March 2013 - The Epidemiology Monitor

Recommendations Made and Actions Proposed To Transform Epidemiology For 21st Century Medicine and Public Health An ambitious and sweeping set of broad recommendations and more specific actions to transform cancer epidemiology research, training, and practice have been published by an ad hoc group of investigators convened under the auspices of the National Cancer Institute. Many of these investigators, such as Julie Buring, Muin Khoury, Margaret Spitz, and Robert Hoover are among the best known names in epidemiology today.

According to Khoury, a strong rationale for the workshop is the need to make epidemiology more impactful on population health outcomes in a time of unprecedented scientific discoveries and technological developments and resource constraints for scientific research. Describing their work as a “collective intellectual discourse” -Recommendations continued on pg 2

Epidemiologists Testify About Serious Research And Ethical Failures In Veterans Administration Epidemiologic Studies “…if the studies produce results that do not support OPH’s (Office of Public Health, Department of Veterans Affairs) unwritten policy, they do not release them…On rare occasions when embarrassing study results are released, data are manipulated to make them unintelligible…Anything that supports the position that the Gulf War illness is a neurological condition is unlikely to ever be published.”

These accusations are not your general run of the mill statements about flaws in a study. Nor are they minor violations of informed consent or breaches in protecting confidentiality. Instead they are accusations of serious failures in the responsible and ethical conduct of research, possibly including deaths, made by Steven Coughlin, former senior epidemiologist for the Office -VA continues on page 9

In This Issue:

-3Risk Factors for Breast Cancer

-5Six Essays Describing Key Concepts in Epidemiology

-14Jobs

Check our online Job Bank for more offerings http://tinyurl.com/cy6k3fu

March 2013 Volume Thirty Four Number Three

-Recommendations continued from pg 1 “The time is right to ensure greater credibility of all epidemiologic studies”

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carried out at an interdisciplinary workshop and through multiple other means online, the authors believe their statements apply to the whole field of epidemiology.

The recommendations are targeted to the research community, funding agencies and professional organizations. While the recommendations may not be controversial because they seek to be responsive to trends already evident in several areas of society and science more generally, the authors acknowledge that further deliberation is called for. The Epi Monitor invites your comments and will publish the feedback obtained.

The NCI also invites your comments directly on its “cancer epidemiology matters blog” at: http://tinyurl.com/ah2g3fo The 8 broad recommendations are: 1. Extend the reach of epidemiology.

This recommendation calls for recognizing a whole spectrum of epidemiologic activities beyond an initial discovery. It calls for a more balanced portfolio of epidemiologic research that addresses more directly the development and evaluation of interventions that can improve the public’s health, as well as dissemination and outcome evaluation in real world settings.

Epidemiology as a field has a major role in developing and understanding the use of data for both clinical and public health practice.

2. Transform the practice of epidemiology.

This recommendation focuses on opening up access to data and the research process so that more people can use data, more can collaborate in using data, and greater transparency and associated credibility can be achieved.

“The time is right to ensure greater credibility of all epidemiologic studies by adopting a reproducibility culture through greater sharing of data, protocols, and analyses,” according to the authors.

3. Expand cohort studies across the lifespan including multiple health outcomes This recommendation is targeted at getting more out of cohort studies by studying more outcomes and by combining different cohorts. It is a plea to accomplish more by coordinating and collaborating with more investigators and for funding agencies to synergize resources across multiple diseases and health outcomes. Cohorts can also be a great resource for developing predictive and diagnostic tests, embedding clinical trials and for other translational activities.

4. Develop, evaluate, and use novel technologies appropriately The advent of genomic and other technologies provide tremendous opportunities for epidemiologic investigations. However, there are -Recommendations continues on page 8

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Review Essay Discusses The “Big Picture” About Risk Factors For Breast Cancer [Editor’s Note: We are reprinting a very readable and comprehensive article on breast cancer written by Albert Einstein epidemiologist Geoffrey Kabat which recently appeared in Forbes. We contacted Dr. Kabat to get permission to reprint his essay and to ask him about what prompted the article.

He told the The Epidemiology Monitor he was motivated to write the piece when he realized that most recent epidemiologic studies tend to focus on one or a small number of risk factors (in the past, studies tended to be broader in their approach), and there are increasingly pooled analyses looking at a single risk factor, such as physical activity or alcohol consumption.

Questions He was interested in trying to answer the question---What proportion of breast cancer incidence is explained by known risk factors and what proportion remains unexplained? In the early 1990s there were attempts to answer this admittedly difficult question, but it appeared that the field had become increasingly fragmented.

Many studies tend to be focused on one aspect of the problem – hormones, reproductive factors, obesity, genetics, diet, environmental exposures, etc. He had the impression that there were few attempts to integrate all the different risk factors, many of which are quite modest and many of which are intercorrelated. Such an undertaking would help by conveying their relative magnitudes.

Methods Kabat sent e-mails to a dozen prominent breast cancer epidemiologists asking their view on two questions: 1) what proportion of breast cancer is explained by known risk factors? and 2) what do you consider to be established environmental risk factors for breast cancer above and beyond the hormonal factors (OCs, HRT, DES, etc.), ionizing radiation, and alcohol consumption?

“but it appeared that the field had become increasingly fragmented”

Kabat said he heard back from three researchers, but, interestingly, in even this small sample people had very different views – some believing that most of breast cancer can be explained by known risk factors and others feeling that there is a lot that remains unexplained.

The three respondents did not address the second question.

According to Kabat, “When you try to see the big picture – that is, what we really know about these risk factors -- you realize that there are a lot of inconsistencies and a lot we don’t know. But somehow this is not the message that is relayed to the public.”]

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“this is not the message that is relayed to the public.”

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"After 40 Years Of Research, What Do We Know About Preventing Breast Cancer?"

By: Geoffrey Kabat

“there is widespread confusion on this most important question”

“these breast cancer risk factors are nothing like cigarette smoking”

Hundreds of scientific articles are published each year about risk factors for breast cancer and about prevention of the disease. However, the most basic questions about what we really know get very little attention. How much of the occurrence of breast cancer can be explained by our current knowledge?

What can women do to reduce their risk? And where should we look for the remaining pieces of the puzzle?

Recently, a federal inter-agency task force issued a report emphasizing the need to redouble research efforts focused on the prevention of breast cancer. And another report claimed that between 12 and 18% of breast cancer deaths are attributable to alcohol consumption. These and many similar studies focus our attention on specific risk factors or possible risk factors. But rarely are we given a critical overview of what we actually know and how useful this information is for the prevention of breast cancer. As a result, there is widespread confusion on this most important question.

Risk Factors Breast cancer is the most commonly occurring cancer in women both in this country, as well as worldwide.

In the U.S. breast cancer accounts for nearly one-in-three cancers among women.

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Epidemiologic studies over the past 40 years have identified numerous risk factors for breast cancer, including: older age, an early age at menarche, a late age at first full-term birth, not having children, a family history of breast cancer in a firstdegree relative, greater height, higher circulating estrogen levels, postmenopausal hormone use, breast density, history of breast biopsies, obesity (for postmenopausal breast cancer), and exposure to ionizing radiation.

Other, probable risk factors are alcohol intake, physical activity (protective), and breast feeding (protective). Many other factors that have been studied do not seem to affect the risk of breast cancer (dietary fat intake, cigarette smoking, past oral contraceptive use, exposure to electromagnetic fields).

Risk Comparisons Known risk factors for breast cancer are relatively weak, contributing only a small elevation in risk. Even having a family history of breast cancer in a first degree relative carries about a twofold increase in risk. And the more recently discovered breast density is the strongest with roughly a 4-fold increase in risk. Thus, these breast cancer risk factors are nothing like cigarette smoking as a risk factor for lung cancer, where a current smoker has roughly a 15-fold increased risk compared to that of someone who never smoked, and a heavy smoker might have a 40 or 50-fold increased risk. Smoking accounts for the vast majority of lung cancer cases.

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Six Essays Describing Key Concepts In Epidemiology Now Available At The People’s Epidemiology Library Six essays which constitute a short primer on epidemiology have been posted to the website of the People’s Epidemiology Library, a joint project of Columbia University’s Alfredo Morabia and Leiden University’s Jan Vandenbroucke to bring together documents and essays about the development of epidemiologic methods. These essays were commissioned to help explain epidemiology for laypersons coming to the site for resources. The essays are a work in progress and both Morabia and Vandenbroucke contributed to them.

The principal author of the essays is McMaster University’s Stephen Walter who was selected for the task in an essay competition run by the Library in 2011. Walter told The Epidemiology Monitor, which helped to sponsor the contest, that writing for the public was not something which academic epidemiologists do very often but which he thought is important. He said he would try to convey his enthusiasm for the discipline and why epidemiology is so important in contemporary society.

The topics for the six essays along with selected excerpts from each one are included below, along with links to the essays. Some of the excerpts have links to references as well.

#1 Introduction to Epidemiology For a sample of this essay, here is a how Walter presents Snow for the lay public.

In London, some 200 years after Graunt, the epidemiologist John Snow’s studies compared the mortality from cholera between the clients of two companies providing water in London.[Snow, 1855] The study confirmed his hypothesis that getting cholera was somehow linked to contaminated drinking water. The specific inquiry of a cluster of cases which occurred in the vicinity of Broad Street famously led to the removal of the handle of the Broad Street water pump.

This was a controversial move at the time, because several other theories about the cause of cholera existed, including the notion that living at a low altitude would increase the population’s exposure to dangerous vapours. We know nowadays that Snow was right, and the provision of a clean and secure drinking water supply was one of the main elements of a major movement towards improving public health during the 19th century and subsequent.[Vandenbroucke et al, 1991]ly http://tinyurl.com/adho779

#2 How to Count For a sample of this essay, we have chosen Walter’s paragraph on the distinction between risks and incidence rates The formal distinction between risks and incidence rates goes back to William Farr’s work between the 1830s and 1850s [Vandenbroucke, 1985]. Farr explained that people were more afraid of cholera than tuberculosis, not because of its ultimate mortality, but because cholera kills more swiftly, -Essays continued on page 11

“These essays were commissioned to help explain epidemiology for laypersons”

“he would try to convey his enthusiasm for the discipline and why epidemiology is so important in contemporary society”

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“our extensive knowledge about risk factors affords little basis for women to reduce their risk”

epidemiology.

“this knowledge does not enable us to accurately predict who will develop breast cancer and who will not”

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(The strongest risk factors for breast cancer are older age and being female: women between the ages of 65 and 69 have 15 times greater breast cancer incidence compared to women between the ages of 30 and 34, and women have more than one hundred times the incidence of breast cancer compared to men.)

where rates of breast cancer have been about one-fifth of rates in the U.S. An understanding of the hormonal nature of breast cancer has led to the development of highly effective treatments for the most common form of breast cancer in postmenopausal women.

Prevention

Mechanisms The “classical” reproductive and hormonal risk factors are generally explained by the effects of exposure of breast tissue to ovarian hormones, primarily estrogen but also progesterone. The greater the interval between menarche and menopause, the greater the number of menstrual cycles with spikes in exposure to these hormones.

Following menopause, the main source of estrogen is from fat deposits, and this is believed to explain the association of obesity with postmenopausal breast cancer.

Finally, current or recent use of postmenopausal hormones modestly increases the risk of postmenopausal breast cancer.

The protective effect of an early pregnancy is thought to be due to the fact that a first, full-term pregnancy stimulates the full differentiation of the cells lining the milk ducts, where most breast cancers arise.

Thus, from the point of view of reducing breast cancer risk, having a later onset of menstruation followed by an early pregnancy and a large number of children is beneficial. This was the pattern 150 years ago in this country and more recently in Asia,

Unfortunately, our extensive knowledge about risk factors affords little basis for women to reduce their risk, since most of these factors (family history, reproductive factors, etc.) are not modifiable.

And this knowledge does not enable us to accurately predict who will develop breast cancer and who will not.

Furthermore, this knowledge does not fully account for changes in breast cancer incidence. For example, on the basis of known risk factors, one would expect women of the “baby boom” generation to have increasing rates of breast cancer due to delayed child-bearing, having fewer children, and greater use of hormone therapy. But, in fact, breast cancer rates among women of this generation have declined.

Regarding the possible impact of environmental exposures (in the more narrow sense, e.g., pesticides, industrial pollutants, etc.), studies to date have not yielded any strong signals. However, most studies have focused on exposures in adulthood rather than in earlier periods when susceptibility may be greater.

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early adolescence (possibly a caloriedense diet) may influence the risk of breast cancer.

New Developments Over the past twenty years, thinking about the causes and prevention of breast cancer has advanced in important ways, and the picture has become much more complicated than the overly simple focus on the “classical” risk factors allows for.

First, the discovery of rare, highpenetrance germ-line mutations of BRCA1 and BRCA2 identified a small subset of women with a very high lifetime risk of breast and ovarian cancer.

However, only 1-2 percent of breast cancer is accounted for by these mutations.

Second, there is an increasing awareness that experiences starting in the womb may influence future risk of disease, that there are “windows of vulnerability,” and that the timing of exposures may affect future risk. Such periods include: in utero exposure, puberty, and the period between menarche and a first full-term pregnancy. Thus, the timing of exposure to hormones and other factors at different points in the lifespan can have very different effects.

For example, obesity actually appears to be protective for premenopausal breast cancer, whereas it is a risk factor for postmenopausal breast cancer.

Furthermore, follow-up of women exposed to the atomic bomb at Hiroshima showed that exposure during adolescence (during breast development) carried a much higher risk of breast cancer than exposure later in life. The association of adult height with increased risk suggests that exposures during childhood and

Third, researchers have focused on so-called gene-environment interactions, reasoning that some exposures that have relatively weak associations with breast cancer in the general population may have a much stronger effect in subgroups with a specific genetic make-up.

This line of research has to date yielded few instances of important interactions.

Enormous efforts have gone into examining the contribution of other normally-occurring genetic variants (single nucleotide polymorphisms, or SNPs), but these studies have only identified a few SNPS with very slight increases in risk. It is now believed that there may be as many as a hundred genes that each contributes a small added increment to a woman’s risk of breast cancer.

Further complicating the landscape is the realization in the past decade that, rather than being a single disease, breast cancer is at least five distinct diseases, with (to some extent at least) different risk factors, pathology, prognosis, and treatment.

“that there may be as many as a hundred genes that each contributes a small added increment to a woman’s risk of breast cancer”

“breast cancer is at least five distinct diseases”

Bottom Line For Now Where does this leave us?

First, while we know a good deal about breast cancer, knowledge of established risk factors provides few opportunities for reducing risk.

Therefore, it is important to realize that there is still a great deal we -Breast continues on page 8

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“women should bear in mind that heart attacks kill 6 times more women than breast cancer does”

“The unquestionable reality of 21st century epidemiology is the tsunami of data”

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-Recommendations continued from pg 2

don’t know about what causes breast cancer. Some of what we know may be useful. For example, avoiding, or minimizing, weight gain and engaging in physical activity may reduce a woman’s risk.

multiple challenges which come with new technologies and new ways of measuring exposures. Many of these challenges cannot be resolved at the time studies are done. The authors advocate careful attention to the collection and handling of specimens for future evaluation as one strategy to use in mitigating this problem.

Second, it should be noted that breast cancer incidence rates are not increasing, and mortality rates have been decreasing in all age groups over the last two decades as result of improved treatment.

As research increasingly addresses the roles of early life events and interactions between a variety of factors in relation to specific types of breast cancer, we may acquire significant new knowledge that lends itself to prevention.

In the meantime, it is important to focus on the bigger picture. For cultural and psychological reasons, breast cancer has a special status and is a focus of enormous anxieties and confusion. However, women should bear in mind that heart attacks kill 6 times more women than breast cancer does. We have identified more modifiable risk factors for heart disease than for breast cancer.

These include: serum cholesterol level, high blood pressure, smoking, obesity, and sedentary behavior.

Owing in large part to changes in these risk factors, heart disease rates have declined dramatically over the past 50 years. And a heart-healthy pattern may also carry benefits for breast cancer risk. ■

5. Integrate “big data” science into the practice of epidemiology.

Here the authors are clear about the challenge and how much needs to be learned. “The unquestionable reality of 21st century epidemiology is the tsunami of data spanning the spectrum of genomic, molecular, clinical, epidemiologic, environmental, and digital information…we currently do not have a firm grasp on how to systematically and efficiently tackle the data deluge.”

6. Expand knowledge integration to drive research, policy, and practice.

What is knowledge integration? It involves managing information from different sources, systematically synthesizing that knowledge, and using that knowledge in engaging stakeholders and in creating influence on policy and practice. In short, knowledge integration means making more effective use of what we know by interacting differently with data and with the persons responsible for making things happen with data.

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- Recommendations continued from pg 8

-VA continued from page 1

7. Transform training of 21st century epidemiologists.

of Public Health at the Department of Veterans Affairs, in testimony before the Veterans Affairs Committee of the US Congress on March 13, 2013. According to our sources, fellow researchers at the VA think Coughlin has been “very courageous” in making his stand on these issues.

What is a 21st century epidemiologist?

According to the authors, it is someone with a problem-solving, action-oriented approach. It is someone who does not leave the translation of research results to others. In short, a 21st century epidemiologist is one who is a truly applied scientist. This call for action is reminiscent of the call for a new subspecialty in epidemiology issued

by David Dowdy and Madhukar Pai in a paper published in Epidemiology last year. The paper was covered in an article in the October 2012 issue of The Epi Monitor.

8. Optimize the use of resources for epidemiologic studies.

Here the authors call for researchers to be more resourceful and practice the art of bricolage, a French word which Webster defines as construction (as of a sculpture or a structure of ideas) achieved by using whatever comes to hand. The authors call it “creativity under constraints”.

At the same time, funding agencies need to maximize the use of resources in a time of fiscal constraint. Part of this recommendation involves jettisoning research studies which are not being productive to make room for funding new ones, creating new funding mechanisms, producing more enlightened review teams, and creating the incentives for researchers to behave differently in more productive ways. ■

Second Epidemiologist Also testifying with Coughlin was Baylor University epidemiologist Lea Steele who has worked on Gulf War Illness for many years and served as Scientific Director for the Research Advisory Committee on Gulf War Illnesses. In her testimony, Steele said, “…in some sectors within VA, there appears to have been backward movement, with actions that seem intended to ignore the science and minimize the fact that there is a serious medical condition resulting from military service in the 1991 Gulf War.” She also stated that “Together, VA’s poor representation of the Gulf War illness problem, and failure to apply current scientific knowledge to develop a focused, state-of-the-art research program, have led to relatively little in the way of tangible benefits for ill Gulf War veterans.

From my perspective as a scientist who has worked in this area for many years, it is time to get this right…”

“it is someone with a problemsolving, actionoriented approach”

“it is time to get this right…”

Case Definition Gulf War Illness is the term commonly used for the symptomatic condition that affects military personnel who served in the 1990-91 Gulf War. At least one in four of the -VA continues on page 10

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-VA continued from page 9 700,000 military personnel who served in the war are affected, according to the Department of Veterans Affairs.

VA Testimony

“appropriate follow-up care by a trained mental health professional varies widely across these studies”

At the same session, Dr Victoria Davey, Chief Officer, in the Office of Public Health and Environmental Hazards at the VA did not address in her testimony the statements made by Coughlin and Steele.

However, she told the Committee “We remain committed to providing evidence-based, compassionate care for these Veterans, and for all of the Veterans it is our privilege to serve.

VA intends to continue our ongoing efforts to improve our abilities to provide health care for Gulf War Veterans; to better educate our health care providers; and to expand the evidence basis for the treatments we provide Gulf War Veterans, and all Veterans.”

experiencing pronounced psychiatric distress receive appropriate followup care by a trained mental health professional varies widely across these studies.

For example, in the National Health Study for a New Generation of US Veterans, which reached out to more than 60,000 US Veterans (20% women), only about 5% of nearly 2,000 men and women who selfreported suicide ideation ever received a call back from a study clinician. Some of those research participants are now homeless and deceased. The Cooperative Studies Protocol CSP Biorepository and Gulf War Survey initiative is currently reaching out to 100,000 Veterans who served in the first Gulf War. Although the majority of US Veterans are not "vulnerable," it is clear that many do have profound life challenges due to neurologic illness or injury, and other medical and psychiatric conditions.

Ethical Failures

“I can tell you that 9 to 10% self-report that they are having thoughts that they would be better off dead”

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In an email to epidemiology colleagues following his testimony, Coughlin wrote about another concern of his, namely the responsibility of VA researchers to provide access to care for medical problems they encounter in the course of doing their research.

Coughlin has tangled with the VA on that score as well.

According to Coughlin, “the VA currently has ongoing large scale epidemiologic studies that involve hundreds of thousands of US service men and women and US Veterans; the safeguards for ensuring that vulnerable men and women who are

As a former Principal Investigator and co-investigator on large-scale, national epidemiologic surveys involving tens of thousands of US Veterans, I can tell you that 9 to 10% self-report that they are having thoughts that they would be better off dead, and that much more needs to be done to help these men and women who fought in a war, came home, and are now unemployed, sick, at-risk of homelessness, and in many cases "falling through the cracks."

Call for Consideration Coughlin told colleagues that the -VA continues on page 11

- VA continued from page 10 Gulf War Veterans advocates who attended the Congressional panel stated that they feel that the epidemiology profession should examine these important issues and look inwardly about what happened and how to improve the situation in the future. I agree with that viewpoint which is why I am writing to you with this summary information, so that you can share it with potentially interested colleagues.”

Steele told the Monitor that the scientific research and results produced by Coughlin’s former office at the VA corroborate some of his individual allegatons, specifically in relation to Gulf War illness research.

For example, a current national survey targeting 30,000 Gulf War veterans dos not include a symptoms inventory that would permit the study of Gulf War Illnes in a survey involving 30,000 veterans. A committee which had reviewed the study protocol had been very critical of the study and had advised the VA to include such an inventory. It was not done.

In interviews with media, Coughlin was even more outspoken about the deficiencies he says he witnessed. For example, in an interview with the Daily Beast, Coughlin said his bosses intimidated him every time he spoke about any alleged unethical activity.

When he went over their heads, “that’s when all hell broke loose,” he told the Daily Beast. “My supervisors tried to remove me from the study, and I received a written admonition. It was shocking. All I was trying to do was help ensure the safety of veterans participating in our study.”

The VA is reportedly investigating and says that all allegations of malfeasance are taken seriously and investigated fully. ■

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“When he went over their heads, “that’s when all hell broke loose”

i.e. in lesser time: cholera kills in a week, while tuberculosis may take years to kill; thus, the incidence of mortality from cholera is larger. However, of all people with clinical signs and symptoms of cholera, fewer die of that disease than of all people who develop clinical tuberculosis; thus the ultimate risk of cholera is less than that of tuberculosis.[Farr, 1838] Even today, the distinctions that Farr made - far ahead of his time - continue to give rise to confusion.[Vandenbroucke 2004]. http://tinyurl.com/cwvu9w5

#3 How To Set Up Comparisons Walter discusses case series, cohort, case-control, randomized trial, and other designs in this essay. Here is Walter’s introduction to case-control design Recognizing the practical difficulties of carrying out cohort studies, an alternative design which may be more efficient is often used. This alternative is known as the case-control method.[LaneClaypon, 1926],[Stocks and Karn, 1933],[Lombard and Doering, 1928] In this approach, epidemiologists compare people who have already developed disease (the cases) with other people known as controls - who do not have the

“Even today, the distinctions that Farr made - far ahead of his time continue to give rise to confusion.”

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“despite these best efforts, it remains true that many factors studied by epidemiologists are inherently hard to measure”

disease. So, for example, if we were interested to identify risk factors for breast cancer, [Lane-Claypon, 1926] the casecontrol method would identify a series of cases, such as all newly diagnosed breast cancer who are admitted to a hospital within a certain time period. Additionally, the controls would be selected in some way as a a comparison for the breast cancer cases. These controls might be drawn from people who were admitted to the same hospital for some other reason, or sampled from the general community.

The idea is that these control persons should reflect the ‘exposure that the cases would have had, if they had not become diseased’ - i.e., the expected distribution of exposure in the general population. http://tinyurl.com/bv46xv4

#4 Errors In Measurements and Comparisons The sample here is Walter’s conclusion for the essay

“Most people carry with them a relatively simple and intuitive interpretation of causality”

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In designing and executing research studies, epidemiologists must be aware of the many errors in measurements, comparisons and analysis that might affect their results. As we have seen, random errors of measurement tend to obscure the picture in the data, and consequently study results will tend to be imprecise.

Systematic errors of measurement may cause bias in the distribution of observed data values, and may also lead to biases when making comparisons between study groups. Other general categories of bias exist, such as selection bias,[ Hernan et al, 2004] which can occur if the groups of people being compared differ in some systematic way that affects the study outcome. For instance, in evaluating the risks of diseases or death in an occupational group, it would be

inappropriate to compare people working in a certain industry with the population at large; the reason for this is the socalled “healthy worker effect”, which is the fact that individuals who are working in any occupation are generally more healthy than those not working.Epidemiologists respond to these challenges by trying to design measurement instruments that have good measurement properties, so that they are easily understood and interpretable, and give reliable and accurate answers. They also pay considerable attention to making sure that data analyses involving group comparisons do not suffer from the bias problems we have identified. Finally, they try to ensure that study sample sizes are sufficiently large that the problem of statistical uncertainty in the results is reduced. However, despite these best efforts, it remains true that many factors studied by epidemiologists are inherently hard to measure, and furthermore their associations with health outcomes may be only moderate or weak. This ultimately can lead to continuing uncertainty about the study findings. In such cases the epidemiologist must try to determine what additional evidence would be required to eliminate the uncertainty and arrive at more definitive conclusions. http://tinyurl.com/abc3zej

#5 What Do Epidemiologists See As Causes?

In this sample, Walter’s discusses intuitive ideas about causality in the first two paragraphs, and a second excerpt presents the final paragraph of this section Most people carry with them a relatively simple and intuitive interpretation of causality, but nevertheless one which is -Essays continues on page 13

- Essays continued from page 12 quite useful in practice. When they observe that an outcome follows some particular exposure or event, and they believe that the outcome would not have occurred without the prior exposure or event, they conclude that the outcome was “because of” the exposure, or that the exposure “caused” the outcome. For instance, if there is a head-on traffic traffic collision and all the passengers are found dead at the scene, one would probably conclude that the accident “caused” the deaths of those individuals.

Implicitly, we are saying that had the accident not occurred those people would not have died.

This kind of logic is known as counterfactual causation. We observe that A (the accident) preceded B (the deaths) and we imagine that failure to observe A would also have led to a failure to observe B. Unfortunately, simple conclusions like this may not be adequate. In the traffic accident example, suppose that the drivers had been drinking, or that the road surface was icy. Suppose one car was full of noisy teenagers playing the radio at high volume and distracting the driver, while the driver of the other car was trying to locate his cell phone in his pocket and answer it. While initially we thought that the accident caused the deaths, now we are not so sure. Perhaps it is a combination of risk factors that might be thought of as responsible for the accident itself and hence for the deaths.

We will discuss the problems of separating the effects of several possible causes in the final essay of this series. …As we have seen, epidemiologists are usually not able to adopt the ideal experimental approach to causality, nor even a very approximate experiment, because they cannot control or dictate who is or is not exposed to risk. And even if randomisation of exposure is possible, the results of randomised studies may still not provide adequate evidence of

causality. Instead, epidemiologists must observe people in their day-to-day lives, but without artificially exposing them to risk. While this considerably considerably complicates the causal interpretation of epidemiologic data, such a challenge is also one of epidemiology’s greatest strengths. By studying these issues in the the real world outside the laboratory, epidemiologists are confronting health problems in the most relevant way for human populations.

“epidemiologists are confronting health problems in the most relevant way for human populations”

http://tinyurl.com/afy64pq

#6 How To Deal With Multiple Causes This short excerpt explains confounding and gives the Latin root of the term.

A further major difficulty that confronts epidemiologists in many cases is that the exposure to various risk factors may be correlated in the population. For instance, persons who smoke may be less likely to engage in regular activity. Both smoking and the lack of physical activity are risk factors for heart disease, so it becomes a difficult task to determine which of the two factors might be more or less responsible for cases of disease. This phenomenon of correlated exposures is known as confounding. “Confounding” come from the Medieval Latin word “con-fundere” which meant “pour together.” In a certain sense, the two potential causes are ‘poured together’ and it becomes difficult which is the real agent and which is not. This leads often to confusion, which, amusingly, in the English language is linked to the other meaning of the word “confounding”, like in “Confound Thy Enemies”, which means, bring your enemies in a state of utter confusion.

“Confounding” come from the Medieval Latin word “confundere” which meant “pour together.”

http://tinyurl.com/abmt5hp ■

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CHAIR, PUBLIC HEALTH SCIENCES “What does it take to find the career of a lifetime—Medicine of the Highest Order” The University of Rochester School of Medicine and Dentistry invites applications and nominations for the position of Chair in the Department of Public Health Sciences. The Department is a vibrant, multidisciplinary group, including approximately 25 full-time faculty members and over 35 jointly-appointed faculty members from other Departments representing many disciplines. All enjoy close collaborations with faculty and programs across the Medical Center and region. Departmental divisions include epidemiology, health policy and outcomes research, social and behavioral sciences, and healthcare management. Supported by 28 grants totaling approximately $6.5 million annually from the NIH, AHRQ, HRSA, New York State DOH, and other public and private sources, Department faculty have diverse research foci including: viral-induced lymphomagenesis; impact of air pollution on reductions in birth in Beijing; quality of care for cardiac patients; end-of-life care outcome measures in nursing homes; HIV risk reduction; tobacco control in the Dominican Republic; cardiovascular risks in the deaf population; breast feeding; and aging-related biodemography among others. Educational activities include three master’s programs (MPH, MS in Clinical Investigation and MS in Clinical Translational Research), two doctoral programs (PhD in Epidemiology and PhD in Health Services Research and Policy), two postdoctoral programs (in Preventive Cardiology and Health Services Research and Policy) and an ACGME-accredited residency in General Preventive Medicine and Public Health. Department faculty members also play key roles in teaching medical students and undergraduate students in the University’s Public Health-related programs. The Department, centrally located in a new translational research building, works closely with the medical school’s Clinical and Translational Science Institute and with its Center for Community Health. The Department also benefits from the broader resources of the Medical Center and a wide array of community-based, regional, and national and international collaborations.

We seek candidates with a strong record of scholarship in a field relevant to public health, as well as experience in teaching and mentorship. Candidates should have the outstanding leadership skills required to promote collaboration and excellence in research, education, and community partnerships, and to foster programmatic growth in a medical center and university environment that prizes teamwork, innovation, and mentorship. The candidate must have a doctoral degree in a relevant field and qualify for appointment as Professor at the University of Rochester.

Applicants should apply on line at www.rochester.edu/jobopp, job number 178879, and forward their cover letter and curriculum vitae to Jeffrey Lyness, M.D., Senior Associate Dean for Academic Affairs at jeffrey_lyness@urmc.rochester.edu. Phone number is 585-275-6321 The University of Rochester has a strong commitment to principles of diversity and, in that spirit, actively encourages applications from groups underrepresented in higher education

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The University of New Mexico Health Sciences Center, Department of Internal Medicine, seeks a faculty member to serve as Chief of the Division of Epidemiology, Biostatistics, and Preventive Medicine. This position is at the Associate or Full Professor rank and open track. Salary and rank will be commensurate with experience and education.

Minimum Requirements: (1) a Ph.D. in Epidemiology, Biostatistics, Health Services or a closely related field or M.D. with post-graduate training in Epidemiology, Biostatistics, Health Services or a closely related field (2) peer-reviewed research publications in Epidemiology, Biostatistics, Health Services or in a closely related field (3) record of extramural funding and peer-reviewed publications in Epidemiology, Biostatistics, Health Services or closely related field; 4) must be eligible to work in US. Desirable Qualifications: 1) experience mentoring junior and midcareer researchers; 2) demonstrated administrative leadership experience; and 3) experience developing education and training programs in epidemiology, biostatistics, health services or preventive medicine.

For best consideration apply by February 28, 2013; however, the position is open until filled. For complete description and application requirements for posting # 0819280 please see the UNM jobs application system at: https://unmjobs.unm.edu. Inquiries may be directed to Edward J. Bedrick, Ph.D. Division of Epidemiology, Biostatistics, and Preventive Medicine, Department of Internal Medicine, University of New Mexico ( EBedrick@salud.unm.edu ).

Cancer Epidemiologists The Dan L. Duncan Cancer Center at Baylor College of Medicine in Houston, Texas is seeking cancer/molecular epidemiologists at all academic levels. The Center has considerable resources to expand the program in Cancer Prevention and Population Sciences, and the successful candidates will have an important role in the continued growth of this program. The individuals will have the opportunity to collaborate with other epidemiologists, geneticists, biologists, and clinicians in the Cancer Center and its affiliated hospitals. Previous research experience, history of successful peer-reviewed grant funding, and a relevant publication record are required. The candidate will be expected to develop an independent research program with peer-reviewed funding Salary and start-up package will be commensurate with qualifications and prior experience. Interested candidates should submit curriculum vitae, a summary of past work, a brief outline of future plans, and the names of at least three individuals who will provide letters of support. Open until filled.

Applications: Melissa Bondy, Ph.D., Associate Director for Cancer Prevention and Population Sciences Program, Baylor College of Medicine, One Baylor Plaza, BCM 600, Houston, Texas 77030 or email to mbondy@bcm.edu.

Baylor College of Medicine is an Equal Opportunity/Affirmative Action/Equal Access Employer.

Executive Director Position Summary Public Health Director and Medical Officer of Tri-County Health Department (“TCHD”), the district public health agency for the Counties of Adams, Arapahoe and Douglas, pursuant to the provisions of C.R.S. 25-1-501, et. seq. Serves as the chief administrator who is responsible for the overall operation of TCHD.

Education & Experience Requires graduation from an approved school of medicine and completion of residency in a board-recognized specialty such as primary care or preventive medicine. At least ten years' progressive experience in public health, community medicine, and/or preventative medicine. Must have at least five of the last ten years experience in a high level administrative or management position for a health department or similar agency, including experience in supervising public health professionals.

Licensed to practice medicine in Colorado.

Apply: http://www.tchd.org/jobs.htm for a full job description. Please submit cover letter, curriculum vitae, application and three references to the Office of Human Resources at: humanresources@tchd.org

Asst / Assoc Professor – Epidemiology The University of Kentucky College of Public Health Department of Epidemiology is recruiting candidates for tenure-track regular title series faculty positions at the Assistant or Associate Professor level, depending on experience, scholarly record, and external funding history. These full-time 12-month tenure-track appointments in the College of Public Health.are to fulfill the College and University missions of research, teaching, and service. Teaching responsibilities include both core and specialty courses in the Department of Epidemiology, designed to prepare students who are working towards MPH, DrPH, and PhD degrees. Teaching may also include undergraduate teaching in a developing Bachelor’s in Public Health degree. Responsibilities also include student advising, curriculum development, and serving on capstone, thesis, and dissertation committees. The successful candidates will be able to demonstrate a strong potential for or established record of excellence. The candidates will be expected to establish collaborations with colleagues across departments, colleges, and universities. The person selected for this position will serve on appropriate committees and professional organizations on a local, regional and national level, and appropriate departmental, College of Public Health and University committees. Qualifications include PhD, DrPH, or ScD. in Epidemiology from an accredited school or college of public health or equivalent training To apply, send a CV, contact information for three references, and one copy of at least three recent or representative publications to: Wayne T. Sanderson, PhD, University of Kentucky College of Public Health, Department of Epidemiology, 111 Washington Avenue, Lexington KY 40536-0003 or e-mail wayne.sanderson@uky.edu .

AA/EOE Employer.

New Endowed Faculty Position In Violence Epidemiology University of California, Davis, School of Medicine The Violence Prevention Research Program in the Department of Emergency Medicine is seeking to fill a faculty position at the Associate or Full Professor in Residence level. Its focus is on the design and execution of large-scale observational and experimental research into violence and its prevention. This faculty member will serve as VPRP’s Associate Director and as the Vice Chancellor’s Chair in Violence Prevention, an endowed position.

The Vice Chancellor’s Chair will conduct independent research, collaborative research, teaching, and mentoring. Applicants must possess a doctoral degree in epidemiology, medicine, or a related discipline. There must be an established record of independent and collaborative research on violence or injury, including demonstrated experience in the design, conduct, and reporting of large-scale observational and/or experimental studies. The position is open to both clinicians and non-clinicians.

Please see the full announcement at: http://tinyurl.com/c3zswp5 Review of applications will begin in March 2013 and will continue until position is filled. Applicants should send a cover letter outlining their qualifications and areas of interest; a CV; and contact information for five references to Garen J. Wintemute, MD, MPH, at gjwintemute@ucdavis.edu .

Biostatistician The National Academy of Sciences seeks a scientist to fill a biostatistics position at the Radiation Effects Research Foundation (RERF) in Hiroshima, Japan.

Primary responsibilities are statistical consulting on the design of radiation research protocols and analysis of research data in consultation with RERF epidemiologists, clinical researchers, and laboratory scientists, with additional independent research on related statistical methodologies and applications.

Please visit: http://tinyurl.com/6umootf EOE, M/F/D/V

Opportunities This Month 14 – Rochester / Chair, Public Health Sciences 15 – Geisinger / Dir – Epidemiology Research 16 – U. NM / Division Chief 16 – JHSPH/ Graduate Summer Program 17 - Baylor / Cancer Epidemiologists 17 - UK / Asst – Assoc Prof. Epi 17 - Tri-County / Executive Director 17 – UC Davis / Faculty – Violence Epi 18 - UTMB / PostDoc Womens Repro Hlth 18 - NAS / Biostatistician 18 - Emory / Career MPH 19 - U MI / Epi Summer Program 20 - Harvard SPH / Asst – Assoc Prof 20 - Harvard SPH / Prof Pop & Fam Hlth

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Assistant or Associate Professor of Global Maternal and Child Health

Professor of Population and Family Health/Professor of Demography

The Department of Global Health and Population invites applications for a tenure-track faculty position. The department wishes to conduct research on the epidemiology of maternal and child health including neonatal health, infectious diseases, and nutrition. The successful candidate will be expected to play a central role in the department's research and teaching programs in low and middle-income nations.

Candidates should hold a doctoral degree in epidemiology, demography, or related public health discipline.

The Department of Global Health and Population invites applications for a tenure-track faculty position. The department wishes to expand its research efforts on the demographic and epidemiologic patterns in low- and middleincome countries (including aspects of mortality, fertility, and migration), and the design and evaluation of large-scale implementation programs addressing maternal and child health, family planning, or other substantive areas of major significance in global health. Candidates should hold a doctoral degree in demography, epidemiology, or a related population science discipline.

More Info: http://tinyurl.com/d4hpe95 More Info: http://tinyurl.com/d4hpe95