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

i ssue 5.03

Gambl ing wi th publ ic heal th

Why gun contro l is a loaded issue

Searching for the cause of a myster ious

epidemic

Br ing ing surgery into the g lobal hea l th agenda

BAR BAR

BAR

ON THE COVER: A slot machine illustration symbolizes the health questions surrounding legal gambling, which is the subject of this issue’s feature story.

Sandro Galea, MD, DrPH Gelman Professor and Chair Department of Epidemiology

EDITORS Barbara Aaron Administrative Director Elaine Meyer Associate Director of Communications

CONTRIBUTING EDITORS Dana March, PhD Assistant Professor of Epidemiology Joshua Brooks Senior Communication in Health and Epidemiology Fellow

ASSOCIATE DESIGNER Kristen Byers Web Developer / Graphic Designer

DESIGNER Jon Kalish

CONTRIBUTING WRITERS Kathleen Bachynski Communication in Health and Epidemiology Fellow ‘14 PhD candidate in Sociomedical Sciences Stephanie Berger Director of Communications for Media Relations, Mailman School of Public Health Justin Knox PhD Candidate in Epidemiology Anna Larsen MPH Candidate in Epidemiology Steve Mooney PhD Candidate in Epidemiology Alfredo Morabia, PhD Professor of Clinical Epidemiology Tim Paul Associate Director for Strategic Communications, Science Editor, Mailman School of Public Health Ambereen Sleemi, MD MS Candidate in Epidemiology

1DEPARTMENT OF EPIDEMIOLOGY

CONTENTS

Publication highlights

FEATURES

Gambling with public health?

Gun violence as a public health issue

Searching for the cause of a mysterious epidemic a century ago

Bring surgery into the global health agenda

Epidemiologist report: ‘A hopelessly prevention-oriented guy’

Training report: New HIV science implementation program

Symposium report: Preventing brain disorders

In the news

In memoriam

Faculty publications

3

10

24

29

33

37

40

42

44 48

49

2

Colleagues,

Welcome to our fall issue of 2x2.

In this issue, we take an epidemiologic perspective on issues that are often viewed through an individual lens, including gun violence, gambling addiction, the use of surgery in global health, and brain disorders. We also profile a legendary alumnus, Dr. Sten Vermund, a new training program that marries the methods of epidemiology to the practice of HIV implementation science, and an interesting and instructive story about a mysterious disease that afflicted the southern United States in the early 1920s and 1930s.

We are continuing to expand our list of contributing writers and look forward to engaging more of you in the translation of epidemiology over the coming academic year.

Warm regards,

chair’s message

3DEPARTMENT OF EPIDEMIOLOGY

publication highlights

Stress is associated with a greater

likelihood of fertility problems

for men, according to a study

published in the journal Fertility

and Sterility by epidemiologists at

Columbia’s Mailman School of Public

Health.

“Men who feel stressed are more

likely to have lower concentrations

of sperm in their ejaculate, and the

sperm they have are more likely

to be misshapen or have impaired

motility,” says senior author Dr. Pam

Factor-Litvak, associate professor of

epidemiology. “These deficits could

be associated with fertility prob-

lems.” Epidemiology PhD graduate

Dr. Teresa Janevic was a lead author

on the study, and epidemiology doc-

toral candidate Ms. Linda Kahn was a

co-author.

Although the study is not the first

to look at the link between stress and

fertility, the research group says this

one uses the most comprehensive

measure of stress to date.

The researchers looked at 193

healthy men age 38-49 enrolled in

the Kaiser Foundation Health Plan

in Oakland, California. To measure

“subjective stress,” the men were

asked to rate how often they per-

ceived events at work and in the rest

of their life as stressful. To measure

“objective stress,” they filled out a

survey answering whether they had

experienced various stressful events

over the past year, such as a divorce or

death in the family.

Samples of the participants’ semen

were analyzed to measure concen-

tration of sperm, sperm movement

or motility, and defects in the size

and shape of the sperm—or sperm

morphology.

The researchers adjusted for poten-

tial confounding factors, including

income, education level, and race.

Men who experienced subjective

and objective life stress were sig-

nificantly more likely to have worse

sperm quality. However, there was not

an association between work stress

and semen quality. Dr. Factor-Litvak

Stressed men more likely to have fertility problemsComprehensive study of stress finds association with sperm quality

hypothesizes that men may be adept

at blocking out work stress. Her team

suggests using other measures in

future studies to measure work stress,

such as “effort-reward imbalance,”

long work hours, or “organizational

injustice.” Additionally, unemployed

men had lower sperm quality than

employed men.

While past research has drawn

associations between stress and

sperm, the Columbia group noted that

those studies did not measure stress

as comprehensively. One used only

subjective measures of stress, another

asked just one question about stress,

and a third used a survey that was not

designed specifically to measure per-

ceived stress.

The mechanism for how stress

could influence sperm quality is not

clear. One possibility is through a

neuroendocrine process that would

impair creation of sperm. In one such

process hypothesized by the research-

ers, stress would cause increased

production of steroid hormones called

glucocorticoids which would lead to

decreased excretion of testosterone

from cells that produce sperm, known

as Leydig cells, as well as to the pro-

duction of fewer of these cells.

A further possibility is that stress

affects a reproductive hormone known

as the follicle-stimulating hormone, or

FSH, but researchers found no associ-

ations between stress measures and

either FSH or total testosterone.

“Although this area of research

needs further development, it sug-

gests the importance of stress across

the life course and intergenerational

stress to male reproductive health,”

say the authors.

Janevic T, Kahn LG, Landsbergis P, Cirillo PM,

Cohn BA, Liu X, Factor-Litvak P. Effects of

work and life stress on semen quality. Fertil

Steril. 2014 May 22. pii: S0015-0282(14)00381-

1. doi: 10.1016/j.fertnstert.2014.04.021.

related media coverage

TIME Magazinetime.com/138592/stress-sperm

4 FALL 2014 : ISSUE 5.03

Problems faced by National Guard

soldiers upon coming home to

the U.S., such as unemployment,

financial and legal problems, and

divorce, better predict whether they

develop an alcohol use disorder than

the traumatic experiences of combat,

according to a new study published

in the American Journal of Preventive

Medicine. The study was authored by

Drs. Magdalena Cerdá, assistant pro-

fessor of epidemiology; Dr. Karestan

Koenen, professor of epidemiology; Dr.

Sandro Galea, Gelman Professor and

chair of the department of epidemiol-

ogy; Dr. Catherine Richards, associate

research scientist in epidemiology; and

predoctoral candidate in epidemiology

Mr. Greg Cohen; all at Columbia’s Mail-

man School of Public Health, along with

faculty at Case Western Reserve Univer-

sity, the University of Michigan, and the

University of Toledo.

Alcohol problems are of particular

concern among reservists. Fourteen

percent abuse or are dependent on

alcohol, compared to about 7 percent

of the general American population,

according to a 2012 survey from the

Substance Abuse and Mental Health

Service Administration. Alcohol abuse

happens when alcohol interferes with

one’s life, such as responsibilities at

home, work or school, and when people

place themselves in dangerous situa-

tions or have social or legal problems

due to their drinking. The more severe

form, alcoholism, also includes physical

dependency.

The investigators conducted phone

surveys of 1,095 members of the Ohio

National Guard who served in the Wars

in Iraq and Afghanistan from June 2008

through February 2009. The reservists

answered questions about whether

they had experienced any traumatic

events while deployed, such as receiv-

ing incoming fire, seeing the bodies

of severely wounded enemy soldiers,

or being sexually harassed. They also

answered questions about whether

they had experienced various stressors

Alcohol problems in National Guard linked to stress upon returning homeStudy suggests reservists are not getting adequate help

the2x2project.org

2x2.ph/alcohol-national-guard

after coming home. This included, in

addition to job, financial, and relation-

ship problems, mental illness, family

problems, or difficulties accessing ade-

quate healthcare.

Nearly 60 percent of soldiers experi-

enced combat-related traumatic events,

36 percent experienced stressors as

civilians, and 17 percent reported sexual

harassment during their most recent

deployment. Experiencing at least

one civilian stressor along with sexual

harassment was associated with higher

odds of newly developing an alcohol

use disorder. Combat and post-com-

bat stressors were only marginally

associated.

The study spotlights the significant

challenges of transitioning back into

civilian life for reservists. “Exposure

to the traumatic event itself has an

important effect on mental health in the

short-term, but what defines long-term

mental health problems is having to

deal with a lot of daily life difficulties

that arise in the aftermath—when sol-

diers come home,” says Dr. Cerdá.

Additionally, members of the

National Guard do not have the same

access to services as regular military

personnel when they return home.

“Guardsmen who return home need

help finding jobs, rebuilding their mar-

riages and families, and reintegrating

into their communities. Too many of our

warriors fall through the cracks in our

system when they return home,” says

Dr. Koenen.

Cerdá M, Richards C, Cohen G, Calabrese JR,

Liberzon I, Tamburrino M, Galea S, Karestan

Koenen KC. Civilian Stressors Associated

with Alcohol Use Disorders in the National

Guard. American Journal of Preventive

Medicine. Epub 30 July 2014. http://dx.doi.

org/10.1016/j.amepre.2014.06.015.

PUBLICATION HIGHLIGHTS

5DEPARTMENT OF EPIDEMIOLOGY

PUBLICATION HIGHLIGHTS

Those who had significant expo-

sure to the events of September

11, 2001, reported highly ele-

vated levels of binge drinking five and

six years after the attacks, according

to a new study by researchers at

Columbia University’s Department of

Epidemiology at the Mailman School

of Public Health, Columbia’s Depart-

ment of Psychiatry, and the New

York City Department of Health and

Mental Hygiene. Among the authors

are Dr. Deborah Hasin, professor of

epidemiology in psychiatry, Dr. Steven

Stellman, professor of clinical epide-

miology and research director for the

New York City Department of Health’s

Word Trade Center Health Registry,

and Dr. Katherine Keyes, assistant

professor of epidemiology. The study

adds to previous research that has

found a relationship between binge

drinking and exposure to large-scale

disasters.

“Our findings are relevant for

long-term post-9/11 monitoring and

treatment under existing federally

funded healthcare services for sur-

vivors and responders, and more

broadly for psychological and alcohol

screening and counseling following a

disaster,” says Dr. Stellman.

The researchers looked at the drink-

ing habits of 41,284 individuals from

the registry who were at or near the

World Trade Center during and after

the terrorist attacks on September 11.

This included workers and volunteers

involved in rescue, recovery, and

cleanup efforts and people who lived,

worked, or happened to be near the

site.

To determine how exposed an

individual was to the attack, the

researchers measured the number of

attack-related events that a person

experienced, such as being in one of

the towers when the planes hit, being

exposed to the intense dust cloud that

formed after the attacks, or sustaining

an injury. The research team defined

binge drinking as consuming five or

more alcoholic drinks on five or more

occasions in the last 30 days. Nearly 14

percent of those who had “very high”

Binge drinking elevated in people who experienced events of 9/11Frequent drinking persisted many years later

exposure to 9/11 reported binge drink-

ing, as did nearly 10 percent of those

with “high” exposure. Of people who

had “medium” exposure, 7.5 percent

reported binge drinking, while 4.4 per-

cent of those with “low” exposure did.

The study also looked at the rela-

tionship between frequent binge

drinking and post-traumatic stress

disorder, or PTSD, after the attacks.

Rates of binge drinking were signifi-

cantly elevated in people with PTSD,

at 14.8 percent, over people without

PTSD, at 6.3 percent. The researchers

excluded all people who had been

medically diagnosed with PTSD before

the attacks.

Past research has found an

elevated use of alcohol among pop-

ulations exposed to the Oklahoma

City bombing and Hurricane Katrina.

“Many studies have shown a rela-

tionship between adult trauma and

drinking outcomes, but the present

study contributes important new

information by showing that the rela-

tionship between a major trauma and

drinking persists over many years,”

says Dr. Hasin.

Dr. Stellman adds that the 9/11

registry “has a program of actively

referring enrollees to healthcare ser-

vices that could serve as a model for

future disasters.”

Welch AE, Caramanica K, Maslow CB, Cone

JE, Farfel MR, Keyes KM, Stellman SD,

Hasin DS. Drug Alcohol Depend. Frequent

binge drinking five to six years after expo-

sure to 9/11: Findings from the World Trade

Center Health Registry. 2014 Apr 28. pii:

S0376-8716(14)00839-4. doi: 10.1016/j.drugal-

cdep.2014.04.013. [Epub ahead of print]

the2x2project.org

2x2.ph/binge-drinking-911

6 FALL 2014 : ISSUE 5.03

PUBLICATION HIGHLIGHTS

Most people know that avoiding

smoking and engaging in

physical activity are beneficial

to health, but the benefits are not

necessarily easy to quantify. A new

study provides estimates for how

many years of life are lost to smoking,

physical inactivity, and obesity. The

number is anywhere from two to 14

years. Dr. Luisa N. Borrell, an adjunct

faculty member in the Department

of Epidemiology at Columbia’s

Mailman School of Public Health and a

professor in the Department of Health

Sciences at Lehman College’s School

of Health Sciences, Health Services

and Nursing, authored the study,

which was published in the Annals of

Epidemiology.

Dr. Borrell analyzed data from the

federal government’s National Health

and Nutrition Examination Survey,

which collects health measures from a

representative sample of Americans.

Participants answer questions about

their smoking habits and physical

activity levels and have their weight

and height measured.

Twenty-nine percent of adults in

the study group report currently smok-

ing, 25.7 percent report being former

smokers—defined as having smoked at

least 100 cigarettes in their lives, and

45 percent do not smoke. Thirty-nine

percent report being “physically inac-

tive”—which means engaging in zero

to one form of exercise or sports per

week, 30.1 percent are “infrequently

inactive”—which means they engage

in between one to five activities, and

30.9 percent are “active”—engaging

in five or more physical activities per

week.

The study looked at whether people

fit into multiple categories, such as

those who are current smokers, physi-

cally inactive, and obese— 2.7 percent

of the study group. Current smokers

who are physically inactive and over-

weight represented 3.5 percent of the

people surveyed, and current smokers

of normal weight who engage in no

physical activity made up 5.9 percent.

Those who report never smoking,

regular physical activity, and normal

weight made up 7.6 percent of the

group.

For years of life lost, the worst off,

as might be expected, were those

who currently smoke, are physically

inactive, and are obese. They died

on average 14.2 years earlier from all

causes of death than those who never

smoked, are physically active, and are

normal weight. Current smokers of

normal weight who aren’t physically

active lost nearly 10 years. The study

also isolated cardiovascular disease

as a cause of death, which strongly

correlated with smoking, physical inac-

tivity, and obesity.

The results bolster a 2009 study

that suggested that the obesity epi-

demic could erase gains in years of

lifetime, which came from the decline

in the prevalence of smoking over

the last 40 years. “The joint effects

of smoking, physical inactivity, and

overweight or obesity on advanc-

ing all-cause and cardiovascular

disease-specific deaths among U.S.

adults could have serious public health

implications,” says Dr. Borrell.

“While a lot of attention has been

paid to the effects of smoking over the

years and of obesity recently, physical

inactivity should not be neglected,”

she adds. “Programs should be devel-

oped to prevent and monitor these

health risk factors, especially in the

adolescents and young adults, as

singly or together they are associated

with most chronic diseases in the U.S.

population.”

Borrell LN. The effects of smoking and phys-

ical inactivity on advancing mortality in U.S.

adults. Ann Epidemiol. 2014 Jun;24(6):484-7.

doi: 10.1016/j.annepidem.2014.02.016. Epub

2014 Mar 21.

Death comes earlier for smokers, obese, physically inactiveThese groups live up to 14 years less than those in better health

the2x2project.org

2x2.ph/death-inactive

7DEPARTMENT OF EPIDEMIOLOGY

0

2

4

6

8

10

12

14

16

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Originally published on the GRAPH website, at cugraph.org

DATA SOURCE: FIGURE 1. LN BORRELL. THE EFFECTS OF SMOKING AND PHYSICAL INACTIVITY ON ADVANCING

MORTALITY IN U.S. ADULTS. ANN EPIDEMIOL. 2014 JUN;24(6):484-7

This dot graph shows the average number of years death is advanced due to the joint

effects of smoking, physical inactivity, and obesity. Along the y-axis is the rate advance-

ment period, or the average number of years death is advanced, ranging from 0 to 18

years. Along the x-axis are categories that represent the different joint effects of smoking,

physical inactivity and obesity. Those who currently smoke, are physically inactive, and

are obese die on average 14.2 years earlier from all causes of death than those who never

smoked, are physically active, and are normal weight. Current smokers of normal weight

who are not physically die almost 10 years earlier.

8 FALL 2014 : ISSUE 5.03

PUBLICATION HIGHLIGHTS

A federal program that put

money toward making it safer

for children to walk or bike

to school saved money and lives in

New York City, according to a study

from the Columbia Mailman School of

Public Health’s Dr. Charles DiMaggio,

associate professor of epidemiology;

Dr. Guohua Li, Finster Professor of

Anesthesiology and Epidemiology;

and Dr. Peter Muennig, associate

professor of health policy and man-

agement, who was lead author.

Between 2005 and 2012, the Safe

Routes to School Program gave $1.1

billion for states to make roadway

modifications around schools. New

York City transportation officials used

the funds to narrow intersections by

building out sidewalks, set off dedi-

cated bike lanes, install speed bumps,

and program lights so pedestrians

have more time to cross the streets.

These improvements led to $230

million in cost savings as a result of

a decline in pedestrian injuries and

deaths and less money going into

busing students. The authors did not

include other sources of savings, such

as reductions in pollution, traffic con-

gestion, and obesity rates, because

they are difficult to quantify. The pro-

grams also saved an estimated 2,055

quality-adjusted years of life.

The study is particularly rigorous

because the investigators had data on

census tracts before, during, and after

the modifications were made, which

are usually not available.

The success of Safe Routes sug-

gests that interventions such as urban

reengineering, which aim to protect

the public from harm by creating

a safer environment, can be more

effective than education campaigns

that rely on individuals to protect

themselves. “Public health practi-

tioners have moved beyond initiatives

that require actions on the part of

the public, such as health education

campaigns, and onto innovative

approaches to public health,” say the

investigators.

The federal Safe Routes program

lost dedicated funding in 2012 and

now falls under a larger umbrella of

“Transportation Alternatives” that

states can choose to fund. “That’s one

reason why we think evaluation of

safety programs, particularly in terms

of cost effectiveness, is so important,”

says Dr. DiMaggio. He and his team

are hoping to run the same kind of

analysis on some of the city’s Vision

Zero efforts, and this fall the Mailman

School of Public Health plans to hold a

research summit on that program.

Muennig PA, Epstein M, Li G, DiMaggio C.

The cost-effectiveness of New York City’s

Safe Routes to School Program. Am J Public

Health. 2014 Jul;104(7):1294-9. doi: 10.2105/

AJPH.2014.301868. Epub 2014 May 15.

NYC pedestrian safety program saves $230 million Study bolsters case for urban reengineering

the2x2project.org

related media coverage

HealthCanal.com

2x2.ph/pedestrian-safety

bit.ly/1kCX33I

9DEPARTMENT OF EPIDEMIOLOGY

PUBLICATION HIGHLIGHTS

Teen sleeplessness piles on risk for obesity

T IM PAUL

Teenagers who don’t get enough sleep may

wake up to worse consequences than nod-

ding off during chemistry class. According

to new research, risk of being obese by age

21 was 20 percent higher among 16-year-

olds who got less than six hours of sleep

a night, compared with their peers who

slumbered more than eight hours. (The

Centers for Disease Control and Prevention

recommends nine to ten hours of sleep for

teenagers.)

Dr. Shakira Suglia, assistant professor

of epidemiology at the Mailman School

of Public Health at Columbia University,

former MPH in epidemiology student Ms.

Seema Kara, and colleagues at the Univer-

sity of North Carolina Gillings School of

Public Health are the first to examine the

effect of sleeplessness on obesity in teen-

agers over time, providing the strongest

evidence yet that lack of sleep raises risk

for an elevated BMI.

Read more about the study http://epi.is/

teens-sleep-obese

Suglia SF, Kara S, Robinson WR. Sleep Duration

and Obesity among Adolescents Transitioning

to Adulthood: Do Results Differ by Sex? J Pedi-

atr. 2014 Jul 24. pii: S0022-3476(14)00597-6. doi:

10.1016/j.jpeds.2014.06.052. [Epub ahead of

print] PMID: 25066064 [PubMed–as supplied by

publisher]

America’s troubled mental health system

STEPHANIE BERGER

Mental healthcare reform is much needed

in our country, and providing better care is

one of our greatest challenges, according

to Dr. Lloyd Sederer, adjunct professor of

epidemiology at the Mailman School, in a

paper published in JAMA. Those who suffer

from acute mental illness discontinue treat-

ment or never seek services mostly because

of the stigma of mental illness or due to

bad experiences in the past, according to

Dr. Seder and colleagues. In his approach

to improve the mental health system he

outlines three important questions that

need addressing: What is affordable

mental health care? How should progress

be assessed? What are the essential next

steps?

“Providing safe and humane mental

health care is a responsibility of our com-

munities and neighborhoods and not for

our jails or shelters,” writes Dr. Sederer,

who is also medical director of the New

York State Office of Mental Health. “In

fact, federal and state governments should

make it a priority to move patients from the

criminal justice system to the treatment

system.”

Sederer LI, Sharfstein SS. Fixing the Troubled

Mental Health System. JAMA. 2014 Aug 14. doi:

10.1001/jama.2014.10369. [Epub ahead of print] No

abstract available.

Link between inflammation in mother and schizophrenia in offspring STEPHANIE BERGER

Maternal inflammation as indicated by the

presence in maternal blood of early gesta-

tional C-reactive protein—an established

inflammatory biomarker—appears to be

associated with greater risk for schizophre-

nia in offspring, according to researchers.

“This is the first time that this associ-

ation has been demonstrated, indicating

that an infection or increased inflammation

during pregnancy could increase the risk

of schizophrenia in the offspring,” said Dr.

Alan Brown, professor of epidemiology

and psychiatry and senior author. “To the

extent that the increased inflammation is

due to infection, this work may suggest that

approaches aimed at preventing infection

may have the potential to reduce risk of

schizophrenia.”

Read more about the study http://epi.

is/1qd9a98

Canetta S, Sourander A, Surcel HM, Hinkka-Yli-Sa-

lomäki S, Leiviskä J, Kellendonk C, McKeague IW,

Brown AS. Elevated Maternal C-Reactive Protein

and Increased Risk of Schizophrenia in a National

Birth Cohort. Am J Psychiatry. 2014 Jun 27. doi:

10.1176/appi.ajp.2014.13121579. [Epub ahead of

print]

briefs

10

The public health costs of legal gambling

BY ELAINE MEYER

Gambling with America’s health?

the2x2project.org

2x2.ph/ gambling-public-health

12 FALL 2014 : ISSUE 5.03

IMAGE: EIJI SAITO

First exposed to slot machines at a trade

show in Las Vegas in 2007, Stevens became

a regular slot player at the Mountaineer

Casino, Racetrack, & Resort, about 30

minutes away in Chester, West Virginia. By

2010, he had embezzled $7 million from his

employer to gamble, and when they found

out, he lost his job. Stevens continued to

gamble secretly for the next 10 months,

going to Mountaineer nearly every day,

drawing money from his family’s savings,

his 401(k), and his children’s college fund.

On August 13, 2012, that money ran out.

In a suicide note to his wife, he wrote: “I

know you don’t believe it, but I love you so

much. I have hurt you so much. Our family

only has a chance if I’m not around to

bring us down any further.” That evening,

Stevens asked his 13-year-old daughter to

bring him his hunting bag from the attic.

He drove to a local park he had helped

develop and called 9-1-1. When the sheriffs

arrived, he shot himself.

“If it can happen to a guy as smart as he

was, then it can happen to anybody,” said

Indianapolis attorney Terry Noffsinger

in a talk last November at Harvard Law

School. Noffsinger, with other attorneys,

Publicly, Scott Stevens, a chief operating offi-cer of a company in

Steubenville, Ohio, was a well-regarded member of his community. A married father of three, he was active in his local Catholic church, involved with high school sports teams, and helped develop parks in the area. Privately, Stevens was addicted to gambling.

is representing Stevens’ widow Stacy in

a lawsuit filed last month against Moun-

taineer Casino, its parent company MTR

Gaming Group, and slot machine maker

International Game Technology, alleging

they are liable for her husband’s suicide.

The suit accuses both the casino and

the slot designer of using predatory and

deceptive tactics to profit from people with

gambling problems, like Scott Stevens.

“Mountaineer Casino knew, or should

have known, that the condition of disor-

dered gambling, especially slot machine

addiction, is associated with severe

adverse health and other consequences for

individuals and their families. Not only are

gambling addicts like Scott Stevens liable

to literally gamble away everything they

own and end up in crippling debt, but also

to become suicidal at far higher rates than

the general population and even the pop-

ulation of persons addicted to substances

such as illegal drugs and alcohol,” the suit

states.

Although the suit’s success is not

assured—the few other cases in this area

have not succeeded—it is part of a growing

movement of activists, academics, lawyers,

13DEPARTMENT OF EPIDEMIOLOGY

about the addictive properties of cigarettes

and advertised to young people and other

vulnerable consumers.

According to Les Bernal, the national

director of Stop Predatory Gambling, a

Washington DC-based nonprofit, “This is

one of the biggest public health issues in

America today that no one has been paying

attention to.”

A few experts predict that as stories

of gambling addiction become more

common, suits like that of Stacy Stevens

will increase and could even succeed, as

tobacco lawsuits did. “Ultimately gambling

will be linked to the increase in social costs,

gambling will be linked to the problems it

creates, just like smoking was ultimately

linked to cancer,” says Dr. Earl Grinols, a

professor of economics at Baylor Univer-

sity. “It can take a while.”

Addictive properties

In the world of gambling, the most addic-

tive property is electronic video gambling

machines, often slots, which bring in 70 to

85 percent of the revenue for casinos. In

seven states, electronic video terminals

are even available in other venues, like

restaurants and bars. The machines do

not typically have warning labels or cut

offs for heavy users. Casinos aggressively

market to frequent patrons, giving them

complimentary flights, hotels, and other

perks. Meanwhile, the success of state vol-

untary exclusion programs where problem

gamblers sign up to ban themselves from

casinos is unclear.

Today’s slots are not the old

and former gambling addicts who are

trying to spotlight the health, economic,

and social costs of legal gambling. This

group believes the gambling industry preys

upon vulnerable people, including low-in-

come individuals, youth, and problem

gamblers and that gambling availability

is linked to larger societal problems like

crime and economic inequality.

For its part, the gambling industry

points to a record of funding research into

gambling addiction and efforts to educate

the public about problem gambling. They

maintain that they offer a fun activity

that most people can do without serious

consequences.

The opening of new gambling venues

shows no signs of slowing down, despite

the planned closing of four casinos in

Atlantic City and financial problems for

casinos in other states. Last fall, New York-

ers approved the building of up to seven

casinos. Many other states are in various

stages of building casinos. Some in the

gambling industry are trying to legalize

online gambling, which is currently allowed

in only three states, Nevada, New Jersey,

and Delaware.

A debate over the social and health

costs of legal gambling has largely been

sidelined even as availability has expanded

dramatically in the last 25 years. This is not

because of a lack of merit, say experts and

activists, but because of the political power

of the gambling industry. They allege that

the industry has employed tactics in the

same spirit as those of tobacco companies,

which for many years misled consumers

lever-operated “one-armed bandits” but

video game-like terminals that keep users

playing by deliberate design, according

to Dr. Natasha Dow Schüll, an associate

professor in the program of science, tech-

nology, and society at the Massachusetts

Institute of Technology and the author of

Addiction by Design: Machine Gambling in Las Vegas. “The particular addictiveness

of modern slots has to do with the solitary,

continuous, rapid wagering they enable. It

is possible to complete a game every three

to four seconds, with no delay between

one game and the next. Some machine

gamblers become so caught up in the

rhythm of play that it dampens their aware-

ness of space, time and monetary value,”

writes Dr. Schüll in a New York Times

commentary.

“A lot of people think it’s a tax on the

stupid,” recovering gambling addict Kitty

Martz told the Oregonian. “Really, we’re

behaving exactly the way the machines

want us to.”

The idea that gambling lends itself to

addiction like drugs or alcohol has taken

some time to be acknowledged. Until the

2013 publication of the fifth edition of the

Diagnostic Statistics Manual, or DSM-5,

problem gambling was classified as an

“impulse control disorder” in the same cat-

egory as pyromania and kleptomania, even

though most clinicians who treated prob-

lem gamblers recognized it as an addiction,

says Dr. Silvia Martins, an associate pro-

fessor of epidemiology at the Columbia

University Mailman School of Public Health.

These gamblers exhibit many of the

“This is one of the biggest public health issues in America today that no one has been paying attention to.”

14 FALL 2014 : ISSUE 5.03

same problems as other addicts. “Every-

thing you see with substance abuse you

can make an analogy to gambling prob-

lems,” Dr. Martins says, citing family strife,

financial hardship, and struggles with

depression or anxiety.

“Give your dreams a chance”

To gamble legally 40 years ago, one had to

travel to Nevada, go to a racetrack, or live

in one of the handful of states that offered

lotteries. In most towns, the closest one

came to a betting game was playing chari-

table Bingo at church. Video slot machines

had not yet come to market.

For most Americans today, a casino is

just a car ride away. There are about 1,400

of them in 39 states, and 43 states sponsor

lotteries with games that are recognizable

even to non-gamblers, like Mega Millions,

Powerball, Pick 10, and instant scratch off

tickets. In advertising to citizens, states use

slogans like, “Hey you never know,” “Give

your dreams a chance,” and “Believe in

something bigger.” Hawaii and Utah are

the only states that offer no forms of legal

gambling.

Casinos represent a substantial part of

the nation’s economy and enjoy support

from members of both political parties.

In 2012, the industry took in $37 billion in

gross revenue, employed 332,075 people,

paid $13 billion in wages, and contributed

$8.6 billion in taxes, according to the Amer-

ican Gaming Association. Many casinos are

not just places to play blackjack and slots

but to eat or take in live music and comedy

acts.

In this environment, gambling addic-

tion is often considered a small cost, one

brought upon by the individual unwise

gambler. “They think that it’s an easy pain-

less way to raise revenue but they don’t

see the other side of it,” says Arnie Wexler.

Wexler quit gambling over 45 years ago

after a nearly three-decade addiction and

has since served as executive director of

New Jersey’s Council on Compulsive Gam-

bling. He also runs counseling services for

compulsive gamblers with his wife, Sheila.

According to a conservative interpre-

tation of the available research by the

National Center for Problem Gambling,

1.1 percent or 3.4 million Americans have

a pathological gambling disorder and 2

percent or 6.2 million engage in problem

gambling, a less severe form of gambling

addiction. (The term problem gambling is

often used to refer to both problem and

pathological gambling). Internationally,

prevalence is as low as .5 percent of the

population in Denmark and the Nether-

lands and as high as 7.6 percent in Hong

Kong, according to a 2012 review for the

province of Ontario. Though problem gam-

blers are a minority of visitors to casinos,

their spending accounts for anywhere from

35 to 50 percent of the revenues, according

to several studies summed up in a paper by

the Institute for American Values.

Betting on science

Neuroscientists have found commonalities

between the brains of gambling and drug

addicted people, like increased impulsivity

and lower levels of activity in a region of

the brain’s reward system, which leads

people to seek bigger and potentially dan-

gerous thrills. But it is not clear from this

research when or how someone becomes

addicted to gambling.

Compared to other nations, there

has been relatively little epidemiologic

research on rates of problem gambling in

the U.S. The existing studies find that prob-

lem gambling increases with proximity to

casinos. The federal government’s 1999

National Gambling Impact Study found

that areas within 50 miles of a casino had

twice as high a rate of problem gambling

as those within 250 miles. The presence

of a casino within 10 miles of a survey

respondent’s home was positively related

to problem or pathological gambling,

according to a 2004 study by the University

of Buffalo’s Research Institute on Addic-

tions published in the Journal of Gambling Studies.

“Basically what we’ve learned is that as

with many other kinds of environmental

exposures, there typically is an increase in

the prevalence rate of problem gambling

in the wake of major introductions of new

forms of gambling, whether it’s lotteries

back in the 1980s and 1990s or casinos

in the 1990s and 2000s,” says Dr. Rachel

Volberg, a research associate professor of

epidemiology at University of Massachu-

setts at Amherst and a researcher for the

Massachusetts Gaming Commission. Dr.

Volberg has found that rates of problem

gambling began increasing during the

most rapid expansion of gambling opportu-

nities in North America and in Australia.

Yet she says problem gambling rates

seem to level off after awhile. A study by

the Research Institute on Addictions that

has not been published yet found that rates

of problem gambling did not continue to

rise between 2010-2012 despite greater

opportunity to gamble. Principal investiga-

tor Dr. John Welte, senior research scientist

in psychology at the University of Buffalo,

says it is not clear why, but he says it could

be a result of the economic crisis.

The National Center for Responsible

Gambling, or NCRG, is the charitable

arm of the gambling industry’s trade

association, called the American Gaming

Association. NCRG cites a few studies

that it says show problem gambling has

not risen since the 1970s. After a casino

moves in, problem gambling may become

more widespread initially, but after a while,

people “adapt”—they become more aware

of the risks, seek treatment, or simply lose

interest, says Christine Reilly, the senior

research director of NCRG. This is called an

“adaption effect.”

But prevalence studies do not tell the

full story, says Dr. Stephen Q. Shafer, the

chairman of the Coalition Against Gam-

bling in New York. “One of the fallacies is

that, let’s say you assume that your preva-

lence statistics are absolutely correct and

you show that the prevalence of pathologi-

cal gambling has not risen. It was, say, five

years ago 1.1 percent. Last year it was 1.2

percent. What that forgets is that the prev-

alence is a pool out of which people move

and into which people come, and looking at

prevalence compared to time one and time

two, you have to account for the people

who have recovered, died, moved away.”

For instance, a prevalence study conducted

in 2008 would have counted Scott Stevens,

but one in 2013 would not have.

For this reason, there need to be stud-

ies that use more rigorous epidemiologic

methods, says Dr. Shafer, who is also a

retired professor of medicine and epidemi-

ology at Columbia’s College of Physicians

& Surgeons and the Mailman School. He

has pushed to get New York State to com-

mission such a study, but the state’s health

15

department, the legislature, and the gam-

bling commission have shown no interest.

Individual disease or public health problem?

Funding for gambling addiction research in

the U.S. is about one-twentieth of funding

in Australia and Canada, where gambling

availability has also risen significantly in

the past several decades, according to Dr.

Volberg. Within the National Institutes of

Health, there is an institute for research

on alcohol disorders and an institute for

research on drug addiction, but no institute

for general addiction. Investigators who

study problem gambling typically have to

propose to look at it in conjunction with

drug or alcohol use in order to win grants.

The NCRG is the only private funder of

gambling addiction research in the country.

According to Reilly, they fund research by

top scientists at universities like Caltech,

Duke, and Stanford, which are published in

peer-reviewed journals. “We are funding

some of the best people in the country,

people who will lead us and force the issue

at a national level,” says Reilly.

The majority of the NCRG’s funding

goes to research based on a “disease

model”—which investigates what goes

on in the brains of individuals addicted to

gambling—rather than the public health

model, which looks at how availability

affects population rates of problem gam-

bling and potential social costs.

Both the disease model and the public

health model “have points of truth, and

they’re not mutually exclusive,” says Dr.

Welte. But he adds, “If I were the gambling

industry, I would want to fund people who

had the disease point-of-view…because

[they are] putting the source of problem

gambling between the ears of the gambler.”

According to Reilly, the disease model

is more practical because it can lead to

treatments and that it is less prone to the

“They think that it’s an easy painless way to raise revenue but they don’t see the other side of it.”

16 FALL 2014 : ISSUE 5.03

board, which she says mimics the structure

of the National Institute of Health and does

not interfere in the work of its researchers.

As for self-reporting, there are ways to

validate responses. Dr. Robert Williams, a

professor of addiction counseling at the

University of Lethbridge in Alberta Canada,

has compared what respondents report

they spend on gambling to actual gambling

revenue. He says the more reliable studies

are those in which the total of the revenue

reported by participants is closer to the

total revenue made by the gaming industry.

Dr. Williams points out that self-reporting

may also underrepresent problem gam-

blers, who would be more likely to have

their phone disconnected.

Growing the economy or exacerbating inequality?

Gambling availability has other public

health ramifications beyond addiction.

It may exacerbate economic inequality,

which has a strong relationship to health.

It levies regressive taxes which take a

larger share of income from lower than

from upper income Americans. If taxes on

gambling revenues substitute tax increases

on income—which are progressive—the

tax structure in a state becomes even more

regressive. And those who spend money

on certain forms of gambling are more

likely to be low income.

flaws of survey research. “To me it seems

kind of silly to spend time and money on an

issue that is extremely difficult to research,

because you can’t count on people’s

memory,” she says.

But it is not in the gambling industry’s

interest to have good research conducted

on the social and economic costs of casi-

nos and other forms of gambling, says

Dr. Grinols. He points out that the federal

government’s 1999 National Gambling

Impact Study Commission recommended

a moratorium on further gambling expan-

sion until more research could be done on

the economic and social costs and ben-

efits. “No research of the type and focus

hoped for by the Commission has been

forthcoming since. That’s because the

gambling industry has done what it could

to question these studies and has not itself

funded such studies,” says Dr. Grinols.

“The whole conclusion of the Commission

has been ignored and in fact thwarted by

the failure of money to be available for

good research.” Dr. John Warren Kindt, a

business administration professor at Uni-

versity of Illinois whose research looks at

the social and economic costs of gambling,

calls what NCRG funds “pabulum research

designed not to hurt the gambling industry

and to misdirect the debate.” In response

to such criticisms, Reilly is adamant that

the NCRG has a totally independent review

Gluten free products now fill the shelves.

Funding for gambling addiction research in the U.S. is about one-twentieth of funding in Australia and Canada.

IMAGE: JOE RAEDLE/GETTY IMAGES

Vegas-style slot machines debut

November 2006 in the state of Florida

at the renovated Gulfstream Park

Racing & Casino.

17DEPARTMENT OF EPIDEMIOLOGY

There is “a strong positive relationship”

between state lottery sales and the pov-

erty rates, according to a 2007 study in the

American Journal of Economics and Sociol-

ogy by economists at Cornell University

that looked at data over 10 years. The most

typical lottery player is a black, male, high

school dropout making less than $10,000

a year, according to a 1999 report to the

National Gambling Impact Study commis-

sion. Problem gambling is significantly

worse in economically disadvantaged

areas according to two studies from 2013,

one by Dr. Welte and his colleagues and

another by Dr. Martins and her colleagues.

And the presence of a casino is associated

with rises in bankruptcy filings, according

to a 2005 study from Creighton University.

While casinos may bring new jobs when

they open, most are low-paying service

work. The national median wage in the

gambling industry is $10.76 per hour. While

better than some service jobs, it is less

than the $16.87 hourly median wage for all

industries, according to 2013 data from the

Bureau of Labor Statistics.

And rather than boosting a local econ-

omy, casinos often draw business away

from other food and entertainment venues.

Many casinos are losing patrons to newer

competition in neighboring states, strain-

ing state budgets and threatening local

economies.

When casinos lose money or fail, the

repercussions are significant. Delaware

is spending hundreds of millions to keep

struggling casinos afloat. In Atlantic City,

several casinos plan to close by the end

of the month, including the Revel, a two-

year-old, $2.4 billion casino, entertainment,

and conference center that was supposed

to buoy the city’s flagging economy. The

closures leave thousands of jobless people

in a city that already has one of the high-

est unemployment rates in the country at

over 15 percent as of April 2014, a violent

crime rate six times the rest of New Jersey,

and 29 percent of its population in pover-

ty—a 7 percent increase since 1974, two

years before New Jersey voters legalized

gambling.

Although these statistics do not prove

that the city’s gambling economy caused

its problems, they do call into question

claims by politicians and developers that

casinos are an engine for economic growth.

Nevertheless, some New Jersey politi-

cians and business leaders are now talking

about opening a new casino—or four—at

the Meadowland Sport Complex in Bergen

County, New Jersey.

Tribal lands that have casinos have seen

improvement in jobs and county-level mor-

tality rates, according to a 2002 study from

the National Bureau of Economic Research.

Yet these communities still see more bank-

ruptcy, violent crime, and auto thefts and

larceny after a casino opens.

Legal gambling is also linked to social

problems like rises in crime and risky

behavior in youth. Counties where casi-

nos have opened have seen rises in the

number of rapes, robberies, aggravated

assaults, burglaries, larcenies, and auto

thefts, compared with counties without

casinos, according to a study by econo-

mists Dr. Grinols and Dr. David B. Mustard,

which looked at county FBI data from 1977

to 1996.

Because children are now growing

up in an environment where gambling is

so widely advertised and available, they

could be especially vulnerable. Youth are

at greater risk for problem gambling than

adults, according to a 2007 study from

The Showboat Casino with the Revel

Casino behind it, in Atlantic City. Both

are closing in September.

18 FALL 2014 : ISSUE 5.03

Canada. Two percent or about 750,000

teens ages 14 to 21 described gambling

with three or more negative consequences

in a national survey by Dr. Welte and

colleagues in 2008. Another 11 percent

gambled twice or more per week, which

is considered frequent. Teen boys who

gamble are more likely to become fathers

before age 20, especially those who prob-

lem gamble, according to a study by Dr.

Martins. African-American teens who are

problem gamblers are more likely to have

sex and get arrested at a younger age than

those who don’t gamble. Teens who had

depressive symptoms early in adolescence

are more likely to have gambling problems

later in adolescence, according to another

Martins study from 2011.

A “pervasive gambling culture”

Former U.S. Representative Robert Steele

has observed the casino economy at work

in southeastern Connecticut, the district

he represented from 1970-75, which in the

early nineties became home to both Fox-

woods and Mohegan Sun Casinos.

“They became almost instant successes

and the two biggest casinos in the world,”

says Steele, who has written a novel, The Curse, which is inspired by the story of the

two casinos and the tribes behind them.

With Atlantic City as their only competition

in the Northeast United States, Foxwoods

and Mohegan Sun drew about 60 percent

of their customers from out of state and

created 20,000 jobs.

But soon came problems no one seems

to have anticipated. Drunk driving arrests

in nearby Norwich more than doubled, and

annual calls to the local police department

went up fourfold, according to Steele.

There was a sharp spike in the number of

people who sought treatment for gam-

bling addiction. The rate of embezzlement

increased 400 percent, according to a

report from the state. Steele’s own tax col-

lector went to prison in 2001 for embezzling

money from the town to gamble.

Much of the promised employment was

in low-paying service jobs, sometimes

part-time and often filled by non-English

speaking workers who came from outside

the area. This influx put pressure on local

housing and social services. The local

school system gained 400 children who

collectively spoke 31 different primary

languages, requiring them to create an

“English for speakers of other languages”

program. Teachers observed value

changes in their students, says Steele.

“[They] say, ‘we try to teach the kids the

way to succeed in life is through hard work.

Then the casino culture comes in and says,

‘you hit it big, you hit the lottery. You hit the

payoff.’”

Today, revenue from Connecticut’s casi-

nos is down 35 percent since its high point

of 2007. Ultimately, says Steele, who used

to have a property abutting Foxwoods, the

casinos created a “pervasive gambling cul-

ture.” He adds: “the people in southeastern

Connecticut were in no way ready for the

casinos.”

Citizen action

In Massachusetts, citizens are campaign-

ing to repeal a deal that allows for MGM

Resorts International to build an $800 mil-

lion casino in the economically depressed

town of Springfield. “We see this as very

much a perpetuation of income inequality,

and the implications that income inequality

has on public health—that people stay in

poverty basically, stay undercompensated.

It’s the transfer of wealth from people who

don’t have money to people who have

abundant resources,” says Steven Abdow,

a senior staff member of the Episcopal

Diocese of Western Massachusetts. “This

would be intentionally bring[ing] in a prod-

uct that destroys lives.”

Abdow is working on a campaign to

oppose the building of an $800 million

casino by MGM Resorts International. Once

viewed as a way to revive the city’s dwin-

dled fortunes, the casino’s fate is now in

jeopardy. In June, a judge ruled in favor of

ballot measure that would allow the citi-

zens of Massachusetts to repeal a 2011 law

that authorized casinos in the state.

Tyre, New York, is a town of less than

1,000 people 270 miles northwest of New

York City. The town’s website boasts of a

community that “strives to maintain its

rural flavor,” welcoming visitors to stop by

and visit the Montezuma National Wildlife

Refuge and the Erie Canal. Last December,

residents learned that a Rochester-based

real estate company called Wilmorite

was bidding to open the Lago Resort and

The Mohegan Sun casino.

“We see this as very much a perpetuation of income inequality, and the implications that income inequality has on public health.”

19DEPARTMENT OF EPIDEMIOLOGY

THEN AND NOW:

Older slot machines,

known as “one-armed

bandits” (above) and

the newer video slot

machines that are

common today.

Casino on agricultural land, across from an

Amish farm.

“I grew up my whole life in this area. A

casino certainly is not what you anticipate

showing up on your doorstep,” says Jim

Dawley, a resident whose property borders

the proposed spot.

Dawley and his wife, who own and

run a small manufacturing company, and

two friends formed an organization called

Casino Free Tyre to oppose Wilmorite’s

plans. “When everybody knows everybody,

a good portion of the people you know are

going to be affected—even if not directly—

through broken homes, bankruptcy, the

whole gamut,” says Dawley.

Over 200 residents have signed a peti-

tion against the casino, but members of the

town board are supportive of Wilmorite,

which is promising multi-million dollar

revenues. The Dawleys are not letting

up, even though they are new to activism.

“This is so far outside of my normal realm,

it’s unbelievable. I have a little manufac-

turing business out in the woods. I’ve been

involved in our church and things like that

but as far as any political-rooted opposi-

tion, this is our first time.”

Following in the footsteps of tobacco?

In the court case over the Massachusetts

casino deal, an organization called the

Public Health Advocacy Institute filed a

friend-of-the-court brief that made a public

health argument against the gambling

industry. “Legalized casino gambling

causes devastating effects on the public’s

health, including not only the gambler but

also their families, neighbors, communities

and others with whom they interact,” the

brief says. Electronic gambling machines

“are designed to addict their customers in

a way that is similar to how the tobacco

industry formulates its cigarettes to be

addictive by manipulating their nicotine

levels and other ingredients.”

“Mirroring the tobacco industry’s strat-

egy of creating scientific doubt where

none truly exists, the casino industry

has co-opted and corrupted scholarship

on the effects of gambling through the

use of front groups that funnel money to

beholden scientists who are able to sani-

tize its origin,” the brief continues.

“The commercialization of a dangerous

product that threatens both individual and

public health has been called an ‘industrial

epidemic,’” the brief continues, citing a

2007 paper published in the journal Addic-tion by Drs. René I. Jahiel and Thomas F.

Babor. This is an epidemic “driven at least

in part by corporations and their allies who

promote a product that is also a disease

agent.”

The brief argues that the citizens of

Massachusetts have an interest in regulat-

ing gambling the way they have regulated

cigarettes.

Given the power of the gambling

20 FALL 2014 : ISSUE 5.03

industry and the dependence of states on

gambling revenues, winning legal damages

and regulating availability may presently

seem like a pipe dream in the U.S. However,

other countries employ harm reduction

strategies in casinos to intervene on poten-

tial problem gambling, according to a 2011

report from the Cleveland Plain Dealer. In

Holland, computers identify anyone who

visits a casino more than 15 times a month

as having a gambling problem. In the

United Kingdom, casinos have to display

the odds of winning on slot machines. And

in Australia, there are limits on playing

speeds and betting amounts.

The underlying principle behind this is

articulated by Dr. Williams: “If provincial

governments are going to make gambling

available to their citizens, then concerted

efforts are needed to prevent problem

gambling, to effectively treat gambling

addiction, and to minimize the amount of

gambling revenue that comes from prob-

lem gamblers.”

Little help available

People with gambling problems tend

to elicit little sympathy. They are seen

typically as exercising bad judgment when

it is known that the “house always wins.”

They have often hurt people they are clos-

est to, both financially and emotionally.

Former gambling addicts readily admit

to their flaws. But, like most people, they

typically started gambling because it

was available, entertaining, and provided

a potential if unlikely monetary reward.

Catherine Townsend-Lyon began playing

video lottery terminals at delis and restau-

rants near her home in Grant Pass, Oregon,

sometime after they were introduced in the

1990s. She became “hooked” to a game

called Flush Fever and soon began playing

before and after work and during her lunch

hour. She lied to her husband about her

whereabouts and started secretly gam-

bling their mortgage payments. She stole

from the collection company she worked

for and sometimes wore bladder control

underwear so she wouldn’t have to get up

to use the restroom while playing. When

she lost money, she played to win it back,

and when she won, she played to win more.

In an extreme moment, she skipped the

funeral of a close friend to drive 40 miles to

an Indian casino so she could win enough

The commercial-ization of a dangerous product that threatens both individual and public health has been called an “industrial epidemic.”

21DEPARTMENT OF EPIDEMIOLOGY

money to prevent her home from being

foreclosed. Instead, she lost everything.

She drove home in tears and slit her wrists.

“It’s like a battle you have with yourself

with the triggers and the urges and the

obsessiveness. You don’t even have to

be in action or sitting behind a machine

because you’re constantly thinking about:

When am I going to gamble? When am I

going to win or lose? It just compounds.

It’s exhausting. It’s never-ending,” says

Townsend-Lyon, who, after seeking treat-

ment several times, has managed to stay

away from gambling for the last seven and-

a-half years.

Townsend-Lyon says she turned to

gambling at a difficult time in her life. With

her husband frequently traveling for work,

she found herself bored and looking for a

way to fill the time. She had undiagnosed

bipolar II disorder and had been sexually

abused when she was younger but had

not been raised to know to seek therapy. “I

wasn’t a drug person or an alcoholic or

anything like that, although I did drink more

when I gambled. And because I was gam-

bling, that was my coping skill. That’s what

I was using to escape it, those feelings. I

In some states, electronic video ter-

minals are available in other venues

besides casinos, like restaurants, bars,

and convenience stores.

couldn’t stuff them away anymore. I would

just use gambling to escape, not feel, zone

out, you know what I mean?” she says.

She published a book last year about

her former life, called Addicted to Dimes (Confessions of a Liar and a Cheat). What

troubles her is how easy it is for people in

her position to gamble. She didn’t have to

fly to Nevada or even drive to a casino in

state. The video poker and slot machines

she played, which are sponsored by the

Oregon State Lottery, are allowed at bars,

restaurants, and delis.

“[I]f these machines weren’t in the bars

and delis, then I would not be gambling.

It’s that simple for me,” says a 33-year-old

man quoted in a recent series on the state

lottery by the Oregonian. He estimates he

has lost $15,000 over 12 years from gam-

bling. “That may sound like an excuse, but

‘out of sight is out of mind.’”

For people who are trying to recover

from gambling addiction, it can be diffi-

cult to find help. Calls per month to the

National Problem Gambling hotline are

over two-and-a-half times what they

were 14 years ago, from 9,642 in 2000 to

24,475 in 2013, according to Keith Whyte,

22 FALL 2014 : ISSUE 5.03

executive director of the National Council

on Problem Gambling. Yet funding for

treatment centers, hotlines, and programs

to prevent gambling addiction is minimal,

says Dr. Martins. Funding for substance

abuse treatment is about 281 times greater

at $17 billion than public funding for prob-

lem gambling, at $60.6 million, although

substance use disorders are only 3.6

times more common than gambling dis-

orders, according to a 2013 survey by the

Association of Problem Gambling Service

Administrators and Problem Gambling

Solutions. Just a little over half of the 50

U.S. states have someone whose full-time

job is to administer problem gambling

services, according to the same survey. By

comparison, there are 113 lottery employ-

ees in Iowa and approximately 80 in Rhode

Island. In several states legislators have

cut gambling treatment funding or seen

declines as a result of decreases in gam-

bling revenue, which sometimes funds

such programs, according to a Wall Street

Journal report from 2011.

Gamblers’ Anonymous, a 12-step

program modeled after Alcoholics’ Anon-

ymous, is the most widely available and

used treatment in the U.S. Members admit

they are powerless over their gambling

addiction and embark on changing their

character through group meetings and the

support of a “sponsor” or older mentor

in the group. Little research exists on the

efficacy of Gamblers’ Anonymous. A study

from 1988 found that only 7.5 percent of

members had abstained after one-year,

and nearly a quarter of members did not go

to a second meeting. However, those who

regularly attend Gamblers’ Anonymous

say they benefit significantly.

As with any kind of addiction, there

is no pill for treating problem gambling.

Medication and therapy may be used with

varying success to treat a related psy-

chiatric illness like depression or bipolar

disorder. Moreover, a small number of

problem gamblers seek treatment.

For these reasons, a public health

approach, which would favor limiting the

“exposure” of gambling to prevent addic-

tion from occurring in the first place, is

compelling. It is the same as the argument

to tighten access to prescription opioids

in order to prevent people from becoming

hooked.

A disease of society?

At a Gamblers’ Anonymous meeting in

New York in August, about 65 people,

mostly men, are celebrating one member’s

five-year anniversary of abstaining from

gambling. He gets to choose the topic for

the night, and he picks “starting over.”

Other members stand up to say that adher-

ing to the Gamblers’ Anonymous program

has fundamentally changed them. They

have gone from being selfish and unable

to make mature decisions to being better

spouses, parents, friends, and members

of society. They talk about small triumphs,

their families, jobs, illness, and making

amends with the people they hurt and stole

from during their addiction.

“I think it was known to pretty much

everyone in this room that I was an ass-

hole. And I think I have become a decent

member of society,” says a man in his early

30s who has been abstinent for 10 years.

Another man echoes this sentiment. “I

was anything but a good citizen,” he says.

He has been abstinent for over 22 years,

but like many others in this room, attends

meetings on the Gamblers Anonymous

principle that former addicts are always

in recovery. “It’s not just starting over, we

still have to own our past. We have to settle

up with people as best we can.” When his

mom passed away, he says he was grateful

that he could access his emotions—not

something he could have done in his gam-

bling days.

“I can say without a doubt, gambling

has ruined my life,” says another member.

He has gone to Gamblers’ Anonymous for

eight years but has had relapses, and it has

been 201 days since he last bet. “Absti-

nence is for real this time.”

Compulsive gambling is often viewed

as an addiction to money, but Gamblers’

Anonymous believes it is an emotional

rather than financial disease. The addicted

person “wants to escape into the dream

world of gambling” and “finds he or she

is emotionally comfortable only when ‘in

action.’” But it doesn’t end up being much

comfort, say formerly addicted gamblers

who speak of how lonely their life was then.

Dr. Bruce K. Alexander, a psychologist

and professor emeritus at Simon Fraser

University in British Columbia, believes

the loneliness experienced by those with

gambling and other addictions has a

strong social dimension. In his book, The Globalization of Addiction: A Study of the Poverty of the Spirit, he says: “A free-mar-

ket society is magnificently productive, but

it subjects people to irresistible pressures

towards individualism and competition,

tearing rich and poor alike from the close

social and spiritual ties that normally con-

stitute human life. People adapt to their

dislocation by finding the best substitutes

for a sustaining social and spiritual life that

they can, and addiction serves this function

all too well,” he says.

Bernal of Stop Predatory Gambling

believes that our nation’s dependence on

gambling reveals a deeper civic problem.

“What we incentivize as a government

shapes the national character,” he says.

“We look at the greatest generation: we

encouraged people to buy savings bonds,

in the Great Depression. After World War II,

we had the highest savings rate in modern

American history because the government

encouraged Americans to save. Today, half

“I can say without a doubt, gambling has ruined my life.”

23DEPARTMENT OF EPIDEMIOLOGY

of Americans don’t own any assets.”

Terry Noffsinger, the lawyer for Stacy

Stevens, admits that it has not been easy

to make the legal public health case against

gambling. Neither of the two cases he has

represented has won in court, and one

even provoked the Seventh Circuit Court

of Appeals to threaten to sanction him for

filing a frivolous claim. But he says the tide

is turning. He has a conference call with a

group of lawyers across the country about

once a month to discuss the issue. Last

November a group of Harvard Law stu-

dents published a white paper making the

case for legal action “to protect problem

gamblers from the predatory behavior of

casinos, including legislative reforms, tort

litigation, regulations, and public policies.”

A couple of well-known trial attorneys

have joined him on the Stevens suit, includ-

ing Sharon Eubanks, who was lead counsel

on the U.S. case that ended in a judgment

in 2006 that the nation’s big tobacco com-

panies fraudulently covered up the health

risks of smoking and marketed to children.

The Stevens case also makes product lia-

bility claims that the slot machines from

which casinos draw so much revenue are

intentionally designed, manufactured, and

distributed to hurt people. Such claims

have never been tried before.

“This is a blockbuster case. There are

other cases that are starting to come out of

the woodwork. The courts are ready to look

more favorably upon addicted gamblers,”

says Dr. Kindt of University of Illinois. Dr.

Kindt published several academic articles

in the early 2000s outlining the legal jus-

tification for mega-lawsuits against the

gambling industry, similar to those which

states, individuals, and classes of people

filed against Big Tobacco.

In his Harvard talk, Noffsinger said he

has had 100 or more people call him for

help, many suicidal, nearly all of whom

he has had to decline to represent. One of

the calls came several years ago from a

Boeing employee in Seattle who begged

him for legal assistance. She had lost all

of her money gambling, sold all of her fur-

niture, and was ready to end it all. When

Noffsinger told her he couldn’t represent

her, she said she had nothing left to live for.

Alarmed, he referred her to a lawyer friend

in Seattle who found her counseling. About

a year ago, she called Noffsinger and

thanked him for saving her life.

“Somebody needs to do something…it

may not be me.” Noffsinger told the Har-

vard students. “It’s going to be an uphill

battle, but at the top there’s going to be a

great big flag to wave.”

A smartphone app for a slot machine

game.

24 FALL 2014 : ISSUE 5.03

Fully loadedThe politics of framing gun violence as a public health issue

BY KATHLEEN BACHYNSKI , PHD CANDIDATE

the2x2project.org

2x2.ph/gun-violence-public-health

25DEPARTMENT OF EPIDEMIOLOGY

It took only 11 minutes to transform a quiet ele-mentary school into the

scene of one of the deadli-est school shootings in U.S. history. On December 14, 2012, Adam Lanza entered Sandy Hook Elementary with a Bushmaster Model XM15-E2S semiautomatic rifle. He used the weapon to murder twenty school children and six adults. One state trooper warned the medical person-nel who arrived at the school to formally declare the vic-tims dead: “This will be the worst day of your life.”

The Sandy Hook shootings prompted an

outpouring of national grief and outrage.

Yet sadly, this tragedy—while especially

shocking and visible—only represents the

tip of the iceberg when it comes to deaths

from gun violence. Every day in the U.S.,

friends and family must make funeral

preparations for an average of 86 people

who were intentionally or unintentionally

killed with a firearm.

If measles or mumps killed 31,672

people a year, we would undoubtedly

consider the situation to be a public health

emergency. And indeed, gun violence

shares many characteristics with other

widespread safety threats that have been

framed as public health issues.

In a Q-and-A published in a 2008 book,

The Contested Boundaries of American Public Health, epidemiologist Dr. Mark

Rosenberg recalls early efforts to frame

gun violence as a public health issue in the

1980s. Finding that the burden of deaths

from guns was similar to those of cars,

he realized that gun violence was an area

where public health could “make a big

contribution and save lives by applying the

same kind of science that had been applied

to road traffic crashes.”

Indeed, like motor vehicle deaths, gun

fatalities result from a consumer product

that is integral to many Americans’ lives.

And both cars and guns can be made safer

with technology and engineering—air bags

in cars and loading indicators for guns.

But efforts to frame gun violence as

a public health challenge have met with

considerable resistance, most notably from

gun lobby groups, such as the National

Rifle Association.

Lobbying powerfully against a public health perspective

The NRA is a powerful force in Amer-

ican political life that attracts many

supporters, not only with its ideological

positions, but with its message of self-em-

powerment. And the organization has long

and vociferously opposed the framing of

gun violence as a public health issue, por-

traying research on the subject as biased

and misguided. For instance, the NRA’s

chief lobbyist, Chris Cox, told the New York Times that the U.S. Centers for Disease

Read more from the 2x2 project’s Gun Week series

ff Guns and public health in the crosshairs

2x2.ph/gunweek

ff Mental health is the wrong target for preventing gun violence

2x2.ph/guns-mental-health

ff PopAds: Advocacy groups pack heat with ads

2x2.ph/gun-ads

ff Racial recoil

2x2.ph/race-guns

ff Gun violence in Chicago is indivative of a national public health crisis

2x2.ph/Chicago-guns

26 FALL 2014 : ISSUE 5.03

Control and Prevention was guilty of pub-

lishing “political opinion masquerading as

medical science.”

The NRA has worked to translate their

objections into policies that circumscribe

public health research on the effects of gun

violence. In the mid-1990s, after a failed

campaign to eliminate the CDC’s National

Center For Injury Prevention, gun lobbyists

helped persuade Congress to include lan-

guage in its budget stating that “none of

the funds made available for injury preven-

tion and control at the Centers for Disease

Control and Prevention may be used to

advocate or promote gun control.”

Despite this limitation, the agency has

since developed other mechanisms to

study causes of violent deaths, notably

the National Violence Reporting System.

But to this day, the CDC’s funding level for

research explicitly devoted to gun violence

prevention remains at zero dollars. Due to

fears of getting attacked by the NRA, many

foundations have avoided funding such

research, according to Dr. David Hemen-

way, director of the Harvard Injury Control

Research Center and a professor of health

policy at the Harvard School of Public

Health. “It’s one of the reasons that there’s

been relatively little gun research com-

pared to other research in public health,”

Dr. Hemenway says.

More recently, the NRA succeeded in

A public service announcement from momsdemandaction.org. View more gun-related PSAs at

2x2.ph/guns-ads

If measles or mumps killed 31,672 people a year, we would undoubtedly consider the situation to be a public health emergency.

adding a provision into the Affordable Care

Act to limit doctors’ ability to gather data

about their patients’ gun use. The Washing-ton Post dubbed this provision “a largely

overlooked but significant challenge to a

movement in American medicine to treat

firearms as a matter of public health.”

Then, in 2011, Florida Governor Rick

Scott signed into law a “docs vs glocks”

bill, which banned physicians from asking

their patients about gun ownership. In

2012, a federal judge permanently blocked

this NRA-backed law because it violated

the First Amendment rights of doctors.

Nonetheless, such laws and provisions

indicate the extent to which policymakers

have attempted to limit medical and public

health conversations and research on gun

safety.

Shifting a heated debate

Despite this already remarkable influence

in setting and limiting the terms of public

health research, this year the NRA has

wielded its power in an extraordinary new

way by obstructing President Obama’s

nomination of Dr. Vivek Murthy as U.S. Sur-

geon General. The organization opposed

Dr. Murthy’s characterization of gun control

as a health issue and his support of regula-

tory measures, such as mandatory safety

training for gun owners.

But by blocking Dr. Murthy’s

27DEPARTMENT OF EPIDEMIOLOGY

Originally published on the GRAPH website, at cugraph.org

DATA SOURCE: 1) CENTERS FOR DISEASE CONTROL AND PREVENTION, NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL. WEB-

BASED INJURY STATISTICS QUERY AND REPORTING SYSTEM (WISQARS). [2010 DATA EXTRACTED MARCH 2, 2014]. AVAILABLE FROM URL: WWW.

CDC.GOV/NCIPC/WISQARS. 2) U.S. CENSUS BUREAU, POPULATION DIVISION. ANNUAL ESTIMATES OF THE RESIDENT POPULATION BY SEX, RACE,

AND HISPANIC ORIGIN FOR THE UNITED STATES, STATES, AND COUNTIES: APRIL 1, 2010 TO JULY 1, 2012. RELEASE DATE: JUNE 2013

This bar chart shows the potential years of life lost by race and sex from firearm-related

homicide and suicide. Along the Y-axis is years of potential life lost per 100,000 people.

The y-axis ranges from 0 to 1,400 for men and ranges from 0 to 140 for women. Non-His-

panic blacks lose more years of life every year from guns in the hands of others while

non-Hispanic whites lose more years of life from guns in their own hands. This is true for

men and women.

Years of potential life lost due to firearm-related homicide and suicide by race

28 FALL 2014 : ISSUE 5.03

nomination, the NRA prompted prominent

medical and public health voices to take

a stand. In a remarkable op-ed, the New England Journal of Medicine stated that

“the NRA is taking its single-issue political

blackmail to a new level.” And in April 2014,

Michael Bloomberg took a bold step into

the ongoing debate, announcing that he

would donate $50 million of his own money

to counter the NRA.

The New York Times described how

Bloomberg intends to restructure current

gun control advocacy efforts to more effec-

tively counter the NRA. Part of the idea is

to combine forces and model advocacy

efforts on the success of other safety-re-

lated groups, notably Mothers Against

Drunk Driving. The resulting new group,

Everytown For Gun Safety, has already pro-

duced an ad that directly challenges claims

made by the NRA.

Whether these new strategies and influx

of money can effectively promote a public

health perspective on gun violence and

safety interventions remains an open ques-

tion with high stakes. In fact, even after the

Sandy Hook shootings of 2012, many states

have been loosening their gun restrictions.

Georgia, one of the most prominent and

recent examples of this trend, recently

passed into law a bill that allows licensed

gun owners to carry their weapons in

schools, churches, bars, and airports. The

public is often unaware of the extent to

which gun owners may legally carry and

display their weapons in public spaces

across the country.

American values and valuing American public health

What policy changes do gun safety advo-

cates seek? A recent Massachusetts report

identified 44 strategies to reduce gun

violence that all committee members,

including public health professionals and

gun owners, endorsed. Of the range of

possible strategies to reduce gun violence,

strengthening the existing background

check system has the most public support.

In fact, although the NRA as an organiza-

tion does not support universal background

checks, a 2013 poll found support among

74 percent of NRA members.

This approach is also supported by

public health research. As reported by Nora

Caplan-Bricker in The New Republic, a 2014

study found that the murder rate in Mis-

souri jumped 16 percent after the repeal

of a state law that required anyone pur-

chasing a handgun to obtain a background

check permit.

Safe storage practices and more safely

designed guns would also likely make an

impact on reducing the number of uninten-

tional gun deaths among young children.

As Dr. Hemenway told WBUR’s All Things

Considered, “We have childproof aspirin

bottles; we should have childproof guns.”

Yet entrepreneurs seeking to market

and sell “smart guns,” or weapons which

can only be fired by authorized users, have

encountered harassment and outrage from

gun enthusiasts. This month, a Maryland

gun dealer who had intended to sell the

nation’s first smart gun backed down after

enduring protests and death threats. And

fewer than 20 states have enacted laws to

hold adults criminally liable if they fail to

safely store their guns, putting children at

risk.

Former U.S. Surgeon General Dr. Julius

Richmond and medical economist Dr. Rashi

Fein have proposed three essential factors

involved in addressing a societal problem:

scientific data, a social strategy guiding the

pursuit of public health goals, and polit-

ical will. Public health researchers have

sought to collect data on the effects of gun

violence despite the obstacles, and gun

safety advocates are currently seeking new

strategies.

But ultimately, it seems that whether

gun violence can be framed as a public

health problem will come down to political

will.

Update: On July 25, 2014, two judges

on the 11th U.S. Circuit Court of Appeals

overturned the previous ruling on Florida’s

“doc vs. glocks” bill. The court has upheld

the law prohibiting doctors from asking

patients about guns as constitutional.

Consequently, as Slate writer Mark Joseph

Stern comments: “For asking a patient a

question that could save his child’s life, a

doctor in Florida could lose her medical

license or be fined $10,000.”

29

Searching for the cause of a mysterious epidemic a century agoA lesson from history shows how epidemiology can get it right—or wrong

BY STEVE MOONEY, PHD CANDIDATE JUSTIN KNOX, PHD CANDIDATE ALFREDO MORABIA, PHD

the2x2project.org

2x2.ph/pellagra-outbreak

30 FALL 2014 : ISSUE 5.03

In the period from 1906 to 1940, a disease once seen only in Europe reached

epidemic proportions in the American South, resulting in over 3 million cases of infection and 100,000 deaths. This disease was pellagra, an ailment marked initially by dry, scaly skin sores on the neck, arms, and legs, and by diarrhea. It could sometimes progress to dementia and even death. Pellagra struck hardest among the very poor, blacks, and women.

At the time of this epidemic, the dis-

ease’s cause was unknown. Some health

authorities suspected an as-yet uniden-

tified bacterium or virus that thrived in

the squalid living conditions of the poor,

whereas others believed it was caused by

the monotonous and corn-heavy diet.

In 1912, two northern industrial-

ists-turned-philanthropists concerned with

public health funded a large-scale pellagra

investigation named the Thompson-Mc-

Fadden Commission—a Gates Foundation

of the progressive era, albeit smaller and

focused on one issue). The Thompson-Mc-

Fadden Commission explored both the

dietary and infectious hypotheses among

six relatively isolated towns in South

Carolina where many pellagra cases were

reported and the sole employer was a

cotton mill. To investigate diet, the com-

mission asked all residents, both with and

without diagnosed pellagra, what they

usually ate. To investigate infection, they

classified every house according to its

distance to a previously confirmed pella-

gra case and compared incidence rates

between those close to prior cases and

those farther away.

From the survey results, the

Mrs. Lloyd, pictured here in 1939, is a 91-year-old victim of pellagra living near Carboro, North Carolina.

Commission dismissed the dietary

hypothesis, finding that most food types,

including meat, eggs, and corn, had no

association with pellagra—choosing to

ignore pellagra cases who claimed to drink

milk frequently. They noted that unlike beri-

beri, a known dietary disease, pellagra was

almost never found among nursing infants.

In contrast, the zone analysis yielded a

striking clustering of pellagra cases in all

six villages. Furthermore, villages with

modern sewers had less pellagra than vil-

lages that relied on outhouses. Backed by

this evidence, the Thompson-McFadden

Commission concluded that the disease

was caused by an infectious agent rather

than diet, although they were unable to

identify a bacterium or virus.

The epidemic proceeded unabated,

driving Congress to appropriate funding

for another major investigation. Dr. Joseph

Goldberger, an officer of the U.S. Public

Health Service, was appointed to lead the

investigation and immediately noticed

several details from previous studies that

conflicted with the Thompson-McFadden

Commission’s conclusions that pellagra

was infectious. For one, outbreaks never

affected the staff of institutions that

31DEPARTMENT OF EPIDEMIOLOGY

housed infected patients. Most outbreaks

occurred in the late spring, before summer

crops had been harvested. Pellagra cases

occurred among individuals with a calori-

cally adequate—albeit monotonous—diet,

similar to beriberi and scurvy, another

disease caused by nutritional deficiency.

Additionally, while pellagra was associated

with poverty, it rarely affected poor farm-

ers with cattle.

Dr. Goldberger conducted several small-

scale investigations in institutions such as

orphanages and asylums, where diet could

be tightly controlled. While the results of

these investigations supported the dietary

hypothesis, they were dismissed by critics

as applying only in highly selected popula-

tions. Undaunted, Dr. Goldberger decided

to follow-up on the Thompson-McFad-

den Commission’s study by undertaking

another study in an overlapping set of cot-

ton-mill villages. However, Dr. Goldberger’s

study featured two notable differences.

First, to increase accuracy in measuring

villagers’ diets, Dr. Goldberger relied not

only on survey results of villagers but also

on sales records from the company stores

that were the predominant sources of food

in cotton-mill villages. Second, Dr. Gold-

berger also selected a more geographically

diverse set of cotton-mill villages than the

Thompson-McFadden Commission had,

allowing him to assess a broader range of

dietary and sanitary environments.

In his study, Dr. Goldberger found an

overall association between poor diet and

pellagra, but was unable to identify a single

food or food category that was present in

all non-pellagrous households and missing

in all pellagrous households. Furthermore,

because poverty was the reason villag-

ers had a poor diet and lived in squalid

conditions where infectious agents could

proliferate, it was still difficult to affirm the

dietary hypotheses conclusively.

To disentangle the effects of poverty

and poor diet, Dr. Goldberger decided to

integrate assessment of both household

and village influences on diet in an early

form of multi-level epidemiologic analysis.

Goldberger compared the food environ-

ment of a village with high incidence of

pellagra, Inman Mills, to one with only a

single case, Newry. Inman Mills had a com-

pany store with little fresh food and almost

no nearby farms, whereas Newry had a

well-stocked store and a wealth of nearby

farmers selling food in town. House-

hold-level purchase records confirmed far

more fresh meat and milk in Newry diets,

even among the poorest residents.

From these findings, Dr. Goldberger

wove a narrative highlighting the role

of diet in explaining pellagra variation

through multiple levels of analysis, making

an analogy to beriberi. Women and chil-

dren had pellagra at higher rates because

of a dinner table hierarchy that privileged

men. Men also could supplement their

diet while working outside the home. Pel-

lagra was more common among the poor

because income determined both ability

to purchase high-quality food and portion

sizes of those foods. One’s village also

determined access to food. Furthermore,

A family in Coffee County, Alabama, in

1939 who were part of the federal Rural

Rehabilitation program. The children have

hookworm and the mother has pellagra

and milk leg. The father works on the

Work Projects Administration.

32 FALL 2014 : ISSUE 5.03

changes in the southern economy, which

included a transition from primarily grow-

ing food that was sold in local markets

to growing cotton, had led to large-scale

dietary changes privileging corn and hog

products over more varied meats and

garden vegetables.

Although the cotton mill village study

fully convinced Dr. Goldberger that pel-

lagra was a disease caused by dietary

deficiencies, political obstacles remained.

Dr. Goldberger turned his attentions to

finding an agent that could prevent pella-

gra, eventually, discovering brewer’s yeast,

which was cheap and readily available.

The discovery helped prevent pellagra in

lower Mississippi after a 1927 flood, but Dr.

Goldberger died in 1929 at age 54 of kidney

cancer before he could figure out why

brewer’s yeast prevented pellagra.

That did not occur until nearly 20 years

after the cotton mill village studies and

eight years after the death of Dr. Gold-

berger, when Drs. Conrad Elvehjem and

Carl J. Koehn identified a deficiency of

nicotinic acid—later renamed niacin or vita-

min B3—as the cause of pellagra. The mill

villages, with their lack of access to nutri-

tious food, were like early examples of food

deserts. Niacin supplementation of flour

became widespread in the early 1940s, and

pellagra was fully eradicated by 1945.

Why did the Thompson-McFadden

Commission, a well-funded, well-inten-

tioned, and professionally run study, fail

where Dr. Goldberger succeeded?

For one, the Thompson-McFadden

Commission’s survey of diets was not as

accurate or comprehensive as Dr. Gold-

berger’s, which supplemented the survey

with company store records. Second, Dr.

Goldberger’s decision to compare both

households and villages allowed him to

make contrasts the Commission could not.

Finally, the Thompson-McFadden Commis-

sion selectively ignored inconvenient facts,

such as the evidence that milk was associ-

ated with pellagra, and that the apparent

clustering of cases in households and in

the poorest parts of the villages did not

prove their hypothesis.

In an era in which epidemiology is being

challenged to renew its focus on public

health and is besieged with potential keys

to insight from genomics, proteomics,

metabolomics, and microbiomics, it is

important to remember that the thorough

data collection and development of rigor-

ous study designs, which Dr. Goldberger

used nearly 100 years ago, are still the fun-

damental building blocks of our science.

This article was based on a paper pub-lished by the authors.

Mooney SJ, Knox J, Morabia A. The Thomp-

son-McFadden Commission and Joseph

Goldberger: Contrasting 2 Historical Investigations

of Pellagra in Cotton Mill Villages in South Car-

olina. Am J Epidemiol. 2014 Aug 1;180(3):235-44.

doi: 10.1093/aje/kwu134.

Why did the Thompson-McFadden Commission, a

well-funded, well-intentioned, and professionally run study,

fail where Dr. Goldberger succeeded?

33DEPARTMENT OF EPIDEMIOLOGY

Bring surgery into the global health agendaDearth of surgical services available in many parts of the world

the2x2project.org2x2.ph/surgery-agenda

BY AMBEREEN SLEEMI , MS ‘15

34 FALL 2014 : ISSUE 5.03

In Mendefera, Eritrea, I am part of a small team of visiting surgeons who work with and

train local surgeons to care for women with severe maternal birth trauma. This trauma is almost always the result of lack of access to emergency obstetric care, primarily a cesarean delivery. The women we care for, like Elsa, who labored at home for two to three days before her family could bring her to the hospital, are mostly poor.

In most cases, the baby dies, but the

agonies of childbirth in a resource-de-

prived setting do not end there.

Prolonged labor, usually treated by

a cesarean delivery, causes severe

damage to the vaginal birth canal,

resulting in damaged tissue that

sloughs off, leaving holes between the

bladder and vagina, and sometimes,

between the rectum and vagina.

After her ordeal, Elsa sustained

nerve damage. She constantly leaked

urine, and was plagued by a sense

of shame and embarrassment. Our

team operated successfully, and Elsa

recovered fully, returning home to

her family with a restored sense of

confidence.

Surgical procedures that we often

take for granted in wealthy countries

are key to preventing or repairing dam-

ages that in low and middle-income

countries would be both devastating

and permanently life altering. Despite

their profound implications, access

to surgeries like the one our team

performed on Elsa remains effectively

absent from the global public health

agenda.

The neglected stepchild of global public health

In 2008, Dr. Paul Farmer and Dr. Jim

Kim wrote a definitive article on the

role of surgery as the “neglected

stepchild of global public health.” Drs.

Farmer and Kim emphasize that an

alarming lack of physicians in low-re-

source areas is eclipsed by the lack of

surgeons, who remain concentrated in

large urban centers, resulting in many

days of travel for the rural poor.

On the international global health

agenda sit many diseases and con-

ditions that are treatable by surgical

procedures, namely maternal hemor-

rhage, obstructed labor, motor-vehicle

accidents, blindness, and traumatic

farm accidents.

Over 250,000 women die annually

in childbirth. Life-threatening maternal

conditions relieved by surgery include

cesarean delivery to treat obstructed

labor, potentially saving the lives of

both mother and child, and hysterec-

tomy, or removal of the uterus, which

can arrest severe maternal hemor-

rhage and prevent a mother’s death.

If a mother survives obstructed

labor and/or hemorrhage, the lasting

sequelae are vast—weakness, severe

anemia, infertility, and neurologic

trauma resulting in chronic pain or dif-

ficulty walking, resulting in a condition

called “footdrop.” These conditions

can hinder both a family’s nuclear and

economic development. Other com-

plications such as chronic urinary or

fecal incontinence are conditions that

potentially can be treated by surgical

interventions, and can literally give a

woman her life back.

Among the very poor in low-in-

come countries, motor vehicle and

farm accidents, blindness caused by

cataracts or glaucoma, and peritonitis

are conditions surgically treatable.

Surgical conditions account for up

35DEPARTMENT OF EPIDEMIOLOGY

A patient undergoes obstetric fistula

repair at Haiti’s National hospital.

IMAGE: AMBEREEN SLEEMI

to 15 percent of total disability adjusted

life years (DALYs) lost globally. Pediatric

conditions that can be treated with evi-

dence-based procedures that are safe and

effective, such as congenital cleft-lip and

palate, cardiac disease due to infection

or birth defects, and clubfoot, are left to

develop into tremendous burdens on the

individuals, the families and the communi-

ties that care for those affected. The loss of

productivity of our world’s bottom billion is

of paramount consideration.

The great divide

In addition to the dearth of surgical ser-

vices available, another axis of inequality

exists. Most surgical services are found

in urban environments and reserved for

those who can pay for them. In Haiti, for

example, an early study showed that the

rate of cesarean deliveries in rural areas

was almost non-existent, but among the

wealthy, the rates rivaled those of the U.S.

At this time, the maternal mortality rate

was 1,400 per 100,000 live births. It was not

until 2007 that the Haitian central district

health commissioner announced that all

emergency obstetric services would be

free of charge. There still remain stagger-

ing numbers of people without access to

treatment for trauma services, emergency

abdominal conditions such as ruptured

appendices, intestinal obstruction and

other potential fatal conditions.

There is no global funder or organiza-

tion that focuses on the inequity of surgical

care. No major donors have proclaimed

a willingness to acknowledge surgery as

global health crisis. Surgery is not included

in the any of the United Nations’ 2015 Mil-

lennium Development Goals, but seems

key to achieving three, four, and five:

promoting gender equality, reducing child

mortality and improving maternal health,

as noted previously.

Injuries and insults

Some experts contend that much of this

neglect is due to common misconceptions

about surgical interventions. Many think sur-

gical care can only address a small portion

of the global disease burden. Still, surgery

is often the only means to address injury,

which according to the World Health Orga-

nization’s 2002 Injury Chart Book, kills more

than 5 million people worldwide annually.

36 FALL 2014 : ISSUE 5.03

There is no global funder or organization that focuses on the inequity of surgical care. No major donors have proclaimed a willingness to acknowledge surgery as global health crisis.

Many victims are the primary house-

hold earners and almost 50 percent of the

injuries occur in 15-44 year olds, which is

the most economically productive portion

of the population. Similarly, a significant

proportion of congenital anomalies and

obstetric conditions, which together are

responsible for over 600,000 deaths annu-

ally worldwide, can be treated surgically

and avert many thousands of deaths from

these conditions.

Cost effectiveness

Another misconception is that surgical

care is cost-prohibitive to implement

widely. Surgery is seen as a highly techni-

cal discipline that requires an abundance

of specialized equipment. While that

may be true in some cases, surgery can

also be cost-effective when compared to

some common non-surgical public-health

interventions. For example, the cost for

emergency obstetric care in Bangladesh is

approximately 11 dollars per disability-ad-

justed year averted and over 32 dollars per

disability-adjusted year averted in Sierra

Leone. These figures are comparable to

common public heath interventions like

vitamin A distribution, which is 9 dollars

per disability-adjusted year averted, and

measles immunization, which is 30 dollars

per disability-adjusted year averted.

Dr. Adam Kushner, co-founder of Sur-

geons Overseas, recently stressed that

there needs to be a surgical component to

the health system. “We’re not talking about

going in and doing a single operation,

but setting up surgical care for the entire

population and that requires the appropri-

ate personnel, infrastructure, equipment,

supplies and training,” Dr. Kushner says.

Sustainability

Finally, in the context of low-resource set-

tings, global surgery usually takes the form

of short-term surgical mission trips, con-

tributing to a kind of patchwork aid, which

is the object of criticism. The role that these

trips play is one that may be beneficial but

cannot substitute for a nation’s ability to

invest in the long-term development of a

medical infrastructure that sustains sur-

gical capacity. Such health infrastructure

must not only provide care for the entire

population, including the most marginal-

ized and vulnerable, but also commit to

staff development and training of its future

healthcare workforce with medical and

nursing schools and post-graduate training.

Drs. Farmer and Kim encourage us to not

abandon the short-term surgical trips, but

to do them better, by integrating them into

broader public health efforts.

Uniting and paying it forward

The role of surgery needs to be recognized

as integral to the broader goal of global

public health initiatives to build a sus-

tainable health care delivery system that

improves health and supports its ability

to meet population demands. A recent

survey evaluated the basic infrastructure of

hospitals and health centers in five coun-

tries in sub-Saharan Africa and the ability

to provide the most basic emergency

and surgical care. None of the over 2,000

surveyed hospital or health facilities met

the minimum requirements of infrastruc-

ture that the WHO has deemed essential for

the provision for emergency and surgical

care, from electricity and infection control

to quality assurance and supervision of

providers. The authors urge donors and

organizations to recognize the need for

investment in strengthening infrastructure,

much like efforts to stem HIV. In this way,

the global community pays it forward, and

in the end, as with HIV, cost effectiveness

will be achieved.

While surgery may be thought of as

the ultimate individual intervention, it is

indeed a public health issue. As Dr. Ray

Price, of the University of Utah, a practic-

ing surgeon in the U.S. and in low-middle

income countries states, “We need to put

the surgical language in an understandable

language of our public health colleagues.”

And as Drs. Farmer and Kim note, the

global health need can be met with a col-

laborative approach to “build a coherent

movement that comes to include surgery.”

Isn’t it time we all sat at the table

together, even if it hurts just a bit? Lives

like those of Elsa depend on it.

37DEPARTMENT OF EPIDEMIOLOGY

‘A hopelessly prevention-oriented guy’

epidemiology role models

As a pediatrician-in-training in 1970s New York City, Sten Vermund, MPhil ’87, PhD ’90,

became interested in a career in public health after observing that many of the medical conditions he saw in patients were preventable. Forty years later, Dr. Vermund is a leading figure in HIV and

cancer prevention for women and children. As director of

Vanderbilt University’s Institute of Global Health and in prior

roles, he has worked nationally and abroad to build a health-

care infrastructure based upon his early ideals of prevention.

“I am a hopelessly prevention-oriented guy,” he says.

“I’m so inspired when we can avoid illness altogether.”

Dr. Vermund is this year’s winner of the Mailman School

of Public Health’s Allan Rosenfield Alumni Award. The award

is given in honor of the late Dr. Allan Rosenfield, who served

as dean of the school from 1986 to 2008, to recognize the

achievements and leadership of outstanding alumni in the

field of public health.

“[Dr. Vermund’s] work has played a vital role in

steadily improving programs to prevent mother-to-infant

transmission of HIV in diverse venues,” the Mailman School

said in a statement announcing the award.

Alumnus Sten Vermund honored for global health work

BY ELAINE MEYER

Sten Vermund

38

“If every student was like Sten, my job would have been discontinued.”

In addition to being a major figure in

global health and HIV/AIDS research, Dr.

Vermund counts as his former students

the current head of the U.S. Centers for

Disease Control and Prevention and prior

Rosenfield awardee Dr. Thomas Frieden;

MacArthur Fellow Dr. Wafaa El-Sadr

who is also director of the global health

center ICAP and University Professor of

medicine and epidemiology at Columbia’s

Mailman School of Public Health; and

the renowned HIV researcher, Dr. Salim

Abdool-Karim, director of the Centre for

the AIDS Programme of Research in South

Africa and professor of epidemiology at the

Mailman School, also a prior Rosenfield

awardee.

Raised in Madison, Wisconsin, to

parents who emigrated from Norway,

Dr. Vermund became interested in global

health while he was an undergraduate

at Stanford University. His professors

included renowned anthropologist Dr.

Jane Goodall and biologist Dr. Colin

Pittendrigh. During college, he read and

became inspired by Dr. Albert Schweitzer’s

autobiography, Out of My Life and Thought, about Dr. Schweitzer’s time as

a missionary doctor in Gabon, one of

the poorest countries in the world, and

U.S. Navy physician Dr. Tom Dooley’s

autobiographical trilogy about going to

Laos after his Southeast Asian military

service to build a primary care system.

After graduating, Dr. Vermund moved

across the country to New York City to

attend medical school at the Albert Einstein

College of Medicine in the Bronx. It was

there that he met his wife, Dr. Pilar Vargas,

a child psychiatrist, when they were

paired in histology lab—an “alphabetical

romance,” he jokes.

While he did his internship and

residency in pediatrics at what was

then the Babies Hospital of Columbia-

Presbyterian Medical Center (now the

New York-Presbyterian/Morgan Stanley

Children’s Hospital), he decided that he

did not want to take a traditional career

path: “I felt the impact of my workday

might be greater if I were focused on

global health issues and health disparity

issues in my own backyard. I’m a big fan of

pediatricians-in-practice, but it wasn’t my

calling.”

During his residency and internship,

he became aware of the importance of

geography and environment on health.

He saw Dominican-origin patients who

came to him with parasites and other

health conditions not commonly seen in

a U.S. practice, and he benefited from the

mentorship of Drs. Michael Katz, Dickson

Despommiers, and Philip D’Alesandro in

the tropical medicine group of the Mailman

School of Public Health.

“He was a wonderful person to have on

the staff. Everybody liked him. He was very

effective, and he was wonderfully naïve—

meaning that he was open to all new ideas

before he formed his own judgment. It was

a beautiful example of maturity,” says Dr.

Katz, then chairman of the department of

pediatrics at Columbia and director of the

residency program and currently senior

advisor of transdisciplinary research at the

March of Dimes Foundation.

At the end of his residency, Dr. Vermund

and his wife moved to England where he

earned a master’s degree in community

health in developing countries at the

London School of Hygiene & Tropical

Medicine.

After a stint as a visiting researcher

at the CDC’s labs in San Juan studying

schistosomiasis, a parasitic worm, with Dr.

Ernesto Ruiz-Tiben, Dr. Vermund returned

to do his PhD at Columbia, persuaded by

Dr. Zena Stein, a mentor and professor

in the department of epidemiology at

Mailman. The PhD was a part of a clinical

epidemiology fellowship supported by

the new Mellon Foundation Program of

Epidemiology in medicine and pediatrics,

directed by Drs. Mervyn Susser and

Nigel Paneth, with fellow co-trainee Dr.

Al Neugut, a professor of epidemiology

and medicine at Mailman and New York

Presbyterian Hospital.

Dr. Dickson Despommier, an expert on

parasites and vertical farming, remembers

Dr. Vermund as being “brilliant” and having

a “photographic memory.” “He was able to

integrate and synthesize and hypothesize

from disparate knowledge sources, stuff

that would never occur to everyone else,”

adds Dr. Despommier, a professor of

public health in environmental sciences at

Mailman. “If every student was like Sten,

my job would have been discontinued.”

Like many of his colleagues in New York

City in the 1980s, Dr. Vermund’s career was

rocked by the emergence of AIDS, which

had hit epidemic levels in several sub-pop-

ulations. In his practice, he saw sick

children who did not respond to medicine

he gave them. There were limited thera-

peutic options for AIDS, and he regularly

saw patients die. This inspired his interest

in prevention of mother-to-child-transmis-

sion of HIV. “I got a sense that it was a very

historic moment and that because I had

trained in infectious disease epidemiology,

I could make a difference,” he says.

39DEPARTMENT OF EPIDEMIOLOGY

In 1988, the National Institutes of Health

offered Dr. Vermund a job that would take

epidemiologic approaches and apply them

to HIV interventions. The next six years

were a time of significant advances in the

understanding of the virus, including the

importance of regulating the “viral load”

of HIV, the behaviors that put people at risk

of contracting it, and various prevention

strategies involving combination drug

therapies.

In 1994, Dr. Vermund accepted a

position at University of Alabama-

Birmingham as head of geographic

medicine in the School of Medicine and as

chair of the department of epidemiology

at the School of Public Health. “I thought

it would be interesting to work in the Deep

South where the public health challenges

were immense,” he says.

During his time there, he began focus-

ing on how to get proper medical care for

people in low-income settings. “You get

a bigger bang for your buck when you’re

working with people who are disadvan-

taged. There’s just more benefits to accrue

in those populations whose life expectan-

cies aren’t as high—where we worry about

disproportionately high infant mortality,

child mortality, maternal mortality,” he

says. “If a patient is privileged, the health

system may put a lot of resources for a

little gain, whereas if your clientele is not

in great shape, you can put in those same

resources for a lot more gain.”

Dr. Vermund built up a program that

trained over 50 health professionals in

Zambia on developing screening programs

to diagnose and treat HIV and cervical

cancer before the diseases spread. “It has

been immensely successful,” he says. “We

really focused on trying to keep things

pragmatic and trying to keep things able to

be implemented in low resource settings.”

He has helped similar programs

take root in China, India, Pakistan, and

Mozambique working with professors at

Vanderbilt, the University of North Carolina

at Chapel Hill, and the University Teaching

Hospital in Zambia. This work has inspired

the “Red Ribbon, Pink Ribbon” campaign,

a partnership of government, non-profits,

and pharmaceutical companies to integrate

cervical and breast cancer prevention

into existing healthcare programs in sub-

Saharan Africa, Asia, and Latin America.

Dr. Vermund has also set his sights

closer to home, beginning a program in

rural Alabama, Mississippi, and Louisiana

to help people in low-income settings

better access health care. He calls this

“global health at home, applying the same

principles of global health but in our own

backyard.”

Dr. Vermund discovered that the health

needs of the South are often overlooked

when one of his papers was rejected by

the American Journal of Public Health.

According to the journal, the paper was

“only of regional interest.” “For the AJPH

in the 1990s not to review a paper—one of

the only papers—about health access in the

rural south, just showed how marginalized

the south was in terms of people’s

consciousness,” he says.

For the last nine years, Dr. Vermund has

directed Vanderbilt University’s Institute

for Global Health, which partners with

Meharry Medical College, a historically

black college that is a legacy of the

region’s formerly segregated hospital

system. The center manages development

programs in resource-limited areas around

the globe. In addition to treatment and

prevention programs for HIV, the Institute

for Global Health focuses on building

and strengthening healthcare systems,

improving agricultural investment and

water sanitation, and educating medical

practitioners and researchers.

Dr. Vermund was principal investigator

of the HIV Prevention Trials Network

(HPTN), when the group made the

breakthrough finding in 2011 that

early initiation of HIV treatment using

combination antiretroviral drugs reduces

the risk by 96 percent of an infected person

passing the virus to an uninfected person.

“He is a passionate advocate for advanc-

ing the field of HIV prevention and public

health in general,” says Dr. El-Sadr, the cur-

rent co-principal investigator of the HPTN.

Dr. Vermund is honored to receive the

Allan Rosenfield Alumni Award, especially

because the former dean of the Mailman

School was his mentor and a very good

friend: “He and I shared a passion for

health disparities work and international

work so it’s a very personal award for

me. We miss him tremendously. He had

indefatigable energy. He inspired me and

a whole generation of people in public

health.”

“You get a bigger bang for your buck when you’re working with people who are disadvantaged. There’s just more benefits to accrue in those populations whose life expectancies aren’t as high—where we worry about disproportionately high infant mortality, child mortality, maternal mortality.

40

training report

This fall marks the launch of a new training program in the department of

epidemiology that will immerse scholars in HIV implementation science, a growing field that focuses on how to best translate research findings into effective healthcare policy and practice.

The Global HIV Implementation Science Research Training Fellowship will

have spots for three predoctoral and two postdoctoral trainees. The first-of-its-

kind program is funded by the National Institute of Health’s National Institute of

Allergy and Infectious Diseases and is run by faculty in ICAP and Epidemiology.

The program incorporates implementation science, which draws on research

findings and evidence-based interventions to improve the quality and effective-

ness of how health care is delivered. It combines a broad range of disciplines,

including epidemiology, biostatistics, health economics, decision science, and

sociology.

Implementation science offers a unique opportunity for universities, accord-

ing to a perspective piece that was published in the New England Journal of Medicine in March by Dr. Wafaa El-Sadr, university professor of medicine and

epidemiology at the Mailman School of Public Health and director of ICAP, Dr.

Jessica Justman, associate professor of medicine and epidemiology at Columbia

and senior technical director of ICAP, and Ms. Neena M. Philip, a program coor-

dinator at ICAP. “Academic institutions have an opportunity to embrace societal

challenges more fully by placing value not only on discovering the ‘what’ but

also on elucidating the ‘how’ and bringing to action discoveries with broad ben-

efits,” they say.

Cancer researchers have drawn on the principles of implementation science

for a while, but it is relatively new to scientists in the field of HIV/AIDS, who in

earlier years were focused on finding treatments and means of preventing the

deadly virus. While there is still no AIDS vaccine, scientists have developed

antiretroviral treatments that keep the disease from worsening and reduce the

risk of transmitting the virus. However, because resource-limited areas have

been some of the hardest hit by HIV/AIDS, one of the greatest challenges has

been getting this treatment to those who are infected. Challenges include getting

people tested for HIV, linking those who test positive to care, and ensuring that

people who are infected are regularly taking antiretroviral medicines.

“We know what needs to be done, but it’s how to deliver the services and

thinking at the provider, patient, and programmatic level. It’s about, how do

you take scientific findings and bring them to a programmatic setting?” says Dr.

Andrea Howard, associate professor of epidemiology at Columbia University

Medical Center and clinical and training unit director of ICAP, who is the principal

investigator and director of the training program. This is often described as the

“know-do gap,” she says.

Each trainee in the program will be placed in the field with a faculty mentor.

Possible projects include several sponsored by ICAP: a trial in Swaziland look-

ing at a strategy for preventing transmission of HIV from mothers to children, a

study of combination care for patients who are infected with both tuberculosis

and HIV in Lesotho, and an evaluation in Harlem of the use of pre-exposure pro-

phylaxis or PreP to prevent HIV from spreading between black men who have

sex with men.

Bridging the ‘know-do gap’New global HIV Implementation Science Training program begins this fall

BY ELAINE MEYER

program information

epi.is/hiv-training-program

41

Trainees will also meet in a weekly faculty-fellow seminar, a

popular feature of several other Epidemiology training programs,

work on manuscript and grant preparation, and get instruction

on how to conduct responsible research. Predoctoral fellows will

complete coursework in epidemiology, and postdoctoral fellows

will take select courses based on their individual training needs.

In addition to ICAP and Epidemiology, faculty will come from

the departments of Sociomedical Sciences, Health Policy and

Management, and Population and Family Health; the College

of Physicians and Surgeons; the Psychiatric Institute; and the

School of Social Work. “It really builds upon the medical center’s

experience and expertise in this area,” says Dr. Howard. “We’ve

assembled a large number of research mentors who are known

not only for their excellent science but also for their track record as

excellent mentors.”

“We’re really thrilled to implement this program. We’re very

excited,” she adds. “I think there’s a rich training environment

here at Mailman, with a wide range of opportunities for field place-

ments both here in the U.S. as well as abroad.”

TRAINING REPORT

Staff workers test blood samples at the

laboratory at Muranga District Hospital in

Kenya.

IMAGE: CASEY KELBAUGH

42

symposium report

In the public health arena, mental health has struggled to gain attention. But participants

at a daylong Columbia University symposium were hopeful that with a recent focus on subjects such as gun violence and post-traumatic stress disorder in veterans of the Middle East wars, this could change.

The Columbia University Epidemiology Scientific Symposium (CUESS) on “Pre-

venting brain disorders: Improving global mental health” took place on May 2.

Jointly organized by the Department of Epidemiology, the Peter C. Alderman

Foundation, and Columbia’s Global Mental Health Program (GMHP), the event

brought together national and international researchers, policymakers, non-

profit workers, and others to discuss how socioeconomics, violence, and war

can influence mental health in high and low-income countries alike and how

understanding the causes of psychiatric and other brain disorders can lead to

prevention.

Today, almost half of the world’s population lives in countries with only one

psychologist for every 200,000 people. Many are low-income countries dealing

with other heavy disease burdens and a shortage of healthcare personnel. In the

U.S., while causes of death such as stroke, AIDS, heart disease, leukemia, and

homicide have declined since 1965, the suicide rate has remained unchanged

for two decades, at 38,000 lives per year. Research is increasingly pointing to

links between mental and physical health. For instance, the Global Burden of

Disease Study by the Institute of Health Metrics and Evaluation recently found

that depressive disorders are the second leading cause of years lost to physical

disabilities and the leading contributor to disability adjusted life years.

At the center of the CUESS discussion was the World Health Organization’s

Comprehensive Mental Health Action Plan for 2013-2020—the first of its kind—

which is focused on expanding and improving mental health care around the world.

The WHO Action Plan has two target goals for 2020. The first is for 80 percent

of countries to have at least two mental health promotion and protection pro-

grams running, one targeted to vulnerable groups and one universal. The second

is to reduce the suicide rate in countries by 10 percent. “The burden of mental

disorders cannot be reduced without effective prevention,” said Dr. Shekhar

Saxena, director of the department of mental health and substance abuse at

WHO in opening remarks.

In order to achieve global mental health aims, prevention should be discussed

in the same conversation as treatment, said Dr. Kathleen Pike, executive director

of Columbia University’s Global Mental Health Program and a clinical professor

of psychology in the psychiatry and epidemiology departments. She pointed out

that in some cases, treatment of mental health disorders can serve as preven-

tion. For example, treating a mother’s depression with medication and therapy

reduces depression in her children, according to research.

Early childhood and adolescence is the ideal time for prevention, accord-

ing to Dr. Pamela Collins, director of the office for research on disparities and

global mental health at the National Institute of Mental Health, because mental

disorders typically occur between age ten and early adulthood, often in conjunc-

tion with early adversities. As people grow older, the “return on investment”

decreases, she added.

Areas of global conflict and violence, such as those in African and the Middle

Preventing brain disorders Symposium looks forward on global mental health

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.

BY ANNA LARSEN, MPH ‘15

Read more about the symposium

the2x2project.org

2x2.ph/prevent-brain-disorders

43DEPARTMENT OF EPIDEMIOLOGY

SYMPOSIUM REPORT

East, contribute to a high burden of child-

hood adversities. Traumatic experiences in

war are clearly associated with psycholog-

ical disorders, said Dr. Muthoni Mathai, a

psychiatrist and senior lecturer at the Uni-

versity of Nairobi.

“Trauma is toxic,” said Dr. Adam

Karpati, former executive deputy com-

missioner for mental hygiene at the New

York City Department of Health and Mental

Hygiene, comparing violence to risky envi-

ronmental exposures that we should seek

to mitigate. For example, after New York

City strengthened its gun control laws,

suicide rates plummeted to 6.2 per 100,000

compared to the national average of 12.4

suicides per 100,000, he noted. (Dr. Karpati

is currently senior vice president for public

health impact at the North America section

of the International Union Against Tubercu-

losis and Lung Disease).

Changing social norms around activities

that are linked with mental health disorders

should also should be taken into account,

according to Dr. Katherine Keyes, assistant

professor of epidemiology at Columbia

University’s Mailman School of Public

Health. For instance, attitudes around

binge drinking among teenagers have

relaxed at the same time that rates of binge

drinking has increased, according to data

from the 30-plus year national Monitoring

the Future survey.

Additionally, many of the interventions

that wealthy countries use face challenges

in post-conflict and low-resource settings,

said Dr. James Okello, a psychiatrist and

researcher at the Centre for Children in Vul-

nerable Situations.

For instance, after Sierra Leone’s civil

war, there was only one hospital that pro-

vided psychiatric services for a population

of 6 million, said Dr. Adeyinka M. Akinsu-

lure-Smith, assistant professor of women’s

studies at City College of New York. To

help the children of Sierra Leone deal with

the fallout from their war experiences, Dr.

Akinsulure-Smith worked on a program

that created an environment based around

traditional concepts of healing, communi-

cating, and celebrating progress.

Participants spoke of the need for more

research on the prevalence and impact

of mental health disorders in

society, especially in middle

and low-income countries, in

order to understand how wide-

spread mental health problems

are. Coordination of clinicians,

researchers, and programs

internationally is required to

strengthen surveillance and

share successful methods,

said Dr. Pike. She spoke about

WHO’s Global Clinical Practice

Network which is made up of

10,039 committed clinicians

who provide data to inform the

International Classification of

Diseases 11th Revision (ICD-11).

On the ground, things can be difficult,

however. In South Africa, 5 percent or

less of the health budget is allocated for

mental health, according to Dr. Solomon

Rataemane, head of the department of

psychiatry at the University of Limpopo.

Because public ignorance about mental

health is pervasive, Dr. Rataemane said

most mental health professionals are stig-

matized and difficult to retain.

On the other hand, the U.S. spends a lot

of money on brain disorder research. But, it

goes primarily to biomedical studies, said

Dr. Robert Kaplan, who at the time of the

symposium served as director of the office

of behavioral and social sciences research

at the National Institutes of Health. “Most

of my colleagues believe it’s not only the

best way, but the only way,” he said. Yet

this approach is limited in its capacity to

address the complex causes that lead to

mental disorders and may not even be

working well, according to Dr. Kaplan, who

is now serving as the chief science officer

for the Agency for Healthcare Research and

Quality. “We need to redistribute some of

the money we are spending on medical

care and to public health services.”

Dr. Gerald Oppenheimer, professor

of sociomedical sciences at Columbia

University and a public health historian,

offered the mental health professionals in

the audience an example of the successful

public health campaign to reduce heart

disease, which had the “evangelical” and

“zealot-like” commitment of members of

medical and public health advocates who

drew attention to it in the mid twentieth

century.

In California, the state’s 2004 Mental

Health Services Act, which put $9 million

from new taxes toward prevention and

early intervention in mental health disor-

ders, has shown early success, according

to Dr. Wayne Clarke, the behavioral health

director for Monterey County. The initiative

focused on lowering suicides, reducing

stigma, and improving student mental

health. Nearly 40,000 students participated

in initiative activities, and many more were

reached through a social media campaign

called “suicide is preventable.” Early

results indicate that participants are now

more likely to recognize warning signs and

properly intervene when mental distress or

suicidal tendencies are displayed.

Dr. Sandro Galea, chair of the depart-

ment of epidemiology and Gelman

Professor of epidemiology, acknowledged

challenges of the new global mental health

agenda yet pointed to the auditorium full

of motivated, highly influential symposium

attendees as an example of the growing

recognition of global mental health.

“What struck me was that we had a

synthesis of public health perspectives that

are essential if we are to affect change in

mental health. The challenge to all of us as

a community is to capitalize on this con-

versation to bring to fruition the innovative

ideas that we heard, such that not only is

mental health a topic of conversation, but

that it yields results,” he said.

44

in the news

Understanding the worst Ebola outbreak in history

Over the summer, the Ebola outbreak in West Africa became the largest and most devastating in the virus’s 40-year history. Unlike past outbreaks that have not spread past rural parts of Africa, this one reached urban areas where “there isn’t enough manpower to track all these cases and make certain we educate people,” says Dr. Ian Lipkin, John Snow Professor of Epidemiology and director of the Center for Infection and Immunity at Columbia’s Mailman School of Public Health.

While the governments of Sierra Leone, Liberia, Guinea, and Nigeria have struggled to contain Ebola, there is little chance it will spread in the U.S., despite the infection of two American aid workers who were brought back to Atlanta for treatment: “It doesn’t spread easily. Casual contact isn’t enough to spread it. And it doesn’t really spread through the respiratory route,” says Dr. Stephen Morse, professor of epidemiology at Columbia. “[I]f a hospital that has a patient uses rigorous infection control procedures there is no danger of spread to others.”

Read more of Dr. Lipkin who wrote an op-ed for the Wall Street Journal ›

bit.ly/1zuysBN and has been quoted in National Geographic › bit.ly/1olTuw8, Newsweek › bit.ly/1p61rFQ, and appeared on CNN › cnn.it/1qcY97L and Bloomberg. › bloom.bg/1mJXmYe

Read more of Dr. Morse, who was a guest on WNYC’s The Brian Lehrer Show. › bit.ly/1pahubR and was quoted on ABC › abcn.ws/VOzCuF, the Wall Street Journal › on.wsj.com/1l9RTyv, and participated in an Ask Me Anything on Reddit. › bit.

ly/1mJXF5n

45

IN THE NEWS

Robin Williams’ death spotlights suicide and mental health

The coverage of actor Robin Williams’ death raised concerns that suicide rates would spike afterward. “Suicide contagion is real, which is why I’m concerned about it,” said Dr. Madelyn Gould, professor of epidemiology in psychiatry at Columbia University, to the New York Times. Dr. Gould has found that media coverage that emphasizes the method of suicide and other details is linked to more suicides. Fortunately, for those who call suicide hotlines the risk goes down significantly, according to another study by Dr. Gould. Read more in the New York Times › nyti.ms/1BWuHsR and Al Jazeera. › alj.am/1t7q1xF

For Vietnam veterans, little improvement in PTSD over time

A new study finds that most veterans who had persistent post-traumatic stress disorder a decade or more after serving in Vietnam have shown little improve-ment since then. “This is a tremendously important effort, tracking the course of war-related trauma from young adulthood past middle age — we have noth-ing else like this,” said Dr. Bruce Dohrenwend, professor of epidemiology and professor of psychiatry at the College of Physicians and Surgeons at Colum-bia. Read more in the New York Times. › nyti.ms/1txDkpL

Small DNA modification may affect body’s response to stress

A modification of a gene that is known for its involvement in depression and PTSD may lead to exaggerated responses to stress, according to a study in the journal Nature Neuroscience by Dr. Karestan Koenen, professor of epidemiology, and Dr. Sandro Galea, Gelman Professor of Epidemiology and chair of the Department of Epidemiology, both at Columbia’s Mailman School, with scientists at Duke University. Read more in Medical Express. › bit.ly/1vgodDf

Too soon to know if e-cigarettes help

E-cigarettes exist in an “evidence-free zone,” according to Dr. Stephen Leeder, adjunct professor of epidemiology at Columbia and professor of public health and community medicine at the University of Sidney School of Public Health. It is too soon to know if they help people quit smoking. Read more on ABC. › ab.co/1pzxzqC

Antibiotic residues found in chickens in India

A new study found antibiotic residue in nearly half of chicken samples tested across the Delhi National Capital Region in India. “Repeated and prolonged exposure to antibiotics lead, by natural selection, to the emergence of resistant strains of bacteria,” said Dr. Neil Schluger a professor of medicine, epidemiology, and environmental health sciences and chief of the pulmonary, allergy, and critical care medical division at Columbia University. Read more in the Business Standard. › bit.ly/YVTjTn

46

Weight may not be an issue for efficacy of morning-after pills

European regulators have said data from a study finding the morning after pill is less effective for heavier people is not substantial enough. Says Dr. Carolyn Westhoff, professor of epidemiology, population and family health, and gyne-cology at New York Presbyterian Hospital and at Columbia University: “People in the field have been scratching their heads since [the 2011 study] was pub-lished, saying ‘what sorts of studies could we do to get more data to help us understand this better?’ To my knowledge, nobody has done those additional studies.” Read more in Time. › ti.me/1vgow0R

Tropical infections diagnosed in 3 Long Island patients

Dr. Jennifer Calder, adjunct assistant professor of epidemiology at Columbia’s Mailman School and associate professor of public health practice at New York Medical College, discussed how to detect mosquito-born illnesses like West Nile, the Chikungunya Virus and Dengue Fever after three people in Long Island were diagnosed with these debilitating diseases. Watch more on NBC New York. › bit.ly/1tNui6m

LGB people who sought help from religious/spiritual advisor had elevated risk of suicide attempt

For lesbian, gay, or bisexual individuals, seeking counseling from a religious or spiritual advisor was associated with greater chance of a suicide attempt than seeking mental health treatment or no help at all, according to a study by Dr. Sharon Schwartz, professor of epidemiology at Columbia, and a colleague. Read more in Edge Boston. › bit.ly/1rvGwDT

Renowned AIDS researcher shot down in Malaysian Airlines flight

“His loss is more than just a summary of his efforts and his papers. He was not shy about speaking truth to power,” says Dr. Scott Hammer, professor of public health at Columbia’s Mailman School and Harold C. Neu Professor of Infectious Diseases at New York Presbyterian Hospital of Epidemiology, about Dr. Joep Lange, a renowned HIV/AIDS researcher who was one among dozens of people traveling to the International AIDS Conference in Melbourne, Austra-lia, on board the Malaysia Air flight shot down over Ukraine in July. “He spoke softly and carried a lot of moral heft.” Read more in the LA Times. › lat.ms/1l9Tl3T

Dr. Lange “was not only a scientist dealing with the specificities of the virus itself but also thinking about the global health equity challenges that the virus faced,” said Dr. Abdul El-Sayed, assistant professor of epidemiology at Colum-bia’s Mailman School.

IN THE NEWS

47

Retire the “retirement community”

“We need to invest in an America where older adults are healthy and remain among us, living out important roles and responsibilities that leave a lasting legacy,” says Dean Linda Fried in an article about rethinking retirement. Read more in the Wall Street Journal. › on.wsj.com/1p61QrN

ADHD drugs misused by college students

A new survey documents notable use by college students of drugs meant to treat attention deficit hyperactivity disorder. Despite the belief that they enhance academic performance—which is up for debate—these drugs “are not something you want to mess with without a physician’s oversight,” says Dr. Katherine Keyes, assistant professor of epidemiology at Columbia’s Mailman School. Read more in the Detroit Free Press. › on.freep.com/1sATyel

2 drugs could offer hope for people with fatal lung disease

Randomized clinical trials have found that two drugs appear to slow the advance of idiopathic pulmonary fibrosis. One of the drugs, Pirfenidone “very clearly slowed down progression of the disease as measured by lung function, and seems to have an effect on mortality as well,” said Dr. David Lederer, associate professor of epidemiology and medicine in pediatrics at Columbia’s College of Physicians and Surgeons.

Read more in the Philadelphia Inquirer. › bit.ly/1oxRAur

Unexpected death of loved one could trigger psychiatric disorders

The unexpected loss of a loved one can trigger a range of psychiatric disor-ders, including mania, in patients with no history of mental illness, according to a study by several faculty members in the department. “Our findings should alert clinicians to the possible onset of mania after an unexpected death in oth-erwise healthy individuals,” say Drs. Katherine Keyes, Sandro Galea, Karestan Koenen, and their co-authors in the study. Read more on Medwire News. › bit.ly/1nTcf06

IN THE NEWS

48

Remembering Mervyn Susser

in memoriam

We remember Mervyn Susser, MB, BCH, Sergievsky Professor of Epidemiology Emeritus, who

passed away on August 14, 2014, at the age of 92. Dr. Susser was a pioneer of epidemiology in the twentieth

century and chair of the department of epidemiology for 12

years. His emphasis on the relationship between society

and disease is fundamental to the discipline as it is practiced

today. Dr. Susser drew attention to the interrelationships

between health, disease, and social injustice. His influence

extends to the foundations of life course epidemiology,

genetic epidemiology, epidemiology of neurodevelopmental

disorders, global health (later including HIV/AIDS), and other

areas.

Read more about Dr. Susser

ff Department of Epidemiology website

epi.is/remembering-mervyn-susser

ff New York Times obituary

nyti.ms/1C6ruqL

ff 2x2 article from 2011

epi.is/susser

ff Interview in the journal Epidemiology from 2003

bit.ly/1paLoGP

Mervyn Susser with wife and partner Zena Stein.

IMAGE: HELENE KRENISKE

49DEPARTMENT OF EPIDEMIOLOGY

faculty publications

Abdool Karim Q, Kharsany AB, Leask K, Ntombela F, Humphries H, Frohlich JA, Samsunder N, Grobler A, Dellar R, Abdool Karim SS. Prevalence of HIV, HSV-2 and pregnancy among high school students in rural KwaZulu-Natal, South Africa: a bio-behavioural cross-sectional survey. Sex Transm Infect. 2014 May 29. pii: sextrans-2014-051548. doi: 10.1136/sex-trans-2014-051548. [Epub ahead of print]

Accordino MK, Neugut AI, Hershman DL. Cardiac Effects of Anticancer Therapy in the Elderly. J Clin Oncol. 2014 Jul 28. pii: JCO.2013.55.0459. [Epub ahead of print].

Adeleye AJ, Palmeri N, Wang SH, Liu-Jarin X, Wright JD. Spindle Cell Sarcoma of the Vulva With Myofibroblastic Differ-entiation. J Low Genit Tract Dis. 2014 Jul 24. [Epub ahead of print]

Admon AJ, Seymour CW, Gershengorn HB, Wunsch H, Cooke CR. Hospital-level variation in intensive care unit admission and critical care procedures for patients hospitalized for pulmonary embolism. Chest. 2014 Jul 3. doi: 10.1378/chest.14-0059. [Epub ahead of print]

Adriaanse M, Van domburgh L, Hoek HW, Susser E, Doreleijers TA, Veling W. Prevalence, impact and cultural context of psychotic experiences among ethnic minority youth. Psychol Med. 2014 Aug 7:1-10. [Epub ahead of print]

Akinyemiju TF, Mcdonald JA, Tsui J, Greenlee H. Adherence to cancer preven-tion guidelines in 18 african countries. PLoS ONE. 2014;9(8):e105209.

Ananth CV, Friedman AM. Ischemic placental disease and risks of perinatal mortality and morbidity and neurode-velopmental outcomes. Semin Perinatol. 2014 Apr;38(3):151-158. doi: 10.1053/j.semperi.2014.03.007.

Ananth CV. Semin Perinatol. Ischemic placental disease: A unifying concept for preeclampsia, intrauterine growth restriction, and placental abruption. 2014 Apr;38(3):131-2. doi: 10.1053/j.semperi.2014.03.001.

Anglin DM, Lighty Q, Yang LH, Green-spoon M, Miles RJ, Slonim T, Isaac K, Brown MJ. Discrimination, arrest history, and major depressive disorder in the U.S. Black population. Psychiatry Res. 2014 May 20. pii: S0165-1781(14)00391-6. doi: 10.1016/j.psychres.2014.05.020. [Epub ahead of print]

Arnold MP, Andrasik M, Landers S, Karuna S, Mimiaga MJ, Wakefield S, Mayer K, Buchbinder S, Koblin BA. Sources of Racial/Ethnic Differences in Awareness of HIV Vaccine Trials. Am J Public Health. 2014 Jun 12:e1-e7. [Epub ahead of print]

Baldin E, Hauser WA, Buchhalter JR, Hesdorffer DC, Ottman R. Yield of epileptiform electroencephalogram abnormalities in incident unprovoked seizures: A population-based study. Epi-lepsia. 2014 Jul 9. doi: 10.1111/epi.12720. [Epub ahead of print]

Banducci AN, Hoffman E, Lejuez CW, Koenen KC. The relationship between child abuse and negative outcomes among substance users: Psychopathol-ogy, health, and comorbidities. Addict

Behav. 2014 Jun 2;39(10):1522-1527.

Barondess JA. Scanning the chronic disease terrain: prospects and oppor-tunities. Trans Am Clin Climatol Assoc. 2014;125:45-56.

Barral S, Reitz C, Small SA, Mayeux R. Genetic variants in a cyclic adenosine monophosphate responsive element binding protein-dependent histone acetylation pathway influence memory performance in cognitively healthy elderly individuals. Neurobiol Aging. 2014. pii: S0197-4580(14)00462-X. doi: 10.1016/j.neurobiolaging.2014.06.024. [Epub ahead of print]

Barros FC, Melo AP, Cournos F, Cher-chiglia ML, Peixoto ER, Guimarães MD. Cigarette smoking among psychiatric patients in Brazil. Cad Saude Publica. 2014 Jun;30(6):1195-206.

Basch CH, Ethan D, Hillyer GC, Berdnik A. Skin Cancer Prevention Coverage in Popular US Women’s Health and Fitness Magazines: An Analysis of Advertise-ments and Articles. Glob J Health Sci. 2014 Apr 2;6(4):33988. doi: 10.5539/gjhs.v6n4p42.

Basch CH, Hillyer GC, Ethan D, Berdnik A, Basch CE. Tanning Shade Gradations of Models in Mainstream Fitness and Muscle Enthusiast Magazines: Impli-cations for Skin Cancer Prevention in Men. Am J Mens Health. 2014 Jul 18. pii: 1557988314543511. [Epub ahead of print]

Beauclair R, Petro G, Myer L. The asso-ciation between timing of initiation of antenatal care and stillbirths: a retrospec-tive cohort study of pregnant women in Cape Town, South Africa. BMC Pregnancy Childbirth. 2014 Jun 13;14(1):204. [Epub ahead of print]

Benetos A, Dalgård C, Labat C, Kark JD, Verhulst S, Christensen K, Kimura M, Hor-vath K, Kyvik KO, Aviv A. Sex difference in leukocyte telomere length is ablated in opposite-sex co-twins. Int J Epidemiol. 2014 Jul 23. pii: dyu146. [Epub ahead of print]

Black-Shinn JL, Kinney GL, Wise AL, Regan EA, Make B, Krantz MJ, Barr RG, Murphy JR, Lynch D, Silverman EK, Crapo JD, Hokanson JE; the COPD Gene Investigators. Cardiovascular Disease is Associated with COPD Severity and Reduced Functional Status and Quality of Life. COPD. 2014 May 15. [Epub ahead of print]

Borrell LN. The effects of smoking and physical inactivity on advancing mortal-ity in U.S. adults. Ann Epidemiol. 2014 Jun;24(6):484-7. doi: 10.1016/j.annep-idem.2014.02.016. Epub 2014 Mar 21.

Brickman AM, Zahodne LB, Guzman VA, Narkhede A, Meier IB, Griffith EY, Provenzano FA, Schupf N, Manly JJ, Stern Y, Luchsinger JA, Mayeux R. Reconsidering harbingers of dementia: progression of parietal lobe white matter hyperintensities predicts Alzheimer’s disease incidence. Neurobiol Aging. 2014. pii: S0197-4580(14)00488-6. doi: 10.1016/j.neurobiolaging.2014.07.019. [Epub ahead of print]

Brinjikji W, El-Sayed AM, Kallmes DF,

Lanzino G, Cloft HJ. Racial and insur-ance based disparities in the treatment of carotid artery stenosis: a study of the Nationwide Inpatient Sample. J Neurointerv Surg. 2014 Jul 11. pii: neurintsurg-2014-011294. doi: 10.1136/neurintsurg-2014-011294. [Epub ahead of print]

Brinjikji W, El-Sayed AM, Rabinstein AA, McDonald JS, Cloft HJ. Disparities in Imaging Utilization for Acute Isch-emic Stroke Based on Patient Insurance Status. AJR Am J Roentgenol. 2014 Aug;203(2):372-376.

Brubaker SG, Friedman AM, Cleary KL, Prendergast E, D’Alton ME, Ananth CV, Wright JD. Patterns of Use and Predictors of Receipt of Antibiotics in Women Under-going Cesarean Delivery. Obstet Gynecol. 2014 Jul 7. [Epub ahead of print]

Campa D, Mergarten B, De vivo I, Boutron-Ruault MC, Racine A, Severi G, Nieters A, Katzke VA, Trichopoulou A, Yiannakouris N, Trichopoulos D, Boeing H, Quiros JR, Duell EJ, Molina-Montes E, Huerta JM, Ardanaz E, Dorronsoro M, Khaw KT, Wareham N, Travis RC, Palli D, Pala V, Tumino R, Naccarati A, Panico S, Vineis P, Riboli E, Siddiq A, Bue-no-de-Mesquita HB, Peeters PH, Nilsson PM, Sund M, Ye W, Lund E, Jareid M, Weiderpass E, Duarte-Salles T, Kong SY, Stepien M, Canzian F, Kaaks R. Leukocyte telomere length in relation to pancreatic cancer risk: a prospective study. Cancer Epidemiol Biomarkers Prev. 2014 Aug 7. pii: cebp.0247.2014. [Epub ahead of print]

Canetta S, Sourander A, Surcel HM, Hinkka-Yli-Salomäki S, Leiviskä J, Kel-lendonk C, McKeague IW, Brown AS. Elevated Maternal C-Reactive Protein and Increased Risk of Schizophrenia in a National Birth Cohort. Am J Psy-chiatry. 2014 Jun 27. doi: 10.1176/appi.ajp.2014.13121579. [Epub ahead of print]

Cannizzaro DL, Elliott JC, Stohl M, Hasin DS, Aharonovich E. Neuropsychological Assessment Battery-Screening Module (S-NAB): Performance in treatment-seek-ing cocaine users. Am J Drug Alcohol Abuse. 2014 Jun 20:1-8. [Epub ahead of print]

Cárdenas V, Román GC, Pérez A, Hauser WA. Why U.S. epilepsy hospital stays rose in 2006. Epilepsia. 2014 Jul 9. doi: 10.1111/epi.12719. [Epub ahead of print]

Carlini C, Andreoni S, Martins SS, Benjamin M, Sanudo A, Sanchez ZM. Environmental characteristics associated with alcohol intoxication among patrons in Brazilian nightclubs. Drug Alcohol Rev. 2014 Jun 30. doi: 10.1111/dar.12155. [Epub ahead of print]

Castaldelli-Maia JM, Nicastri S, de Oliveira LG, de Andrade AG, Martins SS. The Role of First Use of Inhalants Within Sequencing Pattern of First Use of Drugs Among Brazilian University Students. Exp Clin Psychopharmacol. 2014 Aug 25. [Epub ahead of print]

Cerdá M, Bordelois P, Keyes KM, Rob-erts AL, Martins SS, Reisner SL, Austin SB, Corliss HL, Koenen KC. Family ties: Maternal-offspring attachment and young adult nonmedical prescription opioid

use. Drug Alcohol Depend. 2014 Jun 30. pii: S0376-8716(14)00952-1. doi: 10.1016/j.drugalcdep.2014.06.026. [Epub ahead of print]

Cerdá M, Richards C, Cohen GH, Cal-abrese JR, Liberzon I, Tamburrino M, Galea S, Koenen KC. Civilian Stressors Associated with Alcohol Use Disorders in the National Guard. Am J Prev Med. 2014 Jul 22. pii: S0749-3797(14)00313-4. doi: 10.1016/j.amepre.2014.06.015. [Epub ahead of print]

Cerdá M, Tracy M, Ahern J, Galea S. Addressing population health and health inequalities: the role of fundamental causes. Am J Public Health. 2014 Sep;104 Suppl 4:S609-19.

Cerdá M. Posttraumatic growth in the aftermath of a disaster: looking for the role of gender. Soc Psychiatry Psychiatr Epidemiol. 2014 Aug 7. [Epub ahead of print]

Chauhan SP, Blackwell SB, Ananth CV. Neonatal brachial plexus palsy: Incidence, prevalence, and temporal trends. Semin Perinatol. 2014 Jun;38(4):210-8. doi: 10.1053/j.semperi.2014.04.007.

Chen I, Cummings V, Fogel JM, Marz-inke MA, Clarke W, Connor MB, Griffith S, Buchbinder S, Shoptaw S, Rio CD, Magnus M, Mannheimer S, Wheeler DP, Mayer KH, Koblin BA, Eshleman SH. Low-level Viremia Early in HIV Infection. J Acquir Immune Defic Syndr. 2014. [Epub ahead of print]

Chen L, Mathema B, Pitout JD, DeLeo FR, Kreiswirth BN. Epidemic Klebsiella pneumoniae ST258 Is a Hybrid Strain. MBio. 2014 Jun 24;5(3). pii: e01355-14. doi: 10.1128/mBio.01355-14.

Chen LY, Crum RM, Martins SS, Kaufmann CN, Strain EC, Mojtabai R. Patterns of concurrent substance use among non-medical ADHD stimulant users: Results from the National Survey on Drug Use and Health. Drug Alcohol Depend. 2014 Jun 10. pii: S0376-8716(14)00904-1. doi: 10.1016/j.drugalcdep.2014.05.022. [Epub ahead of print]

Chen YP, Pettis JS, Corona M, Chen WP, Li CJ, Spivak M, Visscher PK, DeGran-di-Hoffman G, Boncristiani H, Zhao Y, vanEngelsdorp D, Delaplane K, Solter L, Drummond F, Kramer M, Lipkin WI, Pala-cios G, Hamilton MC, Smith B, Huang SK, Zheng HQ, Li JL, Zhang X, Zhou AF, Wu LY, Zhou JZ, Lee ML, Teixeira EW, Li ZG, Evans JD. Israeli Acute Paralysis Virus: Epidemiology, Pathogenesis and Implica-tions for Honey Bee Health.

Cherry KE, Sampson L, Nezat PF, Cacamo A, Marks LD, Galea S.Long-term psycho-logical outcomes in older adults after disaster: relationships to religiosity and social support. Aging Ment Health. 2014 Jul 31:1-14. [Epub ahead of print]

Choi H, Hamberger MJ, Munger Clary H, Loeb R, Onchiri FM, Baker G, Hauser WA, Wong JB. Seizure frequency and patient-centered outcome assessment in epilepsy. Epilepsia. 2014 Jun 5. doi: 10.1111/epi.12672. [Epub ahead of print]

Ciccolo JT, Williams DM, Dunsiger S, Whitworth JW, McCullough AK, Bock

JULY–SEPTEMBER 2014

50 FALL 2014 : ISSUE 5.03

BB, Marcus BH, Myerson M. Efficacy of Resistance Training as an Aid to Smoking Cessation: Rationale and Design of the Strength To Quit Study. Ment Health Phys Act. 2014;7(2):95-103.

Cohen R, Budoff M, Mcclelland RL, Sillau S, Burke G, Blaha M, Szklo M, Uretsky S, Rozanski A, Shea S. Significance of a Positive Family History for Coronary Heart Disease in Patients With a Zero Coronary Artery Calcium Score (from the Multi-Ethnic Study of Atherosclerosis). Am J Cardiol. 2014 doi: 10.1016/j.amj-card.2014.07.043. [Epub ahead of print]

Constant D, de Tolly K, Harries J, Myer L. Mobile phone messages to provide sup-port to women during the home phase of medical abortion in South Africa: a ran-domised controlled trial. Contraception. 2014 Apr 24. pii: S0010-7824(14)00193-0. doi: 10.1016/j.contraception.2014.04.009. [Epub ahead of print]

Cornell M, Lessells R, Fox MP, Garone DB, Giddy J, Fenner L, Myer L, Boulle A; for the IeDEA-Southern Africa collabora-tion. Mortality among adults transferred and lost to follow-up from antiretroviral therapy programmes in South Africa: a multicentre cohort study. J Acquir Immune Defic Syndr. 2014 Jun 24. [Epub ahead of print]

Cousins MM, Konikoff J, Sabin D, Khaki L, Longosz AF, Laeyendecker O, Celum C, Buchbinder SP, Seage GR 3rd, Kirk GD, Moore RD, Mehta SH, Margolick JB, Brown J, Mayer KH, Kobin BA, Wheeler D, Justman JE, Hodder SL, Quinn TC, Brookmeyer R, Eshleman SH. A Compar-ison of Two Measures of HIV Diversity in Multi-Assay Algorithms for HIV Inci-dence Estimation. PLoS One. 2014 Jun 26;9(6):e101043. doi: 10.1371/journal.pone.0101043. eCollection 2014.

Cross WF, Pisani AR, Schmeelk-Cone K, Xia Y, Tu X, McMahon M, Munfakh JL, Gould MS. Measuring Trainer Fidelity in the Transfer of Suicide Prevention Train-ing. Crisis. 2014 Jan 1;35(3):202-212.

Cuello JP, Ortega-Gutierrez S, Linares G, Agarwal S, Cunningham A, Mohr JP, Mayer SA, Marshall RS, Claassen J, Bad-jatia N, Elkind MS, Lee K. Acute Cervical Myelopathy Due To Presumed Fibrocar-tilaginous Embolism: A Case Report And Systematic Review of The Literature. J Spinal Disord Tech. 2014 Jun 4. [Epub ahead of print]

de la Peña JB, Ahsan HM, Botanas CJ, Sohn A, Yu GY, Cheong JH. Adolescent nicotine or cigarette smoke exposure changes subsequent response to nico-tine conditioned place preference and self-administration. Behav Brain Res. 2014 Jun 30. pii: S0166-4328(14)00427-6. doi: 10.1016/j.bbr.2014.06.044. [Epub ahead of print]

Dechartres A, Altman DG, Trinquart L, Boutron I, Ravaud P. Association between analytic strategy and estimates of treat-ment outcomes in meta-analyses. JAMA. 2014;312(6):623-30.

DeVylder JE, Burnette D, Yang LH. Co-oc-currence of psychotic experiences and common mental health conditions across four racially and ethnically diverse pop-ulation samples. Psychol Med. 2014 Apr 25:1-11. [Epub ahead of print]

Di Castelnuovo A, Agnoli C, de Curtis A, Giurdanella MC, Sieri S, Mattiello A, Matullo G, Panico S, Sacerdote C, Tumino R, Vineis P, de Gaetano G, Donati MB,

Iacoviello L. Elevated levels of D-dimers increase the risk of ischaemic and hae-morrhagic stroke. Findings from the EPICOR Study. Thromb Haemost. 2014 Jul 17;112(5). [Epub ahead of print]

DiCarlo AL, Mantell JE, Remien RH, Zerbe A, Morris D, Pitt B, Abrams EJ, El-Sadr WM. ‘Men usually say that HIV testing is for women’: gender dynamics and per-ceptions of HIV testing in Lesotho. Cult Health Sex. 2014 May 22:1-16. [Epub ahead of print]

Dik VK, Murphy N, Siersema PD, Fedirko V, Jenab M, Kong SY, Hansen CP, Overvad K, Tjonneland A, Olsen A, Dossus L, Racine A, Bastide N, Li K, Kühn T, Boeing H, Alek-sandrova K, Trichopoulou A, Trichopoulos D, Barbitsioti A, Palli D, Contiero P, Vineis P, Tumino R, Panico S, Peeters PH, Wei-derpass E, Skeie G, Hjartaker A, Amiano P, Sanchez MJ, Fonseca-Nunes A, Barricarte A, Chirlaque MD, Redondo ML, Jirstrom K, Manjer J, Nilsson LM, Wennberg M, Bradbury KE, Khaw KT, Wareham N, Cross AJ, Riboli E, Bueno-de-Mesquita HB. Prediagnostic intake of dairy products and dietary calcium and colorectal cancer survival–results from the EPIC cohort study. Cancer Epidemiol Biomarkers Prev. 2014 Jun 10.

Dougados M, Soubrier M, Perrodeau E, Gossec L, Fayet F, Gilson M, Cerato MH, Pouplin S, Flipo RM, Chabrefy L, Mouterde G, Euller-Ziegler L, Schaeverbeke T, Fautrel B, Saraux A, Chary-Valckenaere I, Chales G, Dernis E, Richette P, Mariette X, Berenbaum F, Sibilia J, Ravaud P. Impact of a nurse-led programme on comorbid-ity management and impact of a patient self-assessment of disease activity on the management of rheumatoid arthritis: results of a prospective, multicentre, randomised, controlled trial (COME-DRA). Ann Rheum Dis. 2014 May 28. pii: annrheumdis-2013-204733. doi: 10.1136/annrheumdis-2013-204733. [Epub ahead of print]

Dowdy DW, Azman AS, Kendall EA, Math-ema B. Transforming the fight against tuberculosis: Targeting catalysts of trans-mission. Clin Infect Dis. 2014 Jun 30. pii: ciu506. [Epub ahead of print]

Duggan C, Xiao L, Terry MB, McTiernan A. No effect of weight loss on LINE-1 methylation levels in peripheral blood leukocytes from postmenopausal over-weight women. Obesity (Silver Spring). 2014 Jun 13. doi: 10.1002/oby.20806. [Epub ahead of print]

Eduardo E, Lamb MR, Kandula S, Howard A, Mugisha V, Kimanga D, Kilama B, El-Sadr W, Elul B. Characteristics and Outcomes among Older HIV-Positive Adults Enrolled in HIV Programs in Four Sub-Saharan African Countries. PLoS One. 2014;9(7):e103864

El-Sadr WM, Harripersaud K, Bayer R. End of AIDS--hype versus hope. Science. 2014 Jul 11;345(6193):166.

El-Sayed AM. Complex systems for a complex issue: race in health research. Virtual Mentor. 2014 Jun 1;16(6):450-4. doi: 10.1001/virtualmentor.2014.16.06.stas1-1406.

Elliott D, Davidson JE, Harvey MA, Bemis-Dougherty A, Hopkins RO, Iwashyna TJ, Wagner J, Weinert C, Wunsch H, Bienvenu OJ, Black G, Brady S, Brodsky MB, Deutschman C, Doepp D, Flatley C, Fosnight S, Gittler M, Gomez BT, Hyzy R, Louis D, Mandel R, Maxwell

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57DEPARTMENT OF EPIDEMIOLOGY

Zamora-Ros R, Sacerdote C, Ricceri F, Weiderpass E, Roswall N, Buckland G, St-Jules DE, Overvad K, Kyrø C, Fagherazzi G, Kvaskoff M, Severi G, Chang-Claude J, Kaaks R, Nöthlings U, Trichopoulou A, Naska A, Trichopoulos D, Palli D, Grioni S, Mattiello A, Tumino R, Gram IT, Engeset D, Huerta JM, Moli-na-Montes E, Argüelles M, Amiano P, Ardanaz E, Ericson U, Lindkvist B, Nilsson LM, Kiemeney LA, Ros M, Bueno-de-Mes-quita HB, Peeters PH, Khaw KT, Wareham NJ, Knaze V, Romieu I, Scalbert A, Bren-nan P, Wark P, Vineis P, Riboli E, González CA. Flavonoid and lignan intake in relation to bladder cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Br J Cancer. 2014 Aug 14. doi: 10.1038/bjc.2014.459. [Epub ahead of print]

Zeitlin J, Blondel B, Ananth CV. Character-istics of Childbearing Women, Obstetrical Interventions and Preterm Delivery: A Comparison of the US and France. Matern Child Health J. 2014 Aug 15. [Epub ahead of print]

Department of EpidemiologyMailman School of Public Health

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