Health Affairs

September 9 , 2005
by Tom O'Keefe

The scope of Health Affairs at Carolina is extensive. Carolina is home to the consolidated UNC Health Care which includes a top-ranked public medical school and cutting-edge hospitals for women, children, neurological patients, psychiatric patients, and general adult patients. The School of Public Health is among the best in the country and celebrated the opening of a new research facility at the beginning of September 2005. The School of Dentistry is also among the best in the country and is working hard to produce enough qualified graduates to serve the state. The School of Nursing and the School of Pharmacy round out the five schools within Health Affairs; Carolina is distinguished as one of only a few universities to have schools in all five major health professions and each of these serves an integral role in training practitioners and researchers to serve the health needs of the state, the country, and the world. Cumulatively, the Division of Health Affairs consumes more than $700 million from the university’s total annual operating budget of more than $1.6 billion.

Tarrson and Braur Halls are home to the School of Dentistry, the only dental school in the state. These buildings house the public and private dental clinics, clinics for adults and for children, classrooms, and the state-of-the-art lab in which dental students practice procedures on plastic teeth inside the mouths of plastic dummies. Dr. Ronald Strauss, the Chair of the Department of Dental Ecology and an expert in craniofacial surgery, hosted the class and offered insights into the operation of the dental school and the vital role this school plays in North Carolina.

Many people are unaware that North Carolina is experiencing a shortage of dentists. Four counties in the state are without a single dentist, and five others have only one dentist each. As expected, rural counties are greatly underserved. It is an ongoing challenge to entice graduates to locate their practices in North Carolina and particularly in these underserved rural communities. The extreme need in these areas often proves to challenge, and sometimes overwhelm even the most talented and dedicated recent graduates.

Dental schools are also expensive to operate. To cover operating costs, the UNC Dental School depends on the revenue generated by faculty who work at least one day per week in the Dental School's private clinics on site. Hence, faculty in the Dental School sacrifice the often lucrative profits they might make in private practice beyond the university’s auspices.

Currently, the average graduating class has roughly 80 dentists, and no more than 18% of those are from out-of-state. To help meet the needs of the state, the School has proposed to the state legislature that their facilities be expanded and budget increased to accommodate class sizes of 120. East Carolina University has also expressed interest in recent years in establishing a dental school on their campus, but the price of such a project has been estimated as at least $100 million. The UNC Dental School argues that based upon economies of school and a history of ex cellence, it is more practical to expand classes at Carolina than to make the monstrous capital investment at ECU.

Underlying this wrangling is a fundamental concern for the needs of the citizens (and resident aliens) of the state—as well as interest in prestige and institutional advancement. The UNC Dental School is among the best in the country and the world. It trains highly qualified dentists, and the faculty pursue research with far-reaching practical applications. In the most prosperous country in the world, there are still too many communities to count that lack adequate access to health care. Dental education and research are a few means by which the university reaches out to these underserved communities on a state, national, and international scale.

Created in 1975, the Lineberger Comprehensive Cancer Center is the largest research entity at Carolina, boasting more than 250 affiliated faculty from 25 different departments. Dr. Jack Griffith, a recent inductee to the prestigious National Academy of Arts and Sciences and one of the world’s foremost experts on imaging proteins and DNA using electron microscopy, showed the class his lab and discussed his research.

Dr. Griffith’s research involves the telomeres that mark the ends of the long coils of DNA in our chromosomes and in those of animals. The shortening of these telomeres is believed to play a role in the aging process and in the development of cancer. The research of the Griffith Lab is classified as basic science research. Though this research has potentially broad applications in the treatment of cancer, slowing the aging process, and even in the treatment of HIV/AIDS, the progression that might lead to development of a marketable drug from it is not so obvious that pharmaceutical companies have taken an interest. Much of the funding for such health-related basic science research comes from the federally-funded National Institutes of Health (NIH). For Fiscal Year 2005, the NIH had a budget of $28.8 billion dollars, only a slight increase over that for the previous year, and notable in view of the doubling of the NIH budget between 1998 and 2003. Many faculty researchers rely on NIH grants to underwrite the costs of their work, and the overhead receipts included in such grants are used by universities in the construction of new facilities and to account for the expenses associated with the depreciation of capital.

Even beyond the grants, research science is competitive, and Dr. Griffith seemed ready to play the game. Publication is key in this field, as with many. But, in a field where competition for funding is ferocious, researchers are sometimes rewarded for opting not to share new knowledge with their competitors in a timely fashion. Some might also argue that students are neglected since excellence in research is rewarded over excellent teaching.

Dr. Griffith expressed particular interest in the role that private philanthropists can play in shaping the research agenda. A UNC School of Medicine and School of Pharmacy professor, Dr. Richard Tidwell, is principal investigator on a $15 million grant from the Bill and Melinda Gates Foundation to develop new drugs for Sleeping Sickness and a currently incurable parasitic infection called leishmaniasis. The Gates Foundation has an endowment in the range of $21 billion and during the summer of 2005 gave away close to a $500 million in grant money to researchers working toward solutions of the Grand Challenges regarding prevention and treatment of infectious diseases.

Federal, state, and private dollars flow into basic research which is fueling the pharmaceutical and biomedical industries in America—arguably industries that have enjoyed booms reflecting the American medical systems' disproportionate focus on hospital-based medicine, drug treatments, and surgery or generally high-tech medical care. Simultaneously, the research these dollars fund has potential to lead to health advances that could greatly improve material quality of life in places like Sub-Saharan Africa and South Asia that are hit hardest by infectious disease. Additionally, at a public university, controversy can arise over the desire of researchers to patent their discoveries and profit from them. How does such private enterprise on behalf of faculty relate to the public mission of the institution, and how will resistance by the institution impact faculty retention if private universities are more supportive of faculty entrepreneurship? Questions like these highlight the complexity of the scientific research as it relates to the role of the university.

The School of Public Health is composed of nine departments with areas of focusw ranging from Maternal and Child Health to Health Policy and Administration. Naman Shah, an undergraduate in the Department of Environmental Engineering with the School of Public Health, served as our guide in the new Michael Hooker Research Center. The new building was completed at a cost of $38.6 million with $10 million from the record $3.1 billion 2000 bond referendum, $15.2 million from overhead receipts from faculty grants, and $10 million from the ongoing $1.5 billion dollar private fundraising campaign, Carolina First.

Mr. Shah had just returned from a month in Cambodia working on a collaborative project that illustrates the interconnectedness of public health work today. He was an employee of the United States Navy which was acting in cooperation with the Cambodian Ministry of Health, The Pasteur Institute, and the World Health Organization. While in Cambodia, Mr. Shah trained local health workers on new malaria treatment techniques developed in the lab of Dr. Steven Meshnick on the UNC campus. The Meshnik lab conducts epidemiological research related to the emergence of drug resistant malaria strains. Through the work of an undergraduate, breakthroughs from the lab found application in South East Asia.

Dr. Jesse Kwiek, a post-doctoral researcher in the Meshnick Lab, joined Mr. Shah to address the students on the tremendous scale of the scourge of infectious disease in “developing countries.” It is estimated that there are roughly 2 billion latent carriers of Myobacterium tuberculosis, 2 million of whom will die from the infection in a given year. It is also estimated that between 300 and 500 million people are infected with malaria each year, and that 1 million of them die from the infection. The vast majority of affected people are urban and rural poor in countries in South America, Africa, and Asia. However, as recently as the 1990s, an outbreak of Multidrug-Resistant Tuberculosis killed patients and health workers in Harlem in New York City. Pharmaceutical companies lack strong incentives to develop drugs aimed at treating these epidemics of the poor, and those drugs and vaccines that they do develop are typically only affordable for relatively wealthy tourists from developed countries.

An interesting aside, Dr. Kwiek, having already completed his doctorate in pharmacology, is now in the midst of a five year fellowship in the Meshnik lab. He commented that, if he were unable to get a teaching position at the end of that five year period, he would have to entertain leaving the field. He is in his mid thirties. It is not the lucrative returns or easy lifestyle that attracts most of these researchers, but rather a passionate commitment to doing their part to improve what they regard as the terrible inequity in health outcomes internationally.