TAG: "Public health"

Secondhand smog


Scientists determine amount of ozone pollution drifting to California from overseas.

Ian Faloona, UC Davis

By Kat Kerlin, UC Davis

Approximately 10 percent of ozone pollution in California’s San Joaquin Valley is estimated to be coming from outside of the state’s borders, particularly from Asia, according to preliminary research presented today (March 31) by the University of California, Davis.

Secondhand smog from Asia and other international sources is finding its way into one of the nation’s most polluted air basins, the San Joaquin Valley. UC Davis atmospheric scientist Ian Faloona shared his research with air quality regulators and scientists today at a transboundary pollution conference near Yosemite National Park. The issue serves as an example of how air quality is a global — not just local — problem.

“To me, it’s an exciting new chapter of how we think of air pollution,” Faloona said. “How do we deal with this not just as an air district of a couple of counties, but as a nation and a global citizen of the planet? Traditionally, air pollution has always been considered an issue to be handled locally, ‘It’s your backyard, it’s your problem.’ But we’re going to have to treat air pollution to some extent how we treat greenhouse gases.”

[Audio clip (1 min, 3 sec) ]

Up in the air

When someone smokes a cigarette next to you, you know that secondhand smoke is harmful to your lungs, even though you aren’t the smoker. But what about when your neighbor is thousands of miles away, and the pollution they are emitting is from an industrial plant, millions of cars, or a raging wildfire?

Scientists have long known that a portion of ozone pollution was coming from overseas, but attempts to quantify just how much were hamstrung by coarse computer models that overlooked or broadly simplified California’s complex terrain.

Faloona describes California as if it were a human body: The Golden Gate bridge is the mouth, breathing in air from across the Pacific Ocean, sucking it through the throat of the Bay Area and into the lungs of the San Joaquin Valley. Previously unknown is how much air comes over the coastal mountain range and mixes from above into the bathtub of the San Joaquin Valley.

UC Davis researchers have spent the past three years trying to measure that contribution from a mountaintop air quality monitoring station near California’s Point Sur. They’ve also gathered it from a plane equipped with scientific instruments that measure air pollutant levels — a flying air monitoring station of sorts. The combined data has allowed them to analyze the “signature” of the sources and quantify how much of the valley’s ozone pollution is locally produced, and how much is drifting across from international sources.

Every little bit counts

The research comes as the U.S. Environmental Protection Agency has proposed tightening ozone limits from 75 parts per billion to between 65 ppb and 70 ppb, later this year. (A final rule is due Oct. 1.) In the San Joaquin Valley, which includes the cities of Fresno, Stockton and Bakersfield, asthma rates are roughly twice that of the rest of the state. Such a change by the EPA is expected to push much of the valley further out of compliance.

Air districts are financially penalized and considered out of compliance for going over federal ozone pollution thresholds, known as National Ambient Air Quality Standards. As they continue to work to improve local air quality, regulators have an increasing stake in being able to account for how much pollution is within their local control and how much is not.

“In addressing the tremendous public health challenge we face in reducing ozone, it is critical to accurately identify the sources of ozone pollution so that solutions can be appropriately targeted,” said Seyed Sadredin, executive director of the San Joaquin Valley Air Pollution Control District. “The scientific information being discussed at the transboundary ozone conference will be invaluable to many regions throughout the nation.”

Share the air

Faloona notes that the majority of the air pollution in California is coming from local sources, which requires further work. His research is not about pointing fingers but about having a clearer picture of where pollution comes from — and how a global community can help reduce it.

“One of the reasons I was so drawn to atmospheric science is because we’re intimately sharing this substance that’s totally vital to us,” Faloona said. “Air is something that we have to share. To me, it’s always been an obvious connector of people. We’re becoming more cognizant of how connected we are and how all of our decisions have to be made on a global scale from here on in.”

[Audio clip (27 sec) ]

The research was funded by the San Joaquin Valley Air Quality Control District.

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Emergency medicine physicians urge colleagues to prevent gun violence


Editorial follows Feb. 24 call to action by eight health professional organizations.

By Carole Gan, UC Davis

In an editorial posted online today (March 25) in the Annals of Emergency Medicine, two practicing emergency medicine physicians from UC Davis and Brown University — both thought leaders at the forefront of finding solutions to the public health crisis of gun violence — urge their colleagues to take direct action to protect the health and safety of patients and communities.

Their editorial follows the Feb. 24 call to action by eight health professional organizations, including the American College of Emergency Physicians and the American Bar Association, to reduce firearm injuries and deaths in the U.S. — unprecedented support that suggests mobilization to prevent firearm violence may be underway.

“Firearm violence causes nearly as many deaths as motor vehicle crashes,” said Garen J. Wintemute, an emergency medicine professor at UC Davis and a national authority on evidence-based strategies to prevent firearm violence. “Firearms are involved in most homicides and suicides, and the number of suicides by firearm is increasing — especially among older white men.

“Emergency medicine physicians have limited opportunities to prevent a death once a shooting has occurred, because most people who die from their wounds do so where they are shot. Gun ownership or having a gun in the household is a well-documented risk factor for a violent death. For that reason, we believe physicians should also work to help prevent shootings,” he said.

The authors describe how America successfully reduced motor-vehicle-related deaths by better vehicle and roadway design and public policies that make driving under the influence a crime. Yet no comparable public-health campaign focused on reducing gun violence has been launched.

The authors particularly emphasize the need for a national policy requiring background checks on all transfers of firearms to help prevent access to firearms by those who are prohibited from having them. They recommend adding two other high-risk groups to the list of individuals who are prohibited from purchasing firearms. These include persons with a history of violent misdemeanor convictions, such as assault and battery and domestic violence, as well as those with a documented history of addiction and alcohol abuse.

“Controlled studies of felons, those who have committed violent misdemeanors and persons prohibited for mental-health reasons have all shown reductions in risk for future violence of 25 percent or more when these individuals are denied firearm purchases,” said Megan Ranney, an emergency medicine physician and director of the Emergency Digital Health Innovation program at Rhode Island Hospital and the Warren Alpert Medical School of Brown University.

The authors also address mental illness and gun violence. While they agree with recommendations that focus on behavior and expanded access to treatment, they emphasize that serious mental illness directly accounts for only 4 percent of interpersonal violence. In contrast, mental illness is associated with between 47 and 74 percent of suicides. The risk of firearm injury increases when mental illness coexists with alcohol abuse, drug abuse and a history of prior violence.

“Physicians need to include questions about firearms when assessing risk of violence in their patients, and need to act on the information, especially when patients are expressing thoughts of dangerousness to themselves or others, are intoxicated or are in the emergency department for a violence-related injury,” Ranney said.

At a time when civilian fatalities from gunshot wounds for 2004 to 2013 have outnumbered combat fatalities from World War II, the authors welcome the unprecedented support from leading organizations of health and legal professionals for policy recommendations to reduce gun violence.

“Physicians can take direct action to protect the health and safety of patients and communities,” Wintemute said. “While we may not all agree on all the specifics, enough of us will agree on enough of them to make a difference for the better.”

The Violence Prevention Research Program is an organized research program of UC Davis that conducts leading-edge research to further America’s efforts to understand and prevent violence. Since its founding over 30 years ago, the program has produced a uniquely rich and informative body of research on the causes, nature and prevention of violence, especially firearm violence. Current areas of emphasis include the prediction of criminal behavior, the effectiveness of waiting period and background-check programs for prospective purchasers of firearms, and the determinants of firearm violence. For more information, visit www.ucdmc.ucdavis.edu/vprp.

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Public health researchers go to church to promote hepatitis B screening


UCLA team held small group discussions in more than 50 L.A.-area Korean churches.

To reach a vulnerable population largely unaware of the health risks, a team from the Fielding School for Public Health held small group discussions in more than 50 Los Angeles-area Korean churches. (Photo by UCLA-Kaiser Permanente Center for Health Equity)

By Dan Gordon, UCLA

For the large Korean American-community in Los Angeles, chronic infection with the hepatitis B virus looms as a significant — and too often unspoken — health threat, associated with the highest rates of liver cancer for any ethnic group in Los Angeles. Knowing one’s hepatitis B status can be critical — it allows those who test HBV-negative to be immunized against the virus while pointing the way toward early treatment as well as more vigilant efforts to prevent transmission for those who are positive. But most adults in L.A.’s Korean-American community have never been screened and are unaware of whether they carry the virus.

In an effort to change that, a research team from the UCLA Fielding School for Public Health’s Kaiser Permanente Center for Health Equity and Center for Cancer Prevention and Control Research, working in partnership with leaders of Los Angeles’ Korean-American community, set out to increase HBV screening in the population through small group discussions led by trained community members. For their study testing the impact of this strategy, they chose unlikely venues: 52 Korean churches in Los Angeles.

“When we started, people questioned the feasibility of having discussions about a sexually transmitted virus at church,” said Roshan Bastani, the Fielding School professor with leadership roles in both centers who headed the study. “But if you want to target a general population of Koreans in Los Angeles, you have to go where they tend to gather. We learned that most Koreans go to church, and that it’s not just religious but also a social experience where non-religious services are delivered to members. In talking with church leaders and other members of the community, we were encouraged to pursue what they saw as an important project.”

If not treated, chronic HBV infection can lead to liver cirrhosis in as many as 1 in 4 carriers, which can ultimately progress to liver cancer. HBV is also highly infectious — spread not only via sexual contact and sharing needles, but also through household items such as razors or toothbrushes, or from an infected mother to her child during birth.

Because it is so common in many Asian countries, HBV disproportionately affects Asian Americans, particularly newer immigrants. The problem is particularly serious among Korean Americans. In Los Angeles, an estimated 12 percent of the Korean-American population is infected — and because the virus causes no symptoms until the liver damage becomes severe, the majority of them doesn’t know it. Although routine HBV vaccination of children has been implemented in the United States and much of Asia for two decades, most adults were born before childhood HBV vaccination became commonplace and can benefit from immunization only once they are tested and found to be HBV-negative. The potential for uninfected adults to get vaccinated, and for carriers to receive early treatment and monitoring while taking measures to prevent transmission to others, all point to the public health benefits of promoting HBV screening.

The Fielding School team relied heavily on the wisdom of its Korean-American community partners for both the design and implementation of an intervention aiming to increase screening. A seven-member community advisory committee included two church pastors, a pastor’s wife, a church elder, a church health leader, a physician and a representative of a Korean-American, nonprofit, faith-based organization. Fifty-one bilingual community members were hired as staff members for the study and trained to administer surveys and facilitate the small group discussion sessions with the churches — ensuring that the intervention could be sustained beyond the three-year study period.

One member hired for the study team with deep roots in the Los Angeles Korean community, Hosung Kim, was assigned the task of inviting the participation of pastors and other church leaders. “My role was to convince them that our project could improve the lives of their members through health care awareness,” said Kim, who covered the activities of Korean churches as a reporter working for a Korean newspaper chain. “I explained that because the overwhelming majority of Korean immigrants participate in Sunday services, this would provide the best opportunity to recruit participants … Most of the responses were very positive.”

Of the 52 Korean churches that participated, half were randomly assigned to the study’s intervention arm, which featured small group discussions on hepatitis B among Korean adults who had either not previously been tested or couldn’t recall their results; the other half, which served as the control group, discussed nutrition and physical activity. The HBV discussions provided facts about hepatitis B and liver cancer, the risk for Koreans, and the rationale for testing. Through scripts and role-playing, participants were guided on how to bring up the topic with their doctors and encouraged to discuss HBV with family and friends. Testing and vaccination were framed within Korean medicine concepts of keeping the body healthy.

The project identified and addressed factors that prevent many Koreans from getting tested, even when they are aware of the HBV risk. Many participants expressed fear about the consequences of learning they were infected, or the potential for bringing shame to their family if they tested positive. There was also concern about the cost of the test — 57 percent of the study participants reported lacking health insurance. In an effort to overcome that barrier, the project staff provided a list of clinics offering low-cost or free HBV screening.

In the end, the discussions proved highly effective: Participants in the intervention group were three times more likely to get a hepatitis B test than those who were in one of the groups that discussed nutrition and physical activity.

“Few previous studies have attempted to identify effective strategies to promote hepatitis B screening among Koreans,” said Beth Glenn, associate professor of health policy and management and a member of the study team. “We were excited to see that a one-time, small-group discussion intervention produced a meaningful increase in hepatitis B screening in a population at high risk for hepatitis B and liver cancer.”

Any concerns the Fielding School team had about testing the intervention in Korean churches were quickly eased.

“For some of our projects, even when we are actively recruiting, it can be hard to find people to participate,” said Alison Hermann, project director for the study. “In this case we would simply go to the churches, set up a table with our banner, and people would come to us. Part of it had to do with the sense of community in the churches, where if something was going on, members wanted to know about it. But we also found that the interest in health-related issues was tremendous.”

This story originally appeared in the UCLA Fielding School of Public Health magazine’s Fall 2014 issue.

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Insuring undocumented residents could help solve multiple health care issues


UCLA health policy care analysis finds four key problem areas for Latinos under ACA.

Alex Ortega, UCLA

By Mark Wheeler, UCLA

Latinos are the largest ethnic minority group in the United States, and it’s expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers.

Latinos’ low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.

Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA:

  • The consequences of not covering undocumented residents.
  • The growth of the Latino population in states that are not participating in the ACA’s Medicaid expansion program.
  • The heavier demand on public and private health care systems serving newly insured Latinos.
  • The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.

“As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels,” Ortega said. “Resolving these four key issues would be an important first step.”

Insurance for the undocumented

Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.

For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA’s expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.

For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA’s exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.

In addition, previous research has shown that undocumented people often delay seeking care for medical problems.

“That likely results in more visits to emergency departments when they are sicker, more complications and more deaths, and more costly care relative to insured patients,” Ortega said.

Insuring the undocumented would help to minimize these problems and would also have a significant economic benefit.

“Given the relatively young age and healthy profiles of undocumented individuals, insuring them through the ACA and expanding Medicaid could help offset the anticipated high costs of managing other patients, especially those who have insurance but also have chronic health problems,” Ortega said.

The growing Latino population in non-ACA Medicaid expansion states

A number of states opted out of ACA Medicaid expansion after the 2012 Supreme Court ruling that made it voluntary for state governments. That trend has had a negative effect on Latinos in these states who would otherwise be eligible for Medicaid benefits, Ortega said.

As of March, 28 states including Washington, D.C., are expanding eligibility for Medicaid under the ACA, and six more are considering expansions. That leaves 16 states who are not participating, many of which have rapidly increasing Latino populations.

“It’s estimated that if every state participated in the Medicaid expansion, nearly all uninsured Latinos would be covered except those barred by current law — the undocumented and those who have been in the U.S. less than five years,” Ortega said. “Without full expansion, existing health disparities among Latinos in these areas may worsen over time, and their health will deteriorate.”

New demands on community clinics and health centers

Nationally, Latinos account for more than 35 percent of patients at community clinics and federally approved health centers. Many community clinics provide culturally sensitive care and play an important role in eliminating racial and ethnic health care disparities.

But Ortega said there is concern about their financial viability. As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.

“These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time,” he said. “So it remains unclear how these clinics will continue to provide care for them.”

Need for diversity in health care workforce

Language barriers also can affect the quality of care for people with limited English proficiency, creating a need for more Latino health care workers — Ortega said the proportion of physicians who are Latino has not significantly changed since the 1980s.

The gap could make Latinos more vulnerable and potentially more expensive to treat than other racial and ethnic groups with better English language skills.

The UCLA study also found recent analyses of states that were among the first to implement their own insurance marketplaces suggesting that reducing the number of people who were uninsured reduced mortality and improved health status among the previously uninsured.

“That, of course, is the goal — to see improvements in the overall health for everyone,” Ortega said.

Other authors of the study were Arturo Vargas Bustamante of UCLA and Hector Rodriguez of UC Berkeley. Funding was provided by the National Heart, Lung, and Blood Institute (P50 HL105188).

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‘Sugar Papers’ reveal industry role in 1970s dental program


Sugar industry worked closely with NIH on research agenda on preventing tooth decay.

By Kristen Bole, UC San Francisco

A newly discovered cache of industry documents reveals that the sugar industry worked closely with the National Institutes of Health in the 1960s and ‘70s to develop a federal research program focused on approaches other than sugar reduction to prevent tooth decay in American children.

An analysis of those papers by researchers at UC San Francisco appears today (March 10) in the open-source scientific journal, PLoS Medicine.

The archive of 319 industry documents, which were uncovered in a public collection at the University of Illinois, revealed that a sugar industry trade organization representing 30 international members had accepted the fact that sugar caused tooth decay as early as 1950, and adopted a strategy aimed at identifying alternative approaches to reducing tooth decay.

Meanwhile, the National Institutes of Health had come to the conclusion in 1969 that focusing on reducing consumption of sucrose, “while theoretically possible,” was not practical as a public health measure.

Thus aligned, the sugar industry trade organization and the NIH worked in parallel and ultimately together on developing alternative research approaches, with a substantial portion of the trade organization’s own research priorities — 78 percent — directly incorporated into the 1971 National Caries Program’s first request for research proposals from scientists.

“The dental community has always known that preventing tooth decay required restricting sugar intake,” said first author Cristin Kearns, D.D.S., M.B.A., a UCSF postdoctoral scholar who discovered the archives. “It was disappointing to learn that the policies we are debating today could have been addressed more than 40 years ago.”

While tooth decay is largely preventable, it remains the leading chronic disease among U.S. children, according to the Centers for Disease Control and Prevention. The CDC estimates that more than half of American children and teens have cavities in their adult teeth, and 15.6 percent of children age 6 to 19 have untreated tooth decay, which can lead to tooth loss, infections and abscesses.

Kearns discovered the papers in a collection that was left to the University of Illinois library by the late Roger Adams, a professor emeritus of organic chemistry who served on the Sugar Research Foundation (SRF) and the scientific advisory board of the International Sugar Research Foundation (ISRF), which became the World Sugar Research Organization.

They include 1,551 pages of correspondence among sugar industry executives, meeting minutes and other relevant reports from between 1959 and 1971. Kearns and UCSF co-authors Stanton A. Glantz, Ph.D., and Laura A. Schmidt, Ph.D., analyzed the papers against documents from the National Institute of Dental Research (NIDR) to explore how the sugar industry may have influenced the research policies of the 1971 National Caries (Tooth Decay) Program.

The analysis showed that in the late 1960s and early 1970s, the sugar industry funded research in collaboration with allied food industries on enzymes to break up dental plaque and a vaccine against tooth decay. It also shows they cultivated relationships with the NIDR and that a sugar industry expert panel overlapped by all but one member with the NIDR panel that influenced the priorities for the NIH tooth decay program. The majority of the research priorities and initial projects largely failed to produce results on a large scale, the authors found.

“These tactics are strikingly similar to what we saw in the tobacco industry in the same era,” said Glantz, whose similar discovery in the 1990s of tobacco industry papers led to massive settlements between the industry and every U.S. state, and to the Department of Justice’s successful prosecution of the major tobacco companies and their research organizations under the Racketeer Influenced and Corrupt Organizations Act. The Legacy Tobacco Documents Library at UCSF now contains 14 million of those documents.

“Our findings are a wake-up call for government officials charged with protecting the public health, as well as public health advocates, to understand that the sugar industry, like the tobacco industry, seeks to protect profits over public health,” Glantz added.

While the authors recognize that the Adams papers provide a narrow window into the activities of one sugar industry trade association, they noted that the sugar industry’s current position remains that public health should focus on fluoride toothpaste, dental sealants and other ways to reduce the harm of sugar, rather than reducing consumption. They concluded that industry opposition to current policy proposals — including the World Health Organization’s newly released guidelines to reduce added sugar to less than 10 percent of daily caloric intake — should not be allowed to block this prudent public health standard.

“There is robust evidence now linking excess sugar consumption with heart disease, diabetes and liver disease, in addition to tooth decay,” said Schmidt, who also is principal investigator on the UCSF-led SugarScience initiative. “Times have definitely changed since that era, but this is a stark lesson in what can happen if we are not careful about maintaining scientific integrity.”

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Are we closing the gender gap?


UCLA report reveals marked inequalities in legal rights for women and girls around world.

The report found that although all but seven countries have made primary education tuition-free, 40 charge tuition before the end of secondary school. (Photo courtesy of UCLA's World Policy Analysis Center)

By Carla Denly, UCLA

On March 9, the United Nations will convene to evaluate the global community’s progress on gender equality in the 20 years since 189 countries adopted the Beijing Declaration and Platform for Action. The U.N. session will continue through March 20.

Closing the Gender Gap,” a new report by UCLA’s World Policy Analysis Center (World), reveals that more than 170 countries have legal barriers preventing women and girls from experiencing the same rights, protections and liberties as men and boys.

World’s new report and accompanying online resource bank take a heightened approach to global accountability and transparency by detailing the rights, laws and policies pertaining to gender equality in 197 countries and Beijing Platform signatories. The resource bank includes quantitatively analyzable data, policy briefs, mobile-friendly interactive maps, infographics, fact sheets and more.

Analysis by World shows that in most countries, gender inequality continues to be embedded in national constitutions, laws and policies:

  • More than 150 countries lack protections critical to ensuring women’s economic participation.
  • Sixty-one countries provide girls with less legal protection from early marriage than they do for boys.
  • Ninety-two countries guarantee paid leave to mothers of infants, but not to fathers, perpetuating inequalities in the burden of caregiving and limiting equal opportunities at work.

The U.S. is not immune from these concerns — here, for example, mothers are not ensured paid leave to care for their newborn children, making the U.S. the world’s only high-income country not to provide such a guarantee. And while more than 80 percent of countries in the world have a constitutional guarantee of gender equality, the U.S. does not.

Yet the report findings indicate that progress is possible. More than 95 percent of the 56 new national constitutions adopted around the world in the past 20 years legally guarantee gender equality. Good legislation and policies exist in all regions and at all country income levels.

“Citizens need and deserve to know their rights and how their country fares when compared to others,” said Dr. Jody Heymann, founding director of the World Policy Analysis Center and dean of the UCLA Fielding School of Public Health. “Only by getting data into the hands of citizens and leaders alike on what effective steps have been taken — and what haven’t — can we close the gender gap in our global community.”

The study examined whether laws treat women and men equally, and whether concrete steps have been taken to reduce inequality. Among the findings:

Constitutions

  • Constitutional guarantees are nearly universal in newly passed constitutions. More than 95 percent of the 56 constitutions that have been adopted since 1995 include guarantees for gender equality, compared with just 79 percent enacted before then. These protections of equality provide a foundation to challenge discriminatory laws.
  • Thirty-two constitutions still do not explicitly guarantee gender equality.
  • Eleven constitutions allow customary or religious law to supersede constitutional protections of gender equality, potentially jeopardizing equal rights for women.
  • Despite constitutional guarantees, discriminatory laws remain in place in many countries around the world.

Families and marriage

  • Only 56 constitutions guarantee equality within marriage and there has been little change in the level of protection over the past 20 years.
  • Legislation also lags behind in this area. Sixty-one countries allow girls to be legally married younger than boys.
  • Inequalities in the law contribute to more girls being married young than boys: Nearly five times more girls than boys are married before the age of 18.
  • While large gaps remain, many countries have strengthened child marriage legislation since Beijing. Among 105 low- and middle-income countries, the percentage of countries that allow girls to be married before age 18 with parental consent fell from to 56 percent in 2013 from 80 percent in 1995.

Families and work

  • One hundred and eighty-eight countries guarantee paid leave for new mothers (the U.S. does not), but only 96 countries provide paid leave for new fathers. This legal inequality reinforces social norms that women are responsible for care and limits women’s economic opportunities, contributing to lower employment rates and wages for women.
  • Caregiving doesn’t end at infancy. Eighty-one countries provide no leave that can be used to meet children’s health needs and five other countries place the burden of meeting children’s health needs solely on women. In 143 countries, no leave can be used to meet children’s educational needs and two other countries place the burden of meeting children’s educational needs solely on women.
  • As the global population ages, leave to care for adult family members is increasingly important. Ninety-seven countries do not provide any leave to meet adult family members’ health needs. This gap disproportionately affects women who carry far more of the elder caregiving globally.
  • Countries that do guarantee paid leave for men and women exist in every region and income level.

Education

  • All but seven countries have made primary education tuition-free, but 40 countries continue to charge tuition before the end of secondary school.
  • When cost is a barrier, girls are more likely to be kept out of schools than boys. Unsurprisingly, the regions with the largest gaps in secondary enrolment for boys and girls are also those that are most likely to charge tuition.
  • Among those countries with available expenditure data, 43 percent that charge tuition before the completion of secondary school spend less than 4 percent of their gross domestic product on education.

Economy and work

  • Only 64 countries constitutionally guarantee women protection from discrimination at work or guarantee equal pay for equal work.
  • Only 40 countries have legislative protections from gender discrimination in hiring and pay.
  • Of constitutions adopted in the past 20 years, 38 percent guarantee protection from discrimination at work, compared to only 12 percent of those that existed previously.

World’s findings provide an opportunity to examine countries’ progress in closing the gender gap, especially in critical areas that impact the daily lives of women and girls — access to quality education and the ability to remain in school, protection from child marriage, equal rights in employment, and policies that ensure health at work and at home.

“When the status of women and girls improves, population health improves and the economic strength of companies and countries increases. Entire families, communities, and countries are lifted up,” Heymann said.

The Maternal and Child Health Equity research program at McGill University helped develop longitudinal data on child marriage, breastfeeding breaks and maternal leave for the study.

The Bill & Melinda Gates Foundation provided grant support for this work to improve the quantity and quality of comparative policy data available in partnership with the Bill, Hillary & Chelsea Clinton Foundation’s No Ceilings Initiative.

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$13M gift launches new maternal and child health center


UC Berkeley’s School of Public Health to launch Wallace Maternal and Child Health Center.

By Jose Rodriguez, UC Berkeley

Dr. Helen Wallace, a world-renowned professor, mentor and advocate known for her passion for improving the lives of women and children, has left a bequest valued at more than $13 million to UC Berkeley’s School of Public Health. The funds will launch the Wallace Maternal and Child Health Center, the campus announced today (March 2).

The new center will engage in innovative, evidence-based research aimed at creating healthier generations of women, mothers, children and families in the United States. It will focus on educating and training public health leaders primarily, but not exclusively, from states west of the Mississippi River through interdisciplinary scholarships and fellowships. The funds also will create a new endowed chair.

By fostering partnerships at every level of research, from discovery science to implementation and dissemination of evidence, the Wallace Center will complement the school’s existing maternal and child health (MCH) program — one of the pre-eminent MCH leadership training programs in the nation — and the Bixby Center for Population, Health and Sustainability.

Wallace, who died in 2013 at the age of 99, mentored generations of students as a professor and chair of the school’s MCH program from 1962 to 1980. She laid important groundwork in the field by fostering collaboration across disciplines at a time when it was rare to do so, and she implemented these practices within the school, in research partnerships and in her writing. She was particularly interested in infant health, maternal mortality, health systems that improved health outcomes, and expanded delivery of health care to mothers and children.

“We are extremely excited and gratified to move our work forward with greater focus and commitment in the arena of maternal and child health, which was the vision of Dr. Helen Wallace,” said Dr. Stefano Bertozzi, dean of the School of Public Health. “The School of Public Health has been taking a leadership role on these issues at the global level for some time now through the Bixby Center for Population, Health, and Sustainability. The new Wallace Maternal and Child Health Center will deepen our work and allow us to focus on attracting and supporting students from the western United States.”

The Wallace Center will embody the values of the School of Public Health: equity, excellence, diversity, innovation, impact and collaboration. By supporting and engaging faculty and students and attracting new talent, the center will play an important role in workforce development while sustaining UC Berkeley’s reputation as a game-changer at the forefront of public health.

Wallace is remembered for visionary efforts that brought together scholars from separate disciplines, such as public health and social welfare, to advance common research goals, and for attracting the school’s first maternal and child health training grant from the federal government.

“She was well-known for mentoring her students and ensuring that what they learned on campus was put to use to benefit society,” said Sylvia Guendelman, professor and chair of the maternal and child health program at UC Berkeley. “She inspired her students to be leaders, to make a positive difference in the world.”

Among the leaders Wallace trained was Dr. Peter van Dyck, who served as associate administrator of the U.S. Health Resources and Services Administration’s Maternal and Child Health Bureau from 1999 to 2011.

“Helen Wallace assured me and others at Berkeley that in maternal and child health, we could touch individual children as well as influence public health by implementing good policy,” said van Dyck. “She was correct. She was a great mentor.”

Guendelman, who will lead the planning effort, said that the center will allow new generations of students to see Wallace’s “vision, spirit and effort endure over time.”

Wallace received her bachelor’s degree from Wellesley College in 1933, her master’s in public health cum laude from the Harvard School of Public Health in 1943 and her medical degree from the Columbia University College of Physicians and Surgeons in 1937.

She was the author of 336 journal articles and 16 textbooks — most recently, ”Health and Welfare for Families in the 21st Century,” the second edition of which was published in 2003. Besides serving as the national health chair of the National Congress of Parents and Teachers, Wallace was secretary of the maternal and child health section and a member of the committee on child health of the American Public Health Association.

She was, in addition, assistant editor of the Journal of the American Women’s Medical Association, as well as a diplomate of both the American Board of Pediatrics and the American Board of Preventive Medicine. She consulted with the World Health Organization in many countries including Uganda, the Philippines, India, Turkey, Iran, Thailand, Burma, Sri Lanka and Nepal, and trained numerous physicians in Africa and Asia.

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On-board school bus filtration system reduces exposure to pollutants


UCLA-developed technology would protect children from harmful exposure.

By Kim Irwin, UCLA

An on-board air filtration system developed specifically for school buses reduces exposure to vehicular pollutants by up to 88 percent, according to a study by researchers at the UCLA Fielding School of Public Health.

The high-efficiency cabin air, or HECA, system could help protect the 25 million American children who commute on school buses nearly every day. Children are more susceptible to air pollution than adults because they breathe more quickly and their immune and cardiovascular systems are still developing, said Yifang Zhu, the study’s senior author and an associate professor in the department of environmental health sciences.

Pollution reduction was even greater under freeway driving conditions, which was surprising because freeways have particularly high pollutant concentrations due to traffic congestion and increased emissions. The study found that the air inside buses with the HECA system was as clean as air near the beach in Santa Monica, California.

The study appears today (March 2) in the early online edition of the peer-reviewed journal Environmental Science and Technology.

“During school bus commuting, children can be exposed to significantly greater levels of air pollutants than a typical resident in the South Coast air basin,” Zhu said. The South Coast air basin encompasses all of Orange County, California, and the non-desert regions of Los Angeles County, Riverside County, and San Bernardino County.

“Studies have shown that exposure to high levels of vehicle pollution is associated with pulmonary and cardiovascular health risks, including oxidative stress, mitochondrial damage and acute pulmonary inflammation,” she said.

Studies have also found that children exposed to pollutants from vehicles tend to perform less well in school.

The new study tested six school buses without children on board while the buses were still, and while they were driving on freeways and major arterial roadways in Los Angeles. Researchers tested the air both inside and outside of the buses for vehicle-emitted particulate matter, including black carbon and fine and ultrafine particles, down to a few nanometers in size.

A study funded by the California Air Resources Board more than a decade ago was the first to find serious air quality problems inside diesel-powered school buses. That study led to efforts to retrofit school buses with exterior pollution-reducing devices. While that method is promising for minimizing emissions from buses’ tailpipes, it doesn’t always provide cleaner air inside the buses. A majority of school buses today are not equipped with any interior mechanical filtration systems, said Eon Lee, the study’s first author and a postdoctoral researcher in Zhu’s lab.

A previous study by Zhu and her team found that commercially available household air purifiers can reduce pollutant levels inside school buses by about 50 percent. However, they are not designed to work in moving vehicles.

As part of the new study, researchers developed a prototype on-board HECA filtration system for buses and installed two in the rear of each of the six buses tested. Air was drawn in through diffusers on the sides of each unit and fed through the HECA filter. The filtered air was then delivered at a constant rate through air ducts.

“School buses are by far the safest way to transport children between school and home,” Zhu said. “Our goal is to make it also the cleanest way.”

A long-term follow-up study will evaluate how much exposure can be reduced by operating the HECA filtration system in a large number of school buses with children aboard, Zhu said.

“The developed HECA filtration system has great potential to substantially reduce children’s exposure to vehicle pollutants while commuting inside school buses,” the study states.

The study was funded by the California Air Resources Board. The HECA filtration system was developed in collaboration with IQAir North America.

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Recommendations for improving farmworker health to be unveiled


Briefing will be held March 17 at UC Center Sacramento.

>>Register for briefing

By Pat Bailey, UC Davis

An update on the status of health among agricultural workers and their families, as well as policy recommendations for making related health care advances, will be presented from noon to 1 p.m. Tuesday, March 17, at UC Center Sacramento.

“A variety of social, economic and political factors have converged to create a uniquely opportune moment to take action and improve the health of farmworkers and their families,” said Marc Schenker, distinguished professor of public health sciences and medicine at UC Davis and co-director of the Center of Expertise on Migration and Health of the UC Global Health Institute (UCGHI).

Policy recommendations will involve health care funding and insurance, occupational safety, labor law enforcement, and improving farmworker living conditions.

In addition to Schenker, speakers at the briefing will include Gil Ojeda, director of the California Program on Access to Care at the UC Berkeley School of Public Health, and Tom Coates, director of UCLA’s Center for World Health and co-director of the UC Global Health Institute. A panel including representatives from a nonprofit social services organization, a farmworker advisory group and a major California berry grower will provide responses to the presentation.

The presentation is free and open to the public, however attendees are asked to register at http://tinyurl.com/pjlgge7. The UC Center Sacramento is located at 1130 K St., Sacramento.

The event is sponsored by the UC Global Health Institute, with support from the California Program on Access to Care, Western Center for Agricultural Health and Safety, Migration and Health Research Center, and Health Initiative of the Americas.

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Income inequality is taking toll on health of American workers


The degree of income inequality can lead to shortened life expectancy.

By Mark Wheeler, UCLA

“Income inequality” has already become a buzz phrase for the campaigns leading up to the 2016 elections. Likely candidates and pundits on both ends of the political spectrum have begun to talk about how fairness, social justice and — even after the implementation of the Affordable Care Act — the cost of health care insurance are contributing to the large and growing gap between the rich and poor.

But a commentary by researchers at the UCLA Fielding School of Public Health points out another disturbing impact of income inequality: its effect on people’s health. The article appears in the current online edition of the American Journal of Public Health.

It has long been recognized that, even beyond access to high quality health care, people’s income is a key factor in determining how healthy people are. But the commentary provides evidence that the degree of income inequality also can lead to a long list of health issues, including shortened life expectancy and poorer self-reported health status.

Dr. Linda Rosenstock, the report’s senior author, said lower- and sometimes middle-income wage workers often face additional workplace stresses that take a toll on their health — among them, lower pay, lack of paid sick leave, an inability to find full-time work, the need to work double shifts to make ends meet. Those challenges can lead to high levels of stress, exhaustion, cardiovascular disease, lower life expectancy and obesity, and the effects can easily trickle down to impact families and children.

“We interpret the evidence to find that income inequality is taking a toll on worker health,” said Rosenstock, a UCLA professor of health policy and management and the former dean of the Fielding School. “Low- and middle-income workers face stagnant wages and pressures from a changing work environment. These changes in the work environment changes — such as increasing job insecurity, work performed outside of a regular full-time contract, and having fewer workers to do the same amount of work — are taking their toll on a workforce.”

The gap between the rich and the poor has expanded significantly since 1980, when the top 5 percent of wage earners accounted for almost 17 percent of all incomes, according to U.S. Census Bureau data. In 2013, that segment of the population earned 22 percent of total income. The changes were even more dramatic for those at the highest end of the income ladder, the top 1 percent and even the top one-tenth of a percent.

Another measure that reflects the divide between the economic elite and all others is the gap in pay between production workers and the CEOs of the companies they work for. In 1970, CEOs’ cash compensation averaged $25 for every $1 earned by nonsupervisory workers. Yet a mere 30 years later the ratio was 90 to 1, and, if the expected value of stock options in CEOs’ compensation is included, the ratio reaches more than 500 to 1.

“Out-of-pocket expenses for health care such as premiums, deductibles and co-payments are an increasing portion of stagnant wages,” Rosenstock said. She noted that one organization estimated that such costs increased by 89 percent from 2003 to 2013. “In 2013, among firms with at least 35 percent of their workforce making $23,000 or less per year, 48 percent of workers for single coverage had a deductible of at least $1,000 — a significant portion of their income.”

The commentary points to the health care industry — where there is a large disparity between the salaries for the lowest earners, such as nurses aides, and the top earners, such as surgeons — as one microcosm of the problems caused by inequality and changes in work organization.

“As the costs of medical care have risen in the United States, pressure on the industry has increased to improve efficiency,” said Jessica Allia Williams, the report’s first author, a former UCLA doctoral student in health policy and management who is now a postdoctoral fellow at the Harvard School of Public Health.

As a result, she said, lower-paid workers face the perfect storm of income inequality — being asked to work more with less, while also paying more for insurance premiums and out-of pocket medical expenses.

“Also, across the spectrum, health care workers face relatively high rates of injury owing to physical hazards such as lifting patients or getting stuck by needles,” Williams said, adding that they also are likely to work nonstandard shifts and more overtime and to face hazards such as violence in the workplace that further contribute to poor health.

Rosenstock said the effects of the Affordable Care Act on these trends are still unclear, especially because of the delay in implementing the employer mandate for health insurance. But despite the benefit of having more of the population insured, early evidence suggests that the ACA is causing lower-income workers to have to pay more of the costs of care out of their cash compensation.

“It’s clear that income inequality and working conditions affect the health of the U.S. workforce,” she said. “Although political differences may divide the policy approaches our elected officials may take, addressing income inequality is likely to improve the overall social and health well-being of those currently left behind.”

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Eat.Think.Design: A public health course for the startup generation


UC Berkeley course feeds need for rethinking problems of food and nutrition.

By Tamara Straus, UC Berkeley

For the creators of the UC Berkeley course Eat.Think.Design, two things are certain.

First, the United States is facing a food and nutrition crisis, with rocketing rates of diabetes, hunger and health disparity.

Second, graduate students today — from fields as different as public health, business, information technology and engineering — want their education to be more hands-on, more interdisciplinary and more “impactful” to society at large.

In the case of the Eat.Think.Design course, they want to spend class time not just learning about food and nutrition problems, they want to devise actual food and nutrition solutions.

This may sound grand, but for the course’s three instructors — Jaspal Sandhu, a UC Berkeley lecturer in design and innovation; Nap Hosang, a longtime Kaiser Permanente medical doctor and UC Berkeley School of Public Health instructor; and Kristine Madsen, an associate professor in the Joint Medical Program and Public Health Nutrition at Cal’s School of Public Health — there is nothing grand or inappropriate about letting students attempt societal solutions while in graduate school.

“The reason we emphasize experiential learning is because it has proved to be more effective,” says Sandhu, who is also a partner at the Gobee Group, a consulting firm he runs with two other multilingual Fulbright scholars with UC Berkeley roots. Sandhu speaks Punjabi, Spanish, Mongolian and English, and prior to Gobee worked with the Mongolian Ministry of Health designing mobile health information systems.

Sandhu emphasizes that his students’ backgrounds demand more than lecturing. Among the 25 people enrolled in Eat.Think.Design this spring, many have relevant work experience. At least three have started their own companies, several have worked for big companies like IBM, Deloitte and Eli Lilly, and most have about five years under their belts working for government agencies or large nonprofits. “To keep the attention of such students,” says Sandhu, “we need to give them actual problems to focus on.”

Working in interdisciplinary teams of three under an instructor, Eat.Think.Design students spend the bulk of the semester on one project, conducting ethnographic and market research, investigating models and constantly devising and then revising potential solutions. Members of last year’s class, for example, streamlined SNAP federal nutrition benefits payments at San Francisco’s Heart of the City Farmer’s Market, worked with the Kossoye Development Program in Ethiopia on strategies to make home gardening more accessible and built a pilot program with Partners In Health: Navajo Nation to test a pop-up grocery store in areas that are one hour’s drive from fresh food. Although the project in the Navajo Nation helped COPE to receive a three-year, $3 million REACH grant from the Centers for Disease Control & Prevention to pursue healthy eating programs in the vast American Indian territory — Hosang argues that the course is not designed to incubate social innovations per se.

“Our goal is to incubate innovative people — people who can be influencers in the public health sector,” he says.

Hosang, who has served as head of the interdisciplinary online MPH degree program for the past 15 years and executive director of the Interdisciplinary MPH degree program since 2010, is not subtle in his criticism of public health teaching.

“Most academics are in a silo,” he said, “and their silo has driven them more and more into their specialist thinking.”

Yet this specialist thinking, Hosang argues, is running counter to the view that public health is enmeshed in almost every field — from architecture and transportation, to product design and education.

“We need to change the way public health professionals approach problems,” said Hosang, “and we need them to be in touch with people from other disciplines to inform their problem-solving processes.”

Hosang and Sandhu started working on their public health course in October 2010, after Hosang read Sandhu’s dissertation on public health design research in rural Mongolia and was impressed by the combination of grassroots and trial-and-error learning. In the spring of 2011, they launched their course, with financial support from the Blum Center for Developing Economies, which seeds interdisciplinary, social impact courses on campus. Madsen joined the course in 2014 when the focus narrowed from designing innovative public health solutions to designing innovative food solutions. In a forthcoming article in the American Journal of Public Health titled “Solutions That Stick: Activating Cross-Disciplinary Collaboration in a Graduate-Level Public Health Innovations Course at the University of California,” the three instructors describe how their approach is part of a much-needed pedagogical shift. They write:

A Lancet Commission, convened to discuss the education of health professionals in the 21st century, argued that educational transformation is critical to meet the public health problems we face in this century. Specifically, the commission called for a higher level of learning, moving beyond informative learning, which transmits knowledge to create experts, to transformative learning, which transmits leadership attributes to create agents who can successfully implement change.”

Sandhu explained that when he and Hosang came up with the idea for the course, not only was this “change agent” approach novel but no one was applying design thinking or human-centered design approaches at the School of Public Health at UC Berkeley. (He describes those approaches as ones that enable teams to systematically develop novel, effective solutions to complex problems.) Yet Sandhu says it is clear there’s a demand for this kind of problem solving.

Sandhu’s proof is the continual over-enrollment in and rave reviews of his course. This year, 60 students applied for 25 spots. And for the past four years, 40 percent of students indicated it was the “best course” they took at UC Berkeley, with the other 40 percent stating it was in the “top 10 percent” and the rest saying it was in the “top 25 percent.”

Christine Hamann, an M.B.A./M.P.H. candidate who took Eat.Think.Design in 2014, confirmed that “the teaching team is phenomenal — both in terms of the academic leadership and the mentoring of graduate students.”

She also confirmed that she and her fellow students want “practical challenges in graduate school,” adding, “we are tired of theory.”

Hamann is one of the many students who has brought past work into the classroom. Before grad school, she worked for seven years at Partners In Health, most recently on the nonprofit’s COPE Project in the Navajo Nation. She said the course forced her to look at Navajo Nation residents’ consumer needs around food and nutrition — and to see food less as a supply issue and more of a demand issue.

“Traditional public health approaches focus on supply, but that is why you see programs that don’t meet the needs of the community,” she said.

Hamann and the three other graduate students opted not to focus on the best truck routes to bring fresh produce into the 27,000 square mile territory — and instead focused on seeing what citizens there want to consume and what can last in what is a food (and actual) desert. During the summer of 2014, with funding from the Blum Center, Hamann created pop-up grocery stores in Navajo, to determine which food items were most in demand and could help reduce chronic diseases like diabetes, which affects 20 percent of residents. This exploration helped lead to the aforementioned $3 million CDC grant for COPE.

As to why so many Cal students are so focused on food and nutrition, Hamann has this to say: “From a public health perspective, I think we’re seeing the ramifications of the American diet play out in really scary chronic disease indicators.” She also noted that there is a general heightened awareness of food systems — “of where food is coming from, the corporations that own it, and the detrimental effects those relationships can have on both health outcomes and business models.” Third, Hamann said a growing number of students want to see tech innovation applied to less wealthy and less urban populations—“the people,” she said, “who need it.”

Then, there are the galling statistics: Americans throw out an estimated 40 percent of food grown per year. An estimated 50 million Americans do not have access to enough food. As of 2012, about half of all adults — 117 million people — have one or more chronic health conditions, such as heart disease, stroke, cancer, diabetes, obesity and arthritis. And childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years.

Sandhu is aware that a course on food innovation is well timed at UC Berkeley. In 2013, UC Berkeley’s College of Natural Resources, the Goldman School of Public Policy, the Graduate School of Journalism, Berkeley Law and the School of Public Health joined forces to create the Berkeley Food Institute to improve food systems locally and globally. A year later, UC President Janet Napolitano launched the UC Global Food Initiative — to prompt all 10 campuses, UC’s Division of Agricultural and Natural Resources, Lawrence Berkeley National Lab, and a consortium of faculty, researchers and students to address food security, nutrition and sustainability issues. Even BigIdeas@Berkeley, the annual student innovation prize, has a contest category on food systems innovation.

“Our timing is either well forecasted or extremely lucky,” said Sandhu.

Eat.Think.Design may be a popular course — and may inspire copycats — but both students and instructors are quick to point out that the course cannot serve as a model for every graduate-level class.

“It is difficult to take more than one experiential class per semester,” said Hamann. “The time commitment with fellow students and with our client is just too big.”

Amy Regan, who took the course in 2013 and now works with the San Francisco Unified School District’s Future Dining Experience program, agrees that “compromising and agreeing on the best approach among a group takes time.”

For instructors, professor Madsen estimates the course requires one and a half to two times more time than an average School of Public Health offering, because she, Sandhu and Hosang each mentor three student groups during and after class time. The three instructors also spend time cultivating their connections to bring in student projects from nonprofits and government agencies. During the class on Feb. 4, 16 pitches were made by representatives of various organizations, including California Farm to Fork, San Quentin State Prison and Project Open Hand.

“Much more work goes into creating the class because of all the connections to be made,” said Madsen.

And very little is scripted. This gives the course the feeling of a kind of pedagogical startup, exciting but uncertain. Madsen said this atmosphere comes with a distinct disadvantage for professors.

“You have to admit you don’t know as much,” she said. “If your identity is wrapped up in being an academic expert, this won’t work; you’ll always default to the more narrow but comfortable path.”

For Sandhu and Hosang, who are adjuncts, there is less face to lose.

“I think over the last seven years, since the start of the Great Recession, there’s been a transformative energy happening in higher education,” said Hosang. “It’s coming from the younger generation who see the world has changed and who no longer see college as a ticket to success. That’s where this move toward an interdisciplinary, hands-on approach is coming from.”

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It’s a bird, it’s a plane, it’s a ‘superhero of public health’


UC Irvine professor’s article finds creative way to highlight public health giants.

Brandon Brown, UC Irvine assistant professor of public health, found a novel way to honor the heroes in his field in the current issue of the Journal of Public Health.

His article, “Childhood Idols, Shifting from Superheroes to Public Health Heroes,” promotes the use of superheroes in campaigns to teach young children about the vast world of public health — from basic hygiene to emerging diseases.

Pioneering physician and cholera foe John Snow is transformed into “the hero of Broad Street” in a poster that raises awareness of the British doctor’s role in bringing about changes in the water and waste systems of London.

“Public health figures serve as role models to fight diseases or promote healthy living and serve as an inspiration to improve global health for future generations,” Brown says. “We must strive to realize the imagined world where children idolize heroes that they can become in the future.”

Other public health giants immortalized in Brown’s article are Ignaz Semmelweis and Luther Terry. Brown co-authored the article with Melissa Nasiruddin, Alejandra Cabral and Melissa Soohoo.

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