Today more than at any other period in modern history, policy makers, health professionals, and researchers are devoting increasing time and resources to understanding the determinants of human health and wellbeing.

With the complex and myriad number of factors impacting public health in developed as well as developing countries – issues ranging from poverty, pandemics and the spread of infectious disease, access to healthcare, aging populations, education, and vaccine distribution – in a rapidly globalizing world, researchers are taking an increasingly inter-disciplinary approach to understanding these problems.

At Princeton University’s Woodrow Wilson School, the Center for Health and Wellbeing (CHW) is a locus for research and teaching that examines the role public policy plays in shaping the quality of people’s lives, and which seeks to educate undergraduates and graduate students who aspire to careers in health and health policy.

The Center was founded at the School in 2000, led by Christina Paxson, a Professor of Economics and Public Affairs, whose research focuses on health and economic development, particularly on how income and education impacts children’s health outcomes.

Just before CHW was created, “we had a number of people at the Woodrow Wilson School who were researching topics in health and health policy, but we weren’t known for this at all despite considerable expertise,” said Paxson. “It was [then-WWS Dean] Michael Rothschild who decided to highlight and strengthen the work that the School was doing in this area, to attract a broader group of students focusing on health, both domestically and internationally.”

In her role as founding director, Paxson began taking stock of faculty at the School and in the wider University who were researching health and related issues, and began to put together a list of potential scholars who might be interested in being affiliated with the new Center.  Given the work already underway, identifying faculty at Princeton who were conducting health-related research “wasn’t very hard,” Paxson recalled.  She assembled approximately 20 faculty associates at the start, and CHW currently has 24 faculty associates attached to the Center.

From the beginning, Paxson said, “we decided to take a broad perspective,” unlike some programs that focus narrowly on specific issues such as health services.  “Our strengths were much broader, and with an emphasis on how health is related to wellbeing more generally - how health related to economic wellbeing, for example. Plus, we had a good deal of domestic as well as international expertise.”

Today, that vision can be seen in the research and teaching programs sponsored by CHW, which focus on both domestic and international aspects of health policy. For example, in addition to sponsoring faculty’s policy research on health and wellbeing, each year the Center hosts a cohort of visiting fellows from outside institutions; sponsors both graduate and undergraduate certificates in health and health policy; sponsors or co-sponsors major ongoing research projects, including The Future of Children policy journal and the Demography of Aging Center; and hosts seminars, academic roundtables and an annual lecture series.

CHW is also part of the University’s Grand Challenges Initiative, an integrated research and teaching program at Princeton - co-sponsored by the Princeton Environmental Institute, the Woodrow Wilson School, and the School of Engineering - designed to promote student involvement and faculty research on three important issues related to the environment, technology and public policy. CHW manages the Health Grand Challenge, which addresses the serious problem of infectious disease around the globe, particularly the heavy burden infectious disease imposes on developing countries.

A Cross-Disciplinary Approach to Health Policy Research

Faculty’s and fellows’ research at CHW addresses a number of aspects of health and health policy. For example, in recent years Paxson and colleague Anne Case, a Professor of Economics and International Affairs and Director of the School’s Research Program in Development Studies, have been involved in a series of projects examining the implications of health during childhood for economic success in adulthood. 

“We view this as one of the really important pieces of health policy,” Paxson said. “What does it mean to have poor health, especially in childhood?  We’ve written a series of papers in which we look at the effects of poor health in early childhood on things like educational attainment and on earnings, and we investigate how economic status and health are related in childhood, and how that changes over time.”

The complicated picture that emerges “is one in which we know that poorer children are much more likely to have a wide variety of health problems,” Paxson noted.  “We can show rather convincingly that these health problems result in lower education attainment and lower earnings in adulthood.  And then around the time when people are having children of their own, people who are less healthy are less wealthy and then their children are brought up in those environments. You can see the beginnings of a cycle.”

Other Center faculty associates are working on major projects investigating the determinants of wellbeing. For example, Professor of Economics and Public Affairs Alan Krueger and Daniel Kahneman, a psychologist and emeritus faculty member who was a co-recipient of the 2002 Nobel Prize in Economics, are developing with colleagues new methods by which researchers and policy makers can measure the quality of people’s daily lives.  Using one such measure, dubbed the “Day Reconstruction Method,” Krueger and Kahneman revealed that income levels do not necessarily determine how happy people are.

As such, CHW houses the Center for Research on Experience and Wellbeing, a National Institute Of Aging center, based on research conducted by Kahneman and Krueger, as well as former CHW visiting fellow David Schkade of the University of California, San Diego, Norbert Schwarz of the University of Michigan, and Arthur Stone of Stony Brook University. The overall objectives of this center are to develop new methods for the measurement of well-being and health, and use these measures to better understand and document the experience of aging.

Meanwhile, Center faculty associate and Professor of Economics and International Affairs Angus Deaton, working with Gallup polling firm data, is examining the relationships between income levels, wellbeing, and health status across a wide range of countries. “One of the things we see happening in the Center that is working well: people start to collaborate and one person’s area of research starts to spill over into another person’s area,” noted Paxson.

The Center for Health and Wellbeing is also involved in The Future of Children policy journal, jointly published by the Woodrow Wilson School and The Brookings Institution and which seeks to promote effective policies and programs for children by providing policymakers, service providers, and the media with objective information based on the best available research.

The journal draws on the expertise of three WWS research centers. Professor of Sociology and Public Affairs Sara McLanahan, Director of the Bendheim-Thoman Center for Research on Child Wellbeing, is editor-in-chief; senior editors include Paxson and Professor of Economics and Public Affairs Cecilia Rouse, Director of the Education Research Section.

The Center is also home to a Demography of Aging Center, funded by the National Institute of Aging, part of the U.S. National Institutes of Health.  The Demography of Aging Center, founded in 2004, fosters new research on the interrelationships between socioeconomic status and health as people age, and explores the determinants and policy consequences of increased longevity and population aging across and within countries over time. University faculty from such diverse fields as neuroscience, psychology, demography, and epidemiology, and economics are involved with the center.

In addition to faculty research, each year CHW brings between three to five visiting fellows, as well as post-doctoral researchers, who are engaged in a broad range of health-related projects.  “We bring in people from other institutions who are conducting  creative research on important issues,” said Paxson.

A current visiting fellow, Ronald Brookmeyer, is a professor of bio-statistics at Johns Hopkins University’s School of Public Health. In addition to teaching epidemiology this spring at the Woodrow Wilson School, Brookmeyer is using the tools of statistical science to better measure public health problems.  At CHW this year he’s focusing on “developing new approaches to better measure and track HIV/AIDS on a global basis,” Brookmeyer said.

By employing statistical methods and models, Brookmeyer seeks to more accurately answer such questions as, “How many people are living in the country with HIV/AIDS, how many new infections are occurring each year, where are the numbers coming from, and what evidence are they based on?” he explained. “I look at the statistical underpinnings and what the source of the evidence is for the data and the models.”

Other current visiting fellows are examining a range of public health issues in both domestic and international contexts, such as maternal-child health; reproductive health and sexual behavior; education and its impacts on health and wellbeing; and the causes and consequences of health inequalities among children and young adults.

Further contributing to the intellectual life of the Center, practitioners who have been or currently are associated with CHW include former U.S. Senate majority leader and surgeon Bill Frist ’74, who was a visiting professor at WWS during the 2007-08 academic year, and Adel Mahmoud, a physician and former president of Merck Vaccines, who is jointly appointed to the School and the Department of Molecular Biology, where he studies a range of global health issues - from mitigating the impacts of deadly diseases like malaria which kill millions each year, to improving the access of people in developing countries to necessary vaccines.

“The broad range of disciplines our associates represent is one of the main advantages of the Center,” said Kristina Graff M.P.A. ’05, Associate Director of CHW.  Center faculty and fellows include “molecular biologists, sociologists, anthropologists, economists, as well as people from the University’s politics and engineering departments - academics as well as practitioners - who bring their connections and experience to CHW, and apply their research to the problems of the outside world.”

Working in a collaborative environment like CHW is appealing to scholars and practitioners because “it’s multi-disciplinary,” said Brookmeyer, “and it’s bringing people together from all over the campus with different expertise - that’s what is exciting about it.  You’ve got economics, demography, statistics, the biological sciences, infectious disease expertise all coming together… a center like CHW, that’s cross-disciplinary with a focus on improving healthiness, is where we’re going to start making progress.”

From Field Research to the Classroom and Back Again

A key role of CHW is to support the teaching mission of the Woodrow Wilson School and the University.  Today the Center sponsors two certificate programs: a certificate in Global Health and Health Policy open to all Princeton undergraduates and which formally began in Fall 2009; and a WWS graduate certificate in Health and Health Policy (HHP), launched in 2003.

“When we first started, our aim was to build a center that would support teaching programs in the Woodrow Wilson School’s graduate program.” Paxson said.  Thus, the HHP certificate is designed for School M.P.A. and M.P.P. students with domestic and international health interests, and provides both broad training in core topics in health and health policy as well as courses in more specialized areas. Students take two core courses, a course on the political economy of healthcare systems and a course on epidemiology. Students also take two electives on topics related to their interests and field of study.

The HHP certificated attracted Catherine Harrision M.P.A. ’09 to the School, who before coming to WWS worked in Washington, D.C. analyzing federal healthcare policy. Harrison’s decision to come to Princeton was based on the School’s graduate program and the HHP certificate offered by Center for Health and Wellbeing. “It was the exact, right combination of disciplines for me because I was interested in public health but didn’t want a public health degree, I wanted to pursue a broader course of study in policy and policy making,” she said. The HHP certificate allowed Harrison “to put together a kind of program that was most like a public health degree, but one that I felt had more advantages.”

Today Harrison is the student liaison for her peers interested in pursuing the HHP certificate or just getting involved with CHW. As part of her course of study, she also had the opportunity to participate in a WWS graduate policy workshop on public health, which involved field research in India and was led by Jeffrey Hammer, a Center associate and visiting professor at the School who worked for 25 years at the World Bank on issues of poverty and economic development. Her experience has been “a great way for me to learn how to translate academic work into effective policy and practice,” she said.

Center for Health and Wellbeing staff have also worked to create the new undergraduate GHP certificate: an interdepartmental program in which undergraduates can study the determinants, consequences, and patterns of disease across societies; the role of medical technologies and interventions in health improvements; and the economic, political, and social factors that shape domestic and global public health.

To complete the GHP certificate students take two core courses, one on epidemiology as well as an overview course on global health and health policy. Students then take three electives, complete a research-related global health internship, and write their senior thesis in the student's department of concentration that addresses global health and health policy in an interdisciplinary manner.

“The Global Health and Health Policy certificate was approved by the faculty last spring, and we now have a  group of 19 students in the program, all undergraduates in  their junior year,” noted Paxson.

“We attract a number of pre-med students who plan to do clinical health work or studies,” said Graff, “but we also attract students who want a broader view, either because they want to have a wider perspective as clinicians, or who want to go into health administration or health policy.”

The Center also sponsors the Adel Mahmoud Global Health Scholars program, which provides Princeton students funding for travel and research to pursue global health-related internships and senior thesis research.

The Mahmoud Scholars program, which is competitive and open to undergraduates from all Princeton departments, is supported by theMerck Company Foundation, and named in honor Dr. Mahmoud for his pioneering work in global health. The first cohort of scholars was admitted in the fall of 2007, and are pursuing research in diverse areas. For example, one is investigating causes behind shifting HIV rates in southern India, another is examining the introduction and administration of vaccines in the Philippines,  and another is conducting anthropological analysis of HIV/AIDS treatment in Mexico. (Read the announcement about the newest cohort of Mahmoud Scholars.)

The Mahmoud Global Health Scholars program also features a lecture series, which brings one leading researcher and practitioner in global health policy to Princeton annually. Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, delivered the first Mahmoud lecture last April.

Grand Challenges

“Grand Challenges was founded by the Princeton Environmental Institute in collaboration with the School of Engineering and Applied Sciences and the Wilson School. It has three areas of focus,” Paxson explained.  “One area focuses on energy and the environment.  Another piece focuses on sustainable development in Africa. Finally, it has the Health Grand Challenge, which CHW manages.”

In this role CHW supports research collaboratives – that is, a group of faculty members who come to the Center with an idea for a project that will engage students at all levels.  “Undergraduate involvement is essential,” said Paxson, and “most projects involve graduate students and some post-docs, as well.”

The Center has eight different Health Grand Challenges projects ongoing, all of which focus on different aspects of infectious disease around the globe. According to Paxson, 18 Princeton undergraduates worked on health Grand Challenges last summer; some in the U.S., some overseas, on a wide range of issues. 

“For example, two projects are headed by colleagues in molecular biology,” Paxson noted. “One is on malaria, another on basic bacteriology. We also have several projects that are being run by chemists, on tuberculosis.  We have work on HIV/AIDS led by an anthropologist, and another interdisciplinary project on drug resistance.”

One of Paxson’s favorite Health Grand Challenge research projects is led by a colleague in the Department of Engineering “who’s working with students to develop ceramic water filters that can be used to purify water in Africa and Latin America,” Paxson said.  “He’s taking students into the field, to villages where they are conducting surveys and teaching people how to make these filters. And then they’re going to do a follow-up evaluation to see how they affected health.”

Alex Gertner, a Princeton junior from Brazil majoring in anthropology who is taking the GHP certificate this fall, is involved in the Grand Challenges Initiative, noting it “gives young scholars a voice – it values their perspectives.” In his experience, he said, “it’s a unique opportunity, people are usually very surprised when they hear of undergraduates participating so deeply and fully in research.”

Importantly, Gertner explained, “[Grand Challenges] gives young scholars critical insights into the knowledge production process, and how knowledge interacts with environments. This has been particularly interesting in my research because we’re creating a database in southern Brazil that will provide information for public health purposes, in order to improve existing institutions and mechanisms,” in that region.

Paxson hopes that students involved in the Health Grand Challenge will gravitate toward the GHP certificate.  “I think the two programs are really going to complement each other,” she pointed out.

In terms of her future plans for the Center, Paxson said “I would like to take this overarching collaborative model and use it in other areas of health.  We’ve been identifying partners who can help us find good placements for students who are interested in doing work possibly on their own, but possibly as part of a collaborative.”