A Dean for Our Time: Nurse and Epidemiologist Brings Compelling History, Vision

May 2011Andrew Schwartz

David Vlahov arrived as the new dean at the UCSF School of Nursing at a time when health care professionals – and nurses especially – face a complex, but invigorating set of challenges.

In the United States, health care reform has the potential to elevate the role of nurses through its focus on preventive care and interprofessional collaboration. That focus emerges from a growing understanding of the ways biological, psychological, familial, cultural and institutional factors intersect to influence individual well-being and population health. Increasingly, health care professionals believe that improving health and health care depends on drawing on and deepening that understanding.

Nursing, of course, has long held that holistic perspective, and Vlahov is an internationally recognized leader in devising models that exemplify it. His career has yielded a series of prominent, multilevel, community-based interventions and the publication of hundreds of articles that rigorously evaluate such efforts.

As such, he is the ideal choice to succeed the much loved and admired Kathleen Dracup as dean. In her decade of leadership, Dracup extended a tradition at UCSF that has forged a unique and essential role for academic nursing. Vlahov is fully aware of that tradition and has a vision for how to build on it.

“The Institute of Medicine’s Future of Nursing report provides a blueprint for us to work in a number of complementary directions,” he says. “For example, using the best science available, we need to devise more effective interprofessional practice models that take advantage of nurses’ full scope of practice. Nurses also will have a central role in optimizing models for transitional care, particularly for an aging population. And we need to expand our understanding of and methods for symptom management.

“In short, as other parts of health care focus on technological cures, nurses’ understanding of the equally important human concerns will play a critical role in new care models.”

A Distinguished Career

When UCSF Chancellor Susan Desmond-Hellmann announced Vlahov’s appointment, she noted, “David brings an exciting combination of community-based research and intervention to UCSF, a unique blend of experience, leadership skills and interests that is highly relevant, given the continually evolving landscape of health care in general and the field of nursing in particular.”

The first male dean at UCSF School of Nursing, Vlahov arrives from the New York Academy of Medicine, where he served as senior vice president for research and director of the Center for Urban Epidemiologic Studies. He also edits the Journal of Urban Health, was a professor of clinical epidemiology at the Columbia University Mailman School of Public Health and remains an adjunct professor in epidemiology at the Johns Hopkins Bloomberg School of Public Health, where he has been on the faculty for more than 22 years. He also is the recipient of the 2011 Johns Hopkins University Distinguished Alumnus Award.

In addition, he founded the International Society for Urban Health, serving as its first president; is a visiting professor at the Federal University of Minas Gerais medical school in Belo Horizonte, Brazil; and works with the World Health Organization’s Urban Health Center in Kobe, Japan.

Vlahov is a pioneer in urban health research. His particular areas of expertise are epidemiology, infectious diseases, substance abuse and mental health, having conducted studies on those topics while forging partnerships with urban populations in Baltimore and the New York City communities of Harlem and the South Bronx.

Building Community Interventions in Harlem

Vlahov’s work in Harlem for the last 11 years provides one of the clearest examples of his research approach. By respectfully building relationships among neighborhood residents, academia and the New York City Health Department, he’s conducted a series of community-based, participatory studies that have made real progress in addressing health disparities and the social determinants of health.

“In the beginning, we worked entirely on creating trust – making sure each partner brings something to the table and each one gets something out of the relationship,” says Vlahov, who notes that the work began with monthly meetings of a community advisory board that have been a staple of the program ever since. “We made a commitment to exploring how we can truly work together to improve the health of people in Harlem.”

Eventually, the group arrived at processes for identifying health concerns, and then creating intervention groups that report back regularly to the board to enforce a process of continual improvement. One of the first intervention groups addressed HIV infection among injection drug users.

“We knew that individual education and counseling about needle sharing only had a modest effect, so we began with network interventions – identifying the people the infected population hung out with, and then conducting interventions with the user and the peer group,” says Vlahov. “That was effective, but not efficient. Then something fell into our lap.”

While reading the paper one morning in spring 2000, Vlahov saw an item about a New York law that would remove the need for a prescription to a get a needle. Before the bill went into effect, Vlahov’s team spoke with pharmacists to gauge their response, and found many were reluctant to participate out of concerns about having known IV drug users in their pharmacy.

Then, once the bill became law, the researchers looked at uptake in Harlem and found that it was next to nothing because IV drug users were largely unaware of the law. This prompted a full-scale mobilization that engaged the entire community and thoroughly evaluated all of the potential approaches.

The result was a program that identified and trained pharmacists willing to participate in the program; the creation of maps that guided IV drug users to those pharmacists; and a careful evaluation that assessed how much the pharmacists and community members understood about the program, why they were willing to engage and what it meant to them. For additional rigor, the team set up a control area in the South Bronx.

The evaluation found not only that a fully engaged Harlem community viewed the program as a positive HIV prevention program that substantially reduced needle sharing, but that the community’s support of the program remained stable over time. In contrast, in the Bronx, after initially high interest and support, community support declined over time.

Vlahov’s teams are now using a similar process to improve the low rate of influenza immunizations in Harlem. The project is rooted in a 2001 effort that the group conducted in the wake of the post-9/11 anthrax scare, where they tried to figure out how to quickly immunize underserved communities.

“What we found in 2001 was that there are a lot of underserved communities that would be excluded from an immunization effort without truly rich outreach,” says Vlahov, who will be continuing the influenza project even as he assumes his new role at UCSF. “Our first step is to always try to find out why. What are the public messages? What is the availability of vaccines?”

Bringing His Research to the Bay Area

Though he will clearly be busy in his new role as dean at UCSF, Vlahov would like to bring research efforts similar to those he created in New York and Baltimore to the San Francisco Bay Area and UCSF, where he looks forward to working with faculty members who are already doing complementary work.

“One area we’re interested in is violence against women,” he says. To date, much of the focus on this significant health threat is on treating women after the violence has occurred. “It’s possible that we can delicately shift norms to address the perpetrator, perhaps by addressing the culture of tolerance for this violence. Can you increase the speed of bystander interventions? Can you engage young men to be champions? We’ve got some people in New York who have done some pilot work, and I’m optimistic that we can see some results.”

Vlahov is also keenly interested in the emerging area of resilience, having studied post-traumatic stress disorder among New York City residents after the 2001 World Trade Center attack.

“A lot of our focus in health care is disease-oriented – looking at risk factors for disease – but I think we’ve got to refocus to also examine the factors associated with resilience,” he says. “A lot of people think it’s reciprocal, but that’s not necessarily so. I’m interested in the work in genomics and epigenetics that looks at the individual markers for resilience to particular threats, and the ways various environmental exposures can turn a client gene on or off.”

Finally, in Brazil and Japan, Vlahov expects to continue his international research, which often concentrates on more effective use of nursing expertise by expanding the limited role nurses tend to play in less affluent areas of the world.

A Collaborative Leadership Style

Vlahov’s approach to research appears to have two essential ingredients. The first is to understand the multiple levels of influence that have an impact on health and well-being. “My work has gone progressively from the individual to the network and community,” he says. “As we understand how each influences individual health, we can then better shape multilevel, multicomponent interventions.”

The second is to understand the work as a continual process, especially because what works today may not work tomorrow. “For me, using this approach is always about showing impact,” he says. “What worked? What didn’t? And how can we improve? The example is our influenza program, where every year there’s a new strain. We’re putting these elements together, and then figuring out how to reshape for the next iteration to continually improve outreach programs.”

He will likely bring similar sensibilities to his role as dean, as well as real-world experience in working out the complex relationships between the public health arena and the education and training of nursing professionals: He served as a member of the Institute of Medicine’s Committee on Public Financing and Delivery of HIV Care.

One of his top priorities as dean is to update the School of Nursing’s strategic plan by engaging faculty in a collaborative process to develop shared goals and objectives. The strategic plan will define the role of the School and nurses in health care reform, and set a direction for the training of nursing school faculty, clinical education and the types of research to pursue.

“This is a very exciting opportunity,” says Vlahov. “I am energized by the enthusiasm, the intelligence and the great leadership here. It’s a terrific environment.”