The evolution of Public Health Sciences in an academic medical center. (Wake Forest Centennial).

THE MOST EFFECTIVE DISEASE-PREVENTION STRATEGIES require the integration of both clinical and public-health approaches. With that premise in mind, the Department of Public Health Sciences (DPHS) was established at Wake Forest University Health Sciences (formerly Bowman Gray School of Medicine) to conduct state-of-the-art research, teaching and community service in the area of chronic disease prevention. Thanks to the vision of Dr. Richard Janeway and the leadership of Dr. Curt Furberg, the department has evolved over the 13 years since its founding into the second-leading public health/preventive medicine department in the United States in research funding by the National Institutes of Health (NIH) (total research funding exceeds $30 million), and is playing a key role in the clinical research, teaching, and community-health missions of the school. This article provides a brief summary of the rationale for establishing the department and strategies that have contributed to the success of this venture.

PUBLIC HEALTH AND CLINICAL MEDICINE: A DYNAMIC PARTNERSHIP

Substantial changes have occurred over the past 100 years in the leading causes of death in the United States (Table), evolving from a predominance of infectious diseases in 1900 to a predominance of chronic diseases in 2000. (1,2) As might be expected, the focus of clinical and public-health research efforts has shifted towards developing a better understanding of chronic disease etiology and prevention. Improvements in public-health hygiene were a crucial component of the observed shift away from some previously common infectious causes of death. The interaction of clinical and population-based practitioners has always been a key part of the biomedical research approach in the US, and the current focus on the major chronic diseases certainly necessitates the formation of interdisciplinary teams for the integration of excellent clinical research with excellent population-based disease-prevention research.

A MODEL FOR ESTABLISHING A NEW DEPARTMENT OF PUBLIC HEALTH SCIENCES

The newly established department's overall goals in 1989 were to further research programs in the areas of biostatistics, epidemiology, nutrition, health promotion/disease prevention, and social sciences/behavioral medicine; to strengthen research at the school by providing consultation in the development of research proposals, study design, analysis, and other methodologic issues. This department was built around the successful Center on Prevention Research and Biometry established 3 years earlier. Targeted recruitment of faculty with specific content-area expertise was a major issue in building the new department. The decision was made to focus the department's research efforts on the major causes of morbidity and mortality in the US (cardiovascular disease, cancer, and stroke). We were fortunate in that these areas also mirrored the global clinical and basic research expertise at the medical center, since the institution had NIH-funded centers in these areas in 1989. Efforts were made to find and recruit y oung to midlevel faculty members who were seeking opportunities to fully develop their own independent research careers. Hallmarks of the department have been to foster a nurturing work environment, to assure excellent faculty mentoring, to encourage the formation of multidisciplinary teams, and to work closely with clinical colleagues from throughout the Wake Forest University School of Medicine. To accomplish our research goals, faculty experts in epidemiology, biostatistics, and social sciences/behavioral medicine were recruited. New faculty members were expected to participate in cutting-edge research activities, not only in a leadership role, but also as vital, contributing team members. Thus, care was taken to assure the maintenance of a collaborative work environment, even after the department grew larger, with a considerable number of highly successful investigators and groups.

As the research base in the originally targeted areas became more successful, the department was able to expand its research base into complementary areas. For example, we built upon our population-based expertise in cardiovascular disease (both observational and clinical trials) by seeking to develop a major focus on diabetes. Early success by our excellent cadre of biostatisticians allowed for the expansion of our multicenter study coordinating activities while still seeking a balance between the applied and methodologic research expertise required to meet the statistical research needs of the entire institution. The need to better understand health-related quality of life as an outcome in both research studies and clinical care provided an opportunity to recruit an excellent group of social scientists to the institution. Given the need to better understand optimal strategies for chronic disease prevention in women, faculty from throughout the institution worked together to answer pertinent questions in thi s area. The active clinical research environment was an important catalyst to establish an academic-based health-service research group in the department. The combination of excellent biostatisticians, along with the expertise associated with large cohort studies, was important as the department expanded its research base into both population genetics and statistical genetics.

ACHIEVING SUCCESS IN CHRONIC DISEASE RESEARCH

The DPHS was formed in 1989 from the Center for Prevention Research and Biometry. This center was founded in 1986 as evidence of the school's commitment to programs in prevention research. The DPHS was directed by Curt D. Furberg, MD, PhD, from 1989 to 1999, and Gregory L. Burke, MD, MS, from 1999 to the present. To achieve its goals, the department was divided into 3 program sections: Biostatistics, Epidemiology, and Social Sciences and Health Policy.

Section on Biostatistics

The biostatistics section of the DPHS provides expertise in biostatistics, clinical trial design and conduct, computer programming, and advanced research data processing services. Faculty members in this section conduct methodologic research in survival analysis, sequential analyses, clinical trial design, categorical data analysis, analyses with missing data, measurement/misclassification errors, multivariate/longitudinal analysis, resampling techniques, robust regression, meta-analysis, psychometrics, regression diagnostics, quantitative epidemiology, genetic methods, and health service methods. Faculty and staff collaborate with investigators on study design, remote or centralized data entry systems, data management, quality assurance, data analysis, development of new statistical methods, sample-size calculations, survey and questionnaire development, publications, and manuscript reviews.

The Research Computing Unit of the Section on Biostatistics provides Wake Forest University with state-of-the-art computing facilities, computing methodology, and programming support. This unit has developed databases and data management protocols for many multicenter studies.

Section on Epidemiolgoy

Areas of research by faculty in the Section on Epidemiology include cardiovascular disease epidemiology, diabetes epidemiology, the epidemiology of aging, cancer control, cancer epidemiology, demography of aging, genetic epidemiology, and nutrition. There is also a focus on clinical trials methodology; the section houses both coordinating centers and clinical centers. Faculty have extensive experience with large, multicenter studies. Faculty members collaborate with clinicians and scientists from a variety of other departments in the medical school.

Section on Social Sciences and Health Policy

The Section on Social Sciences and Health Policy has expertise in health-related quality of life, prevention of substance abuse, medical effectiveness, health care outcomes research, psychosocial factors in health and disease, prevention of adolescent high-risk health behaviors, women's health issues, community interventions, and cost-effectiveness analysis of medical treatments. Members of this section have headed or participated in multicenter studies of cerebrovascular disease, dementia, breast cancer, and hypertension.

COLLABORATION INSIDE AND OUTSIDE THE UNIVERSITY

Figure 1 shows DPHS extramural research support overall, and Figure 2 includes the specific funding sources from 1988 through the end of 2001 (note that this includes only research funding when DPHS faculty members led the effort). These data show that there were 2 remarkable growth spurts in research funding: from 1989 to 1996, and again from 1997 to the present. While all sources of support generally increased over the entire period, the period from 1989 to 1996 was associated with increased NIH and industry activity, whereas the second peak period. (from 1997 to the present) was associated with an increase in NIH and foundation/other federally supported projects. Not surprisingly, the increase in the research base was associated with an increase in the number of faculty members required to perform the scientific discovery mission of the projects (Fig 3). Thanks to our institutional support and the creativity and hard work of our faculty members, the DPHS is currently the second-leading recipient of NIH fu nding of departments of preventive medicine/public health sciences in the nation. More important than the absolute dollar amount is the impact of findings from our research efforts on improving health in our city, our region, and our country.

Outside our university and medical school setting, the DPHS has formulated close collaborative relationships with a variety of other schools and programs across the state and country on numerous projects, including the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study; the Asymptomatic Carotid Artery Plaque Study (ACAPS); the Autoimmune Inner Ear Disease (AIED) study; the Atherosclerosis Risk in Community (ARIC) study; the Cardiovascular Health Study (CHS); Brachial Artery substudy of CHS (CHS-BA); the Coronary Artery Risk Development in Young Adults (CARDIA) study; the Carotid Artery Follow-Up Study (CAFUS); the Cognition in the Study of Tamoxifen and Raloxifene (COSTAR); the Family Heart Study (FHS); FHS-Scan; the Fracture Intervention Trial (FIT); the Ginkgo Enhancing Memory (GEM) study; the Multiethnic Study of Atherosclerosis (MESA); Heartquest; the Hemochromatosis and Iron Overload Study (HEIRS); the Insulin Resistance and Atherosclerosis Study (IRAS); the Multicenter Isradipine Diuretic Atherosclerosis Study (MIDAS); the Postmenopausal Estrogen/Progestin Interventions (PEPI) study; the Pravastatin, Lipids and Atherosclerosis in the Carotids (PLAC-II) study; Look Ahead; the Polyp Prevention Trial (PPT); the Prospective Randomized Evaluation of the Vascular Effects of Norvasc Trial (PREVENT); Rural Health and Nutrition (RUN); the Southeastern Consortium on Racial Differences in Stroke (SECORDS); the Soy Estrogen Alternative (SEA) study; the Trial on Nonpharmacologic Interventions in the Elderly (ONE); the Type 1 Diabetes Consortium; the Women's Health Initiative (Will); the Will Study of Cognition (WHISCA); and the Will Memory Study (WHIMS).

ACHIEVING SUCCESS IN TEACHING PUBLIC HEALTH CONCEPTS

Through the Wake Forest University Graduate School, the DPHS offers a Master of Science degree in Epidemiology and Health Services Research. The initial goal of this program was to provide a forum for the training of junior faculty (often clinical colleagues) and postdoctoral fellows. The program not only provides an excellent training opportunity, but also gives DPHS faculty an opportunity to work closely with clinical faculty, both while they are in the program and after they matriculate. The program to grant Masters degrees in Health Services Research was subsequently added in an effort to meet the demand for training in evidence-based medicine. Graduates of our programs have either remained within the institution or moved on to other academic settings as they initiated the next stage of their research careers. Since the program's inception, 47 individuals have matriculated through the program, and 18 are currently faculty members in the institution.

In addition to their participation in the Masters program, faculty members from the department are active participants in the undergraduate medical school curriculum. Wake Forest University's problem-based approach to teaching provides an opportunity for medical students to interact with DPHS faculty, both in the public-health-oriented curriculum and in more clinically oriented areas.

COMMUNITY PUBLIC HEALTH ACTIVITIES

The public-health mission of the department involves an active community-based component. Given the content-area expertise of DPHS faculty and staff, they are involved in key public-health community groups. In addition, our research activities focus on integrating state-of-the-art disease prevention strategies into community settings. This involves using the latest behavioral models to optimize chronic disease prevention. Included in these activities are a number of studies that seek to determine strategies for reducing health disparities in underserved populations. Being part of an academic health center provides a tremendous opportunity to integrate classic public health concepts as well as clinical care delivery into our community disease-prevention activities.

FUTURE OPPORTUNITIES

Although we have accomplished a great deal in this brief period, many issues remain to be addressed in our understanding of chronic disease etiology and in preventive-care delivery. Examples of future challenges include the developing epidemic of obesity/diabetes, the challenges associated with delivering optimal health care to an aging America in an era of lower health care reimbursement, the harnessing of discoveries in genomics to provide useful etiologic and treatment information at the bedside, and the existing racial/ethnic disparities in health. We look forward to continued success in addressing these and other challenges in public health, and plan to make a substantial impact on these important outcomes. More information is available on our Web site (www.phs.wfubmc.edu).

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TABLE

The 10 Leading Causes of Death in the United States in 1900 and 2000

Causes of Death in 1900    Causes of Death in 2000

Pneumonia                  Heart disease
Tuberculosis               Cancer
Diarrhea and enteritis     Stroke
Heart disease              Chronic lower respiratory disease
Chronic nephritis          Accidents
Unintentional injury       Diabetes
Diabetes                   Pneumonia/influenza
Diseases of early infancy  Alzheimer's disease
Cancer                     Nephritis, nephrotic syndrome,
                           and nephrosis
Diphtheria                 Scpticemia

Adapted from Grove and Hetzel, (1) and Minino and Smith. (2)

FIGURE 1

Total extramural research funding in the Department of Public Health
Sciences at Wake Forest University School of Medicine, 1988-2001.


1988   4,887,727
1989   5,299,570
1990   6,484,732
1991   9,205,267
1992  11,619,062
1993  12,184,530
1994  16,428,276
1995  17,568,486
1996  17,987,065
1997  15,096,186
1998  17,735,351
1999  22,759,875
2000  31,647,084
2001  30,488,438

Note: Table made from bar graph

References

(1.) Grove RD, Hetzel AM: Vital Statistics Rates of the United States, 1940-1960. Washington, DC, US Government Printing Office, 1968

(2.) Minino AM, Smith BL: Deaths: preliminary data for 2000. National Vital Statistics Reports, Vol. 49, No. 12, Hyattsville, Md, National center for Health Statistics, 2001

From the Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC.

Reprint requests to Gregory L. Burke, MD, MSc, Department of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1063.