October 2014 the epidemiology monitor final

Epidemiologists Speak Out About The Transmissibility Of Ebola And Adequacy Of Control Measures

In This Issue

CDC Director Sees Positive Developments In Controlling Ebola But A Long Hard Fight Ahead

-3Goal to Save 17M Lives

“Transmission I think is the ultimate boogey man in the United States for a lot of people,” said one reporter at a CDC press conference characterizing the dramatic increase in the level of US public concern or anxiety about the transmissibility of Ebola.

Dissecting this public concern in greater detail, Columbia University epidemiologist Abdulrahman El Sayed told New York Magazine “Ebola’s the kind of disease that zombie movies are made out of…It’s the kind of thing where if you’re not

close to the science and don’t understand the epidemiology of it, it’s a very scary-sounding disease — you bleed all over the place, it kills more than 50 percent of the individuals who contract it, it’s spreading like wildfire in West Africa.”

The increase in public concern follows the occurrence of the first imported and spread cases in Dallas Texas, and the first spread case in Europe in a Spanish nurse who cared for an - Ebola continues on page 2

Tony McMichael, Farsighted Champion Of Climate Change / Health Research, Dies At Age 71 Many epidemiologists, particularly those who had just heard him give the keynote address at the International Epidemiological Association meeting in Anchorage Alaska in August, were surprised and saddened to learn of the passing of Tony McMichael in Australia on September 26.

McMichael was widely recognized in epidemiology and public health as the voice on the real and potential

adverse health effects of climate change. His obvious dedication to the issue was always something his colleagues appreciated, even if they did not free themselves from studying traditional public health problems to undertake some of the urgent research which McMichael called for.

- McMichael continues on page 8

-11Reprint of McMichael Interview

-4"Today, Ebola is Winning" -Doctors Without Borders

October 2014 Volume Thirty Five Number Ten

-Ebola continued from page 1 The Epidemiology Monitor ISSN (0744-0898) is published monthly (except August) by Roger Bernier, Ph.D., MPH at 33 Indigo Plantation Rd, Okatie, SC, 29909, USA. All rights reserved.

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Ebola patient. These US and European experiences reveal potential inadequacies or shortcomings in airport screening programs or breakdowns in the recommended safety protocols for handling infected persons in hospitals. With public alarm running at high levels, the US has announced it will begin screening at selected US airports and providing additional training to hospital staff.

Epidemiologists On The Spot Epidemiologists seemingly everywhere are being asked about the disease, the risks it may pose, and the adequacy of control strategies. The answers have in some cases been encouraging and reassuring while other statements have raised concerns even further.

Robert Haley, chief of epidemiology and professor of internal medicine at UT Southwestern, played down the risk of spread to the general public in a radio interview in Dallas. “I don’t know if we can limit it to one case because his family, the people who were in the home with him over the last several days before he came in, they are at grave risk…There may be some additional cases in the family but they are now under quarantine or surveillance by the local health department. If any of those become ill, they’ll be carefully controlled. So it won’t spread beyond them…There could be an ER person or maybe an ambulance driver who would possibly come down with it. I would be very surprised because our hospital workers and paramedics are

very well trained to protect themselves. If they develop fever they will immediately go to hospital and not be infectious to others.” [Ed: This has now occurred in Dallas with the first spread case to a nurse].

More Reassurance Oklahoma state epidemiologist Kristy Bradley said “We do understand it’s a scary disease…But we want people to understand it’s not spreading anywhere in the United States…The likelihood that anyone in Oklahoma would be exposed is not very high…If an Oklahoman did not travel to Liberia, Guinea, or Sierra Leone and come into contact with a person who has Ebola, they have a very low risk.”

The Good News CDC Director Thomas Frieden told the press on October 7 there are real signs of progress in controlling the outbreak both in Texas and in other parts of the world. He said the teams in Dallas carrying out contact tracing and monitoring are doing “a terrific job dealing with what is really an unprecedented situation”. In Liberia, he recounted the example of one district which had been at the epicenter of the outbreak and where cases have now plummeted possibly due to an increase in the number of isolation beds and changes in burial practices. “So even in West Africa, even in a place that [was] at the heart of the outbreak, there are signs of progress, ” said Frieden. On October 13 after announcing the spread case - Ebola continues on page 4

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Researchers Call For Setting Quantitative Health Target Of Preventing 40% Of Under Age- 70 (Premature) Deaths By 2030 Desire Is To Have Simple, Understandable, Measurable Targets What is life expectancy worldwide now? How many millions of deaths occur in the world each year? Are they increasing or decreasing? How many of these deaths are preventable? These are some of the topics which have engaged the authors of a recent paper in The Lancet.

Driven by the value of setting plausible goals and the fact that death in old age in inevitable but death before old age is not, researchers writing in The Lancet in September provide analyses of decreasing national mortality trends which they hope will influence the United Nations in setting disease and death reduction targets for the next round of international development goals. The current set of goals, called the Millenium Development Goals is set to expire in 2015 and will be replaced by a new set of Sustainable Development Goals. (see related article for a list of these proposed goals).

Past Achievements 2000-2010 Lead author Ole Norheim of Norway and epidemiology and public health colleagues from around the world reported that between 2000 and 2010, proportional decreases in death rates fell by 13-34% depending on the age group. The largest decrease took place in the 0-4 year age group.

Comparing causes of death, rates fell by 30% for communicable, perinatal, maternal, or nutritional causes, by

14% for non-communicable diseases, and by 13% for injuries.

According to Richard Peto, one of the co-authors, “In all major countries, except where the effects of HIV or political disturbances predominated, the risk of premature death has been decreasing in recent decades, and it will fall even faster over the next few decades if the new Sustainable Development Goals get the big causes of death taken even more seriously.”

The authors of the Lancet paper make the important points that if targets are to be pursued seriously, progress towards them needs to be measured.

Also, the measures need to be robust and easy or simple to communicate.

In the paper in The Lancet, the authors propose giving greater definition to the current health goal which is currently formulated as “Ensure healthy lives and promote well-being for all at all ages.” The Lancet authors call for the broad health goal to be accompanied by a specific target to avoid 40% of all premature deaths in each country (that is 40% of the deaths that would occur in the 2030 population of that country, if its 2010 death rates continued). The 40% target is considered feasible, according to Peto writing also in Science in September, because it would “…reinforce current successful efforts to reduce maternal and child mortality and death from HIV, tuberculosis, malaria, and other communicable diseases, but would also require - Death continues on page 5

"...death in old age in inevitable but death before old age is not...”

"... the risk of premature death has been decreasing in recent decades..."

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- Ebola continues from page 2 in Dallas, Frieden reiterated that "we know how to stop Ebola" and he is confident we will stop Ebola in the US.

“...the current epidemiologic outlook is bleak."

"Today, Ebola is winning.”

Halting Spread In Africa Likewise, a report from the World Health Organization about the interruption of Ebola transmission in Telimele district of Guinea provides an example local success in halting spread. Some of the interventions carried out were creating a treatment center close to the population, obtaining WHO experts to provide technical support, constituting a local crisis committee which delivered one strong message—come early for treatment you survive; you come late—you die, and allowing loved ones to talk to patients from a distance. Also religious and traditional leaders worked together to quell rumors, and a contact tracing team on motorbikes cruised throughout the district. The mortality rate locally was 38% which appears to be much lower than in other parts of Guinea, and cases have ceased in the area while continuing elsewhere in Guinea.

Success in Nigeria and Senegal Also encouraging are the reports from Nigeria and Senegal which each had imported cases. According to WHO, both countries faced many difficult challenges yet now have achieved good prospects for success. No new cases have been reported for almost 6 weeks which is the time period required to be considered disease free (2 times the 21-day incubation period).

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The Bad News Other epidemiologists provide less encouraging assessments. A NEJM paper on September 23 concluded that “the current epidemiologic outlook is bleak. Forward projections suggest that unless control measures— including improvements in contact tracing, adequate case isolation, increased capacity for clinical management, safe burials, greater community engagement, and support from international partners—improve quickly, these three countries [Liberia, Sierra Leone, and Guinea] will soon be reporting thousands of cases and deaths each week…” They add that there is the possibility that Ebola could become endemic in West Africa and this prospect calls for “forceful implementation of present control measures.”

Ebola Is Winning Other voices continuing to raise alarm include that of Doctors Without Borders. Its international director told the UN in late September “…the promised surge has not yet delivered…Fear and panic have set in, as infection rates double every three weeks. Mounting numbers are dying of other diseases like malaria because health systems have collapsed…Today, Ebola is winning.”

Admitting Defeat in Sierra Leone A discouraging news report in the NY Times on October 10 described the situation in Sierra Leone where a decision had been taken to distribute kits to help families tend to patients at home because the treatment centers are overwhelmed and cannot meet the - Ebola continues on page 8

-Death continued from page 3 serious and successful efforts to substantially reduce accidents and NCD mortality.”

Serious Extra Effort Required Nordheim said “we are going to need improved health care, intensified international efforts to control communicable diseases, and more effective prevention and treatment of non-communicable diseases and injuries. He called these efforts “realistically moderate improvements in current trends” and said the target is realistic where deaths are not dominated by new epidemics, political disturbances, or disasters.

Making these points at this time is important because the United Nations is in the process of setting new ambitious Sustainable Development Goals for the period 2016-2030 which will replace the Millenium Development Goals expiring in 2015.

The Lancet authors consider some of the draft goals to be implausible and they wish to add an overarching numerical target that could with serious extra effort be feasible by 2030 or the 2030s. Commentators on the Lancet article urged the medical community to develop a common position that can help the international community arrive at a single health goal with a limited number of simple, understandable, and measurable targets.

In their Lancet conclusion, the authors provide the estimated numbers of lives saved if the goal could be achieved. They state, “if achieved, these reductions avoid about 10 million of the 20 million deaths at ages

0-49 years that would be seen in 2030 at 2010 rates, and about 17 million of the 41 million such deaths at ages 0-69 years…”

The currently proposed draft of Sustainable Development Goals including the goal for health and its subgoals are listed in abridged form in the following article and are available in entirety at: http://tinyurl.com/nasnrsy The broad health target and four global subtargets for health proposed

by Nordheim and colleagues are: Target: Avoid in each country 40% of premature deaths (that is under-70 deaths that would be seen in the 2030 population at 2010 death rates) AND improve health care at all ages.

Sub-targets: 1. Avoid two-thirds of child and maternal deaths.

2. Avoid two-thirds of TB, HIV, and malaria deaths.

3. Avoid one-third of premature deaths from non-communicable diseases.

4. Avoid one-third of deaths from other communicable diseases, undernutrition, and injuries.

"... if achieved, these reductions avoid about 10 million of the 20 million deaths at ages 0-49 years that would be seen in 2030 at 2010 rates, and about 17 million of the 41 million such deaths at ages 0-69 years…"

Achieving these subtargets would translate into halving under 50 deaths and avoid a third of the deaths at 50-69 years and altogether avoid 40% of under-70 deaths. ■

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Proposed Sustainable Development Goals for 2016-2030 Being Considered

By The United Nations Goal 1. End poverty in all its forms everywhere Goal 2. End hunger, achieve food security and improved nutrition, and promote sustainable agriculture Goal 3. Ensure healthy lives and promote well-being for all at all ages Goal 4. Ensure inclusive and equitable quality education and promote life-long learning opportunities for all Goal 5. Achieve gender equality and empower all women and girls Goal 6. Ensure availability and sustainable management of water and sanitation for all Goal 7. Ensure access to affordable, reliable, sustainable, and modern energy for all Goal 8. Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all Goal 9. Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation Goal 10. Reduce inequality within and among countries Goal 11. Make cities and human settlements inclusive, safe, resilient and sustainable Goal 12. Ensure sustainable consumption and production patterns Goal 13. Take urgent action to combat climate change and its impacts* *Acknowledging that the UNFCCC is the primary international, intergovernmental forum for negotiating the global response to climate change .

Goal 14. Conserve and sustainably use the oceans, seas and marine resources for sustainable development Goal 15. Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss Goal 16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels Goal 17. Strengthen the means of implementation and revitalize the global partnership for sustainable development

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- Goals continues on page 7

-Goals continued from page 6

Health Goal in More Detail Goal 3. Ensure healthy lives and promote well-being for all at all ages 3.1 by 2030 reduce the global maternal mortality ratio to less than 70 per 100,000 live births 3.2 by 2030 end preventable deaths of newborns and under-five children 3.3 by 2030 end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases 3.4 by 2030 reduce by one-third pre-mature mortality from non-communicable diseases (NCDs) through prevention and treatment, and promote mental health and wellbeing 3.5 strengthen prevention and treatment of substance abuse, including narcotic drug abuse and harmful epidemiology. use of alcohol 3.6 by 2020 halve global deaths and injuries from road traffic accidents 3.7 by 2030 ensure universal access to sexual and reproductive health care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes 3.8 achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all 3.9 by 2030 substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination 3.a strengthen implementation of the Framework Convention on Tobacco Control in all countries as appropriate 3.b support research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration which affirms the right of developing countries to use to the full the provisions in the TRIPS agreement regarding flexibilities to protect public health and, in particular, provide access to medicines for all 3.c increase substantially health financing and the recruitment, development and training and retention of the health workforce in developing countries, especially in LDCs and SIDS 3.d strengthen the capacity of all countries, particularly developing countries, for early warning, risk reduction, and management of national and global health risks http://tinyurl.com/nasnrsy â–

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-McMichael continued from page 1

" I share the universal sorrow felt by all epidemiologists everywhere at this untimely death.."

McMichael’s work was devoted to helping others both inside and outside of epidemiology and public health to grasp what he had come to see so clearly, namely the underlying importance of a sustainable environment as a key determinant of population health. He saw this early in his career when he began a weekly column for an Australian newspaper entitled “Spaceship Earth.”

Tributes Tributes to McMichael have already mushroomed into dozens of written appreciations of him both personally and professionally. On a site dedicated to honoring his memory, there is a two part obituary, one a conventional description of his academic achievements and a second devoted to tracing the trajectory of his career, including comments and

-Ebola continued from page 4

"The truth is that we are failing miserably at containing Ebola…"

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need. A similar distribution effort was planned for Liberia where even more people are dying from the disease, according to the Times report.

Modern Tragedy Epidemiologist Mike Osterholm from the Center for Infectious Disease Researh and Policy has written on September 30 that “Ebola is spreading faster than anyone would like to admit, and the current slow international response to the deadly disease is morphing into a modern tragedy…The truth is that we are failing miserably at containing Ebola…

tributes left by his colleagues surprised and saddened by his untimely passing. [http://tinyurl.com/pwjwfzd] We include here excerpts from the comments of colleagues.

From John Last I share the universal sorrow felt by all epidemiologists everywhere at this untimely death, although I am not shocked because he confided in me years ago that he was living on borrowed time, and on a kidney transplanted from his wife Judith.

Tony had congenital renal disease.

I first met him briefly when he was still a medical student, introduced to him by his mentor Basil Hetzel. I got to know him well when he was a - McMichael continues on page 9

Slow Speed Response The essence of criticisms is not with the control strategy but with the slow speed of the response which has so far not been rapid enough to get ahead of the virus. A worst case scenario is that the outbreak will remain out of control long enough to spread even further to other countries and create even more of a catastrophe. According to Osterholm, an international coordinated plan to respond to this even greater potential outbreak is needed as are urgent efforts to produce millions of doses of a vaccine that could be administered broadly in Africa. He called for mobilizing people and resources on a massive scale. ■

-McMichael continued from page 8

From Conor Kretsch

young epidemiologist, and our professional interests coalesced around the most urgent crisis of our time, the unsustainable pressure of human predation on ecosystems and environments everywhere on our fragile planet… It would be hard to find anyone with the same breadth of scholarship, the same degree of knowledge and understanding of the dangers facing life on earth, the same clear vision of contributions epidemiologists can make to finding solutions, to making the world a better, happier place for humans and other living creatures.

As someone who is a relative newcomer to the arena of environment and health, I have been greatly influenced and educated by his work and writings. But more so, I have been influenced by his demeanour. He was never anything other than forthcoming and kind in his responses to my queries, never unwilling to engage, and always encouraging. I have often said that one of the reasons I love my work is that there are so many wonderful people involved whom I get to meet; perhaps there is just a shared empathy and interest in humanity which drives some people to pursue this field of work, and to change the world for the better, and the chance to speak and work with them is fantastic. Tony McMichael was one of those wonderful people.

Tony was a warmly compassionate, charismatic man, an inspiring intellectual and moral leader. Like all who knew him, I will miss him very deeply and I mourn his loss.

From Nancy Krieger Tony’s work, as an epidemiologist, contributed in so many ways to the bettering of people’s lives and also life on this planet. He had a profound understanding of the need for deep theoretical and historical analysis of past and present conditions, always with an eye to the future, including the threats posed by global climate change, and always with an eye towards equity. I always appreciated and benefited from our exchanges (and his humor). And I have always made sure to assign his writings to my students — so that they may learn from his wisdom and insights, all as part of carrying on the work to build a more just and sustainable world.

I’m minded to think of him particularly this week – the UN biodiversity summit takes place in the Republic of Korea, and on the agenda is the issue of how health and biodiversity conservation are linked, and how they can be better integrated in sustainable development. It has taken many years of hard work to get the discussions to where they are, and while there will certainly still be much more to do when the summit closes, there have been enormous strides taken this year and at other recent UN meetings – changes in policy that can have a tangible benefit for human well-being and nature conservation. This is part of Tony’s legacy – quite simply, a chance to make a better world, and a healthier -McMichael continues on page 10

"Tony’s work, as an epidemiologist, contributed in so many ways to the bettering of people’s lives and also life on this planet."

“...have been influenced by his demeanour..."

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-McMichael continued from page 9 planet. It would have been so much harder if those of us involved were not in so many ways standing on his shoulders.

From John Vena (Received at the Epi Monitor) I will miss Tony’s soft smile, humble perspective, keen wit and superb scientific insights. I have fond memories of Tony throughout my career beginning in graduate school as I studied environmental and occupational epidemiology and read his sentinel paper on the healthy worker effect which informed my early career work on the study of the Buffalo Municipal Workers. I enjoyed many interactions and personal conversations at the International Society of Environmental Epidemiology (ISEE) annual meetings including when Tony was the plenary speaker as the John Goldsmith Award winner at the meeting in 2000 which I hosted in Buffalo, NY. The memories give me comfort as I reflect on his passing but also know that his work will continue to inspire us all.

From the health blog at Croakey Just a few days before his death, Professor McMichael was emailing colleagues about climate change and health. Colleagues have

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described him as a giant of public health, an eminent scientist, a generous mentor and a visionary leader.

A 2012 festschrift in Canberra celebrated the breadth of his career and achievements: “Professor McMichael has made seminal contributions to scientific and human understanding of the health implications of tobacco, the health risks from lead production, uranium mining, rubber production, and ozone depletion as well as climate change.

Many of those present recounted how their careers had been influenced by Professor McMichael’s’ work, particularly his seminal text: “Planetary Overload”, published in 1993, which outlined the threats to health from climate change, ozone depletion, land degradation, loss of biodiversity and the explosion of cities.

Professor McMichael’s work as a public health researcher and epidemiologist has been instrumental in the phasing out of lead in more than 100 countries; key to legal decisions to determine what constituted scientific proof in relation to harm to human health from tobacco; and profoundly influential in highlighting how the health of the natural environment and the health of the biosphere is fundamental to human health.” http://tinyurl.com/negtvds ■

Tony McMichael

Reprint Of An Interview “Spaceship Earth”--McMichael’s Vision And The Importance Of Research On Health Effects Of Climate Change [Ed. Note: The following interview of Tony McMichael was carried out by the National Health and Medical Research Council in Australia in May 2008. The following is an edited version of the interview with excerpts here selected to help understand McMichael’s vision. The full interview can be accessed at http://tinyurl.com/jwyy99j] Interviewer: Tony, I wonder if we could start with a bit of a macro view of the issue…could you just give us a picture of what the problem is that you see emerging.

Prof. McMichael: Well, I think the basic problem, that you've alluded to already, is that we really haven't got the full measure of what the significance, the impacts, of climate change, and indeed the various other global environment changes of which climate change is just part of the syndrome. We haven't got the measure of what they really signify. We've been fretting about the impact on the economy, disruption of economic activity, loss of jobs in some sectors.

We worry about the threat to tourism, to physical infrastructure, to iconic species, and those things are all important.

But I think what we haven't done is to realise that now that we've started to disrupt the world's climate system and very many other of the great natural systems that are this planet's life support system, we are actually beginning to change the conditions of

life on earth. And that's a big deal.

That's what I would regard as the most important aspect of the climate change story. And we're just now starting to realise that as we begin to see that in addition to all the other impacts that climate change has already begun to have, we can see effects on human wellbeing, human health, in some parts of the world, and we're expecting that there'll be many more in the future. It includes infectious diseases as an important part of the story, but it's only part.

There will be a whole range of adverse health effects.

"...we are actually beginning to change the conditions of life on earth. And that's a big deal."

Panel on Climate Change Interviewer: You were part of the latest report from the Intergovernmental Panel on Climate Change. And what was the statement in there about this particular area?

Prof. McMichael: Well, the evidence has been stiffening up over the last decade as slowly an increasing number of epidemiologists and others have begun to engage in this question of how might climate change affect patterns of health and disease around the world. So this time around, this was the fourth five-year cycle of the Intergovernmental Panel on Climate Change, the evidence was much broader and much stronger than it had been when I first got involved in the early 1990s when the story was -Spaceship continues on page 12

“...an increasing number of epidemiologists and others have begun to engage in this question of how might climate change affect patterns of health and disease around the world."

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-Spaceship continued from page 11

"...it was really the province of just a few marginal epidemiologists..."

really a new one and, indeed, one that wasn't much on the radar scheme for science at large, it was really the province of just a few marginal epidemiologists, who had a sense that this was going to become an important story. So we're now much more confident that we are beginning to get the measure of the risks to human health, but we also are beginning to realise that in addition to trying to model the ways in which future climate change would affect patterns of disease around the world that in fact it's already beginning to happen in some parts of the world and we've got to work among ourselves as researchers, but work with government, with policy makers, to develop risk lessening strategies, what we call adaptive strategies.

Government Response

“So it's a pretty wide spectrum of risks to health that we have to be concerned about."

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Interviewer: Now clearly governments all around the world are concerned and they need to have a response to these emerging issues.

What's your take on what governments are trying to do in terms of preparedness scenarios for the emergence of these particular problems?

Prof. McMichael: Well, I should say at the outset that of course the problem is rather wider than infectious diseases.

They capture a lot of our attention and we know that they're sensitive to climate. And it includes mundane things like food poisoning, salmonella food poisoning, also very temperature sensitive, and which we would expect to increase, particularly in poorer and more remote parts of this country. But we're also talking about the effect of

increasing frequency and intensity of heatwaves and extreme weather events. We're talking about the effect of climate change on our fresh water supplies in this country, how that's going to continue to do damage to our rural sector, our food production. We know that the disruption of productive life in some parts of rural Australia is exacerbating mental health problems. There's always the tragedy of suicide lurking in the background as farmers lose livelihoods and families get displaced. So it's a pretty wide spectrum of risks to health that we have to be concerned about.

I think it would be fair to say that up until pretty recently our governments in this country and elsewhere have been slow to realise that this is an important part of the story. There's been an undue preoccupation with protecting local economies and not enough recognition that we now face actually a threat to our wellbeing, to our health, and in some parts of the world to our survival. And I must say in this part of the world there is also increasing concern in the background that the effects of climate change, along with population pressures and depletion of fresh water aquifers, exhaustion of agricultural soils, depletion of ocean fisheries, that all of these things will add up to severe food shortages, fresh water shortages, in the region around us, causing destabilisation, most probably, increased flow of environmental refugees. It could lead to lots of tensions and conflicts. And that, of course, inevitably has a range of adverse health consequences. So, you know, it's a big picture and -Spaceship continues on page 13

-Spaceship continued from page 12 governments really need to get serious about understanding that climate change carries huge risks increasingly over the coming decades to wellbeing and health of human populations.

Research Program Interviewer: This past year you were awarded an Australian Fellowship from the NHMRC. What does that mean for you and what is the work that you're going to continue doing?

Prof. McMichael: Well, the first thing it means, of course, is it provides a wonderful opportunity for me to think within a five-year time frame in the first instance, because I have funding for that period, and it's very generous funding, so it's an opportunity to develop a full-blown program of research, particularly around the topic of climate change and human health. I must say the timing is also quite auspicious.

Just within this past 12 months we've seen really an upturn, a very dramatic upturn, in awareness that climate change and health is an important research issue. We're now starting to see governments, and particularly health departments, responding to this. It's surprising that within the last 12 months there have been just so many workshops, conferences, consultations, on this topic at the state, national and international levels. So the timing is very good from my point of view.

What I'm in the process of doing now is recruiting a research team, developing this program, so we can engage not just within Australia,

where our primary focus is, but also within the region at large begin to engage more with Asian and Pacific countries in developing a better understanding and making better use of comparative data from populations in different geographic and climatic circumstances, to get a better understanding of the risks that exist and a better capacity to model those risks, to understand how the disease patterns could change in future. Out of all of that, of course, to begin to work increasingly with government in the development of appropriate adaptive strategies to lessen risks to populations.

Future Oriented Research Interviewer: It's quite an exciting time for epidemiology, because we interviewed on this series recently John Hopper, in Melbourne, and we discussed the comment about being an epidemiologist you're often looking backwards. But in fact you're going to be looking backwards and forward at the same time, so this is almost like a new dimension.

Prof. McMichael: It is. It's quite challenging in that respect, in that very often when you're dealing with environmental health problems the agenda really is to understand from recent experience what the health risks have been and then to take appropriate action to eliminate that exposure. Now for something like climate change, of course, we can't realistically talk about eliminating the exposure, no matter what we do - and we now understand this better than we did five or 10 years ago. No matter what we do, climate change is going to -Spaceship continues on page 14

"...we've seen really an upturn, a very dramatic upturn, in awareness that climate change and health is an important research issue."

“Now for something like climate change, of course, we can't realistically talk about eliminating the exposure...�

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-Spaceship continued from page 13

"So this is really an unusual challenge for epidemiologists..."

continue for the next few decades and I must say on current appearances and the difficulties national governments around the world are having in achieving a radical and progressive way of curtailing the problem, that it's going to escalate foreseeably for a number of decades. So this is really an unusual challenge for epidemiologists to have to engage not just in studying the world as it is around us at the moment, but trying to work with mathematicians, modellers, climate scientists and others, social scientists, to try and foresee the ways in which these risks will play out and to develop strategies for lessening those risks.

Inspiration Interviewer: What inspired you to start on a research career? I note that you initially did a medical degree?

Prof. McMichael: Yes.

“...this looks to me as if it's going to have very important consequences for human health."

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Interviewer: And I'm not sure whether you've ever practised medicine.

Prof. McMichael: I didn't practise it for very long, because I got caught up in the hurly-burly of student politics, and I moved to being the full-time president of the National Union of Australian University Students in the year after I graduated in medicine. I did do some general practice in Victoria for a couple of years, but then I moved to Monash University to do a PhD in the newly created Department of Social and Preventive Medicine.

And it was during that time, actually, that I began to read some quite stimulating and ground-breaking

works in the area of environment and the consequences for human societies.

I particularly remember a book by Paul and Anne Ehrlich on population resources and environment, published in about 1970, I think. And I had a friend who was editing a new newspaper - his name was Richard Walsh; he was editing Nation Review. I offered to do a review of the book in that newspaper. He liked it and said, 'Would you like to write a regular column?' So then, whilst finishing my PhD, I wrote a column called 'Spaceship Earth' for the next couple of years, a weekly column.

Interviewer: And it was on?

Spaceship Earth Prof. McMichael: Well, it was really on environmental issues, the spaceship earth notion that we live within this closed system, this little planet, and the damage that we do to the environment around us will have ways of coming back to bite us, and particularly as the scale of that damage begins to increase we will start to see systemic changes on a larger scale that would have wider ranging consequences for human health both now and into the future.

And I suppose the climate change story which I started to notice about 15 years later, in the mid 1980s, was really an extension of that longstanding interest. And I saw it coming over the horizon and I thought this is, firstly, very interesting, I must find out about it, but secondly this looks to me as if it's going to have very important consequences for human health. So I got involved in reading about it. I remember when I was -Spaceship continues on page 15

-Spaceship continued from page 14 president of the Public Health Association of Australia in the late 1980s I actually concentrated on it in my presidential address and said we need to take notice of this. Not many people did at that stage. But in the subsequent decade or two, it's really come clearly on to the agenda. And now it's fair square on the agenda and I'm hoping to really carry it forward with this new program of work.

Careers for Young People Interviewer: It seems like a great time to think about a career for younger people in the area of epidemiology. It doesn't matter what their background is - if you're a mathematician, as you say, or a computer modeller, or interested in the environment, this would be a great time to get into the game. Any advice to any younger people who are trying to think about what they could do in the future and why should they become an epidemiologist?

Prof. McMichael: Well, I think the first advice is don't be fainthearted. You don't have to imagine that you've got to have a lot of specialist skills. This is an area in which we're all learning.

I've had to pick up ideas, information, from a range of disciplines in the last decade - climate scientists, oceanographers, ecologist s. I've been listening to them all and reading their stuff. I didn't have specialised skills in those areas, but I've learnt enough to be able to integrate it now with my epidemiological research and to know with whom I should collaborate. I mean, this is an area in which we need multidisciplinary collaboration. So young people shouldn't imagine that

they're entering a terrifying world of science in which they're going to be solely responsible for carrying out research. It'll be a team effort and it'll be good fun and it will be very important.

It's interesting for me to see that there's now quite an upsurge in inquiries that my group is receiving from young people wanting to come on and do PhDs. We weren't getting this five years ago. But I think a number of young people can now see that this is not just a scientifically interesting and challenging area, but this is actually something that has enormous social relevance, enormous consequences for human futures, including the futures of themselves as young people and the families that they might have in future. So there's concern, there's engagement, and there's going to be enormous opportunity. These problems are going to escalate, unfortunately, for the next few decades. We're seriously understaffed. We need a lot more young people coming in to work in the area. So I'd encourage anyone with an inkling of interest in this area to get into it. We need them and they would be doing something very interesting and hugely important.

"...it's really come clearly on to the agenda..."

“I think the first advice is don't be fainthearted."

Interviewer: On that upbeat note I thank you very much for your time and wish you well with your Australian Fellowship. It sounds like you're going to enjoy it. And all the best for the future.

Prof. McMichael: Thank you very much. It's going to be a challenging five years, but it's timely and I think we're going to do some good and important work. â–

15

T32 POST-DOCTORAL RESEARCH TRAINING OPPORTUNITY The Cancer Epidemiology and Prevention Program at the University of Pittsburgh Cancer Institute is pleased to announce 3 trainee openings for its newly funded Translational Research Training Program in Cancer Prevention and Control. Candidates must have (1) career interests in cancer etiology and prevention research; (2) the ability to recognize important research problems and a demonstrated capacity to seek solutions; (3) clear career plans and potential for independent research in an academic setting; (4) an MD and/or PhD and (5) status as a U.S. citizen, non-citizen national or permanent resident at the time of appointment. For more information or requests for applications, please email Brooke Spencer at spencerbd@upmc.edu.

Co-Directors: Lesley Butler, PhD and Jian-Min Yuan, MD, PhD Email Addresses: ButlerL3@upmc.edu and yuanj@upmc.edu This postdoctoral research training is supported by the National Cancer Institute of the National Institutes of Health under Award Number T32CA186873.

Pilot Study on Cancer Risks near Nuclear Facilities The National Academy of Sciences is requesting information regarding provision of research support and the associated costs for executing a feasibility pilot study on cancer risks near seven nuclear facilities in the United States. The pilot study is designed to help confirm whether a nationwide study of cancer risks near nuclear facilities is feasible.

The National Academy of Sciences invites interested individuals to submit written responses to a Request for Information (RFI). You can access the RFI document that contains background information, the services desired by the National Academy of Sciences, and instructions on response format here: http://nas-sites.org/cancerriskstudy/.

The RFI is being issued strictly for the purpose of gaining knowledge of responders, understanding their research capabilities, and estimating the costs for carrying out the tasks listed by the National Academy of Sciences. No contract is guaranteed as a result of any response to this RFI. RFI responses must be received prior to 5 PM (ET), November 24, 2014 at the following e-mail address: crs@nas.edu.

UNC-China PostDoctoral Fellows HIV Research Project The University of North Carolina – Chapel Hill Project-China is accepting applications for two postdoctoral fellows supported by an NIH R01 grant. This research project focuses on developing, implementing and evaluating HIV testing and linkage campaigns using crowdsourcing and social marketing approaches. Primary responsibilities of this position include coordinating and implementing study activities with local investigators and the study team, serving as the link between US and China investigators, preparing manuscripts for peer-reviewed journals, and assisting developing grant applications. One fellow will be based in Jinan, China and the other fellow will be based in Guangzhou, China.

Minimum Requirements: 1. Doctoral level degree in medicine, public health, epidemiology, behavioral health, social science, or other related field; 2. Demonstrated ability to analyze qualitative or quantitative data or both; 3. Demonstrated ability to produce peerreviewed scientific articles; 4. Proficient in English and Mandarin Chinese.

Preferred Qualifications: 1. Experience in HIV research with key populations in international settings; 2. Comprehensive knowledge of HIV/AIDS, sexual health, and sexual minority health; 3. Experience with intervention studies or programs in HIV prevention; 4. Experience working with governmental or community-based organizations in international settings, particularly in China and Asia; 5. Strong quantitative statistical analysis skills; 6. Experience with LGBT research, advocacy, and service.

Appointment and Salary: One year full-time appointment with salary and benefits package consistent with NIH standards with an option to extend to a second year contingent on meeting benchmarks.

Application: Email Ye Zhang at cetacean.413@hotmail.com with your CV, cover letter, and names of three references. Application deadline is on October 17th, 2014.

Assistant / Associate / Full Professor Epidemiology The School of Public Health-Bloomington is accepting a new cycle of applications for multiple tenure-track/tenured Assistant/Associate/Full Professor positions in EPIDEMIOLOGY in the Department of Epidemiology and Biostatistics. The IU School of Public Health-Bloomington emphasizes its strengths in social and behavioral health, environmental health, epidemiology and communitybased research and practice. For information and to apply please go to https://indiana.peopleadmin.com Indiana University is an equal employment and affirmative action employer and a provider of ADA services. All qualified applicants will receive consideration for employment without regard to age, ethnicity, color, race, religion, sex, sexual orientation or identity, national origin, disability status or protected veteran status.

For full job description, please go to : http://tinyurl.com/n2qx5ek

BIOSTATISTICS National Academy of Sciences / Radiation Effects Research Foundation September 2014 The National Academy of Sciences (NAS) seeks a biostatistician to join the highly collaborative and productive research team at the Radiation Effects Research Foundation (RERF) in Hiroshima, Japan.

Candidates must be U.S. citizens; hold an earned M.S. or Ph.D. degree in biostatistics, bioinformatics, or statistics; have a demonstrated record of productivity in a relevant research field commensurate with the level of appointment; and have the ability to relocate to Japan. The appointment can be made at the early to senior career levels for a minimum of two years with the possibility for renewals.

Position level, salary, and responsibilities will be commensurate with earned degrees and experience.

NAS offers an outstanding package of benefits and relocation allowances for this position.

Please visit http://ch.tbe.taleo.net/CH04/ats/careers/requisition.jsp?org=NAS&cws=1&rid=7911 for additional information about and to apply for this position or contact Dr. Kevin Crowley at NAS (kcrowley@nas.edu) or Dr. Harry Cullings at RERF (cullings@rerf.or.jp) for additional information. EOE, M/F/D/V

Center for the Study and Prevention of Suicide

Epidemiology - Health Svc Research Position The Veterans Administration VISN 2 Center of Excellence (CoE) for Suicide Prevention, Canandaigua (NY) VA Medical Center, together with its academic affiliate, the Center for the Study and Prevention of Suicide at the University of Rochester Medical Center, is seeking a junior investigator or a mid-career researcher to conduct public health, epidemiological, and/or health services research involving Veterans, with a focus on suicide risk and prevention.

Training and experience conducting epidemiological studies, public health research, and/or health services studies on suicidal behavior and/or on populations at risk for suicidal behavior is required, and it is expected that the successful candidate will have the ability to obtain research funding. The position provides considerable “hard money� salary support for this position, with the expectation that s/he will develop a program of research supported by additional external funding.

The incumbent will be eligible for a faculty appointment at the University of Rochester Medical Center, which is commensurate with experience.

Position: Health Science Specialist, GS-13.

Send cover letter and vita to: Kenneth R. Conner, PsyD, MPH, CoE Director, ken.conner@va.gov, and copy Ms. Lisa Lochner, lisa.lochner@va.gov.

Clinical Researcher / Professor of Surgery Dept of Surgery / Div of Trauma, Emergency Surgery and Surgical Critical Care at the NYU School of Medicine is seeking to hire a full-time clinical researcher as an assistant or associate professor of surgery. This person will provide leadership for conceptualizing and conducting research in Trauma and Injury Prevention. As a member of the Department of Surgery, the successful candidate will have access to all the resources available and the collaborative potential at the NYU School of Medicine. The ideal applicant will have expertise in study and database design, complex statistical modeling and successful grant writing. peerreviewed publications in the field of public health, a history of successful grant-writing, and a PhD in public health, epidemiology, biostatistics or a related discipline.

The division is based at Bellevue Hospital Center (BHC), a level 1 trauma center in New York City. BHC receives over 100,000 emergency room visits and 1,400 trauma admissions annually. The trauma faculty currently conducts epidemiologic research focusing on pedestrian and bicycling road safety and health services research focusing on fall prevention and older adult trauma. The goal of the Trauma Division is to expand and develop its research core and mission.

Applicants should send a letter indicating interest and a curriculum vitae to Spiros.Frangos@nyumc.org

Assistant / Associate Professor Position in Environmental and Occupational Health Drexel University School of Public Health Drexel University School of Public Health invites applications for a tenure-track faculty position in the Department of Environmental and Occupational Health. We seek an Assistant or Associatelevel Professor with expertise in a range of environmental and occupational health areas including but not limited to exposure assessment and modeling, industrial hygiene, or toxicology.

Both population and laboratory-based research are of interest, and of particular interest is the candidate who can bridge the two in their scholarship. This full-time appointment involves teaching and advising students, conducting research, and contributing to the service mission of the Department and the School. The successful candidate will be expected to play an important role in the development of multi-disciplinary research on crosscutting environmental or occupational health themes.

Competitive candidates will have a doctoral degree in a related field, an established externally funded research program or strong potential for research funding, and teaching experience commensurate to rank. Laboratory facilities and equipment are available. Excellent collaborative opportunities in occupational and environmental health are available within the Department, the School, the University, and in the Philadelphia region.

Drexel School of Public Health is a vibrant, growing school with a unique commitment to public health practice and experiential learning. The School’s mission focuses on improving urban public health, eliminating health disparities, and conducting policy-relevant research. The EOH department includes 6 tenured and tenure-track faculty and several part-time faculty with expertise in environmental and occupational epidemiology, exposure assessment, and occupational medicine. Ongoing research interests in the department focus on occupational causes of cancer, air pollution health effects, pesticides, healthy housing, and injury.

Drexel is a top-50 private research university and has been ranked as an “up-and-coming school” in the nation by U.S. News & World Report. The University’s goal to become “the most civically engaged university in America” drives its work with the City of Philadelphia and diverse community partners.

Drexel University is an equal opportunity/affirmative action employer. The School of Public Health is especially interested in qualified candidates who can contribute to the diversity and excellence of our academic community.

Interested candidates should submit their curriculum vitae and a cover letter describing relevant experience and goals to DrexelJobs (www.drexeljobs.com). Confidential informal queries are also welcome. Interested candidates may direct any questions to the search committee chair, Dr. Anneclaire De Roos (aderoos@drexel.edu). Review of applications will start immediately, and will continue until a successful candidate has been identified.

Department of Public Health Assistant/Associate Professor (Tenure Track) in Epidemiology The Division of Epidemiology and Biostatistics within Temple University’s Department of Public Health seeks applicants for a tenure track faculty position in Epidemiology at the Assistant or Associate Professor level. We are looking for a talented and energetic faculty member with expertise and a research portfolio in the areas of chronic disease or infectious disease epidemiology. We are especially interested in individuals with interests in diabetes, cancer, and cardiovascular disease. The successful candidate will either have a nationally recognized research program, demonstrated success securing extramural funding or a demonstrated ability to develop an independent research portfolio. The candidate must also have an ability to develop interdisciplinary collaborations. For a full job description, please go to

http://tinyurl.com/l8vqmmo

Boston University School of Public Health (BUSPH) invites candidates to apply for open faculty positions in the Department of Epidemiology. Successful applicants will be recognized researchers and educators in epidemiology with an established record of externally funded research.

BUSPH is a top-tier school of public health and globally recognized leader in graduate education and public health research, with strategic emphases in assuring affordable, quality health care; creating a clean environment; eliminating health disparities; and promoting health globally.

A description of the Department of Epidemiology can be found at http://www.bu.edu/sph/academics/departments. There are opportunities to collaborate with the School’s Center for Global Health and Development, Slone Epidemiology Center, Framingham Heart Study, and clinicians serving the diverse patient population at Boston Medical Center.

Candidates should have a PhD or equivalent degree in epidemiology, and have demonstrated a commitment to graduate education and mentorship of students, and shown outstanding scholarship through publication and an established record of externally funded research. Interested candidates are invited to submit a curriculum vitae and a cover letter in confidence to Shelley Barnes, Epidemiology Faculty Search Committee by email to sbbarnes@bu.edu. The cover letter should briefly describe the candidate’s research and teaching experience. The positions will remain open until filled. www.bu.edu/sph/faculty-openings/ Boston University is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.

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