Voices Carry

For Mor, Florence Pirce Grant University Professor of Health Services, Policy and Practice, hospice care was both personal and good public health. His mother had died of cancer a few years before he came to Brown. Mor recalls, “She was at a world-class cancer center, but when she was dying, she was down at the end of the hall. Her morphine pain management was scheduled rather than as needed. Rather than being close to the nurses she was far away because the nurses kept the patients they were trying to save close to them.”

At the time, care of the dying was undergoing a seismic change. Dr. Elisabeth Kubler-Ross published On Death and Dying in 1969, drawing public attention to the care of the terminally ill. A first attempt to provide federal funding for hospice care failed in 1974, but the movement continued to grow, driven by a community of caregivers who felt that medicalizing the end of life did not always serve the best interests of the dying and their loved ones. Just a few years later, a task force convened by the U.S. Department of Health, Education, and Welfare reported that “the hospice movement … is a viable concept and one which holds out a means of providing more humane care for Americans dying of terminal illness while possibly reducing costs. As such, it is the proper subject of federal support.”

Working together with the growing hospice movement, Mor sought to build a more humane pathway for those approaching the end of their lives by building evidence of the effectiveness of hospice care. It worked. Drawing on work by Mor and others, Congress made the Medicare hospice benefit permanent in 1985, and allowed states to use Medicaid to cover hospice care. In 2020, 1.72 million people were cared for by hospice services, and in 2023 President Jimmy Carter celebrated his 99^th birthday in hospice care.

This collaboration, between public health researchers and an emerging, community-based movement to create new models of care and support, has become part of the DNA of public health at Brown. Communities best understand the human dimension of the health challenges they face—the complexities and obstacles as well as the resources and synergies.
Erica Walker, who joined the school’s faculty in 2021 as RGSS Assistant Professor of Epidemiology, asks “Would public health exist if there was no community? I don’t think so. Community is important because they can tell you what you need to focus on. They can tell you when you‘re doing things right. They can tell you when you’re doing things incorrectly. They can tell you about future things to look out for. I think it’s ground zero for relevant, useful information.”

No Longer Silent

In 1982, as Mor was working to build the evidence base to support federal funding of the growing hospice movement, Brown’s Department of Community Health launched its first research center: the Center for Alcohol and Addiction Studies (CAAS). At the time, Americans were drinking more alcohol than ever before, including young people. Raising the federal legal minimum drinking age to 21 in 1984 helped to curb widespread youth drinking, but Americans of all ages continued to struggle with alcohol dependence, often in secret.

The health consequences of alcohol dependence were compounded by profound social stigma, making it difficult to gather data on the burden of the disease and the effectiveness of treatments. Alcoholics Anonymous, which had recently surpassed one million members, had made the community of those struggling with substance use disorder more visible and helped members of that community share their experiences. But public health science had not kept up, driven by an outdated view of addiction as an individual moral failure. 

Peter Monti, then a young clinical psychologist at Brown, wanted to apply the tools of public health to understand alcohol use disorder as a disease. “A lot of people who were studying psychiatric patients were omitting people who had alcohol use disorders,” Monti, Donald G. Millar Distinguished Professor of Alcohol and Addiction Studies, said. “We decided that we may be throwing the baby out with the bathwater, and decided to focus on the substance use.”

By developing a tool to measure cravings, Monti and his colleagues were able to demonstrate the bio-behavioral components of substance use disorder. With more robust empirical evidence, the community of people struggling with substance use disorder and those who love them were able to begin to overcome the stigma of addiction and advocate for a much broader range of interventions. “Addiction is multifaceted,” Monti says. “To understand it better, you need behavioral scientists and microbiologists, and pharmacologists, to study different aspects of the elephant.” 

Just as CAAS helped bring about a sea change in the understanding of alcohol use, the School of Public Health’s People, Place and Health Collective (PPHC) is working to change the paradigm around opioid use disorder. The PPHC advocates and applies harm reduction principles, rather than punitive approaches, to addressing the opioid overdose epidemic. Working in and with the community, the research lab disseminates its findings and presses for change. Brandon Marshall, who founded PPHC in 2021, studied the pioneering supervised consumption site in Vancouver, Canada, but knew it would be an uphill battle to achieve similar community-oriented policies in the United States. 

“The immense stigma that results from the criminal justice approach to substance use makes it harder for communities to advocate publicly,” says Marshall, professor of epidemiology. But in Rhode Island, he found dynamic community partners. “The harm reduction community is very strong here, with community efforts like RICARES [the Rhode Island Communities for Addiction Recovery Efforts],” Marshall says. “Rhode Island is a small state, and the opioid crisis has affected all communities. People feel the effects of the crisis on a familial and visceral level.”

Marshall and his PPHC colleagues study the full spectrum of harm reduction interventions, from outreach, to monitoring changes in the local drug supply, to the provision of overdose reversal treatments like naloxone, while centering the experiences of those who use drugs. Marshall says, “We want to make sure communities can advocate for specific interventions based on research that shows the benefit of those interventions.”

This collaboration between public health researchers, the community of people who use drugs, the recovery community and state officials has led to a transformation in thinking about harm reduction and safe consumption sites in Rhode Island. Recently opened sites in New York City face crackdowns by federal prosecutors, while in Philadelphia, the city council recently passed a preemptive ban on such sites in response to community efforts to open a site in the city. Meanwhile, Rhode Island is set to open the first state-authorized Safe Consumption Site in the country in early 2024. Brown public health researchers will study the impact of the pilot site to help affected communities understand and navigate this uncharted territory with the benefit of scientific evidence.

A New School for a New Century

At the same time that Brown public health researchers were responding to community priorities as they evolved in the mid-to-late 20^th century, the University was also responding to student priorities and demands. In 1968, a group of undergraduates wrote a report asking the University to embrace what became known as the “Open Curriculum.” That same year, a group of Black students walked out to demand support and greater representation of Black students at the University.

Student interest and engagement in public health was also growing. While Brown undergraduates were able to take classes offered by researchers in the Department of Community Health, and could participate in faculty-led research, students increasingly found this ad hoc approach inadequate. In 1995, Brown University acquiesced to student demands for a program in public health that would allow undergraduates to focus their studies on HIV, tobacco use, vehicle safety and other public health challenges of the day. The original cohort of Brown Community Health concentrators received their AB degrees in 1999, ushering in a new era at the University. Over the decade that followed, the process of uniting several disparate educational programs and public health research centers into a school began.

Perhaps the single most important step in that process was the recruitment of Terrie “Fox” Wetle to the Department of Community Health in 2000. “Vince Mor came to me and he said, ‘Have I got a deal for you. We want to build a school, and you’re the person to do it,’” says Wetle, professor emerita of health services, policy and practice and the inaugural dean of the School of Public Health. At the time, Wetle says “there were ten or eleven centers, and two programs, in epidemiology and biostatistics. Those were the building blocks. We had a very strong research portfolio, we had some service activities. But I knew those had to be grown.”

Spurred on by a unanimous faculty vote of approval, Brown University formally moved to create a School of Public Health in 2013, drawing together its diverse public health centers and programs into a unified enterprise dedicated to the advancement of population health. In its first decade of existence, the school continued to grow rapidly while evolving to meet emerging health challenges. 

2020 was a watershed year for the School of Public Health—as Dr. Ashish Jha assumed his deanship, America was in the throes of the first COVID-19 outbreak. It was evident that saving lives would mean collaborating with communities at the federal, state and municipal levels. Researchers at the school supported the response to the COVID-19 pandemic by developing tools to track infections, share critical information, and, importantly, to improve access to tests, treatments, and vaccinations in underserved communities. “Health equity really runs through all of our public health problems,” says Jennifer Nuzzo, professor of epidemiology and director of Brown’s Pandemic Center.

Nuzzo sees partnership with communities as central to pandemic preparedness. “Pandemic means pan-demos, right? All of society. We can’t be prepared for a pandemic unless the community is part of it. Government can’t do everything, even if it tries, because it doesn’t have the important insights that community members and community groups do. It’s really essential that we get communities to be part of our pandemic preparedness, to make sure that the plans that we are proposing actually work for them, and to make sure it’s aligned with their values and something that they would support. And to get their help in doing so.”

Centering Communities

For Erica Walker, who joined the Department of Epidemiology in 2021, there is no public health without community leadership. Walker’s research has focused on the public health impacts of noise, working primarily in New England, including around Fenway Park, the Red Sox baseball stadium. In 2021, Walker received funding to expand her work to her childhood hometown of Jackson, Mississippi, where residents live in close proximity to factories, a railyard, the local airport and other significant sources of noise. But as Walker began talking to community members in Jackson about noise, a different crisis was growing.

In August 2022, the largest water treatment facility in the city failed, leaving 160,000 people without a source of clean, safe water, including schools and hospitals. When residents approached her with these health concerns, Walker understood she needed to meet their needs.

Jackson’s acute water crisis was the result of decades of inequitable public health policies, including a federal consent decree for violations of the Clean Water Act in 2012. A broken pipeline first discovered in 2016, remained unrepaired in 2023, spilling enough clean water to serve 50,000 residents. At the same time, those residents were being told to boil the water that came out of their faucets.

“We have to come in, not with an agenda, but with an attitude of service,” says Walker. “What can we do for you? We have all of these tools. We have all of this expertise, this knowledge. How can we leverage these resources to work on a problem that’s meaningful for you?”

As Walker listened to community members, it quickly became clear that noise pollution was not their top concern. “Listening is the first step,” she says. “Not only listening, but then implementing what you heard.” Walker pivoted her research project in Jackson to focus on water quality and safety, with the goal of supporting communities in understanding the health threats they faced and implementing steps to protect themselves. One of the first outputs of the project was an activity book aimed at children and adults that explained their local water system, why their water supply was dangerous and how to make water safe to drink.

Before she came to Brown, Walker says that she sometimes struggled to reconcile her career as a public health researcher with her commitment to community partnership. “Until I got to Brown, I was told ‘You’re not a community organizer, you’re a scientist.’ Or, ‘you are a community organizer, and you’re not a scientist, and you need to find somewhere else to go.’” She found a different point of view at Brown. “This was the first place,” Walker says, “where I felt like I could dream, and I could implement, and it could be considered valuable.”

Walker is the most practical kind of dreamer. The founder of the Community Noise Lab has built open data platforms so that community users have access to the same data as policymakers. The Mississippi Environmental Scholars Program she runs out of her lab trains high schoolers in core public health skills, and collaborates on environmental justice classwork with the co-educational independent historically African-American boarding school, Piney Woods.

The definition of public health is public health. Communities—their needs and challenges, but also their insights, resources, and leadership—are at the heart of public health, often driving innovations in the public health toolkit and evidence base. Long before Brown’s School of Public Health was officially a school, researchers at the University were responding to this challenge by collaborating closely with communities to understand their vulnerabilities and by developing new scientific methods and evidence bases to enable communities to pursue better health. 

“We really need to remember that ultimately, we are in service to the community and not to our careers,” Walker says. “I think that when we refocus, our outputs are just that much more meaningful at the end of the day.”