An Up-Close Look At The Big Picture
Look closely at a painting by French pointillist George Seurat, and you see thousands of individual, colored dots. Take a step back, then another, and the dots begin to form patterns that become people strolling through a park on a sunny afternoon.
Public health is much the same. When you step back and look at the health issues Alabama physicians are seeing in their offices on a daily basis, you get a clearer picture of the health of our population, and the priorities that need to be addressed from a broader perspective.
Portrait Of A Public Health Professional At Work
If you count all the pixel's on Dr. Ryan Irvin's computer screen and then set 2,000 screens beside it and count all the pixels in those, you'd have a general idea of the number of genes the Birmingham epidemiologist is looking at these days.
She is part of the team working on two genome-wide association studies in Dr. Donna Arnett's lab in the Department of Epidemiology and International Health at UAB.
"We're looking at over 1,000,000 genetic markers in approximately 2,000 participants in the two studies of families with cardiovascular and metabolic diseases," Irvin said. "We're hoping to identify genomic regions associated with hypertension, hypercholesterolemia, left ventricular hypertropy, metabolic syndrome and related conditions. I specifically study type 2 diabetes and related traits including insulin, glucose and HOMA in these populations.
One study was designed to identify genomic regions that determine the response of lipids to interventions to raise and lower them. The other investigation looks at the genetics of left ventricular hypertrophy in families with at least one hypertensive sibling pair,
"This is something we couldn't do just a few years ago when technical advances in high density genomic arrays enabled the genotyping of hundreds of thousands of single nucleotide polymorphisms (SNPs) that provide dense coverage across the genome."
Following up on her long-time interest in genetics, Irvin studied epidemiology at the UAB School of Public health and began her career there after graduation studying Alzheimer's Disease.
Today, she is gathering data that could uncover clues to solving some of Alabama's most serious healthcare problems.
"When I take the data to the IT team and we enter it into the computer, the sheer numbers of genetic markers we're dealing with can take days for the computers to process. When we get the results, we hope to see patterns that show us where to look for genes that could be related to these conditions," she said.
"We are currently in the data analysis phase and expect to have results published within the year. We're hoping that genomic regions that are associated with T2D and related traits will help us uncover genes and disease pathways previously undiscovered and eventually lead to the development of new treatments physicians here in Birmingham can use to help their patients."
"Alabama is in the midst of several epidemics that touch individual physicians in their practice every day," said Max Michael, MD, Dean of Public Health at UAB and an internist in practice at Cooper Green Mercy Hospital. "Why do we have more strokes and hypertension here—and higher infant mortality, more diabetes and obesity, and higher rates of some STDs than other areas of the country? Are the factors genetic, environmental or both? "
These are questions public health professionals in Alabama are working to answer. When people think of public health, immunizations or restaurant inspection scores may first come to mind. However, those working in the field play a much greater role in protecting and improving the health of our citizens.
Using biostatistics, epidemiology and other tools of science, public health professionals detect patterns, identify risk factors, and seek out the pivot points where new interventions are more likely to succeed.Through the study of health behaviors and policy, they help to get those interventions where they are most needed.
Focusing On Local Health Issues From The Edges Of Space
More than 150 years have passed since the celebrated case where public health pioneer Dr. John Snow helped to end a typhoid epidemic in London through the simple intervention of removing the handle from a pump at a contaminated well.
Today, public health professionals continue to protect local neighborhoods through direct steps to address the risk factors that contribute to illnesses. They are also applying high tech tools from the frontiers of science to gather information that helps them detect and target the sources of health problems with greater precision.
One prime example is a team effort between NASA and the UAB School of Public Health that searches for factors that could be linked to increases in asthma attacks in inner city children. Investigators use satellite images of local streets to track changes in air quality block by block. They then look for correlations between the children's condition and the quality of the air they are breathing.
Birmingham physicians could soon be using the same tools by going to the computers on their desks to check the air quality on the streets where their patients live. If asthma and other lung diseases aren't responding to treatment, physicians can look for answers in snapshots from space before making decisions on therapies.
"Our researchers are also using satellite images to study environmental factors that might coincide with increases in strokes and other cardiovascular problems," Michael said. "From the lab in Birmingham, they are helping to fight malaria in Africa by looking for mosquito breeding grounds. They are also using the same technology to detect possible tire dumps across Alabama that could be providing a habitat for mosquitoes here."
Almost every summer, mosquito-borne illnesses such as West Nile virus and encephalitis are reported in Alabama. Knowing how to find mosquitoes where they live and breed is the first step in stopping them.
Fears of bird flu, bioterrorism and other illnesses are also in the news. The UAB School of Public Health is an academic partner with the South Central Center for Public Health Preparedness (SCCPHP) in training public health practitioners to prepare for public health threats.
Pursuing The New Plagues
Although centuries have passed since the black death wiped out a fourth of Europe, and few alive today remember the great influenza pandemic of 1918, epidemiologists trained here in Birmingham are helping to track and stop both old enemies in third world countries and the new plagues of HIV, STDs, diabetes and hypertension in our own backyard.
"Biostatistics is another tool helping us understand what is happening in health issues we're dealing with in Alabama," Michael said. "It uses advanced mathematics and information technology to detect patterns and trends. One good example is the REGARDS study of the Reasons for Geographic and Racial Differences in stroke that contribute to a stroke death rate in the Southeast that is one and a half to two times higher than the national average."
Investigators in the Biostatistics Department are sorting through a collection of data from more than 30,000 subjects, looking for clues that might explain why stroke mortality disproportionately affects people in this region, particularly those of African American ancestry. Factors ranging from high rates of diabetes and hypertension to drinking water, income, education and lifestyle are being explored in a multi-center effort financed by the National Institute for Neurological Disorders and Stroke.
Turning The Tide Toward Wellness
To confront Alabama's high rates of infant mortality and lifestyle-related diseases head on, local students are training for careers in Maternal and Child Health, and Health Behaviors.
The UAB Department of Environmental Science is teaching the public health guardians who will be protecting the quality of our air, water, food and other essentials of life. The department's Occupational Health and Safety program prepares public and corporate workers to protect health and safety in the workplace. The program also trains first responders to handle the challenges of confined space rescues, hazardous materials and biohazards.
In the Department of Healthcare Organization and Policy, students are preparing to tackle the difficult issues of health economics and how we as a society will be dealing with issues such as Medicare and an aging population.
The Elephant In The Room
"There are so many serious public health issues we need to be dealing with here in Alabama and nationally, but the question is, can those issues be heard over the debate on healthcare reform?" Michael said.
"It has come to the top of the national agenda, and the questions of what we need to do and what will happen dominate almost every conversation about public health."
Even with a large number of our people without coverage and with limited access to healthcare, the U.S. spends more per capita on health than most first-world countries, yet its people are less healthy in several areas. In infant mortality, Alabama ranks with some third world countries.
"There is a lot of fear out there," Michael said. "People who are already at the table and have coverage and those who depend on healthcare for a living have a vested interest to avoid change. They are understandably concerned that change will mean loss. However, those who don't have a seat at the table are also dealing with the fear of what not having access to healthcare could mean for their families. With the unpredictability in the economy, those who have health coverage today may not have it tomorrow.
"When you look at the economics of costs versus what the average person earns, even with the huge commitment of money the administration is talking about putting toward reform to try to make care accessible to all, our healthcare system is simply not affordable as it stands today.
"We have to ask ourselves, is there a better way? What are we going to have to do to have healthcare for all our people? There is hope that information technology will help to reduce costs, but it is going to take more, and quite likely sacrifices based on prioritizing what makes sense."
Where public health can help is to save money on avoidable costs related to health behaviors such as smoking and protecting against other health risks. Through preventive care, nutrition and policies that foster health rather than disease, it can reduce some of the pressure on the healthcare system. Through the tools of biostatistics and epidemiology, it can help to identify the Achilles' heels of disease and injury where healthcare dollars can have the greatest impact.
Alabama Public Health Professionals Battle Swine Flu
The value of the public health profession is being demonstrating with the recent swine flu outbreak. In a letter dated April 26, the Alabama Department of Public Health (ADPH) advised physicians to test and report any potential swine flu cases to the department. At that time, ADPH staff will investigate. "They will try to determine where this person has been and who they've been in contact with," says Ryan Irvin, PhD, in the Department of Epidemiology and International Health at UAB. "When they find contacts, they will ask them not to go to work or school. Contacts might be treated with anti-virals, as well. This is how public health officials attempt to contain the risk."
ADPH will monitor the disease in conjunction with the CDC and provide resources, such as masks and oseltamivir. ADPH updates information on the disease at its website www.adph.org
"So much of health is influenced by policy, and by the choices we make as individuals and as a society," Michael said. "It takes more than healthcare to have healthy people. It takes jobs that earn decent wages so people can live in safe neighborhoods with clean air and afford healthy food. It takes education so people understand what healthy choices are, and it takes access to deal with small issues before they become big, expensive problems."
Looking Toward Tomorrow
Beyond healthcare reform, creating a healthy Alabama will require a continued effort to solve several public health issues specific to our region. Like other regions, we will also be dealing with the effects of a growing and aging population. Some problems we've made progress on, such as clean air and clean water, once again need attention. During droughts, Alabama, Georgia and Florida are likely to once again be competing in court for access to supplies of fresh water.
Whatever the challenges we must address together, by drawing on the tools of public health, the people, physicians and policymakers of Alabama will be better prepared to create a healthier future.