J. Lloyd Michener, M.D., is at the forefront of connecting health centers in the community and academia, to spark innovative collaborations that will improve public health. He visited NIEHS Sept. 16 to talk with NIEHS scientists about the role of environmental factors in persistent and often puzzling public health patterns.
NIEHS and National Toxicology Program Director Linda Birnbaum, Ph.D., hosted Michener’s talk, in which he explored analysis of large-scale data and the sometimes surprising patterns that have been discovered. “We’re trying to make sense of these clusters and patterns,” Michener said, describing an array of government and other organizations studying variations in health status across sometimes very small geographic areas.
Michener, from Duke University, is a lead researcher for the Practical Playbook (see sidebar). He also served on the Institute of Medicine committee that produced the 2012 report, Primary Care and Public Health: Exploring Integration to Improve Population Health.
New challenges for care providers
According to Michener, reforms in Medicare payment systems will challenge care providers in areas where puzzling disease patterns persist, because those providers will bear more responsibility for demonstrating improvements. This is leading to change at all levels of government.
By the same token, health care, public health, and community organizations are coming together in new ways. “We need new partners,” he said. “We need folks from behavioral health, we need folks from social services, and increasingly, we need folks who understand environmental factors.”
Insights from data aggregation
More states are using large-scale data as they explore evidence-based interventions. A Durham County, North Carolina project mapped the residences of individuals with hypertension. The map was overlaid with locations of grocery stores, churches, fast food restaurants, and other facilities, to see what patterns emerged.
One cluster of hypertension cases occurred in an area with liquor stores and fast food, but no grocery stores. The county stepped in with zoning changes and tax abatement, to encourage a full service grocery store to locate there. “That has now happened, and they hire folks from the community to work there,” Michener said.
He stressed the value of community-led interventions that are data-driven. In Cleveland, mapping of asthma cases revealed clusters in three housing projects, which were then found to have significant mold problems. Cleaning up the housing is a far more effective intervention than continued training on how to use inhalers, Michener said.
Enlisting communities and environmental health scientists
Other patterns have so far resisted explanation. He pointed to clusters of colon cancer that appear to be developing in a few U.S. counties, while decreasing in many others. Stroke patterns that seem to follow river basins also remain unexplained. Michener stressed the need to use scientific rigor in developing potential explanations.
Stavros Garantziotis, M.D., medical director of the NIEHS Clinical Research Unit, suggested that teasing out environmental influences from the data could be difficult because those influences can be very personalized. “This is where community-engaged research techniques come in,” Michener replied. “We recommend the data be shared with the groups affected, because they may have interpretations we would never have thought of.”
Birnbaum pointed out that for environmental health scientists, some answers are well-known, such as how getting rid of mold can reduce asthma. “What I hope is that you will come join the discussion,” Michener replied, addressing the whole audience. “We’re finding more and more that we’ve been asking the wrong questions.”