Dr. Stuart Brown makes a house call every time he shows up for work. His only patient is Georgia, and lately Brown hasn't been very happy with the state's condition. It's become sluggish in body and mind, isn't eating right and hasn't done a great job of caring for its young. Yeah, sure, it's cut down on its smoking, but it's also put on far too much weight, and with its chronic susceptibility to infection, plus about a billion and a half chickens in the yard, there's no telling what would happen if the bird flu landed here and got serious.
"We've got quite a few challenges for a state that has enormous wealth potential and a substantial investment in public health," says Brown, director of Georgia's Division of Public Health (GDPH), which falls under the Department of Human Resources umbrella.
Brown's thermometer is the United Health Foundation, which releases "America's Health Rankings" each year, a state-by-state public health scorecard of the population's relative health. In 2005 Georgia was 43rd - better than 2004 (45th) but the same as 1990 (also 43rd).
Georgia's symptoms are varied and across the board. We're heavier than most of the country (24.7 percent obesity prevalence). We're 49th in graduation rates (54 percent of our ninth graders graduate high school, and there is an absolute relationship between bad health habits and bad education). Immunization coverage has increased, but the incidence of infectious disease remains among the highest in the nation. Smoking has declined 37 percent since 1990, but childhood poverty rose 12 percent in 2004 alone. Infant mortality has decreased but Georgia still ranks 44th in that category. And the number of uninsured Georgians keeps rising.
"There is definitely a huge problem with Georgia's health," Brown says. "But we think all of that can be changed. That's what we're all about."
Public health is the science and practice of protecting and improving the health of populations (as opposed to individuals). Public health workers measure the well-being of whole communities, identifying the consequences of smoking, obesity, poverty, disparities in (and lack of access to) health care; they examine trends and behaviors that drive up health care costs; they study patterns, causes and control of disease; they monitor environmental hazards, apply sanitary measures, preach preventive medicine.
The Institute of Medicine defines public health as "what we, as a society, do collectively to assure the conditions for people to be healthy." It's a succinct description with broad possibilities of interpretation. The notion of public health and the mission of its workforce seem to be expanding, in Georgia and everywhere else.
"The mission has changed dramatically," says Brown, who runs a $322 billion (FY2006) state agency responsible for the health of Georgia's entire population.
The division is divided into more than 40 branches, sections, programs and offices at the state level, from Adolescent Health & Youth Development to the WIC Branch (the nation's seventh largest supplemental nutrition program for women, infants and children). At the local level, the GDPH works through 18 health districts and 159 county health departments, employing nurses, lab workers, researchers, data analysts, administrators - all of them key players as the division redefines itself in a new era of public health threats.
"We have to be prepared for every kind of emergency, whether it's tornadoes and hurricanes, a pandemic flu attack or a deliberate human attack on our population," Brown says. "The shift in attention to preparing for those possibilities has grown significantly over the last five years."
Pandemic anxiety has only increased in recent years with the advent of the Avian flu, which doesn't spread easily from person to person - yet; but is particularly deadly and is expected to land in the United States this year. Pandemic influenza is flu that causes a global outbreak. As steward of the state's pandemic plan, Brown's department will receive more than $8 million in federal aid to help Georgia's towns and counties prepare. The state plan predicts, as a possible worst-case scenario, that 6,200 residents could die, 22,000 would need hospitalization and a million would become infected if a pandemic flu reached Georgia.
But Georgia rates pretty high in the planning department. The latest emergency preparedness report from the non-profit Trust for America's Health gave Georgia a seven out of 10 (which means the state scored in seven out of 10 preparedness indicators, placing it among the top five in the country).
Leveling The Field
In November, the GDPH sponsored the Summit for a Healthy Georgia. More than 800 participants convened at the Cobb Galleria Center for the statewide public health strategic planning meeting. The group included representatives from business, education, the faith community, the general public, government, the health care industry and the public health community.
Focusing on topics such as the state's lagging health status, access to care and the need to develop public-private partnerships in an era of reduced governmental budgets, these stakeholders identified Georgia's top public health priorities.
"The group came up with some things that we in public health probably would not have had on our list," Brown says. These included increased access to care, the problem of poverty (a leading predictor of poor health), the problem of poor education (ditto) and the issue of Georgia's uninsured (about 17 percent of the population).
That last part doesn't surprise Ken Thorpe.
"There are about 45 million uninsured people in this country in a typical month, and it presents a tremendous public health problem," says Thorpe, who chairs the Department of Health Policy and Management at the Rollins School of Public Health at Emory. "These people get less health care than people with insurance. They are diagnosed later and die earlier. They have a very clear public health impact.
"They also impact the cost of health insurance. About $45 billion worth of care doesn't get paid, and it winds up in the cost of private insurance. We all pay higher health insurance costs because this country has been incapable of dealing with the issue."
Another priority is the issue of disparities in health status. "There are enormous inequities in Georgia, whether you're talking about race, ethnicity, rural vs. urban, rich vs. poor," Brown says. "Every way you slice it."
For example, disparities in education, access, treatment and survival among African Americans make it difficult for public health organizations to address cancer control in a comprehensive way, says Leslie Given, public health advisor with the Centers for Disease Control and Prevention. Given's fellow CDC researcher Nikki Hayes adds, "Experiences across populations may vary considerably. These differences in cancer experiences have created an unequal disease burden."
In their research, Given and Hayes identified specific interventions from communities that have improved access and removed barriers that influence cancer-related disparities. Brown will want to get his hands on their results.
Another CDC specialist, Howard Frumkin, has studied disparity of a different kind in his research of urban sprawl, which takes a toll on public health. Frumkin says communities designed with public health in mind offer alternative modes of transportation, taking people out of cars (reducing traffic fatalities) and putting them on their feet or on bikes, promoting cardio, respiratory and mental health, which means longer, healthier lives.
"One danger of healthy development is it often turns into gentrification," says Frumkin, director of the National Center for Environmental Health. "People at the bottom of the income ladder are priced out. The affordability question is interesting. It presents a challenge that we have to meet if we want to achieve more equity and eliminate disparities."
Ralph DiClemente and Gina Wingood, two of the Rollins School's most prolific researchers, are working on another sort of urban disparity project. Together they have built volumes of data on HIV prevention for teens, particularly African Americans. This fall they plan to embark on a project in Macon as part of a four-city, nationwide program. Other cities in the project are Columbia, S.C., Providence, R.I. and Syracuse, N.Y.
"We felt it was important to begin to do some of this prevention work in smaller urban areas which often are ignored, because so much prevention work is done in large cities with large universities," DiClemente says.
The team will tailor its research to meet adolescents at their level, using local radio and TV as well as young, trained facilitators, mostly African American, who are familiar with the neighborhoods, the population and the age group's unique characteristics. The program will focus on sexual health and HIV prevention, but also on smoking prevention, nutrition and obesity.
"What is clear is that these are young people who are, as a group, at risk," DiClemente says. "This is a generation in jeopardy."
Halls Of Knowledge
Georgia's sagging health status means the state is more or less starving on a buffet line, because Atlanta is the nation's public health capital.
There's the CDC, of course, and the American Cancer Society, The Carter Center, the Task Force for Child Survival, CARE USA, the Arthritis Foundation, the Georgia Cancer Coalition, the Morehouse School of Medicine (and the Morehouse Public Health Sciences Institute, separate from the med school), Georgia State's Center for Health Policy and Institute of Public Health, and the Rollins School (one of only 37 accredited schools of public health in the nation, and the only one in Georgia).
The Rollins School and CDC are like conjoined twins. Rollins Dean James Curran can see the CDC from his office window. He was the CDC's leading AIDS researcher at a time when AIDS wasn't really identified, led its HIV prevention efforts for 15 years. Curran says the CDC has been the beacon for public health's best and brightest.
"So many of our students and faculty have come here because they are attracted to the CDC and its mission," Curran says. "And we add value to the CDC. A large number of our graduates are employed at the CDC, and a large number of CDC employees are adjunct faculty members. I think we are crucial to one another."
Rollins currently has about 1,000 grad students who pursue careers around the globe. Over time, more than 50 percent of the school's 3,750 grads have remained in Georgia, while only 20 percent are actually from Georgia. "We think we're making a fairly large impact on the state by bringing these professionals here," Curran says.
The public health workforce is aging and shrinking, so the mission of the Rollins School and Georgia's other public health institutes (see story, page 54) is more critical than ever. It helps to have a teacher like David Kleinbaum on staff.
Kleinbaum, professor of epidemiology at the Rollins School, was selected last year as recipient of the Association of Schools of Public Health Pfizer Award for Career Teaching Excellence, which makes him the MVP among faculty in all disciplines in all schools of public health in the United States.
Epidemiology is the study of patterns, causes and control of disease in populations, and Kleinbaum has figured out a way to make it interesting with his style and his introduction of ActivEpi, an innovative CD-based text on epidemiology fundamentals.
"Learning this stuff doesn't have to be pain and drudgery," says Kleinbaum, who plays flute in a jazz band and wears a different Hawaiian shirt every day to class - a few months ago the rack in his closet at home broke from the weight of so many shirts. "The main idea is to provide a thoughtful way of dealing with public health problems."
Kleinbaum is less involved in his own research, more involved with evaluating the research of others. He teaches epidemiologists, the front-line gatherers of key public information, how to do their jobs correctly. Some of his students include members of the CDC's Epidemic Intelligence Service, the stealthy rapid-response force of disease detectives who place themselves at ground zero of major outbreaks, including bioterrorism.
Kleinbaum might take an enlightened approach with his students, but he has never taken the job of teaching future public health professionals lightly and has been outspoken in his belief that good public health teachers have been undervalued
"It is important to realize that excellence in teaching does not simply refer to being a good classroom lecturer and/or performer," he told the audience during his acceptance speech for the Pfizer Award, later adding, "To paraphrase an American hero of mine and yours, I have a dream that someday outstanding teachers will earn salaries on a par with outstanding researchers, that there will be as many awards for outstanding teaching as there are for outstanding research, that such awards will be of equal size monetarily, that salaried chairs for outstanding teachers will be the norm rather than the exception, that someday there will be an National Academy of Science for Teachers, and last, but not least, though least likely, a Nobel Prize for Teaching."
Well, a guy can dream, can't he?