions, serve

biweekly dinners, and facilitate bimonthly visits to

the Genesee County Jail. With input from Alison

Miller, a developmental psychologist and SPH

research professor, Cochran has recently started to

implement a new intervention, the Strengthening

Families Program (developed by Karol Kumpfer of

the University of Utah), which deepens family

bonds among kids, parents, and caregivers by

strengthening parenting, communication, and

problem-solving skills.

The needs are great, Miller says. Kids whose

mothers and fathers are incarcerated are emotionally

at risk, and their caregivers are often burdened

by the physical, emotional, and financial stresses

that come with extended—and often unexpected—

child care. Miller notes that many caregivers are

elderly, underresourced, and can be in frail health.

“What I like about this program is it’s very

focused on building a family bond first, before you

try to get in there and teach disciplinary strategies,”

she says. There are separate groups for caregivers

and children, but also joint sessions where

caregivers and children share meals and get to

practice what they’re learning. Additional sessions

focus on reintegrating parents into the family unit.

Currently 38 children, from preschool to high

school, are enrolled in the program, and there’s a

waiting list. The overall goal is to help young

children, in particular, “stay on track,” Miller says.

“This is a pretty critical transition period.” <

FactCheck: Children with Incarcerated Parents

> More than one in every 100 adults in the U.S. are in jail or prison

> On any given day, over 1.5 million children in the U.S. have a parent

serving a sentence in a state or federal prison

> Seventy-five percent of incarcerated women in the U.S. are mothers

> Sixty-three percent of federal prisoners and 55 percent of state prisoners

are parents of children under age 18

> Forty-six percent of all imprisoned parents lived with at least one of

their minor children prior to incarceration

> The average age of children with an incarcerated parent is eight years old

> African-American children are nine times more likely and Hispanic children

three times more likely than white children to have a parent in prison

These facts come from the Annie E. Casey Foundation.

For more information visit www.aecf.org.

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R E S E A R C H N E W S

35

Doing Battle with Bugs

Although epidemiologist Betsy Foxman doesn’t think of herself as a children’s health researcher,

“it works out that that’s where the action is,” she says. Foxman and her colleagues in the UM Center

for Molecular and Clinical Epidemiology of Infectious Diseases (MAC-EPID), which Foxman directs,

study the transmission, pathogenesis, evolution, and ecology of infectious disease—and as anyone

with a preschooler knows, children are prodigious carriers of bugs. So it’s hardly surprising that

Foxman’s center is currently engaged in four studies focused on kids’ health:

Ear Infections

Although otitis media, or ear

infection, is “not a killer, thank

goodness,” says SPH epidemiologist

Janet Gilsdorf, it’s nevertheless a

“huge problem.” By the time they

turn three years old, more than 80

percent of U.S. children have had at

least one episode of acute otitis

media, and 40 percent have had

three or more infections. Not only do

ear infections keep parents awake at

night, but nationwide the annual

cost of preventing, diagnosing, and

treating otitis media ranges from

three to five billion dollars.

Gilsdorf and her colleagues in

MAC-EPID are trying to identify otitis

media–related genetic components of

Haemophilus influenzae, a bacterium

that commonly causes ear infections.

Because these germs normally live

in the throat, where they cause no

disease, the researchers are working

to distinguish between the throat

and ear strains of the bacterium and

ultimately to identify potential vaccine

components that can target the

strains that cause ear infections.

Preterm Births

Preterm birth—defined as a birth

before 37 weeks’ gestation—and its

complications are the single greatest

cause of infant death in the U.S.

Researchers at MAC-EPID are

trying to find out whether the presence

of microbial “communities” in

the vaginal cavity and mouth can predict

a woman’s risk of giving birth to

a preterm baby. Independently, both

bacterial vaginosis and periodontal

disease have been linked to a twofold

increased risk of preterm birth, but

it’s not clear, says MAC-EPID director

Betsy Foxman, whether the cause

is direct or indirect. “It may be

indirectly due to systemic inflammation,

or because bacteria end up

in the bloodstream and then in the

uterus,” she says. “It’s unclear what

the mechanism is, but systemic

inflammation is a pretty common

hypothesis.”

In a collaborative study with

colleagues at Wayne State University,

researchers at MAC-EPID are

working to identify the genetic

sequences

of both

oral and

vaginal

microbial

communities.

By

sequencing all the microbes in these

communities, the scientists hope to

deepen their understanding of the

existing functional pathways and

how they may contribute to the risk

of preterm birth.

Dental Caries

By the time they enter kindergarten,

nearly half of all American kids

have dental caries. For a variety of

reasons—including diet, behavior, and

genetics as well as access to dental

care—Native American, African-American,

and Hispanic children in the U.S.

suffer disproportionately higher rates

of tooth decay than white children.

In the worst cases, dental caries

can lead to life-threatening infections.

Even mild cases of tooth decay can

lead to sleep deprivation, eating difficulties,

tooth loss, hearing problems,

and other chronic conditions.

In a collaborative study with the

University of Pittsburgh and West

Virginia University, Lixin Zhang,

Carl Marrs, Usha Srinivasan, and

Betsy Foxman are studying both the

transmission of cariogenic bacteria

in the mouth—with a focus on

transmission within families—and

the genetics of Strep mutans, a

significant cause of dental caries.

Working with migrant populations in

Appalachia, a region with extremely

high rates of dental caries among

kids, Zhang and his colleagues are

attempting to untangle the complex

interactions between microbes and

the environment—including food—

that cause tooth enamel to erode

and bacteria to take root and grow.

Group B

Streptococcus

A bacterial infection that can be

passed to babies during delivery,

Group B Streptococcus (GBS) can

cause life-threatening

injuries in newborns

and debilitating

disease in

pregnant women,

the elderly, and

adults with other

illnesses. Infants who get

GBS at birth can contract neonatal

sepsis or meningitis and die. Prior to

delivery, GBS can cause miscarriages.

Although physicians are able to

screen for GBS during labor, and

commonly use antibiotics to protect

infants whose mothers have the

infection, GBS remains a source of

fear to women worldwide.

At MAC-EPID, researchers

Carl Marrs, Lixin Zhang, and Usha

Srinivasan are working to understand

how new subtypes of GBS emerge

and spread. They’re also looking to

identify genes in GBS that may be

resistant to antibiotics. While GBS is

susceptible to penicillin, it is developing

resistance to second-line antibiotics,

and this poses a challenge to

physicians because ten to 15 percent

of women are allergic to penicillin.

The MAC-EPID team is using

new molecular genetic tools to

find out what makes GBS such a

successful pathogen and how it’s

being transmitted. They hope their

work may someday contribute to a

vaccine against GBS. <

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36

F I N D I N G S

Michael McGowan

Childhood Asthma

Asthma afflicts nearly seven million

children in the U.S., many of them in

low-income urban settings, where particulate

matter is often dense and

access to health care can be

problematic. Asthma is a major

cause of childhood disability

and can severely constrain a

child’s ability to learn, play, and

even sleep. “It’s also life-threatening,”

says SPH Associate

Professor Edith Parker, who has

been studying the disease since 1998. “And

it shouldn’t be, if it’s managed properly.”

With fellow SPH faculty members

Tom Robins, Stuart Batterman, Barbara

Israel, and Bhramar Mukherjee, pediatric

pulmonologist Toby Lewis of the UM

Medical School, and community partners

in Detroit, Parker is part of a team called

Asthma

is a major

cause of

childhood

disability.

Community Action Against Asthma, which

for the past 12 years has been studying both

indoor and outdoor environmental triggers

of asthma. The team has also

been developing and testing

interventions to reduce those

triggers and improve asthmarelated

health.

Current projects include a

Detroit-based intervention

designed to test the capacity

of air filters, both with and

without air conditioners, to reduce indoor

environmental triggers for asthma; a study

of the extent to which viral interactions

with particulate matter exacerbate childhood

asthma; and two studies of roadway

pollution and asthma, including one

funded by the U.S. Environmental

Protection Agency (see sidebar, right). <

Kids and Food Allergies

Fully six percent of kids in the U.S. have life-threatening food allergies, and those numbers

are growing. In fact, says SPH researcher and pediatric allergist Harvey Leo, as

recently as 20 years ago, food-allergic children were something of a rarity. Leo is working

with colleagues in the UM Center for Managing Chronic Disease to understand why the

numbers are rising and what parents and communities can do to help keep kids safe.

He’s especially

concerned about

the impact of

food allergies

on children in

socioeconomically

disadvantaged

communities.

Through the UM’s eight childcare centers and other local childcare centers, he and his

research team are working to devise a systematic approach to the care of allergic children

in childcare settings, so that food-allergic kids are safe but not socially or developmentally

isolated, and staff members feel more secure in their knowledge about food allergies and

treatment plans.

Leo hopes the approach they develop can serve as a model for other childcare

programs. He’s especially concerned about the impact of food allergies on children in

socioeconomically disadvantaged communities, and he hopes to see this research translate

into programs to improve their health. <

More than 45 million

people in the U.S.

live within 300 feet

of a four-lane road,

airport, or railroad.

Road Work

In a collaborative study with UM scientists, the

U.S. Environmental Protection Agency, and the

community-based participatory research partnership

Community Action Against Asthma, SPH

Professor Stuart Batterman is analyzing the health

effects of air pollution on children living near the

nation’s heavily traveled thoroughfares. The study is

funded through a $1.4 million grant from the EPA’s

Science to Achieve Results program.

“The knowledge gained from this study will

arm local governments with the best available science

when planning some of their most important

projects, such as road and school design,” says

Lek Kadeli, acting assistant administrator for the

EPA Office of Research and Development. “This

information will help build safer communities for

our children.”

Batterman and his colleagues are studying

traffic-associated pollution in Detroit and whether

it could lead to more severe asthma attacks in

children ages six to 16. They’re examining the types

of pollutants common near roadways, how people

are exposed to them, the extent of exposures, and

the types and severity of health effects. More than

45 million people in the U.S. live within 300 feet

of a four-lane road, airport, or railroad. <

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R E S E A R C H N E W S 37

Study Shows Parents Both Hesitant and Confident about Childhood Vaccines

Parents hear a lot of information about the benefits of vaccines, but

they also hear about dangers that can come with shots. How are parents

making sense of all this conflicting information?

In a national study from the

Child Health Evaluation and Research

(CHEAR) Unit at UM, researchers

report that 90 percent

of parents believe that getting

vaccines helps protect children

from disease. The study, which

was published online in March

in the journal Pediatrics, also

shows that 54 percent are concerned

about serious side effects

from vaccines, and 25 percent believe that some vaccines cause autism.

“Our study shows the vast majority of parents in the U.S., nine in

10, are confident about the protection that vaccines give children,” says

lead author Gary Freed, professor of pediatrics and communicable

diseases in the CHEAR Unit at the UM Medical School. “But about one

All reputable

evidence on

this issue fails

to show a link

between

vaccines and

autism.

of every two parents in our study also expressed concerns about negative

side effects they believe can occur with vaccines.”

Parents’ concern that some vaccines may cause autism is particularly

disturbing. “All reputable

evidence on this issue fails

to show a link between vaccines

and autism,” Freed says. “But

it appears that current public

health education efforts on this

issue have not yet satisfied many

parents’ concerns.”

Parents’ reasons for refusing

vaccines differ by vaccine,

the study reveals. Freed says

this is a “very important discovery. It shows us that parents are

weighing the pros and cons for each vaccine for their children.

Sometimes, health care providers think that parents who are

against one vaccine will be against all of them. But that does not

seem to be the case.” —UM Health System <

P O L I C Y

M A T T E R S

Where Practice Meets Policy, Kids Benefit

Watch pediatrician Gary Freed examine a

newborn infant’s body, and you see

decades of experience at work. Gently,

he cups his fingers around the baby’s skull, feeling

for soft spots. He checks the location of the ears—

too low, and it may indicate a serious congenital

problem. He places a finger inside the baby’s

mouth, looking for signs of cleft palate, then listens

to her heart and palpates the abdomen, checking

for a healthy liver and spleen. He works the hip

joints, counts the child’s fingers and toes, checks

her hand and foot reflexes.

As he works, Freed talks to the small circle of

medical students and interns who’ve accompanied

him on newborn service this morning. “See this

redness?” he asks as he points to a pink streak on

the newborn’s chest. “It’s perfectly normal—just

skin getting used to the world.” The examination

takes fewer than 10 minutes, and when he’s done,

Freed turns to the infant’s parents and smiles.

“Congratulations on your beautiful daughter.”

Twice a year Freed spends a week examining

newborns as an attending physician at UM C.S.

Mott Children’s Hospital. He also sees patients

once a week at a pediatric clinic in nearby Canton.

Both activities are part of his job as the Percy and

Mary Murphy Professor of Pediatrics and Child

Health Delivery at the UM Medical School, but

“I’m not just an ivory-tower researcher.

Some of my best research ideas come

from patient interactions.”

Freed says they’re also an important component

of his work as a professor of health management

and policy at UM SPH.

Freed directs the UM Child Health Evaluation

and Research (CHEAR) Unit, a multidisciplinary

research center involving faculty from nine different

UM schools, which is dedicated to improving

children’s lives by evaluating the impact that

government policies have on kids’ health.

“Every day, people are making decisions in this

country about how to implement health care

delivery, and most of those are made without data”

Freed says. “We believe the more we can inject

data into the decision-making process, the better

those decisions will be.”

Since its inception in 1999, CHEAR has

addressed a number of high-profile issues,

including access to care for low-income children,

childhood immunizations, subspecialty care for kids

with chronic illnesses, obesity, and pediatric dental

care. CHEAR takes no sides on these issues—

but the group’s work has an impact. The state of

Michigan relies on CHEAR to help determine the

most efficient use of Medicaid funds for kids, and

the U.S. Centers for Disease Control and Prevention

has collaborated with CHEAR for the past 11 years

to analyze and implement childhood immunization

programs—most recently for H1N1 influenza.

Freed loves working with kids—whether it’s as

a pediatrician making the rounds of the newborn

service or as a researcher seeking to improve the

health policies that directly affect children’s care.

One job fuels the other, he says. “I’m not just an

ivory-tower researcher. Some of my best research

ideas come from patient interactions.” <

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38

F I N D I N G S

A Rats’ Tale

Childhood Obesity

Kids hate fruits and vegetables—it’s an old

story. But Craig Cousineau has given it a

new twist with Skippy and Oaf (DNA Press,

2007), a little book about a pair of laboratory

rats that’s making waves in elementary

schools in northern Michigan and elsewhere.

Cousineau, a student in the SPH human

nutrition program who hopes to combine

a career as a primary care physician with

public health research, wrote the book for

the Delta-Schoolcraft Intermediate School

District in Michigan’s Upper Peninsula,

where he grew up. The idea was to teach

young children why vegetables and fruits

are good for them.

Enter Skippy and Oaf, a couple of

lab rats who get into a long conversation

about plants and their role in human

health. It’s a complicated tale that involves

DNA, oxygen radicals, and antioxidants,

but Cousineau manages to make the hard

science accessible—while driving home the

message that fruits and vegetables help prevent

disease, lower weight, and boost energy.

The idea

was to teach

young children

why vegetables

and fruits

are good

for them.

Dozens of elementary schools in the

Upper Peninsula have begun using the

book in their science curricula. It comes

with two weeks’ worth of lesson plans, posters,

worksheets, and activities—including

smoothies, Cousineau says. “We bring in

different fruits, and the kids get to say what

they want.”

Surveys show Skippy and Oaf is making

an impact. At one school, a first-grader

who used to come to school every day with

nothing but a candy bar for lunch now

shows up with a sandwich, carrots, and

a piece of fruit. <

Twenty-five million children in the United

States are overweight or obese—triple the

number 40 years ago. The American Heart

Association estimates that of those 25 million,

70 percent will become overweight or obese

adults, many of whom will develop chronic (and

costly) conditions like diabetes and cardiovascular

disease. Today’s kids, in fact, may be the first generation

of Americans to live shorter lives than their

parents. Here’s how UM SPH faculty, students, and

alumni are working to stem the tide:

> SPH student

Noam Kimelman

has launched the

Ypsilanti Health

Initiative, an

alliance involving

UM students

and members of

the Ypsilanti community.

The initiative

aims to make healthy foods more accessible and

affordable to lower-income families by providing

health-education workshops, subsidized groceryshopping

trips,

Noam Kimelman

and exercise

classes. In its first

year, the initiative

organized

15 workshops,

and disbursed

$3,000 in healthy

groceries.

> SPH Professor Noreen Clark and colleagues in

the UM Center for Managing Chronic Disease serve

as the evaluation team for the W.K. Kellogg Foundation’s

Food and Fitness/Food and Community

project, a nationwide initiative aimed at providing

children and families in vulnerable communities

with improved access to affordable, healthy,

locally grown food, as well as opportunities for

physical activity and play.

> Stacy Goldberg, MPH, RN, BSN, has created

A Weigh of Life/What’s in Your Cart?, LLC, a

family-centered approach to preventing childhood

obesity. Offered exclusively by the Detroit-based

Plum Market, What’s in Your Cart? provides interactive

nutrition education in a real-life grocerystore

setting. Goldberg is also

the nutritionist for Danialle

Karmanos’ Work It Out, a

holistic, yoga-based, not-forprofit

program that helps kids

and families in Detroit make healthy choices.

> SPH faculty members Alison Miller and Karen

Peterson are collaborating with UM pediatrician Julie

Lumeng on a new study that’s looking at eating

behavior, stress, cortisol production, and obesity in

low-income preschoolers attending Head Start. The

researchers hope to learn whether young children

who are overweight show aberrations in their stress

physiology, and whether such aberrations relate to

their eating behaviors—specifically the consumption

of “comfort foods” high in fat and sugar.

> Through a statewide coalition called Healthy

Kids, Healthy Michigan, SPH Associate Professor

Amy Schulz and colleagues in the Department of

Health Behavior and Health Education are working

to identify a slate of statewide policies to reduce

childhood obesity. The coalition was initiated with

the support of the state’s Surgeon General, SPH

alumna Kimberlydawn Wisdom, MS ’91.

> Karen Peterson, director of the SPH Human Nutrition

Program, is leading the evaluation of the Healthy

Choices Initiative, a multi-program intervention

designed to improve diet and activity behaviors and

weight status in

20,000 adolescents

in 46 Massachusetts

middle

schools over a

three-year period.

> Through its “Building Healthy Communities”

grant program, Blue Cross Blue Shield of Michigan is

investing in a school-based preventive intervention

strategy in 17 elementary schools across the state.

SPH Associate Research Scientist Tom Reischl is

evaluating the impact of the strategy, which provides

grants to help schools complete school- and community-based

assessments, implement physical-activity

and nutrition curricula for both students and families,

and initiate running/walking programs. <

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R E S E A R C H N E W S

39

Health Literacy, Teens,

and Type 2 Diabetes

As recently as a decade ago, clinicians and researchers

mostly referred to type 2 diabetes as adult-onset

diabetes. With the rise in childhood obesity in the

U.S., however, more and more young people are

developing the disease. Nationwide, some 3,700

young Americans between the ages of nine and 18

are diagnosed with

type 2 diabetes every

year. African Americans

and Hispanics are

especially vulnerable,

and because these

groups also have

disproportionate

rates of lower health

literacy—meaning the

ability to obtain, process, and use health-related

information—that risk is compounded. Information

about diet, exercise, health care, and personal risk

is critical to preventing and/or delaying the onset

of type 2 diabetes, says SPH Assistant Professor

Melissa Valerio. But if people have trouble accessing

and understanding health-related information, their

health may suffer.

Through a feasibility study involving at-risk

Hispanic and African-American teens in Detroit, Valerio

and a team of community partners are examining the

impact of functional health literacy in diabetes

prevention. Both individuals and society stand to

benefit from the elimination of health disparities in

chronic illness. “If we’re able to promote the prevention

or delay of type 2 diabetes in a large portion of the

population, we’ll see both lower health care costs and a

healthier, more productive work force.” <

Together with her

mother, Diana Rodríguez,

this young girl is taking

part in an exercise class

led by a promotora,

or community health

worker, at a church in

Brownsville, Texas. For

weights, they’re using

plastic bottles filled with water. Several SPH students helped

provide the classes during a week-long spring-break

immersion trip to the South Texas Rio Grande Valley area.

Obesity and type 2 diabetes are serious problems in the

border region, and this intervention is designed to help lower

the incidence of both through the promotion of exercise.

Gloria Lam

P O L I C Y

M A T T E R S

National Children’s Study

Seeks Root Causes of Disease

What role does the environment play in human health and development? That’s the

driving question behind the federally funded National Children’s Study, which is

planning to follow 100,000+ children in the U.S. from before birth through 21

years of age. SPH biostatistician Michael Elliott and colleagues at Michigan’s major

pediatric health research institutions—Michigan State University, UM, Wayne State

University, the Henry Ford Health Systems, and the state government—are scheduled

to conduct the study in five Michigan counties.

Nationwide, more than 100 counties or groups of counties representing diverse

ethnic, racial, economic, religious, geographic, and social groups will be involved in the

study—the largest long-term assessment of environmental and genetic influences on

children’s health ever conducted in the U.S. By tracking children’s development through

infancy, childhood, and early adulthood, researchers hope to determine the root causes

of many childhood and adult diseases. Over the next 25 years

they’ll be looking at:

> Air, water, and

house dust

> Asthma

> Birth defects and

pregnancy-related

problems

> Nutrition

> Injuries

> Neighborhood

safety

> Frequency of doctor visits

> Obesity

> How children are cared for

> Diabetes

> Learning and mental

health disorders

> Diet, environment,

chemical exposures,

and emotional stress

during pregnancy

For more on the National Children’s Study, visit

www.nationalchildrensstudy.gov. <

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40

F I N D I N G S

Childhood Liver Disease

Pediatric liver diseases are something of a

mystery. Many of them are rare, so it’s hard

to gather information about them. They’re

notoriously difficult to diagnose, and it’s not clear

what causes them.

What is clear is that to the kids who have a liver

disease—and to their families—life can be an ordeal.

In some cases, children as young as two years old

require surgery or even a liver transplant in order

to survive. Even when a transplant isn’t necessary,

liver disease can impair a child’s ability to eat, sleep,

and perform basic functions. Some disorders alter

physical appearance and cause intractable itching

and skin infections. Abnormalities caused by liver

disease can also impair cognitive development and

brain and linear growth.

Even when a transplant

isn’t necessary, liver

disease can impair a

child’s ability to eat,

sleep, and perform

basic functions.

In short, says SPH biostatistician Cathie Spino,

“nasty things can happen.”

Spino and a team of SPH biostatisticians are

serving as the data coordinating center for a series

of liver studies being conducted nationwide as part

of the National Institutes of Health Children’s Liver

Disease Education and Research Network. Trivellore

Raghunathan, chair of the SPH biostatistics

department, is lead biostatistician for the project.

Researchers affiliated with the liver disease network

are looking at the genetic determinants of pediatric

liver disease as well as at neurodevelopmental milestones,

growth, and nutrition. “These are complex

diseases,” Spino notes, and because they’re also

rare, it’s a challenge to collect and evaluate data.

But as with AIDS, another complex disease she

has studied, Spino says it’s possible to get a lot of

information from a small number of people, and

she’s optimistic the work she and her colleagues

are undertaking will lead to new therapeutic

approaches for kids who have liver disorders,

and to newfound hope for their families. < <

P O L I C Y

M A T T E R S

The Challenges

of Children’s

Health Research

Both the Centers for Disease Control and

Prevention and the National Institutes of Health

recognize the need for community engagement

if health research is to lead to real-life practice.

But when clinical or community-based research

involves children and adolescents, there are

additional challenges:

> Parents may be concerned about—or fear—

the nature, purpose, and potential impact of

research.

> Children and adolescents need to be

guaranteed confidentiality, especially when a

research study involves sensitive issues such

as sexual identity or sexual behavior.

> Researchers need both assent from children

(who are not legally able to give their consent)

and consent from parents.

> Research studies must be sensitive to the

complexities of childhood development.

> One of the most effective ways for researchers

to reach both children and their parents is

through the school system, and yet for safety

reasons, school policies and regulations restrict

access to students.

> It can be difficult to track children over long

periods of time, especially with low-income or

disadvantaged populations.

In collaboration with the UM SPH Office of

Public Health Practice, the Michigan Institute for

Clinical and Health Research (MICHR) addressed

these and other issues during a workshop,

“Improving Children’s Health through Community-

Engaged Research,” in April. Workshop presentations

are available online at www.michr.umich.

edu. Funded by a National Institutes of Health

Clinical and Translational Science Award and

based in Ann Arbor, MICHR is a community

resource aimed at accelerating the translation of

research into practice by providing infrastructure

and other support services. <

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R E S E A R C H N E W S

41

From Boys to Men

Cleo Caldwell has spent years

working to help African-American

teens navigate the tricky waters

from childhood into adulthood. She’s

especially interested in the health and

well-being of African-American boys,

who disproportionately grow up in

single-parent households, she notes,

and often lack meaningful relationships

with their biological fathers.

In fact, says Caldwell, an associate

professor of health behavior

and health education, if young

African-American men are to avoid

problem behaviors—including

early sexual encounters, substance

abuse, poor academic achievement,

and violence—it’s critical they have

strong bonds with their fathers. So in

partnership with the Flint, Michigan,

community, Caldwell and a team of

SPH researchers have developed an

intervention called the Fathers and

Sons Project, which is designed to

strengthen the bonds between nonresident

African-American dads and

their eight-to-12-year-old sons by

improving communication, deepening

cultural awareness, and increasing

healthy behaviors.

Caldwell has long understood

that the family “is a vital social

context for understanding

the health and well-being of

adolescents.”

Results from the intervention

have been so positive that the Centers

for Disease Control and Prevention,

which funded the project, lists Fathers

and Sons as a “promising intervention

program” on its website, and

Caldwell and her colleagues are now

planning to replicate the program in

New Haven, Connecticut; Baltimore,

Maryland; Saginaw, Michigan; and

New York City.

Caldwell has long understood that

the family “is a vital social context for

understanding the health and wellbeing

of adolescents,” she says, and her

research therefore focuses on identifying

both risk and protective factors

within diverse family environments.

In separate studies, she is examining

discrimination and psychological

well-being among African-American

and Caribbean black adolescents and

depression rates among adolescent

African-American mothers and fathers

—rates she says are “concerning.”

Preliminary research suggests that the

prenatal relationship between adolescent

fathers and maternal grandmothers

is an important link to fathers’

post-partum mental health. <

When kids get into trouble, fingers point. But when they

stay out of trouble, who’s responsible? For the past 12 years,

Marc Zimmerman and his research team in the Prevention

Research Center of Michigan have been seeking to answer

that question by studying what’s known as “adolescent resiliency”—the

ability of young people to overcome the negative

effects of risks. Zimmerman, who chairs the SPH Department

of Health Behavior and Health Education, says two factors

are key.

One is the presence of adults. Whether it’s support from

a parent or some other caring adult, or simply the existence of

an adult role model, kids benefit from “natural mentors”—adults

with whom they feel a natural connection and whose advice, guidance, and

support they seek out. Even high school seniors do better in school and avoid

problem behaviors, like drug use, when they have an adult mentor in their

A d u lt s M at t e r

Even high school

seniors do better in

school and on the

streets when they

have an adult

mentor in their lives.

lives. “It’s true that peers have influence, but that doesn’t

mean parents don’t,” Zimmerman says. “It just means they

have to share more. But their adolescent is still paying attention

to them.”

A second important factor is involvement in extracurricular

activities. Young people who participate in sports,

clubs, youth programs, church events, and the like tend to

avoid trouble in school and with the law. Part of the reason

for that, Zimmerman notes, is again the presence of caring

adults. “So it comes back to the question of what sort of

world are we making for our children? Adults make the world

that their kids live in—we play a role in their lives. If kids are

having problems, part of the responsibility is on us. We can create structures,

opportunities, programs, and relationships to help kids develop healthy

behaviors and achieve positive developmental outcomes.” <

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42

F I N D I N G S

Kids and the War on Smoking

On a daily basis, nearly 4,000 U.S. children

under the age of 18 try their first

cigarette. At least a thousand of those go on

to become regular smokers. “Many of these

kids will become addicted before they are old

enough to understand the risks and will ultimately

die too young,” says Food and Drug

Administration Commissioner Margaret A.

Hamburg, calling this “a preventable public

health disaster for our country.”

New FDA guidelines will prohibit tobacco manufacturers

from giving children free T-shirts, hats, and other

memorabilia bearing tobacco-product names.

In Combating Teen Smoking: Research and

Policy Strategies, SPH faculty members Peter

Jacobson, Paula Lantz, and Kenneth Warner

tackle the question of why adolescents take up

smoking and what we can do both to keep them

from starting and to help them quit. Published in

2001 by UM Press, the book synthesizes much of

the relevant research on the topic and recommends

multiple ways to reduce

teenage tobacco use, including

antismoking media campaigns,

clean indoor air laws, and

increased cigarette prices. The

book’s additional co-authors are

Jeffrey Wasserman, Harold

Pollack, and Alexis Ahlstrom.

In an effort to lower the number of

kids who take up smoking, the FDA—

which last year received unprecedented

powers to regulate the manufacturing,

marketing, and sale of tobacco products—

is instituting new requirements this June

that will:

> Prohibit the sale of cigarettes or smokeless

tobacco to people younger than 18

> Prohibit the sale of cigarette packages

with fewer than 20 cigarettes

> Prohibit distribution of free samples

of cigarettes

> Restrict distribution of free

samples of smokeless tobacco

> Prohibit tobacco brandname

sponsorship of any

athletic, musical, or other

social or cultural event

> Keep tobacco manufacturers from

giving children free hats, T-shirts, and

other memorabilia bearing tobaccoproduct

names on them

Despite everything

we know

about tobacco,

46 million

Americans—

fully 20

percent of the

population—

still smoke.

“If you can keep kids from starting to

smoke, that’s key to ensuring that we defeat

this epidemic,” says Cliff Douglas, SPH

adjunct lecturer and director of the UM

Tobacco Research Network. “Despite everything

we know about tobacco, 46 million

Americans—fully 20 percent of the population—still

smoke, and that’s an extraordinarily

high percentage. Our long-term

prospects for success rest on our ability to

denormalize tobacco use in society and

drastically cut youth initiation.” <

Teens, Jobs, and Risky Sex

If teens work too many hours in the

wrong environment, it can be dangerous

for their sexual health, because it may

foster conditions that lead them to older

sex partners. This is just one of the key

findings in a recent UM study of youth

on what predicts the age of sex partners.

SPH Assistant Research Professor Jose

Bauermeister, one of the study’s authors,

says the age difference of sex partners

is important, because a larger age difference

is associated with riskier sexual

behavior and STDs, including HIV.

Working too many hours in an

adult atmosphere without adequate

supervision can lead to sexual

activity with older partners.

The study also found that a youth’s

self-esteem and alcohol use play a role in

the age difference between sex partners.

Overall, the research shows that teenagers

who work part-time benefit in almost all

areas over those who don’t have jobs—

but those benefits come with caveats.

Working too many hours in an adult

atmosphere without adequate supervision

can lead to exposure to adults and eventually

sexual activity with older partners,

especially for young girls, Bauermeister

says. “It’s OK to let kids work, but we

want to make sure they are spending time

in an environment where it’s safe to work.

Parents must ask the right questions

and make sure it’s a safe place for their

children.”

High self-esteem and low use of

alcohol offset the negative effects of

working too many hours, Bauermeister

notes. Those factors also protect youths

overall from engaging in riskier sexual

behavior. —Laura Bailey <

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R E S E A R C H N E W S

43

Driven to

Distraction

On the Road

For Americans between the ages of have also made an enormous difference.

one and 34, motor vehicle injuries These programs exist in almost every state

are the leading cause of death. But there’s and have reduced crash deaths and injuries

involving 16-year-old drivers by 20 to

good news. Thanks to vehicle and road

improvements and to safety programs, as 40 percent, Shope says, “and that’s huge.”

well as two decades of collaborative work She points out that young people age and

between both faculty and students at SPH mature as they go through the gradual

and researchers at the UM Transportation

Research Institute, driving the iconic obtain full driving privileges. Some states

steps they need to complete in order to

American car is safer today than ever are considering enhancing their licensing

before. Jean Shope, a research professor programs to get even better outcomes.

in the Department of Health Behavior and

Health Education and director of the UM

Center for Injury Prevention among Youth,

reports these advances:

> In states across the country, legislative

policies and law enforcement initiatives

have led to a substantial drop in the

percentage of fatalities attributable to

alcohol-impaired drivers;

> Safety-belt use has increased

significantly;

> Where highway speed limits have

been lowered to 55 mph, fatalities

have decreased;

> Cars have more safety features, including

antilock brakes, electronic stability

control, and airbags that are positioned

throughout the vehicle (Shope notes, however,

that seatbelts must be worn in order

for airbags to be effective).

Graduated licensing programs for teen

drivers—Shope’s own area of research—

The biggest risks

for teen drivers are

night driving and

teen passengers.

The biggest risks for teen drivers,

Shope says, are night driving and teen

passengers. “The higher the number of

passengers, the greater the risk, especially

if the passengers are young

men.” Driving requires “very complex

psycho-motor skills,” Shope

explains. What she and her fellow

researchers now want to

know is “what are the

extra teenage issues

that make driving such

a high-risk activity for

them, and how can

we reduce those risks

further?” <

Noting that 21 percent of all reported

injury crashes in the U.S. in 2009 involved

distracted driving, and that young drivers

who text-message while driving are at six

times the risk of a collision than drivers

who don’t text, SPH Professor Peter

Jacobson argues that policymakers must

urgently address the dangers to public

safety posed by new technologies.

Jacobson’s remarks appear in a commentary

he co-authored with Lawrence O.

Gostin of the Georgetown University Law

Center in the April 14, 2010, issue of the

Journal of the American Medical Association.

Jacobson and Gostin discuss the dangers

of texting, dialing, e-mailing, and talking

on cell phones while driving—as well as

other distracting activities, like eating

and grooming—and outline the legal

precedents for government intervention

at both the state and federal levels. They

also examine corporate responsibility.

“Reducing distracted driving requires

concerted action at every level of government,”

they write. “A combined program

of legislative restrictions, educational

campaigns, and manufacturer

design changes

offers the best

prospect to improve

highway

safety.” <

On

April 30,

Michigan

Governor

Jennifer

Granholm

signed a

state ban on

texting while

driving,

effective July 1.

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A L U M N I N E T W O R K

The Peace Corps at 50:

A Michigan Celebration

On October 1 4 , 19 60, Senator John F. K en n edy

capped off a day of campaigning with a brief appearance in front of the Michigan

Union. It was well after midnight. The presidential election was just three weeks

away, and the race was tight, but Kennedy was upbeat. People packed the streets and leaned

out of windows, straining to see the candidate. Kennedy

joked that his talk that night was “the longest short

speech I’ve ever made”—but his words made history,

for that night he challenged the students of the University

of Michigan to devote themselves to global peace and

justice by living and working in developing nations.

His speech, and the enthusiastic response of

The university is collecting

stories from

the UM grads who’ve

volunteered for the

Peace Corps. Are you

one of them?

Michigan’s students and faculty—hundreds of whom signed petitions endorsing

Kennedy’s idea—led to the creation of the Peace Corps, the signature program

that has defined global volunteer service for the past half-century.

This October, UM will host the national kick-off of the 50th anniversary

of the Peace Corps. As part of the celebration, the university is collecting

stories from the more than 2,200 UM graduates who’ve volunteered for the Peace

Corps. Are you one of them? If so, we want to hear from you. Where did you go, and

when? What did you do? How did the experience change your life?

The fall issue of Findings will feature a special section on SPH alumni who’ve lived

abroad in the service of world peace. To submit your story or to sign up for e-mail updates on

anniversary events, visit www.peacecorps.umich.edu or e-mail sph.alumni@umich.edu. <

C L A S S N O T E S

1950s

The Institute of Medicine/National

Academy of Sciences has appointed Bailus

Walker Jr., MPH ’59, to its Committee on

Long-Term Health Consequences of Exposure

to Burn Pits in Iraq and Afghanistan.

As one of 12 occupational and environmental–medicine

scientists named to the

committee, Walker will examine the health

hazards that result from the burning of

waste mixtures in large, uncontrolled pits

in Iraq and Afghanistan. The committee

will also assess both feasibility and design

issues for an epidemiological study of veterans

exposed to these health risks.

1960s

Central Queensland University, in Queensland,

Australia, has named its Rockhampton

Campus nursing headquarters “The Amy

Zelmer Building,” in honor of Emeritus Professor

Amy (Elliott) Zelmer, MPH ’63, the

former Foundation Dean of the university’s

Faculty of Health Science. In addition to a

distinguished nursing, research, and academic

career, Zelmer is actively involved in a

variety of community and consumer groups

dedicated to the long-term improvement of

health services and the well-being of communities

through education and research.

Hear Zelmer discuss her work at www.sph.

umich.edu/findings.

1970s

Last fall, Chih Liang Yaung, PhD ’79,

became the Minister of Health of Taiwan.

He is a past Deputy Minister of Health and

past dean of the College of Health Science,

Asia University. In addition to being chief

medical officer of the Queens Long Island

Group, J. Ronald Rowes, MD, MPH ’76,

is chair of the board and medical director

of Lypris Medical, a company based on his

patented device for pressure ulcers.

continued on p. 47

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A L U M N I N E T W O R K 45

M A K I N G A D I F F E R E N C E

Don Hammond

Steve Kuzma

Questions for Pat Warner, MPH ’77

The Best

Care Possible

The executive director of the University of Michigan

C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital

talks about the challenges of treating kids.

What’s the toughest thing about running a children’s hospital?

Number one, finding the support for the resources we need to take care of not only the child

but the child’s family—because children don’t come to us all by themselves. They’re part of

a unit, and our reimbursement structure isn’t based on that. Families arrive here and don’t

“They can be as

sick as can be,

and a child still

sees the best in

life, still plays,

still has an unbelievable

ability

to rebound.”

have housing and can’t pay for transportation.

If you have a child who lives in the

Upper Peninsula and has multiple chronic

conditions, and we’re the only provider in

the state, or one of only two, how do family

members leave their jobs to come down here

to be with their child? We consider it part of

our responsibility to help those families.

Number two, our funding source is a medical/surgical

funding source, but to take care

of a child you need to take care of them as they continue to develop—their psychosocial,

emotional, and play needs—which is different from the adult environment, and there’s not

much funding in the current reimbursement structure for that.

What’s most gratifying?

The affirmation of life that children bring. They can be as sick as can be, and a child still

sees the best in life, still plays, still has an unbelievable ability to rebound.

How has your SPH degree benefited you?

A graduate degree from SPH gives you the framework to think more comprehensively

about how something’s going to operate, how you’re going to fund it, how you’re going to

make those cost-benefit decisions, how this will impact the health of the community, and

about what you’re doing to create future knowledge and train the future workforce.

You’re a grandmother now. Has that changed the way you think about your job?

It just fuels my passion for making sure that we are creating the best care possible

for children. <

<

A Hospital for

the 21st Century

For the past 15 years, Pat Warner has overseen the

day-to-day operations of a hospital U.S. News and

World Report ranks among the nation’s finest for

pediatric care. At the same time, she’s led the drive

to build a new, $754-million C.S. Mott Children’s

and Women’s Hospital at the University of

Michigan. When it opens in 2011, the 1.1-million

square-foot facility will feature the latest in health

care technologies. In addition to UM faculty and

staff members, hundreds of patients and families

were involved at every stage of the project, from

design to operational planning. “One of our guiding

principles is that we want to give patients and their

families as much control over their environment as

possible,” Warner says. Here’s some of what’s on

offer at the new Mott:

> Single rooms for every patient, to foster

support and privacy for family units and help

minimize the spread of infection

> Flat screens in every room, with wireless

access and remote keyboards, so that patients can

watch movies, communicate with friends, maintain

care pages, check schedules, and order food

> New fetal diagnostics and

intervention technologies

> A dedicated pediatric

emergency and urgent-care

department

> An open MRI machine that

lets young children watch

videos or movies and thus

minimizes the need to sedate

patients during procedures

> An intraoperative MRI that allows doctors

to obtain brain or spine images during

surgical procedures

> HEPA filtration throughout the entire in-patient

hospital, to help prevent the spread of infection

> À la carte dining

> A two-story lobby with a Family Resource

Center overlooking an outdoor garden park

> Environmentally sustainable practices

and materials, including a green roof, recycled

rubber, and more efficient heating and ventilation

systems.

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46 F I N D I N G S

O N T H E J O B

B R I G H T S M I L E S

In Finland Long before he

came to Michigan, Heikki Tala, DDS, PhD,

MPH ’72, worked as a school dentist in

rural Finland. The job, he says, “was more

like slaughter” than dentistry, because he

spent so much time pulling rotting teeth

from children’s mouths. “It was so terrible

to see those suffering kids. I had no other

goal than to change that picture.”

But how? Even after he became an

assistant chief dental officer in Finland’s

Ministry of Health in 1970, Tala realized

he lacked the skills and knowledge to

organize the nation’s dental system so

that its children would grow up with

healthy teeth.

So he set out to learn. With scholarship assistance, Tala spent a year at

Heikki Tala on the job in Finland’s

Ministry of Health, 1989.

UM SPH from 1971 to 1972. “When I came to Michigan I was a dentist, and

when I returned back home I was a public health person,” he remembers.

Back in Finland, Tala became the country’s chief dental officer and began

transforming the Finnish oral health care system. Using World Health Organization

guidelines for oral health, he set national goals, organized courses for the

country’s leading dentists, launched dental education programs for expectant

parents, built a network of community clinics where kids under 18 could get free

dental care, and implemented a nationwide information system.

“It was so terrible to see those

suffering kids. I had no other goal

than to change that picture.”

Communities in Finland began competing with one another to be number one

in oral health. Dental schools began adding public health experts to their faculty.

Tala himself started working as a consultant with WHO, doing for countries on four

other continents what he was doing for Finland.

At his retirement in 1991, Finnish children enjoyed some of the best dental

health in world. Tala had achieved his life’s goal: “Healthy teeth, healthy dentition,

a healthy mouth in a healthy child. All of this comes from my year in Michigan,”

he recalls. “It was fantastic. I must give big, big, big credit to Michigan.”

In Connecticut

Kathy Stack, a dental hygienist with

an MPH (’95) in dental public health,

spent the past two years working to

improve kids’ teeth in her home state

of Connecticut. Through a program

called “Home by One,” Stack helped

set up ongoing relationships between

dental providers and children six

months and older. Because lowincome

kids are at high risk for dental

disease and often have trouble

accessing dental care, Stack worked

with a local WIC (Women, Infants and

Children) office to establish “dental

homes” for clients and to

provide information for

parents on best dietary and

oral-hygiene practices,

referrals and recommendations

for preventive care,

and the application of

fluoride varnish to young

children’s teeth.

In Michigan Amanda Roffe, MPH ’09, never meant to work in dental public health. But a

field-placement internship led to a job offer, and the next thing she knew she was the coordinator of dental

services for the Henry Ford School-Based and Community Health Program in metro Detroit. It’s public

health at its best, says Roffe, who studied health behavior and health education at SPH.

With 11 clinics—nine of them housed in the Detroit Public Schools—the Henry Ford program provides

medical, mental health, vision, and dental care to children throughout the city. Roffe works in clinics with

kids and staff, writes grants, and helps parents navigate the health system. In workshops, she teaches parents what

a cavity looks like and how to get their children to brush their own teeth at night. “The parents are very excited and

welcoming,” she says. “After our first workshop, they said, ‘We want you to come back!’”

Grand Rapids schoolchildren contribute saliva samples as part of their city’s

water fluoridation trials. Photo courtesy of the National Library of Medicine.

From the Archives

As a graduate student at SPH, David Ast, MPH ’42,

wrote his master’s thesis about fluoridated water and its

potential to reduce tooth decay. As dental director for

the state of New York, he made a bid to conduct the

nation’s first trials of fluoridation. Although he failed in

that bid, Ast conducted the second trials, in upstate

New York. And his initial proposal helped prompt the

federal government to begin field trials of fluoridation in

Grand Rapids, Michigan, in 1945. Evidence from those

trials showed a dramatic reduction in caries as a result

of fluoridation—so much so that in the 1960s the U.S.

Public Health Service began promoting fluoridation

programs throughout the country.

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A L U M N I N E T W O R K 47

C L A S S N O T E S continued from p. 44

1980s

Adjunct Professor Donald Chen, DrPH

’82, is helping to set up a new Department

in Environmental Health Sciences for

postgraduate studies and research at the

International Medical University in Malaysia.

Chen notes that the new department

will seek to emulate the UM SPH model for

teaching and research. In the future, he and

his colleagues hope to arrange academic

exchanges between the two institutions.

Steven C. Gold, MPH ’75, is the new

health department director/health officer

for Macomb County, Michigan. Los Angeles–based

David Adam Holtzman, MPH

’85, serves as a consultant to government

agencies and private real-estate developers

on air quality and health-risk assessments.

Previously, he was a principal scientist

in the air-quality, climate, and acoustics

division of PCR Services Corporation, an

environmental-consulting firm in Santa

Monica, California. Holtzman is president

of the League of Women Voters of Los

Angeles. As the assistant vice chancellor

for capital development at the University

of California, Merced, John O. White,

MHSA ’85, is engaged in capital development

for the new UC, Merced, campus and

its adjoining university community. He also

serves on the board of directors of the Society

for College and University Planning.

Terri D. Wright, MPH ’84, is the new director

of the Center for School, Health and

Education in the Division of Public Health

Policy and Practice at the American Public

Health Association.

1990s

(Julia) Zoe Beckerman, MPH ’97, is a partner

in the Washington, D.C., law firm of

Feldesman, Tucker, Leifer, Fidell, LLP, where

she is also managing principal of FT Solutions,

the firm’s consulting arm. Anchorage

resident Chung Nin Ha, MPH ’92, is a

health educator for the State of Alaska.

Jonathan Segal, MHSA ’96, is the chief

financial officer for Planned Parenthood of

New York City.

In a March 8, 2010, column on fitness, New

York Times health writer Jane Brody

endorsed the approach that Michelle Segar,

PhD, MPH ’97, studies and advocates. Segar

is a research investigator at the Institute for

Research on Women and Gender and a

translational fellow at the Michigan

Institute for Clinical and Health Research

at the University of Michigan. Read Brody’s

article at www.sph.umich.edu/findings.

Ritola Tasmaya, MD, MPH ’90, is the

executive secretary for the governor of

Jakarta, Indonesia. Tasmaya is the former

city secretary of Jakarta.

2000s

Mari Embertson, MHSA ’08, is a special

projects manager with The Everett Clinic

in Everett, Washington. Loren Hamel,

MHSA ’06, of Berrien Springs is the new

president and CEO of Lakeland HealthCare.

A long-time family physician, Hamel has

been part of Lakeland’s senior leadership

team for 10 years. He replaces UM SPH

alumnus Joseph Wasserman, MHA ’70,

who has retired after 25 years as Lakeland’s

president and CEO. In his new

role as patient care operational manager

for St. Joseph Mercy Oakland (Michigan),

Jacky Lagrace, MHSA ’08, works with the

vice president for patient care services on

operations and quality-improvement initiatives.

Last year, Kirk Larson, MHSA

’04, became Chief Information Officer of

Natividad Medical Center, a hospital in

Monterey County, California. Alicia

(Watkins) Okoh, MPH ’01, MSW, is a

program manager for Catholic Charities

CYO, a nonprofit provider of social services

in San Francisco, California. Alicia

Simmer, MHSA ’07, is a senior healthcare

consultant with Ann Arbor–based KHC, a

woman-owned business that provides customized

solutions to the unique challenges

faced by hospitals, outpatient facilities, and

academic medical centers. As a recipient

of a U.S. Department of State Critical

Language Scholarship, Ashley Strahey,

MPH ’10, will study Arabic in an intensive

language institute this summer and will enter

the Peace Corps this fall. Strahey hopes

to use her Arabic to work in international

development, with a focus on maternal and

child health and human rights. The Critical

Language Scholarship Program is part of a

U.S. federal government effort to expand

the number of Americans studying and

mastering critical-need foreign languages.

Deena Thomas, MPH ’09, is the MPH

coordinator for the new Sri Ramachandra

University (SRU)–University of California,

What’s N

N E W S , N O T I C E S , N E T W O R K I N G & S T O

Berkeley, Inter-Institutional Collaboration

and Master of Public Health Program in

Occupational and Environmental Health.

The collaboration and MPH program were

Your classmates would like to know where

officially launched in January. SRU is located

you are and what you are doing. Please

in Chennai, send us India. information < for the Alumni

Network section of Findings magazine and

Findings online. Information can be in the

form of news items, press releases, a written

entry Services on the lines in the & middle Networking

of this

Career

Need page. a job Or you or have can send one this to information fill? SPH by

e-mail to sph.alumni @umich.edu. The form

Career Connection matches SPH students

is also available at www.sph.umich.edu/

and grads with companies and agencies.

alumni/resources.

Check out www.umsphjobs.org or

Please complete this page and fill in the circles

if the information you are providing is a

e-mail sph.jobs@umich.edu.

change in address or title, if you know of job

openings for students, if you are willing to

Stay

be a

in

resource

Touch

person for SPH students/alumni,

Keep and/or up with if you your would alma like to mater! suggest Update a story

your idea SPH for contact Findings. info from our home page

at www.sph.umich.edu. Return to:

Be sure to provide

the Office e-mail of address Communications where you want us to

University of Michigan

send brief updates on school news. You

School of Public Health

can opt out at any time.

109 S. Observatory

Ann Arbor, MI 48109-2029

Share What You Know!

The Sreal-world H A R E Wknowledge H AT YO U and K Nexperience

OW !

of SPH The real-world alumni can knowledge be invaluable and experience to current

and of prospective SPH alumni can students. be invaluable If you to current would like

and prospective students. If you would like

to be part of Ask an Alum, please contact

to be part of Ask an Alum, please contact

Kim Elliott at elliottk@umich.edu.

Kim Elliott at elliottk@umich.edu.

Name

Employer

Title


Professiona

Home Add

SPH Degre

E-mail Add

❍ In the bo

Class Note

❍ Yes, I kno

❍ Yes, I am

and/or g

Internship/

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


48

F I N D I N G S

L I F E ’ S W O R K

Research for Kids’ Sake

“Many

kids who have

high risk factors

already show

evidence of the

atherosclerotic

process.”

Cardiovascular Disease

Most people think of cardiovascular disease as

something that happens in old age, but it actually

starts in childhood, says Trudy Burns, MPH ’76,

PhD ’82. A professor of epidemiology at the

University of Iowa College of Public Health, Burns

studies the links between childhood risk factors

and subclinical cardiovascular disease.

Burns has been interested in cardiovascular

disease ever since she was a doctoral student

in biostatistics at SPH. Early in

her career, she coauthored a

study with SPH epidemiologist

Pat Peyser showing

that BMI, or bodymass

index, has

a significant

genetic basis.

At Iowa,

Burns has been

using data

from The

Muscatine

Study—including

CT scans and

ultrasounds of the

heart and blood

vessels—to further

her understanding

of the links between

childhood risk factors

and cardiovascular

disease. The

Muscatine Study is a

longitudinal study that’s been tracking a cohort

of children from Muscatine, Iowa, since 1970.

“Many kids who have high risk factors

already show evidence of the atherosclerotic

process,” says Burns. “And we know from looking

at the cause of death of their adult relatives, that

those kids also have a higher probability of dying

from cardiovascular causes. So it really is a

lifelong process.”

Indeed, she adds, “this may be the first

generation where kids don’t live as long as

their parents—and a primary reason is because

of the increase in obesity. And that’s exactly

what we’re studying.” <

Influenza and Rotovirus

Because there’s no real winter in Africa, influenza

threatens much of the continent year-round. Yet

researchers don’t fully understand how the disease

works in Africa. They don’t know how sick it makes

people, for example, or how much it contributes

to pneumonia, which kills more than two million

children a year in the developing world. Nor do

scientists have firm data on the effectiveness of

seasonal-flu vaccines in Africa.

It’s the largest

influenza vaccine

study ever done in

Africa and among

the first of its kind.

But that’s changing, says John “Chris” Victor,

MPH ’97, PhD ’04, an advisor for epidemiologic

science and clinical trials at PATH, an international

health nonprofit based in Seattle. Through a

three-year, $4 million cooperative agreement

between the U.S. Centers for Disease Control and

Prevention and PATH, Victor is directing a study

aimed at determining the rates of influenza illness

in an African population, and at measuring the

effectiveness of seasonal influenza vaccine to reduce

those rates. It’s the largest influenza vaccine study

ever done in Africa and among the first of its kind.

The influenza study involves approximately 32,000 people in 20 villages in rural Senegal.

The study involves

approximately

32,000 people

in 20 villages in

rural Senegal and

is designed in part

to resemble research conducted

in 1968 by Victor’s mentor,

Arnold Monto, SPH professor of

epidemiology, as part of the famed

Tecumseh (Michigan) Study. In that

trial, Monto found that vaccinating

children in one part of a community

reduced transmission rates throughout the

entire community.

While working with Monto as a student at

SPH, Victor collaborated on trials of hepatitis A

vaccine and seasonal influenza vaccine. The skills

he learned led directly to his job at PATH, where

he has also studied Japanese encephalitis and

rotovirus. In part as a result of Victor’s recent work

on rotovirus—a disease that is estimated to kill

more than half a million children a year worldwide—the

World Health Organization has changed

its immunization guidelines to recommend that

infants in every country in the world be vaccinated

against rotovirus. Victor says it’s a public health

dream come true—“to have generated data that

helped change global policy for one of the most

important infectious diseases in the world.” <

John “Chris” Victor

F I N D I N G S W W W . S P H . U M I C H . E D U S P R I N G / S U M M E R 2 0 1 0


!

Name

Employer

Title

m This is a new title

Notices,

Networking &

Story Ideas

( )

( )

During her internship in India,

Fax

Antara developed a health screening

≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈

program for slum children and

mobilized a meeting among health

officials, UNICEF, and NGO

representatives to monitor

the health of schoolchildren.

She came back knowing she’d

made a difference.

You can help UM SPH students

like Antara build a better world

by giving to the Student Global

Experience Challenge Fund, a

matching gift program for creating

international student citizens.

To make a gift, visit

www.sph.umich.edu/alumni/

giving.html or call 734.764.8093.

≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈

≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈

What’s New?

News,

Your classmates would like to know where you are and what you are doing. Please send us information for the

Alumni Network section of Findings magazine and Findings online. Information can be in the form of news

items, press releases, or a written entry on the lines in the middle of this page. Or you can send this information

by e-mail to sph.alumni@umich.edu. The form is also available at www.sph.umich.edu/alumni/resources.

Please complete this page and fill in the circles if the information you are providing is a change in address or

title, if you know of job openings for students, if you are willing to be a resource person for SPH students/

alumni, and/or if you would like to suggest a story idea for Findings.

Return to: Office of Communications, University of Michigan School of Public Health, 1415 Washington Heights,

Ann Arbor, MI 48109-2029

Professional address (City, State, Zip) m This is a new address Business/Work Phone

Home address (City, State, Zip) m This is a new address Home/Cell Phone

SPH Degrees/Year/Department

E-mail Address

Class Note I would like to share the information below with the SPH alumni network:

Internship/Job Information

m Yes, I know of summer internships and/or regular job openings for SPH students/alumni.

m Yes, I am willing to be a resource person for SPH students/alumni interested in my public health specialty

and/or geographic location.

m Yes, I have a story idea for Findings:


50

F I N D I N G S

I N M E M O R I A M

Q U O T E / U N Q U O T E

1940s

Clyde Blaine Eller, MPH ’47 February 26, 2010

Elaine Alice Schwinge, MD, MPH ’48 February 17, 2010

1950s

George T. Carmichael, MPH ’51 August 23, 2009

Irene A. Prisloe, BSPHN ’53 September 9, 2009

Helen M. Benson, MPH ’56 August 28, 2009

Robert N. Beck, MPH ’57 March 10, 2010

Vester J. Lewis, MPH ’57 November 7, 2009

Nancy A. Schmitt, BSPHN ’57 November 3, 2006

Dr. Jefferson D. Farris Jr., MPH ’58 January 16, 2009

1960s

Phillip R. Spangler, MPH ’60 December 21, 2009

Blanche J. Feitl, MPH ’64 August 19, 2009

John S. Stock, MPH ’64 August 19, 2009

William L. Thomason, DDS, MPH ’64 September 29, 2009

Monica M. LaSarge, MPH ’65 August 18, 2009

Sister Helen Murphy, MPH ’68 December 4, 2009

Robert Lee Bavelock, MPH ’69 October 29, 2009

Mary Alma Soule, MD, MPH ’69 March 29, 2008

1970s

Oliver D. Cook, MPH ’70 January 15, 2010

Frances J. McGuire, RN, MPH ’70 August 2, 2009

Naomi Barber Ament, MPH ’71 February 24, 2010

Sr. Mary Ellen Creedon, MPH ’71 February 8, 2010

Juanita P. Fralick, MPH ’71 August 27, 2009

Warren M. Kleinberg,MD, MPH ’72 November 20, 2009

Willy Grunspan, MPH ’74 September 29, 2009

Jean Hanmer Pearson, MPH ’76 January 11, 2010

2000s

Kamilah O. Neighbors, MHSA ’01 March 4, 2010

A Son of Ghana

Returns Home

(Again and Again)

With more than a million frequent-flyer miles to his credit, Kofi Gyan arguably lives

not in the United States or his native Ghana—the two countries where he spends

most of his time—but somewhere in the air between them. That’s because Gyan,

MPH ’96, is on a mission to improve the health system of his homeland and the

health of his fellow Ghanaians. As program manager for all UM health-related

programs in Ghana, he’s uniquely able to do both.

Gyan is especially keen to help lift the burden of infant and maternal mortality

in Ghana. The problem is particularly severe in rural areas, where physicians and

medical facilities are scarce, and women often

can’t get the help they need for conditions like

eclampsia and post-partum hemorraghing. In

parts of the country there is just one doctor for

a population of 200,000, says Gyan, who is

collaborating with the UM Center for Global

Health and SPH Associate Professor Rachel

Snow on a Gates Foundation grant to increase

the number of doctors in rural Ghana. Gyan also works closely with Tim Johnson,

chair of the UM Medical School’s Department of Obstetrics and Gynecology, and

other UM medical faculty and students to help train physicians, midwives, and

medical personnel in Ghana.

In parts of the

country there is

just one doctor

for a population

of 200,000.

Any given year, I live about six months in Ghana and six months in the U.S.,”

Gyan says. “I help Ghana more this way than if I lived there. Right now two UM

emergency medicine doctors are in Ghana training eight Ghana doctors. Family

medicine physicians have been to Ghana three times—also physical medicine

doctors and orthopedic surgeons. Faculty and students ask lots of questions

before they go over. I tell them who to see. I make things happen, more or less.

I tell them to forget about your morning hot shower and this Internet on demand—because

you won’t get all those things. What UM faculty and students

take away from Ghana is how privileged they are. They also learn a lot, because

a lot of the things they see there they never see here. Like eclampsia—you never

see it. And infectious disease. The number one cause of death for children in the

U.S. is injury. But where I’m from it’s not injury, it’s infectious disease.

Peter Smith


S P H D AT E B O O K

July 11–30, 2010

Graduate Summer Session in Epidemiology

Now in its 45th year, the internationally recognized Graduate Summer Session in Epidemiology

provides instruction in the principles, methods, and applications of epidemiology.

For more information contact Jody Gray at 734.764.5454, umichgss@umich.edu, or visit

www.sph.umich.edu/epid/GSS.

October 4, 2010

Human Rights: Reframing the Public Health Agenda

Held in Rackham Auditorium and open to SPH students, staff, faculty, and alumni, this

year’s all-school symposium examines the critical interplay between health and human

rights. Registration is required; watch for details on the SPH website.

October 14–15, 2010

50th Reunion Celebration and Emeritus Weekend

This UM weekend is a great opportunity for members of the Class

of 1960 and earlier to reconnect with friends, meet new people,

and stay connected. Registration required; for information visit

http://reunions.umich.edu.

November 4, 2010

Thomas Francis Jr. Medal Ceremony

UM President Mary Sue Coleman bestows one of the university’s highest honors, the Thomas

Francis Jr. Medal in Global Public Health, on Alfred Sommer, dean emeritus of the Bloomberg

School of Public Health, Johns Hopkins University. The event begins at 2 pm in Blau Auditorium,

Stephen A. Ross School of Business; for more information visit www.sph.umich.edu.

November 5, 2010

HMP Leadership Symposium: “Reaching Excellence

in Health Management and Policy”

Included in this special event honoring the retirement of UM SPH Professor

John R. Griffith is Professor Griffith’s last lecture. To volunteer or assist in

sponsorship, contact Linda Grosh, managing director, Griffith Leadership

Center: lgrosh@umich.edu or 734.936.5556.

November 6–10, 2010

APHA Annual Meeting, Denver, Colorado

Join us in Denver! Even if you’re not registered for APHA, alumni

and their guests are invited to Michigan’s Keep-In-Touch reception,

Monday, November 8, 6:30 to 8 pm. For more information contact

sph.keepintouch@umich.edu or 734.764.8093.

November 12, 2010

Influenza as a Global Concern:

Where Do We Go from Here?

This all-day symposium honoring UM SPH Professor Arnold Monto

features internationally renowned influenza experts as well as the

Thomas Francis Jr. Lecture, to be delivered by Professor Monto,

on the topic of “The Francis Legacy of Influenza.” For details visit www.sph.umich.edu.

Please Change My Address

Visit www.sph.umich.edu and click on Alumni Record Update or indicate changes

on the address label and mail in an envelope to the address on the back cover.

www.sph.umich.edu www.sph.umich.edu www.sph.umich.eduw

ww.sph.umich.edu www.sph.umich.edu www.sph.umich.edu ww

sph.umich.edu www.sph.umich.edu www.sph.umich.edu www.s

umich.edu www.sph.umich.edu www.sph.umich.edu www.sph.u

mich.edu www.sph.umich.edu www.sph.umich. 51 www.sph.um

ich.edu www.sph.umich.edu www.sph.umich.edu www.sph.umic

edu www.sph.umich.edu www.sph.umich.edu www.sph.umich.e

www.sph.umich.edu www.sph.umich.edu www.sph.umich.edu w

ww.sph.umich.edu www.sph.umich.edu www.sph.umich.edu ww

sph.umich.edu www.sph.umich.edu www.sph.umich.edu www.s

edu www.sph.umich.edu www.sph.umich.edu www.sph.umich.e

New on the Web

Michigan Workplaces

Go Smokefree!

That includes bars and restaurants! A new

SPH topic page gives background on the state

smoking ban,

with video and

audio. Note

that the bill is

named after

the late Ronald

M. Davis, MD, a former American Medical Association

president and SPH faculty member

and advocate for healthy living. More at

http://www.sph.umich.edu/news_events/

smokefree.html.

A Woman’s Place

Is Everywhere

SPH’s Forum on Gender, Sexual, and Reproductive

Health put on an intriguing series of

lectures in early 2010 revolving around global

issues in women’s and reproductive health.

Several were videotaped and are available for

your review at http://www.sph.umich.edu/

sgph/meetings.html.

Get Centered

If you haven’t visited

the SPH Centers &

Initiatives hub lately,

you may not know

about cutting-edge

work in SexLab,

or how Value-Based Insurance Design was

written into U.S. health care reform, or how

to peruse the map of where SPH faculty are

working in global health. Take a refresher tour:

http://www.sph.umich.edu/faculty_

research/research_centers.html.

New Nearly Daily

Aside from the calendar of events, the most

frequently updated section of the SPH website

is probably the Faculty in the News citation

index. That’s because our expert faculty are

quoted nearly daily in popular and scientific

media. We have Google alerts and propriety

software out there continually trawling the

Internet for who’s citing our research, and we

share the results at http://www.sph.umich.

edu/iscr/news_events/clips.cfm.

Tell us how the UM SPH website can serve you

better. Send an e-mail to sph.web@umich.edu.

U N I V E R S I T Y O F M I C H I G A N S C H O O L O F P U B L I C H E A L T H


S N A P S H O T

Massy Mutumba, 27, in front of

Ann Arbor’s Neutral Zone, a teen

center where she volunteers.

Peter Smith

As a nursing student in her native

Uganda, Massy Mutumba came

face to face with the ravages of

HIV/AIDS. “My first patient was 14

years old,” Mutumba remembers.

“She had contracted HIV through

sex work. After her parents passed

away, she’d taken up the sex trade

to feed her siblings. It was such a

very painful experience having to

tell her, ‘You’re positive.’” Mutumba

then took a job at a research

center in Kampala, where she

tested antiretroviral drugs in HIVpositive

children, many of whom

had also been orphaned by AIDS.

A brand-new SPH graduate,

Mutumba, MPH ’10, is about to

embark on a doctorate in health

behavior and health education

at SPH. Ultimately she wants

to return to Uganda to help

the children in her country—

especially HIV-positive children.

“I want to establish programs

where you teach life skills to

these children, because if they

are orphans and have to depend

on others, they are more vulnerable

to exploitation.”

The biggest challenge with

HIV-positive kids, Mutumba says,

“is teaching them how to lead

their lives without spreading the

virus to other people. You have to

teach them life skills—negotiating

for safer sex practices, disclosing

their status to people they want

to have sex with. You also have to

teach them alternatives. If their

partner is not positive, and they

want to have a child, how can

they go about that? Everyone

wants to get married. It’s something

they really want as they

grow up.”

F I N D I N G S W W W . S P H . U M I C H . E D U S P R I N G / S U M M E R 2 0 1 0


f i n dings

Findings is published twice each year

by the University of Michigan School of

Public Health Office of Communications.

Dean Kenneth E. Warner

Director of Communications

Terri Weinstein Mellow

Editor Leslie Stainton

Staff Writers Laura Bailey,

Mary Beth Lewis

Online Editor Mary Beth Lewis

Art Direction/Design Hammond Design

Spread

the News

Copies of Findings may be ordered

from the editor. Articles that appear

in Findings may be reprinted by obtaining

the editor’s permission. Send

correspondence to Editor, Findings,

School of Public Health, University of

Michigan, 1415 Washington Heights,

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available online at www.sph.umich.

edu/findings. ©2010, University of

Michigan

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Regents of the University of Michigan

Julia Donovan Darlow, Ann Arbor

Laurence B. Deitch, Bingham Farms

Denise Ilitch, Bingham Farms

Olivia P. Maynard, Goodrich

Andrea Fischer Newman, Ann Arbor

Andrew C. Richner, Grosse Pointe Park

S. Martin Taylor, Grosse Pointe Farms

Katherine E. White, Ann Arbor

Mary Sue Coleman, ex officio

The University of Michigan, as an equal

opportunity/affirmative action employer,

complies with all applicable federal and state

laws regarding nondiscrimination and

affirmative action. The University of Michigan

is committed to a policy of equal opportunity

for all persons and does not discriminate on

the basis of race, color, national origin, age,

marital status, sex, sexual orientation, gender

identity, gender expression, disability, religion,

height, weight, or veteran status in employment,

educational programs and activities,

and admissions. Inquiries or complaints may

be addressed to the Senior Director for

Institutional Equity, and Title IX/Section 504/

ADA Coordinator, Office of Institutional Equity,

2072 Administrative Services Building, Ann

Arbor, Michigan 48109-1432, 734.763.0235,

TTY 734.647.1388. For other University of

Michigan information call 734.764.1817.

The University of Michigan School of Public Health now

offers a Certificate in the Foundations of Public Health,

a 16-credit graduate program taught entirely online by leading

UM SPH faculty and consisting of these five courses:

> Principles of Environmental Health Sciences

> Psychosocial Factors in Health-Related Behavior

> Introduction to Biostatistics

> Strategies and Uses of Epidemiology

> Survey of the U.S. Health Care System

The 16 credits graduates receive after completing the program

may be applied to a residential or executive MPH/MHSA

program at UM SPH.

For more information visit www.sph.umich.edu/distance,

email CFPHinquiries@umich.edu,

or phone 734.764.5425.

Application deadline for fall 2010 admission: July 15

Public health is where the action is,

so tell everyone you know.

www.sph.umich.edu


University of Michigan School of Public Health

Office of Communications

1415 Washington Heights, Ann Arbor, MI 48109-2029

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ANN ARBOR, MI

PERMIT NO. 14 4

Peter Smith

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