consequentialist epidemiology big push initiatives in global health nyc’s new health commissioner

issue 5.01

FROM THE DEPARTMENT OF EPIDEMIOLOGY SPRING 2014 MAILMAN SCHOOL OF PUBLIC HEALTH – COLUMBIA UNIVERSITY Sandro Galea, MD, DrPH Gelman Professor and Chair Department of Epidemiology

EDITOR Barbara Aaron Administrative Director

EDITOR / WRITER Elaine Meyer Associate Director of Communications

CONTRIBUTING WRITERS Rachel Kitchenoff Tim Paul

ASSOCIATE DESIGNER Kristen Byers Web Developer / Graphic Designer

DESIGNER Jon Kalish

ON THE COVER: A graphic reduction of John Snow’s mapping of the 1854 London cholera outbreak. The map has been reduced to the representation of deaths—marked by rectangular bars set perpendicular to streets. The bars are colored red for emphasis. Featured in Bringing ‘consequentialism’ back to epidemiology on page 10. CONTENTS

3 Publication highlights

FEATURES

8 Bringing ‘consequentialism’ back to epidemiology

14 Big push initiatives in global health

21 How cities affect urban health

25 Epidemiology role models: Trainees draw lessons from NYC’s new health commissioner

29 Symposium report: Explanation and prediction in population health

30 In the news

32 Faculty publications

DEPARTMENT OF EPIDEMIOLOGY 1 chair’s message

Colleagues,

2x2 has a new look. Our spring 2014 issue has been redesigned to accommodate more in-depth articles about epidemiology, and to draw on and better synchronize with our online presence on the2x2project.org

This move reflects our growing focus on communicating our findings to better inform and influence the epidemiologic conversation. Our ultimate goal is to translate our science into policy and action that improves population health. We see communicating the science of epidemiology with the broadest possible audience as a step in that direction.

In keeping with this shift, two of the feature articles in this issue reflect some of our musings on the role of epidemiology in the public health sphere: where should the science be going, and how should it best be implemented? We also feature a profile through the eyes of our trainees of our colleague Dr. Mary Bassett, New York City’s new health commissioner, who exemplifies the translation of epidemiologic knowledge into policy.

Welcome to the new 2x2.

Warm regards,

2 publication highlights

lose relatives of people with The family members of individuals epilepsy are at a greater risk whose epilepsy had a known cause C of developing the disorder occurring after birth, such as a stroke, compared to the general population, severe traumatic brain injury, or brain according to a new study led by Dr. tumor were not at increased risk. Ruth Ottman, professor of epidemiol- Epilepsy is characterized by recur- ogy (in Neurology and the Gertrude rent seizures caused by abnormal H. Sergievsky Center) at Columbia electrical discharges in the brain. University, with co-author Dr. W. Approximately 1.3 percent of individ- Allen Hauser, professor emeritus of uals will develop epilepsy by age 40, epidemiology at CUMC, and other col- and 3 percent will develop it before leagues from Columbia’s department age 80. While epilepsy cannot be of neurology, the Mayo Clinic, and the cured, seizures can be controlled with University of Calgary. medication in about two-thirds of Although this group is not the first affected individuals. to find that risk for epilepsy runs in It is believed that genetics are families, past studies had potentially involved in the majority of cases, serious methodological limitations although how exactly the disorder according to the paper, which will run comes about is complicated, involving in the March issue of the journal Brain. interplay among the environment and The researchers analyzed data from multiple genes. the Rochester Epidemiology Project, “One of the most important a partnership of three medical centers concerns of people with epilepsy in Minnesota, which allows all records is whether the disorder is inherit- of medical care received by patients ed--what are the risks in their family residing in the area it covers to be members, and especially in their off- used for population studies. spring?” says Dr. Ottman. The researchers studied the fam- Although genetic research is New evidence ilies of 660 residents of Rochester, moving quickly, in most individuals Minnesota, with new cases of epilepsy with epilepsy, the specific genes that for genetic basis occurring during a 60-year period— affect risk of the disorder have not from 1935-1994. Among the nearly been identified. of epilepsy 2,500 parents, siblings, and children “That means we need to rely on of these individuals, the risk of devel- solid risk estimates from rigorous oping epilepsy by age 40 was 4.7 studies like this one to obtain answers percent—three times that of the gen- about risks to family members,” Dr. eral population. Ottman says. “One thing that’s import- Those at highest risk were ant about our findings is that people relatives of individuals with idiopathic with epilepsy tend to overestimate generalized epilepsy, which, though the risk in their children, and we found its origins are uncertain, is believed that risks in offspring are only about to have a strong genetic basis. Also 4 percent overall, and are less than at greater risk were relatives of 10 percent even in the highest risk individuals who have types of epilepsy groups—so that even though risk is associated with intellectual or motor higher than in the general population, disability that are likely related to more than 90 percent of the offspring the2x2project.org prenatal or developmental problems. will remain unaffected.” Epilepsies of unknown cause and 2x2.ph/1koJ3Iv of prenatal/developmental cause Peljto AL, Barker-Cummings C, Vasoli VM, clustered within families, suggesting Leibson CL, Hauser WA, Buchhalter JR, shared genetic influences. Ottman R. Familial risk of epilepsy: a popula-

IMAGE: ARTHUR TOGA, UNIVERSITY OF tion-based study. Brain. 2014 Jan 26. [Epub

CALIFORNIA AT LOS ANGELES VIA THE NATIONAL ahead of print] PMID: 24468822

INSTITUTE OF GENERAL MEDICAL SCIENCES

DEPARTMENT OF EPIDEMIOLOGY 3 PUBLICATION HIGHLIGHTS

edical professionals should was greatest (4 percent) for women on take note of a recent study SSRIs compared with 3.8 percent for M that reported a significant women using anti-depressants that association between the use of antide- were not SSRIs and 2.8 percent for pressants during pregnancy and the women who were not on medication. risk of hemorrhage after giving birth, These are significant enough two Columbia University Medical numbers for medical professionals Center researchers said in an editorial to take notice, wrote Drs. Ananth in the late November issue of the BMJ and Friedman: “While the benefits of group journal Evidenced-Based Nurs- antidepressants may outweigh the rel- ing. Use of antidepressants has not atively small attributable maternal and been commonly recognized as a risk neonatal risks for many women, clini- factor for abnormal bleeding during cians should be aware of a modestly pregnancy or childbirth. increased risk for this serious adverse “The findings from this study add obstetric outcome.” considerably to limited prior research More evidence is needed to estab- on this subject, which has found lish whether antidepressants directly similar associations despite method- cause hemorrhage, they say. Research ological shortcomings,” write Drs. has suggested that SSRIs might Cande Ananth, professor of epidemi- deplete serotonin that is stored in ology and obstetrics and gynecology, platelets, which are cells in blood that and Dr. Alexander M. Friedman, pro- reduce bleeding. Yet a 2008 study by fessor of obstetrics and gynecology. scientists at the University of Toronto “The magnitude of increased hem- found that SSRIs do not put women orrhage risk in relation to serotonin at greater risk of postpartum hemor- exposure demonstrated in this study is rhage than non-SSRI antidepressants. clinically relevant.” Comparisons of risk between SSRI and The study at issue, which was non-SSRI antidepressants are gener- Antidepressant published in BMJ in August by epi- ally limited by the relatively infrequent demiologists at Harvard’s School of use of drugs in the non-SSRI class use associated Public Health, adds to a growing body during pregnancy. of research that has connected the Celexa, Lexapro, Prozac, Paxil, and with risk of popular class of antidepressants known Zoloft, and their generic versions are as SSRIs (selective serotonin re-uptake all popularly-prescribed SSRIs. These hemorrhage after inhibitors) to hemorrhage, as well as drugs are commonly used to treat psy- excessive bleeding in the gastrointesti- chiatric problems such as anxiety and pregnancy nal system and during surgery. depression that may occur during or Hemorrhage during delivery is predate a women’s pregnancy. one of the leading causes of maternal Rates of maternal mortality and death in the United States. It has been severe morbidity are high in the U.S. on the rise in the U.S. and several other compared to other rich countries, and developed countries since the 1990s, findings from this study may help despite no change in the frequency of clinicians anticipate increased risk in a multiple pregnancies or induction of specific subset of patients. labor, which are established risk fac- tors for postpartum hemorrhage. Ananth CV, Friedman AM. Late pregnancy the2x2project.org The Harvard study looked at seven use of selective serotonin reuptake inhibitors years of Medicaid data on 106,000 and serotonin and norepinephrine reuptake 2x2.ph/1gF54Ao low-income women who were preg- inhibitors is associated with increased risk of nant and had a diagnosis of mood or postpartum haemorrhage. Evid Based Nurs. anxiety disorder, comparing those who 2013 Nov 28. doi: 10.1136/eb-2013-101595. had been prescribed antidepressant [Epub ahead of print] PMID: 24288247 medication against those who had not. Risk for postpartum hemorrhage

4 SPRING 2014 : ISSUE 5.01 PUBLICATION HIGHLIGHTS

lthough their attitudes are Over a third of the providers said more positive than the general they would be unwilling to have an A public, a significant number individual with schizophrenia as a of mental health professionals would coworker, and about one-third said this be unwilling to live near or work individual was likely to use violence with someone who has an untreated toward others. psychiatric disorder, especially schizo- Negative perceptions toward phrenia, according to a new study in disorders that involve psychosis has the journal Psychiatric Services. increased with rising news coverage “How people with mental disorders of mass shootings implicating people are viewed by treatment providers and with mental illness, according to the the general public can have a signif- authors, even though such illness is icant impact on treatment outcomes almost never the only reason for this and the quality of life of clients,” violence. writes Dr. Bruce Link, professor of Older, male mental health pro- epidemiology and sociomedical sci- fessionals were more likely to view ences at Columbia’s Mailman School people in the depression and schizo- of Public Health, with co-author Dr. phrenia vignettes as less competent, Jennifer Stuber and her team at the compared to younger, female profes- University of Washington. sionals. Providers with more advanced The researchers compared the degrees held more positive attitudes survey responses of a representative than those with less education. sample of 731 providers of mental So did those who had been profes- health services, including psychia- sionally active for longer, or had been trists, therapists and psychologists, diagnosed with a mental illness (32 case managers, psychiatric nurses, percent of the sample). program directors and managers, with Among the general population a general population sample of 770. sample, older people and women were Mental health The mental health providers were more likely to have positive attitudes recruited from community mental than younger people and men. professionals health agencies in Washington State “People with mental illnesses and were demographically represen- often ask me whether I have studied hold stereotypes tative of the national mental health stigmatizing responses of mental workforce. The general population health providers. They say that the of those with sample came from the General Social experience of negative attitudes from Survey, an in-person survey that is providers is particularly troublesome psychiatric illness widely used for its extensive data to them because it occurs in the on Americans’ attitudes about a vari- place where they go to get help for ety of subjects. such problems,” says Dr. Link. “I can Both groups were presented with now answer that we have done such vignettes that described people with a study and can use the results to untreated depression and schizo- advocate for interventions that might phrenia without being told of their improve attitudes and thereby the diagnosis. The groups were asked how treatment experience of people who they would respond if these people seek help.” lived next door, worked closely with the2x2project.org them, married into their family, or lived Stuber JP, Rocha A, Christian A, Link BG. in a nearby group home. Conceptions of Mental Illness: Attitudes of 2x2.ph/1kB8TMs Both providers and the general Mental Health Professionals and the Gen- population had more positive attitudes eral Public. Psychiatr Serv. 2014 Jan 15. doi: toward those with depression com- 10.1176/appi.ps.201300136. [Epub ahead of pared to those with schizophrenia, print] PMID: 24430508 who they sometimes viewed as poten- tially violent.

DEPARTMENT OF EPIDEMIOLOGY 5 PUBLICATION HIGHLIGHTS

elson Rolihlahla Mandela was a AIDS Conference, his most important lawyer, protester, revolutionary, contribution as an anti-AIDS activist, N anti-apartheid leader, prisoner, according to Dr Abdool Karim. There, negotiator, president, statesman, anti- Mandela told the audience that South AIDS campaigner, and philanthropist, Africa and the world should make says Dr. Salim Abdool Karim, pro- AIDS treatment accessible to all. His fessor of clinical epidemiology at the speech received 17 standing ovations. Mailman School of Public Health and In the foreword for the book HIV/ director of the Centre for the AIDS Pro- AIDS in South Africa, coedited with gramme of Research in South Africa, Dr. Abdool Karim, Mandela acknowl- in a tribute published in Science maga- edged the delicate gender politics and zine in January. damaging social attitudes holding Although as president of South back prevention, testing and AIDS Africa, Mandela’s top priority was treatment efforts, stating, “we will bringing together a nation torn by not succeed until we appreciate the apartheid, he made invaluable contri- gender dimension of vulnerability to butions toward the fight against AIDS HIV” and “until we have addressed both during and in the years after his the stigmatization and discrimina- presidency. tion.” He fought stigma around the When Mandela took office in 1994, disease, announcing in 2005 that his 7.6 percent of the population and 1 in son had died of AIDS and by wearing 13 pregnant women were HIV positive. and posing for pictures in a Treat- To reduce rates of HIV in pregnant ment Action Campaign “HIV Positive” mothers and newborns, Mandela t-shirt. declared these groups should have In the words of Dr. Abdool Karim, free health care. He also appointed a Mandela’s “long walk was the first leading local AIDS scientist to direct a step toward freedom from oppression, Nelson Mandela national AIDS program. As a personal freedom from want, and freedom from project, in 1995 he founded the Nelson disease. With his passing, his legacy is and AIDS Mandela Children’s Fund to support in each of us as we follow in his foot- community programs working to pre- steps in the enduring quest to make vent mother-to-child-transmission and our world a better place for all.” to care for children orphaned by AIDS. Despite these efforts, AIDS was only Abdool Karim SS. Retrospective. Nelson one of many priorities of his govern- R. Mandela (1918-2013). Science. 2014 ment and as a result did not receive Jan 10; 343(6167): 150. doi: 10.1126/sci- the amount of attention Mandela ence.1249822. https://www.sciencemag.org/ knew it deserved. By the time he left content/343/6167/150.full office in 1999, 1 in 4 pregnant women was HIV positive. Unfortunately, his BY RACHEL KITCHENOFF, MPH ‘15 successor, Thabo Mbeki, denied the existence of the AIDS virus, signifi- cantly holding back South Africa in the fight against AIDS. Mandela, filled with regret for not prioritizing AIDS, spent the next chap- ter of his life as an influential anti-AIDS activist, framing the epidemic as a human rights issue. He directed the Nelson Mandela Foundation to pay for IMAGE: DANIEL BEREHULAK a household survey to gauge the AIDS’ impact upon South Africa. In 2000, he spoke at the 13th International

6 SPRING 2014 : ISSUE 5.01 PUBLICATION HIGHLIGHTS

cientists are proposing a new Dr. Brown and colleagues have pre- approach to treating schizo- viously shown in large birth cohorts S phrenia, one which would that elevations in prenatal serum cyto- draw on research that connects the kines measured over time and several psychiatric condition with early life in utero infections are associated with exposures to infection. schizophrenia. In an article in the February issue The authors suggest a novel clinical of the journal Biological Psychiatry, trial to test a medication with an anti- Dr. Alan S. Brown, professor of body that can neutralize IL-6 proteins epidemiology at Columbia, with by binding to their receptors. One such Columbia colleagues Dr. Ragy Girgis, drug is called tocilizumab, which has assistant professor of psychiatry, been approved by the Food and Drug and Samhita S. Kumar, an MPH Administration for rheumatoid arthritis student in epidemiology, propose in patients who haven’t responded to running a clinical trial of a biological other therapies. immunotherapy that would target the The authors say they only know brain’s inflammatory response. of one study in which a “cytokine A chronic and debilitating disorder antagonist” has been used to treat of the brain, schizophrenia is one of a psychiatric disorder. In this trial, the most difficult psychiatric illnesses patients diagnosed with depression to treat. Often emerging in the late who took infliximab, an antibody teen years or early twenties, it can that neutralizes a different cyto- cause hallucinations, delusions, kine protein, and who had elevated disordered thinking, unusual speech inflammatory biomarkers initially, sig- or behavior, and social withdrawal. nificantly improved after 12 weeks. Individuals with schizophrenia are Since publishing the study, Dr. often stigmatized as violent, even Brown and Dr. Girgis have begun a though only a small number act out. trial of tocilizumab, which is under- The only current medication treat- written with a grant from the Stanley Novel ment for schizophrenia is a class of Foundation. medications known as “antipsychot- “If the medication is successful, schizophrenia ics.” These drugs are usually only and is replicated by other investiga- partially effective and can cause side tors, the study has the promise of a treatment effects such as metabolic syndrome, novel approach to treating schizophre- tremor, and sedation. nia by reversing a key component of draws on The treatment proposed by the its putative pathophysiology,” says authors is based on the “cytokine Dr. Brown, adding that the medication early infection model” of schizophrenia. may be most effective in patients with This model hypothesizes that evidence of systemic inflammation. theory schizophrenia arises from prenatal or “Moreover, the study provides a early childhood exposure to infection, more robust test of the cytokine model which leads to chronic peripheral of schizophrenia, since it is based on nervous system inflammation in a randomized controlled design, in adulthood. contrast to previous studies of cyto- Cytokines are a group of proteins kines in schizophrenia, which were that are important in immune and observational and therefore subject to inflammatory responses and to the confounding.” development of the nervous system. They are produced in increased num- Girgis RR, Kumar SS, Brown AS. The cyto- bers when exposed to infections. If a kine model of schizophrenia: emerging woman experiences certain viral or therapeutic strategies. Biol Psychiatry. bacterial infections during pregnancy, 2014 Feb 15;75(4):292-9. doi: 10.1016/j.bio- her cytokines may transmit immune psych.2013.12.002. Epub 2013 Dec 11. PMID: and inflammatory signals to the devel- 24439555 oping prenatal brain, studies suggest.

DEPARTMENT OF EPIDEMIOLOGY 7 Bringing ‘consequentialism’ back to epidemiology

In a challenging funding environment, epidemiologists urge more action

BY ELAINE MEYER

8 he large and But in July the Framingham website The critics compare observational research announced a 40 percent cut to the $9 of risk factors unfavorably to the methods long-enduring million budget contract with the National of randomized controlled trials that are Framingham Heart Institutes of Health’s National Heart, Lung commonly used in drug studies. “While T and Blood Institute (NHLBI), which sup- the tools of epidemiology—comparisons of Study is known as one ports the study’s core operations. The populations with and without a disease— of the success stories cuts are not only a blow for Framingham have proved effective over the centuries but indicative of a more worrying trend, in establishing that a disease like cholera of epidemiology. The according to some observers. is caused by contaminated water, as the Washington Post in 2000 “[NHLBI] is dramatically reducing its British physician John Snow demonstrated support for the large cohort studies that are in the 1850s, it’s a much more compli- named it a top ten medical ongoing because they are very expensive,” cated endeavor when those same tools accomplishment of the says Dr. Lewis Kuller, a cardiovascular are employed to elucidate the more subtle epidemiologist at the University of Pitts- causes of chronic disease,” writes one of 20th century. Data the burgh Graduate School of Public Health. the most vocal critics, science journalist study has gathered through “However they generate a huge amount of Gary Taubes, in the New York Times in 2007. valuable data, so you might say on a value While this is a controversial view among its regular and detailed basis they are not expensive, and they’re epidemiologists, some still believe their physical examinations of certainly not more expensive than the field needs to re-assert its relevance. “I think amount of funding that goes into what you over time, a lot of epidemiology has become over 15,000 participants might say is basic research.” data analysis and data dredging and highly since 1948 have led to a A field that is devoted to scientifically sophisticated statistical modeling but studying the distribution, cause, and without any emphasis on the application of number of breakthroughs effects of disease and injuries, epidemio- epidemiology on public health and preven- that are credited with logic discovery has motivated public health tive medicine,” says Dr. Kuller. campaigns and policy changes that have ‘Consequentialist epidemiology’ dramatically reducing led to longer life spans across the globe, deaths from heart disease. such as anti-smoking regulations, seatbelt In June, Dr. Galea stood before a hotel laws and speed limits, water treatment, ballroom filled with his peers to give the vaccines against infectious diseases, sex annual outgoing president’s speech at the education, and folate supplementation in Society for Epidemiologic Research (SER) water to prevent birth defects. meeting in Boston. Despite those “big wins” of the past, “We are seeing a gross failure in our some epidemiologists are concerned that improving the health of populations,” he because their field hasn’t achieved compa- said. Epidemiology risks being shunted rable public health improvements in the last aside if its practitioners do not use it for decade, it will have difficulty weathering “consequentialist” purposes. “Academic the current financial climate. “Implicit in epidemiology now spends most of its time pressures [from large funders] is a growing concerned with identifying the causes dissatisfaction outside the field of epidemi- and distributions of disease in human ology with epidemiologic description and population, and far less of its time and correlation and a sense that our current imagination asking how we might improve approaches are not leading to ‘wins,’ to prac- health,” Dr. Galea wrote in a follow-up tical solutions to diseases and challenges to article published in September in the Amer- health, or to science that is more saliently ican Journal of Epidemiology. useful to decision makers with a responsi- Reviewing articles in the four leading bility to the health of the public,” says Dr. epidemiology journals, Dr. Galea and Sandro Galea, chair of the department of his colleagues found that over 85 per- epidemiology at Columbia University’s Mail- cent focused on causality or etiology of man School of Public Health. a disease “with little particular attention On top of this, a few critics have argued to how that etiology may be relevant to that the observational cohort studies com- intervention.” The 14 leading epidemiology monly used in epidemiology are “lead[ing] textbooks “devote[d] the overwhelming the public astray,” as Drs Paul Sorlie and majority of their content to educating the Gina S. Wei put it in a 2011 article that itself reader about how we may identify causes is sympathetic to the use of such studies. and distribution of disease.”

DEPARTMENT OF EPIDEMIOLOGY 9 “Our focus on causal thinking at the these concerns. In 1967, the president of expense of pragmatic thinking is not cost the American Public Health Association free, and runs the risk of marginalizing us (APHA), Dr. Milton Terris told attendees as a discipline,” he says, citing as examples at the organization’s annual meeting that: journal articles that focus on “illicit drug “Public health problems, whether new or Dr. John Snow’s map of cholera cases use and cognitive function in the mid-adult old, are essentially social in character and in London. The map has been colorized years” and “the relationship between pre- can only be solved in terms of social policy. to enhance the mapping of deaths mature birth and age at onset of puberty.” “The task of public health workers is to depicted by bars running perpendicular Epidemiology needs “a demanding, rigor- convince society to undertake the specific to streets. After mapping the area’s ous approach that focuses us ruthlessly on social measures, governmental or other, 13 public wells, Dr. Snow noted the our outcomes—rather than our approaches which are required to solve specific health spatial clustering of cases around one and methods,” he continues. problems, and to participate in the imple- particular water pump on the southwest One example of where epidemiology mentation of these policies,” said Dr. Terris, corner of the intersection of Broad (now could be more focused on outcomes is who was known as an outspoken advocate Broadwick) Street and Cambridge (now on the issue of gun violence. Although for a progressive public health policy. Lexington) Street. epidemiologists have found evidence that At another APHA annual meeting, in gun availability leads to an increase in 1983, Dr. William Foege made his own call homicide and suicide, the field could make for a consequential epidemiology. In his a more meaningful contribution if it studied talk, he said that epidemiologists should the consequences of different regulatory not shy away from political involvement. approaches to gun control. “[Epidemiology] is a tool to change the “This approach would have epi- world, not merely to study the world,” said demiology leading the way on both Dr. Foege, whose own consequentialist implementation science and on translation resume included working on the 1970s of population health science, when, in campaign that eradicated small pox and actuality, we are at best involved in these directing the U.S. Centers for Disease Con- emerging movements on the margins.” trol and Prevention (CDC). Dr. Galea is not the first to express Eleven years later, as president of SER,

10 SPRING 2014 : ISSUE 5.01 “The bulk of our research efforts identified risk factors but rarely affected public health actions,” says Dr. Cates.

Based on the deaths and a water sample budget is slated to shrink by 8.2 percent from the Broad Street source, he became annually. convinced that cholera was transmitted “I’m very worried about the effect of not through the atmosphere—the popular cuts. I think it will change the nature of theory of the time—but through contam- epidemiologic research. Epidemiology has inated water. He took this theory to the been able to build itself up as its own disci- local government parish, prevailing on pline because we have been able to get large authorities to remove the Broad Street grants to fund our work,” says Dr. Galea. pump handle so it could no longer be used Dr. Michael Lauer, director of the divi- as a water source. Although Dr. Snow did sion of cardiovascular science at NHLBI, is not have complete information to prove his more optimistic. “Look at [the budget cuts] theory, cholera stopped spreading soon as an opportunity to do things in ways that after. (It would take many more years for are bigger and better and more effective health authorities to embrace water and than what we’ve ever done before,” he says. sewage treatment). “When resources become scare, people Dr. Snow’s decision to act for the public become resourceful. There are a lot of excit- Dr. Willard Cates reinvigorated the call good based on the imperfect information ing developments that are happening that for a consequential epidemiology, telling he had is what epidemiology of the best should make it possible for epidemiology to his peers to “seize the day of impending kind looks like, say consequentialists. “It is not only stay relevant but to actually grow to healthcare reform.” unlikely that John Snow would be revered much higher levels than we’ve ever seen.” He saw in the field the same problems in public health if he had merely studied In fact, some epidemiologists have been as Dr. Galea describes today. “The bulk of cholera,” says senior vice president of concerned about the future of the NHLBI, our research efforts identified risk factors the Robert Wood Johnson Foundation which funds many notable epidemiology but rarely affected public health actions. Dr. James S. Marks in a 2009 article in the cohort studies. NHLBI last year suspended We were told that epidemiologists tended journal Preventing Chronic Disease. “Our Framingham’s regular exams, which its to ‘torture’ our data until some—frequently heroes have been tied to action.” principal investigator has called “the life- obscured—associations were found,” blood of the study,” and future exams in Worries in a time of austerity recalls Dr. Cates, who is currently presi- the Multi-Ethnic Study of Atherosclerosis dent of Family Health International and an Epidemiologists admit that whether or not cohort (MESA), a medical research study adjunct professor at University of North the field can adapt, the funding climate is involving more than 6,800 men and women Carolina-Chapel Hill, Emory University, and one of the worst in recent memory. from six communities in the United States. University of Michigan School of Public The 2013 budget sequester forced the Patient health information will, however, be Health, in a response to Dr. Galea’s article. CDC to slash 5 percent of its $285 billion collected by phone or mail. Those who talk about a consequential budget for 2013, which will reduce global “We cut exams to allow us time to epidemiology don’t see it as a departure efforts to eliminate malaria, polio, and engage in longer term strategic planning but rather as a return to the field’s roots. other infectious diseases and cuts to pre- in the setting of ever decreasing budgets,” These roots are embodied by the story of vention programs for HIV, cancer, heart says Dr. Lauer, adding that the NHLBI’s Dr. John Snow. An anesthesiologist living attack, and stroke. buying power is 30 percent lower than in nineteenth century London, Dr. Snow The sequester also cut 5 percent or it was ten years ago because of flat or began monitoring cases of a deadly chol- about $1.6 billion of the $30 billion budget decreasing budgets and inflation. era outbreak in 1854. He found that nearly for the NIH, which is now funding only 15 “As part of being careful stewards of everyone who had died lived near a water percent of grant applications, a decline public monies, we see a need to carefully pump on Broad Street in the city’s Soho from about 30 percent from nearly a review all long-term, higher-cost projects,” neighborhood. decade go. Going forward, the NIH’s he adds, noting this is not the first time

DEPARTMENT OF EPIDEMIOLOGY 11 PHOTO: HYPERSAPINES [FLICKR]

Although epidemiologists have found evidence that gun availability leads to an increase in homicide and suicide, the field could make a more meaningful contribution if it studied the consequences of different regulatory approaches to gun control.

in its history that NHLBI has suspended approaches in these cohorts allows us to population level findings, it has been deval- exams. “In this era of big data and small start to re-define the disease for clinical ued in the eyes of NIH, and it has devalued budgets, we need to think about how we purposes,” he adds. “MESA, for example, the extent to which epidemiologic findings realign our strategies in order to maximize has the longest longitudinal follow-up of are useful, particularly as NIH has become what we get out of the dollars we receive.” measures of emphysema on computed more interested in translation of its find- Yet some experts believe that the data tomography of any study.” ings to clinical cures,” says Dr. Galea. from contemporary cohort studies still The infrastructure of the cohorts has Epidemiologists point out that such provide the most thorough and up-to-date also allowed rapid responses to new public clinical cures can be expensive and can picture of the changing risk factors and health concerns, such as acquiring data on take years or decades to become available prevalence of chronic diseases in the U.S. e-cigarette use, says Dr. Barr. to the general public, while preventive Cohorts have shifted focus to study not just Even before the cuts, some observers approaches that often come about because cardiovascular events—which have been believed that epidemiology was already of epidemiologic research—such as on the decline for several decades—but losing influence at the NIH to biological awareness campaigns, regulations, and contemporary problems like rising rates of sciences like genetic and molecular biology improving access to health care—can be diabetes, obesity, and lung disease using and neurology. implemented sooner. “Epidemiology is a state-of-the art technologies, says Dr. R. “I don’t think it gets the same kind crucial part of the way that case is made Graham Barr, an associate professor of of respect as some of the most basic sci- for the public and policy makers. We can’t epidemiology and medicine at Columbia ences, and there are some reasons for that. afford to treat ourselves out of our health University’s College of Physicians and It seems to many a little bit more subjec- crisis. We can’t continue to pay for more Surgeons who studies respiratory illness tive. Rarely are there randomized trials,” and more treatment for more and more using MESA data. says Dr. Marks. disease,” says Dr. Marks. “The ability to use novel imaging “Because epidemiology is ultimately “What’s happened over the last couple

12 SPRING 2014 : ISSUE 5.01 Read more of decades has been the growing aware- legalization of abortion, which was put ness of the implications of social factors for forward by two economists. “The methods original content on health, whether that’s education, poverty, used in that kind of assertion are the same the2x2project.org transportation, parks, etc.—the social envi- type as used in epidemiology. But epide- ronment. Epidemiology or its techniques miology would never have the boldness to Impact of the food stamp cuts are one of the few ways that those factors make that assertion,” he says. “[Economics] can be assessed.” gets bashed around for its shortcomings. Mayor Bloomberg’s legacy That’s where the saying ‘dismal science’ Should epidemiologists be more like The relationship between comes from. It is a dismal science but at the economists? bigotry and health same time, it is a science that has an impact Despite this sense of urgency, epidemiolo- on day to day public discourse.” Neglecting homelessness gists as a culture are hesitant to over-state Medical anthropology the meaning of their data and rarely use in public health their research to take strong policy posi- The need for conversation tions. They commonly offer the disclaimer about HPV vaccination that a study they’ve done does not show that an exposure caused a disease, simply The paradox of American health care spending that there is a link between the two. “The challenge for us as epidemiolo- Funding the future of gists is we can get committed to an issue public health and sometimes over-interpret or over-value the science that we’ve done and push the policy decision that is premature,” says Dr. Marks. “On the other hand, science that is immature or incomplete may be better than no knowledge. If a body of work, even if relatively modest, points in a single “Epidemiology is a direction it probably indicates a higher likelihood that that direction is causal than crucial part of the another—not a certainty, but a higher like- lihood. When you’re in a policy discourse way that case is sometimes you have to speak with greater confidence than your data warrant in order made for the public to be heard,” he adds. He acknowledges that “the most import- and policy makers. ant issues” are “among those that are the hardest to measure: connectedness, support We can’t afford to for each other. And many things that are outside of medical care: quality of a diet, the treat ourselves out of access to fresh food, safe places to play.” According to Dr. Galea, by not getting our health crisis. We involved in policy discourses, epidemiolo- gists are ceding an important policy role to can’t continue to pay another discipline: economics. “Epidemiology is very conservative for more and more about its causal thinking. In some respects that’s a good thing and sort of refreshing. treatment for more But what it has done is it has allowed the insertion of economics into the health and more disease,” arena. Economists have positioned them- selves as people who ask big questions says Dr. Marks. that are of societal interest. They have the self-confidence as a discipline to say that their findings shed light,” he says. He points to the theory that attributes lowering crime rates in the U.S. to the

DEPARTMENT OF EPIDEMIOLOGY 13 Big push initiatives in global health

BY ELAINE MEYER “Big push” global health initiatives are popular, but do they work?

the2x2project.org http://2x2.ph/NDfVSP

14 Employees at a textile mill manufacture durable insec- ticide-treated mosquito nets for distribution to high-risk areas for malaria.

Above: British Rotarians immunize children in the streets of Lucknow during the polio immunization campaign in Northern India. Right: Charles Machiridza, 52, a nurse at the Chiparawe Clinic in Zimbabwe, administers a rapid HIV test.

PHOTOS TOP TO BOTTOM:

GATES FOUNDATION, MARC GIBOUX, DFID - UK laundry list of United Nation’s Millennium Development ambitious global Goals, which are a significant motivator for national government and NGO public targets now greatly health efforts. A “Most of the discussion on post-2015 has influence the agendas of been what I call ‘if I ruled the world.’ So a the many non-government, range of people, businesses, politicians, private, and government NGOS, in spades, have said, ‘if I ruled the world, I would do x, y, zed, and the world organizations that work would be a better place, which is a fascinat- on global health. ing conversation, and you know, it’s great, but it’s also weirdly sort of self-indulgent,’” Faced with what they view as colossal Dr. Green recounted having to facilitate global health challenges, public health the participation of 200 NGOs in a consulta- advocates have increasingly turned to tion with a high-level panel. Each NGO had “big push” approaches, focusing enormous 15 seconds to suggest a focus for the UN financial and human resources on a single after 2015. “It was a Christmas tree. It was specific issue for a finite time, with high decorating the Christmas tree with your target goals. issue,” he said. This includes eradicating malaria, Nothing may better illustrate both eliminating new cases of pediatric HIV, strengths and the flaws of an aggressive curing dementia, eradicating polio, and big push health initiative better than the reducing cancer mortality and heart World Health Organization’s (WHO) Global disease by one-fourth what it is today. Malaria Eradication Program, begun in While aggressive global targets like 1955 with a target of eradicating the dis- those above from the United Nations, the ease in five years. G8, and private foundations are credited From the start GMEP, as it was known, with motivating funders and improving the saw containment of the disease as at effectiveness of aid, critics have accused odds with eradication. A UNICEF regional these initiatives of imposing on local struc- director called the two priorities “as great tures and approaches, diverting resources a difference as that between night and from more urgent needs, and being diffi- day,” according to a 2011 article published cult to sustain after the interest and initial in PLOS Medicine about GMEP. Believing cash infusions from rich nations and pri- that the science of malaria eradication was vate funders is gone. settled, GMEP dismissed local knowledge “We have a lot of unfinished objectives about disease control if it didn’t align with Posters from the NIH archive. in global health. The whole field is littered the new eradication technique of spraying with partially achieved objectives,” says DDT or other insecticides. The program Dr. Stephen Morse, a professor of epide- also did not integrate well with communi- miology at Columbia University who is the ties, sometimes creating separate, parallel co-director of the USAID program PREDICT, structures from already existing local which conducts global surveillance for health services. emerging infectious diseases. By 1969, facing financial constraints and Concern about the proliferation of a new outbreak in Sri Lanka, a country that incomplete or abandoned initiatives is was once a model of success for those who Read about India after becoming more acute with the decline in studied eradication, GMEP determined their eradication of polio: global aid from the flush aught years even goal was not feasible and abandoned it. as awareness of new global health needs When GMEP was disbanded, there emerges. The fear is that in this environ- were drastic cuts in human and financial the2x2project.org ment, these “big push” initiatives are too resources that resulted in weakened ability 2x2.ph/1cgqyqk single-minded. to control malaria. These cuts, combined That fear was expressed by Dr. Duncan with the emergence of resistance to first Green, the senior strategic adviser for line anti-malarial drugs and the withdrawal Oxfam Great Britain, who spoke at a of DDT from many control programs for seminar in 2013 about the future after environmental reasons, contributed to a 2015, the target year for achieving the resurgence of malaria in many parts of

16 SPRING 2014 : ISSUE 5.01 Asia, Africa, and Latin America during the 1970s and 1980s. “There were real costs to having failed to achieve eradication,” says Dr. M. Randall Packard, chair and professor of history of medicine at Johns Hopkins University, who is the author of The Making of a Tropical Disease: A Short History of Malaria and is currently working on a book about the his- tory of global health. Presciently, the League of Nations’ Malaria Commission wrote in 1927: “the history of special antimalarial campaigns is chiefly a record of exaggerated expectations followed sooner or later by disappointment and abandonment of the work.” Yet, GMEP did drive down rates of malaria and help to mobilize resources that would not have been brought to bear without the campaign. “While it didn’t eradicate the disease and there were lots Safe Motherhood Action Group member (left) and pregnant women at antenatal care of criticisms about that campaign, nonethe- clinic in Lundazi District, Zambia. less, you look at where malaria was before and where it was afterword, I don’t think anyone would argue that we’re not better off, and we probably wouldn’t have gotten there without that,” says Dr. Packard. The contemporary “big push” efforts for better or worse are a legacy of that new infections. But that number is a signif- initiatives in global health,” experts inside campaign. People who have worked on icant improvement compared to the years and outside the project weighed in. these campaigns say that they mobilize 2000-2008, when new infections dropped “Big pushes are in fact a recipe for chaos, resources that would otherwise be hard to by 26 percent. however there’s something to be said for bring together. McClure says he is not sure at this point quick wins. Saving a life is saving a life,” “There’s always debate: do you set a whether the Global Plan targets will be met, said Dr. Angeli Achrekar, a senior public target that’s easy to achieve or do you set but he credits them with making a difference health adviser for the U.S. Centers for Dis- an ambitious target that’s harder to achieve in bringing together resources and giving ease Control and Prevention, which was that kind of puts a fire under people’s butts the governments a concrete goal to aim for. involved in the Saving Mothers campaign. that you probably know in your heart might According to executive director of Others at the event acknowledged that not be achieved in that timeline but will be Merck for Mothers Dr. Priya Agrawal, the program’s long-term prospects remain achieved shortly thereafter?” says Craig having a goal of reducing maternal mor- to be seen. “Sustainability is probably the McClure, the chief of the HIV/AIDS section tality by 50 percent in 5 years was key to hardest nut to crack,” Dr. Margaret Kruk, of UNICEF, who is based in New York. “You bringing everyone, including the govern- an assistant professor of health policy and have to strike a balance of how ambitious ments of Uganda and Zambia, together in management at the Mailman School who you want to go because if you get too a private-public $200 million effort called with Dr. Sandro Galea, chair of the school’s ambitious you could de-motivate people.” Saving Mothers, Giving Life. department of epidemiology, led the exter- McClure leads UNICEF’s participation An external evaluation from researchers nal evaluation of Saving Mothers, Giving in the UNAIDS Global Plan to eliminate by at Columbia and New York Universities Life, said in closing remarks. 2015 new cases of HIV transmitted from found that in its first year, the program was She expanded on that idea in a later mother to child, which means reducing largely successful in the approaches it took interview: “Having an ambitious goal is the rate of transmission by 90 percent, or toward achieving this goal, including work- very motivating. The converse of that from 400,000 new infections to fewer than ing with the community to improve quality though is that it’s not enough. There is 40,000 worldwide. of health facilities and providers and rais- almost no one who would disagree with There is still a way to go. At the end ing positive awareness of these facilities. the statement that you can change a lot of 2012, there had been a 35 percent drop At a symposium held in November at in a short time with a lot of money and in the rate of new infections from when Columbia University’s Mailman School of a lot of motivated people. That’s not the the Global Plan started in 2009, to 260,000 Public Health on “the potential of big push trick. The question is how does this sustain,

DEPARTMENT OF EPIDEMIOLOGY 17 BIG PUSH Eradicating malaria. Zabibu Athumani and her son Abirai Mbaraka Sultani rest under an insecticide-treated bed net at their home. (Bagamoyo, Tanzania, 2011)

PHOTO: GATES FOUNDATION

year two, year five, year ten. That requires this mosquito. We managed to control it an invested government, a committed and then it came back. So why were they workforce. These kinds of projects can talking about eradication? And the reason demonstrate the possibility, but to sustain is that eradicating motivates people.” the success, you need a long-term view Even the Gates Foundation appears to and an increasing role for government.” have scaled back its expectations, says Dr. Sometimes an ambitious goal can be Packard. “I don’t know that they actually too ambitious, like the Gates Foundation’s believe in their hearts of hearts it’s pos- decision in 2007 to renew the goal of sible. I’ve had a lot of conversations with malaria eradication. “Eradication is not people at Gates, people who have a direct something that is normally feasible. It’s a role with malaria. My sense is that early on, BIG PUSH rare event,” says Dr. Morse. there was optimism and much concern that Eliminating dementia. Shinako Tsuchiya, To this day, smallpox is the only disease without that kind of goal, the achievements Senior Vice Minister of Health, Labour that has been eradicated by humans. And that would be gained with the rollback of and Welfare, Japan. The summit on 11th smallpox was “low-hanging fruit,” says Dr. malaria would not be sustainable, and they December brings together G8 ministers Packard. “It was a real achievement, but it were afraid ministers of finance as well and other delegates to discuss dementia. was the easiest of all diseases to eradicate. as international donors would get to the The unfortunate part is having become suc- point where they’d say, ‘things have gone cessful, it became this model of ‘oh we did well, there are lots of other problems in the it once, we can do it again,’ without really world, let’s move on.’” looking at the realities of what it took to do Another issue that has surfaced around it and how relatively easy it was.” big push initiatives is measurement. In Dr. Morse recalls attending a meeting in December, the WHO released a damning the 1990s of a pan-American organization evaluation of the once highly regarded about eradicating the mosquito that causes Chiranjeevi Yojana program to reduce malaria and dengue and yellow fever—the maternal and child mortality in India, which Aedes aegypti. “We knew it’s not feasible to are two of the United Nations’ Millennium do this. There’s no strategy for eradicating Development Goals.

18 SPRING 2014 : ISSUE 5.01 Several experts admit that while there have been mistakes in big push initiatives, the global health community have learned a great deal from them. partners—rather than having to start from square one,” she says. The investments in obstetric care infrastructure and personnel have also improved the health facilities’ capacity to The $25 million public-private pro- themselves have been criticized for not deliver other services as well. “It’s not just gram, based in the northwestern state of taking into account where different coun- going to benefit mothers but people who Gujarat, aimed to prevent deaths related tries are in being able to meet those targets, have car accidents and trauma victims, and to pregnancy complications by paying something many hope will change when various events of this nature,” says Dr. Kruk. women under the poverty line to deliver new global priorities are set after 2015. For these efforts to work, it is important at designated private hospitals. Initially Several experts admit that while there to be flexible, say others. In the world of the program received positive reviews, have been mistakes in big push initiatives, HIV/AIDS, the goal of treatment used to be and won the Wall Street Journal’s Asian the global health community has learned pitted against the goal of prevention—not Innovations Award, which honors private a great deal from them. “One of the big dissimilar to the WHO’s malaria eradication companies or academics that have devel- lessons learned by most people, if they’re effort. But now the mantra in the AIDS field oped an innovative idea in Asia. The Indian honest with each other, who work with is “treatment as prevention,”—the scien- government began recommending it be HIV is that when the money started to flow tifically proven idea that treating HIV also adopted in other parts of the country. around 2000—big money started to flow— helps prevent its transmission. But the WHO evaluation found that and targets began to be set, the way the “There has been an evolution in the there was no statistically significant world approached the support to countries global aspirations for HIV over time, and change in the probability that women and spending that money was kind of like this has often been motivated by availability would deliver in health care institutions, in an emergency operation—parachute in, of new scientific evidence, new resources the rate of complications during delivery, create a vertical program, and get some- or new imperatives,” says Dr. Wafaa El-Sadr, and the likelihood that physicians or nurses thing done. And now, 13 years later, we are university professor and professor of epi- would be present during birth—all goals trying to undo the parallel systems and demiology at the Mailman School and the of the program. “[T]he program’s accom- better integrate,” says McClure. director and founder of ICAP. plishments are likely far more modest than Several people involved in global health “The HIV world has learned that achiev- have been claimed,” says Dr. Manoj Moha- initiatives say that they have been better at ing results is complicated, and it’s not going non, an assistant professor of public policy, integrating with already established health to take one technology or one magic bullet global health, and economics at Duke Uni- infrastructure and with communities since that will make a difference,” she adds. versity, who led the recent evaluation. the more competitive days of the early 2000s. Regarding the Global Plan to Eliminate Earlier evaluations that rated the pro- A contributing factor to the success of Pediatric HIV, she says it has been important gram as successful were based on possibly Saving Mothers, Giving Life was that it that the big picture goal is translated into inaccurate data from participating hospi- provided care by building on infrastruc- clear local targets “to enable those at the tals, rather than population-based surveys ture that was put in place as a result of the frontlines to know what they need to do—to of mothers who gave birth, and did not President’s Emergency Plan for AIDS Relief, have clarity as to what needs to be their pre- account for increases in hospital deliveries says one of the evaluators, Dr. Miriam cise contribution to achieving the big goal.” that were unrelated to Chiranjeevi Yojana Rabkin, associate professor of epidemiol- “Having goals, having timelines is a or for the self selection of women who ogy at and director of systems strategies great motivator,” she adds. “Whether it be chose to deliver in hospitals, according to for ICAP, a center at Columbia’s Mailman the Millennium Development Goals or the the WHO study. School that works on building and sustain- PEPFAR goals or the Global HIV goals, I Another effort, the Millennium Villages ing systems for prevention and treatment think having very concrete objectives with Project out of Columbia’s Earth Institute, of HIV and related health issues. clear targets is enormously helpful. Targets has also been the target of criticism around “This approach prevented duplication of motivate me, they motivate my teams on how it measures success, which research- effort and enabled implementers to lever- the ground. These targets can be very ers there have defended. age their existing resources—from staff, to ambitious and their achievement not easy, And the Millennium Development Goals vehicles, to relationships with district-level but they serve an important purpose.”

DEPARTMENT OF EPIDEMIOLOGY 19 Columbia Public Health Executive MS in Epidemiology

The Executive MS in Epidemiology is an the executive format intensive research degree designed to provide is designed to accommodate working health professionals with the additional the busy lives of working pro- fessionals. Students meet in knowledge, skills and credentials needed to New York City for one week- engage in rigorous population health research. end (Friday, Saturday, Sunday) a month over a 2-year period. The curriculum includes foundational and advanced courses in epidemiology and biostatistics with a strong focus on the practical application of research skills learned in the classroom.

The program is intended for professionals who work in a broad range of health settings, such as health departments, academia, the pharmaceutical industry, or hospitals. Applicants will typically have several years of work experience in healthcare and must meet the regular admission requirements of the Mailman School.

Apply online by June 1 for Fall 2014 Visit our webpage cuexecmsepi.org How cities affect health

The complex influence urban features have on health

The Red Square the2x2project.org apartments in New York’s 2x2.ph/1fWLs9b Lower East Side were gentrified in the 1980s.

IMAGE: STEPHEN HARLOW BY TIM PAUL

WRITER, MAILMAN SCHOOL OF PUBLIC HEALTH OFFICE OF COMMUNICATIONS

DEPARTMENT OF EPIDEMIOLOGY 21 hen the influential to move as their rents skyrocket, noted Dr. Diana Hernandez, assistant professor urban thinker Jane of sociomedical sciences at the Mailman Jacobs wandered School. Dr. Lovasi agreed, noting, that W many people in rezoned areas resist the streets of New York’s the changes. “There is tension between West Village in the 1950s, improving facilities and potentially dis- placing some of that population if there she recognized the vitality of is a market response that values those the city in its chaotic side- improvements.” Further clouding the picture: these walks and stores—a notion interventions don’t work for everyone. Dr. that upended the orthodoxy Lovasi cited studies showing neighbor- hood density and proximity to mass transit of city planners who prized encourages walking and cycling and is order and efficiency. linked with healthier weights but noted that associations suggesting a potential benefit Today’s urban health researchers carry were strongest among the educated and on that tradition, honing in on aspects affluent. “Interventions to make neigh- Hudson River Greenway of urban life that shape our health, and borhoods more walkable may not work in in doing so, challenging conventional disadvantaged groups,” said Dr. Lovasi. thinking. For those groups, safety concerns may be In a January 28 presentation, the first more salient as barriers to walking than the in Columbia University’s Maiman School built environment. of Public Health’s Urban Health Conversa- Related outcomes were seen in a study tions series, Dr. Gina Lovasi, an assistant of trees. Working with colleagues at the professor of epidemiology at the Mailman Columbia Center for Children’s Envi- School, mapped out current thinking in ronmental Health, Dr. Lovasi set out to urban health and invited the audience to measure the health benefits of a city initia- add to the discussion. As a member of the tive to plant trees in low-income areas. The school’s research group on the built envi- expectation was improved air quality and ronment and health, Dr. Lovasi examines less asthma. Instead they found asthma the health impact of urban features from rates were steady in children who lived green space to fast food restaurants, often near a tree canopy, but they had more tree MillionTreesNYC at Hunts Point in the Bronx uncovering surprises. pollen allergies. “It may be that we need to One fertile area of inquiry is the recent be more strategic in how we go about tree large-swath transformation of New York City planting,” Dr. Lovasi said. “It’s a cautionary through the policy of “upzoning” neighbor- tale pointing us to unintended side-effects hoods to promote greater density, giving of interventions envisioned as health READ MORE more people access to bike lanes and mass promoting.” the2x2project.org transit. “Creating new buildings may not be The tree study also serves as an exam- an obvious choice to improve health,” said ple of how urban research could reshape Lovasi, but “getting people to move through- policy. Selecting tree species that are less The power of place in out their day is an important priority.” allergenic could help maximize the health population health in the 2x2 Some at the talk questioned whether all benefits of massive tree planting cam- project’s PopPlaces series: density is created equal. Dr. James Colgrove, paigns like MillionTreesNYC. associate professor of sociomedical sci- Another line of research has looked 2x2.ph/1cgwHmc ences at the Mailman School, pointed to the at whether living near a lot of fast food Barclays Center in Brooklyn and luxury devel- restaurants makes people more obese. How hosting the Olympics opment in Manhattan. “I’m not sure how Surprisingly some studies have seen the affects cities: bringing high-rise condominiums to Tribeca opposite, where proximity to fast food is going to increase the health of populations restaurants is associated with healthier 2x2.ph/NduX1y who are most in need,” Dr. Colgrove said. weights. How is this possible? One expla- Gentrification was another concern. nation points to the underlying level of Investments in the built environment could commercial investment as a driver for be detrimental to people who are forced both restaurant locations and a healthier

22 PHOTOS TOP TO BOTTOM: ANDREW BOSSI, MATT GREEN SPRING 2014 : ISSUE 5.01 Rocinha favela, Rio de Janeiro PHOTO: MAXIMEBF [FLICKR]

There is a tension lifestyle. “We looked at whether having better job at monetizing those impacts,” banks and credit unions nearby predicted added Dr. Frederica Perera director of the between wanting lower BMI, and it did,” said Dr. Lovasi. Columbia Center for Children’s Environ- Singling out fast food restaurants is mental Health. to design perfect, also a challenge for researchers since cal- On the other hand, health may hold a orie-dense foods are available everywhere special place as a prerequisite and starting completely formed from bodegas to pharmacies. Supermar- point for everything else. “When you don’t kets on the other hand may turn out to be have health, it stands in the way of other communities that the superheroes of the urban environment, goals,” said Dr. Lovasi. “Making cities more lowering rates of obesity. supportive of health is making cities more support health, and Jane Jacobs, who is one of Dr. Lova- supportive of people.” si’s favorite writers, wrote that every city letting communities is distinct and has its own stories to tell. This article originally appeared on the Mailman This spring, Dr. Lovasi will travel to Rio de School of Public Health website. change in a way that Janeiro to spend time in the favelas to learn from communities that grow organically serves the needs of and make decisions for themselves. “There is a tension between wanting to design the population. perfect, completely formed communities that support health, and letting communi- ties change in a way that serves the needs of the population,” she said. In thinking about ways to shape urban health, it’s important to realize that cities aren’t made to create health. “Cities aren’t a pharmaceutical or healthcare inter- vention,” said Dr. Lovasi. Interventions must mesh with the larger goals of urban life. Doing so may require thinking about co-benefits and tri-benefits. For example, lowering reliance on automobiles has ben- efits for health, the environment and the economy. “I think we need to do a much

DEPARTMENT OF EPIDEMIOLOGY 23 Preventing Brain disorders: Improving global mental health

RSVP CUESS.ORG MAY 2, 2014

8:30 AM – 3:30 PM Alumni Auditorium, Black Building | 650 West 168th Street

COLUMBIA UNIVERSITY EPIDEMIOLOGY SCIENTIFIC SYMPOSIUM epidemiology role models

Trainees draw lessons from NYC’s new health commissioner

Dr. Mary Bassett’s commitment to an epidemiology that makes a difference

BY ELAINE MEYER

n January, Mayor Bill de Blasio appointed Dr. Mary Bassett, a long- Istanding associate professor of epidemiology at Columbia’s Mailman School of Public Health, to be New York City’s health commissioner.

About one year ago, Dr. Bassett spoke at the department’s DrPH seminar series about her career in public health, which has spanned from training epidemiologists and conducting AIDS research in Zimbabwe to implementing New York City’s ban on smoking and trans fats in restaurants. Recently, the five DrPH students who attended that sem- inar came together to recount the lessons they drew from Dr. Bassett’s talk, inspired by her story as an academic who has made a difference in community and global health and Mary Bassett policy and now prepares to lead one of the world’s most influential health departments. “What she gave the students is a thoughtful example of how you combine rigorous research design, research translation and implementation globally and locally with making things happen,” says Dr. Leslie Davidson, professor of epidemiology at Columbia University and director of the department of epidemiology’s doctoral programs. Dr. Bassett earned an MD at Columbia with other Columbia department of epidemiology faculty including Drs. Davidson, Steven Shea, and Ezra Susser, and did a residency at Harlem Hospital. She then moved to Seattle to complete an MPH as a Robert Wood Johnson clinical Scholar at the

DEPARTMENT OF EPIDEMIOLOGY 25 “The focus will shift to overcoming health disparities among the underserved and University of Washington. “What I liked about Mary’s profile a lot was that she had marginalized of NYC,” says this academic background but also this really interesting public work,” says Julian DrPH trainee Michael Rosanoff. Santaella, a second-year student. “You could feel how passionate she is about public health work, of being involved with communities.” In 1985, Dr. Bassett moved to Africa, where she would work at the University of Zimbabwe and the Rockefeller Institute and and prevent HIV/AIDS in nations struggling and white and Hispanic and white groups, consult for the World Bank and UNICEF. with the virus. “She can form an opinion and also reducing the gap in risk factors, She published papers on many facets of very quickly, and she sticks by it. You could such as access to healthy food, knowl- HIV/AIDS, including how to monitor the hear her voice in every meeting, in every edge of how to make healthy food, spaces progress of antiretroviral treatment among discussion. She’s very vocal about her that would increase walkability, and the HIV-positive patients, co-incidences with perspective,” says González. “She’s going problem gentrification causes for minority other diseases like cancer, and prevention to tell you what she thinks, but she’s very populations,” says Santaella. strategies such as getting men to increase reasonable.” Students believe she will bring her their participation in safe sex. Charlene After Dr. Bassett’s discussion, Santaella, academic background and training in epi- Goh, also a second year student, recalls Dr. who is interested in working in domestic demiological methodology to her job as Bassett telling the seminar to “think of jour- violence, approached her for advice. She health commissioner. nal writing not as advancing your career subsequently helped him get in touch “She is someone who knows and but as communication.” with people at a child welfare program in understands the utility of evidence-based In 2002, Dr. Bassett was asked by then Harlem. “She was really nice in her emails medicine and reliable epidemiologic New York City health commissioner Dr. and really open to help me contact those information; in fact she has contributed Thomas Frieden (who is now head of the people,” he says. extensively to the field” says Victor Centers for Disease Control and Preven- Dr. Bassett has several challenges ahead Puac-Polanco. “It elevates our hopes that in tion) to serve as deputy commissioner of as health commissioner, including pushing the near future if we are called upon to sup- health promotion and disease prevention. forward with Mayor Michael Bloomberg’s port and assist with a state health project, Students were impressed that Dr. Bas- controversial proposal to ban large size we will be collaborating with someone who sett could transition from researching sugary drinks in certain venues and helping will be open to listening.” infectious diseases in a low-income coun- to implement Mayor de Blasio’s Vision Zero Other students agreed that it is meaning- try to implementing policy to decrease program to eliminate pedestrian vehicle ful to see someone with a strong academic obesity prevalence and related non-com- crash deaths. background in such a high policy position. municable diseases like cardiovascular Students hope that despite these imme- “To get that political appointment, coming illness and diabetes under a mayor and diate demands, she will not shy away from from academia, coming from research, it’s health commissioners who made public tackling underlying causes of disease and just inspiring,” says González. “If you truly health improvements a high priority. pursuing a progressive agenda in line with want to work in public health, in programs, “She was part of many key decisions her past history. “Clearly the focus will shift in policy, and you’ve had a long trajectory in that led to the ban of trans fats in restau- to overcoming health disparities among academia and research, why not?” rants,” says second-year student Mila the underserved and marginalized of NYC, González. and Dr. Bassett is an ideal choice to steer González worked as an associate that ship,” says Michael Rosanoff, a sec- program officer when Dr. Bassett served ond-year student. on an Institute of Medicine committee Focusing on health disparities means that evaluated the President’s Emergency “improving the health outcomes for immi- Plan for AIDS relief, or PEPFAR, the U.S.’s grants without any legal rights, reducing multi-billion dollar aid program to treat the gap in health outcomes between black

26 Epidemiology and Population Health Summer Institute at Columbia University SUMMER 2014 JUNE 2 – JUNE 27

EPIC provides opportunities to gain foundational knowledge and applied skills for advancing population health research. Our short courses are offered in New York City and in online distance learning formats. cuepisummer.org Register before April 1, 2014 and receive up to 20% off your

CLASSROOM entire order Week-long courses are held on-campus in New York City

DIGITAL Courses are one month long, available anywhere in the world

SATURDAYS Epidemiology and Population Health Single-day workshops are held on-campus in New York City Summer Institute at Columbia University Conversations around public health, architecture, and cities Presented by the Urban/Health Program

RSVP CUESS.ORG APRIL 22, 2014

8:30 AM – 4:30 PM Studio X | 180 Varick Street symposium report

Explanation and prediction in population health Disciplines come together to discuss a unifying philosophy of causal inference

n the middle of the twentieth Because of resulting government regulation and public health campaigns, smoking and lung cancer both declined in the US. That story is an example of century, epidemiologic how understanding causation is at the heart of epidemiologic analysis. Because studies began to establish epidemiologists must study the health of populations in the absence of con- I trolled variables, they must often infer causes of health and illness. a statistically significant link The process of causal inference can be controversial. Critics have charged between smoking and lung that epidemiologic studies are not rigorous at it, that they too often contra- dict each or are contradicted by later clinical trials. However, the continuing cancer. Although scientists evolution of the field has led to breakthroughs in methodology that minimize did not know the mechanism uncertainty and produce ever more finely tuned findings that result from infer- ring a cause. This has led to vast improvements in public health that would not by which exposure to have been possible if scientists and policymakers had waited to make recom- tobacco smoke gave rise mendations until a cause was definitively established, such as in the cases of smoking or in other examples such as the link between diet, high cholesterol, to cancerous growth in the and heart disease. lungs, the correlation became Struggles with causal inference are not unique to epidemiology. Many other social sciences face the same difficulties. Recognizing this, the department brought increasingly overwhelming together researchers from across many disciplines for a CUESS in November on when assessed through a “Philosophy and medicine: Explanation and prediction in population health.” “[R]epresentatives of epidemiology, economy, psychology, and philosophy process known as causal may shed some light on what is needed to build a valid and philosophically inference. While tobacco sound inferential process in the social sciences in general and in epidemiology in particular,” said symposium organizers Dr. Alfredo Morabia, professor of epi- companies argued that the demiology at Columbia University, and Dr. Jeremy R. Simon, associate professor proof was not strong enough, of medicine at Columbia and scholar-in-residence at the Center for Bioethics. Speakers talked about what causal inference looks like in their particular epidemiologists and other field and how methods might be improved and generalized across disciplines— scientists believed taking or whether this is even possible. The event represented a rare instance of different disciplines discussing a action to reduce smoking path toward a common underlying philosophy of causal inference. Participants was necessary. acknowledged that establishing such a philosophy is not simple, given varying methods of causal inference in each discipline, such as systems models that can make predictions by accounting for complex and interwoven parts and “big data” sets that enable scientists to study large populations. As the CUESS con- cluded, participants and attendees were eager to keep the conversation going, The Columbia University aware of the opportunities this unique event presented. Epidemiology Scientific Symposium (CUESS) series brings the best minds in epidemiology and other disciplines together for a full day of discussions on the most pressing health questions of our time.

DEPARTMENT OF EPIDEMIOLOGY 29 in the news

The death of acclaimed actor Philip Seymour Hoffman is the “story of a life Philip Seymour abruptly cut short by addiction during his peak of creativity,” says Dr. Lloyd Sederer, medical director of the New York State Office of Mental Health and Hoffman’s death a adjunct professor of epidemiology at the Mailman School of Public Health. reminder of the toll The leading cause of preventable death in the U.S., there is “no one size fits of addiction all” approach to treating addiction, he adds.

PSYCHOLOGY TODAY http://bit.ly/1ea4RCb

There were more than 100 public health measures during Michael Bloomberg’s Mayor Bloomberg’s 12 years as mayor of New York City, according to a review of government data- bases by Dr. Ryan Demmer, assistant professor of epidemiology at Columbia public health legacy, University’s Mailman School of Public Health, and colleagues. Read more in by statistics Scientific American.

SCIENTIFIC AMERICAN http://bit.ly/1eHtHeQ

30 IN THE NEWS

A study by Dr. Myrna Weissman, professor of epidemiology and psychiatry Spirituality may protect at Columbia and chief of the division of epidemiology at New York State Psychiatric Institute, and colleagues has found an association between thick- against depression ness of the brain cortex, level of spirituality, and depression.

REUTERS HEALTH http://reut.rs/1lPOpLV

Post-traumatic stress disorder may be a cause of sizable weight gain in Significant weight-gain women, according to a study in JAMA Psychiatry that compared female participants with and without PTSD diagnoses over time. The paper was a side effect of PTSD? co-authored by Dr. Karestan Koenen, associate professor of epidemiology at the Mailman School, and Dr. Magdalena Cerdá, assistant professor of epidemiology at the Mailman School.

LA TIMES http://lat.ms/KEixPe

Deadly car crashes involving marijuana use rose sharply over the period Car crashes involving of 1999 to 2010. “Currently, one of nine drivers involved in fatal crashes would test positive for marijuana,” says Dr. Guohua Li, Finster Professor pot use tripled over of Epidemiology and Anesthesiology at Columbia, who authored the study 10 years with Mailman School epidemiology doctoral student Ms. Joanne Brady.

WEBMD http://bit.ly/1gbil3I

People with celiac disease lower their likelihood of bone damage if they stick Gluten-free diet to a gluten-free diet, according to a study by Dr. Benjamin Lebwohl, assistant professor of medicine and epidemiology at Columbia, and colleagues. Celiac may reduce fracture disease is an auto-immune response in the small intestine to the protein risk for people with gluten. Long-term intestinal damage increases the risk of hip fracture. celiac disease HEALTH DAY http://bit.ly/1f20dHr

Dr. Salim Abdool Karim, professor of clinical epidemiology at the Mailman Africa’s under- School and director of the Centre for the AIDS Programme of Research in South Africa, co-authors an article that points to the “troubling myths” appreciated about Africa that persist, such as that it can’t develop new medical vaccines. medical talent “The fact is globalization of research over the past few decades has seen the strengthening of international links and a steady flow of external investments for research that has enabled African countries to train highly qualified scien- tists and establish a research infrastructure,” the authors say.

BUSINESS DAY http://bit.ly/1ngEIqP

31 faculty publications DECEMBER 2013 – MARCH 2014

Abdool Karim SS. Retrospective. Nelson Ananth CV, Keyes KM, Wapner RJ. Modig L, Havulinna AS, Lanki T, Turunen pregnant women in a pilot programme, R. Mandela (1918-2013). Science. 2014 Pre-eclampsia rates in the United States, A, Oftedal B, Nystad W, Nafstad P, De Cape Town, South Africa. AIDS Care. 2013 Jan 10;343(6167):150. doi: 10.1126/ 1980-2010: age-period-cohort analysis. Faire U, Pedersen NL, Ostenson CG, Frati- Nov 7. [Epub ahead of print] science.1249822. BMJ. 2013 Nov 7;347:f6564. doi: 10.1136/ glioni L, Penell J, Korek M, Pershagen G, Boltz VF, Bao Y, Lockman S, Halvas EK, bmj.f6564. Eriksen KT, Overvad K, Ellermann T, Eeft- Abel KM, Heuvelman HP, Jörgensen L, Kearney MF, McIntyre JA, Schooley RT, ens M, Peeters PH, Meliefste K, Wang M, Magnusson C, Wicks S, Susser E, Hallkvist Angell SY, Yi S, Eisenhower D, Kerker Hughes MD, Coffin JM, Mellors JW; for Bueno-de-Mesquita B, Sugiri D, Krämer J, Dalman C. Severe bereavement stress BD, Curtis CJ, Bartley K, Silver LD, Farley the OCTANE/A5208 Team. Low-Frequency U, Heinrich J, de Hoogh K, Key T, Peters during the prenatal and childhood periods TA. Sodium Intake in a Cross-Sectional, Nevirapine (NVP)-Resistant HIV-1 Variants A, Hampel R, Concin H, Nagel G, Ineichen and risk of psychosis in later life: popula- Representative Sample of New York City Are Not Associated With Failure of Antiret- A, Schaffner E, Probst-Hensch N, Künzli tion based cohort study. BMJ. 2014 Jan Adults. Am J Public Health. 2014 Jan 16. roviral Therapy in Women Without Prior N, Schindler C, Schikowski T, Adam M, 21;348:f7679. doi: 10.1136/bmj.f7679. [Epub ahead of print] Exposure to Single-Dose NVP. J Infect Dis. Phuleria H, Vilier A, Clavel-Chapelon F, 2014 Jan 16. [Epub ahead of print] Ahsan H, Halpern J, Kibriya MG, Pierce Angermeyer MC, Matschinger H, Link BG, Declercq C, Grioni S, Krogh V, Tsai MY, BL, Tong L, Gamazon ER, McGuire V, Schomerus G. Public attitudes regarding Ricceri F, Sacerdote C, Galassi C, Migliore Borrell LN, Samuel L. Body Mass Index Felberg A, Shi J, Jasmine F, Roy S, individual and structural discrimination: E, Ranzi A, Cesaroni G, Badaloni C, Foras- Categories and Mortality Risk in US Paul-Brutus R, Argos M, Melkonian S, Two sides of the same coin?. Soc Sci tiere F, Tamayo I, Amiano P, Dorronsoro M, Adults: The Effect of Overweight and Chang-Claude J, Andrulis IL, Hopper JL, Med. 2014 Feb;103:60-6. doi: 10.1016/j. Katsoulis M, Trichopoulou A, Brunekreef Obesity on Advancing Death. Am J Public John EM, Malone KE, Ursin G, Gammon socscimed.2013.11.014. B, Hoek G. Effects of long-term exposure Health. 2014 Jan 16. [Epub ahead of print] MD, Thomas DC, Seminara D, Casey to air pollution on natural-cause mortality: Anthony SJ, Garner MM, Palminteri L, Brady JE, Li G. Trends in Alcohol and Other G, Knight JA, Southey MC, Giles GG, an analysis of 22 European cohorts within Navarrete-Macias I, Sanchez-Leon MD, Drugs Detected in Fatally Injured Drivers in Santella RM, Lee E, Conti DV, Duggan D, the multicentre ESCAPE project. Lancet. Briese T, Daszak P, Lipkin WI. West Nile the United States, 1999-2010. Am J Epide- Gallinger S, Haile RW, Jenkins MA, Lindor 2013 Dec 6. pii: S0140-6736(13)62158-3. Virus in the British Virgin Islands. Eco- miol. 2014 Jan 29. [Epub ahead of print] NM, Newcomb PA, Michailidou K, Apicella doi: 10.1016/S0140-6736(13)62158-3. [Epub health. 2014 Feb 7. [Epub ahead of print] C, Park DJ, Peto J, Fletcher O, Dos Santos ahead of print] Breuer E, Stoloff K, Myer L, Seedat S, Silva I, Lathrop M, Hunter DJ, Chanock SJ, Austin S, Murthy S, Wunsch H, Adhikari NK, Stein DJ, Joska JA. The Validity of the Begg MD, Galea S, Bayer R, Walker JR, Meindl A, Schmutzler RK, Muller-Myhsok Karir V, Rowan K, Jacob ST, Salluh J, Bozza Substance Abuse and Mental Illness Fried LP. MPH Education for the 21st Cen- B, Lochmann M, Beckmann M, Hein R, FA, Du B, An Y, Lee B, Wu F, Nguyen YL, Symptom Screener (SAMISS) in People tury: Design of Columbia University's New Makalic E, Schmidt DF, Bui QM, Stone J, Oppong C, Venkataraman R, Velayutham Living with HIV/AIDS in Primary HIV Care Public Health Curriculum. Am J Public Flesch-Janys D, Dahmen N, Nevanlinna V, Dueñas C, Angus DC; On behalf of the in Cape Town, South Africa. AIDS Behav. Health. 2013 Nov 14. [Epub ahead of print] H, Aittomäki K, Blomqvist C, Hall P, Czene International Forum of Acute Care Trialists. 2014 Jan 23. [Epub ahead of print] K, Irwanto A, Liu J, Rahman N, Turnbull Access to urban acute care services in high- Benitez BA, Jin SC, Guerreiro R, Graham Brown AS, Borgmann-Winter K, Hahn CG, C, Dunning AM, Pharoah PD, Waisfisz Q, vs. middle-income countries: an analysis of R, Lord J, Harold D, Sims R, Lambert Role L, Talmage D, Gur R, Chow J, Prado Meijers-Heijboer HE, Uitterlinden AG, seven cities. Intensive Care Med. 2013 Dec JC, Gibbs JR, Bras J, Sassi C, Harari O, P, McCloskey T, Bao Y, Bulinski JC, Dwork Rivadeneira F, Nicolae D, Easton DF, Cox 13. [Epub ahead of print] Bertelsen S, Lupton MK, Powell J, Bellen- AJ. Increased Stability of Microtubules in NJ, Whittermore AS. A Genome-wide guez C, Brown K, Medway C, Haddick PC, Balkus JE, Richardson BA, Rabe LK, Cultured Olfactory Neuroepithelial Cells Association Study of Early-onset Breast van der Brug MP, Bhangale T, Ortmann Taha TE, Mgodi N, Kasaro MP, Ramjee from Individuals with Schizophrenia. Prog Cancer Identifies PFKM as a Novel Breast W, Behrens T, Mayeux R, Pericak-Vance G, Hoffman IF, Abdool Karim SS. Neuropsychopharmacol Biol Psychiatry. Cancer Gene and Supports a Common MA, Farrer LA, Schellenberg GD, Haines Bacterial Vaginosis and the Risk of Tricho- 2013 Oct 24. pii: S0278-5846(13)00236-4. Genetic Spectrum for Breast Cancer at JL, Turton J, Braae A, Barber I, Fagan monas vaginalis Acquisition Among doi: 10.1016/j.pnpbp.2013.10.015. [Epub Any Age. Cancer Epidemiol Biomarkers AM1, Holtzman DM1, Morris JC1; The HIV-1-Negative Women. Sex Transm ahead of print] Prev. 2014 Feb 3. [Epub ahead of print] 3C Study Group, the EADI consortium, Dis. 2014 Feb;41(2):123-8. doi: 10.1097/ the Alzheimer's Disease Genetic Con- Broz D, Pham H, Spiller M, Wejnert C, Le Aleksandrova K, Boeing H, Nöthlings U, OLQ.0000000000000075. sortium (ADGC), Alzheimer's Disease B, Neaigus A, Paz-Bailey G. Prevalence of Jenab M, Fedirko V, Kaaks R, Lukanova A, Balneaves LG, Lee RT, Tomlinson Guns Neuroimaging Initiative (ADNI), the HIV Infection and Risk Behaviors Among Trichopoulou A, Trichopoulos D, Boffetta ES, Zick SM, Bauer-Wu S, Greenlee H. GERAD Consortium, Williams J, Kauwe Younger and Older Injecting Drug Users in P, Trepo E, Westhpal S, Duarte-Salles T, Tenth international conference of the JS, Amouyel P, Morgan K, Singleton A, the United States, 2009. AIDS Behav. 2013 Stepien M, Overvad K, Tjønneland A, society for integrative oncology trans- Hardy J, Goate AM, Cruchaga C. Missense Nov 16. [Epub ahead of print] Halkjaer J, Boutron-Ruault MC, Dossus lational science in integrative oncology: variant in TREML2 protects against Alz- L, Racine A, Lagiou P, Bamia C, Benetou Bruce RD, Winkle P, Custodio JM, Wei from bedside to bench to best practices. heimer's disease. Neurobiol Aging. 2013 V, Agnoli C, Palli D, Panico S, Tumino R, X, Rhee MS, Kearney BP, Ramanathan Integr Cancer Ther. 2014 Jan;13(1):5-11. Dec 21. pii: S0197-4580(13)00649-0. doi: Vineis P, Bueno-de-Mesquita B, Peeters S, Friedland GH. Investigation of the doi: 10.1177/1534735413517743. 10.1016/j.neurobiolaging.2013.12.010. PH, Gram IT, Lund E, Weiderpass E, Interactions between Methadone and [Epub ahead of print] Quirós JR, Agudo A, Sánchez MJ, Gavrila Banducci AN, Hoffman EM, Lejuez CW, Elvitegravir-Cobicistat in Subjects Receiv- D, Barricarte A, Dorronsoro M, Ohlsson Koenen KC. The impact of childhood Bergmann MM, Rehm J, Klipstein-Gro- ing Chronic Methadone Maintenance. B, Lindkvist B, Johansson A, Sund M, abuse on inpatient substance users: Spe- busch K, Boeing H, Schütze M, Drogan Antimicrob Agents Chemother. 2013 Khaw KT, Wareham N, Travis RC, Riboli E, cific links with risky sex, aggression, and D, Overvad K, Tjønneland A, Halkjær Dec;57(12):6154-7. doi: 10.1128/AAC.01229- Pischon T. Inflammatory and metabolic emotion dysregulation. Child Abuse Negl. J, Fagherazzi G, Boutron-Ruault MC, 13. Epub 2013 Sep 30. biomarkers and risk of liver and bilary 2014 Feb 9. pii: S0145-2134(13)00394-3. Clavel-Chapelon F, Teucher B, Kaaks R, Brunner R, Kaess M, Parzer P, Fischer G, tract cancer. Hepatology. 2014 Jan 17. doi: doi: 10.1016/j.chiabu.2013.12.007. [Epub Trichopoulou A, Benetou V, Trichopou- Carli V, Hoven CW, Wasserman C, Sar- 10.1002/hep.27016. [Epub ahead of print] ahead of print] los D, Palli D, Pala V, Tumino R, Vineis chiapone M, Resch F, Apter A, Balazs J, P, Beulens JW, Redondo ML, Duell EJ, An P, Miljkovic I, Thyagarajan B, Kraja AT, Bassett MT, Brudney K. Treating Our Way Barzilay S, Bobes J, Corcoran P, Cosmanm Molina-Montes E, Navarro C, Barricarte Daw EW, Pankow JS, Selvin E, Kao WH, Out of AIDS? Am J Public Health. 2013 Dec D, Haring C, Iosuec M, Kahn JP, Keeley H, A, Arriola L, Allen NE, Crowe FL, Khaw Maruthur NM, Nalls MA, Liu Y, Harris TB, 12. [Epub ahead of print] Meszaros G, Nemes B, Podlogar T, Postu- KT, Wareham N, Romaguera D, Wark PA, Lee JH, Borecki IB, Christensen K, Eckfeldt van V, Saiz PA, Sisask M, Tubiana A, Varnik Baumgartner JN, Burns JK. Measuring Romieu I, Nunes L, Riboli E, Ferrari P. The JH, Mayeux R, Perls TT, Newman AB, Prov- A, Wasserman D. Life-time prevalence social inclusion--a key outcome in global association of pattern of lifetime alcohol ince MA. Genome-wide association study and psychosocial correlates of adolescent mental health. Int J Epidemiol. 2013 Dec 4. use and cause of death in the European identifies common loci influencing circulat- direct self-injurious behavior: A compar- [Epub ahead of print] Prospective Investigation into Cancer and ing glycated hemoglobin (HbA1c) levels in ative study of findings in 11 European Nutrition (EPIC) study. Int J Epidemiol. 2013 non-diabetic subjects: The Long Life Family Baumgartner JN, da Silva TF, Valencia E, countries. J Child Psychol Psychiatry. Dec;42(6):1772-90. doi: 10.1093/ije/dyt154. Study (LLFS). Metabolism. 2013 Dec 4. Susser E. Measuring social integration in 2013 Nov 12. doi: 10.1111/jcpp.12166. [Epub pii: S0026-0495(13)00412-5. doi: 10.1016/j. a pilot randomized controlled trial of criti- Besser A, Zeigler-Hill V, Pincus AL, Neria ahead of print] metabol.2013.11.018. [Epub ahead of print] cal time: intervention-task shifting in Latin Y. Pathological narcissism and acute Calder PC, Deckelbaum RJ. Dietary fatty America. Cad Saude Colet. 2012 Jan;20(4). anxiety symptoms after trauma: a study of Ananth CV, Friedman AM. Late pregnancy acids in health and disease: greater doi: 10.1590/S1414-462X2012000400005. israeli civilians exposed to war. Psychia- use of selective serotonin reuptake inhib- controversy, greater interest. Curr Opin try. 2013 Winter;76(4):381-97. doi: 10.1521/ itors and serotonin and norepinephrine Beelen R, Raaschou-Nielsen O, Stafoggia Clin Nutr Metab Care. 2014 Jan 20. [Epub psyc.2013.76.4.381. reuptake inhibitors is associated with M, Andersen ZJ, Weinmayr G, Hoffmann ahead of print] increased risk of postpartum haemorrhage. B, Wolf K, Samoli E, Fischer P, Nieuwen- Black S, Zulliger R, Marcus R, Mark D, Callaghan B1, Choi H, Schlesinger M, Evid Based Nurs. 2013 Nov 28. doi: 10.1136/ huijsen M, Vineis P, Xun WW, Katsouyanni Myer L, Bekker LG. Acceptability and Rodemer W, Pollard J, Hesdorffer DC, eb-2013-101595. [Epub ahead of print] K, Dimakopoulou K, Oudin A, Forsberg B, challenges of rapid ART initiation among Hauser WA, French J. J Neurol Neurosurg

32 SPRING 2014 : ISSUE 5.01 Psychiatry. Increased mortality persists and meta-analysis in 11 European cohorts kynurenine pathway and lung cancer risk. Dal Pan G, Stern Y, Sano M, Mayeux R. in an adult drug-resistant epilepsy prev- from the ESCAPE Project. BMJ. 2014 Jan Cancer Epidemiol Biomarkers Prev. 2013 Clock-drawing in neurological disorders. alence cohort. 2014 Feb 19. doi: 10.1136/ 21;348:f7412. doi: 10.1136/bmj.f7412. Dec 19. [Epub ahead of print] Behav Neurol. 1989;2(1):39-48. doi: jnnp-2013-307074. [Epub ahead of print] 10.3233/BEN-1989-2104. Chadeau-Hyam M, Tubert-Bitter P, Gui- Chudal R, Gissler M, Sucksdorff D, Lehti Canetta SE, Bao Y, Co MD, Ennis FA, henneuc-Jouyaux C, Campanella G, V, Suominen A, Hinkka-Yli-Salomäki S, Davis LK, Yu D, Keenan CL, Gamazon ER, Cruz J, Terajima M, Shen L, Kellendonk Richardson S, Vermeulen R, De Iorio M, Brown AS, Sourander A Bipolar Disord. Konkashbaev AI, Derks EM, Neale BM, C, Schaefer CA, Brown AS. Serological Galea S, Vineis P. Dynamics of the Risk Parental age and the risk of bipolar disor- Yang J, Lee SH, Evans P, Barr CL, Bellodi Documentation of Maternal Influenza of Smoking-Induced Lung Cancer: A ders. 2014 Feb 6. doi: 10.1111/bdi.12182. L, Benarroch F, Berrio GB, Bienvenu OJ, Exposure and Bipolar Disorder in Adult Compartmental Hidden Markov Model for [Epub ahead of print] Bloch MH, Blom RM, Bruun RD, Budman Offspring. Am J Psychiatry. 2014 Jan 31. Longitudinal Analysis. Epidemiology. 2013 CL, Camarena B, Campbell D, Cappi C, Chudal R, Sourander A, Polo-Kantola P, doi: 10.1176/appi.ajp.2013.13070943. [Epub Nov 14. [Epub ahead of print] Cardona Silgado JC, Cath DC, Cavallini Hinkka-Yli-Salomäki S, Lehti V, Sucks- ahead of print] MC, Chavira DA, Chouinard S, Conti DV, Chang SC, Glymour MM, Rewak M, Cor- dorff D, Gissler M, Brown AS. Perinatal Cook EH, Coric V, Cullen BA, Deforce D, Carli V, Hoven CW, Wasserman C, Chiesa F, nelis MC, Walter S, Koenen KC, Kawachi factors and the risk of bipolar disorder in Delorme R, Dion Y, Edlund CK, Egberts Guffanti G, Sarchiapone M, Apter A, Balazs I, Liang L, Tchetgen Tchetgen EJ, Kubzan- Finland. J Affect Disord. 2013 Oct 26. pii: K, Falkai P, Fernandez TV, Gallagher PJ, J, Brunner R, Corcoran P, Cosman D, Haring sky LD. Are genetic variations in OXTR, S0165-0327(13)00768-4. doi: 10.1016/j. Garrido H, Geller D, Girard SL, Grabe HJ, C, Iosue M, Kaess M, Kahn JP, Keeley H, AVPR1A, and CD38 genes important to jad.2013.10.026. [Epub ahead of print] Grados MA, Greenberg BD, Gross-Tsur V, Postuvan V, Saiz P, Varnik A, Wasserman social integration? Results from two large Ciaranello A, Lu Z, Ayaya S, Losina E, Haddad S, Heiman GA, Hemmings SM, D. A newly identified group of adolescents U.S. cohorts. Psychoneuroendocrinology. 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DEPARTMENT OF EPIDEMIOLOGY 33 Ayurvedic and Modern Medical Perspec- Association of Prenatal Participation in Marker After Lacunar Stroke: Levels of Farber HJ, Avila PC, Brigino-Buenaven- tives on Cancer: Results of a Qualitative a Public Health Nutrition Program With Inflammatory Markers in the Treatment of tura E, Lenoir MA, Meade K, Serebrisky Study. J Altern Complement Med. 2013 Healthy Infant Weight Gain Am J Public Stroke Study. Stroke. 2014 Feb 12. [Epub D, Borrell LN, Rodríguez-Cintrón W, Dec 17. [Epub ahead of print] Health. 2013 Dec 19. [Epub ahead of print] ahead of print] Estrada AM, Mendoza KS, Winkler CA, Klitz W, Romieu I, London SJ, Gilliland Diamond JM, Akimova T, Kazi A, Shah RJ, Ekamper P, van Poppel F, Stein AD, Lumey Elliott JC, Aharonovich E, O'Leary A, F, Martinez F, Bustamante C, Williams Cantu E, Feng R, Levine MH, Kawut SM, LH. Independent and additive association Wainberg M, Hasin DS. 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