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Epidemiology of esophageal cancer has been undergoing significant change over the past 30 years; it wont be extra-aggregate to term it one of the biggest epidemiological shifts in the cancer domain in the Unites States. Squamous cell carcinoma used to be the most common histological type of  esophageal cancer, but it was replaced by adeno-carcinoma. Esophageal adenocarcinoma is one of the most lethal cancers in the US with a five-year survival of less than 20%. The relative rarity and high lethality of esophageal adenocarcinoma make this a challenging yet crucial malignancy to study. It highlights the importance of prevention when compared to the effect and cost of cure. The risk of esophageal cancer is greatest among those with the lowest socioeconomic status (SES). In case-control studies, income, education and occupation are assessed to measure the SES. Gastroesophageal reflux is proved to be the culprit of adenocarcinoma. Do you have heartburn? How long and how often determines the magnitude of the risk of developing esophageal adenocarcinoma in individuals.

Despite investment of many years and lot of resources including money, we are not succeed to say certainly which patients are going to get what cancer. But recent study by leading investigators at National Cancer Institute, Dr. Michael Cook , is somewhat right step in that direction, which found monotonic relationship between the duration of the symptom of heartburn and the magnitude of the risk of getting adenocarcinoma of esophagus.

The international Barrett’s and Esophageal Adenocarcinoma Consortium (BEACON) was formed in 2005. The primary aim of BEACON is to provide an open scientific forum for epidemiological research into the etiology and prevention of both Barrett’s esophagus and esophageal adenocarcinoma by facilitating the sharing of data across population-based studies. Although previous studies have provided evidence for the positive association between GERD and esophageal adenocarcinoma risk, it was unknown to what extent these associations vary by sex, BMI, and cigarette smoking, or whether duration and frequency of GERD symptoms confer risk independent of each other. In this study of BEACON data, Cook et al not only found strong associations between GERD and esophageal adenocarcinoma, but also found that the relationship between GERD duration and esophageal adenocarcinoma was monotonic: Odds ratios (ORs) were 2.80, 3.85, and 6.24 for symptom durations of <10 years, 10 to <20 years, and ≥20 years, each compared with no GERD symptoms. Researchers also observed that both frequency and duration of GERD were independently associated with higher risk; individuals who had both high frequency (≥weekly) and long duration (≥20 years) were at a much higher risk of developing esophageal adenocarcinoma (OR=9.27, 95% CI: 5.02, 17.10), compared to those without GERD. Results were not notably altered when stratified by sex, BMI or cigarette smoking.Limitations of this analysis include the moderate-to-high heterogeneity associated with a majority of summary estimates presented–cautious interpretation as to the magnitude of these estimates is therefore warranted.

(I interviewed Dr. Michael Cook , scientist at National Cancer Institute, on his recent study: Gastroesophageal Reflux in Relation to Adenocarcinomas of the Esophagus: A Pooled Analysis from the Barrett’s and Esophageal Adenocarcinoma Consortium (BEACON).)

Smoking has various dimensions: cultural, political, religious, geographical, racial, ethnic, health, corporate and gender. To counter smoking,  public health also had to use multi-dimensional approach. In the February edition of 2006, American Journal of Public Health (AJPH ) discuss the status and perception of smoking among physicians in the earliest twentieth century. Tobacco companies exclusively used doctors to market their brands as pharmaceuticals companies do today to sell its drugs. For example, to advertise camel brand cigarette, Reynolds Company in 1940s,used catchy quotation, “More doctors smoke Camels than any other cigarette.” Advertisements of various cigarettes brands kept medial journals and organizations solvent. It finally came to rest when American  Medical Association (AMA) publicly disapproved the Kent Ad campaign. . In short, smoking cigarette was fashion and was believed  healthy those days. Manufacturer Allen and Ginter were even offered prize for innovative work of building machine to fasten the process of producing cigarettes at higher rates. First world war also helped in popularizing smoking among soldiers. They believed that smoking relieved them from stress. And they even considered tobacco as important as guns in war.

Those days, stomach cancer was the leading cause of cancer deaths. Lung cancer was rapidly taking the second position because of increasering reports of new lung cancer cases. Fritz Lickint,German physician first published the possible association between smoking and lung cancer. Few years later, Muller reported the finding of case control study, which underlined smoking as the cause of lung cancer. In the United States, Hammond and Wynder provided evidence for the causation link.

More than 50 carcinogens have been reported in cigarette ingredients as potential carcinogens. Smoking causes elastin damage and cause peri-acinar emphysema, it also damages cilia epithelium. It hastens multiple sclerosis and other white matter degeneration disorders. The association between lung cancer anf smoking is well established. However, not every lung cancer is related to smoking, for example bronchoalveolar cancer and carcinoid are not associated with smoking. Smoking is strong risk factor for cardiovascular diseases. It is also concluded from the analysis that if with zero smolers in the United States, one in three cancers are completely avoidable. Smoking  effect is highly perceived  in head neck cancer studies; it is routine independent variable for many multivariate model. Smoking also has effect on the pregnant women and their babies. There are more cases of still births, preterm births and ectopic pregnancy in pregnant women who are smokers. Risk of developing diabetes is high in smokers compared to non-smokers. Smoking even decreaes the productivity at work place, and increase utilization of health care services, resulting in increase health care cost.

Center for disease control and prevention (CDC) estimates that 42 million adult Americans are smokers, which stands at 18% (declined from 20% to 18% from 2005 to 2012) of  adult population of country and prevalence of smoking is more in men than women. Adding further, people who are below poverty lines are more likely to smoke (27% vs 18%). Applying GIS knowledge, Midwest of United States has higher prevalence of 26% while west has far less prevalence of 14%. Prevalence of smoking in Harlem is 22%, which is more than national average of 18% and far more than northeast region 16.5%. 20% of children in Bronx have asthma, and smoking prevalence in the area is the key reason. Globally,Russia has one of the highest prevalence of smoking, around 40% population of Russia smokes. Cigarettes shortage triggered riots in Russia some twenty years ago.It is 29% in Europe. Indonesia and East Timor has more than two third men indulge in smoking, which elucidates the dangerous trend in these countries. In developing countries, smoking is more common in men than women. But for few years, percentage of new smokers among women has been increasing.

I lived in more than 20 neighborhoods in New York, and generally I observe smoking pattern on the street or open space. So in my observation, I found that there could be high prevalence of smoking in the Flushing area. Further supporting my  observation, I am also adding my experience of living in the Flushing neighborhood. Wonderful place for food , great diversity  and good nightlife!  I was sharing apartment with Chinese friends . I don’t know why that house didn’t have the smoke detector in place. I became public health officer for our apartment.  My African friend also moved from DC to stay in our house. It was African, Chinese and Indian staying under same roof. We had always-friendly altercation on smoking issue. My observation was apparently right; except for Native Americans (ritual value for smoking), Chinese American has the highest prevalence rate of smoking than all other ethnicities.

Native Americans have used tobacco for religious/ceremonial reasons. Judaism and other religions prohibited smoking once its harmful effects were established. For example, Rabbi Kagan prohibited smoking on the basis of health effects. Zorastrism prohibit smoking but with different rationale. It actually termed it abuse of fire. Sikhism is the religion, which clearly denounced smoking on the basis of Gurus teaching.

Few examples of the past witness the  policy of smoking ban, for instance,  Roman catholic banned smoking in mexican church, but I didn’t get any evidence that it was because of any health concern. Policy in United States has taken a long miles journey to reach the situation where we are comfortably placed. New York City reflects successful story in the framework of public health to counter smoking. Ex-mayors  Bloomberg’s work was exemplary, and perhaps why many people termed him public health mayor. It wasn’t easy walk. It wasn’t cakewalk. Corporate interests were fought first time in the history for the cause of public health. Corporate were the interest group and pressure group for every government, but public health advocacy made biggest impact. It is the biggest victory when we think in terms of health policy.  Now even CUNY has anti-smoking polic in place. Restaurants and bars do not allow smoking now.  Policy included increasing prices of cigarettes, researched found that with every 10 cent increases, smoking reduced by 2 to 5 percent. Banning at public places, and issuing harsh fine also work. New Yorks clean air indoor act has resulted in positive changes. Eight percent of population favored the law where one their to one half of adult smokers. As a result of strong policy in place, significant drop was noted in nicotine by-products in the air at restaurants and bars. New York city extended this ban to Beeches and parks.As a result of policy, smoking rates in the city has come dramatilly down.

 While  visiting Facebook profiles of African American friends,  displeasure (anger) over the recent incident in the state of Missouri is quite palpable. After pondering over this issue in light of public health, I think economic disparity is the root cause;  economic gap is the root cause; and even when if we think of stereotyping, it is also somewhat related with economic differences. There might be many angles involved, but solution lies in reducing this disparities. And coupling it with closing  educational gap!

According to the US census, the poverty rate among African American has increased from 25% to 28% in last ten years between 2005 and 2014. Single mother with children is the most suffered group in the framework of poverty. Statistics reveal shocking layer of the truth when poverty rates among single mothers with children is compared to married couple black families. (its 47% vs 8%). There is need to find out the reason behind this sordid condition of single mothers.  There are 43 million American living under poverty line, of which almost 10 million are African Americans, which means 25% of poor Americans are represented by African Americans. Doesn’t this statistics tell the crux of story? However, everything is not like discouraging, rates have dramatically come down from 1960 statistics.

According to US Bureau of Justice Statistics, nearly 40 percent prison population is non-hispanic blacks, if we imagine its implications such as what happen to their families, who take care of them, what happen to their children, are they more prone to fall into crime like their father (the crime for he was arrested) or sibling committed? Do we have such program in place to observe (just observation) the living condition of relatives or dependent of the person who is in jail? 40% of black population of jails is there for drug and robbery related crimes compared to 30% of others.

It’s a complex issue, it can’t be sorted out overnight, however, sincere and honest initiatives by government and active participation from rich educated members of the community can definitely help in tailoring required program and its effective implementation. Such program, if in place and effectively executed, have potential to produce desirable outcome and long sustaining impact.

It is not that government has closed its eyes ( based on the statistics). Many assistance programs are running well, for example.39% of African Americans are on Medicaid, 25 percent of them are recipients of food stamps, 13% get cash assistance and 11 percent get housing help. Deeper insight into Medicaid reveals that major chunk of Medicaid beneficiaries are children.

In the context of health, African Americans are not only more prone to get disease; they are more likely to die from it. I attended one lecture by family medicine practitioner (also health activist) at Hunter college auditorium, who told surprising fact that African Americans are least likely to obtain retirement social security benefits even though they contribute during their working years. Why? Life expectancy of black is 73, which is five years less than white counterparts. There are few more disturbing stat: almost 80% of black women above 20 are overweight and 40 percent of black men above 20 are living with hypertension.

(Special note: I apologize if there is any statistics or sentence, which is wrongly placed, or convey message that, in case, if hurt someone. This is my sincere attempt to present reality in the context of public health)

One of the brightest and highly accomplished epidemiology era of this century ends with the passing of  Dr.Mervyn Susser….. We all will miss you, but will find you in public health/epidemiology books!!! RIP.

Journey of Dr. Susser was full of zeal, passion and enthusiasm to work for the betterment of community health. Since Epidemiology gives the base for public health action, and policy executes it, the contribution of Dr. Mervyn Susser to the epidemiology and somehow to the policy ( in light of his struggle in South Africa) is immense.His contribution to public health began long time ago in South Africa when only fifteen percent population of the country had privilege to enjoy all power including voting rights. He was then one of the companions of Nelson Mandela in the fight against then ruling government. He was an activist, and he left South Africa with his wife to mark the protest against apartheid. He moved from there to Uk and then to Columbia University.

Those days when Dr.Susser made up his mind for epidemiology, epidemiology was not the part of curriculum in medical school. Dr. Mervyn had no formal training in epidemiology when he joined the department of epidemiology in Columbia’s school of public health in 1966. Contrast to British, United States was still belong to infectious disease era.Measles vaccine implementation program was in place (since measles vaccine was discovered in 1962).In other words, Dr.Susser was witness of  the era  changing  from infection diseases to chronic disease. He proficiently  targeted the social aspect of diseases, perhaps thanks to his appointment  as professor for social and preventive medicine while he was in UK.

Dr.Susser had one of his best publications on the’ future of epidemiology’ with his daughter and he also had many publications with his wife Zena. He married Zena when both were in medical school. Later they both started medical care in Alexandria town. They were medical practitioner and eventually they became epidemiology practitioner. Dr.Susser held Dr.Brad Hill in high regards. He also regarded as one of three fathers of social epidemiology.

His publication, ‘Epidemiology in the united States after world war second, the evolution of technique’  has been guiding torch for epidemiologists for many years. Underlining the evolution in epidemiology, he noted how theory and method became part of epidemiology training. Earlier, the only route to enter epidemiology was through medicine. Considering it as evolution, non-medicine researcher also started entering epidemiology, For example, Austin Bradford Hill was not physician. In his words, ‘newly minted epidemiologists’ were mix of many disciplines.Further adding in his article, he emphasized that Koch’s germ theory shifted epidemiology from miasma to germ-based theory. He beautifully explained how Framingham study was the foundation of the chronic disease studies, and how it denied the notion those only prospective studies could be funded. This paper tactically shows the journey from case control to cohort to the multivariate model study. I consider this paper integral part of epidemiology study.

He was  editor of American Journal of Public Health (AJPH) for six year between 1992 and 1998.  Recognizing  his contribution to epidemiology, American Public Health Association bestowed him With John  Snow Award. Richard Mayeux reportedly told New York Times, ‘his profound impact on critical thinking and causality set the framework for modern epidemiology.’ Tons of respect e to great scientist who will keep enlightening physicians to serve community, and epidemiologist not to forget considering social aspect of causation.

 

When we will turn over pages of public health history in future, battle against HIV would be remembered the same way as we do battle of Austerlitz of the Napoleon era or Trojan war of Greek epic. Of course, characters of the history (in making)  such as Dr. Wafa Sadr, Dr.Anke Ehrhardt, Dr. Anthony Fauci, Dr.James Curran and Former President Bill Clinton would be termed as Heroes. Since we are still many miles away from the actual victory, two names–who shared the same cause, who shared the same passion and unfortunately shared the same end (in death)—really worth to be mentioned for many fights we won so far against HIV. In 1998, we lost Dr. Jonathan Mann in ill-fated Swiss airflight111 crash when he was on the way to UN AIDS vaccine conference. And after 16 years, we lost Dr.Joep in unfortunate Malaysian crash. One accident as natural tragedy and another was human made accident. Crashed two bodies, not vision!

Dr. Mann was former head of WHOs AIDS program. In the very first leg battle against HIV/AIDS, when it was sort of emerging plague, the role of Dr. Mann is very important. He was the architect in defining the problem of HIV AIDS as global. According to James Curran of Center for Disease Control and prevention (CDC), Dr. Mann considered HIV/AIDS as human right and global cause. Dr. Mann used to say, the way you define the problem will determine what you do about it. He started AIDS program with one assistant and in the span of just four years, he made it the biggest program of WHO with 280 employees with annual budget of 100 million dollars. As he always said,‘Against AIDS we will prevail together‘. WHO started award after his name.

Dr.Joep(Joseph Marie Albert) Lange was president of AIDS society in between 2002 and 2004. He was on the way to annual AIDS conference to be held in Australia this year. He was pioneer in making AIDS drugs available to Africa. He used to say, ‘If Coca-Cola can deliver cold beverages to Africa, why can’t we deliver HIV medication?’ and he accomplished this feat in connecting pharmaceuticals to Africa. He also founded ‘pharm access foundation.’ Recently he argued that PreP is more effective than other modes of HIV prevention. At the time of death, he was the director of Amsterdam Institute for Global Health and Development (AIGHD). He also founded Journal Anti-retroviral therapy and remained editor in chief till last moment. He published more than 350 papers and had mentored many PhD students. He conducted several clinical trials on antiretroviral therapy. He was scientist, physician and more importantly he was health right activist.

Dr.Jonathan Mann defined HIV/AIDS as global problem, and Dr. Joep Lange championed the cause of solution in form of treatment globally. We lost both of them, but in Dr. Mann’s word, ‘Against AIDS we will prevail together.’ Their legacy on HIV/AIDS will live on. We are determined to finish the work they wish to see it happen. We will have vaccine what Dr. Mann dreamed of and we will have treatment globally available what Dr.Lange dreamt of. And Finally, we should still be proud of human race whenever people like Dr. Mann and Dr.Lange are born!!

 

Robin Williams, actor who helped people to get rid of sorrows with his comedy, fell himself victim to mental illness. It somehow highlights the problem of mental health issues in the United States. Not always financial reasons are the trigger points for such extreme steps to take own life as we  usually believe. In the same context, but just little deviating from this incident, I would like to shed light on  psychological disorders stemming from cancer. I interned in the Einstein for a year in psych-oncology program where cancer patients were engaged in certain activities to deal with psychological effects of cancer.

United States is home to around 13 million cancer Survivors. Among survivors, some of them are newly diagnosed, some completely treated; some are on treatment while some are in terminal stage. So as per the stage, and diagnosis, mental status of cancer patient is different. It’s all about coping mechanism when symptoms and outcome is concerned. It is roughly estimated that one in three Americans will be diagnosed with cancer at some point of their life. It emphasize the numerical importance of magnitude of psycho-ailments.

Mental health problems are crucial to treat in cancer patients because of the amount of stress it causes, which also result in anxiety, distress and depression. There are many layers of anxiety and distress associated with cancer patients. Treated cancer patients have always fear that cancer can return, and it causes anxiety, worries and depression among them. Their perception to view life also changes. New diagnosed cancer patients are the most vulnerable group to mental condition, earlier they are counseled, better for the outcome of disease. Such patients have misconception and fears, if those are timely addressed, they will start living in the framework of reality with firm resolve. Patient those on treatment suffer from the side effects of the treatment and they are also doubtful about the success of treatment because of ongoing adverse effect of chemo-radiation therapy. When person with cancer is not able to cope with cancer, he is called in distress.

Anxiety depends on the how patients adjust to the diagnosis of cancer. Counseling of the cancer patients is important depending on the distress level. Researcher recommended using distress thermometer to measure the distress level of cancer patients. Distress thermometer ist 10-scale instrument when patients are asked to express distress on the scale of 10. Few researchers and clinicians use questionnaires to judge distress in cancer patients. Another studies reported that those distressed are more likely to use complementary and alternative therapies. Body releases stress hormones such as epinephrine and norepinephrine that invite cardiac ailments. Chronic stress also reduces immunity, which causes infections. There are few studies conducted in mice, which shows that loneliness fastens tumor growth. In another study, cancer is more likely to metastasis in chronically stressed mice than mice, which were not stressed.

Depending on the distress level how patient is made to adjust with the situation is the main challenge for mental health professionals. It is been studied that patient with high distress are more open to engage with social workers to seek advice. Cancer patients can be advised to engage in pleasure activities like music, dance, or origami. They can even engage in talk therapy. Considering the effect of loneliness on the health outcome in experimental studies, social support is very important. Many times animal therapy is also recommended in elderly patients to counter loneliness. Patient should be given useful support from psychologists, social workers, spiritual figures like priests or psychiatrists. Timely intervention will not only help cancer patients, it also helps in reducing health care costs.

 

Many studies have found that public health programs do not sustain without community participation. Recent outbreak of Ebola further highlight the need of educating community about the prevention and treatment. Timely prevention can reduce morbidities and mortalities. It is joked that when HIV was in the very first leg of its knowledge among people, Indians thought that it was something about H1 visa to America. Things have remarkably changed and people are quite aware of prevention and transmission route of HIV to greater extent. Imagine if people were not aware/educated of HIV by now, whole world would have come in its grip. How many other disease (sexually transmitted)  have been prevented while targeting HIV/AIDS.

Could participation by lay public help investigation? Does outbreak investigation underline community participation?

Ebola is already creating havoc in African countries like Liberia, Sierra Leone and Guinea. In global era, we need to prepare for any type of health emergencies stemming from travellers. Any country can become exposed to it barring geographical boundaries. At this juncture what important is to create awareness among people about the outbreak, lethality of virus, and more importantly preventive measures. Just stopping people whoever travelled to the affected area and returning back to our country is not a solution, and neither a good option.

With community participation, it becomes easy to identify suspected case and again with community participation, treatment is made available fast to the diagnosed patients. It also helps to address misconception about disease.

For example, scabies was treated in village of Galilli (Northern Israeli town) with active community participation. It was that time when computers and internet didn’t exist, Television was rare in villages and print media had supreme dominancy.

Physicians and nurses can play a great role in any public health emergency as they have contacts with multiple level of system. Physicians or nurses with community health background or epidemiology can influence investigation outcome, and community participation. Data collection needs involvement of community. Active participation of people would give large sample and accurate data. Even communicating finding also need community support, as if it reaches large population, it could help in creating awareness and healthy habits.

Once a socio-economic-psychological character of community is defined, appropriate program can be designed and implemented.

 Education program as an intervention can be tailored as per the capacity of concerned country. If it is resource limited setting, mode of education changes and materials used in education also vary to some extent. For example, in Africa, people should be discouraged for burial of bodies, intimate contact with monkeies and other animals. Objective of reducing human-to-human transmission should be on priority by educating people: contact with patients (body fluid) should be avoided. Healthcare professional while dealing should wear gloves with patients; in addition, hand should be washed before seeing the patient and after patient leaves. Lay people who come across such patients should notify health care agencies or health care professionals.

Three lethal facts about Ebola : 1) Case fatality rate is very high 2) There is no specific treatment , only supportive measure available. 3) And no vaccine available. Only good news is that at least it is not air borne.

 

 

Ebola outbreak

Ongoing ebola outbreak in West African countries has created public health emergency all over the world. What makes Ebola infection dreadful is that its case fatality rate is very high (50-90%), there is no specific treatment for it and vaccine for infection is still a distant dream. Fortunately, it doesn’t spread by air droplets. I am eagerly observing how Center for Disease Control and Prevention (CDC) responds to such public health emergency.

I am deeply sad by recent Malaysian flight crash which included 298 passengers aboard the flight. Further insult to the injury, victims included leading HIV researchers. Top HIV researcher Dr.Joep Lange {whose  most recent artcile(abstract)  in Clinical infectious disease Journal I read last week} was also traveling in ill-fated flight. How life is unpredictable, I was strongly thinking to attend this conference few months ago, but then left the idea because of technical things and exams compulsions. I pray for victims, their relatives, friends, colleagues and all associates.

Abstract ( Dr.Joep Lenge)

The concept of “treatment as prevention” has emerged as a means to curb the global HIV epidemic. There is, however, still ongoing debate about the evidence on when to start antiretroviral therapy in resource-poor settings. Critics have brought forward multiple arguments against a “test and treat” approach, including the potential burden of such a strategy on weak health systems and a presumed lack of scientific support for individual patient benefit of early treatment initiation. In this article, we highlight the societal and individual advantages of treatment as prevention in resource-poor settings. We argue that the available evidence renders the discussion on when to start antiretroviral therapy unnecessary and that, instead, efforts should be aimed at offering treatment as soon as possible.

Isn’t it a fun to prepare for medical license exam through public health and epidemiology specs? Yes, It adds flavor and spices … For example, when I was studying myocardial infarction before pursuing masters in public health, my earlier approach was starting with pathology. But now, first thing comes to my mind is how many people suffers from myocardial infarction? How many people can we save if treatment is made available within an hour? How can we make tertiary centers available to large chunk of population, and in the same flow, how can we reduce the gap between poor and rich in the United States, and a=the same across globe.

 

Isn’t it interesting to know that, because of hormones, myocardial infarction is less common in young women compared to young men? However, after menopause, women are equally prone to myocardial infarction to their men counterparts.

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