50 Years of Thinking Differently

As deaths from AIDS rose steadily in early 1990s New York City, pediatrician and adolescent medicine specialist Alwyn Cohall, MD, saw another disturbing trend: In the school health clinics he ran on the Upper West Side and in Harlem, more and more students were being diagnosed with sexually transmitted infections. Concerned, his team began to test them for the most frightening sexual infection to date: HIV. “And out of the first ten young people we tested, four were positive,” he recalls. “It was mind-blowing. These weren’t street workers or injection drug users. These were kids in high school. Some of them were ninth graders. And they were developing a life-threatening disease.”

It was a public health challenge without precedent. And as more teens were diagnosed, Cohall realized he had nowhere to send them for care. “There were no adolescent HIV clinics nearby. We had to send them to pediatric or adult clinics, but they didn’t fit in with either population,” he says. Teenagers don’t want to sit in tiny waiting-room chairs. Teenagers think they are invincible. Teenagers are notoriously noncompliant, whether you’re handing them a prescription for an antiviral drug or a supply of condoms. And the predominantly African American and Hispanic teens were up against disparities in access to care because of their race, age, and economic circumstances. Many had limited access to good nutrition and were exposed to stressors like a parent’s unemployment. “I grew up in Harlem,” Cohall recalls. “I know what it’s like to not have heat and to go to bed with gloves on, to have to run the stove all night to keep warm.”

Realizing that adolescents’ experience with HIV would be impacted by their big-picture lives, Cohall, who was employed by St. Luke’s-Roosevelt Hospital, which was then affiliated with Columbia University, reached out to Columbia Mailman School’s Department of Sociomedical Sciences (SMS). The department was a pioneer in understanding the social conditions underpinning the experience of people with HIV/AIDS. Together, department experts and Cohall’s team developed a new model to serve the specific needs of HIV-positive teens and young adults. With an initial grant from the New York State Department of Health, they were able to collaborate with community organizations, high schools, and the city’s departments of health and education. “Each of those folks do what they do very well,” Cohall says. “But a lot of times they, like many of us in healthcare, operate in silos.” He went on to join SMS, and today serves as director of the Harlem Health Promotion Center and Project STAY (Services To Assist Youth). Together they have helped hundreds of young people gain access to HIV medication and comprehensive, interdisciplinary care. Cohall and a team that includes Columbia Mailman School students have also worked to prevent HIV infection by doing aggressive outreach in schools and agencies serving LGBT youth.

SMS was a natural partner for these efforts. Founded in 1968, during a time of social tumult, the department has long had at its core a commitment to advancing health equity—ensuring that everyone has a fair and just opportunity to be as healthy as possible. Ray Trussell, PhD, director of the School from 1955 to 1968, and Jack Elinson, PhD, the department’s first chair, founded the department, which was the first of its kind at any institution in the United States. Its mission: to develop solutions to address disparities in health experienced due to social determinants such as race, gender, age, and sexuality. These determinants play a major role in exposure to factors that affect the ability to be healthy, from lack of nutritious food and opportunities to exercise, to inadequate access to education and housing, to fair pay and exposure to poverty and violence.

SMS’s work addresses a critical need, given that social and behavioral factors account for an estimated half of all premature deaths in the U.S. today, according to a 2015 report from the Institute of Medicine. “We tend to think biomedical factors are the most influential drivers of health outcomes, but nonbiomedical factors—where you live, what nutrition you’re getting, racism, sexism—are just as consequential and sometimes even more consequential,” says Merlin Chowkwanyun, MPH, PhD, Donald H. Gemson Assistant Professor of Sociomedical Sciences. An early landmark study of chronic disease in rural Hunterdon County, NJ, which was led by Trussell and Elinson, combined clinical examinations with social-sciences methods and focused on a geographically defined population. Their findings indicated that a combination of survey and interview yielded a more accurate assessment of health. This groundbreaking approach eventually led the National Center for Health Statistics of the U.S. Public Health Service to initiate a periodic National Health Examination Survey, which is today a valuable source of data about the country’s health.

“What sets our department apart—and what really is its strength—is the depth and breadth of social-science expertise that SMS was one of the only places I could find that really brought to bear the different disciplines that shape our understanding of people’s lives and the factors that influence their health. we bring to every project,” notes professor
James Colgrove, MPH, PhD, whose work focuses on how U.S. public health policies have historically been influenced by social, political, and legal processes. SMS faculty employ methods from anthropology, behavioral science, ethics, history, political science, psychology, sociology, and health promotion and communication. “Our department is diverse in scope, but united by a desire to address social forces that affect health and to seek justice,” says Colgrove.

The department’s innovative and diverse scholarship drew associate professor Marni Sommer, DrPH, MSN, RN, there as a doctoral candidate. “SMS was one of the only places I could find that really brought to bear the different disciplines that shape our understanding of people’s lives and the factors that influence their health. Interdisciplinary research also helps us think about a wider range of interventions we can use to address their health.” Today, Sommer leads the Gender, Adolescent Transitions, and Environment (GATE) Program, which explores the intersections of gender, health, education, and the environment for girls and boys transitioning into adulthood in the United States and low-income countries, including Madagascar and Tanzania.

The deep and broad portfolio of research and teaching at SMS spans topics as diverse as aging, bullying, drug use, healthcare access, homelessness, housing, incarceration, obesity, sexuality, stigma, urban health, and occupational and environmental health. In the incarceration prevention program, Robert E. Fullilove, EdD, teaches incarcerated individuals about health inequity and motivates them to work to reverse it. (Read an essay by Fullilove on page 24.) Meanwhile, Daniel Giovenco, MPH, PhD, a member of SMS’s Lerner Center for Public Health Promotion, examines tobacco marketing in New York City, where he has found that the unhealthiest products like cigars and cigarillos are more likely to be carried and advertised in low-income neighborhoods.

The department’s Center for the History and Ethics of Public Health is one of only a handful of centers of its kind designated by the World Health Organization and the only one in a school of public health. The Center recently developed ToxicDocs, the world’s largest repository of once-secret documents about corporate and public use of toxic substances like lead paint, which disproportionately harms children in low-income communities of color. Looking at history is a critical part of public health work, notes Chowkwanyun. “Study of the past shows that the way we do things is not preordained. It reminds you that societal pathologies are a product of human decisions, not destiny. If we made them, we can undo them.”

There are now 28 full-time SMS faculty, and research is ongoing in Asia, Africa, Europe, and North and Latin America. Many of the department’s more than 3,000 alumni have gone on to be changemakers, with leadership positions in public and private health agencies, corporations, foundations, NGOs, and academia. And this year, SMS welcomes a new department chair and Stephen Smith Professor, Kathleen J. Sikkema, PhD. An expert in HIV-related mental-health interventions, she comes from Duke University where she was the Gosnell Family Professor of Global Health and a professor of psychology, neuroscience, and psychiatry and behavioral sciences. She was also director of the Global Mental Health Initiative at the Duke Global Health Institute. “Kathleen does groundbreaking work at the intersection of global health and mental health,” says Colgrove, who served as interim chair.

Says Sikkema, “The department is very well positioned for impact because faculty focus on the social structure of people’s lives—their economic situation, the role politics plays, shifting social norms—and how that influences well-being.” She adds, “There is so much intellectual synergy and collaboration. Part of the excitement is figuring out how to build on the excellent work SMS has done, and determining where we want to be in a decade or two.”

Today, with colleagues at the Harlem Health Promotion Center and Project STAY, Cohall provides health services for justice-involved adolescents and young adults at risk for, or living with, HIV. He recalls one young man referred to him by the New York City Department of Correction. “He was HIV positive, but when we unraveled his story, we found out that his father was incarcerated because he tried to kill his mother after his mother stole his crack stash. The young man had been bounced around to different homes and had been physically abused. He had a lot of trauma—not to excuse his behavior, but it gives you the context.”

When they assessed the man’s health, not only was he HIV positive, but he was also overweight, with high blood pressure and an elevated risk for diabetes. The team addressed his physical and mental health, as well as his substance abuse and the trauma that had shaped his life. “After three years, his viral load is undetectable. He’s lost weight, his blood pressure is under control, he’s stayed out of jail, and he is working and in school,” says Cohall. “That’s the kind of success story that happens with interdisciplinary teams working together. The beauty of SMS is that the natural next step is to think, ‘How many other young people are like this man? And what can we do on a systemic level?’”

Kristin Bundy, of Pittsburgh, has been writing about HIV since the 1990s. She also writes for Medscape and Pitt Med Magazine.

3 Questions for Kathleen J. Sikkema, PhD

Kathleen J. Sikkema, PhD, remembers, as a graduate student in the late ’80s, sitting in the library with journals spread across the table that represented medicine, psychology, and ethical and political sciences. “I worked in HIV 10 years before we had treatment. Those journals were a visual representation of how the challenges of HIV cut across disciplines—none of them alone were going to help us make progress in the epidemic,” she says. Now, as the newly appointed chair of the Department of Sociomedical Sciences (SMS), she leads a team that lives where these disciplines meet.

What drew you to accept the chair position?

The work I’ve done for almost 30 years has always been interdisciplinary. I’ve worked with individuals and at the community level. So my background reflects the mission and the overall goal of SMS in terms of taking social sciences into account, trying to effect change and develop interventions that impact public health and global health. Columbia Mailman School’s prominence in public health from a social-science perspective, its integration of theoretical and applied research, and its deep commitment to education and service make this the place to be.

How did your background prepare you to lead the department?

People often think of clinical psychology as an individual-level discipline, which it is. But I’ve had the fortune to be mentored and involved in research for decades that is more health- and community-psychology oriented. Global mental health is my specialty, and that involves broader issues like: How does poverty affect mental illness? How do we get treatments to people in low-resource settings? While my background is in social and behavioral sciences, I have held various roles in schools of public health, medicine, and arts and sciences. That exposure helps me think about different perspectives and cultures, which will help me guide SMS into the future.

What are you most looking forward to at SMS?

I look forward to expanding the work SMS already does in mental health to include global mental health—a relatively new subfield in global health. We will continue the mission of SMS, which is to collaborate across disciplines, but I also want to think about how we expand, what areas are ripe for growth, and how we should be thinking about advancing health and reducing disparities in 10 to 20 years. It's great to be able to head a department that is a prominent leader in both the country and the world.