spring 2014 - Mailman School of Public Health

SPRING 2014FROM THE DEPARTMENT OF EPIDEMIOLOGYMAILMAN SCHOOL OF PUBLIC HEALTH – COLUMBIA UNIVERSITY

i ssue 5.01

consequent ia l is t ep idemio logy

big push in i t ia t ives in g lobal hea l th

nyc’s new heal th commiss ioner

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.

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

1DEPARTMENT OF EPIDEMIOLOGY

CONTENTS

Publication highlights

FEATURES

Bringing ‘consequentialism’ back to epidemiology

Big push initiatives in global health

How cities affect urban health

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

Symposium report: Explanation and prediction in population health

In the news

Faculty publications

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8

14

21

25

29

30

32

2

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,

chair’s message


publication highlights

C lose relatives of people with

epilepsy are at a greater risk

of developing the disorder

compared to the general population,

according to a new study led by Dr.

Ruth Ottman, professor of epidemiol-

ogy (in Neurology and the Gertrude

H. Sergievsky Center) at Columbia

University, with co-author Dr. W.

Allen Hauser, professor emeritus of

epidemiology at CUMC, and other col-

leagues from Columbia’s department

of neurology, the Mayo Clinic, and the

University of Calgary.

Although this group is not the first

to find that risk for epilepsy runs in

families, past studies had potentially

serious methodological limitations

according to the paper, which will run

in the March issue of the journal Brain.

The researchers analyzed data from

the Rochester Epidemiology Project,

a partnership of three medical centers

in Minnesota, which allows all records

of medical care received by patients

residing in the area it covers to be

used for population studies.

The researchers studied the fam-

ilies of 660 residents of Rochester,

Minnesota, with new cases of epilepsy

occurring during a 60-year period—

from 1935-1994. Among the nearly

2,500 parents, siblings, and children

of these individuals, the risk of devel-

oping epilepsy by age 40 was 4.7

percent—three times that of the gen-

eral population.

Those at highest risk were

relatives of individuals with idiopathic

generalized epilepsy, which, though

its origins are uncertain, is believed

to have a strong genetic basis. Also

at greater risk were relatives of

individuals who have types of epilepsy

associated with intellectual or motor

disability that are likely related to

prenatal or developmental problems.

Epilepsies of unknown cause and

of prenatal/developmental cause

clustered within families, suggesting

shared genetic influences.

New evidence for genetic basis of epilepsy

IMAGE: ARTHUR TOGA, UNIVERSITY OF

CALIFORNIA AT LOS ANGELES VIA THE NATIONAL

INSTITUTE OF GENERAL MEDICAL SCIENCES

the2x2project.org

2x2.ph/1koJ3Iv

The family members of individuals

whose epilepsy had a known cause

occurring after birth, such as a stroke,

severe traumatic brain injury, or brain

tumor were not at increased risk.

Epilepsy is characterized by recur-

rent seizures caused by abnormal

electrical discharges in the brain.

Approximately 1.3 percent of individ-

uals will develop epilepsy by age 40,

and 3 percent will develop it before

age 80. While epilepsy cannot be

cured, seizures can be controlled with

medication in about two-thirds of

affected individuals.

It is believed that genetics are

involved in the majority of cases,

although how exactly the disorder

comes about is complicated, involving

interplay among the environment and

multiple genes.

“One of the most important

concerns of people with epilepsy

is whether the disorder is inherit-

ed--what are the risks in their family

members, and especially in their off-

spring?” says Dr. Ottman.

Although genetic research is

moving quickly, in most individuals

with epilepsy, the specific genes that

affect risk of the disorder have not

been identified.

“That means we need to rely on

solid risk estimates from rigorous

studies like this one to obtain answers

about risks to family members,” Dr.

Ottman says. “One thing that’s import-

ant about our findings is that people

with epilepsy tend to overestimate

the risk in their children, and we found

that risks in offspring are only about

4 percent overall, and are less than

10 percent even in the highest risk

groups—so that even though risk is

higher than in the general population,

more than 90 percent of the offspring

will remain unaffected.”

Peljto AL, Barker-Cummings C, Vasoli VM,

Leibson CL, Hauser WA, Buchhalter JR,

Ottman R. Familial risk of epilepsy: a popula-

tion-based study. Brain. 2014 Jan 26. [Epub

ahead of print] PMID: 24468822

http://2x2.ph/1koJ3Iv

4 SPRING 2014 : ISSUE 5.01

PUBLICATION HIGHLIGHTS

M edical professionals should

take note of a recent study

that reported a significant

association between the use of antide-

pressants during pregnancy and the

risk of hemorrhage after giving birth,

two Columbia University Medical

Center researchers said in an editorial

in the late November issue of the BMJ

group journal Evidenced-Based Nurs-

ing. Use of antidepressants has not

been commonly recognized as a risk

factor for abnormal bleeding during

pregnancy or childbirth.

“The findings from this study add

considerably to limited prior research

on this subject, which has found

similar associations despite method-

ological shortcomings,” write Drs.

Cande Ananth, professor of epidemi-

ology and obstetrics and gynecology,

and Dr. Alexander M. Friedman, pro-

fessor of obstetrics and gynecology.

“The magnitude of increased hem-

orrhage risk in relation to serotonin

exposure demonstrated in this study is

clinically relevant.”

The study at issue, which was

published in BMJ in August by epi-

demiologists at Harvard’s School of

Public Health, adds to a growing body

of research that has connected the

popular class of antidepressants known

as SSRIs (selective serotonin re-uptake

inhibitors) to hemorrhage, as well as

excessive bleeding in the gastrointesti-

nal system and during surgery.

Hemorrhage during delivery is

one of the leading causes of maternal

death in the United States. It has been

on the rise in the U.S. and several other

developed countries since the 1990s,

despite no change in the frequency of

multiple pregnancies or induction of

labor, which are established risk fac-

tors for postpartum hemorrhage.

The Harvard study looked at seven

years of Medicaid data on 106,000

low-income women who were preg-

nant and had a diagnosis of mood or

anxiety disorder, comparing those who

had been prescribed antidepressant

medication against those who had not.

Risk for postpartum hemorrhage

Antidepressant use associated with risk of hemorrhage after pregnancy

the2x2project.org

2x2.ph/1gF54Ao

was greatest (4 percent) for women on

SSRIs compared with 3.8 percent for

women using anti-depressants that

were not SSRIs and 2.8 percent for

women who were not on medication.

These are significant enough

numbers for medical professionals

to take notice, wrote Drs. Ananth

and Friedman: “While the benefits of

antidepressants may outweigh the rel-

atively small attributable maternal and

neonatal risks for many women, clini-

cians should be aware of a modestly

increased risk for this serious adverse

obstetric outcome.”

More evidence is needed to estab-

lish whether antidepressants directly

cause hemorrhage, they say. Research

has suggested that SSRIs might

deplete serotonin that is stored in

platelets, which are cells in blood that

reduce bleeding. Yet a 2008 study by

scientists at the University of Toronto

found that SSRIs do not put women

at greater risk of postpartum hemor-

rhage than non-SSRI antidepressants.

Comparisons of risk between SSRI and

non-SSRI antidepressants are gener-

ally limited by the relatively infrequent

use of drugs in the non-SSRI class

during pregnancy.

Celexa, Lexapro, Prozac, Paxil, and

Zoloft, and their generic versions are

all popularly-prescribed SSRIs. These

drugs are commonly used to treat psy-

chiatric problems such as anxiety and

depression that may occur during or

predate a women’s pregnancy.

Rates of maternal mortality and

severe morbidity are high in the U.S.

compared to other rich countries, and

findings from this study may help

clinicians anticipate increased risk in a

specific subset of patients.

Ananth CV, Friedman AM. Late pregnancy

use of selective serotonin reuptake inhibitors

and serotonin and norepinephrine reuptake

inhibitors is associated with increased risk of

postpartum haemorrhage. Evid Based Nurs.

2013 Nov 28. doi: 10.1136/eb-2013-101595.

[Epub ahead of print] PMID: 24288247

http://2x2.ph/1gF54Ao



A lthough their attitudes are

more positive than the general

public, a significant number

of mental health professionals would

be unwilling to live near or work

with someone who has an untreated

psychiatric disorder, especially schizo-

phrenia, according to a new study in

the journal Psychiatric Services.

“How people with mental disorders

are viewed by treatment providers and

the general public can have a signif-

icant impact on treatment outcomes

and the quality of life of clients,”

writes Dr. Bruce Link, professor of

epidemiology and sociomedical sci-

ences at Columbia’s Mailman School

of Public Health, with co-author Dr.

Jennifer Stuber and her team at the

University of Washington.

The researchers compared the

survey responses of a representative

sample of 731 providers of mental

health services, including psychia-

trists, therapists and psychologists,

case managers, psychiatric nurses,

program directors and managers, with

a general population sample of 770.

The mental health providers were

recruited from community mental

health agencies in Washington State

and were demographically represen-

tative of the national mental health

workforce. The general population

sample came from the General Social

Survey, an in-person survey that is

widely used for its extensive data

on Americans’ attitudes about a vari-

ety of subjects.

Both groups were presented with

vignettes that described people with

untreated depression and schizo-

phrenia without being told of their

diagnosis. The groups were asked how

they would respond if these people

lived next door, worked closely with

them, married into their family, or lived

in a nearby group home.

Both providers and the general

population had more positive attitudes

toward those with depression com-

pared to those with schizophrenia,

who they sometimes viewed as poten-

tially violent.

Over a third of the providers said

they would be unwilling to have an

individual with schizophrenia as a

coworker, and about one-third said this

individual was likely to use violence

toward others.

Negative perceptions toward

disorders that involve psychosis has

increased with rising news coverage

of mass shootings implicating people

with mental illness, according to the

authors, even though such illness is

almost never the only reason for this

violence.

Older, male mental health pro-

fessionals were more likely to view

people in the depression and schizo-

phrenia vignettes as less competent,

compared to younger, female profes-

sionals. Providers with more advanced

degrees held more positive attitudes

than those with less education.

So did those who had been profes-

sionally active for longer, or had been

diagnosed with a mental illness (32

percent of the sample).

Among the general population

sample, older people and women were

more likely to have positive attitudes

than younger people and men.

“People with mental illnesses

often ask me whether I have studied

stigmatizing responses of mental

health providers. They say that the

experience of negative attitudes from

providers is particularly troublesome

to them because it occurs in the

place where they go to get help for

such problems,” says Dr. Link. “I can

now answer that we have done such

a study and can use the results to

advocate for interventions that might

improve attitudes and thereby the

treatment experience of people who

seek help.”

Stuber JP, Rocha A, Christian A, Link BG.

Conceptions of Mental Illness: Attitudes of

Mental Health Professionals and the Gen-

eral Public. Psychiatr Serv. 2014 Jan 15. doi:

10.1176/appi.ps.201300136. [Epub ahead of

print] PMID: 24430508

Mental health professionals hold stereotypes of those with psychiatric illness

the2x2project.org

2x2.ph/1kB8TMs

http://2x2.ph/1kB8TMs



N elson Rolihlahla Mandela was a

lawyer, protester, revolutionary,

anti-apartheid leader, prisoner,

negotiator, president, statesman, anti-

AIDS campaigner, and philanthropist,

says Dr. Salim Abdool Karim, pro-

fessor of clinical epidemiology at the

Mailman School of Public Health and

director of the Centre for the AIDS Pro-

gramme of Research in South Africa,

in a tribute published in Science maga-

zine in January.

Although as president of South

Africa, Mandela’s top priority was

bringing together a nation torn by

apartheid, he made invaluable contri-

butions toward the fight against AIDS

both during and in the years after his

presidency.

When Mandela took office in 1994,

7.6 percent of the population and 1 in

13 pregnant women were HIV positive.

To reduce rates of HIV in pregnant

mothers and newborns, Mandela

declared these groups should have

free health care. He also appointed a

leading local AIDS scientist to direct a

national AIDS program. As a personal

project, in 1995 he founded the Nelson

Mandela Children’s Fund to support

community programs working to pre-

vent mother-to-child-transmission and

to care for children orphaned by AIDS.

Despite these efforts, AIDS was only

one of many priorities of his govern-

ment and as a result did not receive

the amount of attention Mandela

knew it deserved. By the time he left

office in 1999, 1 in 4 pregnant women

was HIV positive. Unfortunately, his

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

a household survey to gauge the AIDS’

impact upon South Africa. In 2000,

he spoke at the 13th International

AIDS Conference, his most important

contribution as an anti-AIDS activist,

according to Dr Abdool Karim. There,

Mandela told the audience that South

Africa and the world should make

AIDS treatment accessible to all. His

speech received 17 standing ovations.

In the foreword for the book HIV/

AIDS in South Africa, coedited with

Dr. Abdool Karim, Mandela acknowl-

edged the delicate gender politics and

damaging social attitudes holding

back prevention, testing and AIDS

treatment efforts, stating, “we will

not succeed until we appreciate the

gender dimension of vulnerability to

HIV” and “until we have addressed

the stigmatization and discrimina-

tion.” He fought stigma around the

disease, announcing in 2005 that his

son had died of AIDS and by wearing

and posing for pictures in a Treat-

ment Action Campaign “HIV Positive”

t-shirt.

In the words of Dr. Abdool Karim,

Mandela’s “long walk was the first

step toward freedom from oppression,

freedom from want, and freedom from

disease. With his passing, his legacy is

in each of us as we follow in his foot-

steps in the enduring quest to make

our world a better place for all.”

Abdool Karim SS. Retrospective. Nelson

R. Mandela (1918-2013). Science. 2014

Jan 10; 343(6167): 150. doi: 10.1126/sci-

ence.1249822. https://www.sciencemag.org/

content/343/6167/150.full

Nelson Mandela and AIDS

IMAGE: DANIEL BEREHULAK

BY RACHEL KITCHENOFF, MPH ‘15



S cientists are proposing a new

approach to treating schizo-

phrenia, one which would

draw on research that connects the

psychiatric condition with early life

exposures to infection.

In an article in the February issue

of the journal Biological Psychiatry,

Dr. Alan S. Brown, professor of

epidemiology at Columbia, with

Columbia colleagues Dr. Ragy Girgis,

assistant professor of psychiatry,

and Samhita S. Kumar, an MPH

student in epidemiology, propose

running a clinical trial of a biological

immunotherapy that would target the

brain’s inflammatory response.

A chronic and debilitating disorder

of the brain, schizophrenia is one of

the most difficult psychiatric illnesses

to treat. Often emerging in the late

teen years or early twenties, it can

cause hallucinations, delusions,

disordered thinking, unusual speech

or behavior, and social withdrawal.

Individuals with schizophrenia are

often stigmatized as violent, even

though only a small number act out.

The only current medication treat-

ment for schizophrenia is a class of

medications known as “antipsychot-

ics.” These drugs are usually only

partially effective and can cause side

effects such as metabolic syndrome,

tremor, and sedation.

The treatment proposed by the

authors is based on the “cytokine

model” of schizophrenia.

This model hypothesizes that

schizophrenia arises from prenatal or

early childhood exposure to infection,

which leads to chronic peripheral

nervous system inflammation in

adulthood.

Cytokines are a group of proteins

that are important in immune and

inflammatory responses and to the

development of the nervous system.

They are produced in increased num-

bers when exposed to infections. If a

woman experiences certain viral or

bacterial infections during pregnancy,

her cytokines may transmit immune

and inflammatory signals to the devel-

oping prenatal brain, studies suggest.

Novel schizophrenia treatment draws on early infection theory

Dr. Brown and colleagues have pre-

viously shown in large birth cohorts

that elevations in prenatal serum cyto-

kines measured over time and several

in utero infections are associated with

schizophrenia.

The authors suggest a novel clinical

trial to test a medication with an anti-

body that can neutralize IL-6 proteins

by binding to their receptors. One such

drug is called tocilizumab, which has

been approved by the Food and Drug

Administration for rheumatoid arthritis

in patients who haven’t responded to

other therapies.

The authors say they only know

of one study in which a “cytokine

antagonist” has been used to treat

a psychiatric disorder. In this trial,

patients diagnosed with depression

who took infliximab, an antibody

that neutralizes a different cyto-

kine protein, and who had elevated

inflammatory biomarkers initially, sig-

nificantly improved after 12 weeks.

Since publishing the study, Dr.

Brown and Dr. Girgis have begun a

trial of tocilizumab, which is under-

written with a grant from the Stanley

Foundation.

“If the medication is successful,

and is replicated by other investiga-

tors, the study has the promise of a

novel approach to treating schizophre-

nia by reversing a key component of

its putative pathophysiology,” says

Dr. Brown, adding that the medication

may be most effective in patients with

evidence of systemic inflammation.

“Moreover, the study provides a

more robust test of the cytokine model

of schizophrenia, since it is based on

a randomized controlled design, in

contrast to previous studies of cyto-

kines in schizophrenia, which were

observational and therefore subject to

confounding.”

Girgis RR, Kumar SS, Brown AS. The cyto-

kine model of schizophrenia: emerging

therapeutic strategies. Biol Psychiatry.

2014 Feb 15;75(4):292-9. doi: 10.1016/j.bio-

psych.2013.12.002. Epub 2013 Dec 11. PMID:

24439555

8

Bringing ‘consequentialism’ back to epidemiologyIn a challenging funding environment, epidemiologists urge more action

BY ELAINE MEYER


But in July the Framingham website

announced a 40 percent cut to the $9

million budget contract with the National

Institutes of Health’s National Heart, Lung

and Blood Institute (NHLBI), which sup-

ports the study’s core operations. The

cuts are not only a blow for Framingham

but indicative of a more worrying trend,

according to some observers.

“[NHLBI] is dramatically reducing its

support for the large cohort studies that are

ongoing because they are very expensive,”

says Dr. Lewis Kuller, a cardiovascular

epidemiologist at the University of Pitts-

burgh Graduate School of Public Health.

“However they generate a huge amount of

valuable data, so you might say on a value

basis they are not expensive, and they’re

certainly not more expensive than the

amount of funding that goes into what you

might say is basic research.”

A field that is devoted to scientifically

studying the distribution, cause, and

effects of disease and injuries, epidemio-

logic discovery has motivated public health

campaigns and policy changes that have

led to longer life spans across the globe,

such as anti-smoking regulations, seatbelt

laws and speed limits, water treatment,

vaccines against infectious diseases, sex

education, and folate supplementation in

water to prevent birth defects.

Despite those “big wins” of the past,

some epidemiologists are concerned that

because their field hasn’t achieved compa-

rable public health improvements in the last

decade, it will have difficulty weathering

the current financial climate. “Implicit in

pressures [from large funders] is a growing

dissatisfaction outside the field of epidemi-

ology with epidemiologic description and

correlation and a sense that our current

approaches are not leading to ‘wins,’ to prac-

tical solutions to diseases and challenges to

health, or to science that is more saliently

useful to decision makers with a responsi-

bility to the health of the public,” says Dr.

Sandro Galea, chair of the department of

epidemiology at Columbia University’s Mail-

man School of Public Health.

On top of this, a few critics have argued

that the observational cohort studies com-

monly used in epidemiology are “lead[ing]

the public astray,” as Drs Paul Sorlie and

Gina S. Wei put it in a 2011 article that itself

is sympathetic to the use of such studies.

The critics compare observational research

of risk factors unfavorably to the methods

of randomized controlled trials that are

commonly used in drug studies. “While

the tools of epidemiology—comparisons of

populations with and without a disease—

have proved effective over the centuries

in establishing that a disease like cholera

is caused by contaminated water, as the

British physician John Snow demonstrated

in the 1850s, it’s a much more compli-

cated endeavor when those same tools

are employed to elucidate the more subtle

causes of chronic disease,” writes one of

the most vocal critics, science journalist

Gary Taubes, in the New York Times in 2007.

While this is a controversial view among

epidemiologists, some still believe their

field needs to re-assert its relevance. “I think

over time, a lot of epidemiology has become

data analysis and data dredging and highly

sophisticated statistical modeling but

without any emphasis on the application of

epidemiology on public health and preven-

tive medicine,” says Dr. Kuller.

‘Consequentialist epidemiology’

In June, Dr. Galea stood before a hotel

ballroom filled with his peers to give the

annual outgoing president’s speech at the

Society for Epidemiologic Research (SER)

meeting in Boston.

“We are seeing a gross failure in our

improving the health of populations,” he

said. Epidemiology risks being shunted

aside if its practitioners do not use it for

“consequentialist” purposes. “Academic

epidemiology now spends most of its time

concerned with identifying the causes

and distributions of disease in human

population, and far less of its time and

imagination asking how we might improve

health,” Dr. Galea wrote in a follow-up

article published in September in the Amer-

ican Journal of Epidemiology.

Reviewing articles in the four leading

epidemiology journals, Dr. Galea and

his colleagues found that over 85 per-

cent focused on causality or etiology of

a disease “with little particular attention

to how that etiology may be relevant to

intervention.” The 14 leading epidemiology

textbooks “devote[d] the overwhelming

majority of their content to educating the

reader about how we may identify causes

and distribution of disease.”

The large and long-enduring Framingham Heart

Study is known as one of the success stories of epidemiology. The Washington Post in 2000 named it a top ten medical accomplishment of the 20th century. Data the study has gathered through its regular and detailed physical examinations of over 15,000 participants since 1948 have led to a number of breakthroughs that are credited with dramatically reducing deaths from heart disease.


“Our focus on causal thinking at the

expense of pragmatic thinking is not cost

free, and runs the risk of marginalizing us

as a discipline,” he says, citing as examples

journal articles that focus on “illicit drug

use and cognitive function in the mid-adult

years” and “the relationship between pre-

mature birth and age at onset of puberty.”

Epidemiology needs “a demanding, rigor-

ous approach that focuses us ruthlessly on

our outcomes—rather than our approaches

and methods,” he continues.

One example of where epidemiology

could be more focused on outcomes is

on the issue of gun violence. 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.

“This approach would have epi-

demiology leading the way on both

implementation science and on translation

of population health science, when, in

actuality, we are at best involved in these

emerging movements on the margins.”

Dr. Galea is not the first to express

these concerns. In 1967, the president of

the American Public Health Association

(APHA), Dr. Milton Terris told attendees

at the organization’s annual meeting that:

“Public health problems, whether new or

old, are essentially social in character and

can only be solved in terms of social policy.

“The task of public health workers is to

convince society to undertake the specific

social measures, governmental or other,

which are required to solve specific health

problems, and to participate in the imple-

mentation of these policies,” said Dr. Terris,

who was known as an outspoken advocate

for a progressive public health policy.

At another APHA annual meeting, in

1983, Dr. William Foege made his own call

for a consequential epidemiology. In his

talk, he said that epidemiologists should

not shy away from political involvement.

“[Epidemiology] is a tool to change the

world, not merely to study the world,” said

Dr. Foege, whose own consequentialist

resume included working on the 1970s

campaign that eradicated small pox and

directing the U.S. Centers for Disease Con-

trol and Prevention (CDC).

Eleven years later, as president of SER,

Dr. John Snow’s map of cholera cases

in London. The map has been colorized

to enhance the mapping of deaths

depicted by bars running perpendicular

to streets. After mapping the area’s

13 public wells, Dr. Snow noted the

spatial clustering of cases around one

particular water pump on the southwest

corner of the intersection of Broad (now

Broadwick) Street and Cambridge (now

Lexington) Street.


Based on the deaths and a water sample

from the Broad Street source, he became

convinced that cholera was transmitted

not through the atmosphere—the popular

theory of the time—but through contam-

inated water. He took this theory to the

local government parish, prevailing on

authorities to remove the Broad Street

pump handle so it could no longer be used

as a water source. Although Dr. Snow did

not have complete information to prove his

theory, cholera stopped spreading soon

after. (It would take many more years for

health authorities to embrace water and

sewage treatment).

Dr. Snow’s decision to act for the public

good based on the imperfect information

he had is what epidemiology of the best

kind looks like, say consequentialists. “It is

unlikely that John Snow would be revered

in public health if he had merely studied

cholera,” says senior vice president of

the Robert Wood Johnson Foundation

Dr. James S. Marks in a 2009 article in the

journal Preventing Chronic Disease. “Our

heroes have been tied to action.”

Worries in a time of austerity

Epidemiologists admit that whether or not

the field can adapt, the funding climate is

one of the worst in recent memory.

The 2013 budget sequester forced the

CDC to slash 5 percent of its $285 billion

budget for 2013, which will reduce global

efforts to eliminate malaria, polio, and

other infectious diseases and cuts to pre-

vention programs for HIV, cancer, heart

attack, and stroke.

The sequester also cut 5 percent or

about $1.6 billion of the $30 billion budget

for the NIH, which is now funding only 15

percent of grant applications, a decline

from about 30 percent from nearly a

decade go. Going forward, the NIH’s

Dr. Willard Cates reinvigorated the call

for a consequential epidemiology, telling

his peers to “seize the day of impending

healthcare reform.”

He saw in the field the same problems

as Dr. Galea describes today. “The bulk of

our research efforts identified risk factors

but rarely affected public health actions.

We were told that epidemiologists tended

to ‘torture’ our data until some—frequently

obscured—associations were found,”

recalls Dr. Cates, who is currently presi-

dent of Family Health International and an

adjunct professor at University of North

Carolina-Chapel Hill, Emory University, and

University of Michigan School of Public

Health, in a response to Dr. Galea’s article.

Those who talk about a consequential

epidemiology don’t see it as a departure

but rather as a return to the field’s roots.

These roots are embodied by the story of

Dr. John Snow. An anesthesiologist living

in nineteenth century London, Dr. Snow

began monitoring cases of a deadly chol-

era outbreak in 1854. He found that nearly

everyone who had died lived near a water

pump on Broad Street in the city’s Soho

neighborhood.

budget is slated to shrink by 8.2 percent

annually.

“I’m very worried about the effect of

cuts. I think it will change the nature of

epidemiologic research. Epidemiology has

been able to build itself up as its own disci-

pline because we have been able to get large

grants to fund our work,” says Dr. Galea.

Dr. Michael Lauer, director of the divi-

sion of cardiovascular science at NHLBI, is

more optimistic. “Look at [the budget cuts]

as an opportunity to do things in ways that

are bigger and better and more effective

than what we’ve ever done before,” he says.

“When resources become scare, people

become resourceful. There are a lot of excit-

ing developments that are happening that

should make it possible for epidemiology to

not only stay relevant but to actually grow to

much higher levels than we’ve ever seen.”

In fact, some epidemiologists have been

concerned about the future of the NHLBI,

which funds many notable epidemiology

cohort studies. NHLBI last year suspended

Framingham’s regular exams, which its

principal investigator has called “the life-

blood of the study,” and future exams in

the Multi-Ethnic Study of Atherosclerosis

cohort (MESA), a medical research study

involving more than 6,800 men and women

from six communities in the United States.

Patient health information will, however, be

collected by phone or mail.

“We cut exams to allow us time to

engage in longer term strategic planning

in the setting of ever decreasing budgets,”

says Dr. Lauer, adding that the NHLBI’s

buying power is 30 percent lower than

it was ten years ago because of flat or

decreasing budgets and inflation.

“As part of being careful stewards of

public monies, we see a need to carefully

review all long-term, higher-cost projects,”

he adds, noting this is not the first time

“The bulk of our research efforts identified risk factors but rarely affected public health actions,” says Dr. Cates.


in its history that NHLBI has suspended

exams. “In this era of big data and small

budgets, we need to think about how we

realign our strategies in order to maximize

what we get out of the dollars we receive.”

Yet some experts believe that the data

from contemporary cohort studies still

provide the most thorough and up-to-date

picture of the changing risk factors and

prevalence of chronic diseases in the U.S.

Cohorts have shifted focus to study not just

cardiovascular events—which have been

on the decline for several decades—but

contemporary problems like rising rates of

diabetes, obesity, and lung disease using

state-of-the art technologies, says Dr. R.

Graham Barr, an associate professor of

epidemiology and medicine at Columbia

University’s College of Physicians and

Surgeons who studies respiratory illness

using MESA data.

“The ability to use novel imaging

approaches in these cohorts allows us to

start to re-define the disease for clinical

purposes,” he adds. “MESA, for example,

has the longest longitudinal follow-up of

measures of emphysema on computed

tomography of any study.”

The infrastructure of the cohorts has

also allowed rapid responses to new public

health concerns, such as acquiring data on

e-cigarette use, says Dr. Barr.

Even before the cuts, some observers

believed that epidemiology was already

losing influence at the NIH to biological

sciences like genetic and molecular biology

and neurology.

“I don’t think it gets the same kind

of respect as some of the most basic sci-

ences, and there are some reasons for that.

It seems to many a little bit more subjec-

tive. Rarely are there randomized trials,”

says Dr. Marks.

“Because epidemiology is ultimately

population level findings, it has been deval-

ued in the eyes of NIH, and it has devalued

the extent to which epidemiologic findings

are useful, particularly as NIH has become

more interested in translation of its find-

ings to clinical cures,” says Dr. Galea.

Epidemiologists point out that such

clinical cures can be expensive and can

take years or decades to become available

to the general public, while preventive

approaches that often come about because

of epidemiologic research—such as

awareness campaigns, regulations, and

improving access to health care—can be

implemented sooner. “Epidemiology is a

crucial part of the way that case is made

for the public and policy makers. We can’t

afford to treat ourselves out of our health

crisis. We can’t continue to pay for more

and more treatment for more and more

disease,” says Dr. Marks.

“What’s happened over the last couple

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.

PH

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SA

PIN

ES

[FL

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of decades has been the growing aware-

ness of the implications of social factors for

health, whether that’s education, poverty,

transportation, parks, etc.—the social envi-

ronment. Epidemiology or its techniques

are one of the few ways that those factors

can be assessed.”

Should epidemiologists be more like economists?

Despite this sense of urgency, epidemiolo-

gists as a culture are hesitant to over-state

the meaning of their data and rarely use

their research to take strong policy posi-

tions. They commonly offer the disclaimer

that a study they’ve done does not show

that an exposure caused a disease, simply

that there is a link between the two.

“The challenge for us as epidemiolo-

gists is we can get committed to an issue

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

direction it probably indicates a higher

likelihood that that direction is causal than

another—not a certainty, but a higher like-

lihood. When you’re in a policy discourse

sometimes you have to speak with greater

confidence than your data warrant in order

to be heard,” he adds.

He acknowledges that “the most import-

ant issues” are “among those that are the

hardest to measure: connectedness, support

for each other. And many things that are

outside of medical care: quality of a diet, the

access to fresh food, safe places to play.”

According to Dr. Galea, by not getting

involved in policy discourses, epidemiolo-

gists are ceding an important policy role to

another discipline: economics.

“Epidemiology is very conservative

about its causal thinking. In some respects

that’s a good thing and sort of refreshing.

But what it has done is it has allowed the

insertion of economics into the health

arena. Economists have positioned them-

selves as people who ask big questions

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

legalization of abortion, which was put

forward by two economists. “The methods

used in that kind of assertion are the same

type as used in epidemiology. But epide-

miology would never have the boldness to

make that assertion,” he says. “[Economics]

gets bashed around for its shortcomings.

That’s where the saying ‘dismal science’

comes from. It is a dismal science but at the

same time, it is a science that has an impact

on day to day public discourse.”

Read more original content on the2x2project.org

� Impact of the food stamp cuts

� Mayor Bloomberg’s legacy

� The relationship between bigotry and health

� Neglecting homelessness

� Medical anthropology in public health

� The need for conversation about HPV vaccination

� The paradox of American health care spending

� Funding the future of public health

“Epidemiology is a crucial part of the way that case is made for the public and policy makers. We can’t afford to treat ourselves out of our health crisis. We can’t continue to pay for more and more treatment for more and more disease,” says Dr. Marks.

http://the2x2project.org

14

Big push initiatives in global health

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

the2x2project.org

http://2x2.ph/NDfVSP

BY ELAINE MEYER

http://2x2.ph/NDfVSP

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


A laundry list of ambitious global targets now greatly

influence the agendas of the many non-government, private, and government organizations that work on global health.Faced with what they view as colossal

global health challenges, public health

advocates have increasingly turned to

“big push” approaches, focusing enormous

financial and human resources on a single

specific issue for a finite time, with high

target goals.

This includes eradicating malaria,

eliminating new cases of pediatric HIV,

curing dementia, eradicating polio, and

reducing cancer mortality and heart

disease by one-fourth what it is today.

While aggressive global targets like

those above from the United Nations, the

G8, and private foundations are credited

with motivating funders and improving the

effectiveness of aid, critics have accused

these initiatives of imposing on local struc-

tures and approaches, diverting resources

from more urgent needs, and being diffi-

cult to sustain after the interest and initial

cash infusions from rich nations and pri-

vate funders is gone.

“We have a lot of unfinished objectives

in global health. The whole field is littered

with partially achieved objectives,” says

Dr. Stephen Morse, a professor of epide-

miology at Columbia University who is the

co-director of the USAID program PREDICT,

which conducts global surveillance for

emerging infectious diseases.

Concern about the proliferation of

incomplete or abandoned initiatives is

becoming more acute with the decline in

global aid from the flush aught years even

as awareness of new global health needs

emerges. The fear is that in this environ-

ment, these “big push” initiatives are too

single-minded.

That fear was expressed by Dr. Duncan

Green, the senior strategic adviser for

Oxfam Great Britain, who spoke at a

seminar in 2013 about the future after

2015, the target year for achieving the

United Nation’s Millennium Development

Goals, which are a significant motivator

for national government and NGO public

health efforts.

“Most of the discussion on post-2015 has

been what I call ‘if I ruled the world.’ So a

range of people, businesses, politicians,

NGOS, in spades, have said, ‘if I ruled the

world, I would do x, y, zed, and the world

would be a better place, which is a fascinat-

ing conversation, and you know, it’s great,

but it’s also weirdly sort of self-indulgent,’”

Dr. Green recounted having to facilitate

the participation of 200 NGOs in a consulta-

tion with a high-level panel. Each NGO had

15 seconds to suggest a focus for the UN

after 2015. “It was a Christmas tree. It was

decorating the Christmas tree with your

issue,” he said.

Nothing may better illustrate both

strengths and the flaws of an aggressive

big push health initiative better than the

World Health Organization’s (WHO) Global

Malaria Eradication Program, begun in

1955 with a target of eradicating the dis-

ease in five years.

From the start GMEP, as it was known,

saw containment of the disease as at

odds with eradication. A UNICEF regional

director called the two priorities “as great

a difference as that between night and

day,” according to a 2011 article published

in PLOS Medicine about GMEP. Believing

that the science of malaria eradication was

settled, GMEP dismissed local knowledge

about disease control if it didn’t align with

the new eradication technique of spraying

DDT or other insecticides. The program

also did not integrate well with communi-

ties, sometimes creating separate, parallel

structures from already existing local

health services.

By 1969, facing financial constraints and

a new outbreak in Sri Lanka, a country that

was once a model of success for those who

studied eradication, GMEP determined their

goal was not feasible and abandoned it.

When GMEP was disbanded, there

were drastic cuts in human and financial

resources that resulted in weakened ability

to control malaria. These cuts, combined

with the emergence of resistance to first

line anti-malarial drugs and the withdrawal

of DDT from many control programs for

environmental reasons, contributed to a

resurgence of malaria in many parts of

Posters from the NIH archive.

Read about India after

eradication of polio:

the2x2project.org

2x2.ph/1cgqyqk

http://2x2.ph/1cgqyqk


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

of criticisms about that campaign, nonethe-

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

campaign. People who have worked on

these campaigns say that they mobilize

resources that would otherwise be hard to

bring together.

“There’s always debate: do you set a

target that’s easy to achieve or do you set

an ambitious target that’s harder to achieve

that kind of puts a fire under people’s butts

that you probably know in your heart might

not be achieved in that timeline but will be

achieved shortly thereafter?” says Craig

McClure, the chief of the HIV/AIDS section

of UNICEF, who is based in New York. “You

have to strike a balance of how ambitious

you want to go because if you get too

ambitious you could de-motivate people.”

McClure leads UNICEF’s participation

in the UNAIDS Global Plan to eliminate by

2015 new cases of HIV transmitted from

mother to child, which means reducing

the rate of transmission by 90 percent, or

from 400,000 new infections to fewer than

40,000 worldwide.

There is still a way to go. At the end

of 2012, there had been a 35 percent drop

in the rate of new infections from when

the Global Plan started in 2009, to 260,000

new infections. But that number is a signif-

icant improvement compared to the years

2000-2008, when new infections dropped

by 26 percent.

McClure says he is not sure at this point

whether the Global Plan targets will be met,

but he credits them with making a difference

in bringing together resources and giving

the governments a concrete goal to aim for.

According to executive director of

Merck for Mothers Dr. Priya Agrawal,

having a goal of reducing maternal mor-

tality by 50 percent in 5 years was key to

bringing everyone, including the govern-

ments of Uganda and Zambia, together in

a private-public $200 million effort called

Saving Mothers, Giving Life.

An external evaluation from researchers

at Columbia and New York Universities

found that in its first year, the program was

largely successful in the approaches it took

toward achieving this goal, including work-

ing with the community to improve quality

of health facilities and providers and rais-

ing positive awareness of these facilities.

At a symposium held in November at

Columbia University’s Mailman School of

Public Health on “the potential of big push

Safe Motherhood Action Group member (left) and pregnant women at antenatal care

clinic in Lundazi District, Zambia.

initiatives in global health,” experts inside

and outside the project weighed in.

“Big pushes are in fact a recipe for chaos,

however there’s something to be said for

quick wins. Saving a life is saving a life,”

said Dr. Angeli Achrekar, a senior public

health adviser for the U.S. Centers for Dis-

ease Control and Prevention, which was

involved in the Saving Mothers campaign.

Others at the event acknowledged that

the program’s long-term prospects remain

to be seen. “Sustainability is probably the

hardest nut to crack,” Dr. Margaret Kruk,

an assistant professor of health policy and

management at the Mailman School who

with Dr. Sandro Galea, chair of the school’s

department of epidemiology, led the exter-

nal evaluation of Saving Mothers, Giving

Life, said in closing remarks.

She expanded on that idea in a later

interview: “Having an ambitious goal is

very motivating. The converse of that

though is that it’s not enough. There is

almost no one who would disagree with

the statement that you can change a lot

in a short time with a lot of money and

a lot of motivated people. That’s not the

trick. The question is how does this sustain,


year two, year five, year ten. That requires

an invested government, a committed

workforce. These kinds of projects can

demonstrate the possibility, but to sustain

the success, you need a long-term view

and an increasing role for government.”

Sometimes an ambitious goal can be

too ambitious, like the Gates Foundation’s

decision in 2007 to renew the goal of

malaria eradication. “Eradication is not

something that is normally feasible. It’s a

rare event,” says Dr. Morse.

To this day, smallpox is the only disease

that has been eradicated by humans. And

smallpox was “low-hanging fruit,” says Dr.

Packard. “It was a real achievement, but it

was the easiest of all diseases to eradicate.

The unfortunate part is having become suc-

cessful, it became this model of ‘oh we did

it once, we can do it again,’ without really

looking at the realities of what it took to do

it and how relatively easy it was.”

Dr. Morse recalls attending a meeting in

the 1990s of a pan-American organization

about eradicating the mosquito that causes

malaria and dengue and yellow fever—the

Aedes aegypti. “We knew it’s not feasible to

do this. There’s no strategy for eradicating

this mosquito. We managed to control it

and then it came back. So why were they

talking about eradication? And the reason

is that eradicating motivates people.”

Even the Gates Foundation appears to

have scaled back its expectations, says Dr.

Packard. “I don’t know that they actually

believe in their hearts of hearts it’s pos-

sible. I’ve had a lot of conversations with

people at Gates, people who have a direct

role with malaria. My sense is that early on,

there was optimism and much concern that

without that kind of goal, the achievements

that would be gained with the rollback of

malaria would not be sustainable, and they

were afraid ministers of finance as well

as international donors would get to the

point where they’d say, ‘things have gone

well, there are lots of other problems in the

world, let’s move on.’”

Another issue that has surfaced around

big push initiatives is measurement. In

December, the WHO released a damning

evaluation of the once highly regarded

Chiranjeevi Yojana program to reduce

maternal and child mortality in India, which

are two of the United Nations’ Millennium

Development Goals.

BIG PUSH

Eliminating dementia. Shinako Tsuchiya,

Senior Vice Minister of Health, Labour

and Welfare, Japan. The summit on 11th

December brings together G8 ministers

and other delegates to discuss dementia.

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


The $25 million public-private pro-

gram, based in the northwestern state of

Gujarat, aimed to prevent deaths related

to pregnancy complications by paying

women under the poverty line to deliver

at designated private hospitals. Initially

the program received positive reviews,

and won the Wall Street Journal’s Asian

Innovations Award, which honors private

companies or academics that have devel-

oped an innovative idea in Asia. The Indian

government began recommending it be

adopted in other parts of the country.

But the WHO evaluation found that

there was no statistically significant

change in the probability that women

would deliver in health care institutions, in

the rate of complications during delivery,

and the likelihood that physicians or nurses

would be present during birth—all goals

of the program. “[T]he program’s accom-

plishments are likely far more modest than

have been claimed,” says Dr. Manoj Moha-

non, an assistant professor of public policy,

global health, and economics at Duke Uni-

versity, who led the recent evaluation.

Earlier evaluations that rated the pro-

gram as successful were based on possibly

inaccurate data from participating hospi-

tals, rather than population-based surveys

of mothers who gave birth, and did not

account for increases in hospital deliveries

that were unrelated to Chiranjeevi Yojana

or for the self selection of women who

chose to deliver in hospitals, according to

the WHO study.

Another effort, the Millennium Villages

Project out of Columbia’s Earth Institute,

has also been the target of criticism around

how it measures success, which research-

ers there have defended.

And the Millennium Development Goals

themselves have been criticized for not

taking into account where different coun-

tries are in being able to meet those targets,

something many hope will change when

new global priorities are set after 2015.

Several experts admit that while there

have been mistakes in big push initiatives,

the global health community has learned

a great deal from them. “One of the big

lessons learned by most people, if they’re

honest with each other, who work with

HIV is that when the money started to flow

around 2000—big money started to flow—

and targets began to be set, the way the

world approached the support to countries

and spending that money was kind of like

an emergency operation—parachute in,

create a vertical program, and get some-

thing done. And now, 13 years later, we are

trying to undo the parallel systems and

better integrate,” says McClure.

Several people involved in global health

initiatives say that they have been better at

integrating with already established health

infrastructure and with communities since

the more competitive days of the early 2000s.

A contributing factor to the success of

Saving Mothers, Giving Life was that it

provided care by building on infrastruc-

ture that was put in place as a result of the

President’s Emergency Plan for AIDS Relief,

says one of the evaluators, Dr. Miriam

Rabkin, associate professor of epidemiol-

ogy at and director of systems strategies

for ICAP, a center at Columbia’s Mailman

School that works on building and sustain-

ing systems for prevention and treatment

of HIV and related health issues.

“This approach prevented duplication of

effort and enabled implementers to lever-

age their existing resources—from staff, to

vehicles, to relationships with district-level

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

deliver other services as well. “It’s not just

going to benefit mothers but people who

have car accidents and trauma victims, and

various events of this nature,” says Dr. Kruk.

For these efforts to work, it is important

to be flexible, say others. In the world of

HIV/AIDS, the goal of treatment used to be

pitted against the goal of prevention—not

dissimilar to the WHO’s malaria eradication

effort. But now the mantra in the AIDS field

is “treatment as prevention,”—the scien-

tifically proven idea that treating HIV also

helps prevent its transmission.

“There has been an evolution in the

global aspirations for HIV over time, and

this has often been motivated by availability

of new scientific evidence, new resources

or new imperatives,” says Dr. Wafaa El-Sadr,

university professor and professor of epi-

demiology at the Mailman School and the

director and founder of ICAP.

“The HIV world has learned that achiev-

ing results is complicated, and it’s not going

to take one technology or one magic bullet

that will make a difference,” she adds.

Regarding the Global Plan to Eliminate

Pediatric HIV, she says it has been important

that the big picture goal is translated into

clear local targets “to enable those at the

frontlines to know what they need to do—to

have clarity as to what needs to be their pre-

cise contribution to achieving the big goal.”

“Having goals, having timelines is a

great motivator,” she adds. “Whether it be

the Millennium Development Goals or the

PEPFAR goals or the Global HIV goals, I

think having very concrete objectives with

clear targets is enormously helpful. Targets

motivate me, they motivate my teams on

the ground. These targets can be very

ambitious and their achievement not easy,

but they serve an important purpose.”

Several experts admit that while there have been mistakes in big push initiatives, the global health community have learned a great deal from them.

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the executive format is designed to accommodate the busy lives of working pro-fessionals. Students meet in New York City for one week-end (Friday, Saturday, Sunday) a month over a 2-year period.


How cities affect healthThe complex influence urban features have on health

BY TIM PAUL

WRITER, MAILMAN SCHOOL OF PUBLIC HEALTH OFFICE OF COMMUNICATIONS

The Red Square

apartments in New York’s

Lower East Side were

gentrified in the 1980s.

IMAGE: STEPHEN HARLOW

the2x2project.org2x2.ph/1fWLs9b

http://2x2.ph/1fWLs9b


When the influential urban thinker Jane Jacobs wandered

the streets of New York’s West Village in the 1950s, she recognized the vitality of the city in its chaotic side-walks and stores—a notion that upended the orthodoxy of city planners who prized order and efficiency.Today’s urban health researchers carry

on that tradition, honing in on aspects

of urban life that shape our health, and

in doing so, challenging conventional

thinking.

In a January 28 presentation, the first

in Columbia University’s Maiman School

of Public Health’s Urban Health Conversa-

tions series, Dr. Gina Lovasi, an assistant

professor of epidemiology at the Mailman

School, mapped out current thinking in

urban health and invited the audience to

add to the discussion. As a member of the

school’s research group on the built envi-

ronment and health, Dr. Lovasi examines

the health impact of urban features from

green space to fast food restaurants, often

uncovering surprises.

One fertile area of inquiry is the recent

large-swath transformation of New York City

through the policy of “upzoning” neighbor-

hoods to promote greater density, giving

more people access to bike lanes and mass

transit. “Creating new buildings may not be

an obvious choice to improve health,” said

Lovasi, but “getting people to move through-

out their day is an important priority.”

Some at the talk questioned whether all

density is created equal. Dr. James Colgrove,

associate professor of sociomedical sci-

ences at the Mailman School, pointed to the

Barclays Center in Brooklyn and luxury devel-

opment in Manhattan. “I’m not sure how

bringing high-rise condominiums to Tribeca

is going to increase the health of populations

who are most in need,” Dr. Colgrove said.

Gentrification was another concern.

Investments in the built environment could

be detrimental to people who are forced

to move as their rents skyrocket, noted

Dr. Diana Hernandez, assistant professor

of sociomedical sciences at the Mailman

School. Dr. Lovasi agreed, noting, that

many people in rezoned areas resist

the changes. “There is tension between

improving facilities and potentially dis-

placing some of that population if there

is a market response that values those

improvements.”

Further clouding the picture: these

interventions don’t work for everyone. Dr.

Lovasi cited studies showing neighbor-

hood density and proximity to mass transit

encourages walking and cycling and is

linked with healthier weights but noted that

associations suggesting a potential benefit

were strongest among the educated and

affluent. “Interventions to make neigh-

borhoods more walkable may not work in

disadvantaged groups,” said Dr. Lovasi.

For those groups, safety concerns may be

more salient as barriers to walking than the

built environment.

Related outcomes were seen in a study

of trees. Working with colleagues at the

Columbia Center for Children’s Envi-

ronmental Health, Dr. Lovasi set out to

measure the health benefits of a city initia-

tive to plant trees in low-income areas. The

expectation was improved air quality and

less asthma. Instead they found asthma

rates were steady in children who lived

near a tree canopy, but they had more tree

pollen allergies. “It may be that we need to

be more strategic in how we go about tree

planting,” Dr. Lovasi said. “It’s a cautionary

tale pointing us to unintended side-effects

of interventions envisioned as health

promoting.”

The tree study also serves as an exam-

ple of how urban research could reshape

policy. Selecting tree species that are less

allergenic could help maximize the health

benefits of massive tree planting cam-

paigns like MillionTreesNYC.

Another line of research has looked

at whether living near a lot of fast food

restaurants makes people more obese.

Surprisingly some studies have seen the

opposite, where proximity to fast food

restaurants is associated with healthier

weights. How is this possible? One expla-

nation points to the underlying level of

commercial investment as a driver for

both restaurant locations and a healthier

Hudson River Greenway

MillionTreesNYC at Hunts Point in the Bronx

The power of place in

population health in the 2x2

project’s PopPlaces series:

How hosting the Olympics

affects cities:

READ MORE

the2x2project.org

2x2.ph/1cgwHmc

2x2.ph/NduX1y

PHOTOS TOP TO BOTTOM: ANDREW BOSSI, MATT GREEN

http://2x2.ph/1cgwHmc

http://2x2.ph/NduX1y


better job at monetizing those impacts,”

added Dr. Frederica Perera director of the

Columbia Center for Children’s Environ-

mental Health.

On the other hand, health may hold a

special place as a prerequisite and starting

point for everything else. “When you don’t

have health, it stands in the way of other

goals,” said Dr. Lovasi. “Making cities more

supportive of health is making cities more

supportive of people.”

This article originally appeared on the Mailman

School of Public Health website.

lifestyle. “We looked at whether having

banks and credit unions nearby predicted

lower BMI, and it did,” said Dr. Lovasi.

Singling out fast food restaurants is

also a challenge for researchers since cal-

orie-dense foods are available everywhere

from bodegas to pharmacies. Supermar-

kets on the other hand may turn out to be

the superheroes of the urban environment,

lowering rates of obesity.

Jane Jacobs, who is one of Dr. Lova-

si’s favorite writers, wrote that every city

is distinct and has its own stories to tell.

This spring, Dr. Lovasi will travel to Rio de

Janeiro to spend time in the favelas to learn

from communities that grow organically

and make decisions for themselves. “There

is a tension between wanting to design

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

Rocinha favela, Rio de Janeiro

There is a tension between wanting to design perfect, completely formed communities that support health, and letting communities change in a way that serves the needs of the population.

PHOTO: MAXIMEBF [FLICKR]

MAY 2, 2014RSVP CUESS.ORG

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

COLUMBIA UNIVERSITY EPIDEMIOLOGYS C I E N T I F I C S Y M P O S I U M

Preventing Brain disorders:Improving global mental health


Trainees draw lessons from NYC’s new health commissioner

epidemiology role models

In January, Mayor Bill de Blasio appointed Dr. Mary Bassett, a long-standing 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

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

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

BY ELAINE MEYER

Mary Bassett

26

University of Washington. “What I liked

about Mary’s profile a lot was that she had

this academic background but also this

really interesting public work,” says Julian

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

consult for the World Bank and UNICEF.

She published papers on many facets of

HIV/AIDS, including how to monitor the

progress of antiretroviral treatment among

HIV-positive patients, co-incidences with

other diseases like cancer, and prevention

strategies such as getting men to increase

their participation in safe sex. Charlene

Goh, also a second year student, recalls Dr.

Bassett telling the seminar to “think of jour-

nal writing not as advancing your career

but as communication.”

In 2002, Dr. Bassett was asked by then

New York City health commissioner Dr.

Thomas Frieden (who is now head of the

Centers for Disease Control and Preven-

tion) to serve as deputy commissioner of

health promotion and disease prevention.

Students were impressed that Dr. Bas-

sett could transition from researching

infectious diseases in a low-income coun-

try to implementing policy to decrease

obesity prevalence and related non-com-

municable diseases like cardiovascular

illness and diabetes under a mayor and

health commissioners who made public

health improvements a high priority.

“She was part of many key decisions

that led to the ban of trans fats in restau-

rants,” says second-year student Mila

González.

González worked as an associate

program officer when Dr. Bassett served

on an Institute of Medicine committee

that evaluated the President’s Emergency

Plan for AIDS relief, or PEPFAR, the U.S.’s

multi-billion dollar aid program to treat

and white and Hispanic and white groups,

and also reducing the gap in risk factors,

such as access to healthy food, knowl-

edge of how to make healthy food, spaces

that would increase walkability, and the

problem gentrification causes for minority

populations,” says Santaella.

Students believe she will bring her

academic background and training in epi-

demiological methodology to her job as

health commissioner.

“She is someone who knows and

understands the utility of evidence-based

medicine and reliable epidemiologic

information; in fact she has contributed

extensively to the field” says Victor

Puac-Polanco. “It elevates our hopes that in

the near future if we are called upon to sup-

port and assist with a state health project,

we will be collaborating with someone who

will be open to listening.”

Other students agreed that it is meaning-

ful to see someone with a strong academic

background in such a high policy position.

“To get that political appointment, coming

from academia, coming from research, it’s

just inspiring,” says González. “If you truly

want to work in public health, in programs,

in policy, and you’ve had a long trajectory in

academia and research, why not?”

and prevent HIV/AIDS in nations struggling

with the virus. “She can form an opinion

very quickly, and she sticks by it. You could

hear her voice in every meeting, in every

discussion. She’s very vocal about her

perspective,” says González. “She’s going

to tell you what she thinks, but she’s very

reasonable.”

After Dr. Bassett’s discussion, Santaella,

who is interested in working in domestic

violence, approached her for advice. She

subsequently helped him get in touch

with people at a child welfare program in

Harlem. “She was really nice in her emails

and really open to help me contact those

people,” he says.

Dr. Bassett has several challenges ahead

as health commissioner, including pushing

forward with Mayor Michael Bloomberg’s

controversial proposal to ban large size

sugary drinks in certain venues and helping

to implement Mayor de Blasio’s Vision Zero

program to eliminate pedestrian vehicle

crash deaths.

Students hope that despite these imme-

diate demands, she will not shy away from

tackling underlying causes of disease and

pursuing a progressive agenda in line with

her past history. “Clearly the focus will shift

to overcoming health disparities among

the underserved and marginalized of NYC,

and Dr. Bassett is an ideal choice to steer

that ship,” says Michael Rosanoff, a sec-

ond-year student.

Focusing on health disparities means

“improving the health outcomes for immi-

grants without any legal rights, reducing

the gap in health outcomes between black

“The focus will shift to overcoming health disparities among the underserved and marginalized of NYC,” says DrPH trainee Michael Rosanoff.

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.

JUNE 2 – JUNE 27

Epidemiology and Population HealthSummer Institute at Columbia University

Epidemiology and Population HealthSummer Institute at Columbia University

SUMMER 2014

CLASSROOM

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

DIGITAL

Courses are one month long, available anywhere in the world

SATURDAYS

Single-day workshops are held on-campus in New York City

cuepisummer.org Register before April 1, 2014 and receive up to 20% off your entire order

APRIL 22, 2014RSVP CUESS.ORG

8:30 AM – 4:30 PMStudio X | 180 Varick Street

Conversations around public health, architecture, and citiesPresented by the Urban/Health Program


symposium report

In the middle of the twentieth century, epidemiologic studies began to establish

a statistically significant link between smoking and lung cancer. Although scientists did not know the mechanism by which exposure to tobacco smoke gave rise to cancerous growth in the lungs, the correlation became increasingly overwhelming when assessed through a process known as causal inference. While tobacco companies argued that the proof was not strong enough, epidemiologists and other scientists believed taking action to reduce smoking was necessary.

Because of resulting government regulation and public health campaigns,

smoking and lung cancer both declined in the US. That story is an example of

how understanding causation is at the heart of epidemiologic analysis. Because

epidemiologists must study the health of populations in the absence of con-

trolled variables, they must often infer causes of health and illness.

The process of causal inference can be controversial. Critics have charged

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

evolution of the field has led to breakthroughs in methodology that minimize

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

have been possible if scientists and policymakers had waited to make recom-

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,

and heart disease.

Struggles with causal inference are not unique to epidemiology. Many other

social sciences face the same difficulties. Recognizing this, the department brought

together researchers from across many disciplines for a CUESS in November on

“Philosophy and medicine: Explanation and prediction in population health.”

“[R]epresentatives of epidemiology, economy, psychology, and philosophy

may shed some light on what is needed to build a valid and philosophically

sound inferential process in the social sciences in general and in epidemiology

in particular,” said symposium organizers Dr. Alfredo Morabia, professor of epi-

demiology at Columbia University, and Dr. Jeremy R. Simon, associate professor

of medicine at Columbia and scholar-in-residence at the Center for Bioethics.

Speakers talked about what causal inference looks like in their particular

field and how methods might be improved and generalized across disciplines—

or whether this is even possible.

The event represented a rare instance of different disciplines discussing a

path toward a common underlying philosophy of causal inference. Participants

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,

aware of the opportunities this unique event presented.

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

The Columbia University

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.

30

in the news

Philip Seymour Hoffman’s death a reminder of the toll of addiction

The death of acclaimed actor Philip Seymour Hoffman is the “story of a life 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 adjunct professor of epidemiology at the Mailman School of Public Health. The leading cause of preventable death in the U.S., there is “no one size fits all” approach to treating addiction, he adds.

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

Mayor Bloomberg’s public health legacy, by statistics

There were more than 100 public health measures during Michael 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 University’s Mailman School of Public Health, and colleagues. Read more in Scientific American.

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

http://bit.ly/1ea4RCb

http://bit.ly/1eHtHeQ

31

IN THE NEWS

Spirituality may protect against depression

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

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

Significant weight-gain a side effect of PTSD?

Post-traumatic stress disorder may be a cause of sizable weight gain in women, according to a study in JAMA Psychiatry that compared female participants with and without PTSD diagnoses over time. The paper was 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

Car crashes involving pot use tripled over 10 years

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

WEBMD http://bit.ly/1gbil3I

Gluten-free diet may reduce fracture risk for people with celiac disease

People with celiac disease lower their likelihood of bone damage if they stick to a gluten-free diet, according to a study by Dr. Benjamin Lebwohl, assistant professor of medicine and epidemiology at Columbia, and colleagues. Celiac disease is an auto-immune response in the small intestine to the protein gluten. Long-term intestinal damage increases the risk of hip fracture.

HEALTH DAY http://bit.ly/1f20dHr

Africa’s under-appreciated medical talent

Dr. Salim Abdool Karim, professor of clinical epidemiology at the Mailman 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” about Africa that persist, such as that it can’t develop new medical vaccines. “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

http://reut.rs/1lPOpLV

http://lat.ms/KEixPe

http://bit.ly/1gbil3I

http://bit.ly/1f20dHr

http://bit.ly/1ngEIqP


faculty publications

Abdool Karim SS. Retrospective. Nelson R. Mandela (1918-2013). Science. 2014 Jan 10;343(6167):150. doi: 10.1126/science.1249822.

Abel KM, Heuvelman HP, Jörgensen L, Magnusson C, Wicks S, Susser E, Hallkvist J, Dalman C. Severe bereavement stress during the prenatal and childhood periods and risk of psychosis in later life: popula-tion based cohort study. BMJ. 2014 Jan 21;348:f7679. doi: 10.1136/bmj.f7679.

Ahsan H, Halpern J, Kibriya MG, Pierce BL, Tong L, Gamazon ER, McGuire V, Felberg A, Shi J, Jasmine F, Roy S, Paul-Brutus R, Argos M, Melkonian S, Chang-Claude J, Andrulis IL, Hopper JL, John EM, Malone KE, Ursin G, Gammon MD, Thomas DC, Seminara D, Casey G, Knight JA, Southey MC, Giles GG, Santella RM, Lee E, Conti DV, Duggan D, Gallinger S, Haile RW, Jenkins MA, Lindor NM, Newcomb PA, Michailidou K, Apicella C, Park DJ, Peto J, Fletcher O, Dos Santos Silva I, Lathrop M, Hunter DJ, Chanock SJ, Meindl A, Schmutzler RK, Muller-Myhsok B, Lochmann M, Beckmann M, Hein R, Makalic E, Schmidt DF, Bui QM, Stone J, Flesch-Janys D, Dahmen N, Nevanlinna H, Aittomäki K, Blomqvist C, Hall P, Czene K, Irwanto A, Liu J, Rahman N, Turnbull C, Dunning AM, Pharoah PD, Waisfisz Q, Meijers-Heijboer HE, Uitterlinden AG, Rivadeneira F, Nicolae D, Easton DF, Cox NJ, Whittermore AS. A Genome-wide Association Study of Early-onset Breast Cancer Identifies PFKM as a Novel Breast Cancer Gene and Supports a Common Genetic Spectrum for Breast Cancer at Any Age. Cancer Epidemiol Biomarkers Prev. 2014 Feb 3. [Epub ahead of print]

Aleksandrova K, Boeing H, Nöthlings U, Jenab M, Fedirko V, Kaaks R, Lukanova A, Trichopoulou A, Trichopoulos D, Boffetta P, Trepo E, Westhpal S, Duarte-Salles T, Stepien M, Overvad K, Tjønneland A, Halkjaer J, Boutron-Ruault MC, Dossus L, Racine A, Lagiou P, Bamia C, Benetou V, Agnoli C, Palli D, Panico S, Tumino R, Vineis P, Bueno-de-Mesquita B, Peeters PH, Gram IT, Lund E, Weiderpass E, Quirós JR, Agudo A, Sánchez MJ, Gavrila D, Barricarte A, Dorronsoro M, Ohlsson B, Lindkvist B, Johansson A, Sund M, Khaw KT, Wareham N, Travis RC, Riboli E, Pischon T. Inflammatory and metabolic biomarkers and risk of liver and bilary tract cancer. Hepatology. 2014 Jan 17. doi: 10.1002/hep.27016. [Epub ahead of print]

An P, Miljkovic I, Thyagarajan B, Kraja AT, Daw EW, Pankow JS, Selvin E, Kao WH, Maruthur NM, Nalls MA, Liu Y, Harris TB, Lee JH, Borecki IB, Christensen K, Eckfeldt JH, Mayeux R, Perls TT, Newman AB, Prov-ince MA. Genome-wide association study identifies common loci influencing circulat-ing glycated hemoglobin (HbA1c) levels in non-diabetic subjects: The Long Life Family Study (LLFS). Metabolism. 2013 Dec 4. pii: S0026-0495(13)00412-5. doi: 10.1016/j.metabol.2013.11.018. [Epub ahead of print]

Ananth CV, Friedman AM. Late pregnancy use of selective serotonin reuptake inhib-itors and serotonin and norepinephrine reuptake inhibitors is associated with increased risk of postpartum haemorrhage. Evid Based Nurs. 2013 Nov 28. doi: 10.1136/eb-2013-101595. [Epub ahead of print]

Ananth CV, Keyes KM, Wapner RJ. Pre-eclampsia rates in the United States, 1980-2010: age-period-cohort analysis. BMJ. 2013 Nov 7;347:f6564. doi: 10.1136/bmj.f6564.

Angell SY, Yi S, Eisenhower D, Kerker BD, Curtis CJ, Bartley K, Silver LD, Farley TA. Sodium Intake in a Cross-Sectional, Representative Sample of New York City Adults. Am J Public Health. 2014 Jan 16. [Epub ahead of print]

Angermeyer MC, Matschinger H, Link BG, Schomerus G. Public attitudes regarding individual and structural discrimination: Two sides of the same coin?. Soc Sci Med. 2014 Feb;103:60-6. doi: 10.1016/j.socscimed.2013.11.014.

Anthony SJ, Garner MM, Palminteri L, Navarrete-Macias I, Sanchez-Leon MD, Briese T, Daszak P, Lipkin WI. West Nile Virus in the British Virgin Islands. Eco-health. 2014 Feb 7. [Epub ahead of print]

Austin S, Murthy S, Wunsch H, Adhikari NK, Karir V, Rowan K, Jacob ST, Salluh J, Bozza FA, Du B, An Y, Lee B, Wu F, Nguyen YL, Oppong C, Venkataraman R, Velayutham V, Dueñas C, Angus DC; On behalf of the International Forum of Acute Care Trialists. Access to urban acute care services in high- vs. middle-income countries: an analysis of seven cities. Intensive Care Med. 2013 Dec 13. [Epub ahead of print]

Balkus JE, Richardson BA, Rabe LK, Taha TE, Mgodi N, Kasaro MP, Ramjee G, Hoffman IF, Abdool Karim SS. Bacterial Vaginosis and the Risk of Tricho-monas vaginalis Acquisition Among HIV-1-Negative Women. Sex Transm Dis. 2014 Feb;41(2):123-8. doi: 10.1097/OLQ.0000000000000075.

Balneaves LG, Lee RT, Tomlinson Guns ES, Zick SM, Bauer-Wu S, Greenlee H. Tenth international conference of the society for integrative oncology trans-lational science in integrative oncology: from bedside to bench to best practices. Integr Cancer Ther. 2014 Jan;13(1):5-11. doi: 10.1177/1534735413517743.

Banducci AN, Hoffman EM, Lejuez CW, Koenen KC. The impact of childhood abuse on inpatient substance users: Spe-cific links with risky sex, aggression, and emotion dysregulation. Child Abuse Negl. 2014 Feb 9. pii: S0145-2134(13)00394-3. doi: 10.1016/j.chiabu.2013.12.007. [Epub ahead of print]

Bassett MT, Brudney K. Treating Our Way Out of AIDS? Am J Public Health. 2013 Dec 12. [Epub ahead of print]

Baumgartner JN, Burns JK. Measuring social inclusion--a key outcome in global mental health. Int J Epidemiol. 2013 Dec 4. [Epub ahead of print]

Baumgartner JN, da Silva TF, Valencia E, Susser E. Measuring social integration in a pilot randomized controlled trial of criti-cal time: intervention-task shifting in Latin America. Cad Saude Colet. 2012 Jan;20(4). doi: 10.1590/S1414-462X2012000400005.

Beelen R, Raaschou-Nielsen O, Stafoggia M, Andersen ZJ, Weinmayr G, Hoffmann B, Wolf K, Samoli E, Fischer P, Nieuwen-huijsen M, Vineis P, Xun WW, Katsouyanni K, Dimakopoulou K, Oudin A, Forsberg B,

Modig L, Havulinna AS, Lanki T, Turunen A, Oftedal B, Nystad W, Nafstad P, De Faire U, Pedersen NL, Ostenson CG, Frati-glioni L, Penell J, Korek M, Pershagen G, Eriksen KT, Overvad K, Ellermann T, Eeft-ens M, Peeters PH, Meliefste K, Wang M, Bueno-de-Mesquita B, Sugiri D, Krämer U, Heinrich J, de Hoogh K, Key T, Peters A, Hampel R, Concin H, Nagel G, Ineichen A, Schaffner E, Probst-Hensch N, Künzli N, Schindler C, Schikowski T, Adam M, Phuleria H, Vilier A, Clavel-Chapelon F, Declercq C, Grioni S, Krogh V, Tsai MY, Ricceri F, Sacerdote C, Galassi C, Migliore E, Ranzi A, Cesaroni G, Badaloni C, Foras-tiere F, Tamayo I, Amiano P, Dorronsoro M, Katsoulis M, Trichopoulou A, Brunekreef B, Hoek G. Effects of long-term exposure to air pollution on natural-cause mortality: an analysis of 22 European cohorts within the multicentre ESCAPE project. Lancet. 2013 Dec 6. pii: S0140-6736(13)62158-3. doi: 10.1016/S0140-6736(13)62158-3. [Epub ahead of print]

Begg MD, Galea S, Bayer R, Walker JR, Fried LP. MPH Education for the 21st Cen-tury: Design of Columbia University's New Public Health Curriculum. Am J Public Health. 2013 Nov 14. [Epub ahead of print]

Benitez BA, Jin SC, Guerreiro R, Graham R, Lord J, Harold D, Sims R, Lambert JC, Gibbs JR, Bras J, Sassi C, Harari O, Bertelsen S, Lupton MK, Powell J, Bellen-guez C, Brown K, Medway C, Haddick PC, van der Brug MP, Bhangale T, Ortmann W, Behrens T, Mayeux R, Pericak-Vance MA, Farrer LA, Schellenberg GD, Haines JL, Turton J, Braae A, Barber I, Fagan AM1, Holtzman DM1, Morris JC1; The 3C Study Group, the EADI consortium, the Alzheimer's Disease Genetic Con-sortium (ADGC), Alzheimer's Disease Neuroimaging Initiative (ADNI), the GERAD Consortium, Williams J, Kauwe JS, Amouyel P, Morgan K, Singleton A, Hardy J, Goate AM, Cruchaga C. Missense variant in TREML2 protects against Alz-heimer's disease. Neurobiol Aging. 2013 Dec 21. pii: S0197-4580(13)00649-0. doi: 10.1016/j.neurobiolaging.2013.12.010. [Epub ahead of print]

Bergmann MM, Rehm J, Klipstein-Gro-busch K, Boeing H, Schütze M, Drogan D, Overvad K, Tjønneland A, Halkjær J, Fagherazzi G, Boutron-Ruault MC, Clavel-Chapelon F, Teucher B, Kaaks R, Trichopoulou A, Benetou V, Trichopou-los D, Palli D, Pala V, Tumino R, Vineis P, Beulens JW, Redondo ML, Duell EJ, Molina-Montes E, Navarro C, Barricarte A, Arriola L, Allen NE, Crowe FL, Khaw KT, Wareham N, Romaguera D, Wark PA, Romieu I, Nunes L, Riboli E, Ferrari P. The association of pattern of lifetime alcohol use and cause of death in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Int J Epidemiol. 2013 Dec;42(6):1772-90. doi: 10.1093/ije/dyt154.

Besser A, Zeigler-Hill V, Pincus AL, Neria Y. Pathological narcissism and acute anxiety symptoms after trauma: a study of israeli civilians exposed to war. Psychia-try. 2013 Winter;76(4):381-97. doi: 10.1521/psyc.2013.76.4.381.

Black S, Zulliger R, Marcus R, Mark D, Myer L, Bekker LG. Acceptability and challenges of rapid ART initiation among

pregnant women in a pilot programme, Cape Town, South Africa. AIDS Care. 2013 Nov 7. [Epub ahead of print]

Boltz VF, Bao Y, Lockman S, Halvas EK, Kearney MF, McIntyre JA, Schooley RT, Hughes MD, Coffin JM, Mellors JW; for the OCTANE/A5208 Team. Low-Frequency Nevirapine (NVP)-Resistant HIV-1 Variants Are Not Associated With Failure of Antiret-roviral Therapy in Women Without Prior Exposure to Single-Dose NVP. J Infect Dis. 2014 Jan 16. [Epub ahead of print]

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