A Healthy Future Starts in California

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Michael Wilson works to protect the next generation from the billions of pounds of potentially
harmful chemicals produced in our nation every day.

Helen Halpin believes we can reduce to zero the hospital acquired infections
that kill more than 10,000 Californians per year.

Thomas Rundall helps to shape federal guidelines such that they are more
useful to people working to improve health.

In some ways, those who work in the field of public health are eternal optimists. Faced with huge, seemingly insurmountable problems, they begin at once to search for solutions. If they can’t fix everything all at once—which is usually the case—they prioritize the most critical tasks or those that are easiest to carry out. They remain dedicated to not only a bold vision of a healthier future, but the oftentimes long and arduous task of actually achieving it. For many at the UC Berkeley School of Public Health, work towards this vision starts and develops in California.

Undisputedly unique, California provides a dynamic environment in which to effect positive change. The third largest state geographically, it is the most populous and most culturally diverse in the nation, with minorities constituting about 57 percent of its population. California is also often a thought leader for the nation, both from a business standpoint, in sectors such as the Internet and green technology, and in developing cutting-edge policies and regulations that are often later adopted by the federal government. And the Golden State boasts one of the finest public university systems worldwide: the University of California.

image of victorian houses“As a part of a public university, we take seriously our obligation to use our comparative advantage in research and teaching to improve human health in the state,” says Dean Stephen Shortell. “We take our production of knowledge and translate it into public policies and practices that are going to improve health.”

The right place for right care

Distinguished Professor of Health Policy and Management. When Cindy Ehnes, director of the state’s Department of Managed Health Care, asked the School to work with the department on improving care for patients with chronic disease and reducing hospital acquired infections, Shortell agreed to chair the Technical Expertise Group for the Right Care Initiative (RCI). The objective of the initiative is to measurably improve clinical outcomes by 2011 in three trouble spots: cardiovascular disease, diabetes, and hospital acquired infections (HAIs). Shortell contributes his expertise towards the first two, where the goal is to prevent catastrophic events in cardiovascular disease and diabetes by helping California hospitals and care groups to perform at the national 90th percentile. Professor Helen Halpin serves as a principal investigator in preventing HAIs. (See From Publication to Public Action)

“Data from California’s health plans shows that we’re not doing very well in California in controlling three things: people’s blood pressure, their lipids and cholesterol levels; and for diabetics, their blood sugar levels,” says Shortell. These data are drawn from Healthcare Effectiveness Data and Information Set (HEDIS) scores of the plans, a tool used by most U.S. health plans to measure performance on important dimensions of care and service. Shortell says, “Most were nowhere near being in the ninetieth percentile, which is the goal.”

Since 2008, Shortell and colleagues from UCLA have helped to identify interventions that would help medical group leaders improve their levels on the blood pressure, blood sugar, and cholesterol markers. They provide examples of interventions that have been proven to succeed—like employing pharmacists to work directly on the medical care team to help with medication management and training patients to improve self management of their illnesses at home.

“We’re drawing on the literature that we and others have produced about interventions that work to improve chronic care management,” says Shortell. “We’re making it available to the health insurance plans and medical groups in the state and providing assistance in changing their behavior to get better results for these patients.” Even within a couple of years, the health care plans under the RCI have shown measured improvements. Most of the plans have seen a positive gain in their HEDIS scores, and some have already achieved the 90th percentile goal. For example, in 2008, Anthem Blue Cross received an RCI award for “Improvement in Blood Pressure and Cholesterol Control Measures.” By 2009, Anthem Blue Cross was extremely close to the 90th percentile in these two measures.

The Right Care Initiative ends in 2011, but Shortell believes the work it has generated will continue. “This project has been very consequential in terms of scope,” he says. “Many groups will have been working on it over the course of three years. It’s a very good thing we’re doing. And it’s not just a research grant. We weren’t the initiators; we were asked to help out and we are stepping up to play a leadership role in improving health care outcomes for Californians.”

A 2020 vision of health

Thomas Rundall, professor of health policy and management, is another faculty member who’s working to bring together stakeholders in California for the health of the state’s population. He plays a lead role in facilitating California’s response to Healthy People 2020, a national health agenda that communicates a vision and strategy for improving the health of the nation’s population and achieving health equity. The School has hosted a series of Public Health Roundtables to collaborate with the State of California Department of Public Health, other local public health agencies, and community-based organizations in the health sector in order to advance a new vision for creating Healthy People 2020 in the state of California.

notetaking“We want to be viewed as a facilitator, to convene groups together, to help them in discussions about how to develop Healthy People 2020 for the state,” says Rundall about the School’s role in the project. The School has already hosted three roundtables between stakeholders, with plans to hold one each semester until the guidelines are developed and implemented.

Although the U.S. Department of Health and Human Services has been producing Healthy People guidelines since 1980, Rundall believes in the past the 10-year targets have not been widely used and did not drive the public health agenda in a meaningful way. He’d like to see changes to the approach in order to increase the effectiveness. “In past years, the Healthy People planning documents for improving the public’s health were more medically oriented and focused on disease, conditions, and specific injuries—and identified activities that could either reduce the incidence of those specific diseases or reduce the disability and harm that’s caused by them,” he explains.

Healthy People 2020 is taking a different approach. “Instead of focusing on specific diseases, this effort is going to focus on social determinants of health, and will try to identify activities that can be engaged in across national, state, and local levels to create healthier environments for people to live in,” he says. “Those in turn will have a favorable impact on many different types of diseases and injuries.” These shifts in focus for Healthy People 2020 should make it easier for public health professionals to put the guidelines to better use and improve public health initiatives.

Although Rundall characterizes this kind of project as “an enormous challenge,” he also believes it is absolutely necessary. “Public health must become an effective partner and collaborator in developing policies that promote healthy environments and healthy behaviors across every stage of life,” he says.

A sea change towards safer chemicals

Chemicals are an enormous problem. More than 42 billion pounds of chemical substances are produced or imported in the United States each day, and about 700 new chemicals are introduced into commerce each year. Global chemical production is doubling every 24 years, rapidly outpacing population growth. Although it’s largely unknown what effect the 83,000 industrial chemicals used in the United States have on health, studies are drawing an increasing correlation between chemical exposures and obesity, cancer, decreased fertility, and chronic diseases.

“What kind of world are we going to deliver to the next several generations?” asks Michael P. Wilson, PhD ’03, MPH ’98, a research scientist at the Center for Occupational and Environmental Health. “During human development, for example, hormones exert effects at the parts per trillion level in blood. We are now seeing endocrine disrupting substances in human blood at levels far higher than that.”

California is leading the nation in the nascent field of green chemistry and chemicals policy, and Wilson and research scientist Megan Schwarzman, MD, MPH ’07, are at the forefront of this effort to create, produce, and use chemicals that are “benign by design.” In 2004, the California legislature commissioned a chemicals policy report from Wilson, which was published in 2006 and described three fundamental weaknesses in U.S. chemicals policy —the data gap, the safety gap, and the technology gap—that are hampering investment and innovation in green chemistry. The Legislature passed two laws in 2008, AB 1879 and SB 509, which Governor Schwarzenegger called “the most comprehensive green chemistry program ever established.” The California Environmental Protection Agency commissioned another report that same year by Wilson, Schwarzman, and colleagues at UCLA, which was signed by 127 University of California faculty members and helped to spur the scientific and political momentum around the state’s Green Chemistry Initiative.

“It’s a success story,” says Wilson, “with UC Berkeley working out these kinds of science policy questions and the legislative leadership following through with action. California is now in a leadership role, and it’s attracting national and international attention because of the potential impact on U.S. policy and the economy.” This attention is also leading to action: In April, U.S. Senator Frank Lautenberg introduced the Safe Chemicals Act of 2010, which could substantially re-write the federal Toxic Substances Control Act.

In recognition of the central role chemistry plays in global sustainability and to support the efforts of California’s Green Chemistry Initiative, Wilson and Schwarzman began working with faculty members across the campus to establish the Berkeley Center for Green Chemistry (BCGC) in 2009. BCGC is becoming an interdisciplinary center with Berkeley faculty and researchers working in the fields of new chemistries, health and the environment, and policy and economy. “We are the first university in the country that is building an intentionally interdisciplinary program in green chemistry,” says Wilson.

Schwarzman agrees: “What’s unique about this is the interdisciplinary element. Environmental health sciences can help inform the design of safer substances and the policies required to make their adoption a reality. The combination of expertise in the sciences, policy, and business can make the necessary change happen.”

Center members will collaborate on teaching, research, and service in the green chemistry field. In the first year, thanks to a $250,000 grant from the California EPA’s Department of Toxic Substance Control, the center is developing undergraduate and graduate curriculum in green chemistry. The new curriculum will not change core requirements for chemistry students, but will integrate principles of green chemistry into existing courses and labs.

test tubes

“In addition to the policy weaknesses, one of the underlying problems is that chemists, in their education, are not trained in the principles of toxicology, environmental fate, exposure, or basically the health and environmental effects of the substances they are designing and working with,” says Wilson. “It’s a universal problem across the United States.”

Schwarzman hopes bringing a public health focus to the chemistry curriculum will help shift the framework of how chemists currently view their chosen field. “A fundamental principle of public health is that of prevention,” she says. “And at its base that’s what green chemistry is trying to get at. So we move from having to clean up pollution to preventing it. That’s a fundamental public health principle, but it is not something that naturally underlies the field of chemistry. We’re hoping it will in the future.” end of line

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