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Immigration is an inflammatory matter and probably always has been. Immigrant groups, with few exceptions, have to endure the brickbats of prejudice of the recipient population. Emigration, by contrast, hardly troubles people — but the departure of one’s people is not a trifling matter. I wonder why these differential responses occur. It seems to me that humans are highly territorial and territory signifies resources and power. Immigration usually means sharing of resources, at least in the short-term, while emigration means more for those left behind and brings hope of acquiring even more from overseas in the long term. This might explain why those most needy of settled immigrant status — asylum seekers, the persecuted or denigrated, and the poor — are most resisted while those least in need of immigration status, such as the rich, are often welcomed.

Notwithstanding, consternation about migration it is rapidly leading to diverse, multiethnic and multicultural nations across the world. Many people dislike the changes this brings but it is hard to see what they are to do except change themselves. The forces for migration are strong, for example, globalization of trade and education, increasing inequalities in wealth and employment opportunities, and changing demography whereby rich economies are needing younger migrants to keep them functioning.

Whether you are a migrant (like me) or the host to migrants it is wise to remember that migration is a fundamental human behavior that is instrumental to the success of the human species. Without migration Homo sapiens would be confined to East Africa, and other species (or variants of humans — all now extinct) would be enjoying the bounties of other continents. Surely, migration will continue to bring many benefits to humanity in the future.

My special research interest is in the comparative health of migrants and their offspring, who together comprise ethnic (or racial, as preferred in some countries) minority groups. There is a remarkable variation in the pattern of diseases (and the factors that cause diseases) among migrant and ethnic groups and very often the minorities are faring better than the recipient populations. Probing these patterns scientifically, especially in the discipline of epidemiology, which describes and interprets the occurrence of disease in large populations, helps in understanding the causes of disease. There are opportunities to apply such learning to improve the health of the whole population; migrants, minorities and settled majority populations alike.

Let me share with you three observations from my research areas that help illustrate this point, one concerns heart disease and diabetes, another colorectal cancer, and the third smoking in pregnancy. Coronary heart disease (CHD) and its major co-disease type 2 diabetes (DM2) have been studied intensively but still some mysteries remain. The white Scottish people are especially notorious for their tendency to CHD. Our studies in Scotland have shown that the recently settled Pakistani origin population has much higher CHD rates than white Scottish people. Amazingly, the recently settled Chinese origin population has much lower rates of CHD than the white Scottish people. These intriguing observations raise both scientific questions and give pointers to public health. If we could all enjoy the CHD rates of the Chinese in Scotland the public’s health would be hugely improved.

Intriguingly, although colorectal cancer, heart disease and diabetes share risk factors (especially high fat, low fibre diet) we found that Pakistani people in Scotland had much lower risks than the white Scottish Group. This makes us re-think what we know about the causes of this cancer. In our scientific paper we put forward the idea that Pakistani people may be protected by their comparatively low consumption of processed meats (fresh meat is commonly eaten).

Might the high risk of CHD in Pakistani populations in Scotland be a result of heavier tobacco use? The evidence shows that while the smoking prevalence in Pakistani men is about the same as in white men, the prevalence in Pakistani women is very low. Smoking in white Scottish woman, even in pregnancy, is about 25% but it is close to nil in pregnant Pakistani women. This raises interesting questions about the cultural and environmental circumstances that maintain high or low use of tobacco in populations. These observations raise public health challenges of a high order — how can we maintain the cultures that lead to low tobacco use in some ethnic groups while altering the cultures that lead to high tobacco use in others?

The intermingling of migrants and settled populations creates new societies that provide innumerable opportunities for learning and advancement. While my examples are from the health arena, the same is true for other fields: education, entrepreneurship, social capital, crime, and child rearing to name a few. This historical perspective on human migration, evolution and advancement can benefit our health, as well as providing a foundation to contextualize the challenges and changes we face.

Heading image: People migrating to Italy on a boat in the Mediterranean Sea by Vito Manzari from Martina Franca (TA), Italy (Immigrati Lampedusa). CC-BY-2.0 via Wikimedia Commons.

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Are you worried about catching the flu, or perhaps even Ebola? Just how worried should you be? Well, that depends on how fast a disease will spread over social and transportation networks, so it’s obviously important to obtain good estimates of the speed of disease transmission and to figure out good containment strategies to combat disease spread.

Diseases, rumors, memes, and other information all spread over networks. A lot of research has explored the effects of network structure on such spreading. Unfortunately, most of this research has a major issue: it considers networks that are not realistic enough, and this can lead to incorrect predictions of transmission speeds, which people are most important in a network, and so on. So how does one address this problem?

Traditionally, most studies of propagation on networks assume a very simple network structure that is static and only includes one type of connection between people. By contrast, real networks change in time — one contacts different people during weekdays and on weekends, one (hopefully) stays home when one is sick, new University students arrive from all parts of the world every autumn to settle into new cities. They also include multiple types of social ties (Facebook, Twitter, and – gasp – even face-to-face friendships), multiple modes of transportation, and so on. That is, we consume and communicate information through all sorts of channels. To consider a network with only one type of social tie ignores these facts and can potentially lead to incorrect predictions of which memes go viral and how fast information spreads. It also fails to allow differentiation between people who are important in one medium from people who are important in a different medium (or across multiple media). In fact, most real networks include a far richer “multilayer” structure. Collapsing such structures to obtain and then study a simpler network representation can yield incorrect answers for how fast diseases or ideas spread, the robustness level of infrastructures, how long it takes for interaction oscillators to synchronize, and more.

Recently, an increasingly large number of researchers are studying mathematical objects called “multilayer networks”. These generalize ordinary networks and allow one to incorporate time-dependence, multiple modes of connection, and other complexities. Work on multilayer networks dates back many decades in fields like sociology and engineering, and of course it is well-known that networks don’t exist in isolation but rather are coupled to other networks. The last few years have seen a rapid explosion of new theoretical tools to study multilayer networks.

And what types of things do researchers need to figure out? For one thing, it is known that multilayer structures induce correlations that are invisible if one collapses multilayer networks into simpler representations, so it is essential to figure out when and by how much such correlations increase or decrease the propagation of diseases and information, how they change the ability of oscillators to synchronize, and so on. From the standpoint of theory, it is necessary to develop better methods to measure multilayer structures, as a large majority of the tools that have been used thus far to study multilayer networks are mostly just more complicated versions of existing diagnostic and models. We need to do better. It is also necessary to systematically examine the effects of multilayer structures, such as correlations between different layers (e.g., perhaps a person who is important for the social network that is encapsulated in one layer also tends to be important in other layers?), on different types of dynamical processes. In these efforts, it is crucial to consider not only simplistic (“toy”) models — as in most of the work on multilayer networks thus far — but to move the field towards the examination of ever more realistic and diverse models and to estimate the parameters of these models from empirical data. As our review article illustrates, multilayer networks are both exciting and important to study, but the increasingly large community that is studying them still has a long way to go. We hope that our article will help steer these efforts, which promise to be very fruitful.

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If you think about big public health challenges of our day — the Ebola virus in Africa, the rising rates of suicide among the middle-aged in the United States, the HIV epidemic everywhere — religions are playing a role. When I speak, I ask audiences, “What was the first thing you heard about the Ebola crisis?”, and they always say “The missionaries who got it were taken to Emory.” “That makes my point,” I say. “You didn’t know anything about it up until that moment, but they did.” Those missionaries, and the faith-based organizations they worked for (Samaritan’s Purse and Serving in Mission) were already there on the ground along with other faith-based organizations, volunteering their time, putting their lives in danger, and providing valuable resources of equipment, supplies, and knowledgeable helping hands to try to contain the outbreak.

In another challenge, the crisis of rising suicides among US veterans and Baby Boomers, religion’s role is more in the background, but no less important. Since sociologist Emile Durkheim first studied the subject in late 19th century France, researchers have consistently found that individuals with more social ties – particularly to religious groups — are more protected from suicide. Religious ties provide caring, support, warmth, and intimacy — the “carrots” of social interaction. They also provide rules for living and guidance for behavior that often require individuals to sacrifice their self-interest for the good of the group. These are the “sticks” of social interaction, which Durkheim argued were just as necessary as the “carrots” in keeping individuals from taking their own lives. So here are two quite different roles that religions play in public health: first in the foreground, deploying resources and religious social capital as partners with public health authorities in countries around the world, and also in the background, providing the sustenance of social integration and regulation that prevents the tailspin of suicide.

But religions are complicated, and in the HIV epidemic we have seen faith traditions playing all of these roles and other less helpful ones as well. One positive thing that religions do — very effectively through religious ritual and practice — is to give individuals a sense of belonging to something larger than themselves; they bestow a social identity that marks individuals as valued members of a group, with all of that group’s rights, privileges, and responsibilities. But group membership by its very nature implies that there are other individuals and groups — outsiders — who are not members, who may be less valued. This is an obvious source of conflict around the world and can lead to violence on a small or large scale. This too, sad to say, is an instance of religions taking a role in determining the health of populations, but not in a good way. And at a less extreme level, if an individual violates the norms of the group, or breaks its rules, it can lead to sanctions, punishment, or even being cast out from membership. So in the HIV epidemic, individuals who were victimized by the disease first, in many cases experienced a secondary victimization of being stigmatized by religious groups who perceived that the disease was a sign of forbidden behaviors, and therefore a just punishment.

Public health organizations and religious organizations are both looking to promote the well-being of their communities. In many cases those interests are perfectly aligned and the two institutions function, implicitly or explicitly, as partners. When they do not, it makes sense that two powerful forces should identify all of the ways in which they can work together, finding a way around the contentious issues to leverage each other’s constructive responses. Religion, along with income inequality, education, and political structures, is one of the social determinants of public health in countries around the world, despite its usual exclusion from the public health paradigm.

Headline image credit: The fight against Ebola in West Africa. ©EC/ECHO/Jean-Louis Mosser. CC BY-ND 2.0 via European Commission DG ECHO, EU Humanitarian Aid and Civil Protection Flickr.

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By Katherine M. Venables

Occupational epidemiology is one of those fascinating areas which spans important areas of human life: health, disease, work, law, public policy, the economy. Work is fundamental to any society and the importance society attaches to the health of its workers varies over time and between countries. Because of the lessons to be learned by looking at other countries as well as one’s own, occupational epidemiology is a truly global discipline. Emerging economies often prioritize productivity over other issues, but also can learn from the long history of improvement in working conditions which has taken place in developed countries. Looking the other way, the West can learn from fresh insights gained in studies set in low and middle-income countries.

Exposures are usually higher in emerging economies and epidemiological methods are an important tool in detecting and quantifying outbreaks of occupational disease which may have been controlled in the West. A recent study of digestive cancer in a Chinese asbestos mining and milling cohort provides additional evidence that stomach cancer may be associated with high levels of exposure to chrostile asbestos, for example. This was a collaborative study between researchers in China, Hong Kong, Japan, and the United States, and illustrates the way that studying an “old” disease in a new context can provide results which are of global benefit.

Issues in occupational epidemiology are never static. Work exposures change along with materials and processes. The ubiquitous printing industry, for example, is always developing new inks, cleaning agents, and processes. A cluster of cases of the rare liver cancer, cholangiocarcinoma, was noted in Japanese printers and this finding was replicated in the Nordic printing industry by using one of the large Nordic population-based databases. This replication is important because it shows that the association is unlikely to be due to a lifestyle factor specific to Japan.

“Big data” sharpens statistical power and there are now specific data pooling projects in occupational epidemiology, to supplement the use of existing large databases. The SYNERGY study, for example, pools lung cancer case-control studies with the aim of teasing out occupational effects from behind the masking effect of smoking, which remains by far the most important driver for lung cancer. A recent analysis with around 20,000 cases and controls was able to show that bakers are not at increased risk of lung cancer, whereas the many previous smaller studies had given inconsistent results.

The addition of systematic reviews to the toolkit has strengthened the evidence base in occupational epidemiology, allowing policy about occupational risks and their prevention to be made with confidence. Health economics, also, can be applied to findings from occupational epidemiology to clarify policy issues.

Development brings its own issues to which occupational epidemiology can be applied. We now live longer in the West, and we will have to work into old age, often while carrying chronic diseases. Despite frequently-expressed concerns about an ageing workforce, a recent study in an Australian smelter confirmed others in that the older workers maintained their ability to work safely and the highest injury rates were in young workers. Patients with previously fatal diseases survive into adult life and, potentially, the workforce; a survey of patients with cystic fibrosis, for example, found that disease severity was less important as a predictor of employment than social factors such as educational attainment and locality. A loss of heavy industry in the West, combined with cheap transport, means that many of us spend most of our waking hours sitting down, promoting obesity and its complications. A sample of UK office workers spent 65% of their work time sitting and did not compensate for this by being more active outside work. The economic downturn is a major political and social preoccupation, bringing uncertainty about future employment, which may fuel dysfunctional behaviour such as ‘presenteeism’. A Swedish study suggested that this may be associated with poor mental wellbeing.

Katherine M. Venables is a Reader in the Department of Public Health at the University of Oxford. Her research has always focused on aetiological epidemiology. At Oxford, she has worked on a cohort study of mortality and cancer incidence in military veterans exposed to low levels of chemical warfare agents, and also on the provision of occupational health services to university staff. She is editor of Current Topics in Occupational Epidemiology.

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Image: Woman smoking a cigarette by Oxfordian Kissuth. CC-BY-SA-3.0 via Wikimedia Commons.

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By Eugene Milne

My card-carrying North London media brother, Ben, describes himself on his Twitter feed as a ‘recovering Northerner’.

In my case the disease is almost certainly incurable. Despite spending a good deal of last year in cosmopolitan London — beautiful, exciting and diverse as it is — I found myself on occasions near tears of joy as my feet hit the platform at King’s Cross.

“I need to know I can be at the coast or in miles of open countryside within 20 minutes,” I told Ben.

“I need to know I can get Vietnamese food at 3.00 a.m.,” he replied.

While mine is clearly the healthier individual craving, the gulf in population health outcomes between the North and South of England, or, perhaps more accurately, between the provinces and the capital and its South Eastern sprawl, remains as wide as ever.

On examining the distribution of age-standardised mortality for Nomenclature of Territorial Units for Statistics regions, the United Kingdom remains the most starkly unequal of European nations. This is starkly illustrated in our new analyses of the North South divide in England, when compared with the experience of East and West Germany following the fall of the Berlin Wall. After that great political upheaval, notably for women, life expectancy in East Germany began to climb rapidly. Twenty years on, it is indistinguishable from that of the former West Germany.

In contrast, the gap between the North East of England and London, which in 1990 was similar to that between East and West Germany, remains just as wide in the most recent figures. Of course, life expectancy has risen markedly in both countries and their regions; modern North East English life expectancy is significantly higher than that which obtained in 1990 for West Germany. But the English failure to narrow its inequality gap despite overt national efforts signals that those efforts are simply too light-touch to be effective.

As Johan Mackenbach has commented, in reflecting on the English strategy from 1997-2010:

“it did not address the most relevant entry-points, did not use effective policies and was not delivered at a large enough scale for achieving population-wide impacts. Health inequalities can only be reduced substantially if governments have a democratic mandate to make the necessary policy changes, if demonstrably effective policies can be developed, and if these policies are implemented on the scale needed to reach the overall targets.”

Of course, fundamental to this problem is economics. The wealth of London and the South East in comparison to, well just about anywhere else in the UK, is now extraordinarily stark. London now feels more alien to my Northern sensibilities than much of Europe, and the reason is not people but cash.

The difference is illustrated rather well by the contrasting artistic expectations of the South Bank Centre — close by the Waterloo offices of Public Health England, for whom I worked last year — and the Culture budget of the City of Newcastle — for whom I now work as Director of Public Health.

On consecutive days in 2013, the Guardian and BBC reported the Southbank Centre’s unveiling of its £100m redevelopment plans (6 March), having made a successful first stage bid for £20m from the Arts Council, and Newcastle City Council was reported (7 March) as having cut its £2.5m culture budget by 50%. This comparison could equally be drawn in many other ways: for transport and infrastructure, investment in business, development of academic institutions (why did the Crick Institute need to be in King’s Cross?). And it all matters because, despite the cleaner air and wide open spaces, the English provinces and in particular the North, are losing out — on culture, mobility, urban environment, jobs, and crucially on health.

The English North has many charms, both for its natives and many who come upon its joys by accident (see this delightful, recent New York Times piece). For too many, however, it remains a place of shorter and poorer lives. The German experience suggests that it need not be so.

Prof. Eugene Milne became Director of Public Health for Newcastle upon Tyne earlier this year, after working nationally for Public Health England as Director for Adult Health and Wellbeing. He is an Honorary Professor in Medicine and Health at the University of Durham, and joint-editor, with his colleague Prof. Ted Schrecker, of the Journal of Public Health. He has research interests in health improvement, inequalities and ageing.

The Journal of Public Health invites submission of papers on any aspect of public health research and practice. We welcome papers on the theory and practice of the whole spectrum of public health across the domains of health improvement, health protection and service improvement, with a particular focus on the translation of science into action. Papers on the role of public health ethics and law are welcome.

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Oxford Scholarship Online (OSO) launched in 2003 with 700 titles. Now, on its tenth birthday, it’s the online home of over 9,000 titles from Oxford University Press’s distinguished academic list, and part of University Press Scholarship Online. To celebrate OSO turning ten, we’ve invited a host of people to reflect on the past ten years of online academic publishing, and what the next ten might bring.

By Nicola Wilson

When I was invited to develop two lists for Oxford Scholarship Online, I jumped at the chance. From the perspective of a commissioning editor, digital publishing has extended the “life” of our copyrights indefinitely, and we no longer need to hold a book in physical print for it to continue to be available to our readers.

The first module that I developed was “Public Health and Epidemiology,” back in 2008. The books contained in the module have been published by our medical department over the course of three decades, and many are now considered public health classics, such as Michael Marmot’s Social Determinants of Health, and Geoffrey Rose’s The Strategy of Preventative Medicine.

The books that we chose to include on Oxford Scholarship Online present research and analysis of global health issues, and insight into the impact of diseases and conditions on populations. Several of the projects in the module have directly influenced policy planning and clinical attitudes to disease prevention and management, transforming scientific investigation methods and treatment approaches worldwide.

The biggest challenge in developing the module was the time that it took to clear permission to reproduce the material online. Many of the contracts and agreements that we held for our older books long pre-dated electronic resources, and we had to ask the authors and editors to sign contract addendums to allow us to proceed with publishing the books online. In some instances, authors had died since the book was published with us, so we needed to contact authors’ estates and ask surviving relatives to grant us permission to reproduce the material online.

In other cases, we needed to trace the ownership of third-party copyrighted material which was included in the books, so I became a detective, trying to identify the current owners of defunct publishers, some of which had changed their ownership through multiple company mergers over a thirty-year period. What naively started out as a few hours of looking through dusty hard-copy records in our basement, turned into a few months of internet heavy investigation and phone calls to numerous publishers’ Rights departments.

The amount of work that clearing permissions created turned it into an “all hands on deck during evenings and weekends” project. Over half of the medical department pitched in extra hours over a four-month period to ensure that we hit the launch deadline that we had been set. (Never underestimate the power of food to complete a project on schedule.)

The trickiest book that we worked on was Nutrition for Developing Countries, which was originally published in 1993 before our copyright clearance rules were defined. It’s full of unique hand drawn illustrations of Tanzanian families, different types of food, and easy-to-read graphs. It was specifically presented in such a way that could be used as a “show and tell” book by doctors working with non-literate families in Africa. For example, they could point at the illustrations of healthy foods in the book and explain to nursing mothers how eating those foods would help their babies to grow strong and remain healthy.

However, our challenge was trying to find out who had drawn the pictures, and subsequently who owned the copyright for them. Many of the illustrations had been drawn by a friend of one of the editors, and given to the editor as a wedding present. Did this mean that the copyright was held by the editor, or was it held by the artist? No copyright permission had ever been signed to state either way, and we had no contact details for the artist to enquire with them directly. We contacted the book editor, but they were often working in areas of Africa where Internet access was non-existent, so it took around four months to liaise with the editor and the artist (whom the editor contacted on our behalf), and acquire permission from both of them (to cover all legal bases) to use the illustrations in a digital form.

A major benefit of putting books online is the global availability of the information they contain; practitioners and academics can access and use these books online wherever they are in world. It’s wonderful that public health and epidemiology books attract a global readership, and through their availability online, they will have an even broader reach, and continue to help develop and improve research and treatment for many years to come.

Nicola Wilson is Commissioning Editor for the “Palliative Care” and “Public Health and Epidemiology” modules on Oxford Scholarship Online.

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By Barry S. Levy and Victor W. Sidel

Out of sight. Out of mind.

Nine countries, mainly the United States and Russia, possess 17,000 nuclear weapons, many of which are hundreds of times more powerful than the atomic bombs dropped over Hiroshima and Nagasaki almost 70 years ago. An attack and counterattack in which fewer than 1% of these nuclear weapons were detonated could cause tens of millions of deaths and could disrupt climate globally, leading to crop failures and widespread famine. A greater conflagration could cause a “nuclear winter” and threaten the future of life on earth.

The recent tensions concerning Ukraine demonstrate that although 23 years have elapsed since the end of the Cold War, nuclear weapons remain a clear and present danger to humanity. Persistent threats include accidental launch of nuclear warheads, proliferation of nuclear weapons among nations, potential acquisition and use of nuclear weapons by non-state actors, and diversion of human and financial resources in order to maintain and modernize nuclear arsenals in the United States and other nations.

Despite safeguards, accidental detonation remains a real possibility. A few years ago, a US Air Force plane transported six missiles tipped with nuclear warheads, unbeknownst to the pilot and crew. Twice, in recent weeks, it was revealed that as many as half of navy and air force personnel who maintain nuclear-armed missiles and would be responsible for launching them if commanded to do so had cheated on their competency examinations. In 1995, Boris Yeltsin, then president of Russia, had only a few minutes to decide whether to launch Russian nuclear-armed missiles against the United States in response to what, on radar, looked like a US air attack with multiple re-entry vehicles (MERVs); it turned out to be a rocket launched by a team of Norwegian and US scientists to study the aurora borealis.

Another major concern is that the leaders of the nine nations that possess nuclear weapons each have absolute authority — unchecked by other government officials or institutions, even in the United States — to launch an offensive or allegedly defensive nuclear strike.

Furthermore, proliferation remains a serious threat. During the past decade North Korea obtained nuclear technology and fissile materials, and developed and tested one or more nuclear weapons. At least until recently, Iran apparently was — and may still be — on the path to developing nuclear weapons. Given the widespread knowledge about nuclear technology and the potential availability of fissile material, non-state actors could acquire and use nuclear weapons.

Highly-enriched uranium (HEU) — the fissile material used in nuclear weapons — is distributed globally, and used in nuclear reactors to perform research or power aircraft carriers and submarines. Converting to low-enriched uranium would eliminate the possibility of HEU being stolen or otherwise diverted to produce nuclear weapons.

Yet another major concern is the huge diversion of financial resources to maintain and modernize the US nuclear weapons arsenal, estimated over the next 30 years to be about $1 trillion. The proposed nuclear weapons budget of the US Department of Energy for fiscal year 2015 is higher than at any time during the Cold War. Meanwhile, substantial cuts have been proposed in programs to dismantle and prevent proliferation of nuclear weapons — and in programs to reduce poverty and protect human rights.

To most Americans, all of these concerns are out of sight and out of mind. Each of us has a responsibility to become more educated about these issues, increase the awareness of other people about them, and advocate for measures to reduce the dangers associated with nuclear weapons, including the abolition of nuclear weapons.

A longstanding proposal to eliminate all nuclear weapons is the Nuclear Weapons Convention (NWC). In 1997, a consortium of experts in law, science, public health, disarmament, and negotiation drafted a model convention. The Convention would require nations that possess nuclear weapons to destroy them in stages — taking them from high-alert status, removing them from deployment, removing warheads from delivery vehicles, disabling warheads by removing explosive “pits,” and placing fissile material under control of the United Nations. Such a convention has had wide public support throughout the world.

An immediate step that could pave the way to the Nuclear Weapons Convention and the eradication of nuclear weapons is a treaty banning nuclear weapons. Such a treaty could be negotiated with or without the participation of those nations possessing nuclear weapons. It could create an international norm of the illegality of nuclear weapons, similar to the norms that have been established concerning chemical and biological weapons, antipersonnel landmines, and cluster munitions. Such a treaty could put substantial pressure on the nations possessing nuclear weapons to comply with their disarmament obligations — which they have been unwilling to do thus far. The International Campaign to Abolish Nuclear Weapons (ICAN) has mobilized 300 civil-society organizations in 90 countries to campaign, on humanitarian grounds, for such a treaty banning nuclear weapons.

Given resurgent Cold-War-era arguments for revitalizing US nuclear-weapons capabilities to deter Russian actions in Ukraine, we must resist measures that would reset the “Doomsday Clock” to a point that places all humanity — and indeed all life on earth — in great peril of annihilation by nuclear weapons.

Barry S. Levy, M.D., M.P.H., and Victor W. Sidel, M.D., are co-editors of the recently published second edition of Social Injustice and Public Health as well as two editions each of the books War and Public Health and Terrorism and Public Health, all of which have been published by Oxford University Press. They are both past presidents of the American Public Health Association. Dr. Levy is an Adjunct Professor of Public Health at Tufts University School of Medicine. Dr. Sidel is Distinguished University Professor of Social Medicine Emeritus at Montefiore Medical Center and Albert Einstein Medical College and an Adjunct Professor of Public Health at Weill Cornell Medical College. Victor W. Sidel was a member of the 1997 consortium of experts in law, science, public health, disarmament, and negotiation that drafted the model Nuclear Weapons Convention. Read their previous blog posts.

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By Julia F. Irwin

President Barack Obama has proclaimed March 2014 as “American Red Cross Month,” following a tradition started by President Franklin D. Roosevelt in 1943. 2014 also marks the 100-year anniversary of the outbreak of the First World War in Europe. Although the United States would not officially enter the war until 1917, the American Red Cross (ARC) became deeply involved in the conflict from its earliest days. Throughout World War I and its aftermath, the ARC and its volunteers carried out a wide array of humanitarian activities, intended to alleviate the suffering of soldiers and civilians alike.

In honor of American Red Cross Month, and in commemoration of the First World War’s centennial, here’s a list of things you might not have known about the World War I era history of the American Red Cross:

(1)   On 12 September 1914, just over a month after the First World War erupted in Europe, the American Red Cross sent its first relief ship to the continent. Christened the Red Cross, the ship carried units of physicians and nurses, surgical equipment, and hospital supplies to seven warring European nations. This medical aid reached soldiers on both sides of the conflict.

(2)   After the United States entered World War I in April 1917, the ARC’s intervention in Europe expanded enormously. Over the next several years, the ARC’s leaders established humanitarian activities in roughly two-dozen countries in Europe and the Near East. The organization provided emergency food and medical relief on the battlefields and on the European home front, but ARC staff and volunteers also took on more constructive projects. They built hospitals, health clinics and dispensaries, libraries, playgrounds, and orphanages. They organized public health campaigns against diseases like typhus and tuberculosis. They took steps to reform sanitation in many countries and introduced nursing schools in several major cities. The ARC’s efforts for Europe, in other words, went well beyond immediate material relief to include long-term, comprehensive social welfare projects.

(3)   During World War I, the American Red Cross experienced astronomical growth. On the eve of war, ARC membership hovered around 10,000 US citizens. By 1918, the last year of the war, roughly 22 million adults and 11 million children – approximately 1/3 of the total US population at that time – had joined the American Red Cross and contributed at least $1.00 to the organization.

(4)   In 1917, the wartime leaders of the American Red Cross established an auxiliary body for US children—the Junior Red Cross (JRC). During the war, American Juniors put on plays and organized bazaars to raise money for the war effort, collected scrap metal and other essential war supplies, and helped produce over 371,500,000 relief articles for US and Allied soldiers and refugees, valued at nearly $94,000,000. After the war ended, postwar leaders transformed the JRC’s mission, moving away from relief efforts and towards international education initiatives. They established pen-pal programs for between US and European schoolchildren and published monthly magazines to teach US students about the culture, geography, and histories of other nations.

(5)   As President of the United States, President Woodrow Wilson was also the President of the American Red Cross. Wilson proved to be a tireless promoter of the ARC. Through many speeches and press releases, he urged all US citizens to join the ARC, defining this as nothing less than a patriotic duty. Wilson also lent his face to ARC posters, magazine covers, and other forms of fundraising publicity. It was on 18 May 1918, perhaps, that Wilson made his commitment to the ARC most visible: on that day, he led a 70,000-person American Red Cross parade down Fifth Avenue in New York City. The visible support of Wilson and his administration played a critical role in defining the ARC as the United States’ leading humanitarian organization—a status that it continues to hold 100 years later.

Julia F. Irwin is an Assistant Professor of History at the University of South Florida. She specializes in the history of US relations with the 20th century world, with a particular focus on the role of humanitarianism in US foreign affairs. She is the author of Making the World Safe: The American Red Cross and a Nation’s Humanitarian Awakening. Her current research focuses on the history of US responses to global natural disasters.

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Image credits: (1) “Help the Red Cross.” Public domain via U.S. National Archives and Records Administration (2) “In the Name of Mercy – Give.” Albert Herter. Public domain via Library of Congress.

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By Karen Blakey and Richard J. Q. McNally

Since their introduction in the United States in the 1940s, artificial fluoridation programmes have been credited with reducing tooth decay, particularly in deprived areas. They are acknowledged by the US Centers for Disease Control and Prevention as one of the ten great public health achievements of the 20th century (alongside vaccination and the recognition of tobacco use as a health hazard). Such plaudits however, have only gone on to fuel what is an extremely polarised ‘water fight’. Those opposed to artificial fluoridation continue to claim it causes a range of health conditions and diseases such as reduced IQ in children, reduced thyroid function, and increased risk of bone cancer. Regardless of the controversy, the one thing that everyone agrees upon is that little or no high quality research is available to confirm or refute any public concerns. The York systematic review of water fluoridation has previously highlighted the weakness of the evidence base by acknowledging the quality of the research included in the review was low to moderate.

Fluoride changes the structure of tooth enamel making it more resistant to acid attack and can reduce the incidence of tooth decay. This is why it is added to drinking water as part of artificial fluoridation programmes. The aim is to dose naturally occurring fluoride to a level that provides optimum benefit for the prevention of dental caries. The optimum range can depend on temperature but falls within the range of 0.7-1.2 parts per million (ppm) for Great Britain. Levels lower than 0.7ppm are considered to provide little or no benefit. Drinking water standards are set so that the level of fluoride must not exceed 1.5ppm in accordance with national regulations that come directly from EU law.

Severn Trent Water, Northumbrian Water, South Staffordshire Water, United Utilities, and Anglian Water are the only water companies in Great Britain that artificially fluoridate their water supply to a target level of 1 ppm. The legal agreements to fluoridate currently sit with the Secretary of State, acting through Public Health England, although local authorities are the ultimate decision makers when it comes to establishing, maintaining, adjusting or terminating artificial fluoridation programmes. As a programme dedicated to improving oral health, all of the associated costs come from the public health budget. Therefore, it is important to know that the money is being spent in the most effective way.

Our study has, for the first time, enabled an in-depth examination of the relationship between the incidence of two of the most common types of bone cancer that are found in children and young adults, osteosarcoma and Ewing sarcoma, and fluoride levels in drinking water across the whole of Great Britain. We have combined case data from population based cancer registries, fluoride monitoring data from water companies and census data within a computerised geographic information system, to enable us to carry out sophisticated geo-statistical analyses.

The study found no evidence of an association between fluoride in drinking water and osteosarcoma or Ewing sarcoma. The study also found no evidence that those who lived in an area of Great Britain with artificially fluoridated drinking water, or who were supplied with drinking water containing naturally occurring fluoride at a level within the optimal range, were at an increased risk of osteosarcoma or Ewing sarcoma.

It is important to note that finding no evidence of an association between the geographical occurrences of osteosarcoma or Ewing sarcoma and fluoride levels in drinking water, does not necessarily mean there is no association. Indeed, intake of fluids and food products that contain fluoride will not be the same for everyone and not taking this variation into consideration is one of the limitations of our study. Nevertheless, the methodologies we have developed could be used in the future to examine fluoride exposure over time and take other risk factors into consideration at an individual level. Such an approach could help the controversy surrounding artificial fluoridation ebb rather than flow.

Another important, although unexpected, finding arose from our use of fluoride monitoring data. We found that the fluoridation levels of approximately one third of the artificially fluoridated water supply zones were below 0.7ppm (the minimum limit of the optimum range). This finding reinforces that it is incorrect to assume an artificially fluoridated area is dosed up to 1ppm. In reality, it may be a lot less. A number of previous studies have mistakenly made this assumption making their conclusions unreliable. Our study shows that you cannot guarantee that fluoride levels in all artificially fluoridated water supply zones are close to the target level of 1ppm. Assuming that water fluoridation is a safe practice and evidence surrounding calculation of recommended dosage is reliable, this finding has economic implications in terms of public health. If public money is paying for artificial fluoridation shouldn’t the water supply zones be dosed up to a level that will provide the greatest benefit? If they aren’t then could it be that public money is merely being thrown down the drain?

Karen Blakey is a Research Assistant at the Institute of Health & Society, Newcastle University. She is interested in geographical information systems and the spatial analysis of disease registry data. Richard J.Q. McNally is a Reader in Epidemiology at the Institute of Health & Society, Newcastle University. He is interested in spatial epidemiology, the epidemiology of chronic diseases and the statistical analysis of registry data. They are authors of the paper ‘Is fluoride a risk factor for bone cancer? Small area analysis of osteosarcoma and Ewing sarcoma diagnosed among 0-49-year-olds in Great Britain, 1980-2005’, which is published in the International Journal of Epidemiology.

The International Journal of Epidemiology is an essential requirement for anyone who needs to keep up to date with epidemiological advances and new developments throughout the world. It encourages communication among those engaged in the research, teaching, and application of epidemiology of both communicable and non-communicable disease, including research into health services and medical care.

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By Richard Bränström

Although there has been much progress in many European countries regarding social acceptance of LGBT individuals in recent decades, much discrimination, social injustice, and intolerance still exists with adverse consequences for both physical and mental health in these populations.

Awareness of health disparities in specific populations, in particular based on ethnical background, gender, age, socioeconomic status, geography, and disability has increased during the past decades. And lately, public health policy and research have begun to address the issues of lesbian, gay, bisexual, and transgender (LGBT) populations, and many official public health agencies call for programs addressing the specific needs of LGBT individuals.

An increasing number of studies, although still limited, points to a higher prevalence of certain conditions among LGBT people that call for the attention of public health researchers and professionals. The most significant area of concern is the increased prevalence of mental health disorders. Recent studies show that LGBT youth are at greater risk for suicide attempts than non-LGBT youths and have higher prevalence of depression and anxiety diagnoses. Studies also show that transgender individuals are regularly stigmatized and discriminated against both in the health care sector and in the society as a whole.

Traditionally LGBT public health research has almost exclusively focused on sexually transmitted diseases. In particular, the start of the HIV/AIDS epidemic in the 1980s brought visibility to the LGBT population as a group with specific health needs. However, the public health consequences of discrimination of LGBT individuals have only recently been focus of greater attention.

The level of acceptance for minority sexual orientations differs greatly between countries. In the European Social Survey 2010, a question was used to assess level of acceptance of gay men and lesbians. The proportion of respondents that agreed to a statement that ‘Gay men and lesbians should be free to live their own life as they wish’ varied greatly between countries, from around 90% in the Netherlands, Sweden, and Norway to about one third of the respondents in Russia and Ukraine.

These results indicate that in many countries LGBT people still live in communities where a majority of the population supports discrimination and inequality for sexual minorities. In many countries, LGBT people are also subject to legal discrimination concerning basic civil rights, e.g. regarding recognition of same-sex unions.

But are these large differences in acceptance and legal discrimination influencing the health of LGBT individuals, and what needs to be done to overcome inequality in Europe’s health based on sexual orientation and gender identities? These questions are difficult to answer in the absence of sufficient data.

In a recent commentary in the European Journal of Public Health, we argue for greater awareness of these issues, and the need for more knowledge about the public health situation of LGBT populations through improved data quality and well-designed studies. Systematic data collection regarding sexual orientation and gender identity is required to better understand factors that can help us reduce and better understand disparities, as well as increase quality of health care provision for LGBT individuals. In addition to working towards greater acceptance to end discrimination and social injustice, greater efforts from public health researchers and policy makers are needed to reduce health disparities among LGBT populations.

Richard Bränström is a health psychologist and researcher. He is currently associate professor at the Karolinska Institute, Sweden, and he works with public health analyses at the Swedish National Institute of Public Health. His main research interest concern health inequalities, predictors of physical and mental health, and health related behaviors. He is the author of the commentary ‘All inclusive Public Health—what about LGBT populations?’, which is published in the European Journal of Public Health.

The European Journal of Public Health is a multidisciplinary journal in the field of public health, publishing contributions from social medicine, epidemiology, health services research, management, ethics and law, health economics, social sciences and environmental health.

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By Barry S. Levy and Victor W. Sidel

Chemical weapons are horrendous agents. Small amounts can kill and severely injure hundreds of people in a matter of minutes, as apparently occurred recently in Syria. Some analysts consider them “poor countries’ nuclear bombs.” The international community has, with the Chemical Weapons Convention, banned their use, development, production, acquisition, stockpiling, retention, and transfer. Nevertheless, several countries have continued to develop, produce, acquire, stockpile, retain, and transfer these weapons.

Chemical weapons were used on a wide scale during World War I and were also used during World War II. Saddam Hussein used them in Iraq in the 1980s to crush internal opposition to his regime. A terrorist cult in Japan used them twice in the mid-1990s, killing 20 people and injuring hundreds. Now they have been used in Syria — maybe more than once.

Their use in Syria cannot go unchecked. But that is not the issue before the US Congress. The issue is whether or not President Obama should authorize the “limited” use of cruise missiles, launched from US ships in the eastern Mediterranean, to “degrade” Syrian President Assad’s ability to launch additional attacks.

There are three reasons why we oppose such a strike.

First, such an attack by the United States would likely violate international law and undermine the United Nations’ ability to enforce the Chemical Weapons Convention. The report of UN weapons inspectors who investigated the recent attack has not yet been issued. The United States does not have the right to enforce international treaties — militarily or by other means.

Second, a strike by the United States would have uncertain consequences within Syria. It is likely to kill and injure noncombatant women, men, and children. It may lead President Assad or others in Syria to use chemical weapons in retaliation. And it may lead to wider access to the massive store of chemical weapons there, leading to further use of chemical weapons in Syria — and beyond.

Third, and most importantly, such a strike by the United States would have uncertain consequences throughout the Middle East and beyond. It could lead to a much wider war in this region, where there is an overabundance of weapons supplied by the United States, Russia, and other countries. Such a strike would be equivalent to tossing a match into a barrel of gasoline. There is already much conflict in this region within countries, most prominently within Egypt and Iraq, and there is much potential conflict between countries. The reaction by several countries and non-state actors in the Middle East (and beyond) to a US strike cannot be predicted, but there is a predictably high likelihood of a miscalculation, or a whole series of miscalculations, that could easily lead to a much wider conflagration. We should remember that the assassination of one person ignited World War I.

The civil war in Syria, which has already led to more than 100,000 deaths and two million refugees, cries out for a nonmilitary solution. There needs to be a response to the chemical weapons attack there, but it should be an international nonmilitary response — not a US cruise missile attack that is likely do more harm than good. The suddenly increased focus on the civil war in Syria represents an opportunity for the international community to find ways to end this conflict and to promote peace in the region.

Barry S. Levy, MD, MPH, and Victor W. Sidel, MD, are co-editors of the following books, each in its second edition, published by Oxford University Press: War and Public Health, Terrorism and Public Health, and Social Injustice and Public Health. They are both past presidents of the American Public Health Association. Dr. Levy is an Adjunct Professor of Public Health at Tufts University School of Medicine. Dr. Sidel is Distinguished University Professor of Social Medicine Emeritus at Montefiore Medical Center and Albert Einstein Medical College and an Adjunct Professor of Public Health at Weill Cornell Medical College.

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By Simone Frizell Reiter

According to Statistics Norway, around 10,000 children under the age of 18 in Norway experience divorce every year. These numbers do not take into account non-married couples that split up. Therefore, in reality far more children experience parental separation.

Status of knowledge

Focus has been on the adversity of parental divorce, emphasising the support and safety an intact family gives. The child may experience conflict, neglect or parental alienation, and insecurity about who belongs to the family. Not only the separation itself but also the period preceding and following the divorce may disturb the child’s well-being. Several studies show that parental conflict, that may be harmful to the child, is perpetuated even after the divorce. However, other studies show that when the parents are able to reduce the level of conflict after the divorce, the divorce is not exclusively negative if the child is moved from a family situation with conflicts to a more harmonious one. Society’s attitude toward divorce has changed as divorce has become more common. Prejudice and stigma are less pronounced. A natural assumption is therefore that mental problems related to divorce are also reduced. However, more recent studies conclude that adults, who experienced divorce in childhood, have more mental health problems than adults from intact families.

Divorce and reduced parental contact are closely linked. Children with loss of parental contact after divorce report more mental health complaints compared to children with preserved contact. Lack of attention, support, and economic insecurity may explain some of the negative effects of a parent’s absence. However, even when provided with at step-parent after divorce, these children report a lower level of well-being than children with preserved parental contact. Biological parents therefore seem to be of particular importance. Regular and frequent contact with both parents after divorce may also reduce the potential harmful effects of parental absence as seen in sole-custody households. Parental support is an important, independent risk factor to children’s sense of achievement and well-being. It is shown that as children’s relationship with their fathers weakens after divorce, they also lose contact with paternal grandparents and stepfamily.

Studies show that when divorce is followed by strong conflict, children may be used as a weapon between the parents. In such conflicts contact with one of the parents may be limited or brought to an end. The child is forced to ally with one of the parents, and suffers from the psychological stress this causes.

What is the concern?

Family law in Western societies generally aims at preserving dual parental contact for the child after divorce. This is also the aim of the Norwegian legislation. The Norwegian Child Act states that the parents may come to an agreement on where the child should primarily reside. However, if the parents cannot agree on this, the court has to decide which one of the parents the child should stay with. In practical life this has, in most cases, been the mother, while the father has been reduced to a weekend parent. Due to this, the experience in Norway is that when it comes to loss of parental contact, children of divorce primarily lose contact with the father. This effect is in some cases strengthened by the primary caregiver intentionally sabotaging the other parent’s visitation rights. To prevent this, the Norwegian legislation has sanctions, but these are very rarely used. A suggestion has been to introduce shared residence as a preferred solution after parental divorce, and that parents who sabotage this agreement may get restrictions on their contact with the child.

Most parents choose to take an active role in their child’s upbringing, and only a small group is absent, either by choice or circumstances. Therefore, social benefit systems have built in mechanisms to compensate the lacking of the absent parent by high financial contributions to sole providers left alone in charge. The downside of these benefits is that one of the parents can gain financially on monopolising the contact with the child and in some cases the sole provider actively sabotages or reduces the other parent’s contact, only to gain financially. This mechanism is strengthened by the Norwegian child maintenance system, where the level of economic support is linked to the amount of time spent with the child. Parents who share the custody in equal parts do not pay any child maintenance to each other. The combination of the systems has turned many fathers in to “child maintenance machines” because the mother would lose so much financially, sharing the custody of the child with the father. The benefits therefore undermine the aim to gain shared custody, and deprive the father of the possibility to have a close relationship with his child.

The concept of “parental alienation syndrome” is used to describe the condition where the child is alienated against one of the parents. If the government wants the children’s voice to be heard in custody conflicts, they must take into account that the child is already involved in a process of demonization and slander of one of the parents. From the literature, we know the term folie à deux. The government should be careful not to act in a game that can be characterized as folie à troi (madness shared by three).

In practice, it is difficult to have an equal amount of contact with both parents unless the child lives in two places equally. What is important to consider is whether advantages of maintaining a close relationship with both parents outweigh the disadvantages of having to change residence, for instance every week or every second week. Equally shared legal custody is not the same as having the child living in two residences fifty-fifty.

The experience is that the Child Act’s intention of parental agreement on a solution of custody between equal parties does not work. This is because the court, when presented the case, is legally bound to choose a single residence and almost exclusively chooses the mother.

On the basis of this knowledge it is important that the government puts effort in protecting the child’s right to have contact with both parents. This work must be as unprejudiced as possible. It is not acceptable that we continue with a practice in which the legislation allows the systematic favoring of one part in conflicted divorces.

Simone Frizell Reiter is a PhD candidate in the Department of Clinical Medicine at the University of Bergen, Norway, and the author of the paper ‘Impact of divorce and loss of parental contact on health complaints among adolescents’, which appears in The Journal of Public Health.

The Journal of Public Health aims to promote the highest standards of public health practice internationally through the timely communication of current, best scientific evidence.

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By Mark S. Gold, MD

Public health officials and academics identified cigarette smoking and related disease as the nation’s number one killer and foremost driver of health costs in the 1980s. At that time overeating and obesity were not major problems, yet they may soon cause more disease, deaths, and health care costs than cigarettes. Food addiction, which may explain part of the epidemic, is slowly and finally  “catching on”. It’s been controversial, with some scientists dismissing it out of hand, so like any hypothesis, it needs additional tests.

If overeating is due to food acquiring drug-like or tobacco-like brain reinforcement properties, then the current globesity and overeating-related health crisis might have lessons to learn from tobacco. For example, taxes on tobacco products have been the single most important prevention tool in reducing smoking. Based on food addiction hypothesis, higher prices might also reduce soda consumption. A review suggested that for every 10% increase in price, consumption decreases by 7.8%. An industry trade publication reported even larger reductions; as prices of carbonated soft drinks increased by 6.8%, sales dropped by 7.8%, and as Coca-Cola prices increased by 12%, sales dropped by 14.6%. It follows that a tax on sweetened beverages might help consumers switch to water or more healthful beverages. Such a switch would lead to reduced caloric intake, and less weight gain.

Changing the attitudes and behaviors of the public combined to reduce smoking and smoking-related health care costs and suffering. Changing access to cigarettes by elimination of cigarette vending machines, raising the price per pack to decrease numbers of cigarettes or packs/day smoked, crafting PSAs to reduce smoking initiation, and training medical professionals to intervene and not look the other way, all helped reduce smoking.

Age of onset and exposure can change genes, and make use and addiction more likely. We know that early exposure to tobacco via second-hand-smoke, either in utero or in early life greatly increases the risk of life-long tobacco use and addiction. In the 1990s, children’s intake of sweetened beverages surpassed that of milk. In the past decade, per capita intake of calories from sugar/HFCS-sweetened beverages has increased by nearly 30%. Beverages now account for 10–15% of the calories consumed by children and adolescents. It is likely that food addiction models can be used to explain early exposure and changes in preference becoming fixed and persistent for life.  An extra can or glass of sugar or HFCS sweetened beverage consumed per day increases the likelihood of a child’s becoming obese increases by 60%.

Our efforts to manage and treat overeating and obesity might benefit from addiction methods and experience. We could develop realistic food addiction models and test new treatments. Would animals self-administer food or food constituents, avidly, with bingeing and loss of control? Yes. Our work (and Bart Hoebel’ s before) clearly demonstrates that sucrose and fructose corn syrup are self-administered as if they were drugs and that an opiate-like abstinence syndrome could be produced by detoxification or antagonist administration. Sugar stimulates its own taking  causes craving, wanting, withdrawal, and can motivate and change our behavior.. If the food addiction hypothesis were relevant to the human condition, these animal models could be used to test new medications. New treatments developed for overeating and obesity were previously shown to be effective in addiction medicine.

These new treatments approved by the FDA include phentermine plus topiramate and bupropion plus naltrexone. Topiramate has been used with success in alcohol dependence, bupropion in nicotine dependence, and naltrexone in opiate and also alcohol dependence. While early, these treatments are important tests of the addiction hypothesis and harbingers of more progress in the future. With addiction medicine and food addiction model systems, we may develop treatments which change food preference and not just appetite.

Food addiction may explain some, but certainly not all obesity. The Yale Food Addiction Scale may be used to screen patients for addiction-like pharmacological and psychological interventions. Medically-assisted smoking cessation efforts were enhanced once treatment advanced from simple nicotine replacement or detoxification, to the brain and the neurobehavioral attachment to cigarettes. With an addiction hypothesis that included dopamine, we discovered the efficacy of bupropion and then Chantix. Thus, rather than a successful short term treatment rate of less than 20%, we routinely helped 30% of smokers. Still, addiction-inspired public health measures rather than medically-assisted treatment were responsible for most of the successful cessation efforts, early intervention, and prevention.

Smoking-related disease caused 400,000 deaths per year in the USA plus an additional 40,000 deaths due to second-hand smoke. Until recently little effort was directed at preventing smoking or treating smokers, although we treated the lung cancers, stroke, erectile dysfunction and other diseases caused by smoking. With all this progress, all of the health savings related to smoking cessation will soon be replaced by obesity-related costs. Are these two events related? As smoking and addiction is associated with decreases in eating and weight, a nation detoxifying from smoking addiction should be expected to become overweight. Until recently, with the scientific support provided by food and addiction models, we have not applied the same lessons learned from tobacco to overeating and obesity.

Proposals for food taxes have been made and calculations formulated of revenue-benefits based on our experiences with tobacco taxation. Even when these fail, the public and health experts have to think through the idea that fruits and vegetables are more costly than fatty, sweet, fast foods. Using taxes on ingredients such as added sugar and fructose corn syrup would decrease exposure according to addiction models. This might make Coca-Cola and other sodas return to sucrose as in Mexican or Kosher Coke. Reducing portion size, while supported by cigarette experience with numbers of cigarettes per pack and purchase limits, is a weaker intervention than other approaches. Now we see food labels and calorie postings. This educates everyone as they consider is it worth the calories and do they have the time and energy to exercise away the calories ingested. Exercise is important, and promotes health, but is not a stand-alone obesity treatment or management strategy. Stigmatizing the overweight with added health premiums and workplace incentives has not worked well in the past. Blaming the patient, creating shame and guilt, doesn’t do much to inspire treatment efficacy.

Obesity has changed the width of the seats in airplanes, dress, and trouser sizes. It has also made high cholesterol, high blood pressure, high blood sugars, knee and joint pain, and other obesity-related problems routine in medical practice and treatment. Over the past three decades, rates of obesity have increased in the United States and elsewhere, so that now more people are obese and in need of treatment than ever. New approaches, evidence-based approaches, like those that have been used successfully to develop novel public health and treatment approaches for tobacco, alcohol, and other addictions are needed.

Mark S. Gold, MD is the co-editor of Food and Addiction: A Comprehensive Handbook with Kelly D. Brownell. He is the Donald Dizney Eminent Scholar, Distinguished Professor and Chair of Psychiatry at the University of Florida. Dr Gold is a teacher of the year, researcher and inventor who has focused for much of his career on the development of models for understanding the effects of tobacco, cocaine, opiates, other drugs, and also food, on the brain and behavior. He began his work on the relationship between food and drug addictions while at Yale working with addicts in withdrawal. He has worked for 30+ years trying to understand how to change food preferences, make eating and drugs of abuse less interesting or reinforcing at the brain’s dopamine and other reinforcement sites. Kelly D. Brownell, PhD is professor of psychology, epidemiology, and public health at Yale University and is director of Yale’s Rudd Center for Food Policy & Obesity. Dr. Brownell does work at the intersection of science and public policy. The Rudd Center assesses, critiques and strives to improve practices and policies related to nutrition and obesity so as to inform the public and to maximize the impact on public health.

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Image credits: (1) Young mother and her baby, sleeping in bed. Photo by SvetlanaFedoseeva, iStockphoto. (2) Shrimp cocktail elegantly served in a martini glass accompanied by a glass of white wine. Photo by sbossert, iStockphoto.

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By Dr Alex Dregan

Do vascular risk factors such as high blood pressure and smoking make us forgetful?

As our bodies start to show the signs of ageing, our brain is naturally ageing too. But some older people can become forgetful and have trouble remembering common words or organising daily activities more than others. There are few proven interventions to prevent this kind of cognitive decline in older adults, although treating modifiable risk factors for vascular disease and stroke, such as cholesterol and body mass index (BMI), has been suggested as a promising approach to preventing or delaying cognitive impairment for a growing UK population of older adults. So is there a link between high blood pressure and forgetfulness?

Despite much recent interest, studies to date have reported inconsistent relationships between blood pressure and cognitive functioning. Evidence suggests that people diagnosed with high blood pressure levels tend to perform more poorly on most domains of cognitive functioning, including memory, learning, attention, and reasoning. However, clinical trials have so far failed to demonstrate that antihypertensive drugs used to lower or control high blood pressure levels are effective in preventing cognitive decline in older adults.  This inconsistent evidence poses a challenge when developing recommendations for the prevention of cognitive ageing.

Cognitive ageing, such as symptoms of forgetfulness, is increasingly seen as the result of the joint effect of several vascular disease risk factors, including high blood pressure, BMI, cholesterol levels, and smoking. However,  the combined influence of these on cognitive decline is less commonly explored among older adults at increased risk of both cardiovascular disease and cognitive decline.

In a recent paper, we looked at Framingham stroke and cardiovascular risk scores (a measure used to assess an individual’s probability of developing stroke or cardiovascular disease over a 10-years period) and investigated their association with cognitive decline in older adults. The study included over 8,000 adults aged 50+ living in private households in England. Participants with the highest risk of future stroke or cardiovascular events, based on their risk factors values, were found to perform more poorly on tests of memory and executive functioning after a four year period. This adds weight to the theory that the combined effects of risk factors for vascular disease and stroke may be associated with more rapid cognitive decline in older adults. In other words, those at greater risk of cardiovascular problems were likely to experience a more rapid onset of symptoms associated with cognitive decline, such as forgetfulness.

We believe that these findings support the need for a multifaceted approach when seeking to prevent cognitive decline. The main implication of this is the need for addressing the combined effect of multiple risk factors, including lowering high blood pressure and high cholesterol levels, weight loss, and stopping smoking. Thus, healthcare professionals should encourage older people to adopt healthy lifestyles that would include stopping smoking and increased exercise (as well as improved diet not investigated here) and taking prescribed medicines aimed at controlling high blood pressure and high cholesterol levels. Such recommendations could potentially prevent or delay future declining memory or reasoning capacities in older adults, particularly those in higher risk groups.

The results also suggest that a harmful effect of high blood pressure on memory or reasoning abilities may develop over a prolonged period of time. This may be one reason why short-term trials have failed to show a consistent benefit from antihypertensive treatment on cognitive decline. For instance, since the negative impact of high blood pressure on memory or reasoning abilities takes place over a prolonged period of time, short-term treatment may not be sufficient to reverse or delay its adverse influence. Therefore, we would expect that any potential cognitive benefits from lowering blood pressure may only be observed over substantial periods of time.

These new results suggest that attention to the combined effects of multiple vascular risk factors may hold some promise as a strategy to prevent cognitive decline in older adults.

Dr Alex Dregan is a Lecturer in Translational Epidemiology within the NIHR Biomedical Research Centre at the Guy’s and St Thomas’ NHS Trust and King’s College London. He trained in Public health at the Institute of Education, University of London. His research interests are in translational epidemiology research as applied to public health. He is co-author of the paper Cardiovascular risk factors and cognitive decline in adults aged 50 and over: a population-based cohort study for the Age and Ageing journal,  and this has been made freely available for a limited time.

Age and Ageing is an international journal publishing refereed original articles and commissioned reviews on geriatric medicine and gerontology. Its range includes research on ageing and clinical, epidemiological, and psychological aspects of later life.

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By William H. Wiist

Because the corporate goal is to obtain the highest profit possible, not social welfare, public health or environmental sustainability, business interests often give little or no consideration to the effects of corporate practices on indigenous peoples. Thus, the estimated 257 to 370 million indigenous peoples in about 5,000 communities in 70 countries, speaking 5,000 of the 6,000 existing languages, often experience severe detrimental consequences from commercial activity. The effects of extractive industries such as mining, agricultural crops and timber, and the theft of intellectual property rights illustrate some of those consequences.

Extractive industries

In many parts of the world, indigenous people inhabit areas that have been identified as areas with abundant resources that are in demand as profitable ventures for global industries:

Forests for the logging industry; oil and gas for exploration and drilling industries; gold and other minerals for mining companies and agriculture; use of the land for mono crop farming such as tobacco, palm oil, coffee, rubber; dams on indigenous land to create lakes or use of rivers to produce electrical energy; and nature reserves established in areas where they displace the indigenous peoples living there.

These extractions are reminiscent of early European appropriation of the Americas under the concept of “terra nulius” that is, land not belonging to anyone, and therefore available for the taking, even though millions of indigenous peoples had inhabited an area for thousands of years prior to European explorations.

The various extractive industries have several effects in common relative to indigenous peoples: ^[1]

1. The industrial operations displace indigenous people from their ancestral homes and land which have been integral to their spiritual, physical, mental and emotional life, requiring indigenous people to move to other remote but unfamiliar areas, or to migrate to the unsanitary, unhealthful fringes of urban areas with unlikely means of earning a decent livelihood. As a result the indigenous people experience social disorganization in their relationships to each other, and disruption of their relations with other indigenous group. They are forced to interact in new and unfamiliar settings with unfamiliar types of people, practices and ways of behavior.

2. This displacement, dispersion and migration leads to loss of their language and culture.

3. Their ancestral land may be confiscated with no or little financial remuneration for the land or for the extracted substance.

4. With loss of land, they lose their traditional livelihood, subsistence farming or place for gathering food and traditional medicinal plants.

5. Their sacred land or water be polluted by the extractive operations.

6. Contacts with extractive industry workers may expose the indigenous peoples to new diseases that they then transmit to their families, neighbors and other groups of indigenous peoples.

The Case of the Nahua and Nati Peoples in Peru

Napolitano described a 20 year history of an indigenous peoples’ contact with extractive industries within a territorial reserve the government established for four groups of indigenous people in an isolated area of the Amazon River. ^[2] Logging of mahogany and cedar, and oil operations in or near the area during the 1970s and 1980s led to some violence against the industry operations, some displacement of one indigenous group, and interethnic clashes between groups. In about 2001, work began on a gas field concession granted by the Peruvian government, 75 percent of which was within the territorial reserve.

Loggers working in an area of the Amazon encountered members of the Nahua indigenous group. Some of the Nahua went down river and interacted with the loggers. Upon their return up river, epidemics, including pneumonia, compli

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On World AIDS Day 2011, we speak with Dr Martin S. Hirsch, MD, FIDSA to find out the latest news on the global fight against AIDS. Dr. Hirsch is editor-in-chief of The Journal of Infectious Diseases, professor of medicine at Harvard Medical School, professor of infectious diseases and immunology at the Harvard School of Public Health, and a physician at Massachusetts General Hospital. – Nicola

Q: Thirty years after the first reports of AIDS, why is HIV/AIDS research still important?
A: Although we have made enormous progress in developing effective combination antiretroviral therapies to control HIV infection, we have been far less successful in preventing infection. Thus, in the US, as well as in the rest of the world, there are more people living with HIV infection today than ever before; worldwide, this number is over 30 million. Many individuals who are infected do not know that they are and, thus, they continue to spread virus to contacts by sexual contact, needle sharing, or mother-to-child transmission. We are not near having an effective preventative HIV vaccine, nor is a cure for those already infected on the immediate horizon. The risk of emerging drug-resistant viruses is also always with us. For all these reasons and more, it is essential that research efforts continue until we can say that HIV has been eradicated or is no longer a public health problem in the world.

Q: What notable important discoveries or research findings have there been in the field recently?
A: In my view, the most notable research advances in the field recently have been in efforts to prevent new HIV infections by using treatment as prevention and pre-exposure prophylaxis. Studies published this year by Myron Cohen and colleagues have shown in placebo-controlled studies that by treating HIV-infected members of discordant couples (one infected, one not), new infections can be reduced by up to 96 percent. This emphasizes the need for early recognition of infections and early treatment. It has also been established that pre-exposure prophylaxis with antiretroviral drugs can reduce transmission in high-risk populations, whether they be heterosexual or men who have sex with men. Pre-exposure prophylactic regimens have taken the form of oral therapy or topical administration of vaginal microbicides. The challenge now is to find ways to implement these strategies worldwide to prevent new infections in cost-effective ways.

Q: What should the public take away from these findings?
A: The public should be aware that only by early recognition of infection can we reduce the scourge of continued HIV transmission and disease. The US Centers for Disease Control and Prevention and other organizations have indicated the need for more routine testing of all populations who enter medical care in the US, and gradually our states and other public health authorities are implementing these suggestions. Nevertheless, there are still thousands of individuals in the US and millions in the world who do not know they are infected and who continue to spread virus. The public should insist on more HIV testing with appropriate measures to protect confidentiality among those tested. It is also critical that efforts to make effective therapies available to those in need not be curtailed in these times of budget stringency. Cuts at this time would reap bitter harvests in years to come.

Q: What do you see as the priority areas for future HIV/AIDS research? Where will the next great advances be?
A: There are several priority areas for HIV research in the years ahead. These include:

- Continued efforts to develop safe and effective prophylacti

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By Bill Wiist In 2009, there were 2,733 corporate foundations with assets of more than $10 billion and an annual donation of $2.5 billion. In that year foundations made grants of more than $38 billion of which $15.41 billion was from family foundations. In 2009, the 50 largest contributors to health donated more than $3 billion through almost 5,000 grants. The extent of corporate-based foundation funding in public health raises two critical questions for public health policy, research, and programming. First, should corporate-based foundations be setting the public health research and program agenda?

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By Bill Wiist

Little more than a year after the January 21, 2010 ruling by the U.S. Supreme Court in the Citizens United v Federal Elections Commission, it is already apparent that the effects of the ruling are widespread, contaminate the democratic processes, and could be long-lasting. Because the effects of the ruling on the 2010 election campaign were significant, the potential effects on public health could be pervasive. Finding new ways to undo its pernicious consequences is an important public health goal.

The Ruling

The Citizens United ruling overthrew previous laws and court rulings ranging from the early 1900’s to parts of the 2002 Bipartisan Campaign Reform Act, sometimes known as the McCain-Feingold law. The Court ruled that previous laws and regulations were so restrictive as to prohibit free speech. The ruling gave corporations the right to use unlimited amounts of money directly from the corporation’s treasury for independent election campaign advocacy. The results of the decision were immediately revealed in the November 2010 mid-term U.S. Congressional election campaign and its aftermath.

The Relevance of the Court’s Ruling to Public Health

Corporate wealth gives companies the special ability to develop and test communications that frame issues, appeal to emotions, provide inaccurate and incomplete information, and increase the cognitive availability of ideas. This allows them to take advantage of voters’ decision-making vulnerabilities. Thus, corporate campaign election funds could be directed into tailored messages for or against candidates who take positions on a variety of public health issues ranging from abortion, coal-fired power plants, menu labeling, and worker health, to budget appropriations and other aspects of health that are vulnerable to market forces. Corporate lobbyists could pressure elected officials based on their contributions to the official’s campaign as a means of gaining legislative favors. Donations from insurance and pharmaceutical corporations in the 2008 election cycle seem to have gained them access and influence during health care financing reform. After the 2010 election Representative Issa (R-Calif.), chair of the House Oversight and Government Affairs Committee, reportedly asked 150 trade associations, corporations and think tanks to provide a wish list of public health, environmental and other public protections they wanted eliminated. The Court’s ruling in Citizens United has raised concerns about the government’s ability to regulate the commercial speech of tobacco and other corporations in advertising their products.

Follow the money

More money ($4 billion) was spent on the 2010 congressional elections by political parties and outside groups than in any previous midterm election cycle.  According to reports by Public Citizen, in the 2010 election independent organizations that were the direct beneficiaries of corporate largess after the Citizens United ruling increased spending more than 400% over the 2006 mid-term election. About 54% of them disclosed anything about their sources. The groups that did not disclose information about sources spent 46% of the total $294 million spent by outside organizations on the election. In 60 of the 75 Congressional elections in which the seat was won by a candidate from a party different than the incumbent, the spending by outside organizations favored the winner. In the Senate election, winners had a 7-to-1 advantage in spending by outside organizations. The corporate funding ties and the political expenditures of some of the most influential of the independent organizations are known.

Campaign finance and disclosure laws in mo

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Bonnie Spring is a Professor of Preventive Medicine, Psychology, and Psychiatry and Behavioral Sciences Director of Behavioral Medicine, and Co-Program Leader for Cancer Prevention at Northwestern University. A Past President of the Society of Behavioral Medicine, she is board-certified in clinical health psychology. Dr. Spring’s most recent book is Smoking Cessation with Weight Gain Prevention, and in the  original post below, she reflects on her own struggle with giving up cigarettes and maintaining her weight.

“You’ve given me new hope.” So read the e-mail that arrived shortly after Parade Magazine published a story about my research showing that trying to manage weight gain while stopping smoking can help rather than hurt successful quitting. A steady stream of similar messages flowed in, taking my mind back to the days when I first started to study weight gain after quitting smoking. I still flinch at the memories. Faculty colleagues asked when I would switch to studying a real health problem – one with serious medical consequences. The reception was about as chilly at the National Institutes of Health. The words of a usually supportive program officer float back to me, “Oh come on…There’s only an average six to eight pound weight gain after quitting. That’s not a health problem – that’s a cosmetic problem. We’re in the business of studying threats to health – not insults to personal vanity!”

The physicians I spoke with weren’t much more helpful. They said things like, “Look, there’s no question that the much greater health risk comes from the smoking rather than the weight gain. The average person would have to gain about 100 pounds to offset the health benefit of quitting.” Indeed, medical practice guidelines conveyed a similar message. The U.S. Public Health Service Guideline on Tobacco Treatment encouraged physicians to tell patients not to worry about weight gain until they were fully confident and secure as non-smokers. The fear was that trying to manage both things at once – smoking and weight – would be overwhelming and would undermine the success of the quit attempt. Yet even though that guidance seemed right-minded and conservative, I watched it prompt my friends to make a life-threatening decision. Nor did I watch detachedly, because I was one of the many smokers who responded by making the same bad decision. Having to choose between being smoke-free and being slender felt like being crushed between a rock and a hard place. Yes, I cared about my long-term health and wanted very badly to quit. However, maintaining a slender, attractive appearance felt essential to sustain the social reinforcers that were vital to my quality of life. We can call it vain, irrational or disordered till the cows come home, but my priorities were certainly not unusual then or now. I continued to smoke.

Living out the truism that “research is me-search,” I began a series of treatment studies to test different ways to help smokers quit smoking without gaining weight. We already knew that ex-smokers gain weight especially because they eat more, but al

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Barry S. Levy, MD, PHH, is an Adjunct Professor of Public Health at Tufts University School of Medicine and a consultant in occupational and environmental health.  Victor W. Sidel, MD, is Distinguished University Professor of Social Medicine at Montefiore Medical Center and Albert Einstein College of Medicine, and an Adjunct Professor of Public Health at Weill Medical College of Cornell University.  Together they edited, Social Injustice and Public Health, which looks at many aspects of social injustice and their relationship to public health. Major sections of the book focus on population groups affected by social injustice, areas of public health and medical care in which social injustice has an adverse impact, and approaches to the reduction and elimination of social injustice and its adverse effects on public health. In the excerpt below, from the essay “Nutrition” by J. Larry Brown, we learn about malnutrition’s effect in the United States.

While debate about the causes and remedies of hunger is conducted in the political arena, hunger itself is a public health issue.  The adverse consequences of chronic undernutrition, as well as the social sequelae, make hunger a critical problem for the nation.  Moreover, an increasing body of knowledge points to the problem of obesity as a health consequence frequently associated with inadequate income and even hunger.

In the United States, hunger presents quite differently than it does in developing nations. Protein-calorie malnutrition, or marasmas, and kwashiorkor, characterized by adequate calories but extreme protein deficiency, now occur in the United States only rarely.  Rather, hunger in this country typically takes the form of what the World Health Organization called “silent undernutrition.”  It is reflected in young children who are several pounds beneath the low end of the pediatric growth chart.  They may look simply like thin children, but a trained health professional will recognize that they are experiencing growth failure.  Although their symptoms are different from those of malnourished children in developing countries, they are, from a health perspective, in difficulty…

Because children grow and their height and weight gains are plotted on internationally used pediatric growth charts, they are perhaps the easiest population group in which to detect the consequences of inadequate nutrition.  Typically, youngsters who fall below the fifth percentile in weight or height for age on growth charts are candidates for further investigation.  To be certain, it is expected that normally 5 percent of any population would fall in this low end of the range; but in studies of low-income children, 10 to 15 percent do so.  This indicates that what is being observed is not normal genetic variation but rather a “human-made” outcome.  Moreover, this analysis is confirmed in the work of child development clinics in urban teaching hospitals across the United States, where children experiencing growth failure due to poverty are nursed back to health with appropriate nutrition.

While the relationship between inadequate nutritional intake and health status reflected in the

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We're supposed to have a new dialysis center at the Commonwealth Health Center. With all of the change orders, it appears that about $22 million dollars of federal and CNMI money was spent building it.


Photo from of CNMI Public Auditor's 2007 Report.

But what we have is a structure that is "built" but not used for dialysis because it is unsafe. The Variety reports today that CNMI Secretary of Public Health Joseph Kevin Villagomez signed off on the project, certifying that the structure was acceptable because of instructions from the "facilities engineer." Who was that facilities engineer? The newspapers don't say.

Joe Kevin Villagomez's role in signing off, though, is being questioned. Shouldn't he have also exercised independent professional judgment?

The problems reported with the new facility:
1. The reverse osmosis (RO) system contains bacteria.
2. The water storage tanks of the reverse osmosis system may be carbon media tanks, not multi-media tanks. Labels on the tanks were changed to disguise the flaw.
3. There is a suspicion of irregularities in materials used in construction: PVC fittings and pipes of the RO system were glued so that excessive glue flaked into the system and would subject patients to possible harm.
4. Public Health officials has told lawmakers that the dialysis center's certification for the RO system was forged.
5. The CNMI sued the contractor Leo A. Daly Company for defective design, and have alleged the facility is useless for its intended purpose. (This lawsuit is only for $10 million, though.) One of the alleged defects (reported in August 15, 2009 Tribune article) is failure to meet stress tests for earthquakes.

And we don't have staff for it.

The CNMI Legislature recently convened two public hearings on the delivery of health services in the CNMI. The House Committee on Health, Education, and Welfare (HEW) invited public health and private doctors to a daytime session, but no one came, according to the today's Saipan Tribune. In contast, the public hearing in the evening, open to the public, drew a small group of about 30 people.


Photo from CNMI Public Auditor's 2007 Report.
What I find interesting is the focus of the hearing: reported as a look at hiring doctors and the necessity of paying for head hunters. Perhaps it's an issue with reporting, but we certainly have much more serious problems than paying head hunters to find us doctors (even at $25,000 / doctor).

In a recent survey, several major problems at CHC were noted, including mismanagement, poor procurement practices, and inadequate billing/accounting and records procedures, along with a doctor shortage.

In Tuesday's KSPN news, Ralph Torres made some remarks that seem unclear: yes he wants to find an experienced person to handle the situation at DPH, and yes, joe Kevin Villagomez has experience. It's not clear to me whether he thinks joe Kevin would be up to the job, but for his health issues that have made him leave island for months now; or whether he was acknowledging that "experience" comes in different varieties and needs to be scrutinized, too.

It's not clear if he just does't like Pete Untalan, either. He reported that Pete said the dialysis center would be open in August and here it is September; but the August 15, 2009 Tribune has Pete saying it will be open in October, with a nephrologist due to arrive on September 23, 2009.

And think of all the earlier times when we've heard that the dialysis center will be opened!

I guess we need Legislative oversight of administration functions; but we also need to recognize that the Legislature's job is making laws, not carrying them out. It's unrealistic to expect the Legislature to take over this problem and fix it. Especially, when you consider that the Legislature's often repeated "solution" is to throw money at the problem, as Ralph Torres says we need to do here.

Nor is the Legislature to be relied on to get things done promptly. They've known about the problems with the dialysis center since at least September 2003, as this flashback from September 2, 2003 shows. The Legislature is a political body that changes with seasonal voting. They get involved with hot topics, but also can cool off before the work is finished.

What do we need to do?

I think we need to start at the beginning and review all that's been done.

So here's a summary of the history of the CNMI Saipan dialysis center, as taken from the newspapers (note, Haidee does a similar thing, in summer 2009, and the link is later, but rather than re-writing and analyzing, yet, I'm just giving the blow-by-blow):

1999-10-28:

"The California-based Transpacific Renal Network has given recognition to the renal hemodialysis section of the Commonwealth Health Center as one of the top units that provide quality care to patients undergoing dialysis.

Public Health Secretary Joseph Kevin Villagomez said such accomplishment shows the commitment of the hospital in making sure that the best possible care is provided to the people in the community....Dr. Hilmer Negrete, director of hemodialysis unit of CHC, said the team has to submit regular progress report to each patient undergoing dialysis treatment to Transpacific Network."

2000-03-06: 51 dialysis patients costing $5 million / year.

2001-09-07: In 2001, we have 2 nephrologists--Dr. Negrete and Dr. Zahid.

2002-06-11: Rota and Tinian to get dialysis centers at $1million apiece.

“We found out that, if you build a structure and the structure is certified by Medicare, then at least 80 percent of the operational funds will come directly from the Medicare and that is the federal funding we are eyeing. So, to ensure that we can tap these funds, we will make sure that the buildings for the dialysis centers are Medicare-certified,” he said.

Earlier, lower chamber lawmakers said that Rota and Tinian dialysis patients are presently inconvenienced by the need to travel to Saipan, the location of the nearest CNMI dialysis center, to receive treatment.

“Responding to the needs of dialysis patients in Rota and Tinian requires the construction of dialysis centers on these islands. By using the un-appropriated Public Law 12-64 funds on Rota and Tinian, patients need not make the arduous trip to Saipan to avail themselves of dialysis care,” said House Floor Leader Jesus T. Attao, the bill's author.

As broken down in the proposed measure, $1 million would go toward a new Department of Public Health Building and Dialysis Center on Rota and another $1 million for a similar building on Tinian.

2002-08-28: Saipan to get dialysis center; this project is estimated to cost $5.6 million.

"On the Department of Public Health building expansion, this will entail the construction of the extension that would house 24 to 25 new dialysis machine units at the CHC.

Bids for the project were received in April and a contractor has already been selected and notified that it would be awarded the project. However, a notice to proceed has yet to be issued pending the release of several construction permits.

“The government has been applying for the building permits and all the permits necessary to start the project, rather than have the contractor obtain the permits, to eliminate unnecessary delays in the project,” said Jordan."

2002-10-26. Project finally underway. Estimated cost for project between $5 and $6 million. Dr. Hofschneider as DPH secretary. Estimated completion date: 4/18/2004. Current situation: 90 patients.

Hofschneider said the project's contractor is AIC Marianas Incorporated, while the construction management contract has been awarded to SSFM, whose principal is John Gentry and whose fee is about $250,000... Jordan said the DPW released the Notice to Proceed to the contractor last Tuesday and the expansion project is expected to be finished in 540 days, with some additions and deletions to be made on the project.

... Although the budget for the project is between $5 and $6 million, Hofschneider expressed hope that some money would be left to be used as additional funding for the water needs of the building, parking and a new MSO building. This (sic) related projects are estimated to cost $4 million.

Note--this is going to lead to problems later.

2002-11-08: CNMI Government (through Chuck Jordan), keeping track of CIP projects including the dialysis center (CHC expansion) project.

2003-02-07. Groundbreaking for the dialysis center/CHC expansion project. Cost now estimated at $10 million. 93 dialysis patients. Estimated opening of new facility-2 years. That would be early 2005.

2003-06-10. CNMI starts new program for peritoneal dialysis. Now 96 patients.

2003-09-02. Problems about design noted. Change orders being sought. It appears that the issues are the inclusion of improved water system and parking lot, which were not part of the original plan.

What did I mention up above?

2004-01-31. Construction of dialysis center is on schedule, despite some design problems.

2004-03-04. Hofschneider asks U.S. Congress to provide $1.1 million to buy equipment for new dialysis center. Says CNMI only budgeted for building the facility, not equipping it.

2004-10-22. Kagman wastewater project funds reprogrammed to dialysis center.

2004-10-29. CNMI Congress considers reprogramming request; wants assurances. Information confusing; Leo Daly out-Tanuguchi Ruth in.

2004-11-02. Joint House and Senate Committee to probe dialysis center construction issues; Governor Fitial asks for Public Auditor's office examination, also. This article says $11 million given from Covenant 702 funds. Project 40% complete.

2004-12-24. Did we really pay $50,000 to the U.S. Army Corps of Engineers to review the construction of the dialysis center? Stanley Torres says so. Where is the Army Corps of Engineers report?

... And then this recap of the finances:

The reprogramming bill came following findings that the public health project's over $11-million funding had been depleted, even as construction work was only about 40 percent completed.

Originally, the government allotted some $11.8 million in Capital Improvement Project funds for the dialysis center. Of that amount, the Department of Public Health awarded a $5.6-million contract to AIC Marianas to construct the facility.

The contractor had repeatedly asked for change orders, totaling over $4 million, allegedly due to faulty design. About $2 million had been spent for two architectural and engineering designs, while other expenses reportedly went to administrative activities.

2005-08-03. In the meantime, CHC gets a few more dialysis stations.

2005-09-18. Also meanwhile, the CNMI provides competent care and exceeds average U.S. standards, according to Dr. Zahid. Good data here.

2006-02-04. Governor Fitial's administration asks for reprogramming of more funds for dialysis center. Project now 70% completed.

2006-04-11. DPH Secretary Joe Kevin Villagomez says dialysis center will open in October 2006.

“It's going very well. There's a lot of involvement in this project,” he said, adding that there would be medical staff that would be assigned to the new building.

2006-07-07. Dialysis center to be named after Dr. V. (It helps when you're the lieutenant governor and get to sign the law naming the facility after your father.)

2006-07-28. Opening delayed to November 2006, to secure Medicare certification.

2006-10-18. Cost of dialysis center now said to be $15 million. Joe Kevin Villagomez enlists political support, like this:

“Our money was well spent,” Rep. Manuel Tenorio said.

2006-10-19. The new building is used as bait to seek more funding for CHC! See, we did a great job and now need to upgrade the rest of the old building... or something like that.

2007-06-08. Inspector General's Report identifies management issues with the dialysis center project.

2007-07-11. Joe Kevin Villagomez says we should privatize the dialysis center building; it's still not open. (This sounds like a scam to me--some way to get a private business some additional cash at government expense.)

2007-10-05. Both CNMI nephrologists have recently left the CNMI; a Guam doctor will be visiting.

2007-12-20. Ribbon cutting and new dialysis center officially opens. Umm, does it?

2007 Public Auditor's Report at page 6 says this:

A joint evaluation of the Saipan Public Health Facility Project (Project) by the Department of the Interiors' Office of the Inspector General (OIG) and OPA showed serious deficiencies in the contracting process, including the failure to adhere to established procurement regulations and the lack of qualified and experienced officials to administer the Capital Improvement Project (CIP) program, which significantly affected construction costs and time frames.

2008-01-26. CNMI spending $8.8 million /year for 96 dialysis patients.

2008-02-07. Children's Clinic and immunizations moved to new dialysis center wing.

2009-05-18. CNMI once again without a nephrologist. Other concerns about CHC raised by Ed Propst.

2009-05-19: Untalan responds: Those concerns are just one person's opinion; Diabetes Prevention Program still operational.

In a recent letter by Rep. Ralph DLG. Torres to DPH Secretary Kevin Villagomez, the former asked for some information on several matters at the CHC.

These include updates on the status of nephrology, updates on dialysis machines to be replaced, local expenditure for Fiscal Year 2009, data as to the number of dialysis patients, the status of the Hemodialysis Center and other issues.

A copy of the letter was sent to Saipan Tribune. Secretary Villagomez has yet to respond to e-mail inquiries about it.

2009-05-23. Legislator asks for information from Secretary of DPH. See, the Tribune does read the letters submitted!

2009-06-06. FDA Certification for dialysis center forged. Information revealed in BUDGET HEARING!

Acting Health Secretary Pete T. Untalan told the House Ways and Means Committee yesterday that the U.S. Food and Drug Administration certification of the reverse osmosis water system at the new dialysis center was “forged” by an individual previously connected with the U.S.-based Severn Trent.

Severn Trent supplied the reverse osmosis water system unit to Saipan Ice, which was one of the subcontractors of AIC Marianas, the main contractor for the construction of the new dialysis building in Garapan.

Saipan Ice's sales supervisor Lito Dizon and AIC Marianas project engineer Ding Lacap separately said in telephone interviews that they're not aware of the forgery and that nobody had told them about the issues that just came about.

Medicare requires the CNMI Department of Public Health to have an FDA-certified reverse osmosis water system for it to operate the new dialysis center, which has yet to open three years after its construction was completed in 2006.

“We found out just a few days ago that the reverse osmosis system is not FDA-certified,” Untalan told the legislative committee chaired by Rep. Ray N. Yumul (R-Saipan) during yesterday's hearing on DPH's Fiscal Year 2010 budget.

(This certification is needed for Medicare approval. Why did it take this long to figure this out? Weren't we seeking Medicare approval back in 2007?)

2009-06-08. Cost for dialysis center now reported at $22 million.

2009-06-09. CNMI Legislature to ask Public Auditor to investigate.
Have they read the existing OIG report or the OPA's 2007 report?

2009-06-12. CNMI to sue over $22 million "fiasco." Good review of situation here.

2009-06-16. The local newspapers finally catch up to the 2007 OIG/OPA report.

2009-06-16. Matt Gregory, former CNMI AG, now files suit as a private attorney against Leo Daly for $10 million on behalf of the CNMI.

We have an Attorney General's Office, but we use a private firm for this. Why? Oh, because the OAG is understaffed. But why not use the money and hire another Assistant Attorney General instead of paying private attorney rate fees? (OMG!)

In my opinion, Gregory should have brought this action while he was the CNMI AG. And his failure to do it then should be reason enough NOT to hire him and pay him more money to do it now.

2009-06-17. Haidee Eugenio continues to dig for the full story.

2009-06-19. The CNMI is not pursuing criminal charges for the dialysis center fiasco. And Juan Reyes at DPW identified as the "expenditure authority" (for at least some of the time? or all of the time?).

2009-07-21. Representative Ralph Torres says we'll have one full-time nephrologist for Saipan/CNMI next month (August 2009).

2009-08-15. Grand opening of dialysis center set for October 2009. It will be old before it is in use!

2009-09-19. Pete Reyes and Arnold Palacios think we need a law establishing a "corporation" as the solution!

The lawmakers said a bill establishing a corporation for public healthcare and related public health services will in the long-term provide a foundation for a high quality, efficient and market-oriented public healthcare delivery system.

Without any analytical basis; without reference to the real studies of the problems done; without regard to the problems we've had from corporations like MPLC. How is a corporate structure going to address the problems! Sheesh. Just like privatizing seems to be a method for economic graft, this is nothing but political graft--imho.

Somewhere in all of this was a report that there were three contractors/project designers(?) involved--Leo Daly, Tanaguchi Ruth, and an unnamed third. Who is the third contractor? Perhaps I missed that information somehow.

Where do we go from here?

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