Dispatches - Spring 2003

BALTIMORE

Gerard Anderson

To understand why Health Policy and Management Professor Gerard Anderson was recently voted one of the 100 “most powerful people in healthcare” by the readers of Modern Healthcare magazine, one need only ask him what may have drawn their attention. “Well, I do a number of things, so I’m known to a number of different audiences,” comes his reply. He then reels off a half-dozen current and ongoing academic interests: Medicare payment reform; a delivery system that is more responsive to those with chronic illnesses; comparative analyses of differing national health systems and outcomes; medical education; hospital payment reform; technology development and assessment; and health care cost analysis. It is no wonder that, as the Modern Healthcare article points out, Anderson serves on multiple editorial committees, has written two books and 140 journal articles, and has been called to testify before Congress on various health care issues more than 25 times.
 

Anderson, PhD, knows the American health care system intimately. Prior to joining the Hopkins faculty in 1984, he held various posts in the Office of the Secretary of the U.S. Department of Health and Human Services. There he helped devise a plan to change how Medicare reimburses hospitals for care—a plan that standardized what had been a wildly uneven system. The approach was subsequently adopted by about 50 other countries around the world.

During his time in government, Anderson became especially intrigued by what Americans spend on health care and what they get in return. Those numbers indicate to him the system is in serious need of reform. We are, he says, entirely unprepared for the third era of modern medicine. “From about 1900 to 1950 was the era of infectious disease, and we got really good at finding solutions for things like polio,” he says. “The next 50 years we got good at heart attacks and other acute episodes. But now people are living longer, the population is getting older, and we’ve entered the era of chronic diseases. But the system is [still] focused on acute illness. We are entirely unprepared for this new reality.”

Anderson notes that about half of all Americans suffer from at least one chronic disease, such as hypertension, asthma, or diabetes. About one in five has multiple chronic conditions, and 5 percent have four or more conditions. This smallest group is of particular concern as they account for a quarter of all U.S. health care spending and fully 80 percent of the costs of Medicare. Managing these cases—and their costs—is the great unmet health care system challenge of the 21st century, says Anderson.

His Rx? Currently, patients with multiple chronic illnesses typically see multiple doctors and receive multiple medications. Yet no one doctor is assigned to review and coordinate this care. “First, we have to start paying one of those doctors for care coordination. Second, we have to create and deploy a standardized computer information system to make care coordination possible. Finally, we gotta convince the doctors that this is worth their time.”

It is the last requirement that Anderson believes will be the biggest obstacle to overcome. “The hard part in all this is convincing doctors that this is important to do, and even worth changing how they do things now. The system can be changed, but not overnight. It’s a 10- to 20-year proposition.” 

PITTSBURGH

Devra Davis

In 1948, a thick, acrid smog blanketed the town of Donora, Pa. A thermal inversion trapped smoke from a steel mill and zinc smelter, creating the smog that killed at least 20 people and sickened thousands.

The landmark incident—now largely forgotten—helped lead to federal clean air regulations and an increased awareness of the dangers of industrial pollution. It also prompted Devra Davis, MPH ’82, a two-year-old Donora native at the time of the tragedy, to write When Smoke Ran Like Water. A scientific yet highly personal account of how pollution can have devastating human health implications, the book was named a 2002 National Book Award finalist in nonfiction.

In her book, Davis makes clear that much more needs to be done to make the nation’s air safe. “We’ve won the war of rhetoric, but now we have to turn our victory to action,” says Davis, a visiting professor at Carnegie Mellon’s Heinz School of Public Policy and Management.

Like much of Davis’ work in the 20 years since she studied at the School with renowned epidemiologist Abraham Lilienfeld, When Smoke Ran Like Water is not without its critics. Dissenters argue that Davis does not have enough scientific evidence to back her assertion that man-made chemicals released into the environment are responsible for increasing rates of cancer, infertility, birth defects, and other health problems. 

When Smoke Ran Like Water didn’t take top honors at the National Book Awards. That distinction went to Robert Caro for his latest volume on Lyndon Johnson. Davis wasn’t surprised. “I figured my odds were less than 10 percent,” she says, a scientist to the core.

UGANDA

Nosa Orobaton

In Africa, where the full force of the AIDS epidemic has hit hardest, governments and service providers have come to recognize the need for urgent, coordinated action through a broad spectrum of entities. Nosa Orobaton, MPH ’90, DrPH ’95, is a leading advocate for this new approach. He believes that in order for the fight against AIDS to succeed, it will need to enlist clinics and schools, governments and private employers, UN agencies and NGOs, foreign aid providers and for-profit specialists—many of which have worked in isolation from one another in the past—in a common effort to reverse rising rates of infection and death.  

“The lingua franca of this effort is skills, effective management, and understanding how to translate ideas into action. That’s what really matters,” Orobaton says. At the start of the year, he began a new posting in Uganda as country representative for John Snow, Inc. after holding a similar position in Zambia since March of 1999.  John Snow is a Boston-based public health consulting firm that works with national and community governments to find innovative and sustainable solutions to pressing public health problems around the globe. The firm’s country representatives are responsible for recruiting, organizing, and leading teams that address public health priorities identified by the host country and lead donor agencies.    

“In Zambia I had a staff of 32 physicians, pediatricians, obstetricians, public health specialists, and others who provided technical assistance to the Ministry of Health and the Central Board of Health,” Orobaton says. Charged with expanding the delivery of quality HIV/AIDS services at the community level while increasing the organizational effectiveness of key Zambian institutions responsible for fighting the epidemic, Orobaton led the John Snow effort in expanding the role of the for-profit private sector in the fight against AIDS.

“We have had great success in expanding and promoting the concept of HIV prevention and management in the workplace,” Orobaton says with some satisfaction. “We helped start a new NGO that is doing incredible work with the corporate sector, helping companies such as Citibank, Zambia Breweries, Coca-Cola, and others develop HIV/AIDS services for their personnel. Shortly before I left, a number of private companies began discussing funding an insurance company to pay for the antiretroviral drugs used in controlling AIDS.” 

Moving the fight against AIDS into the workplace is in part a matter of necessity. Orobaton notes that the most recent government survey in Zambia found HIV infection rates ranging from 8 percent to a high of 22 percent by province. “Every family is affected and HIV pervades virtually every aspect of the health system,” he says. “There is a shortage of workers to operate the health centers. Even our own staff is affected; several precious health workers have either died or are chronically ill.” In the rural areas, farms go untended as the disease devastates entire communities. 

Only through intense and coordinated cooperation, he believes, will nations like Zambia begin to stem the tide of devastation. Recently, USAID helped create the Zambia Integrated Health Project, coordinating the efforts of four entities, including John Snow, Inc., and the Johns Hopkins Center for Communication Programs. Orobaton calls the result “a first-class program” that is able to effectively build upon the expertise of each of its entities. “We had to devise ways of strategizing cooperatively, to make the whole greater than the sum of its parts. This is the future of fighting AIDS in Africa.” 

SINAI DESERT

Sam Ruben

It is 11 time zones and more than 7,000 miles from the redwood forests of the Oregon coast to the sands of the Sinai desert. For the soldiers of Oregon’s 1st Battalion, 186th Infantry Army National Guard unit, it wasn’t just the distance that proved challenging. It was, they found, like being on a whole new planet. 

“When we were first there in July and August, it was about 120 degrees in the sun,” remembers Lt. Colonel Sam Ruben, MD, MPH ’81. “All you could do was [lie] low, drink plenty of water, and stay indoors in the air conditioning.”

For Ruben and the other members of his unit, keeping cool was what their presence in the Sinai was all about. As the U.S. component of the Multinational Force and Observers (MFO), their job was to help enforce the 1979 peace treaty between Egypt and Israel. Though armed, MFO soldiers are stationed only to observe and report, and must obey strict use-of-force guidelines. Just the second National Guard unit to be used in lieu of active army personnel in the Sinai, the Oregon Guard filled the peacekeeping force’s 43rd rotation, scheduled to last about half a year. (The unit was due to return to Oregon as this article was going to press.) Ruben was stationed at South Camp, a former Israeli military base on the coast of the Red Sea that was returned to Egypt after the peace accords were signed. It has been used by MFO soldiers ever since.

As battalion surgeon for his unit while stationed in the Sinai, Ruben treated the everyday injuries of soldiers engaged in peacetime activities. But he also got to help work on a stage-two vaccine trial in a joint Army-Navy development of a Shigella flexneri vaccine. Shigella, he explains, causes severe dysentery, which is a major cause of non-battle injuries in “forward-deployed soldiers and marines,” as well as high morbidity and mortality in children in developing nations. Ruben participated in the research with investigators at the Navy Medical Research Unit–Cairo, an infectious disease research laboratory, he says, “that boasts many achievements by distinguished researchers, quite a few of whom have been Hopkins grads.”

It is hoped the vaccine, developed by the Pasteur Institute in Paris through funding by the U.S. Army, will impart lifetime immunity. Previous clinical trials were conducted in Pakistan and concurrent work is under way by U.S. Air Force researchers in Turkey. If successful, such a vaccine could save the lives of many children, though its approval for use would realize a more immediate goal for the military, which has historically been eager to fight any infectious disease that diminishes combat readiness.

Following his Sinai duty, Ruben will return to his position as staff psychiatrist for California’s Pelican Bay State Prison (just across the state line from his home in Oregon). He earned his MPH at the School as part of his residency in Preventive Medicine at Walter Reed Army Institute of Research. 

After 10 years of service (including three while he was in school), Ruben worked as a district health officer in Hawaii before moving to Oregon.

Most recent news from the Middle East falls into one of two categories: bad or worse. But Ruben reports that in the southern Sinai at least, peace has planted roots and is beginning to blossom: “The Sinai coast of the Red Sea is being built up as a resort area. It’s beautiful and the [scuba] diving is unbelievable.” 

MYANMAR

Thein Thein Htay

In the nine months Thein Thein Htay, MHS ’00, spent studying in Baltimore, she remembers sleeping only about four hours a night. “There was so much to learn,” says Htay, who has the distinction of being the first Gates Scholar to graduate from the School. (Instituted in 1999 as part of the Bill and Melinda Gates Institute for Population and Reproductive Health, the program each year brings a few exceptional mid-career professionals from around the world to the School for graduate study in population and reproductive health.) Initially trained as a physician in her native Myanmar (the country formerly known as Burma), she gradually became immersed in public health policy through her position as a health director in the Ministry of Health. But the more involved she became, the more she realized she needed to know.  

“Previously I had very limited exposure to international programs, so to go to Baltimore was a very educating experience,” Htay says. At home she obtained the most current information by quizzing the occasional aid worker who came through on official business; through persistence she was able to convince her supervisors of the need to study abroad. It was a move that made a critical difference for her. “When I returned, I felt very confident and began briefing my bosses at the ministerial level,” says Htay. 

Htay’s new expertise was quickly recognized, and the following year she was called upon to help draft the reproductive health policy for Myanmar in her capacity as head of the maternal and child health and birth spacing section of the Ministry of Health. A closed country with relatively little outside contact, Myanmar officially encourages large families. Contraceptives are available—the Pill and injectables are the preferred methods, says Htay—but abortion is illegal. 

Htay recognized that important child and maternal health needs were going unrecognized in her country. “Women bear by far the greatest burden of reproductive health problems, as there is a lack of information and services,” she says. The new government policy aims to reduce the maternal mortality rate to less than one per thousand live births, and to cut the infant mortality rate (currently at about 60 per 1,000 live births) in half.

Htay’s efforts are winning widespread recognition, and she reports significant international support from United Nations and non-governmental agencies. With a chronically understaffed office, she spends an average of three weeks a month visiting and monitoring the nation’s 324 townships, where policy is administered at the local level. But it is at the very highest levels where she hopes to bring about the greatest change. “Leaders at the ministerial level have never had a chance to understand the real need for reproductive health in our country,” she says. “As yet, they are quite far from that knowledge. I am trying to request that the UN and NGOs give more emphasis to this.”