Make Penn Your Gym!

Make Penn Your Gym table on Locust Walk

Make Penn Your Gym table on Locust Walk

 

We recently celebrated National Public Health Week (April 6-10) – with a twist! The Center for Public Health Initiatives (CPHI), Penn HR, Student Health Services (SHS), and the Penn Public Health Society (PPHS) collaborated to present “Make Penn Your Gym” to Penn’s campus. This pilot campaign was based on “Make NYC Your Gym”, a program dedicated to showing New  Yorkers how they can take advantage of the surrounding built environment, get in their necessary exercise, and fit daily activities into busy schedules. Added bonus: it’s free! No gym membership required.  For “Make Penn Your Gym”, SHS identified various jogging routes (1-, 2-, and 3-miles) throughout Penn’s campus and University City. PPHS and CPHI then designed and printed trifold maps of these routes, which were distributed from a table on Locust Walk between April 6th and April 10th. The table also featured some public health “swag” – travel hand sanitizers, SPF 23 lip balm, granola bars – as well as a simple survey for those interested (for example, “How could YOU make Penn your gym?”). Going forward, those survey responses will help shape the future of “Make Penn Your Gym”. Thank you to those who participated and stay tuned for more opportunities to “Make Penn Your Gym”!

Written by: Matthew Kearney, MPH Candidate 2016

Fieldwork in Bosquet, Cameroon

Meagan Rubel & research participant

Meagan Rubel & research participant

In the week that I have been doing field work in remote rainforest village of Bosquet in east Cameroon, I have become extremely proficient at asking people if they are able to give a fecal sample. I recognize that this is a strange thing to be “proficient” at, but me and the team that I am working with will have to do this hundreds of times to get enough samples as part of my and the Tishkoff Lab’s research. Walking people discreetly to a side of the school we are using for “base operations” this week, I ask them in my fledgling French, “Vous pouvez faire des selles?” (Can you make stool?). For people who agree, I hand them a new, sterile plastic container with a lid and provide them with toilet paper. After this, we will freeze a portion of the sample in liquid nitrogen for analysis and use another portion to do fecal microscopy directly in the field to identify any infectious agents present in the stool, which can then be treated by a physician working with our collaborators at the University of Yaounde 1.

Sunset with the Baka in the village of Bosquet, Cameroon.

Sunset with the Baka in the village of Bosquet, Cameroon.

I’m here for two months with eight other team members- one, Dr. Alessia Ranciaro, is a senior research scientist in my lab, and our other colleagues are from Cameroon. We are conducting research as part of Dr. Sarah Tishkoff’s investigations into phenotypic (what you see when you look at someone) and genotypic (a person’s genetic makeup) variation in diverse Cameroonian populations. I’m also collecting fecal samples for my PhD research on the gut microbiomes (the microorganisms in your gut including bacteria, fungi, and archaea that have functions in many aspects of our physiology, including immunity and digestion) of Cameroonians practicing different kinds of subsistence, with a focus on how infectious gut parasites, including various soil transmitted helminths and schistosomes endemic to the region may have a role in shaping the composition and diversity of the gut microbiome. This fieldwork will also be part of the required field experience for the MPH degree at Penn.

A Baka woman balances a bucket of water on her head, retrieved from the local covered well.

A Baka woman balances a bucket of water on her head, retrieved from the local covered well.

Cameroon is a country of immense cultural, linguistic, and environmental diversity, with populations that practice pastoralist, agriculturalist, and hunter-gatherer subsistence and have diverse diets. The people of Bosquet are Baka, a recently settled hunting and gathering group of approximately 2,000 people. Their ethnic group, along with those of other equatorial African rainforest hunter gatherers, are more commonly known as pygmies due to their short stature, although this term is considered pejorative by many Baka. Nowadays, the Baka live primarily in mud brick huts with dirt floors, and have very limited access to electricity. While many of them have small gardening plots to cultivate yams, cassava, plantains, and bananas, and they no longer travel in small, mobile bands through the forest, they still rely heavily on the forest to hunt bushmeat such as antelope, giant forest rats, and monkeys, in addition to providing various wild fruits and honey, and several traditional medicines to treat common (and potentially life threatening) ailments such as malaria and diarrheal disease. The Baka of Bosquet have access to a covered well, which provides them with a source of clean water for drinking and bathing, although streams are often used, too.

Cassava (manioc), a dietary staple of the Baka, being harvested and prepared.

Cassava (manioc), a dietary staple of the Baka, being harvested and prepared.

All of these dietary changes we are observing in indigenous groups are important to understanding the structure of the gut microbiome; some groups may possess certain kinds of bacteria that have allowed them to better digest particular kinds of foods as an example of adaptation to local environments. As their diets and health change, we can hypothesize about the kinds of shifts we may see in the microbiome, and consider the downstream implications for disease. For instance- as groups like the Baka become more settled, and potentially rely less on foraging in the rainforest and increasingly eat processed foods, will their gut microbiomes start to look like those of neighboring Bantu agriculturalist groups? This has implications for the kinds of chronic diseases we may begin to see in many of these groups.

Presently, some of the greatest threats to Baka health are issues like food scarcity, access to clean water, infection with intestinal worms, malaria, hernias, HIV, and tuberculosis. The nearest major hospital is over an hour away in the town of Lomie, so the team has brought a doctor to help treat the Baka, who can elect to receive free medical treatment regardless of whether or not they partake in our research. Cameroon has a national deworming campaign that provides periodic, free deworming agents, but populations like the Baka, who live far from major cities in dense rainforests traversable primarily by rough dirt roads, are often logistically hard to treat. The medications provided to the community of Bosquet will be able to alleviate some of their ailments; hopefully, the downstream results of our research can provide evolutionary and health clues as to not only why some groups get more sick than others, but what we might be able to do to help these groups in the future, and to be aware of how rapidly shifting cultural and subsistence practices could affect the health of groups like the Baka.

Labwork in the field: Stool samples in white containers awaiting fecal microscopy screening.

Labwork in the field: Stool samples in white containers awaiting fecal microscopy screening.

Written by: Meagan Rubel, MPH, Rubel@sas.upenn.edu

Health Equity- A Dream or an Achievable Goal?

Source: Saskatoon Health Region Advancing Health Equity

Source: Saskatoon Health Region Advancing Health Equity

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”  – Dr. Martin Luther King Jr.

Nearly half a century after Dr. King’s observation, the Affordable Care Act made tremendous strides towards equality of access in health care. Equality promotes fairness, however it’s only effective if everyone starts from the same place and has the same needs.  When it comes to breaking the barriers to health care equity—we still have a long road.

Dr. David Satcher was the keynote speaker for the Perelman School of Medicine Health Equity Symposium, held at the University of Pennsylvania in January. He was the first African American Surgeon General of the United States and is the current director of The Satcher Leadership Institute at the Morehouse School of Medicine. “In order to eliminate disparities we need leaders who care enough, know enough, will do enough, and are persistent enough,” he said. He encouraged attendees to delve deeper into the realities of health inequity in America.  The symposium provided a glimpse into some of these inequities.

According to the CDC Health Disparities & Inequalities 2013 Report, Non-Hispanic Black adults are 50% more likely to die of heart disease or stroke prematurely than Caucasians.  Until recently, scant efforts in organizational quality improvement were made in health care to address racial disparities. This was evident in the health care inequities of our Veterans population.

Said Ibrahim, co-director of the U.S. Department of Veterans Affairs Center of Health Equity Research, posed the following question at the Symposium,

“How do we make sure the equality of opportunity translates to the equality of health outcomes?”

According to the Department of Veteran Affairs Health Service Research & Development Services, minority veterans are receiving less and lower quality health care, despite needing more and higher quality care (suggesting a form of “regressive” healthcare delivery).

Another population that is currently experiencing health care inequities are Asian Americans. They are currently the fastest growing minority group with a growth rate increase of 46% from 2000 to 2010.  Ironically, this group receives little attention in the statistical analyses of health and health care inequities. The labeling of the “model minority” for Asian Americans is quite paradoxical —simultaneously successful and marginal. The notion has often led to the tuning out of the hardships of prejudices, health disparities, and health care inequities, Asian Americans face.

pic 2

Although the Affordable Care Act benefited Asian Americans in increasing health care access, cultural competence and community engagement is necessary to successfully eliminate the gaps in health care equity.   A concerted effort by public health professionals on local, state, and national levels will help bridge the gap in health care access in the Asian American & Pacific Islander communities.

The LGBT community  faces health care inequity as well. Risk of psychiatric disorders, substance abuse, and suicide are elevated as a result of social stigma and discrimination, calling for a need for culturally competent medical care.

SOURCE: Center for American Progress, 2009

SOURCE: Center for American Progress, 2009

Increasing coverage promotes greater access to care but it won’t translate to equity of health outcomes. Quality improvements in health care delivery must place emphasis on social determinants of health and culturally competent care.  Our health care approach should not be one size fits all, but rather it must be modified to fit the specific needs of vulnerable populations.

Written by: Amy Rajan, RN, MSN/MPH Candidate, Class of 2016

Fellow Feature: Autism Spectrum Disorders – A Look into the Changing Prevalence Over Time with Susan E. Levy, MD, MPH

CPHI Senior Fellow discusses her research on autism spectrum disorders (ASD) and discusses the changing prevalence of ASD and its’ public health implications.

Susan E. Levy, MD, MPH Associate Professor of Pediatrics, Perelman School of Medicine

Susan E. Levy, MD, MPH
Associate Professor of Pediatrics, Perelman School of Medicine

Susan E. Levy is a pediatrician specializing in neurodevelopmental disabilities.  Her clinical and research interests center on the care of children with autism spectrum disorder (ASD).  Her research focuses on early identification, diagnosis, surveillance and treatment of children with ASD.  In particular, Dr. Levy focuses on the use of complementary and alternative medical treatments (CAM).

Dr. Levy is the founder and director of the Regional Autism Center (RAC) at Children’s Hospital of Philadelphia and serves as the co-principal investigator of PA-CADDRE (Pennsylvania Center for Autism and Developmental Disabilities Research and Epidemiology).  PA-CADDRE is a Center for Disease Control and Prevention-funded research program of The University of Pennsylvania School of Nursing and Children’s Hospital.  The goals of this program include ASD surveillance to determine prevalence, screening and early identification of ASD, and research on the etiology of ASD.

Autism Spectrum Disorders – A Look into the Changing Prevalence over Time

Q: What do we know about Autism Spectrum Disorder (ASD)  

Autism spectrum disorder (ASD) is characterized by a number of factors including:

  • Persistent deficits in social communication and social interaction across multiple contexts;
  • Restricted, repetitive patterns of behavior, interests, or activities;
  • Symptoms must be present in the early developmental period (but may not be recognized until later); and cause clinically significant impairment in social, occupational, or other important areas of functioning.

The term “spectrum” refers to the wide range of symptoms, skills, and levels of impairment or disability that children with ASD can have.

Q: How has our understanding of Autism changed over time?

Autism today is quite different compared to 15 years ago when I first became involved in the research.  This is in large part due to changing criteria with different versions of the DSM diagnostic manual, which paralleled some of the changes in the reported prevalence. The biggest change happened in 2013 when the criteria changed to combine social characteristics and communication into one category – which really makes sense because communication that is not for social purposes is not as meaningful. The changes in criteria over the years have made a difference in terms of how we look at the field – the criteria went from being very narrow to much broader.

Q: What would you tell parents who are concerned about the link between Autism and Vaccinations?

I feel that the evidence is firm that vaccinations, particularly the MMR, are not related as a cause of autism. I think that families deciding without full information to withhold vaccination are putting other children and individuals at very high risk.

Q: Where do you see the field of ASD going?  

Moving forward, hopefully we will look at the autism spectrum disorder as a category of disability with a better appreciation for the range in severity of symptoms and core difficulties, and the impact of co-occurring symptoms or disorders which have a large impact on quality of life. That’s an area in the clinic that we’re much more tuned into now because of some of the work we’ve done with our Autism Speaks grant, looking at the impact of   co-occurring conditions such as sleep disorders.

The other important area is the move over the last ten years to earlier identification, and with promising tools and strategies to identify kids at high risk for the diagnosis – such as kids with genetic disorders, premature infants, and siblings of kids with autism.  There’s a really a big push towards early identification.

Q: What research are you currently working on?

My largest project is with Jennifer Pinto-Martin on a CDC funded large multi-site case-control study of risk factors for ASD in children ages 2.5-5 with autism. It’s a case-control study with 3 groups: one group of kids who have ASD, one group of kids who have developmental delay (not autism), and the 3rd group is a population control. It’s a phenomenal study with a very large sample size in all groups. We are just starting to delve into the data, looking at the phenotypes and risk factors.

The other research program I am involved in is through Autism Speaks Autism Treatment Network (AS-ATN). Autism Speaks has funded 17 autism treatment networks across the country and in Canada and is committed to investigating and improving medical care for kids with ASD, as well as identifying difficulties.  We have enrolled families into the database, and have started to study and look at issues about treatment.

Q: How does your research translate into practice?

I’ve recently taken a course from CHOP’s Office of Clinical Quality Improvement and am a champion for my division in terms of looking at quality improvement and improving patient safety. So a big focus of my activities has been developing pathways and strategies for different providers or experts to evaluate children with ASD and other neurodevelopmental disorders and identify comorbid behaviors that could complicate treatment and progress. Thus, what we’ve learned from the CDC study in terms of risk factors and causes and profiles is going to help us in terms of management.

Career Path – From Clinician to Researcher and Public Health Advocate

Q: How did you get started in the field of development disabilities?

I became interested in developmental disabilities during my residency at St. Christopher’s Hospital for Children. As a 2nd and 3rd year resident, I realized I was very interested in taking care of kids with special healthcare needs and chronic neurological and developmental disorders.  My first year of fellowship focused on developmental disorders, and then I received more training at Kennedy-Krieger Institute at Hopkins. I came to CHOP and Penn in the early 80s to work in our general developmental disability evaluation unit.  Shortly after, I became interested in ADHD and along with a child psychiatrist (Dr. Tony Rostain); we founded the CHOP ADHD evaluation and treatment program.

Q: What provoked your work with ASD?

I became interested in ASD In the early 90s and received additional training. At that time I also started working with Jennifer Pinto-Martin. In the summer of 2001, we submitted a grant to the CDC and we were chosen as one of the centers to be a surveillance site and to develop a multi-site case-control study. For me, in a sense, the rest was history.

Q: Why did you decide to receive a Master of Public Health?

In the mid-2000s, I started thinking, ‘I’m doing public health research; I really need to get more training.’ In 2009 I started the MPH program, and then graduated in May 2013. The MPH has given me a great perspective in terms of appreciating the challenges and issues of kids with autism and special healthcare needs. As a clinician, my training in public health also helps me talk to people when they are concerned that ASD is an “epidemic – that there is not an increased risk of having it due to exposure as we would classically talk about an epidemic.”  Rather, we know that the increased numbers are related to the broadening criteria over time, heightened awareness about the diagnosis, and earlier diagnosis. So I started off as ‘just a clinician,’ and morphed into this researcher and public health advocate.

Q: How do you consider yourself a Public health Advocate? 

I’ve been active in the American Academy of Pediatrics, particularly the Council on Children with Disabilities.  I’ve been a contributor to the clinical reports in terms of diagnosis and treatment of kids with autism spectrum disorders; I was a co-author of the autism toolkit to help pediatricians, and using what I learned from my capstone on shared decision making, I’m going to co-author a clinical report for the American Academy on shared decision making for children with developmental disorders, bringing it full circle.

Don’t expect a “Disneyland effect”

Alison Buttenheim, PhD, MBA, Assistant Professor in the University of Pennsylvania School of Nursing, a Senior Fellow of the Leonard Davis Institute and the Penn Center for Public Health Initiatives, and Faculty Affiliate in the LDI Center for Health Initiatives and Behavioral Economics

Alison Buttenheim, PhD, MBA, Assistant Professor in the University of Pennsylvania School of Nursing, a Senior Fellow of the Leonard Davis Institute and the Penn Center for Public Health Initiatives, and Faculty Affiliate in the LDI Center for Health Initiatives and Behavioral Economics

Senior Fellow Alison Buttenheim recently published an article for the Leonard Davis Institute of Health Economics blog. Read it below!

“So how about that Disneyland measles outbreak?”  As a researcher who studies vaccine refusal, I’ve been asked this question a lot recently. More than 50 people have come down with measles after exposure at the iconic Southern California amusement park, and nationwide measles diagnoses exceeded 90 in the month of January alone. (For the record, that’s a lot of measles cases to see in one month in the US in recent years, although 2014 was also banner year for the virus.)

Last week a colleague posed a particularly compelling question: “Do you think we’ll see a ‘Disneyland effect’?” – meaning, could this widespread outbreak produce a backlash against vaccine refusal and thereby reduce rates of vaccine exemptions, “alternative” vaccine schedules, or opting out completely of recommended childhood immunizations.

Parents less likely to refuse vaccines now?

It’s reasonable to expect a Disneyland effect. After all, there was strong evidence of a “Katie Couric effect” on colon cancer screening rates after Ms. Couric underwent an on-air colonoscopy in 2000. Similarly, an “Angelina Jolie effect” on breast cancer screening rates for women with a family history followed Ms. Jolie’s disclosure of her double mastectomy in 2013.

Several features of the Disneyland measles outbreak are also conducive to moving the needle on parents’ beliefs and decisions about childhood immunization: First,  the outbreak has high salience: news stories have run in major print and broadcast outlets almost daily, and the internet and blogosphere are packed with posts from all perspectives. If vaccine hesitancy and worries about the measles virus were just lurking in the back of your brain last month, they are top-of-mind now. The universality of Disneyland may make parents feel more vulnerable in a “this could happen to us” way—it’s no longer possible to imagine that measles outbreaks or high rates of vaccine refusal are happening in another state or another school community.

Second, the Disneyland outbreak could shift both the social norms around vaccine refusal and the framing of the importance of childhood immunization.  In recent years, people arguing against the safety, efficacy, and necessity of vaccines have created a powerful social norm that validates vaccine refusal and privileges claims about vaccine-related harms. In the Disneyland outbreak coverage, we are seeing more stories framed from the perspective of the potential harms of measles: for example, the stress and financial burden associated with quarantining an exposed infant; or the request from a father of an immune-compromised child to keep unvaccinated children out of his son’s school. This could in theory produce more “something must be done about this” sentiment that could then lead, for example, to stricter state vaccine exemption laws.

Third, this recent outbreak very simply plays on inherent present bias—our tendency as humans to heavily discount future costs and benefits of a decision or behavior while overweighting current costs and benefits. For most parents, the benefits of vaccinating are intangible (we take an action so that something doesn’t happen), probabilistic (vaccines are not 100% effective, and the chances of being exposed to measles are small), and in the future.  It’s reasonable to imagine why parents with any level of concern about vaccines might opt out. The Disneyland outbreak shifts this calculus by making the cost of not vaccinating very immediate and tangible, and might therefore lead to decreased refusal.

A prediction (and I hope I’m wrong)

Despite these prior effects and reasonable assumptions, I hereby predict no such Disneyland effect this time. While I would be delighted to be proven wrong, I think there are at least three reasons why we won’t see a lasting impact of the outbreak on exemption or refusal rates.

First, our attention span is limited. While the Disneyland outbreak is getting a lot of coverage now, this will likely last for only a few more news cycles. (Caveat to this point: If someone were to die of measles from this outbreak – which I decidedly hope does not happen – the salience and duration of the outbreak in the news cycle would both increase.)

Second, the parents whose vaccine beliefs and behaviors are most likely to be affected by this outbreak are the slightly hesitant and the undecided. We are not likely to see much shift in the more adamant, hard-core anti-vaccine folks.  In one anecdote from a news article on the outbreak, a non-vaccinating parent in Los Angeles reported that “she hadn’t even been aware of the Disneyland outbreak because she refused on principle to follow the mainstream news media. But she was in no doubt, even without reading the coverage, that ‘they have skewed the facts in favor of trying to sell people more pharmaceuticals’”.  The same facts about the outbreak that might convince a moderately hesitant parent to vaccinate will only reinforce previously-held beliefs in a strongly anti-vaccine parent.

In a terrific recent paper, Brendan Nyhan and colleagues demonstrated this effect in a study in which parents were exposed to information about the dangers of vaccine-preventable diseases and the lack of evidence for an MMR-autism link. This information actually reduced intention to vaccinate among parents with previously unfavorable views of vaccines. Similarly, images of sick children with vaccine-preventable diseases increased beliefs in an MMR-autism link. So, the people whose beliefs we would most want to change in response to the Disneyland outbreak are the least likely to be persuaded. Unfortunately, these beliefs and the vaccine-refusing behaviors that accompany them tend to cluster socially and spatially–and it is this very clustering that leads to outbreak “hot spots” where herd immunity is most compromised.

Finally, I am skeptical about a Disneyland effect because I have spent a lot of time looking for a similar effect in other recent, highly-publicized outbreaks (including a 2008 measles outbreak in San Diego, California) and have failed to find one. That doesn’t mean it won’t happen this time. I will continue to look for shifts in social norms, beliefs, and behaviors in response to vaccine-preventable disease outbreaks, and work towards developing interventions that reduce vaccine hesitancy and boost herd immunity in the population.  Let’s not let any more trips to Disneyland be ruined by Mickey Mouse science.

Why a fake article titled “Cuckoo for Cocoa Puffs?” was accepted by 17 medical journals

Coco Puffs

A Harvard scientist wanted to see exactly how easy it is to get medical research published. In some cases, $500 is pretty much all it takes.

Read through this interesting article by Elizabeth Segran about navigating through the process of medical research publication.

http://www.fastcompany.com/3041493/body-week/why-a-fake-article-cuckoo-for-cocoa-puffs-was-accepted-by-17-medical-journals