Targeting the 'Upstream' Causes of Poor Health

This ScienceLives article was provided to LiveScience in partnership with the National Science Foundation.

For more than 20 years, Marilyn Winkleby has combined epidemiologic study with intervention research to shed light on the ways in which social factors impact health. The author of more than 100 articles in public health, epidemiology, and medical journals, she focuses on many of the issues currently making headlines. Those include cardiovascular-disease risk factors such as obesity, poor nutrition and physical inactivity; women's health; and the health status of ethnic minority and low-socioeconomic groups.

Public health work, she suggests, provides an ideal combination of inspirations — the chance to connect to "real people in real communities" while advocating for changes that improve health at the population level. Winkleby also founded the summer residential Stanford Medical Youth Science Program for low-income high school students, which recently received the U.S. Presidential Award for Excellence in Science, Mathematics, and Engineering Mentoring.

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Name:Marilyn Winkleby, MPH, Ph.D. Age: 65 Institution: Stanford Prevention Research Center, Stanford University Medical Center Field of Study: Public Health and Epidemiology

What inspired you to choose this field of study? Public health is the science of promoting and improving the health of communities. It focuses on the prevention rather than the treatment of disease. Public health also recognizes that the health of an individual is embedded within a social context. An individual's health is largely shaped by his or her own personal behaviors; however, social, cultural, economic and political factors also exert powerful, and often unrecognized, influences.

Therefore public health allows one to work in a field that is closely connected to real people in real communities, with the opportunity to advocate for changes that improve health at the population level. I was drawn to public health for these reasons, and in particular, epidemiology, a branch of public health where researchers look for patterns of health and disease in populations. It's like being a medical detective.

What is the best piece of advice you ever received? The advice my parents gave me was by example. They were very clear about their values and lived their lives accordingly. They valued a good marriage, caring for children and relatives, and public service. We didn't have a lot of extras, but we always made a meal for those who passed through our farm and were hungry. We also picked up hitchhikers.

As my family met these people, we learned that although we were often from different cultures with different beliefs, we had a lot in common. This showed me that knowledge comes from being involved with others. It's a lesson I've applied to my own research, recognizing that public health initiatives only succeed if you involve community members as equitable partners in the process and learn from their experiences.

The other great advice I received was after I had worked as a research assistant for several years but had not received any formal training in public health. A biostatistician from the University of California, Davis sat me down one day and said: "You need to go and get a Ph.D., begin your own research, and quit writing other people's articles and grants."

I had never thought of completing a graduate degree, but followed his advice. I drove to the University of California, Berkeley and met with Len Syme, a world-renowned social epidemiologist. I told him that I wanted to become an epidemiologist and he accepted me into the Ph.D. program and it changed my life.

What was your first scientific experiment as a child? I grew up on a very modest, two-acre farm in California, where we raised avocadoes and chickens. Science was evident in everything around me. I spent hours collecting bugs and plants, and classified them according to common traits — not having ever heard of Linnaean taxonomy. I think that this was my early training in epidemiology, where I have now spent 25 years classifying data and elucidating individual- and neighborhood-level characteristics associated with health outcomes.

One of the questions I ask the students who I advise about career choices is how they spent their time when they were young. I believe that you can identify individual traits at an early age that predict attributes that are related to success in a future career.

What is your favorite thing about being a researcher? I get to work with really smart people who are interested in lots of ideas about health and science, and are excited about their work. Being in public health, part of my time is spent in communities where I meet committed health professionals and diverse members of the community. I form most of the hypotheses for my research using an inductive approach, where I learn from people or observations in the community , then formulate and explore some tentative hypotheses, and finally move on to developing broader generalizations or conclusions.

I've been fortunate to have the independence to integrate public service into my work. I did this through the Stanford Medical Youth Science Program that I founded with two students almost 25 years ago. This organization, for which we just received the U.S. Presidential Award for Excellence in Science, Mathematics, and Engineering Mentoring, reaches out to talented high school students who have faced adversity but are excited about biomedical careers. These young people have inspired my work as they have completed their educations and excelled in their own careers.

Finally, being a researcher has allowed me to have flexible work hours and raise a family. I could go to work early, come home early, cook dinner with my husband, help with homework, and then work some more after the kids were asleep.

What is the most important characteristic a researcher must demonstrate in order to be an effective researcher? Starting on a project early, well before the deadline. I've been successful in getting my research grants and publishing scientific articles because of that characteristic. It is important for several reasons. First, it allows you to think for a longer period of time, and integrate new information as you come across it. Second, it allows you to finish a draft early, and ask peers and other smart people to provide feedback. Finally this characteristic lets you avoid the stress of being late and completing important tasks haphazardly. You don't need to ask your staff to work extra hours on a grant because you are late, and you have time for a life outside of work. The end result is that you have put an extra 10 percent in, above and beyond others, and often this is what refines your research and makes it important.

What are the societal benefits of your research? I have worked to further the understanding of the social determinants of health, by combining basic epidemiology and biostatistics with an applied emphasis on health promotion and disease prevention. My research has focused on the health of low-income and other medically underserved populations, concentrating on at-risk groups and developing tailored intervention programs that accelerate risk-factor change.

The major emphasis of my work has been on cardiovascular disease and its risk factors — elevated blood pressure, cigarette smoking, hypercholesterolemia, excess body weight, sedentary lifestyle, and diabetes — all of which vary substantially across population groups.

This work is especially relevant given the rapid growth of low-income and ethnic minority groups in the U.S. and their disproportionate rates of poverty and disease. Findings from my research have contributed to an understanding of the factors underlying the complex associations between ethnicity and socioeconomic status, and neighborhood environments and health. The long-term goal of my research is to enhance our knowledge about health inequities and develop interventions to address "upstream causes" of poor health.

Who has had the most influence on your thinking as a researcher? S. Leonard Syme, an emeritus Professor of Epidemiology at the School of Pubic Health, at the University of California, Berkeley.

He is regarded as the "father of social epidemiology" and has devoted his career to studying the influence of the environment — social, physical, and cultural — on health. His research delves into the link between social forces and biologic processes. He was one of the first researchers to stress that we must move towards a view of health that includes looking at larger determinants of disease like poverty.

He says: "Until public health can back away from a focus on individual diseases and disease risk factors and look at social circumstances, we are not going to be able to advance, and we are not going to be able to intervene."

What about your field or being a researcher do you think would surprise people the most? Since 1900, the average life expectancy of people in the U.S. has increased by more than 30 years, and it's estimated that 25 years of this gain are attributable to advances in public health!

There has been a tremendous decline in deaths from coronary heart disease and stroke; these leading causes of death have fallen by 60 percent and 70 percent, respectively, since World War II. This is a result of risk-factor modification, including smoking cessation and blood pressure control, along with better early detection and treatment of disease.

Although life expectancy has increased overall, well-to-do people have experienced greater gains, and this has caused widening socioeconomic disparities in life expectancy at birth and at every age thereafter. In addition, obesity is now among the leading preventable causes of death and disability. Current trends suggest that the obesity epidemic will result, for the first time, in an actual decline in life expectancy in the 21st century.

If you could only rescue one thing from your burning office or lab, what would it be? My computer flash drive with copies of my grants and scientific articles.

What music do you play most often in your lab or car? I like the music of the folk music greats like Joan Baez; Bob Dylan; Peter, Paul and Mary; Simon and Garfunkel; and Cat Stevens (Yusuf Islam), whose peace-focused lyrics encapsulate the important issues of our times. And I love the music of Puccini, the Italian composer who wrote "La Bohème."

Editor's Note: The researchers depicted in ScienceLives articles have been supported by the National Science Foundation, the federal agency charged with funding basic research and education across all fields of science and engineering. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author and do not necessarily reflect the views of the National Science Foundation. See the ScienceLives archive.