Category Archives: Voices from the Field
Audrey Dorélien, PhD, is a 2012-2014 Robert Wood Johnson Foundation (RWJF) Health & Society Scholar studying demography, infectious diseases, and maternal and child health.
Reoccurring outbreaks of measles and other vaccine-preventable diseases are a major killer of children, particularly in sub-Saharan Africa. In 2012, more than 226,000 cases of measles were reported worldwide, with a little less than half of those in Africa. For the World Health Organization to meet its global measles eradication goal and implement more effective supplemental vaccination programs, public health officials will need a better understanding of the mechanism driving seasonal and episodic outbreaks.
Infectious disease ecologists have demonstrated the importance of human demography, and in particular the influence of the birth rate on the dynamics of acute childhood immunizing (ACI) diseases. For instance in London, in the few years prior to 1950, the city experienced annual measles epidemics, but the dynamics changed to biennial epidemics as a result of a decline in the birth rate between 1950 and 1968. How can the birth rate influence disease outbreaks? An outbreak can only occur when the fraction of the susceptible population exceeds a critical threshold. In the case of ACI disease, the majority of the susceptible population are young children; therefore the birth rate influences the rate at which the pool of susceptibles is replenished.
Keely Muscatell, PhD, is a social neuroscientist and psychoneuroimmunologist. She is a post-doctoral scholar in the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program at the University of California (UC), San Francisco and UC, Berkeley.
Results from the recent NPR/RWJF/Harvard School of Public Health poll suggesting that Americans are living under high levels of stress probably don’t surprise anyone. In a way, I’ve been taking an informal version of this poll for the last six years, since when I tell people I meet on airplanes or at local bars that I study stress and health, I am unfailingly met with knowing glances and stories about stressors people are facing in their lives. Given that stress is pervasive (and problematic) in modern life, lots of current research in psychology and neuroscience is focused on understanding exactly how stress can get “into our brains” and “under our skin” to make us sick.
When we think of illness, one of the first things that comes to mind is the immune system, with its lymph nodes, white blood cells, and antibodies hanging around to help us fight off infections and heal our injuries. An especially important component of the immune system involves inflammation. If you’ve ever gotten a paper cut, you’ve probably noticed that the area of skin around the cut tends to turn red and warm up shortly after the injury. This happens because proteins called “pro-inflammatory cytokines” swim through your blood stream to the site of the wound, where they call out to other immune cells to come to the area and help heal the cut. In the short term, this is a good thing; those little cytokines are a key part of healing. But if inflammation becomes widespread throughout the body, cytokines can lead to depression and even physical diseases, like arthritis and heart disease.
A. Janet Tomiyama, PhD, an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2009-2011), is assistant professor of psychology and director of the Dieting, Stress, and Health (DiSH) Lab at the University of California, Los Angeles. She was recently named the 2013 recipient of the Early Career Investigator Award from the Society of Behavioral Medicine. Her favorite comfort food: potato chips.
What’s your favorite comfort food? Ice cream, pizza, chocolate—everyone’s got a preference, whether they’re from Los Angeles, London, Sao Paolo, or Tokyo. Stress eating is as universal as eating itself; indeed, even Cervantes in his 1605 classic Don Quixote addressed the practice with the line, “All sorrows are less with bread.” Humans seem to reach for food as a way to soothe negative emotions, and that food is often high-fat, high-sugar, and high-calorie. That’s why comfort eating is often blamed as one reason stress is bad for health—because stress causes us to find comfort in a dozen cookies.
If you’re like me, you’ll be surprised but delighted to know it’s not just humans that engage in comfort eating! Eating high-fat, sugary foods in response to stress is a behavior that we see in non-human species like rodents and primates. Under chronic stress conditions, for example, rats will shift their food intake away from standard food pellets to the rodent version of “comfort food” (researchers often use Crisco mixed with sugar).
Even more amazing: it works. These comfort-eating rats showed dampened biological stress reactivity in a stress system called the Hypothalamic-Pituitary-Adrenal (HPA) axis. Sustained over-activity of the HPA axis is associated with poor health, and these studies suggest that comfort eating is playing an important role in managing an organism’s stress levels.
Brita Roy, MD, MPH, MS, is a Robert Wood Johnson Foundation (RWJF)/U.S. Department of Veterans Affairs Clinical Scholar, and Carley Riley, MD, MPP, is an RWJF Clinical Scholar.
You awake to the sound of your alarm, not feeling as rested as you’d hoped. Hurriedly bathing and dressing, you then grab a breakfast bar and stumble over your long-neglected bicycle to climb into your car, joining other anonymous drivers enduring their morning commutes.
Unfortunately, these sorts of mornings, all too common to Americans, create negative stress and worsen health. Under time constraints and other pressures, stressed individuals engage in less healthy behaviors: eating more unhealthy foods, exercising less, smoking more, and sleeping less than their less stressed counterparts. And the persistent assault of low-grade stressors, such as air and noise pollution, constant rush, lack of nature, and social isolation repeatedly trigger our bodies’ stress responses, promote persistent low-level inflammation, and subsequently undermine our cardiovascular and overall health.
Beyond these familiar stressors, emerging research is showing how the nature of our communities and our relationships within them—our social environment—also influence our health. We are learning that living in neighborhoods in which residents do not know or trust each other increases negative stress levels. And how living in communities in which residents do not have confidence in their government or do not believe they can affect change to better their lives also creates stress.
We have greater understanding of how people living in neighborhoods with high crime and violence rates experience more chronic stress. And we are finding that living and working in environments in which we feel powerless augments the negative health effects of stress.
Arthur Kellermann, MD, MPH, an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars and Health Policy Fellows programs, is professor and dean of the F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. He is co-author of the new RAND report, “Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value.” Here, he shares recommendations for a brave new world of medical technology.
Americans take justifiable pride in our capacity for innovation. From putting the first men on the moon to developing the Internet, we lead the world in developing innovative technologies. Health care is no exception. The United States holds more Nobel prizes in medicine than any other nation.
Novel drugs, biologics, diagnostics, and medical devices have transformed American health care, but not always for the better.
Some innovations have made a big difference. Combination antiretroviral therapy changed HIV infection from a death sentence to a treatable, chronic disease. Before an effective vaccine was developed, Hemophilus Influenze type b, a bacterial disease, was a major cause of death and mental disability in young children. Today, it is virtually eradicated here and in Western Europe.
Chris Feudtner, MD, PhD, MPH, is a pediatrician, epidemiologist, historian, and ethicist at The Children’s Hospital of Philadelphia (CHOP) and professor of pediatrics at the University of Pennsylvania. He is an alumnus of the Robert Wood Johnson Foundation Clinical Scholars program.
Living in a situation beyond almost-unbearable imagination: This is the reality that children with life-threatening conditions and their parents confront, and that the rapidly emerging field of pediatric palliative care seeks to address with compassionate and specialized medical and psychosocial expertise.1
A bit of background: just over half of the 45,000 children who die in the United States each year are infants, who often die within hours of their birth. Others die after traumatic injuries, usually quite suddenly. And a substantial proportion of the children die after a prolonged illness trajectory, due to a wide range of chronic conditions, ranging from cancer to congenital anomalies to neurodegenerative diseases. Most of these children spend days or weeks in hospitals, with frequent hospitalizations, and with the likelihood of hospitalization going up as the condition worsens.
To meet the needs of these patients and their families, many children’s hospitals in the United States have created dedicated pediatric palliative care teams. These interdisciplinary teams—composed of physicians, nurses, social workers, child life and art therapists, chaplains, and other specialists—pursue three core tasks on behalf of these patients. First, they manage pain and other symptoms, using both pharmacologic and complementary methods. Second, they support patients and parents in the often overwhelming process of receiving medical information and making treatment decisions. Third, they help coordinate care both across specialty disciplines within the health system, and across different sites of care, from the hospital setting to home or other residential sites, often in partnership with hospice or home nursing. All of this is done in coordination with the patient’s primary medical or surgical team2—palliative care adds and never subtracts.
In this interview with the Robert Wood Johnson Foundation's Steve Downs, SM, historian Keith Wailoo, PhD, discusses how we define our own cultures of health and shares how deeply held cultural narratives influence our perceptions of health. Wailoo is jointly appointed in the Department of History and the Woodrow Wilson School of Public and International Affairs at Princeton University. This video is part of the RWJF What's Next Health series. Also check out the accompanying infographic.
Infographic: When 'Good' Data Goes Bad
Good data can play a critical role in answering some of our most vexing questions concerning health. But history shows us that data is never collected or analyzed in a vacuum. Instead, the culture of the times acts as a lens that can either obscure or reveal truth. Here is one example, looking at the history of data collection concerning cancer and race.
Kathy Apple, MS, RN, FAAN, is CEO of the National Council of State Boards of Nursing and an alumna of the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows program (2006-2009). She received the Ben Shimberg Public Service Award from the Citizen’s Advocacy Center.
Human Capital Blog: Congratulations on receiving the Ben Shimberg Public Service Award from the Citizen’s Advocacy Center! What does the award mean for you and for your work at the National Council of State Boards of Nursing (NCSBN)?
Kathy Apple: It is quite an honor for both NCSBN and myself, as this recognition comes from an independent, objective organization that advocates for the public interest, effectiveness, and accountability of health care licensing bodies. It confirms that NCSBN is on the right track in supporting its members, the nurse licensing boards in the United States.
HCB: The award is named for a man who is considered the “father” of accountability in professional and occupational licensing. How are you carrying out his mission at NCSBN?
Apple: Dr. Shimberg was an expert on competency testing and challenged all licensing boards to ensure competence assessments meet the highest psychometric and ethical standards. He urged licensing boards to continuously examine how to improve testing procedures. Dr. Shimberg challenged licensing boards to improve communication to applicants and consumers, to keep data and accurate records on all board business, and be accountable for their own performance. He advocated for licensing boards to conduct research in all aspects of regulatory functions. He encouraged collaboration between and among licensing agencies. He challenged all regulators to have and follow their own code of ethics. Dr. Shimberg really was incredibly insightful and visionary regarding the role and work of licensing boards.
Janet M. Banks, MSN, RNC, is an instructor and clinical faculty at the University of Portland, a recipient of the Robert Wood Johnson Foundation Evaluating Innovations in Nursing Education grant. She is working on her Doctor of Nursing Practice degree at Case Western Reserve University, with a focus on nursing clinical education.
It’s no secret that there’s a serious shortage of nursing faculty in the United States. This problem will result in schools of nursing educating too few nurses to meet the growing demand for these health care professionals. One solution to this vexing problem is to increase the number of Dedicated Education Units, or DEUs, to increase faculty capacity.
Chances are good that if you are reading this blog, you know what a DEU is. But, for the sake of being on the same page, it is a collaboration between a nursing unit and an academic institution such as a school of nursing. Often referred to as an academic-service partnership, the school of nursing provides students as well as faculty who are experts in teaching. The nursing unit provides a culture that supports learning, as well as expert nurses to act as teachers.
The students, nurses, and faculty usually work in a ratio of two students to each nurse, with the faculty supporting the nurse as teacher and supporting the student’s professional development.
Michelle Mello, JD, PhD, is a professor of law and public health at the Harvard School of Public Health, and a fellow with the Edmond J. Safra Center for Ethics at Harvard University. She is a recipient of a Robert Wood Johnson Foundation Investigator Award in Health Policy Research.
For years, pharmaceutical companies have been lambasted in the media and government prosecutions for concealing information about the safety and efficacy of their products. In one particularly splashy example, GlaxoSmithKline (GSK) agreed to pay $3 billion in 2012 to settle criminal charges that it failed to report safety data concerning its antidepressant drug, Paxil, and its diabetes drug, Avandia, and engaged in unlawful marketing of these products and one other drug. One mechanism proposed for avoiding such problems is to establish a system through which participant-level data from clinical trials, stripped of identifying information about patients, would be available to the public.
A potential benefit of sharing clinical trial data would be that independent scientists could re-analyze data to verify the accuracy of reports prepared by trial sponsors, which might deter sponsors from mischaracterizing or suppressing findings. Data sharing would also allow analysts both within and outside drug companies to pool data from multiple studies, creating a powerful database for exploring new questions that can’t be addressed within any given trial because the sample is too small to support such analyses.
The potential value of shared data in improving our understanding of the safety and efficacy of drugs, medical devices, and biologics has sparked considerable discussion about how to make data sharing happen. Earlier this year, the European Medicines Agency—the counterpart to the U.S. Food and Drug Administration (FDA) in the European Union—decided to start making data from trials of approved products available in 2014. This begs the question, should the FDA follow suit?