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