Introductions

Jiean

Hi! My name is Jiean and I wanted to extend a warm welcome to our newly admitted students. Being a Californian, I hope the weather does the same in the near future (as my soft upbringing came no-where near sufficiently preparing me for a Midwestern winter).

I am currently a first year student in the Hospital and Molecular Epidemiology program. For those who don’t know (and I’ll admit to being among them when I first got here), HME combines molecular biology with epidemiologic concepts to explore the etiology, distribution, and prevention of diseases within populations at the molecular level. That’s just a fancy way of saying that we like to utilize our science backgrounds to understand how diseases move through a population (much like other epidemiologists do with field work).

I was drawn to Michigan because of the prominent role it plays in oral health research. Many leaders in the field of dental public health (or just about any field) call Michigan home, and as a lowly grad student I have been able to soak up their brilliance and collaborate on their projects. As an undergraduate at the University of California-Berkeley, I found my research in oral cancer to be quite disconnected from a larger picture. While it was neat to understand how this cancer metastasizes and how our sense of pain is augmented by these tumors, it feels a lot more rewarding when the impact of your work on people’s lives is more apparent. My current research focuses on oral spirochetes known to cause periodontal disease, as well as the association between periodontal disease and various systemic maladies. The Department of Epidemiology at Michigan has afforded me the opportunity to explore both parts of this broad research interest; I could not imagine a more perfect fit for me.

As our late president, Teddy Roosevelt, once noted, ”Nothing in the world is worth having or worth doing unless it means effort, pain, difficulty… I have never in my life envied a human being who led an easy life. I have envied a great many people who led diffcult lives and led them well.” Michigan is definitely worth the late-nights in the computer labs with half your cohort clicking away at their workstations, the 5 problem sets you struggle to finish before the week is over, and the daunting 80 slide powerpoint you need to go through for 1 lecture of a pathophysiology exam.

How Public Health Fields Work Together

Carrie Rheingans

Sitting in my introductory environmental health class recently, I had a flash of complete understanding about how all the varied fields of public health work together. U-M School of Public Health divides the fields five ways: Environmental Health Sciences, Health Behavior and Health Education, Health Management and Policy, Epidemiology, and Biostatistics. I’m going to stick to these divisions to explain my understanding.

Professor Hu was discussing how the environmental health scientists would collect information about the exposures people have to something in their environment, and how the epidemiologists would design studies to compare various populations’ health outcomes based on that exposure. Biostatisticians would evaluate the data and create reports in conjunction with the epidemiologists. Health behaviorists and educators would interpret these studies and figure out ways to help people change their behaviors to avoid exposure to things that negatively impact health. People who write health policies would also interpret the epidemiological studies to make policies that can make structural changes to help people be able to change their behaviors to improve their health.

A great example that illustrates all this is smoking. Recently, in Michigan, public places went smoke-free. This was a health policy change, and many of the people working for that law change are actually staff and alumni of U-M SPH! Prior to that, lots of other parts of public health had been trying to reduce people’s exposure to smoke – either first-hand or second-hand. Epidemiologists and biostatisticians had been collecting data for years about the detrimental effects of second-hand smoke on people who work in smoky environments. Health behavior change specialists were working with individuals to quit smoking, or to learn to avoid second-hand smoke if they were non-smokers. In the end, all the fields of public health worked together to bring about individual, community, and state-wide changes that will improve the public’s health.

Want to Help Cure Dengue and Cancer in Your Spare Time?

David McCormick

Modern research endeavors rely on the power of computers to perform complicated analyses, and drug discovery projects are especially computation intensive. Although most researchers have access to powerful computers, getting time on them is difficult (it’s pretty much guaranteed that any researcher will have to compete with physical chemists, climatologists, astronomers, and a host of other scientists for these machines). Fortunately, minds smarter than I have come up with an interesting solution to this problem that relies on one simple observation: the computer that you’re using to read this article is actually a pretty powerful machine, and most of the time you don’t use it to it’s full capacity (especially when it’s sitting idle on your desk…). Your computer can then be linked to a series of other computers and used to help work out complex calculations in its spare time.

Distributed computing may seem like nothing more than a nice addition to more traditional research methods, but a project looking for novel treatments for neuroblastoma, a type of childhood cancer, found that using this distributed grid would cut the time required to finish the calculations from a staggering 8,000 years down to 1-2 years.

One of the most appealing aspects of the World Community Grid is that it allows you to choose the projects to which you’d like to donate your computer’s spare time. Most of them have a fairly direct relation to public health. New treatments for dengue fever are obvious, as are projects looking to improve access to clean water, but a project studying novel ways to predict African climate may seem like it’s not the highest priority at first. However, weather affects mosquito ranges (and thereby the future spread of certain diseases) and which land will become non arable in the future – and food security is  a major issue in public health.

The grid keeps detailed statistics for the projects you’ve participated in, and allows you to join “teams” that pool all it’s members together to earn points (you can’t do much with them but competition makes things more fun). You can join the UMich ESO team by clicking here (those from other departments/institutions are also welcome, but should you feel so inclined you could start your own team and challenges may ensue…).

Best of all, it’s a way to help advance science in your spare time – without having learn any of the detailed biology or math.

A Tale of Two Vectors

David McCormick

On opposite sides of the world in 2009, two vector-borne diseases that we thought were under control – dengue fever in the Florida Keys and human African trypanosomiasis (AHT, more commonly known as African sleeping sickness) in northern Malawi – returned.

AHT is one of the most dreaded tropical diseases, with good reason – it is invariably fatal in the absence of proper treatment. Over 60 million people in sub-Saharan Africa are at risk and 50,000 die each year. The main vector of AHT is the tsetse fly, and control efforts have focused on eliminating this insect from endemic regions. During the 1980′s and 1990′s, a successful vector control program virtually eliminated the tsetse fly from Malawi, but as the disease burden decreased, funding stopped and now it appears that they fly has returned to northern Malawi.

Distribution of the Tsetse Fly in Africa. Malawi is outlined in dark blue. (Courtesy: IAEA)

The return of the tsetse fly isn’t just bad for humans – the fly can also carry a trypanosome that fatally infects cattle, which has a severe impact on the local economy. The economic impacts can be just as devastating – a Malawian villager reported, “Our colleague last year lost almost all his cattle totaling 30 head and remained with only two. We are worried because everybody is losing livestock. The flies are bringing poverty here.“

Dengue fever – also known as “breakbone fever” for the severe pain caused by the first infection – is the most common vector-borne viral disease worldwide. The first infection is rarely fatal, but there are four different dengue serotypes. Infection with one serotype confers immunity to that serotype, but if someone who has already been infected with one dengue serotype is infected by a different serotype, dengue hemorrhagic fever, a life-threatening illness, can result.

In May 2010, the Centers for Disease Control and Prevention (CDC) announced the first locally acquired case of dengue Fever in the United States since 1946 – and that there had likely been an ongoing outbreak of dengue in the Florida Keys since 2009. A serosurvey found that up to 5% of all Florida Keys residents have been exposed to dengue. Yes, you read the first part of that sentence correctly – we eliminated dengue from the United States when we eliminated malaria (both using vector control strategies) in the mid-40′s, and now it’s back.

The Florida Keys are a major tourist destination, and the main fear is that dengue will spread from the Keys to the rest of the United States when travelers return home. Many of the mosquitoes in the United States are capable of transmitting the virus, so the possibility of spread is a real concern. The map below shows the distribution of Aedes albopictus, one of the main vectors of dengue, in the United States. It is present in all of the counties in red, and absent from those in blue. Gray counties represent those that the Division of Vector-Borne Infectious Diseases (DVBID) didn’t have the necessary funding or manpower to survey.

Map Showing the Distribution of Aedes albopictus in the United States (courtesy of: CDC DVBID)

These two outbreaks follow the same pattern – successful vector control programs resulted in the elimination of a deadly disease, and the success of these programs led many to conclude that they were no longer necessary. The problems posed by these two outbreaks are similar, but the official responses couldn’t be more different. In Malawi, the return of the tsetse fly was front page news for the Sunday edition of the national paper, while news of the dengue outbreak in the United States was somewhat more difficult to find (the New York Times ran a nice article on the subject). The Malawian government and local officials have discussed the outbreak openly, asked for help, and are proposing to fund a control initiative. In contrast, the United States has imposed severe budget cuts on the CDC, forcing the closure of the DVBID (the same division that warned us of the problem), and health officials in the Keys are denying that dengue is a problem. Which country’s policies seem more sensible?

More on the dengue outbreak can be found at:

White Coat Underground

TIME

Showing Malaria a Red Card

David McCormick

The World Cup is in full swing and although the only remaining African team was knocked out by the most blatant display of poor sportsmanship I think I’ve ever seen, it’s still the most popular event on TV and one of the main topics of conservation here in Blantyre. For many Malawians, the World Cup may be the only TV event that they  have seen in a few months and they may not see another TV event for a while (“exciting” is not a word I’d use to describe the regularly scheduled programming on Malawi’s only TV station).  Public health officials are taking full advantage of this situation and a constant feature of the broadcasts is a small band of text at the bottom of the screen encouraging the viewers to use the mosquito nets and visit the health clinics if they suspect that they or a family member might have malaria.  To drive the point home, the half-time analysts usually wear shirts with the local “Roll Back Malaria” logo.

Malaria is a major problem in Malawi – it’s not uncommon for a child to suffer from the disease 4-5 times in a single year and it is one of the leading causes of mortality in children under 5.  Although there are some effective preventive measures and treatments available, people must visit a clinic before they take advantage of them.  Visiting a clinic can be expensive – the visit itself is free, but the wait can be as long as 8 hours to see a doctor, and if you have to wait that long that means missing out on a day of work.

One small problem with this campaign is that the notices are only in English.  Although all Malawians learn English in school, it’s certainly possible that these messages would reach more people if they were also presented in Chichewa, the dominant native language. Other than this small quibble, I think it’s great that officials are using the World Cup as an opportunity to bring important public health messages to as many people as possible.

Data Cleaning and New Epidemiology Bloggers

David McCormick

The day-to-day routine of epidemiology is not always thrilling. Although fieldwork and data collection are fun, once you’ve collected the data you have to analyze it – and before you can analyze it, you have to clean it. Before I started my internship, data cleaning was a mystery to me, but after spending 3 weeks cleaning a rather large data set I’ve realized that it’s mostly a tedious process – going through each individual observation (there can be anywhere from a few hundred to over ten thousand) and making sure that all of the variables make sense.  However tedious it is, it’s one of the most important steps in the analysis.  Computers are fundamentally stupid and only do (exactly) what you tell them – if that wasn’t enough, they have a hard time figuring out what letters are, so a major part of data cleaning and entry is devising codes to convert your data into a series of numbers. It’s not exactly the most glamorous part of research, but it needs to be done before you can start asking the questions you set out to answer. The upside of data cleaning is that I spend most of my day looking at screens like the one below:

What I Spend Most of my Day Doing

It appears that I’m rapidly approaching the end of the data cleaning and finishing up some of my analyses, and I’ll be off to Liwonde for the next 2-3 weeks to start collecting data from the district hospital there. Thankfully, I’ll be able to put the computer away for a few weeks and start to learn how the data that make up our datasets get collected.

In other news, a new cadre of epidemiology students have started blogging about their summer internships over at the blog for the Epidemiology Student Organization. This summer we have students working in fields as diverse as infection control and managing chronic asthma.  Some of the recent highlights:

Mike shares his thoughts on the inherent problems with interpreting data in any study and how the questionnaire design can influence a study’s outcome.

Stefanie talks about working in a state epidemiology department and the benefits of applying the knowledge that we’ve spent so long learning.

Laurel gives us an update on changes and regulations in the public health scene that may be coming soon to NYC, and Chelsea talks about why infection control matters.

The View from my Window

David McCormick

I’ll be spending my summer internship in Blantyre, Malawi, where I’ll be working on a few projects.  My office is in the Malaria Alert Centre, which is conveniently located next to the central hospital (where one of my advisers works) and also houses the Blantyre Malaria Project, with whom I’m collaborating on a project that is trying to develop a diagnostic algorithm to differentiate pediatric patients with bacterial meningitis from those with cerebral malaria.  Both diseases have very similar symptoms and a high mortality rate, but unfortunately they both require different treatments.

Complicating the situation, many health care centers (and even some district hospitals) in Malawi don’t have the resources that they need to perform even basic lab work (in some cases they are unable to determine hematocrit or blood glucose), so this algorithm would ideally be based on 4-5 clinical observations that don’t require sophisticated equipment.  While I’m in Malawi I’ll also be collaborating on a project to determine the burden of cancer in Malawi – we take it for granted in the US that we know how many cancer cases occur each year, and what the most common types of cancer are, but that information has not been systematically collected for Malawi, which makes it difficult to allocate health care resources to where they are needed.

The View from my Window.

I share my office with two other researchers – an MD/PhD studying cerebral malaria, and a post-doc working on a device to measure the size of a hole that red blood cells infected with malaria can pass through.  We have a fourth seat in our office which visiting researchers and professors will often use when they need a place to sit and work.  It’s a humble office on the second floor that is well-supplied with tea, coke, and various snacks (including the tasty but unfortunately named “Salticrax” cracker).  The office looks out over fields and the noise from people working will drift in (it’s the cooler dry season and our windows stay open during the day), the MAC insectory, where they raise mosquitoes (and the reason we have to close our windows when it gets dark), and across to the Malawi Liverpool Wellcome Trust.  Combined, it’s a nice view of both average life in Malawi and sophisticated research institutions, highlighting the need for research on infectious disease and the hope that research here will one day lead to better care.

40 Hours Later…

David McCormick

After nearly 40 hours of continuous travel through three countries, including 3 flights, 2 (long) layovers, and a volcano scare, I’ve finally made it to Blantyre, Malawi, where I’ll be working on my summer internship.  Jet-lagged and confused, I landed in Lilongwe, the capital of Malawi, where I met a staff member from the Malaria Alert Center who happened to be in Lilongwe for sample collection and drove me down to Blantyre.

The road from Lilongwe to Blantyre was technically a highway, but not what you or I think of as a highway.  Highways in Malawi are used by everyone - pedestrians and bicyclists often outnumbered the cars, and as it got darker I began to realize why traffic accidents are a leading cause in sub-Saharan Africa (hint: horns are not always effective at getting a cyclist or pedestrian to scoot over quickly).  Most stalls, selling everything from fruit to cell phones to birds on a stick (fun fact: you can buy 5 roasted birds for 100 Kwacha, less than a dollar) set up right along the roadside – there are no real exits or even places to pull over safely off the road.

On the road between Lilongwe and Blantyre

The scenery was amazing.  What struck me first is how different everything is – the crows here have a white torso, but otherwise look like the crows at home and the trees look different, although I can’t quite put my finger on why that is.  The daily life in Malawi is, obviously, very much not like that in America, and it’s easiest to see in how young the population is (most people look to be younger than 25) and by how much work the children have to do.  I saw at least 20 kids under the age of 8 herding goats and cattle on the side of the road – one 6-year old was able to herd 20 cattle with just a stick and lots of running.  So after the trip, I’m finally settled in to the guesthouse in Blantyre and ready to start my summer internship – I can’t wait.

What is Public Health?

David McCormick

So what exactly is public health?  If you’ve ever wondered about this question, you’re not alone – the Association of Schools of Public Health realized about a year ago that most people don’t really have any idea what public health professionals do, or what the field of public health offers, so they made this handy website and the video below.



(Link to the video in its original context.) One of the coolest parts of this campaign: you can get the stickers for free!

I like the idea of the ASPH’s campaign and think it’s great that the video shows a lot of public health’s “hidden” aspects, but I wish that the video would show some of the dramatic effects that public health has had on society. While public health is a very broad field, it doesn’t include everything (although it’s a fun game to try to find some connection to public health in everyday objects – think “Six Degrees of Separation” for public health dorks).

The best example is smoking – once it became clear that tobacco smoking was a major health hazard (from epidemiologic research), programs to help people quit started (thanks to Health Behavior and Health Education), and eventually policy changes were made (courtesy of Health Management and Policy) so that smoking is now banned in public places in most states (MI recently passed such a law).

Other examples of changes made by public health professionals are as basic as the regulation of drinking water and ensuring that our food supplies, especially meat, remain disease-free.  Going back to infectious diseases, the national vaccination program has eliminated almost all of what were formally the “childhood diseases” – no-one born in my generation has had to experience widespread polio, measles, or whooping cough outbreaks.  (A list of the 10 greatest public health achievements is found here).

So as a tool for raising awareness, the video is great, but I hope that it encourages people to look deeper into public health.  There really is something for everyone in this field, from microbiology nerds (like me) to those of a political nature (how else would we get public health laws passed?).

So You Think You Might be Interested in Epidemiology?

David McCormick

I have a confession:  for a long time, I was pretty unclear on what public health, much less epidemiology, actually was.  Given the state of public health in the media (you only hear about it when something goes horribly wrong…), it’s not all that surprising.  However, we have public health to thank for many of the things that we currently take for granted – like the idea that smoking is dangerous and the elimination of many once-dreaded childhood diseases like measles and polio.  My interest in the field of public health in general, and epidemiology in particular, began when I read Richard Preston’s The Hot Zone and I continue to be inspired by popular accounts of how epidemiology interacts with modern life in very hidden ways.

The Hot Zone

The Ghost Map

If you think that you might have even a passing interest in public health, I encourage you to check out the two books above.  They each highlight why epidemiology is such a fascinating field, but they approach it from two different directions.  My favorite of the two is The Hot Zone, which follows the US Army’s attempt to contain an Ebolavirus outbreak (yes, that Ebola) in Reston, VA (yes, the one next to Washington D.C.).  The book has some fairly surreal scenes – like an army clean-up unit staring at a busy playground while the suit up to enter an infected monkey house in secrecy – and it may or may not have contributed to a slightly romanticized view of what epidemiologists actually do (sadly, so far we’ve not been mobilized to contain any outbreaks and I’ve not had to run tests on infected monkeys).  But the book does highlight the extraordinary level of surveillance that our public health officials must maintain and the variety of situations that they need to be prepared to handle.

Stephen Johnson’s The Ghost Map takes a different approach to public health – how it can be used to clean up after a disaster.  In the mid-19th Century, people began flocking from the countryside to the city, creating the lifestyle that most of us now take for granted. The population of most major urban centers exploded, and to borrow a phrase from Johnson, London was “… a Victorian city with an Elizabethan infrastructure.”  The recent conquest of India brought a different kind of immigrant to England’s capital – Vibrio cholerae, a nasty bacterial species that causes cholera, which produced extremely severe diarrhea.  From 1853-54, a cholera outbreak killed 10,000 people in London, and The Ghost Map tracks how the cause of this disease was discovered and how the later public health improvements helped create what we think of as modern urban infrastructure.

Both books are great reads, especially if you think you might be interested in this thing called “public health” – and yet they only scratch the surface of one aspect of one part of one discipline of the whole.  There’s lots more good books out there – The Coming Plague comes to mind, and I’m sure that my fellow bloggers have a few suggestions of their own.