Public Health Research Takes Science Out of the Labs and to the People
Public Health Feature - May 2000
By Johanna Franke
All researchers don't necessarily juggle test tubes, wear white coats, and hide away in laboratories. In fact, Texans can find some researchers in their own backyards.
From the border to deep East Texas, scientists from the state's academic health centers are taking a population-based approach to epidemiology, biostatistics, and environmental, biological, and behavioral sciences.
Though they're the "least sexy kids on the block," these public health researchers are growing in numbers at Texas' medical schools, says R. Palmer Beasley, MD, dean of the School of Public Health at The University of Texas-Houston Health Science Center (UT-Houston).
As the appreciation for this research grows, so does its importance to physicians and their patients.
Part of the challenge of public health research is sharing -- or squeezing into -- the spotlight shining on headline-making bioscience research like the Human Genome Project. Population-based researchers don't have the latest revenue-generating drugs or medical devices to present to advertising companies for their next marketing push. While medical research targets pathogenesis and therapy, public health aims at etiology and prevention. Public health researchers must communicate the significance of their work on their own, which is not easy for scientists whose goal is to maintain quiet.
"It's the Y2K lesson," Dr Beasley said. "A positive public health event is a non-event. People have to learn that things are good when things are quiet, and we're the people trying to ensure that quiet."
But public health researchers are starting to create some noise across the state.
Scientists from The University of Texas Medical Branch (UTMB) at Galveston are targeting higher cancer mortality rates in 19 East Texas counties by conducting a worksite cancer prevention and control program through the Piney Woods Area Health Education Center (AHEC). Preliminary findings of this 5-year project, which began in 1997, suggest that UTMB's work has raised awareness about healthy lifestyles to combat cancer, says Billy U. Philips, Jr, PhD, MPH, professor in UTMB's Department of Preventive Medicine and Community Health.
The area is attractive to UTMB researchers because a fourth of the population is below poverty level, all 19 counties are designated as medically underserved areas, and 3 counties lack hospitals, Dr Philips says. Ten of these counties have been designated health professions shortage areas.
Along with possessing a higher cancer mortality rate than most Texans, Piney Woods patients aren't being diagnosed with the disease until it has reached advanced stages. UTMB's research is attempting to determine if having cancer education materials available to employees at work can produce a measurable change in cancer awareness, prevention, and detection.
"A lot of people wouldn't consider this to be research, although we've had a hypothesis -- and several alternates -- which we will analyze using standard statistical and epidemiological principles and methods," Dr Philips said. "Most people would say, 'Well, this is just a demonstration project,' and the truth is, it is a demonstration project. The difference is that instead of just looking at your typical evaluation measures, we've actually added penetration measures and outcomes measures. That's what makes it public health research."
This research differs from other public health studies in that it is observing a diverse employee population mix -- one that is rural with a large African-American population and a growing Mexican-American population.
"Most experiments incorporate a homogeneous population to eliminate as many barriers -- like poverty and isolation -- to the validity of research findings as possible," Dr Philips said. "So we're doing it exactly backwards."
This type of research addresses real-world situations, as homogeneous populations are not all that easy to find, Dr Philips says.
"The reason we chose to make this bold step is if we can demonstrate that an inexpensive shelf-based program can be sustained after we're gone by the employer for the employee, we're going to revolutionize what we can do in terms of future innovations for other diseases in similarly diverse communities," he said. "So this is clinical public health practice research."
Amelie Ramirez, DrPH, also is involved in clinical public health practice research as deputy director of Baylor College of Medicine's Chronic Disease Prevention and Control Research Center, which has offices in Houston and San Antonio. Formerly known as the Center for Cancer Control Research, the program traditionally has focused on preventing cancer among the state's Hispanic population, but recently expanded its horizons to help those afflicted with other chronic diseases such as substance abuse and diabetes. Public health research frequently offers help through prevention, which doesn't always seem that scientific, Dr Ramirez says.
"People often assume they already know how to cut the fat out of their diets," she said. "But they may have grown up with some harmful behaviors that are very hard to give up. This kind of research involves taking the time to educate people on the skills they need to live healthful lives and on the resources that might help them."
To educate, public health researchers must be able to communicate, Dr Ramirez added.
"Right now, there is such an attraction to find the genetic answer or that magic pill that will take care of everybody, but there is still a large interest in behavioral science and health communications," Dr Ramirez said. "As behavioral researchers, we need to learn more about the psychosocial and cultural issues inherent in a community. Through participatory research involving community members, we can use this knowledge to develop public health programs that will help motivate large populations to modify their lifestyles and utilize preventive services. The goal is to help individuals detect a health problem early and improve chances for a full recovery."
Public health researchers must sharpen their communication skills not only to educate, but also to ensure their work is the object of appreciation and funding.
To deliver cheaper health solutions to the public, scientists in the public health field spend more money on research. But the price of prevention will save patients in the long run, because preventing the disease means they do not have to undergo expensive procedures and purchase costly drugs.
Public health research can be expensive because it follows a quasi-experimental design involving different types of telephone and cross-sectional surveys. Finding investors interested in studies that aren't exactly clinical trials with laboratory layouts can be challenging, Dr Ramirez says.
"Our population-based research is very costly because we're not underwritten, for example, by pharmaceutical companies," she said. "We have to go out into the field and complete very labor-intensive work in terms of the way surveys and educational programs are conducted. Plus, we need large numbers to prove our conclusions work, while your more biomedical research can get away with small numbers -- a trial of 100 or fewer people -- to test efficacies."
Grants from nonprofit organizations like the American Cancer Society and the National Heart, Lung, and Blood Institute provide the monetary lifeline for much of the public health research conducted in this country.
"It is very important for people working in public health to compete for funding from the Centers for Disease Control and Prevention, the Texas Department of Health (TDH), the Texas Cancer Council, and other funding agencies that specifically address public health issues," said Barbara Pence, PhD, associate vice president for research at Texas Tech University Health Sciences Center in Lubbock.
"One of the interesting things about funding for research anywhere -- whether it's in Texas or any institution across the country -- is that the need for research creates a demand, and this demand is communicated to the institutes that have the money, and then funds become available for research and the specific discoveries in that disease," she added.
Lately, researchers in Texas have found themselves following money trails leading to disease prevention and detection programs courtesy of the tobacco lawsuit settlement. Several Texas academic health centers already have received funds for tobacco cessation studies through the Texas Higher Education Coordinating Board's Minority Health Research Education Grant Program.
But academic health centers don't always rely on nonprofit and state agencies to breathe life into their research programs. UTMB's Corporate Health Consortium, for example, is composed of 10 active collaborations and 16 corporations, including Merck, Schering-Plough, United Airlines, and Mobil. These corporations pay fees, used for public health research, to be consortium members in exchange for the opportunity to set a joint research agenda in public health. "This is an innovation intended to provide another mechanism for us to fast track the development of solid, population-based preventive medicine and public health research," Dr Philips said.
Beyond this, much of the support for public health research comes from the communities in which it is conducted.
By using well-established networks to reach these communities, Texas' public health scientists not only save time and money but also learn about health issues impacting even the most rural of the state's populations.
Dr Philips' group from UTMB employs AHECs to bring together a variety of resources -- from labor to office space -- within communities through chambers of commerce, hospital district boards, and employment agencies.
"Because they are nongovernmental community hubs incorporating a lot of local organizations and interests, these AHECs have the capacity to reach into a community without being limited by the confines of the local health department," Dr Philips said.
UTMB scientists spent 9 months developing relationships with Piney Woods AHEC communities before beginning their research.
The Texas A&M University System Health Science Center's new School of Rural Public Health has teamed with the Texas Agricultural Extension Service to provide a "land-grant concept of service and outreach to medicine," said Fuller Bazer, PhD, vice president for research at Texas A&M. "We have agricultural extension services in pretty much every city in Texas. We can overlay that network to educate and to provide information about health."
Texas A&M's South Texas Center for Rural Public Health, based in McAllen, studies nutrition and women's health in colonia residents. Dr Bazer says the center also addresses "environmental injustice" issues, such as the association of spina bifida with the polluted waters of the Rio Grande and the anemias caused by lead pipes in the colonias' old plumbing .
Baylor's Dr Ramirez searches cities for people who want to serve their communities by helping conduct research. "Sometimes we have medical students who have short internship periods who can work with us," she said. "We show them how they can educate the community about some very simplistic needs."
Public health scientists also partner with established physicians in these areas to deliver health messages to their patients. "The physician is the gateway," Dr Philips said. "The physician is the only person who can conduct the age, sex, ethnicity, and risk-profile screening that's necessary for a patient."
Through a collaboration with TMA's Physician Oncology Education Program, UTMB public health researchers have been able to update Piney Woods physicians on the latest cancer information as well as impress upon them the importance of returning screening documentation.
Partnerships with physicians are just the beginning of public health researchers' efforts to join the bioscience world in offering the best possible care to Texans. This alliance also allows findings developed in a lab to be applied to the real world.
"Public health and biomedical science shouldn't be pitted against each other because they're so complementary," said Ciro Sumaya, MD, MPHTM, dean of Texas A&M's School of Rural Public Health. "Those who work in the biomedical arena need to address public health issues, too. Sure, innovations in transplantation are very important, but do they reach everybody or just those who have dollars? What are the implications of this technology? How do Medicare and Medicaid assist with the dissemination of this technology? It is important that these two types of research relate to one another so that they can be applied appropriately by communities," Dr Sumaya said.
Dr Ramirez says physicians are seeing the connection. "There seems to be a growing interest in public health research from the medical profession because physicians would like to be more successful in treating their patients," she said. "Public health research helps physicians detect health problems in patients earlier, and the sooner they catch these problems in patients, the more physicians can do for them," she said.
Officials at the University of North Texas Health Science Center at Fort Worth, where a school of public health was authorized by the legislature last year, believe their training in osteopathic medicine has given them a unique and holistic approach to research.
The school's Consortium on Alzheimer's Research and Education (CARE) Program successfully has blended patient care, education, and research to "build a bridge from basic science and clinicians to what happens in the real world," said Thomas Fairchild, PhD, director of CARE's Special Projects on Aging. CARE also is collaborative in that it pulls together physician scientists, basic research scientists, and industry elements such as assisted-living facilities and long-term care providers, he adds.
Pharmaceutical companies are even beginning to realize the significance of public health research, as they need access to people to make their studies more effective and representative of the populations for which they develop drugs, Dr Fairchild says.
"Without the ability to carry basic science research all the way to application, we will, unfortunately, never be able to address the Alzheimer's challenges that face our society as we find ourselves with an increasing number of older adults," he said. "Baby boomers are marching toward Golden Pond."
With its remote history as a sanitarium and a devotion to public health, The University of Texas Health Center at Tyler has produced one of the few long-term care hospitals for tuberculosis (TB) patients in the nation, says David Griffith, MD, professor of medicine and head of Tuberculosis Services at UT Tyler.
When asked how UT Tyler would decide whether to fund TB public health research or bioscience studies, Dr Fairchild said, "Our priority is always public health, without a doubt."
Despite this progress, public health researchers believe their work does not enjoy the status that molecular research in Texas' medical schools does, but they know where they can find support.
"TMA's influence is in helping the Texas Legislature see the wisdom of creating funding for this research, and it's a very powerful and important one," Dr Philips said. "The association has certainly been a great ally when it comes to public health and public health practice."
Expanding the frontiers: The economic and human dynamics of Texas medical research
Research in Texas
Careers of discovery
The science of success: Research means revenues for Texas
Technology transfer organizations
Research on the Web
May 2000 Texas Medicine Contents
Texas Medicine Back Issues