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Knowledge is power, as the saying goes. And the research
activities of faculty in every department of the School of Public Health and
Health Services (SPHHS) are generating a lot of that power.
In one corner of the campus, faculty members from several departments are
collaborating to identify opportunities for non-physicians to administer HIV
medications in Africa. In another, an exercise physiologist is using a
well-established model of human behavior to learn why people don’t join health
clubs. Along with their many colleagues, they are advancing the science of
public health while burnishing the School’s reputation as an incubator of
knowledge, and driving new approaches to policy and practice.
This article, the last of three features in GW Medicine and Health that
celebrate the School’s tenth anniversary, profiles the scientific work taking
place throughout SPHHS. And it shows how that work gets used in the real
world—to inform the law, shape best practices in public health, and influence
the structure and financing of the healthcare system.
Grounding Policy in Sound Science
Although many people think first of white coats and microscopes when they hear
the word science, the field is more accurately defined as the process by which
verifiable knowledge systematically accumulates. SPHHS’ Project on Scientific
Knowledge and Public Policy (SKAPP) takes that broad perspective as it works to
keep scientists informed and government decisionmakers honest through empirical
research, conversations among scholars, conferences and publications.
“We’re a technological society and there is a scientific component to so much of
what we do,” says David Michaels, PhD, MPH, SKAPP’s director and research
professor in Environmental and Occupational Health, where the project is housed.
“To protect the public health, we need to bring the best available scientific
evidence to the legal and regulatory arenas.”
SKAPP’s recent activities have focused on ”manufactured uncertainty,” a
technique to raise doubt about generally established science in order to
postpone regulatory action and “sequestered science,” where findings are
shielded from public view. SKAPP is also an advocate for stricter research
sponsorship disclosure requirements within federal regulatory agencies.
“Our primary interest is in how science gets translated into policy, both in the
courts and through regulation,” says Dr. Michaels. “We engage in a dialogue with
the scientific community because we think it should have a strong voice, and it
should know how its work is used and misused.”
The Interplay of Clinical Knowledge and Public Health Practice
A foundation of clinical knowledge is often the launching pad for public health
interventions. At SPHHS, some faculty members are laying that foundation,
testing hypotheses that become the basis of clinical practice, while others are
putting the findings to community use.
In Epidemiology and Biostatistics, Sarah Fowler, PhD, MS, who directs GW’s
Biostatistics Center and the Diabetes Prevention Program Research Group, helped
to design and analyze a multi-site clinical trial studying people at high risk
for diabetes. After following more than 3,000 pre-diabetic patients for almost
two years, the study concluded that interventions focused on diet and exercise,
or on pharmaceutical therapy lessened the probability of developing diabetes.
In 2002, The New England Journal of Medicine published the seminal article on
the findings, which led the American Diabetes Association to change its
screening guidelines. “They will only change their guidelines if something is
evidence-based,” says Dr. Fowler. “They need published results.”
Elsewhere, SPHHS researchers are identifying opportunities to apply good
science. In June 2006, the Food and Drug Administration approved a vaccine to
prevent infection with the human papillomavirus (HPV), which causes 70 percent
of all cases of cervical cancer. CDC’s Advisory Committee on Immunization
Practices now recommends immunizing all girls and young women. But HPV’s
association with adolescent sexuality and a legacy of suspicion toward the
medical community have engendered heated resistance in some quarters to its use,
and especially to mandates.
Alexandra Stewart, JD, assistant research professor in Health Policy, is trying
to change that. “We should embrace good technology,” says Stewart. “I’m
reminding people that vaccines are one of the best things that ever happened to
us.” To persuade those who are in a position to influence vaccine policy,
Stewart is on the stump speaking to physician groups, the American Cancer
Society, state legislatures and others about the role of vaccines, the history
of mandates, and available financing and distribution mechanisms.
Richard Windsor, PhD, MS, MPH, professor in Prevention and Community Health,
works both sides of the equation. He has helped to produce new clinical
knowledge, through a series of NIH-funded randomized trials he directed, and
then formed partnerships to guide its dissemination into the healthcare system.
Dr. Windsor developed the Smoking Cessation or Reduction in Pregnancy Treatment
(SCRIPT) method in the early 1980s, combining professional counseling during a
woman’s first prenatal care visit, a videotape and accessible educational
material to encourage her to stop smoking.
The SCRIPT method has subsequently been refined and evaluated in five states and
four countries, and recommended by the federal Agency for Health Care Research
and Quality and the American College of Obstetricians and Gynecologists. West
Virginia, with the highest smoking rate in the U.S., is adopting and evaluating
the program statewide for its Medicaid patients.
“The key to improving science is measurement,” says Dr. Windsor. “When we can
say, ‘this is what the evidence shows,’ we can progressively improve our
methods, recommend them through the peer-reviewed literature, and gain the
support of the professional societies.”
Breaking down Barriers
Another important focus of research at SPHHS is identifying barriers to care and
developing strategies for overcoming them. In Health Policy, assistant research
Professor Taylor Burke, JD, LLM, is part of a faculty team examining legal
impediments to health information technology, such as electronic patient
records, with an eye toward generating the data needed to reduce racial and
ethnic disparities. “Data is automated in almost every other industry,” says
Burke. “We need to understand what is keeping the rate of adoption so slow in
healthcare.”
The analysis, funded by the Robert Wood Johnson Foundation, has identified both
real and perceived legal barriers to technology that allows clinicians to share
patient information. One misperception is that physicians are not allowed to
record race or ethnicity in the medical record. “That is massively incorrect,”
says Burke. “It is perfectly legal to collect these data and we need them to do
the electronic analyses that identify pockets of problems—in a community, in a
hospital, in a doctor’s office.”
Federal privacy regulations, liability concerns and even anti-kickback
regulations are also perceived as barriers, but they need not be. “For us, the
scientific data is the body of case law and our task is to translate that into
quality improvement changes,” says Burke.
When it comes to appropriate treatment for alcohol problems, the law has been a
very real obstacle. But that’s beginning to change, thanks, in part, to the work
of Eric Goplerud, PhD, MA, research professor, Health Policy, and director of
Ensuring Solutions to Alcohol Problems, funded by the Pew Charitable Trusts.
When Ensuring Solutions was launched in 2002, most states allowed insurance
companies to deny reimbursement to individuals whose injuries resulted from
alcohol use. That was a major disincentive for doctors and hospitals to screen
for alcohol use. Working with community and healthcare partners, Ensuring
Solutions has helped to repeal 12 such “alcohol exclusion” laws, including one
in the District of Columbia.
The push to overturn those laws responded to research demonstrating that alcohol
screening, combined with a brief intervention, is cost effective. That also
helped Dr. Goplerud persuade the Centers for Medicaid and Medicare Services
(CMS) to reimburse physicians for certain alcohol-related diagnostic and
treatment services to Medicaid patients, a rule change that happened in January
2007. CMS is likely to soon reimburse care for Medicare recipients as well.
“Our job is to help make the science relevant to the decisions people face every
day,” says Dr. Goplerud. “A lot of what we do is build relationships so we can
take the science and walk it around.”
A body of robust research literature also guides Speaking Together, a national
program of the Robert Wood Johnson Foundation headquartered at SPHHS and
designed to improve care for non-English-speaking people through the use of
interpreters. “We know that the best way to provide communication services to
people with limited English proficiency is through individuals who have been
trained and assessed,” says Marsha Regenstein, PhD, MCP, who directs Speaking
Together and is associate research professor in Health Policy.
Because Speaking Together was designed as a quality improvement initiative,
national program office staff first created performance measures, which had not
previously existed. Ten hospitals around the country then received funds to
collect data and track their progress in enhancing language services.
“We are trying to flip the switch to make communication more seamless,” says Dr.
Regenstein. “If interpreter services are available in a healthcare organization,
but are inconvenient, they won’t be used. If they create long delays, they won’t
be used. These services have to be high quality, they have to be timely, and
they have to be easy.”
Changing Paradigms
Science is a dynamic enterprise, and sometimes new paradigms are needed as
knowledge evolves, theories emerge and novel challenges surface.
Contaminant risk assessment is one of those changing fields. Traditionally, it
has been targeted primarily at chemical exposures, such as toxins in the
workplace or industrial contaminants in the soil. But concerns about
bioterrorism and contaminants in food, water, and human and animal wastes have
increased the awareness of microorganisms, which represent a very different kind
of threat. Unlike chemicals, microbes journey through life stages, behaving
differently at every stage, and they interact with other microbes—and with
humans—in biologically complex ways that change over time.
“Chemical risk assessment is a snapshot, a moment in time,” says Rebecca Parkin,
PhD, MPH, professor in Environmental and Occupational Health. “Microbial risk
assessment has to be more like a movie. A much more complicated framework is
required to understand what that means in terms of human risk.”
Dr. Parkin has helped the World Health Organization identify subpopulations with
special susceptibility to microorganisms and has reviewed microbial risk
assessment frameworks in use around the world for the EPA. ”Most nations have
tried simply to adapt their approach to assessing chemical risks,” Dr. Parkin
says. “That doesn’t work very well to address the complexities of microbial risk
assessment.” To lay the new foundation for appropriate regulatory standards, Dr.
Parkin and her colleagues are instead pushing the boundaries of science.
Sometimes, changing paradigms does not mean inventing something new so much as
returning to an earlier approach. When the system of federally funded health
centers was first developed in the 1960s, its intent was to improve health for
the entire community. In more recent years, the demands of providing individual
patient care have shifted attention away from population-based initiatives.
Seiji Hayashi, MD, MPH, who directs the Community-Oriented Primary Care (COPC)
program in Prevention and Community Health, is looking for ways to reemphasize
that earlier approach. “Under current funding schemes, health centers are not
reimbursed for outreach into the community, so that outreach is difficult to
sustain,” says Dr. Hayashi. “We think if COPC can help the health centers
restructure their services to meet community needs, it would build efficiency
and enable them to expand their scope.”
With support from the federal Health Resources and Services Administration and
the nonprofit Institute for Healthcare Improvement, Dr. Hayashi and his
colleagues have produced a white paper that identifies opportunities to build
synergy among COPC, the patient care model at the health centers, and the
initiatives of HRSA’s Health Disparities Collaborative, which works to improve
chronic disease care in poor and minority communities. Next step: a tool kit for
health centers.
An Eye toward the Future
The projects profiled here offer only a glimpse of the work underway at SPHHS to create new knowledge and turn it into effective practice. They also highlight only a fraction of the challenges.
Since the new century began, bioterrorism and emergency preparedness have captured significant public health resources. The urgency of addressing the problem of obesity and diabetes has also become more apparent. Meanwhile, longstanding challenges, including tobacco use, infectious diseases, vaccine policy, clean water and healthcare disparities, still retain their claim on public health attention.
Developing, implementing, evaluating and disseminating good science are the tools for meeting those challenges. SPHHS has taken a leadership role in using those tools to build the knowledge that powers change.
(This article was written by Karyn Feiden, a freelance writer specializing in public health)