img
img img
img img
img img
img img
img img
img img
img img
img img
img img
img img
img img
img img
img img
img img
img
img
img
img
Welch Wanderings continued

Old Friends, New Synergy

imgWhen Jane Bertrand and Amy Tsui studied sociology and demography at the University of Chicago in the late 1970s, they were more than just friends — "We were commiserators," recalls Tsui. The PhD candidates attended the same courses, shared the same advisor, and took the same exams. But after graduation, the two went their separate ways: Bertrand traveled to Tulane University in New Orleans, where she began investigating the role education campaigns play in reproductive health, while Tsui stayed in Chicago to continue her population research.

In the ensuing years, both women became leaders in their fields. In 1982, Tsui joined the faculty of the University of North Carolina where she began research aimed at understanding why people use contraceptives and how programs can further encourage their use. Recently, she's been working on expanding family planning services. "There's interest now in further integrating family planning into [other] health care services," she says. Meanwhile, Bertrand, who joined the faculty at Tulane in 1979, has worked on different aspects of family planning campaigns in Guatemala, Zaire, and Morocco, and she's seen results. "Family planning, to the surprise of many, has been phenomenally successful," she says. For example, the birth rate in Latin America has dropped from six to three children per family over the past 30 years. In 1991, both Bertrand and Tsui headed a six-year comprehensive USAID evaluation of family planning and reproductive health programs worldwide.

After two decades of achievements, this duo has been reunited at the School. Bertrand will soon head the School's Center for Communication Programs (CCP), and Tsui will direct the Bill and Melinda Gates Institute for Population and Reproductive Health. The two hope to use their skills to take the CCP and the Gates Institute in exciting new directions. Bertrand would like to use her experience in family planning to help the CCP strengthen campaigns for HIV/AIDS prevention, and Tsui wants to promote research aimed at furthering civic and governmental leadership skills and improving reproductive health. Both women bring great leadership and expertise to their positions, says Bernard Guyer, MD, MPH, chair of Population and Family Health Sciences. "Together they will continue to work towards improving the lives of millions," he says.

Geoff Brumfiel

Health Care Choice That's Cost-Effective

When it comes to health care, Americans like to have choices, and now a study led by health policy experts at the School shows that greater choice can be cost-effective as well. In a study led by Christopher Forrest, associate professor of Health Policy and Management, researchers found that plans that allow patients to see a specialist without a referral are affordable for health maintenance organizations (HMOs) because patients rarely use the option and are willing to pay more to have it. The results of this study, says Forrest, MD, PhD '95, should encourage HMOs to offer more choices to their patients and may provide valuable insight for policy makers reforming Medicare.

An HMO patient is often placed under the care of a primary care physician, or "gatekeeper," who decides whether or not the patient should see a specialist. Problems can arise when patient and doctor disagree about whether such referrals are necessary. So, many HMOs have begun providing so-called "point-of-service" (POS) plans, which for an additional fee allow a patient to see a specialist without a referral. POS plans have been gaining popularity among patients ever since the early 1990s, but HMOs have wondered and worried, says Forrest, "Is it going to break the bank?"

The conclusion: Patients don't seem to be making a lot of unnecessary visits, according to the study by Forrest and his colleagues that appeared in the May 2, 2001, issue of the Journal of the American Medical Association. The study, which reviewed data from roughly 386,000 patients enrolled in POS plans nationwide, showed that only 4 to 7 percent of patients referred themselves to specialists without consulting their primary care physician. A follow-up phone survey of 600 patients who went to a specialist on their own showed that most did so because they wanted immediate access to specialty care or because they didn't get along with their primary care doctor. Why don't patients self-refer more often? Forrest believes it's because most patients have good relationships with their primary care physicians and are likely to seek their advice before seeing a specialist. Nonetheless, he adds, patients like to have the peace of mind of knowing they can see a specialist any time they want to.

"There has been a relative dearth of research on point-of-service plans," says Steven Foldes, a senior researcher for Blue Cross Blue Shield of Minnesota. Foldes believes that Forrest's "impressive study" is an important first step in gauging the impact that POS plans will have on the health care industry.

Says Forrest, "I think that this study provides evidence that [a POS plan] may be a viable alternative for Medicare."

GB

imgMegacities, Megachallenges

Of all the global demographic changes occurring in the 21st century, one of the most significant will occur in the next five years when a majority of the world's population will live in cities rather than rural areas for the first time. By 2030, the number of urban residents will double from 2.5 billion to almost 5 billion, according to a June report released by the Johns Hopkins Population Information Program at the Center for Communication Programs. The report also estimates that by 2030, 60 percent of the world's population will live in cities, with many inhabiting "megacities" (cities with more than 20 million residents) like Lagos, Bombay, Shanghai, and Mexico City.

"Often, when we think and teach about international health in developing countries, we think naturally about rural populations," says Bernard Guyer, chair of Population and Family Health Sciences at the School. Rural populations are often considered poorer, more isolated, and less healthy than their urban counterparts, Guyer explains. But the new population report shows that urban dwellers face some serious health problems: The majority of urban inhabitants lack proper sanitation, and air and water pollution kill a combined 8 to 15 million people annually.

In developing countries, the study predicts the concentration in cities will push already overburdened public institutions to the brink — leaving many people without basic services like sanitation and health care. The population shift to urban living will have profound consequences for public health and will require new approaches.

Guyer, MD, MPH, believes that the faculty members are keeping pace with the growing problems associated with urbanization. "There's been a transition in the kind of work that faculty have done, moving away from rural areas into much more urban settings," he says. Many have close ties to urban centers like Jakarta and New Delhi and are working with local officials on issues like sanitation, nutrition, and leadership development.

"These are not new problems, places like London [in the 18th and 19th centuries] had problems of solid waste disposal, overcrowding, and pollution similar to those in modern cities like Dhaka," Guyer says. In some ways, the growing urbanization will diminish differences between developed and developing countries - making research on domestic public health issues, such as controlling urban epidemics, globally relevant, he says.

Ultimately, Guyer foresees the School offering new courses on urban health issues and students increasingly focusing on urban centers for dissertation research. In order to facilitate these coming changes, he says, "We're going to have to be, as a faculty, much more informed about the urban public health situation."

GB

 

Cover Story | Features | Editor's Note | Letters | Weighing In | Welch Wanderings | Prologues
Frontline Focus | Et Al | Table of Contents | JHSPH Home | Publishing Staff | Subscribe