PUBLIC HEALTH REPORT: Increase in Arthropod-Borne Encephalitis a Possibility

THE COMMUNICATION below is the first of what is intended as a continuing series of reports from the State of California Department of Public Health on topics of interest to physicians in private practice. On a number of occasions in the past, Dr. Malcolm H. Merrill, Director of Public Health, has appeared before the Council of the California Medical Association with intensely interesting reports on matters of public health and the attitudes and functions of the department. Since the minutes of the meetings of the Council give only the briefest of notes on such communications, Dr. Merrill was asked—and has agreed—to make use of this section of California Medicine for public health reports that can be informative and useful to all members.     

Five Classic Articles in Public Health

In this brief review, Dr. Jonathan Borak comments on five seminal papers that helped shape the fields of epidemiology and public health. These papers include Hill’s criteria for inferring causality; the first proof of the multistage theory of cancer; the first evidence that subclinical lead exposures can cause neurobehavioral impairment in children; a simple yet robust study that had a major influence on setting current air pollution policies; and a landmark review of the general public’s perception of risk in relation to actual public health hazard.Dr. Jonathan Borak is a Clinical Professor of Epidemiology and Public Health at the Yale School of Public Health, Clinical Professor of Internal Medicine at the Yale School of Medicine, and Director of the Yale Interdisciplinary Risk Assessment Forum. In this article, Dr. Borak provides his perspective on five publications that significantly influenced the study and practice of epidemiology and public health. This article is the first in a series that will identify and provide commentary on the top five seminal papers published in a field related to biology and medicine.A former student, a member of the Yale Journal of Biology and Medicine’s Editorial Board, reminded me of a comment I made in class. I had described a particular assigned reading as “one of those classic articles” that should be read by everyone studying public health. Okay, he challenged me, what other “classic articles” were on my list? And so began the following: my short list of five articles that represent “must reading” for all students in public health.First, note that I do not speak for public health in general, a field of great breadth of interest and activity, but only the narrower slice, including toxicology, risk assessment, and related interests. Also, I was principally concerned to identify articles that provide models of critical thinking, addressed issues of substantial public health importance, and served as stepping stones for subsequent research and the formulation of public health policy. I also wanted to include articles that were observational and opportunistic, i.e., based on real world observations and available data, not complex laboratory models.My five choices below include: 1) a landmark presentation of criteria for inferring causality from observational data (Hill 1965); 2) a thought experiment based on the re-analysis of publicly available cancer mortality data, which shaped the fields of cancer biology and risk assessment (Armitrage & Doll, 1954); 3) an early study of the effects of lead exposure in school children (Needleman, 1979); 4) a study of the impact of air pollution on children’s health, which was enabled by a fortuitous labor dispute that shuttered a polluting steel mill (Ransom & Pope, 1992); and, 5) a critical literature review of cognitive psychology research that shaped our understanding about how public health risks are perceived (Slovic, 1987).     

"C.-E.A. Winslow and the early years of public health at Yale, 1915-1925"

C.-E.A. Winslow was the first chairman of the Department of Public Health at the Yale University School of Medicine. This paper considers the development and changing agenda of his department, the structure of Yale University, and the maturation of public health as a discipline. Winslow's successes and failures are discussed as they relate to Yale and external societal influences.     

ROBERT TEMPLE: an eye for data. Interview

Robert Temple has spent more than thirty years of his career at the Food and Drug Administration-and he still likes it! After medical school, internship, and residency, Temple pursued endocrinology research at the NIH before deciding, in the early 70s, to apply his interests in science to consumer advocacy at the FDA. The FDA was undergoing enormous changes at that time, and Temple enjoyed the challenges associated with improving drug development and patient safety. Always relying on a critical evaluation of data, he is comfortable discussing mechanisms of drug action, experimental design, and regulatory policies, as well as the social implications of direct-to-consumer advertising of drugs. Currently, Temple is Director of one of the six Offices of Drug Evaluation and also serves as the Associate Director for Medical Policy.     

Ergonomics studies in Thailand: a future prospect

Ergonomics studies in Thailand began in 1967 after Professor Kovit Satavuthi graduated from the University of Birmingham, where he worked with Professor Nigel Corlett. Ergonomics was offered as an elective in the IE curriculum at Chulalongkorn University. Professor Satavuthi was later invited to teach manufacturing process and system at the Department of Occupational Health and Safety, School of Public Health, Mahidol University. He then added the ergonomics concept to the class as part of his lectures. The first international conference was organized by the Central Coordinating Board of SEAMEO-TROPMED Project, and it was held in Bangkok from 19-23 June 1972, thus bringing ergonomics into public attention. Most participants came from medical science and public health fields, however. Ergonomics popularity has begun to gain momentum in the past 4-5 years. This could be the result of more universities paying serious consideration to provide ergonomics knowledge to their students. It is also well-accepted that ergonomics is a multidisciplined subject. It requires knowledge from medical sciences, sociology, psychology, public health, and engineering. The results of ergonomics studies will have greater chances of success if they are concluded from all disciplines of knowledge. This paper reports some previous studies in Thailand and discuss how to build up an ergonomics team and to produce reasonable results with a sound application plan.     

“What you don't know can't hurt you”: The right to know and the Shetland Island oil spill

This paper, an account of the Shetland Islands oil spill (1993), examines the public health controversies surrounding the spill and the clean- up response. It critically examines the risk management policies of both the United Kingdom and the Shetland Islands Public Health Office, and suggests that the withholding of critical information contributed to increased anxiety and suspicion among the disaster victims. In an attempt to reassure the victims, the policies contributed to an increased air of uncertainty. It is further argued that the withholding of information prevents those who are at greatest risk from participating in critical decisions that may affect their health and livelihoods and asserts that a right- to- know policy is a critical first step in risk management practices.     

Health departments in the U.S. 1920-1988: statements of mission with special reference to the role of C.-E.A. Winslow.

The mission of local health departments in the U.S. is traced from the 1920s to the present through examination of official promulgations of the American Public Health Association and other organizations. As the communicable diseases came under general control, this mission was conceived more broadly. Nevertheless, in effect their public health role was diminished due to the rapid ascendancy of private and not-for-profit medical care, which consistently sought to keep public health out of potential areas of competition. Thinking both within the public health field (as represented by C.-E.A. Winslow) and outside the public health field (as represented by the American Medical Association), had created boundaries limiting public health's role to preventive medical services. This restriction, in turn, largely excluded the public health field from participation in the tremendous expansion of medical care since World War II. The public health role was further limited in 1970 by the removal of much of environmental pollution from its purview. The sum of these and other forces has left the public health field weakened and in considerable confusion about its role at a time when the resurgence of infectious disease (e.g., AIDS and Lyme disease), environmental hazards, and medical care institutions requires a strong public health presence.     

Carlo M. Croce: Seeking Truth and Beauty

Believe it or not, as a boy Carlo Croce liked to hang out in art museums, to his mother’s chagrin. There are a lot of art museums in Italy, so his mother started dropping him off and going off to the coffee bar to find more interesting company. He bought his first painting, an old master, at age 12 and that used all his savings. He didn't resume his old master collection until he was in his 30s and had saved some money from his job at the Wistar Institute in Philadelphia. He now has an exciting and growing collection.In the meantime, he received his MD degree from the University of Rome “La Sapienza” while reading textbooks and journals in English to supplement the old style medical education. He planned to join Karl Habel at Scripps Clinic in 1970 for a research fellowship just as Dr. Habel was struck in his prime by a monkey B virus infection, so Carlo was diverted from California to Philadelphia to join Hilary Koprowski's internationally known Wistar Institute of Anatomy and Biology. I was a Ph.D. student at Wistar at the time and witnessed the arrival of the quiet 25 yr. old Italian who was too shy to try out his textbook English.He began his work in somatic cell genetics and virology in a large laboratory where a number of us worked on related projects, including Barbara Knowles (now Associate Director for Research at Jackson Laboratory) and Davor Solter (now Director of Developmental Biology, Max Planck Institute, Freiburg, Germany).One of his first accomplishments was to map the very first viral integration site on chromosome 7q in an SV40 transformed fibroblast cell line, using human-mouse somatic cell hybrids that retained human chromosome 7, the SV40 T-antigen and the SV40 genome. Very recently, one of his hybrid clones was used by others to clone the SV40 genome integration site and to show that the SV40 genome had integrated into a common fragile site.Still using somatic cell hybrids, Carlo Croce and his laboratory began in the late 70s and early 80s to map genes important in cancer, such as the immunoglobulin genes that are rearranged in lymphomas, along with the MYC and BCL2 genes among others. These experiments took advantage of the leukemia/lymphoma specific translocation to walk from immunoglobulin loci, and later TCR loci, into the oncogene loci juxtaposed by translocation, the beginning of positional cloning of translocation breakpoints. These studies involved collaborations with valued colleagues, including Peter Nowell, the co-discoverer with David Hungerford, of the Philadelphia chromosome, the first reported cancer specific chromosome alteration. In the exciting decode of the 1980s, the Croce laboratory published 23 reports in Science, including the discovery of the BCL2 gene with Yoshiide Tsujimoto (now University of Osaka). They also observed that mistakes by immunoglobulin family rearrangement/recombination machinery was responsible for the type of chromosome translocations that involved the IG and TCR genes.Carlo Croce has been not only an outstanding laboratory scientist with numerous important discoveries to his credit; he has also been the Director of an NCI designated Cancer Center, first at the Fels Institute for Cancer Research, where he built a first class basic cancer research faculty from the ground up. In 1991, he moved his cancer research faculty to Jefferson Medical College, where it took the name of its benefactor, Sidney Kimmel, and became the Kimmel Cancer Center. At KCI the Croce laboratory continued to find and study genes involved in cancer development: oncogenes activated by translocation such as ALL1, involved in biphenotypic leukemias, discovered with another important collaborator, Eli Canaani and TCL1 (with Gianni Russo’s lab) activated by translocation to the TCRa locus in lymphomas of ataxia telangiectasia patients; or tumor suppressor genes, lost usually through deletions in epithelial cancers, such as FEZ1/LZTS1 at 8p22 lost in prostate, breast and other cancers and the FHIT gene at the 3p14.2 common fragile site (discovered in a collaboration with my laboratory), confirming a long held hypothesis that genes at chromosome fragile sites could contribute to cancer development through frequent chromosomal rearrangements. At the same time, Carlo Croce was living the nearly always tumultuous life of a Director of a Cancer Center, involving recruitment of faculty, constant bargaining with Deans, department chairman, University administrators, but he still manages to fit in a few skiing meetings, gossip sessions with colleagues like Web Cavenee, visits for good coffee, good food and TV appearances in his beloved Italy and most of all, he still manages to study, examine, buy, transport, restore, reframe and admire his old master paintings. I think he loves it as much as science because discovering a beautiful but misattributed painting at an obscure or even well known auction house, buying it and then proving that it is actually a painting by a Gentileschi or a Cavallino is as thrilling and elegant as discovering the connection between a specific gene alteration and its cancer.     

Responsibilities in elderly care: Mr Powell's narrative of duty and relations

In Western countries a considerable number of older people move to a residential home when their health declines. Institutionalization often results in increased dependence, inactivity and loss of identity or self-worth (dignity). This raises the moral question as to how older, institutionalized people can remain autonomous as far as continuing to live in line with their own values is concerned. Following Walker's meta-ethical framework on the assignment of responsibilities, we suggest that instead of directing all older people towards more autonomy in terms of independence, professional caregivers should listen to the life narrative of older people and attempt to find out how their personal identity, relations and values in life can be continued in the new setting. If mutual normative expectations between caregivers and older people are not carefully negotiated, it creates tension. This tension is illustrated by the narrative of Mr Powell, a retired successful public servant now living in a residential home. The narrative describes his current life, his need for help, his independent frame of mind, and his encounters with institutional and professional policies. Mr Powell sees himself as a man who has always cared for himself and others, and who still feels that he has to fulfil certain duties in life. Mr Powell's story shows that he is not always understood well by caregivers who respond from a one-sided view of autonomy as independence. This leads to misunderstanding and an underestimation of his need to be noticed and involved in the residential community.     

Lessons learned from North Carolina public health regional surveillance teams' regional exercises

All-hazards exercises bring together emergency response partners at the local, regional, state, and federal levels for the primary purposes of testing response plans, defining roles and responsibilities, assessing capabilities, and making necessary improvements prior to an actual incident. To better understand the benefits and challenges of conducting regional (ie, multicounty) exercises, a study was carried out by the North Carolina Preparedness and Emergency Response Research Center at the University of North Carolina Gillings School of Global Public Health. This article describes 5 all-hazards regional exercises conducted by Public Health Regional Surveillance Teams (PHRSTs) in North Carolina in 2009 and highlights 4 unique benefits that resulted from the exercises beyond meeting explicit objectives to test plans and identify areas for improvement: (1) building relationships among response partners, (2) promoting public health assets, (3) testing multiple communications systems, and (4) training exercise evaluators. Challenges of planning and conducting regional exercises also are addressed, followed by recommendations for maximizing the effectiveness of regional public health exercises.     

Science for the common good

A smile comes easily to the face of Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, as he encounters visitors to his offices at the Institute. He does not, however, allow himself to be distracted from his duties for longer than it takes to nod warmly. The sense of discipline and the determination and preparedness that were instilled in him through a Jesuit course of education are apparent. He is as direct and as clear spoken in person as you've seen him on television, speaking on innumerable occasions over the past two decades about the pathology and treatment of AIDS, and more recently, delineating the public health from the national security issues precipitated by the bioterrorist events of the past year. The three office assistants who occupy his reception area have been particularly taxed in the management of Fauci's schedule since 9/11; as they pause briefly from their work to share photographs of a friend's recent wedding, Fauci is there to admonish them, semi-good-naturally, as government employees, to return to their official duties. He has been meeting with high government officials and has been courted by the media for interviews regularly since the tragedies began. Given his high profile, it is easy to forget that Fauci is, foremost, a clinical immunobiologist and physician. His dedication to science is part of his commitment to public service, also a value instilled in him by the Jesuits. Fortunately for all of us, Fauci was pursuing this combination of interests--within the venue of bioterrorism--in his official capacity at the NIAID well before the general public had awaken to the threat.     

Counties selecting public health priorities--a "bottom-up" approach (Croatian experience)

The subject of this paper is how to incorporate a multi-disciplinary and inter-sectored approach into development of public health policy and plans at the local (county) level in Croatia by educational program. Method used was the public health capacity building program "Health--Plan for it", which was developed with the aim to assist the counties to overcome recognized weaknesses and introduce more effective and efficient local public health practices. Two main instruments were used: Local Public Health Practice Performance Measures Instrument, and Basic Priority Rating System. This program has helped counties to asses population health needs in a participatory manner, to plan for health and, ultimately, assure provision of the right kind and quality of services (better tailored to population health needs). This program's benefits are going beyond and above the county level. It provides support for the Healthy Cities project locally, and facilitates changes in national policymaking body's mindset that a "one-size-fits-all" approach is sufficient.     

The Claude Bernard Distinguished Lecture. In pursuit of meaningful learning

The Bernard Distinguished Lecturers are individuals who have a history of experience and expertise in teaching that impacts multiple levels of health science education. Dr. Joel Michael more than meets these criteria. Joel earned a BS in biology from CalTech and a PhD in physiology from MIT following which he vigorously pursued his fascination with the mammalian central nervous system under continuous National Institutes of Health funding for a 15-yr period. At the same time, he became increasingly involved in teaching physiology, with the computer being his bridge between laboratory science and classroom teaching. Soon after incorporating computers into his laboratory, he began developing computer-based learning resources for his students. Observing students using these resources to solve problems led to an interest in the learning process itself. This in turn led to a research and development program, funded by the Office of Naval Research (ONR), that applied artificial intelligence to develop smart computer tutors. The impact of problem solving on student learning became the defining theme of National Science Foundation (NSF)-supported research in health science education that gradually moved all of Dr. Michael's academic efforts from neurophysiology to physiology education by the early 1980's. More recently, Joel has been instrumental in developing and maintaining the Physiology Education Research Consortium, a group of physiology teachers from around the nation who collaborate on diverse projects designed to enhance learning of the life sciences. In addition to research in education and learning science, Dr. Michael has devoted much of his time to helping physiology teachers adopt modern approaches to helping students learn. He has organized and presented faculty development workshops at many national and international venues. The topics for these workshops have included computer-based education, active learning, problem-based learning, and the use of general models in teaching physiology.     

Ian Humphery-Smith on current challenges in proteomics

Ian Humphery-Smith is Professor of Pharmaceutical Proteomics at Utrecht University, The Netherlands, and until recently was a Managing Director and Chief Scientific Officer of Glaucus Proteomics. After a PhD in Parasitology at the University of Queensland, he studied virology and bacteriology in France as a post-doc, before returning to Australia as Course-Coordinator in Medical Microbiology and Immunology at the University of Sydney. During this time, Humphery-Smith took up the posts of Executive Director of Australia's second largest DNA sequencing facility and Director of the Center for Proteomic Research and Gene-Product Mapping, which later became the world's first center to focus on studying the proteome. Humphery-Smith has devoted ten years of research to analyzing proteins in health and disease, and it was his work that originally coined the term ‘proteomics’. He was the first to publish the most complete analysis of an entire proteome in 2000, that of the bacterium Mycoplasma genitalium. He currently serves as a council member of the Human Proteome Organization (HUPO) and has been a prime mover in efforts to have the Human Proteome Project become a formally-ratified international initiative to follow-on from the Human Genome Project.     

Lewis W. Hackett and the early years of the International Health Board's Yellow Fever Program in Brazil, 1917-1924

Lewis W. Hackett joined the staff of the International Health Board (IHB) in 1914. He was sent to Brazil in 1916, where his original responsibility was hookworm control, but he was gradually and inevitably drawn into combating other diseases. Hackett had a strong influence on public health in Brazil. In 1922 he instituted grass-roots (local) health units and programs. The next year, he negotiated with the federal government a cooperative yellow fever control program, which was described in the IHB's 1923 annual report as the "new and final campaign against yellow fever" in Brazil. Eleven offices were established in northern Brazil, where it was expected that yellow fever would quickly be eradicated. Just as the new program got underway Hackett was reassigned to Italy, where he remained until the beginning of World War II. Nonetheless, Hackett had done a classic job of developing the IHB program in Brazil, moving carefully but authoritatively from the initial focus on hookworm, to the development of a more comprehensive public health program, and then to the strategic thrust toward yellow fever.     

POLESAT : e-Atlas de santé, planification et développement durable

New knowledge come from detailed hospital activity of the French Medical Information System (PMSI). They allow doing health geography studies in geo-epidemiology, planning and healthcare uses to answer specific Public Health problems. Through our geomatics platform, we aim to give new scientific knowledge and reflection to healthcare professionals and the public thanks to geographical information and geographical analysis. The geographical studies are carried out at several division levels (postal-PMSI zones, proximity zones etc.) in the French Nord–Pas-de-Calais region of four million of inhabitants. In order to improve information, decision-making, and in tandem with each user's rhythm, we will provide access, transmission, communication and information of the geographical studies through our first tool of Health e-Atlas.     

John P. Peters and the committee of 430 physicians

John Peters and his committee had a few basic goals. One was that local, state, and federal governments needed to provide money to construct facilities, support medical research and education, and care for the poor. And they wanted experts to call the shots. Over time, Peters and the committee got what they wanted for the most part: Hill-Burton money for building the hospitals, the rise of the National Institutes of Health, Medicare, Medicaid, a Veterans Administration system, and new and expanded medical schools. The experts calling the shots included David Kessler at the Food and Drug Administration and Surgeon General C. Everett Koop. In the halcyon days of American health system reform, back in 1993, Yale''s Paul Beeson wrote about the Committee of 430 Physicians and its goals in the Pharos of Alpha Omega Alpha. Beeson was optimistic and he quoted from my 1991 JAMA health system reform editorial as a sharp contrast to what Fishbein had written - although coincidentally, we both quote Lincoln. My editorial began, "''with malice toward none, with charity for all...'' so spoke Abraham Lincoln in his second inaugural address recognizing that he had no political consensus regarding either the constitutionality of states seceding or the morality of slavery being abolished. Nonetheless, he knew what was right and was able, through persuasive, often inspiring rhetoric, to conclude a bloody and decisive Civil War and constitute the foundation for this great republic.... Yet access to basic medical care for all of our inhabitants is still not a reality in this country. There are many reasons for this, not the least of which is a long-standing, systematic, institutionalized racial discrimination.... An aura of inevitablitiy is upon us. It is not acceptable morally, ethically, or economically for so many of our people to be medically uninsured or seriously underinsured. We can solve this problem. We have the knowledge and the resources, the skills, the time, and the moral prescience. We need only clear-cut objectives and proper organization of existing resources. Have we now the national will and leadership?" Beeson''s answer to that question in 1993 was, "Yes, but not by one comprehensive act." He quoted Peters from his 1938 Annals of Internal Medicine article: "a sweeping program suddenly imposed in this country as a whole out of the head of any Jove would undoubtedly create confusion if not chaos. Thoughtful investigation and experiment promises more than grandiose projects born of emotional preconceptions. The programs must be built of an evolutionary manner, step by step." Very wise, very valid. But how long must our people wait?     

A conceptual framework for the revision of the ICD-10 classification of mental and behavioural disorders

The World Health Organization (WHO) is revising the ICD-10 classification of mental and behavioural disorders, under the leadership of the Department of Mental Health and Substance Abuse and within the framework of the overall revision framework as directed by the World Health Assembly. This article describes WHO’s perspective and priorities for mental and behavioural disorders classification in ICD-11, based on the recommendations of the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. The WHO considers that the classification should be developed in consultation with stakeholders, which include WHO member countries, multidisciplinary health professionals, and users of mental health services and their families. Attention to the cultural framework must be a key element in defining future classification concepts. Uses of the ICD that must be considered include clinical applications, research, teaching and training, health statistics, and public health. The Advisory Group has determined that the current revision represents a particular opportunity to improve the classification’s clinical utility, particularly in global primary care settings where there is the greatest opportunity to identify people who need mental health treatment. Based on WHO’s mission and constitution, the usefulness of the classification in helping WHO member countries, particularly low- and middle-income countries, to reduce the disease burden associated with mental disorders is among the highest priorities for the revision. This article describes the foundation provided by the recommendations of the Advisory Group for the current phase of work.     

The effect of rising obesity on eligibility to serve in the U.S. public health service commissioned corps

This study investigates how rising obesity has affected eligibility to serve in the United States Public Health Service Commissioned Corps (PHSCC), the uniformed service charged with protecting and promoting public health in the U.S. Data are drawn from the National Health and Nutrition Examination Surveys. Between 1959 and 2010, the percentage of eligible civilians who exceed the weight-for-height and body fat standards of the PHSCC rose from 9.05% to 18.24% among men, and from 6.13% to 23.10% among women. Simulations indicate that a further 1% increase in population body weight will result in an additional 3.42% of men and 5.08% of women exceeding PHSCC accession standards.This study documents an under appreciated consequence of the rise in obesity: fewer Americans eligible to develop and implement a public health response to obesity through the PHSCC. This illustrates how a public health problem can undermine the public health labor force, compromising a response and risking a self-reinforcing trend. These findings are timely as the Patient Protection and Affordable Care Act (ACA) calls for a major expansion of the PHSCC.     

C.-E.A. Winslow and the later years of public health at Yale, 1940-1945

This paper is one of a series of papers in which I consider contemporary Yale medical education in general and the Yale Department of Epidemiology and Public Health in particular. It tells of the retirement in 1945 of C.-E.A. Winslow, Professor and Chairman of the Yale Department of Public Health since its inception in 1915; of the committees established by the dean of the School of Medicine and the president of the University, charged with determining the future direction of the department; and of the outcome, which, in 1945, proved favorable to Winslow's public health philosophy in contrast to the medical school's clinical needs and desires.