A Princeton remedy for ailing public health 

One Saturday in late August, Lara Atwater ’07 sits in a community-college classroom in suburban Maryland, listening as parents explain in halting English how a county-funded health-care program has helped their children. The parents well over with emotion as they speak of a visit to an ophthalmologist who helped restore sight in one boy’s eye; a $10,000 skin-graft surgery performed gratis to replace burn scars; dental and facial reconstruction for a child who broke his jaw. The parents are immigrants from Africa who work at least one job; many also attend school. Their children are considered at risk for obesity: They eat unhealthy meals at school and highly processed, inexpensive food at home, get little exercise, and spend many hours in front of the TV when their parents are at work.

Atwater, a history major who hopes to become a doctor, is moved by what she hears: While the parents want the best for their children, many aspects of their lifestyle and home environment increase the likelihood that their children will become obese. She comes away convinced that these families need help on many fronts: better access to fresh foods, safer places for children to relax and exercise, and more know-how about selecting and preparing nutritious foods. When she returns to her office at the Primary Care Coalition of Montgomery County, which supports 10 community clinics, Atwater draws on the parents’ experiences to apply for a grant for a new obesity-prevention program. Keeping families like these healthy, she says, is “just getting harder.”

Atwater is one of 12 members of the Class of 2007 who are inaugurating a new Princeton Project 55 program in public health. The idea is to attract students before they go to graduate or medical school, introduce them to some of the broad problems prevalent in the health-care system, and pique their interest in careers that address health concerns for society as a whole. It’s the latest effort by the alumni service program that began as a challenge from Ralph Nader ’55 to his classmates — a program that has served as a model for programs begun by other, younger classes. Over the last 17 years, Project 55’s Public Interest Program has sent more than 1,300 Princeton students or graduates to work for organizations devoted to education, the environment, social justice, and public policy; this is its first major venture into public health.

The public-health fellowship program was the brainchild of Princeton alumni from different decades: the late Charlie Bray ’55, a founder and former president of Project 55, and current president James Gregoire ’69, an investment manager. Gregoire took the helm two years ago as the organization — wanting to remain robust even as its founding members grew older and less able to participate — sought leadership from younger classes. (Today, more than half of the Project 55 board and many of the nearly 200 volunteers represent younger classes, says executive director Kim Hendler.) At a board meeting in June 2004, Bray recommended that his colleagues read Mountains Beyond Mountains, Tracy Kidder’s powerful biography of public-health pioneer Paul Farmer. Through his first clinic in rural Haiti and now through work in six other countries, including the United States, Farmer — who received an honorary degree from Princeton in June — and his group Partners in Health provide essential medical care to hundreds of thousands of poor people each year. Gregoire read the book and wondered: Why not help Princeton students follow in Farmer’s footsteps?

The need was compelling: Though public-health initiatives during the 20th century are responsible for most of the greater life expectancy Americans now enjoy, the number of professionals working with public-health agencies has dropped within the last 20 years, according to the American Public Health Association. Federal agencies such as the Centers for Disease Control do not have enough epidemiologists to track pandemic flu or other emerging health threats, and shortages also are acute in nursing, environmental health, and laboratory science. Meanwhile, conditions that respond to public-health efforts, such as obesity and related illnesses like diabetes and hypertension, are on the rise. But while the number of students attending medical school has remained constant in the last decade, not enough are choosing primary care and prevention over higher-paying specialties. The National Institutes of Medicine in 2002 called for all medical students to receive some basic public-health training.

Though graduate fellowships are available for students already attending medical school or schools of public health, Project 55 leaders believe that their fellowship is the first in the country aimed at steering new college graduates into the field. As in Project 55’s Public Interest Program, salaries for the fellows — an average of $26,000, plus health insurance — are paid by the host organizations.

“If we want to grow the size of the pool of talent entering the public-health field, with all the challenges it presents, we have to get them early, before they are too wrapped up in their doctor tracks to think seriously about public health,” Gregoire says. Neurologist William Leahy ’66, a Project 55 board member and a creator of the new program, says it also was established to meet undergraduate demand, and 45 students applied for the dozen positions available. Undergrad-uates, Leahy says, “are coming to realize that the world is a complex place medically” and that diseases are not border-specific; he hopes that exposing the young alumni to the nation’s “dysfunctional” health system will attract some to work in areas like the development of vaccines and epidemiological studies. (Leahy also has worked to bridge the divide between traditional medicine and public health in his own life: In addition to his neurology practice, he has developed a program to train high school students to care for elderly people who suffer from dementia.)

Most of the students entered the program with plans to attend medical school in a year or so. But they soon found that they knew little about the daily routines and demands of working in the American health-care system. Jade Ku ’07 is working at Trinitas Hospital in Elizabeth, N.J., which serves a working-class community where many residents lack primary care and insurance. She has gone on grand rounds with the residents, attended management meetings about Medicaid reimbursement and compliance with government regulations, and become a regular visitor to the pathology lab, where she has peered through slides with cancerous tissue samples and observed an autopsy. She recently accompanied the head of palliative care on a meeting with neighborhood seniors to educate them about difficult end-of-life care decisions. An early highlight in Ku’s fellowship came during her first two days on the job, when she attended a conference on racial disparities in caring for patients with congestive heart failure: Studies show that African-American and Latino patients receive lower-quality care — and have lower survival rates — than whites, as they tend to receive different medications or discharge instructions. The topic intrigued Ku, who had studied race and medicine in an anthropology class at Princeton. At Trinitas, doctors, nurses, and others shared ideas about how to change actual practices and improve care. It struck Ku as far from the theoretical discussion of the classroom or the controlled scientific experiments she had carried out in a Princeton lab.

Medicine, Ku has learned, is not what she expected. “Generally I was surprised, because everyone is working toward the same thing — the best outcome — but it’s funny how government sets it up: ‘We want you to take the best care, but do it in X [number of] days, and then they give us X [amount of] money for it,’” she says. “That really frustrates me and scares me. Before I took this fellowship, I never thought about the pressures — can you get the patient out and into the right environment, can the patient pay for medication? I never imagined that doctors have to deal with this.”

Atwater will be splitting her time for the next year between the Primary Care Coalition, the group for which she wrote the obesity-prevention grant, and the Consumer Health Foundation, a grant-maker that funds area organizations promoting healthier lifestyles. In addition to writing grants, she is developing an electronic inventory of the health services and programs each clinic offers, and creating a survey to study how often and how effectively primary-care doctors in the clinics bring in specialists. She had a passion for community medicine even before beginning her fellowship. At Princeton she became interested in the sometimes-conflicting perspectives between patients and the medical establishment. Her independent work, a project on childbirth practices and another on Typhoid Mary, revealed how people from different social levels interact with each other in the medical and social systems — often leading to a sense of distrust and affecting a patient’s care. “I hoped that by seeing how misunderstandings occur,” she says, “I might not only become a better physician myself, but also contribute to the conversation [about] how physicians can serve their patients better.”

After just a few months on the job, she already has seen medicine from an array of new angles — from the physician’s point of view, but also from that of immigrants, the working poor, and middle-class Americans who find health care unaffordable. She describes a clinic in a local Muslim community, where the staff has all but given up on getting government money and spends time instead raising money and building a corps of volunteers in the community. “Through their own social networks, literally across the country, they have gotten doctors to send sample meds, collected through their friends. They have more in their pharmacy from these sources than what our program ... is able to offer,” she says. “It would take me months to write grants and get funding, but [the medical director] can get friends to send meds and get a pharmacy pulled together for free.”

Other fellows, working in different settings, have learned their own lessons about medicine and the American health-care system. Ruby Greywoode ’07, who expected to learn about the broad policy issues that concern public-health practitioners — how to approach AIDS or asthma in the community, for example — has found that it’s her one-on-one encounters with patients at the Norwalk Community Health Center in Connecticut that most inform her view. “Language and cultural differences are real barriers — many of our patients speak Haitian Creole — but I’m growing more comfortable with the day-to-day rhythm of the clinic,” she says. Dustin Meyer ’07 works at the Aeras Global TB Research Foundation in Rockville, Md., where he is researching scientific breakthroughs in a worldwide TB epidemic that kills about 2 million people each year and has infected nearly 2 billion. “Not only are we developing vaccines and preparing them for distribution, but Aeras has set up professional-development programs in Uganda, Kenya, and soon India,” he says, where the organization is working with local people to build expertise and systems for providing care.

Marie Beylin ’07 has been interested in public health since the summer before her junior year at Princeton, when she trailed a physician at Palo Alto Veterans Hospital and witnessed the difficulties of treating homeless veterans who returned to living on the streets. Then, in her senior year, she took three courses — on biotechnology policy, ethics and public policy, and pharmaceutical research and health policy — that helped her understand some of the complexities and intractable problems in the American health-care system. Now Beylin is the first Project 55 public-health fellow at the Rockefeller Foundation, where she is getting a “bird’s-eye view” of public health. One of her first projects is to investigate how to engage the private sector in developing countries to improve the health of the poor; she is conducting research and interviewing experts in academe, think tanks, and the private sector.

In addition to getting on-the-job training, each fellow is assigned a mentor who has experience in the field. The fellows visit each other’s worksites and share information about their host organizations and responsibilities. And they attend seminars by leading public-health experts on such topics as global health and security policy, infectious and neglected tropical diseases, Medicaid and Medicare, and access to health services in the United States.

Project 55 leaders and volunteers don’t expect that all the fellows will go into public health — in fact, they acknowledge that most will not. But they hope that such intensive exposure to the field before graduate school — be it medical school, a master’s degree in public health, or a law or business degree — will shape students’ thinking, even if they pursue other careers. Leahy notes the growing need for “greater integration of legal scholars, economists, business people, and basic scientists” as they grapple with complicated health-related issues that concern them all, such as the case, earlier this year, of an Atlanta attorney who flew internationally despite being diagnosed with contagious tuberculosis. Sue Suh ’96, a Rockefeller Foundation official who was a Project 55 intern and now serves as a board member, says the program is a “great way to attract a different sector of students who may have not applied to PP55 in the past — to bring them into the fold and add their perspective to questions of public health.” In the future, Project 55 hopes to place fellows in about 30 public-health nonprofits each year, and plans to recruit students who major in subjects like economics and public and international affairs, as well as the science majors who were targeted for the program’s debut.

Some of the fellows say that the experience already has colored their career plans and their outlooks. Ku says her work at Trinitas has inspired her to think “about what I can do on a bigger scale.” She was swayed by a hospital social worker, who reminded her that the health of patients ultimately will depend on the support and resources they have after they are discharged. In the past, she was not very interested in government or public policy, but working in the hospital has changed that. “Before, I thought, ‘[Changing the health care system is] a huge problem, but I don’t think I could do anything about it, so I’m stepping away,’ ” she says. “Now, I’m more willing to learn about it and get involved.” If she goes to medical school, she intends to add courses in public health and possibly even pursue a joint M.D./M.P.H. degree.

Atwater plans to be a doctor who does more than “sit and wait for patients to come and see me in my office.” She still hopes to treat patients one-on-one, but she also wants to help address the medical needs of communities and of patients who never walk through her office door. She, too, is now interested in medical schools with strong public-health programs.

Not long ago, Atwater shared her feelings with a Georgetown University medical researcher with whom she has worked. He told her that she was unusual — that even after four years of medical school, most students are well trained to treat individual patients but know little about the system in which they themselves work, and why it is so important. “You need to see both the tree and the forest — how to think about the health of the tree, but not lose perspective on the health of the whole forest,” Atwater explains. “Most med students leave school having no conception of the forest — and that’s dangerous for everyone.”